NSE111 Final Notes PDF

NSE111 Week One Learning Objectives ∙ Understand how the clinical judgment model (CJM) relates to the implementation of foundational skills. ∙ Identify the approach to care of clients using the Dignity, Independence, Preference, Privacy, Safety (DIPPS) acronym. ∙ Describe wh...

NSE111 Week One Learning Objectives ∙ Understand how the clinical judgment model (CJM) relates to the implementation of foundational skills. ∙ Identify the approach to care of clients using the Dignity, Independence, Preference, Privacy, Safety (DIPPS) acronym. ∙ Describe what person-centred/client-centred care is. ∙ Identify who the College of Nurse of Ontario (CNO) are and describe their purpose. Examine the CNO Entry-to-Practice Competencies for Registered Nurses. A registered nurse is…. - Goal of nursing is to restore, maintain and advance the health of individuals, groups or entire communities. - It is a science and an art. - Science is the application of nursing knowledge and the technical aspects of the practice. - The art is the establishment of caring relationship through which the nurse applies nursing knowledge, skills and judgment in a compassionate manner. - Both focus on the whole person, not just a particular health problem. ` What is the CNO? The College of Nurses of Ontario (CNO) is the governing body for Registered nurses (RNs), Registered Practical Nurses (RPNs) and Nurse Practitioners (NPs) in Ontario, Canada. Who can call themselves a registered nurse in Ontario? Registered by who? For what? What does it mean to be a self-regulating profession? Who is regulating who? And why? The nursing profession has been self-regulating in Ontario since 1963. Self-regulation is a privilege granted to professions that have shown they can put the interests of the public ahead of their own professional interests. It recognizes that Ontario’s nurses have the knowledge and expertise to regulate themselves as individual practitioners and to regulate their profession through the College. 9 COMPETENCIES - Clinician Provides safe, competent, ethical, compassionate, and evidence-informed care across the lifespan in response to client needs. Registered nurses integrate knowledge, skills, judgment and professional values from nursing and other diverse sources into their practice. - Professional RNs are professionals who are committed to the health and well-being of clients. RNs uphold the profession’s practice standards and ethics and are accountable to the public and the profession. - Communicator RNs are communicators who use a variety of strategies and relevant technologies to create and maintain professional relationships, share information, and foster therapeutic environments. - Collaborator RNs are collaborators who play an integral role in the health care team partnerships. - Coordinator  RNs coordinate point-of-care health service delivery with clients, the health care team, and other sectors to ensure continuous, safe care. - Leader RNs are leaders who influence and inspire others to achieve optimal health outcomes for all. - Advocate RNs are advocates who support clients to voice their needs to achieve optimal health outcomes. Registered nurses also support clients who cannot advocate for themselves. - Educator RNs are educators who identify learning needs with clients and apply a broad range of educational strategies towards achieving optimal health outcomes. - Scholar RNs are scholars who demonstrate a lifelong commitment to excellence in practice through critical inquiry, continuous learning, application of evidence to practice, and support of research activities. Person-centred/Client-Centred Care An approach in which; clients are viewed as a whole persons. Involves advocacy, empowerment, and respecting the client's autonomy, voice, self determination, and participation in decision-making. D.I.P.P.S. Dignity – The state of feeling worthy, values, and respected. Independence – Encouraging patients to do what they can themselves. Preferences – Allow patients to make choices and how they would like to have things done. Privacy – Ensure to provide privacy during care and keep the patients. Safety – Patients need to be in an environment that will keep them safe from harm. CLINICAL JUDGMENT AND NURSING When collecting subjective and objective data, you need to consider clinical judgment. In nursing, the purpose of health assessment is to facilitate clinical judgment, defined as ∙ A determination about a client’s health and illness status. ∙ Their health concerns and needs. ∙ The capacity to engage in their own care. ∙ The decision to intervene/act or not - and if action is required, what action. The nursing process is the foundation of clinical judgment. Clinical Judgment is more comprehensive, action-oriented, and guided by the philosophy of client safety. Important to learn when to prevent client deterioration, a worsening clinical state related to physiological decompensation. To facilitate clinical judgment, you must determine if the collected data represents normal findings or abnormal findings. ∙ If findings are abnormal, you must act on these cures as they signal a potential concern & require action. Failing may lead to consequences including sub-optimal health & wellness — & clinical deterioration. ∙ Some abnormal findings are considered critical findings that place the client at further risk if the nurse does not act immediately.  The process leading to clinical judgment is described as clinical reasoning. This process involves: - Thoughtfully considering all client data as a whole, whether each piece of information is relevant or irrelevant, and how each piece of information is Definitions Clinical judgment: A determination about a client’s health and illness status. Client deterioration: A worsening clinical state related to physiological decompensation. Normal findings: Findings that are not of concern & expected for a client’s age developmental stage, and sex. Abnormal findings: Findings of concern because they are not normal & not consistent with a client’s age, developmental stage, and sex. Critical findings: Findings that require prompt & immediate action to prevent clinical deterioration or intervene when a client is deterioration. Clinical reasoning - The clinical reasoning process is encompassed by critical thinking. Cues: Signs or symptom that prompts an action such as an abnormal finding that signals potential concern. Critical thinking: Means that when engaging in the process of clinical reasoning, you should systematically analyze your own thinking so that the outcomes are clear, rational, creative, and objective with limited risk of judgment and error. Competent: The demonstration of integrated knowledge, skills, abilities, and judgment required to practise nursing safely and ethically. related or not related. - Recognizing and analyzing cues. Is the information collected a normal, abnormal, or critical finding? Can the information be clustered to inform your clinical judgment? - Interpreting problems. What is the priority problem? What are the factors causing it? What else do you need to assess to validate or invalidate your interpretation? What other information do you need to collect to make an accurate clinical judgment? - Determining, implementing, and then evaluating appropriate actions. Clinical Judgment facilitated by cognitive steps that help you determine when and how to act to prevent clinical deterioration. THE NURSING PROCESS Steps Considerations Recognizing Cues Involves identifying findings that require action because they are abnormal. Gathering accurate information. Identifying or noticing any cues. You should be asking yourself what matters most.  Analyzing Cues Involves interpreting/making sense of the collected data, what it means, and how it may relate to possible pathophysiological processes. Prioritize Hypotheses Involves figuring out where to start and how to prioritize care. Responding to collected data. Evaluating and ranking hypotheses according to priority (urgency, likelihood, risk, difficulty, time, etc.) Generate Solutions Involves identifying the various options (actions/interventions) to address the problem or the abnormal findings/cues. May involve identifying which solutions are indicated/affected, nonessential, unrelated, contraindicated. Take Actions Involves identifying the action that should be taken. Examples of actions are specific but could be related to notifying the physician or nurse practitioner, calling for help, monitoring the client, collecting further data. Implementing solutions that addresses the highest priorities. Evaluate Outcomes Involves determining if the action taken was effective. May include identifying outcomes that are considered improves, unchanged, or worsened. NSE111 Week Two Learning Objectives - Explain how infection develops in relation to the elements that make up the chain of transmission. - Explain how the body protects itself against infection. - Describe what a Hospital Acquired Infection (HAI) is, how they develop, relate the development of HAIs to client who are most susceptible. - Explain what an antimicrobial resistant organism (ARO) is. - Differentiate between medical and surgical asepsis/technique and recognize practices that are consistent with both. - Explain the rationale and demonstrate the practices of routing and additional precautions including contact, droplet, airborne, combination, and COVID precautions. - Explain the psychological effects a person on isolation precautions might experience, and how the nurse could decrease the risk. - Examine a risk assessment approach for decision-making related to the use of isolation precautions. - Discuss the role of the nursing process and clinical visitors, about infection prevention, control practices, and judgment to determine infection preventions and control how to prevent healthcare-associated infection. strategies. - Ensure effective infection prevention and control strategies; to identify, analyze, assess, and manage any Introduction to Infection Prevention and Control potential risks. Practices for the Interprofessional Learner – OER: Chapter 1 -7 The role of healthcare providers is to ensure What is an infection prevention and control risk safe and effective infection prevention and control assessment? Before entering a healthcare environment or practices are upheld, evidence-based best practice providing any care to a client, you need to perform a risk guidelines are implemented, and continued competency in assessment. The goal is to assess if there are any risks of institutional policies are maintained. infection and determine which infection prevention and - Important to educate and support clients, as well as their control interventions are required to prevent the transmission of infection during the provision of client prioriƟes care. This must be done each time you interact with a opƟmal care. client because their environment and health status - CollaboraƟon is crucial because others may idenƟfy risk continuously change. that you have not considered. RISK ASSESSMENT Working together, facilitaƟng open communicaƟon, and -What type of care is required for the client? building trusƟng relaƟonships promotes client-centred -What us the client’s diagnosis or infecƟon status, and is the client exhibiƟng any signs or symptoms? care and a safe working environment -What type of environment are you entering to provide - Infection Prevention and Control Canada (IPAC) client care? -Will I be exposed to or at risk of exposure to Multidisciplinary, professional, non-profit organization body fluids (blood, excreƟons, or secreƟons) or be within committed to education and developing evidence-based 2 meters of the client? and best practices on infection prevention and control -Will my hands be exposed to or at risk of exposure to practices. blood, body fluids, or contaminated equipment? - Public Health Ontario (PHO) -Will my face (e.g., mucous Keeps Ontarian’s safe and healthy. membranes of the eyes, nose, mouth) come into contact - Canadian Patient Safety Institute (CPSI) with or be at risk for coming into contact with blood or Focuses on creating safe healthcare systems by body fluids due to the spraying of fluids (e.g. coughing, collaborating with governments, health organizations, sneezing, aerosol parƟcles generated by medical healthcare professionals, and clients. - Public Services procedures)? Health and Safety Association (PSHSA) Create safe -Will my clothing (e.g., uniform) or body (e.g., exposed working environments in Ontario. skin) come into contact with blood, body fluids, or - Public Health Agency of Canada (PHAC) contaminated equipment due to touching or spraying of Focuses on preventing disease and injuries, promoting fluids? physical and mental health, and providing information to Interprofessional CollaboraƟon As a healthcare provider; support informed decision-making. - World Health - Responsible for recognizing and applying evidence-based Organization (WHO) strategies to prevent risk of Collaborated with international partners to create key infecƟons. strategies, guidelines, tools, and other resources on - Work as an interprofessional team member. infection prevention and control. - Consult your colleagues as you make decisions to. CLINICAL TIPS Infection prevention and control strategies to consider when in THE ROLE OF THE STUDENT transmission of microorganisms that cause infections. - Healthcare providers are in a unique position to educate Healthcare students are responsible for learning about and empower the public with evidence-based knowledge infection prevention and control practices, becoming about health promotion and preventive measures related competent in infection prevention and control skill to infection prevention and control practices. techniques, and becoming knowledgeable in infection - Students are responsible for learning about infection prevention and control guidelines according to their prevention, control practices; becoming competent in healthcare role. infection prevention, control skill techniques, according to their healthcare role. KEY TAKEAWAYS CHAPTER 2: Introduction to infection prevention and - Infection prevention and control risk assessment is control performed to prevent infection/promote healthy practice; environment; should be performed before providing care -Wear your street clothes to the hospital and change into to a client or entering a healthcare environment. your scrubs or professional aƫre when you get to - Infection prevention and control guidelines; mandated in placement. healthcare settings to maintain safety, provide quality care;-During your shift, be mindful and avoid touching your protect clients, visitors, healthcare providers; from face while at placement. -Keep your food and drinks in your locker or staff room. watch, notebook, pens, penlights, stethoscope, and -Likewise, change out of your scrubs before you go home stationery. at the end of your shift -Bring hand sanitizer with you to your clinical practice to -Bring an extra bag or two to put your uniform and shoes avoid bringing microorganisms from your placement in at the end of your shift. back home with you. -Disinfect any materials you bring with you such as your Infection prevention and control refers to practices that can prevent or reduce the risk of transmission of microorganisms; evidence-based best practices provide guidelines to healthcare providers to ensure safe, quality care is provided to clients, visitors, healthcare providers, and the healthcare environment. HAIs: healthcare-associated infections can be prevented in healthcare settings when infection prevention and control practices are used consistently. HAIs occur when a person is infected with a pathogen during their care in a healthcare setting. Hand hygiene is considered the most important and effective measure to prevent HAIs. Potential risks include blood, body fluids, mucous membranes, non-intact skin, contaminated surfaces or soiled items, and airborne particles. ONCE COMPLETED A RISK ASSESSMENT, NEED TO ASSESS HOW TO DECREASE YOUR RISK OF EXPOSURE. Performing the risk assessment is foundational in the prevention of infection transmission. Public Health Ontario outlines how to perform a risk assessment related to routine practices and additional precautions. Routine Practices Risk Assessment Algorithm for All Client/Patient/Resident Interactions There are two types of techniques used to prevent the spread of infections: Medical asepsis and Sterile asepsis. Medical Asepsis (clean technique); reduces and prevents the spread of microorganisms. Examples: hand hygiene, using personal protective equipment, following routine practices. Sterile Asepsis (sterile technique); strict technique to eliminate all microorganisms from an area. Examples: steam, hydrogen peroxide, sterilizing agents to clean surgical tools. ROUTINE PRACTICES: includes performing of point-of-care risk assessment, hand hygiene, wearing the appropriate personal protective equipment (PPE). May also include respiratory etiquette, safe handling of sharps, controlling the surrounding environment, using avoidance procedures and actions, and following environmental cleaning and disinfecting protocols. If a client is coughing, sit next to the chair, rather than in-front of the client when talking to that client. This is an example of an avoidance action. Certain types of infectious microorganism require; Additional precautions include contact droplet, and airborne precautions or a combination of these precautions. The mode of transmission of the infectious agent will determine which additional precautions are required. Additional precautions can include PPE, specialized equipment (e.g. N95 respirator), specialized accommodation and signage, client-dedicated equipment, advanced cleaning protocols, limited movement of the client and specific environmental protocols (e.g., client placement, negative-pressure -engineered rooms). Routine Practices and Additional Precautions Routine Practices Additional Precautions Point-of-care risk assessment. Routine practices Hand hygiene. Additional PPE requirements according to clients confirmed or suspected diagnosis including contact, droplet, and airborne precautions. Personal Protective Specialized accommodations Equipment (PPE) when (e.g., single room, negative needed. pressure room, cohort room, and signage). Respiratory etiquette Dedicated client equipment Safe handling of sharps Engineering requirements to control environment (e.g., negative pressurized rooms, filtered air). Controlling the Advanced or additional surrounding environment cleaning protocols. Avoidance procedures Limited transportation of and actions. client throughout the healthcare setting. Environmental cleaning and Communication of client’s disinfection including additional precaution status medical equipment and to interprofessional linens. healthcare team. THERE ARE SIX LINKS TO THE CHAIN OF TRANSMISSION 1. Infectious Agent (aka Pathogen; causes the disease in the host) - Most common; bacteria, viruses, and fungi. Others; parasites or prions. Bacteria – streptococcus and salmonella. Viruses – Influenza and chickenpox Fungi – athlete’s foot and thrush mouth in newborns. Parasites – malaria, giardia and toxoplasmosis Prion – Creutzfeldt-Jakob disease. - can live inside a host; dormant phase outside of a living host; ability to invade the body. - Exploit the host’s biology, behaviour, and ecology to live in and move between hosts. - Chain of transmission must be present.  - Important to know how long they survive. - People infected may present clinical symptoms (according to that pathogen). HOW TO BREAK THE LINK? - Need to clean, disinfect, sterilize the environment depending on the pathogen and follow healthcare workplace policies. - Client may be prescribed medication to eliminate the infection agent. 2. Reservoirs - Can be living organism or inanimate object where the infectious agent lives, survives, and has the ability to multiply and grow. - Reservoirs can be people, animals, insects, food, soil and water. - Human reservoirs may be capable of transmitting the pathogen, depending on the stage of the infection and the pathogen. - People : Influenza virus can live in client’s upper respiratory tract (e.g. nose, mouth, throat, and sometimes lungs); up to 48 hours outside their body on inanimate object (e.g. sneezing) Animals – rabies virus; when anima bites a person. Mosquitoes – carry malaria parasites; bitten. Food – become contaminated by poor hygiene; improper washing; undercooked/cross contamination; can cause gastrointestinal issues. Soil – contains a fungal pathogen called blastomycosis-bacteria like tetanus. If humans breathe in they can get infected. Water – giardia parasites live in contaminated water; infect humans during consumption. HOW TO BREAK THE LINK? - Clean, disinfect, sterilize the environment; follow healthcare workplace policies. - Disinfect everything; stethoscope and medical equipment between each client; high touch surface areas in the client room (bed rails, doorknobs, call bell, sink, toilet) - Proper food handling and storage; hand hygiene prior to touching food items; clean table surface. - Assist clients to perform personal hygiene if they are unable to do so. - Educate clients about hand hygiene, respiratory etiquette, and importance of vaccines. (prevent spread of infection) 3. Portal of Exit - How the infectious agent leaves the reservoir or host. - Includes; Mouth (via secretions of saliva/vomit) Respiratory tract (via sneezing, coughing, talking or laughing) Skin lesions (via blood or exudate) Gastrointestinal, genitourinary/urogenital tracts (urine, feces, semen, vaginal secretions) - When infection agent's exit the body, enters a host’s eye, nose, mouth, or contaminate an inanimate surface, potentially transmit infectious agent. HOW TO BREAK THE LINK? - Hand hygiene and routine practices - Teach respiratory etiquette. - Dispose of soiled tissue after use - Cover wounds - Dispose of contaminated linens and waste - Clean from cleanest to dirtiest areas. 4. Modes of Transmission - How the infectious agent travels and spreads; either directly or indirectly. - Contact transmission – directly touching with hands; indirectly touching items that are contaminated. Need to wear gloves and a gown. - Droplet transmission – respiratory secretions from talking, sneezing, coughing; droplets can  travel up to 2 meters. Need to wear a mask and eye protection. - Airborne transmission – small nuclei travelling on air (over 2 metres); must be placed in a negative-pressure room & wear fit N95 respirator. - Vehicle transmission – water, food, or air. - Vector transmission – through living organisms transmitted biologically (mosquitoes) or mechanically from animal to human (e.g., fly or tick) HOW TO BREAK THE LINK - Hand hygiene, routine practices, and additional precautions. - Essential to clean, disinfect, or sterilize contaminated inanimate objects. (stethoscope, client chart, etc.) - Space separation between clients. - Negative-pressure-engineered room protocols to ensure airborne pathogens do not travel outside the room. - Know immunity status. - Educate clients about immunization. 5. Portals of Entry - How it enters another person’s body/new host. - Can enter through mucous membranes of the eyes, nose, mouth, or skin lesion and open wounds. - Includes: Entering through catheter, gastronomy tube, intravenous catheter, or other invasive devices. Enter through the non-intact skin of clients or healthcare providers. Can enter a person’s mucous membrane of the eyes, nose, mouth, and respiratory tract (within 2 meters) Can enter a person’s digestive system via contaminated food. HOW TO BREAK THE LINK - Hand hygiene, routine practices, additional precautions. - Aseptic techniques - Cleaning, disinfecting or sterilizing contaminated items/environments. - Cleanest to dirtiest. 6. Susceptible Host - Anyone at risk of infectious agents. Some are more susceptible than others. - Newborns, children up to 5 years old, pregnant women, older adults over 65 years old, people undergoing invasive procedures and complex treatments, people with compromised immune systems or chronic illness, and unimmunized people are more susceptible to being infected. - Be aware of factors that increase a client’s risk of being infected; increased acuity, age, use of invasive procedures, immunocompromised state, greater exposure to microorganisms, and an increased use of antimicrobial agents and complex treatments are common risk factors. - Symptoms can vary from person to person. Some may not present symptoms (asymptomatic) or can be symptomatic and present different symptoms. HOW TO BREAK THE LINK? - Important to identify high-risk individuals and protect the client’s body defences from infection. (cover up wounds, keep drainage systems closed and intact, maintain skin integrity, follow asepsis protocols). - Healthy lifestyle; proper nutrition, physical activity, rest and sleep, effective coping strategies, staying up to date with vaccines. If a part of the chain of transmission is broken, the infection will not occur. Routine practices and additional precautions are used to break or minimize the chain of transmission. Blood and body fluid (BBF) exposure; exposure to potentially infectious body fluids or blood through the following methods:  - Percutaneous exposure – puncture wound by sharp object - Permucosal exposure – from body fluids that splashes onto your mucous membrane - Non-intact skin exposure – through eczema, open wound, lesion, or scratch. Post-exposure prophylaxis; take this medication after you get exposed to BBF; take it within 72 hours and take for 28 days to reduce the risk of infection. Chapter 3: HAIs An infection is the successful colonization of a host by a microorganism. It can lead to diseases which cause signs and symptoms. Microorganisms that can cause diseases are known as pathogens. Multiplication of pathogens can lead to infection. Local infection – infecting one area in the body Focal Infection – infecting from one area, leading to another area in the body Systemic infection – primary infection (initial infection caused by one pathogen) leads to secondary infection (another pathogen). Signs are objective; symptoms are subjective. Infectious disease – any disease caused by the direct effect of a pathogen. Spread from one person to another. Iatrogenic disease – occurs after procedures involving treatment, catheterization, or surgery. Zoonotic disease – transmitted from animals to humans. Non Communicable infectious disease – not spread from one person to another, for example tetanus. Noninfectious disease – not caused by pathogens, caused by a wide variety of factors such as genetics. Acute disease – pathologic change occurring over a short period of time. Chronic disease – occurs over a longer time span. (months or years) Latent disease – resides in a latent form within cells for long period of time (in nervous system); and then reactivates to become active during time of stress and immunosuppression. Pathogenicity – ability of microbial agent to cause disease. And to which degree an organism is pathogenic is called virulence. Virulence – a continuum, one end are organisms that are avirulent (not harmful) and on the other end are organisms that are highly virulent. (very harmful). Highly virulent pathogens will almost always lead to a disease state; may cause multi-organ/body system failure to healthy individuals. Less virulent may cause initial infection but may not always cause severe illness. Result in mild signs and symptoms of disease. Some might be asymptomatic. Body defence mechanisms: Physical Defences; One of the body’s most important physical barriers is the skin. (Mucous membrane lining the nose, mouth, lungs, urinary and digestive tracts.) Also, epithelial cells. Mechanical Defences: physically remove pathogens from the body. (Shedding of skin cells, expulsion of mucus, the excretion of feces through intestinal peristalsis, and the flushing action of urine and tears.) Chemical mediators; sebaceous glands, saliva, mucus, urine, lactate, and tears. Cellular Defences; located in the blood; red blood cells, platelets, and white blood cells. Inflammation. FIVE CARDINAL SIGNS OF INFLAMMATION  1. Erythema 2. Edema 3. Heat 4. Pain 5. Altered function Fever is also a cellular defence. Nosocomial infection (HAIs) – infections acquired in healthcare facilities, including hospitals. Often related to surgery or other invasive procedures that provide the pathogen with access to the portal of entry. Classified if the client was admitted for other reasons before the infection within 48 hours. COMMON TYPES OF HAIs MRSA (methicillin-Resistant Staphylococcus auerus): antibiotic-resistant bacteria; spread through skin contact; susceptible host = clients with a skin and other wound infection; may cause pneumonia and septicaemia. At risk; chronic illness, immunosuppressed, open wounds, urinary catheters or other external lines. VRE (Vancomycin-Resistant Enterococci) : bacterias that cause infection in the body. Present in the human digestive tract and female genital tract; can also be found in water or soil. At risk; previously received antibiotics for extended periods of time, hospitalized, had surgery, medical devices inserted in their bodies, immunosuppressed, in intensive care, and people who received a transplant. C. Diff (clostridium difficile): bacterium that causes mild-to-severe diarrhea and an inflammation of the colon called colitis. Most cases occur in clients taking antibiotics (however other’s can get c. diff too). At risk; high doses of antibiotics, taking antibiotics over a prolonged period of time, recently completed a course of antibiotics. MDR-TB (Multidrug-Resitant Mycobacterium Tuberculosis): typically affects the lungs; also affect other organs such as the brain, kidneys, or spine. TB is spread through air. At risk; TB who do not take their antibiotics as prescribed or who have been prescribed the wrong treatment, recurrent TB, live or travelled to areas in the world where there is drug resistant Common AMO is Fluconazole-resistant Candida. TB, prolonged exposure to someone with MDR-TB. HEPATITIS: inflammation of the liver caused by a group of viral infections. Hep A; fecal-oral route. Hep B; BBF COMMON ROUTES OF TRANSMISSION enters the body of an uninfected host. Needle-stick Stop the spread of infecƟons injuries/other sharp objects that puncture the skin. Hep C; associated with AROs and AMOs; - Perform hand hygiene. rare but similar to hep B. - Get vaccinated and maintain immunizaƟon status according to provincial and territorial Antimicrobials: stop the growth or kill microbes (harmful schedules. microorganisms that live in the body). (i.e. antibiotics; - Use anƟbioƟcs only when necessary and as instructed. fight bacterial infections. Antifungals; fight fungal - Monitor any chronic infections.) condiƟons such as diabetes or heart disease to maintain health status. AROs and AMOs are microbes that have become resistant - Keep any open sores or cuts covered and clean unƟl to medications intended to kill them, permitting further healed. growth which can cause infections. Common AROs are - Handle food properly. Vancomycin-resistant Enterococcus (VRE) and Methicillin-resistant Staphylococcus aureus (MRSA). Site Associated Risk Clinical Implications Central Line-Associated - Catheter placed in large - Require sterile dressing Bloodstream Infections vein to allow: changes. (CLABSI) 1) Delivery of IV fluids - Dressing site should or nutrition have minimal exposure 2) Blood to be drawn. to air. - Larger than an IV line. - Removed as soon as possible and only - Refer to infections of inserted if necessary. the central line - Should be above the placement that develop waist to reduce the risk within 48 hours and of contamination. confirms by the laboratory. Catheter-Associated - Hollow, flexible tubes - Requires aseptic Urinary Tract Infection inserted through technique procedure (CAUTI) urethra when being inserted. into bladder. - Don sterile gloves when - Allows drainage of the inserting catheter. bladder. - Use bladder scan before - Three main types; inserting intermittent indwelling, external, catheter to ensure short-term catheters. catheterization is indicated. - Majority of HAIs are - Daily monitoring of associated with urinary indwelling catheters to catheters. Should be ensure it remains in situ removed when they are is needed. no longer needed. - Monitor urine for cloudy, foul smell, or unexplained blood. Surgical Site Infection (SSI) - Occurs when harmful - Preoperatively and post bacteria enters the body operatively, through the surgical health-care incision. providers should ensure - Develop shortly after an clients have normal operation (within 30 body temperature. days). - Clip (not shave) hair that needs to be removed. - Wounds should be closed (with stitches) and sterile dressing for 1-2 days after surgery. If wound is open, it should be packed with sterile gauze and covered with a sterile dressing.  Ventilator-Associated - Blows air into lungs in - Aggressive surveillance Pneumonia (VAP) order to maintain is recommended when proper clients are on oxygen levels. ventilators. - Inserted through the mouth or nose, or trachea. CLINICAL TECHNIQUES TO REDUCE THE TRANSMISSION OF HEALTHCARE ASSOCIATED INFECTIONS (HAIs) Two types of techniques: Medical asepsis/clean technique: reducing and preventing the spread of organisms. Sterile asepsis/technique: eliminate all microorganisms from an area. The principles of routine practices are based on the premise that all clients are potentially infectious, even when asymptomatic, and IPAC routine practices should be used to prevent exposure to blood, body fluids, secretions, excretions, mucous membranes, non-intact skin, or soiled items. Cohorting: assigning clients that have the same infections in the same room. CONTACT PRECAUTIONS: Direct contact occurs through touching a client. Indirect contact occurs when touching a contaminated object or surface.  - Hand hygiene before, during, and after care. - Wear gloves and gown when providing direct care, - Private room, if possible, door remain open, cohort room clients with same diagnosis. - Clean area daily; more frequently with high touch areas. - Proper contact=additional precaution sign on the door? DROPLET PRECAUTIONS Infections that spread through the air by large droplets. - Hand hygiene - Surgical mask & eye protection (within 2 metres of the client) - Should be in private room, if possible, door can remain open (if 2 metres away from the entry of the door. Cohorted with clients with the same diagnosis. Dedicated equipments for each client. AIRBORNE PRECAUTIONS Transmitted by small droplet nuclei that may stay suspended in the air and be inhaled by others. - hand hygiene - n95 respirator, must remove after exiting the room. - No immunocompromised person can enter the room. Healthcare provider should know their vaccine status. - Negative pressured room; own dedicated equipment. Door needs to be kept closed. SINGLE ROOM. - Clean environment daily. - If npr are not available, client should be moved to single room wearing a mask at all times. TIPS ON TAKING CARE OF YOURSELF - PSYCHOLOGICAL FACTORS OF ISOLATIONS Acknowledgement and acceptance. - Reaching out; People feel helpless, lonely, and depressed from keep connecƟons; important to engage with others. physical distancing (isolation). Also, stressed, - Meditate (pracƟce mindfulness) - EaƟng healthy, uncertain, worried, and experience fatigue. geƫng rest and sleep, exercising. - Keep up to date on new informaƟon and follow COVID-19 infecƟon Healthcare providers can support clients by talking prevenƟon and control protocols. about their fears, clarifying any myths, and educating - Stay kind and paƟent clients about the most current data on COVID-19. - Accept support. NSE 111 Week Three Learning Objectives: - Review proper body mechanics to prevent musculoskeletal injuries to both nurse and client. - Identify what a pressure injury is and relate the risk factors that contribute to the development of one. - Understand how to use the Braden Scale for predicting risk and reducing progression of pressure injury. - Recognize nursing interventions to decrease the complications associated with immobility. - Explain the purpose and types of range of motion exercises and explain different methods of join mobilization when assisting with active and passive range of motion exercises.  BODY MECHANICS - Coordinated efforts of the musculoskeletal and nervous systems to maintain balance, posture, and body alignments during lifting, bending, moving and performing activities of ADLS (Activities of daily living). - The way you hold your body when you move. - Prevent muscle fatigue and injury. GOOD BODY MECHANICS - Using several muscle groups instead of one or two to combine strength with fluid movement. - Keeping good posture - Maintaining a wide base of support being aware of your current centre of gravity - Close proximity to the person/object you are assisting or moving. - Whole body instead of twisting - Facing direction, you are moving to. - Balancing activity between arms and legs. - Reducing friction, require less force to be needed=less energy. (using slide sheet to reduce friction) Always wear non-slip shoes; reduce the chance of slipping which might create an injury. Plan what you are going to do ahead of time; let the person you are with know what you are going to do (i.e, 1, 2, 3). Push, pull or roll instead of lifting, if possible, to reduce the change of injury and reduce friction with the use of slide products if available. When is it safe to manually lift a patient: - Recommend 35 lbs 16 kg maximum weight limit for use in patient handling tasks where patient is cooperative & unlikely to move to suddenly during the task - When patient exceeds 35 lbs - use assistive device or extra help from other nurses Pressure ulcer, pressure sores, decubitus ulcer, and bedsore; terms describing impaired skin integrity related to unrelieved, prolonged pressure. Commonly known as Pressure Injury; usually over a bony prominence, result of pressure, shear, or friction, or combination of these factors and is affected by moisture, nutrition, perfusion, and comorbidities. RISK FACTORS FOR PRESSURE INJURY DEVELOPMENT Braden Scale provides an initial assessment to determine appropriate interventions and ongoing regular assessment to evaluate skin status and treatment efficacy. Impaired Sensory Perceptions: people who have impaired sensation are at more risk of developing pressure injury, due to the lack of pain and pressure. Impaired Mobility: Unable to independently change positions are at risk for pressure injury. Absent motor and sensory perception; unable to reposition themselves. Alteration in Level of Consciousness: people who are confused/disoriented; might not be able to understand the sensation of pressure. May not be able to communicate discomfort or pain. Patients in a coma cannot perceive pressure and are unable to move voluntarily to relieve pressure. Shear: force exerted parallel to the skin and results from both gravity pushing down on the body and resistance (friction) between the patient and a surface. Shear force occurs when the head of the bed is elevated, and the skeleton starts to slide but the skin is fixed because of friction with the bed. Friction: force of two surfaces moving across one another, such as the mechanical force when skin is dragged across a coarse surface such as bed linens. Causes burns on the epidermis. Moisture: reduces skin resistance to other physical factors such as pressure and shear force. Moisture softens skin, making it more susceptible to damage. Immobilized patients depend on nurses to keep their skin dry and intact. Originates from wound drainage, excessive perspiration, and fecal or urinary incontinence. Nutrition: essential for not only wound healing but also wound prevention. Deficiencies in any of the essential nutrients result in impaired or delayed healing. Skin breakdown: Maceration - Maceration of skin occurs when it is constantly wet - Skin softens & turns white - Caused by: would drainage, excessive perspiration, incontinence: sitting in wet incontinent briefs 15-16 = low risk, 13-14 = mod.risk, 12 or less = high risk Immobility refers to the inability to move about freely. Contractures: an irreversible contracture further decreases the person’s mobility because it makes moving the involved muscles difficult or impossible. Prolonged bed rest due to immobility can cause major physiological, psychological, and social effects. Can contribute to decreased social interactions, social isolation, sensory deprivation, loss of independence, and role changes. May lead to depression. SYSTEMIC EFFECTS Metabolic: endocrine, calcium absorption and gastrointestinal function Cardiovascular: Orthostatic hypotension thrombus Muscle Effects: Loss of muscle mass, muscle atrophy Urinary Elimination: Urinary stasis, Renal calculi Respiratory: Atelectasis & hypostatic pneumonia Musculoskeletal: Loss of endurance & muscle mass, decreased stability &balance Skeletal Effects: Impaired calcium absorption, Joint abnormalities Integumentary: Pressure ulcer, Ischemia Nurses must apply the nursing process and use a critical thinking approach to develop individualized care plans for patients with mobility impairments or risk for immobility. Improve the patient’s functional status, promote-self care, maintain psychological well-being, reduce the hazards of immobility. Reduce Complication of Immobility 1) Assessment Focus on mobility and immobility, must incorporate the following: 1. Patient’s normal mobility status 2. Effects of disease or conditions on mobility 3. Patient’s risk for mobility alterations as a result of treatments. 2) Assisting patient out of Bed 3) Tuning & Positioning 4) ROM Range of Motion (ROM); refers to the maximum amount of movement available at a join in one of the four planes of the body: medial, sagittal, frontal, or transverse. Active ROM; unassisted (patient is able to move all joints) Passive ROM; assisted (patient is unable to move independently, nurse moves each joint through its ROM). 5) Using pressure relieving devices 6) Nutrition Patients with restricted mobility require ROM exercises to reduce the hazards of immobility, such as contractures. Deep vein thrombosis (DVT) is a hazard of restricted mobility. Semi Fowlers – Bed positioning of 45 degrees. Supine – flat on the back; may have pillows in place for comfort (protects skin and tissue from pressure) Side Lateral – Side lying down with pillows in place. Sims – Semiprone, one arm is further back than the other. Logrolling – requires 3 – 5 nurses, Supine, straight alignment of spinal column. Equal distributing of weight among the nurses. NSE111 Week Four Learning Objectives: 1. Review proper body mechanics (see Week 3 readings). 2. Describe the benefits of activity and exercise and how the concepts of mobility and immobility relate. 3. Differentiate activity tolerance, decondition and functional decline. 4. Recognize physiological and psychological changes associated with immobility. 5. Describe how body alignment, body balance, friction, shear and gravity influence body movement. 6. Understand how to use the Morse Falls Scale to improve client safety. BENEFITS OF EXERCISE Regular exercise; conditions the body, improves health, maintains fitness and provide therapy to correct a deformity or restore the overall body to a maximal state of health. Daily activity; measure for a patient’s functional status. Implement activity and exercise strategies: - Assist patient regain mobility and activity capacity. - Restore and promote optimal functioning. - Helps maintain health of bones, muscles, joints, thus promoting mobility. - Reduces the complications associated with immobility. Patients in acute care settings who experienced altered physical mobility may demonstrate problems associated with adverse effects of immobility, such as impaired respiratory status, orthostatic hypo tensions, and impaired skin integrity. Activity Tolerance response a person has to the type and amount of exercise or activity that they are able to perform. Deconditioning: involves physiological changes following a period of inactivity, bed rest, or sedentary lifestyle. Nurses play a key role in assessing patients for complications associated with immobility and performing interventions such as ROM exercises and early mobilization to prevent adverse outcomes. Older persons commonly lead to significant decrease in muscle mass and functional decline. Functional Decline: loss of a person’s ability to perform ADLs, which are fundamental skills required to independently care for oneself, including mobility, eating, and bathing. PHYSICAL EFFECTS Respiratory: Decreased lung expansion, Hyperventilation, Impaired gas exchange, Pulmonary secretion, Pooling Potential complications – atelectasis, hypostatic pneumonia, hypoxemia, pulmonary edema, pulmonary edema, pulmonary embolism. How to prevent – patients who are immobile need to fully expand their lungs to maintain their elastic recoil property. - Expansion of the chest and lungs; frequent repositioning, deep-breathing exercises, incentive spirometry, controlled coughing, and chest physiotherapy are nursing inventions used to promote lung expansion. Musculoskeletal System: Reduced muscle mass, decreased muscle strength, impaired joint mobility, Decreased endurance. Potential complication – Fatigue, muscle atrophy, decreased stability and balance, joint contractures. May cause temporary or permanent impairment that may lead to permanent disability. Disuse atrophy, the reduction in normal size of muscle fibres after prolonged bed rest, trauma, casting, or local nerve damage. How to prevent – Exercise to prevent muscle atrophy and joint contractures, perform passive ROM exercises for immobilized joints (at least two to three times a day). Bed rest patients should perform ROM exercises incorporated into their daily schedules. CPM machines helps with passive ROM. Integumentary System: Decreased delivery of oxygen and nutrients to tissues, Inflammation over bony prominences, Shearing of skin during movement, Tissue ischemia due to pressure between bony prominences and bed or chair. Potential complication – Skin breakdown, Abrasions/excoriation, Pressure injuries, Infection, Ischemia (pressure on the skin is greater than the pressure inside the small peripheral blood vessels supplying blood to the skin. How to prevent – continuous assessment using a standardized tool, positioning, skin care, and the use of therapeutic devices to relieve pressure. Turning the patient every 1 to 2 hours or use devices to relieve pressure on the skin. If seated in a chair, nurses should teach patients to shift their weight every 15 minutes (if they can). PSYCHOLOGICAL CHANGES - Decreased social interaction. - Social isolation. - Loss of independence - Depression. May lead to emotional reactions, behavioural responses, sensory alterations, and changes in coping. By assessing behavioural changes throughout a patient’s restricted mobility, nurses are better equipped to identify changes in self-concept, recognize early signs of depression, develop nursing interventions, and collaborate with the interprofessional team to ensure that proper supports are provided for the patient. *READ OVER TEXTBOOK FOR TECHNIQUES. (favourited) BODY ALIGNMENT Positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying down. - Determining normal physiological changes in body alignment resulting from growth and development for each individual patient. - Identifying deviation in body alignment caused by incorrect posture. - Providing opportunities for patients to observe their posture. - Identifying learning needs of patients for maintaining correct body alignment. - Identifying trauma, muscle damage, or nerve dysfunction - Obtaining information about other factors contributing to poor alignment, such as fatigue,  malnutrition, and psychological issues. BODY BALANCE Centre of gravity is balanced over a stable base of support with proper posture. Person must have adequate balance when standing, running, lifting, or performing ADLs. Controlled by the nervous system, specifically by the cerebellum and inner ear. The wider the base of support, the greater the stability. The lower the centre of gravity, the greater the stability. FRICTION - a force that occurs in a direction to oppose movement. It increases a patient’s risk for skin and tissue damage and potential pressure injuries. Reduced by following some basic principles. - Avoid lifting or moving patients manually. Using a mechanical lift prevent friction. - Use friction-reducing devices such as a slider sheet, slide board, or transfer board to reduce friction. - Use some of the patient’s strength and mobility to assist with transferring or moving the patient in bed. If patients can bend their knees as you assist them in moving up in bed, friction is decreased. Explain the procedure and tell the patient when to move. - Greater surface area of the object to be moved, greater the friction. If patient is unable to assist in moving up in bed, placing patient’s arm across their chest decreases surface area and reduces friction. SHEAR Force exerted against the skin while the skin remains stationary, and the bony structures move is called shear. - Use full-body slings to mechanically lift a patient off the surface of a bed, thereby preventing friction, tearing, or shearing of the patient’s skin and protecting the nurse and other staff from injury. GRAVITY Weight is the force exerted by gravity. For of weight is always downwards. Unsteady patients fall when their centre of gravity becomes unbalanced; the gravitational pull of their weight moves outside their base of support. MORSE FALL SCALE History of falling: added 25 if the patient has fallen during the present hospital admission or if there was an immediate history of physiological falls (such as seizures or an impaired gait prior to admission) Secondary Diagnosis: Scored 15 if more than one medical diagnosis is listed on the patient’s chart. Ambulatory Aids: if patient uses crutches, can, or walker, scored 15. If patient ambulates clutching onto the furniture for support, scored 30. Intravenous Therapy: scored 20 if patient has an intravenous apparatus or heparin lock inserted. Gait: normal gait: 0; weak gait: 1; Impaired gait: 20 Mental status: measured by checking patient’s own self-assessment of his or her own ability to ambulate. “Are you able to go to the bathroom alone or do you need assistance?”: If patient overestimates their own ability, then scored 15. Scoring and Risk Level: Score is tallied and recorded on the patient’s chart. Risk and recommended actions are then identified. No risk; 0-24 (apply good basic nursing care) | Low risk; 25-50 (implement standard fall prevention interventions) | High risk; > 51 (implement high risk fall prevention interventions) NSE111 Week Five Learning Objectives: 1. Examine the client’s need for a safe, comfortable and hygienic environment. 2. Explain how to incorporate infection prevention and control practices during bed making. MAINTAINING COMFORT: The nature of what constitutes a comfortable environment depends on the patient’s age, severity of illness, and level of daily activity. Room temperature should be maintained between 20-23 degree celsius. Infants, older persons, and the acutely ill may need a warmer room. ENVIRONMENTAL FACTORS THAT MAY PREVENT CLIENTS COMFORT: - Odour; prevented by good ventilation, room deodorizers, vanilla (poured onto a gauze inside a basin and put under the bed), uses coffee grounds to absorb smell. - Noises; explain unfamiliar noise to the patient and family members, noises should be controlled as much as possible. - Lights; adjusted by closing or opening drapes, regulating over-bed lights, and closing or opening room doors. USE OF ROOM EQUIPMENT IN PROVIDING COMFORT AND SAFETY FOR CLIENTS: A typical hospital room contains the following basic pieces of furniture: an over-bed table, bedside stand, chairs, and a bed. BED MAKING: - To keep a patient’s bed clean and comfortable; frequent inspection is required to be sure linen is clean, dry, and free of wrinkles. Nurses should check frequently for soiled linen. - Bed is usually made in the morning after patient’s bath or while patient is in the shower, sitting in a chair eating, or out of the room procedures or tests. - Bed linens should be straightened when they become loose or wrinkled. - Checked for food particles after meals and for wetness or soiling. - Nurses need to follow principles of medical asepsis by keeping soiled linen away from their uniform, - Soiled linen; placed in a special linen bah before discarding it in a hamper. - Avoid air currents; can spread microorganisms; avoid shaking. - Avoid transmitting infection; soiled should not be placed on the floor; If clean linen touches the floor; should be immediately removed. - Use body mechanics when bed making. - Bed should be raised to appropriate height before changing linen so that the nurse does not have to bend or stretch over the mattress. Move back and forth to opposite sides of the bed while putting on new linen. EQUIPMENT: 1. Bottom sheet (Flat or fitted) 2. Drawsheet (optional) 3. Top sheet 4. Blanket 5. Bedspread 6. Pillowcases 7. Incontinent pad – can be used as a lifting sheet. MITERED CORNERS Purpose is to hold linen tightly/secure in place Special way of folding the bottom cornerns of bed linen BED MAKING TIPS - Wash hands before & after - Gather all linen/equipment before making bed. - If making an occupied bed, explain what you are doing. Do not expose ur client, protect privacy & ensure safety. (APPYL DIPPS) - Do not let soiled linens touch your uniform. - Make one side of the bed at a time. - Place dirty linen/bedding in hamper/cart, not on the floor - Return to bed to lowest position - Side rails: up or down - Call bell NSE111 Week Seven Learning Objective: 1. Identify factors that influence personal hygiene practices. 2. Relate the conditions (physical/cognitive impairment) that place clients at risk for impaired hygiene to specific nursing interventions. 3. Describe the various approaches to providing hygiene care for clients such as as showers, bed baths and “bag baths”. 4. Relate safe and effective hygiene care to clients with special needs (e.g. cognitive impairment the unconscious client, or those with diabetes). FACTORS INFLUENCING PERSONAL HYGIENE - Social practices: includes type of hygiene products used and the nature and frequency of personal care. Hygiene is influenced by family customs, peer group behaviour, and personal appearance.  - Personal preferences: individual preferences about when to bathe, shave, and perform hair care. - Body image: subjective concept of their physical appearance. Can change frequently. Undergo surgery, illness, or change in physical or mental health status or simply age. Promote comfort and appearance. Consult with patient before making decisions about how hygiene care is to be provided. Patients who appear unkempt or uninterested in hygiene may require an assessment of their hygiene practices or of their mental status or require additional education about the importance of hygiene. - Socioeconomic status: influence the type and extent of hygiene practices used. When basic care items are not affordable, alternatives need to be considered. Important whether the use of these products is an acceptable practice among patients’ social or cultural group. Not all patients may choose to use deodorant or cosmetics. - Health beliefs and motivation:Individual characteristics such as personal factors (psychological, sociocultural, and biological) directly influence an individual’s health promotion activities. When patients recognize that a risk is present and that reasonable action can be taken to reduce the risk, they are more receptive to counselling and teaching efforts. - Cultural Variable: READ TEXTBOOK - Physical conditions: physical limitations, disabilities, or pain often lack the physical energy, dexterity, and range of motion to perform hygiene care. If they have and IV line or other device connected to the body needs assistance with hygiene. - Patients with physical or cognitive impairments need assistance with all or some aspects of personal hygiene. Assessment of a patient’s physical and cognitive statuses determines specifically which aspects of hygiene care can be performed independently, which require some assistance, and which require total assistance. Assessment must include the measurement of the patient’s muscle strength, flexibility and dexterity, balance, coordination, and activity tolerance — these qualities are needed to perform activities such as bathing, brushing teeth, and bending over to inspect the feet. RISK FOR IMPAIRED SKIN/HYGIENE: Immobilization: When restricted from moving freely patients’ dependent body parts are exposed to pressure, reducing circulation to the affected body parts. Nurses should know which patients require assistance to turn and reposition. Reduced Sensation: Patients with paralysis, circulatory insufficiency, or local nerve damage; unable to sense an injury to the skin. While bathing a patient, assess the status of sensory nerve function by checking for paint, tactile sensation, and temperature sensation. Nutrition & Hydration Alteration patients with limited caloric and protein intake can develop thinner less elastic skin, with a loss of subcutaneous tissue. This can result in impaired or delayed wound healing. Secretions & Excretions moisture on the skin’s surface serves as a medium for bacterial growth and can cause irritation, soften epidemical cells, and lead to skin breakdown. The presence of perspiration, urine, fecal material, or wound drainage on the skin can result in breakdown or infection, or both. Vascular Insufficiency inadequate arterial supply to tissue and impaired venous return decrease the circulation to the extremities. Inadequate blood flow can cause ischemia and tissue breakdown. The risk of infection also exists because the delivery of nutrients, oxygen, and white blood cells to injured tissues is inadequate. External Devices an external device applied to or around the skin exerts pressure and friction on the skin. Assess all surfaces exposed to casts, cloth restraints, bandages and dressings, tubing, or orthopaedic braces. Important to do a skin assessment. HYGIENE SCHEDULE Early Morning Care: when nurses work the night shift, may be required to provide basic hygiene to patients getting ready for breakfast, scheduled test, or early morning surgery. Early morning care includes offering bedpan or urinal if the patient is not ambulatory, washing the patient’s hands and face, and assisting with oral care. (referred to as A.M. care) Routine Morning Care: before or after breakfast, care includes offering a bedpan or urinal to patients confined to bed: providing a bath or shower: giving perineal care: giving oral hygiene and foot, nail, and hair care: assisting with shaving, giving a back rub; changing the patient’s gown or pyjamas; changing the bed linens; and straightening the patient’s bedside unit and room. (referred to as complete A.M. care) Afternoon Care: includes washing the hands and face, assisting with oral care, offering a bedpan or urinal to those patient who are not ambulatory, and straightening bed linen. Evening, or Hour-Before-Sleep, Care: nurses can offer personal hygiene care that helps a patient relax to promote sleep. May include changing soiled bed linens, gowns, or pyjamas; assisting the patient in washing the face and hands; providing or assisting with oral hygiene; and offering a bedpan or urinal to non-ambulatory patients. Complete Bed Bath: used with patients who are totally dependent and require total hygiene care. From head to toe. Partial Bed Bath: involved bathing only those body parts that would cause discomfort or odour if not cleaned, and those areas not easily reached by the patient. Includes perineal care. Face, hands, axillae, perineal care, back. Nurse may decide to skip a bath for a day or bathe only badly soiled areas. Tub bath or shower an be used to give more thorough bath than a bed bath. Bag Bath: developed because of concern for patients who are predisposed to dry skin and risk for infection. Specifically prepared to package containing 10 washcloths that are pre-moistened with a mixture of water and a non rinsable cleaner. Warmed in a microwave before use, different cloth is used for each part of the patient’s body. Bathing & Skin Care: Basic Principles - Perform hand hygiene. - Determine type of bath and explain procedure & consent. - Provide Privacy. - Assess client’s self-care ability & preferences. - Offer bedpan or urinal prior to bath. - Gather necessary equipment. - Consider body mechanics. - Assess skin integrity and condition throughout bath. Bathing & Skin Care: Method - Freshly sanitized wash basin, clean, unused linens, face-clothes and towels - Position client head side up the bed; 30-35 degrees - Eyes & face - Arms and hands (distal to proximal areas – fingers to axilla) - Chest and abdomen - Legs and Feet - Peri Care - Back – may be done after peri care with fresh water. o Obtain fresh water. - Buttocks, anus/rectum Bathing & Skin Care: Eyes - Use clean washcloth moistened with plain water. - Soak crust on eyelids 2-3 minutes to soften. - Use different section of mitt for each eye - Wash from inner to outer can-thus. - Do not apply pressure over balls. Bathing & Skin Care: Nose - Encourage client to remove secretions from nose by blowing into a tissue. - May use a wet cloth or cotton-tipped applicator moistened in water or normal saline to cleanse. - Never insert the applicator beyond the length of the cotton tip. Bathing & Skin Care: Ear & Nail - Ear: never use sharp object to remove ear wax (cerumen) or put cotton-tipped applicators into canal. - Nails o Soak fingers in basin of warm water. o Clean under nails o Trim nails straight across and even with fingers. Bathing & Skin Care: Foot Care Inspection: Clients at risk (i.e diabetes) - Wash feet daily with warm water. - Dry thoroughly especially between toes. - Apply lotion if feet are dry. - Clean under toenails. - Trim toenails PRN straight across and even with toes. - Check doctor’s orders for special care. o i.e. podiatrist Bathing & Skin Care: Back Rub - Promotes relaxation. - Relieves muscular tension. - Stimulates circulation. - Improves sleep. - Reduction in blood. - Reduction in pain. - Decrease anxiety and depression. - Enhance comfort. Hair & Shaving Care  - Shampoo depending on client’s routine and hair condition. - Bathing at sink or in bed. - Brush and comb hair daily. - Shaving done usually after bath. o Wear gloves and obtain equipment. o Hold skin taut & blade at a 45 degree. o Short, firm stroke in direction of hair growth. Clients with Special Needs - Obtain a bathing history of what works and what does not work. - Identify hygiene preferences & assess need for assistance. - Determine method that is least distressing (cognitive impairments) - Determine weakness — motor impairment (support weaker side) o Unconscious clients need maximum assistance. - Assess communication needs: glasses, hearing aid. - Diabetes: specialized foot & nail care. o Diabetes mellitus results in chronic vascular change that impair healing of the skin and mucosa. - Stroke can result in paralysis of the trigeminal nerve, which eliminates the blink reflex, increasing risk for corneal drying. NSE111 Week Eight Learning Objectives: 1. Considerations to assess (cognitive/physical functioning) prior to planning the client’s elimination needs. 2. Identify factors that commonly influence urinary and bowel elimination. 3. Identify key terms related to urinary (micturition, voiding, nocturia, urinary retention, urinary incontinence) and bowel elimination (defecation, constipation, diarrhea, bowel incontinence, flatulence). 4. Describe characteristics of normal urine and stool and how to assess intake and output. 5. Identify nursing interventions to promote normal micturition and bowel elimination to reduce urinary incontinence, constipation, and to maintain established routines. 6. Identify nursing interventions that reduces urinary tract infections (cleaning of perineum and catheter care) and maintain skin integrity. URINARY ELIMINATION Normal elimination of urinary waste is a basic function. Many illnesses and conditions, both acute and chronic, can affect urinary function. Nurses play a key role in the assessment of urinary tract function, promoting continence, and management of incontinence and optimal bladder emptying. - Urinary elimination depends on the coordinated function of the kidneys, ureters, bladder, and the act of micturition that involve a failure to store urine, a urethra. Kidney removes waste from blood to failure to empty urine, or both. Disturbances may be acute urine, Ureters transport urine from kidneys to the or chronic bladder, the bladder stories urine until the urge to and results from infection, an overactive bladder, impaired urinate contractibility, obstruction to urine outflow, or inability to develops, urine leaves through the urethra. control micturition voluntarily due to mechanical or neural - Micturition (urination) occurs when a complex dysfunction. neural response allows the bladder to contract, the urethral sphincter to relax, and urine to leave Factors influencing urination: through the urethra. - Disease conditions - Medication Most patients with urinary problems have disturbances in - Surgical procedures  - Physiological factors Urinary incontinence – defined as any complaint - Mobility of involuntary loss of urine. Defecation – discharge of feces from the body. Normal urine production ranges from 1 to 2 L/day and is Constipation – When the slow-mixing contractions affected by many factors, including fluid intake and body increase and the mass peristalsis diminishes, water temperature. An output of less than 30 mL/hr may indicate continues to be absorbed and the feces dry out, renal alterations. resulting in constipation. KEY TERMS: Diarrhea – when the mixing movements are Micturition – occurs when a complex neural decreased and the mass peristalsis is increased, the response allows the bladder to contract, the urethral water has less time to be absorbed, and the stool sphincter to relax, and urine to leave the body will be watery, resulting in diarrhea. through the urethra. Bowel incontinence – inability to control the Voiding – The process of bladder passage of feces and gas from the anus. emptying. Nocturia – urination during the Flatulence – As gas accumulates in the lumen of night. the intestines, the bowel wall stretches and distends, Urinary retention – marked accumulation of urine resulting in flatulence. Common cause of abdominal in the bladder due to the bladder’s inability to fullness, pain, and cramping. empty. CHARACTERISTIC OF URINE AND ASSESSMENT - Colour o Normal urine- pale straw colour to amber (depends on concentration, usually more concentrated in the morning, more liquid less concentrated.) o Dark red urine bleeding from kidney; bleeding from the bladder or urethra causes urine to become bright red. o Medication and food can change urine colours and will cause false positive on urinalysis. o Phenazopyridine causes the colour of urine to turn bright orange; eating beets, rhubarb, or blackberries may cause red urine. o Dark amber urine may result from high concentration of bilirubin caused by liver dysfunction or vitamin B. Nurse should document and report any abnormal colour or sediment, especially if the cause is unknown. - Clarity o Normal urine appears transparent at voiding; some may become cloudy if left standing. o Renal disease: urine may appear cloudy or foamy because of high protein concentration. o Appear thick and cloudy as a result of bacteria. - Odour o The more concentrated the urine, the stronger the odour. o Stagnant urine has an ammonia odour, common in patients who are repeatedly incontinent. o Sweet or fruity odour occurs from acetone or acetoacetic acid seen with diabetes mellitus or starvation. FLUID: INTAKE AND OUTPUT Intake: amount of fluid the client ingests Output: amount of fluids that leave the body - MD/NP will order accurate I/O A change in urine volume is a significant indicator of fluid alteration or kidney disease. - When monitoring client’s intake and output, all fluid consumptions/elimination are recorded on an intake and output record. - Measurement of output o Urine hat, bedpans, urinal, foley, catheter (urometer)  - Report any significant changed in urine volume An hourly output of less than 30 mL for more than 2 hours in cause for concern. Similarly, consistently high volumes of urine (polyuria), over 2000 to 2500 mL daily, should be reported to a physician. PERINEAL CARE: FEMALE - Cleaning method should reduce the risk of transferring microorganisms to the urinary meatus. - Cleaning from area of least contamination to most contamination (Cleanest to dirtiest) - Top to bottom (pubic to rectum) - Outer to inner (labia majora, labia manora, vaginal orifice) - Different swatch of cloth for each stroke (avoid cross-contamination) PERINEAL CARE: MALE - Wash tip of the penis at the urethral meatus first, using a circular motion. - Clean from meatus outward tip of penis. o Foreskin – retract. o Clean shaft of penis and scrotum (downward strokes) o Assess underside of penis (skin) o Ensure rinsed and dried throughly URINARY CATHETERS Catherization of the bladder involved introducing a narrow tube through the urethra and into the bladder to allow a continuous flow of urine into a drainage receptacle. - Catheters may be intermittent, in-dwelling or condom. o Intermittent technique, a single-use straight catheter is introduced urethrally for 5 to 10 minutes, drains the bladder. o Single lumen with a small opening about 1.4cm from the tip. o Urine drains from the tip through the lumen, and into a receptacle. - Intermittent catherization is performed by the patient or by a nurse and is common in patients who have incomplete bladder emptying due to neurogenic conditions (e.g., spinal cord injury). - Condom catheter -> fewer UTI, least invasive, external. Intermittent catherization; used to empty the bladder in people who are unable to empty their bladder completely. Can be used to collect a sterile urine specimen, but only in patients who are unable to provide midstream specimen. In-dwelling urethral catherization is to be avoided if possible. URINARY INCONTINENCE - Involuntary loss of urine - Psychological impact - Assessment - Continued urinary incontinence -> skin breakdown o Importance of frequently cleaning/changing of brief o Apply barrier cream. URINE TESTING - Collect urine for laboratory testing. - Techniques include midstream, sterile, random or timed. - Collection container o Client’s name, date and time of collection - Must be sent to the lab for test results - Storing of specimen (refrigerate) NURSING INTERVENTIONS What are some nursing interventions that promote normal micturition? - Nurse can establish a bowel protocol, including toileting times at a consistent time daily 15 to 20 minutes following a triggering meal (breakfast or lunch), which capitalizes on when gastrocolic reflexes are most active. - Ingest high fibre diet. - Increase fluid intake. - Encourage physical activity. - Maintain privacy. Nursing interventions to reduce UTI’s? - An increase fluid intake results in increased urine formation, which reduces the risk of urinary tract infection. - Nurses need to follow specific guidelines for in-dwelling catheter insertion to reduce the occurrence of catheter-associated urinary tract infections. UNDERSTAND THE GI TRACT - Normal gastrointestinal anatomy and physiology - Common intestinal alteration - Factors that influence bowel elimination o Diet o Fluid intake o Physical activity o Personal bowel elimination habits o Privacy o Age related changes CHARACTERISTICS OF STOOL - Colour Normal: - Brown Abnormal: - White or clay o absence of bile pigment, obstructive jaundice. o Stool with visible mucus or pus may suggest an infection, inflammatory bowel disease, or cancer. - Black o Ingestion of iron or bismuth preparations or upper gastrointestinal bleeding with blood partially digested. - Bright red o Lower gastrointestinal bleeding, haemorrhoids - Pale Yellow, greasy stool o Indicates increased fat content. o Malabsorption of fat - Mucus or pus o Spastic constipation, colitis, excessive straining. - Bloody mucus o Blood in feces, inflammation, infection, or haemorrhoids. - Odour Normal - Pungent; affected by food type. Abnormal  - Noxious change o Blood in feces or infection - Consistency Normal - Soft formed Abnormal - Liquid o Diarrhea, reduced absorption - Hard o Constipation - Frequency Normal - Daily or two to three times a week Abnormal - More than three times a day or less than once a week o Hypomotility or hypermotility (multifactorial) - Shape Normal - Resembles diameter of rectum Abnormal - Narrow, pencil shaped. o Anal or distal rectal carcinoma - Constituents Normal - Undigested food, dead bacteria, fat, bile pigment, cells lining intestinal mucosa, water. Abnormal - Blood, pus, foreign bodies, mucus, worms, excess fat o Internal bleeding, infection, swallowed objects, irritation, inflammation, Malabsorption syndrome, enteritis, pancreatic disease, surgical resection of intestine. NURSING INTERVENTION: PROMOTE NORMAL BOWEL ELIMINATION - Knowing factors that cause constipation. - Establish daily bowel routine - Maintain adequate fluid and food intake  o 1500 to 2000 ml fluid per day o Dietary fibre intake 25 to 30 g per day - Regular exercise - Ensure patient privacy o Curtain should be pulled o Call bell o Closing Bathroom Door NSE111 Week Nine Learning Objectives 1. Discuss factors that affect nutritional intake and status (cognitive/physical limitations). 2. Describe how to promote a client’s appetite. 3. Understand the importance of various therapeutic diets. 4. Distinguish dysphagia and aspiration pneumonia: signs and symptoms, risk factors, prevention. 5. Discuss safe and effective mealtime assistance techniques: clients who cannot eat independently and/or have dysphagia. 6. Describe the principles for provision of oral care. KEY POINTS FROM GAME: GRETA - Ensure a client diagnose with dysphagia has appropriate thickened diet prior to the beginning of their meal. - Correct a client’s technique to decrease the risk of choking on food items. - If a client begins to choke, call for help and stay with the client. Encourage them to continue to cough to help clear their airways. - Check for pocketing of food in the client’s oral cavity as needed. - Encourage the client to remain sitting upright or in the chair for at least 30 minutes after eating. NUTRITION & ORAL CARE - Food is a basic need for good health. - Individuals with disease/illness depend on others for care are negatively impacted. - Need to support/assist clients based on their individual needs. - Poor oral health linked to heart disease, diabetes, etc. FACTORS AFFECTING NUTRITIONAL STATUS - Age related gastrointestinal changes; changes in the teeth and gums, decreased bite force, reduced saliva production, atrophy of oral mucosal epithelial cells, increased taste threshold, decreased thirst sensation, reduced gag reflex, and decreased esophageal and colonic peristalsis. - Disease: such as diabetes and cognitive impairments related to delirium, dementia, and depression, increase risk of poor nutrition. - Malnutrition in older persons; low income, low educational level, lack of physical functional level to meet ADLs, loss, dependency, loneliness, and lack of transportation. - Medications may have adverse effects, such as causing anorexia, xerostomia, early satiety, and impaired smell and taste perception. Likely to be prescribed medications than younger individuals. - Intake of calcium, vitamin D, and phosphorus may be deficient, increases the risk of osteoporosis. Vitamin B12 may be deficient among older persons because of the high prevalence of gastrointestinal pathology and use of medications that alter vitamin b12 pharmacokinetics. - Many nutrients interact with medications, and nurses should consult a drug handbook for information about specific interactions. NUTRITION & COGNITIVE IMPAIRMENT - Alzheimer’s, dementia, delirium - Loss of appetite & weight loss - Issues: o Recognition of food  o Poorly fitted denture. o Medication o Change in smell and taste. - Provide a balanced diet with variety. - Limit refined sugar, saturated fats, cholesterol, and high sodium. NURSING INTERVENTION TO PROMOTE APPETITE IN COGNITIVE IMPAIRMENT - Limit distractions - Table setting -> minimal approach. - Offer one item at a time o Nutrient dense food - Ample time to eat. - Eat together. - Encourage independence. PROMOTING APPETITE - Environment that promotes comfort - Eliminates unpleasant odours. - Provide oral hygiene as needed. - Assist client to select foods. - Promote social time. - Consider food preferences - Small meals/snacks vs large meals. THERAPEUTIC DIETS Clear Liquid diet limited to broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatine, or popsicles. Thickened Liquid all liquids (e.g., juice, tea, coffee, water) must be thickened to the appropriate consistency (nectar, honey, or pudding) as recommended by the speech-language pathologist or feeding team when thin fluids cannot be safely swallowed and may be aspirated. Full Liquid To a clear-or thickened-liquid diet can be added smooth-textured dairy products, custards, refined cooked cereals, vegetable juice, puréed vegetables, or any fruit juices. Puréed This diet includes all of the above with the addition of scrambled eggs puréed meats and vegetables, fruits (ripe bananas, mashed cooked fruits without the skins), or mashed potatoes and gravy, Mechanical Soft this died includes all of the above with the addition of ground or finely diced meats, flaked fish, cottage cheese, cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked or canned fruits, soups, or peanut butter. Soft or Low Residue Low fibre easily digested foods, such as pastas, casseroles, moist tender meats, canned cooked fruits and vegetables, desserts, cakes, and cookies without nuts or coconut, can be added. High Fibre This diet includes fresh uncooked fruits, steamed vegetables, bran, oatmeal, and dried fruits. Low Sodium This diet is restricted to protect or defend oneself, responsive behaviour. Learn what makes the person happy and provide it. Concentrate on the person, not the task. MODULE 2: BRAIN AND BEHAVIOUR ABC of Brain Function A – Affective > emotions B – Behaviour > actions C – Cognitive > thoughts Informative processing (SPEED) Sensation - External stimuli initiate the brain process. Perception - Internal interpretation of the external world. Emotion - Each memory links to an emotion. Evaluation - Feelings are evaluated and a response is determined. Demonstrated Behaviour - Feelings and thoughts become behaviour. Healthy Aging: - Independent in daily activities - Can provide details of incident memory loss. - Individuals more concerned about memory loss. - Recent memories not impaired. - Social skills intact. Dementia - Dependant on others for key daily living activities. - Cannot provide details of incidents of memory loss. - Others are more concerned about memory loss. - Recent memories are very impaired. - Changing social behaviour. TYPE OF LOSS OF… DIFFICULTIES SOLUTION DEMENTIA Amnesia Memory Short term memory Consistent routine; Long term memory Engaging more in May repeatedly meaningful activity; ask “why am I Posting visual aids here?” and prompt. Aphasia Language Impairment Understanding Visually what they read, Demonstrating what expressing you are saying, themselves showing pictures to verbally, the person such as understand what is nursing teeth to said to them. understand what is being said. Agnosia Recognition Unable to Prompting the recognize what individual with they feel, see, gestures like smell, taste, and drinking water on the hear. Might be cup; may help unable to independence by recognize face. drinking by themselves. - Might recognize stuff like a glass of water but are not sure what it is or what it does. Apraxia Purposeful movement Unable to Cover the mirror; independently carry Break down the task out activities such as and label the clothes standing up, in order. dressing, and eating. - Confusion in proper order which is putting underwear on top of the short.  Altered perceptions. Environmental Illusions. Distortion Step back and perception of stimuli, objects consider the or person’s sound. environment by - Might think of their perspective; something Promote the differently than person’s ability to what it actually navigate safely by is. For removing or example, they changing might think environmental that the robe triggers. Eg. that is hanging Covering the at the back of mirror. the door is a stranger. May not recognize themselves when looking in the mirror or remember someone they look like. - Meowing cat as crying baby. - Fireworks as bombs. Anosognosia Diminished self Partially or Apply likes and awareness completely unaware dislikes for personal of their deficit. Brain routine. Avoid no longer arguing and communicates info rationalizing. to them in a way that allows them to appreciate what they can no longer do; think they can care for themselves not knowing that they can't. Delirium - A sudden change or worsening change can indicate delirium. - Sudden onset medical emergency - Is a medical emergency sudden onset and fluctuating course, and can cause confusion, altered consciousness, and disturbances in attention, thinking, perception and language. o Person  wanting to leave so bad. Sudden change – behaviour, mental states Loss of function – cognitive memory Consciousness of (CAM) Confusion Assessment Method - Sudden onset and fluctuating course - Inattention - Disorganized thinking Meaningful - Engagement verbal encouragement - Listening to what the person wants - Redirection MODULE 3: SEARCH FOR THE MEANING PIECES Physical – e.g., delirium, pain, hunger Intellectual – e.g, 8A’s, communication Emotional – Anxiety, depression, fear Capabilities – activities of daily living Environmental – noise, stimulation Social – personality, culture, life story P – represents physical causes such as pain infection or sleep deprivation. A person with dementia who lost their ability to communicate using words or grab during personal care because they are experiencing pain during your interaction. I – represents intellectual causes such as cognitive or perceptual losses. (e.g, personal might move all the food around on their plate and not eat because they don’t recognize the food or do not know what to do with the utensils.) E – represents emotion causes such as anxiety or depression. A person with dementia may feel anxious and see comfort and security by trying to get home from the hospital or nursing home. Developing memory books or visual cues to reassure and redirect the person t