NUR102 Study Guide 2 PDF

Session 3 Safety Key Terms: Asphyxiation: Suffocation; In suffocation, air does not reach the lungs and breathing stops. Common causes of suffocation are drowning, choking on a foreign substance inhaled into the trachea, and gas or smoke poisoning Bioterrorism: involves the deliberate spread of pat...

Session 3 Safety Key Terms: Asphyxiation: Suffocation; In suffocation, air does not reach the lungs and breathing stops. Common causes of suffocation are drowning, choking on a foreign substance inhaled into the trachea, and gas or smoke poisoning Bioterrorism: involves the deliberate spread of pathogenic organisms into a community to cause widespread illness, fear, and panic Bullying: a form of direct or indirect aggression that includes hostile physical, verbal, psychological, and/or relational behaviors Chemical Emergency: could be triggered by the deliberate or unintentional release of a chemical compound that has the potential for harming people’s health -​ Biotoxins—poisons from plants or animals -​ Blister agents/vesicants—chemicals that severely blister the eyes, respiratory tract, and skin on contact -​ Blood agents—poisons that are absorbed into the blood -​ Caustics (acids)—chemicals that burn or corrode the skin, eyes, and mucous membranes on contact -​ Choking/lung/pulmonary agents—chemicals that cause severe irritation or swelling of the respiratory tract -​ Incapacitating agents—drugs that affect the ability to think clearly or that cause an altered state of consciousness or even unconsciousness -​ Long-acting anticoagulants—poisons that cause bleeding by preventing blood from clotting properly -​ Metals—agents that consist of metallic poisons -​ Nerve agents—highly poisonous chemicals that prevent the nervous system from working properly -​ Organic solvents—agents that damage the tissues by dissolving fats and oils -​ Riot control agents/tear gas—highly irritating agents normally used by law enforcement for crowd control or by individual people for protection -​ Toxic alcohols—poisonous alcohols that can damage the heart, kidneys, and nervous system -​ Vomiting agents—chemicals that cause nausea and vomiting Culture of Safety: an organizational environment where “core values and behaviors—resulting from a collective and sustained commitment by organizational leadership, manager and workers—emphasize safety over competing goals” Cyber Terror: involves the use of high technology to disable or delete critical infrastructure data or information Disaster: is broadly defined as a tragic event of great magnitude that requires the response of people outside the involved community Elder Abuse: has no universally accepted definition, but legal, professional, and governmental definitions include elements of physical, sexual, and/or psychological abuse, neglect (including abandonment), and/or financial exploitation Intersectionality: where race, sex, gender, class, and other individual characteristics intersect and overlap with one another, often leading to an increased burden of discrimination on several fronts and other negative outcomes Intimate Partner Violence: involves: physical violence (hitting kicking, or other physical force), sexual violence (forcing a sex act, sexual touching, or a nonphysical event without consent), stalking (a pattern of repeated, unwanted attention and contact) and/or psychological aggression (verbal and nonverbal communication intended to mentally or emotionally harm and/or exert control by a current or former intimate partner, such as a spouse, dating partner, or sexual partner) Nuclear Terrorism: involves intentional introduction of radioactive materials into the environment for the purpose of causing injury and death Poison Control Centers: provide checklists for poison proofing a home and provide lists of toxic household items Restraints: are physical devices or chemical means used to limit a patient’s freedom and movement that cannot be easily removed (or eliminated) by the patient Safety: freedom from danger, harm, or risk—is a paramount concern that underlies all nursing care Safety Event Report: An accident or incident that compromises safety in a healthcare facility requires the completion of this Sentinel Event: an unexpected occurrence involving death or serious physical or psychological injury, or the risk of death or injury Learning Objectives: 1.)​ Identify evidence based practice that improves safety in a person’s environment including home and health care settings -​ Fall prevention: Installing grab bars, removing hazards and using non-slip socks/mats, major risk for older adults -​ Medication Safety: medication reconciliation and electronic prescribing help prevent errors and adverse drug interactions -​ Hand hygiene: proper handwashing and sanitizer use reduces infections in both home and health care settings -​ Infection Control: proper wound care, disinfecting surfaces, and using PPE lowers risk of infection 2.)​ Identify safety risk through assessment to include person and environment -​ Person related risk -​ Fall Risk: history of falls, weakness, dizziness, impaired mobility, or medications affecting balance -​ Medication Safety: risk of overdose -​ Cognitive Impairment: dementia, confusion, or delirium increasing risk of injury -​ Skin Integrity: Risk of pressure ulcers in immobile patients -​ Infection Risk: Immunosuppression, surgical wounds, or poor hygiene -​ Environmental related risk -​ Trip Hazards: clutter, loose rugs, or wet floors increase fall risk -​ Fire Safety: oxygen use near open flames -​ Inadequate lighting: poor visibility increases risk of fall  -​ Infection Control: lack of hand hygiene, contamination of equipment, or improper PPE 3.)​ Discuss how nurses collaborate with team members to promote safe homes and healthcare environments -​ Working with OT/PT therapist: ensures fall prevention strategies, mobility aids, and home modifications -​ Coordinating with pharmacist: review medications for interactions, proper dosing, and patient education -​ Communicating with physicians: rapport safety concerns, pain management needs, and changes in patients condition -​ Educating patients and families: teach safe medication use, infection control, and home safety practices -​ Engaging social workers and case managers: arrange home health services, medical equipment, and community resources -​ Collaborating with infection control teams: implement proper hygiene, PPE, and sanitation protocols Additional Notes: This idea of a culture of safety originated in the business world, but has been translated to health care and includes these key features: (1) acknowledgment of the high-risk nature of health care and the commitment to safe operations (2) maintenance of a blame-free environment where reporting is protected and expected (3) promotion of teamwork and collaboration to prevent and seek solutions to patient safety issues (4) a systems-based perspective where the organization commits resources to address actual/potential safety issues Developmental Stage / safety Teaching Tip Why this is important risk Adult -​ Practice stress reduction As people progress through -​ Stress techniques the adult years, visible signs -​ Domestic violence -​ Enroll in a defensive driving of aging become apparent. -​ Motor vehicle course Lifestyle behaviors and accident -​ Evaluate the workplace for situational or family crises -​ Industrial Accidents safety hazards and utilize can also impact an adult’s -​ Drug and alcohol use safety equipment as overall health and cause disorders prescribed stress. Preventive health -​ Practice moderation when practices help adults improve consuming alcohol the quality and duration of -​ Avoid use of illegal drugs life. -​ Provide options and referrals to those experiencing intimate partner violence Older Adult -​ Identify safety hazards in the Accidental injuries occur -​ Falls environment more frequently in older  -​ Motor vehicle -​ Modify the environment as adults because of decreased accidents necessary sensory abilities, slower -​ Elder abuse -​ Attend defensive driving reflexes and reaction times, -​ Sensorimotor changes courses or courses designed changes in hearing and -​ Fires for older drivers vision, and loss of strength -​ Encourage regular vision and and mobility. Collaboration hearing tests between family and health -​ If prescribed, ensure that care providers can ensure a eyeglasses and hearing aids safe, comfortable are available and functioning environment, and promote -​ Wear appropriate footwear healthy aging. -​ Have operational smoke detectors in place -​ Objectively document and report any signs of neglect and abuse Older adults may have a hard time with discharge and taking their own medications because of: -​ Confusion -​ Reduced vision -​ Polypharmacy -​ Effect of drugs in the aging body Some expected outcomes for patients that promote safety and prevent injury are as follows The patient will: -​ Identify unsafe situations in their environment -​ Identify potential hazards in their environment -​ Demonstrate safety measures to prevent falls and other accidents -​ Establish safety priorities with family members or significant others -​ Demonstrate familiarity with their environment -​ Identify resources for safety information If the expected outcomes have been met and evaluative criteria have been satisfied, the patient should be able to accomplish the following: -​ Correctly identify real and potential unsafe environment -​ Implement safety measures in the environment -​ Use available resources to obtain safety information -​ Incorporate accident prevention practices into activities of daily living -​ Remain free of injury National initiatives encourage health care providers to ask three questions at every encounter with older adults: 1.)​ Have you fallen in the past year? 2.)​ Do you feel unsteady when standing or walking? 3.)​ Do you worry about falling? Restraint documentation must have: -​ Date -​ Time  -​ Type of restraint -​ Alternatives that were attempted (including results) -​ Notification of the patient's family and health care provider -​ Duration of the restraints Restraints -​ Checked every hour -​ A new hour must be placed after duration is up following with a new assessment Asepsis and Infection Control Key Terms: Aerobic: Most bacteria require oxygen to live and grow Airborne Transmission: Transmission spread through airborne route Anaerobic: can live without oxygen Antibody: a blood protein produced in response to and counteracting a specific antigen. Antibodies combine chemically with substances which the body recognizes as alien, such as bacteria, viruses, and foreign substances in the blood. Antigen: a foreign substance that triggers an immune response in the body Antimicrobials: drugs that treat infections by killing or slowing the growth of microbes causing infection …. bacterial infections are treated with drugs called antibiotics Asepsis: includes all activities to prevent infection or break the chain of infection Bacteria: most significant and most commonly observed infection-causing agents in health care institutions, can be categorized in various ways. They are categorized by shape: spherical (cocci), rod shaped (bacilli), or corkscrew shaped (spirochetes). Bacteria can be categorized as either gram positive or gram negative based on their reaction to the Gram stain Bundles: are typically three to five evidence-based practices that, when implemented together, improve patient outcomes. The American Nurses Association initiative to prevent CAUTI outlines three areas of focus: (1) prevention of inappropriate short-term urinary catheter use, (2) timely removal of catheters that is nurse driven, and (3) catheter care during placement Direct Contact: requires close proximity between the susceptible host and an infected person or a carrier, and includes activities such as touching, kissing, and sexual intercourse Disinfection: destroys all pathogenic organisms except spores Droplet Transmission: transmission through droplets (fluid from infected) Endemic: occurs with predictability in one specific region or population Endogenous: infection occurs when the causative organism comes from microbial life harbored in the person Exogenous: when the causative organism is acquired from other people Fungi: plantlike organisms (molds and yeasts) that also can cause infection, are present in the air, soil, and water Health Care-Associated Infections (HAIs): The term HAI encompasses and has replaced the term nosocomial, which was used specifically to indicate something originating or taking place in a hospital. Infections that are community acquired and not associated with health care are differentiated from HAIs. An HAI develops as a result of medical care and may occur in many health care settings including hospitals, rehabilitation facilities, outpatient settings, and dialysis centers. The source of an HAI may be either exogenous or endogenous Host: living being where an infectious, parasitic, or pathogenic agent resides and receives sustenance Iatrogenic: results from a treatment or diagnostic procedure Indirect Contact: involves personal contact with either: (1) a vector, a living creature that transmits an infectious agent to a human, usually an insect; or (2) an inanimate object, called a fomite, such as equipment or countertops Infection: a disease state that results from the presence of pathogens Isolation: a protective procedure that limits the spread of infectious diseases among hospitalized patients, hospital personnel, and visitors Medical Asepsis: clean technique, involves procedures and practices that reduce the number and transfer of pathogens Parasites: are organisms that live on or in a host and rely on it for nourishment Pathogens: disease-producing microorganism PPE: includes gloves, gowns, masks, and protective eye gear Reservoir: for growth and multiplication of microorganisms is the natural habitat of the organism Sterilization: destroys all microorganisms, including spores/endospores Standard Precautions: precautions used in the care of all hospitalized patients regardless of their diagnosis or possible infection status. These precautions apply to blood, all body fluids, secretions, excretions (except sweat), non intact skin, and mucous membranes. New elements included in standard precautions are respiratory hygiene/cough etiquette, safe injection practices, and directions to use a mask when performing high-risk prolonged procedures involving spinal canal punctures. Elements of respiratory hygiene and cough etiquette include education of staff and patients, posted instructions for the population served, review of source control measures (e.g., using masks on patients who are coughing and appropriate use of tissues with sneezes), reinforcement of hand hygiene (especially with managing secretions), and spatial separation when possible. Transmission-based precautions: precautions used in addition to standard precautions for patients in hospitals with suspected infection with pathogens that can be transmitted by airborne, droplet, or contact routes. The 2007 CDC guidelines include a directive to don PPE when entering the room of a patient with transmission-based precautions, and to remove the PPE only when leaving the room. These categories recognize that a disease may have multiple routes of transmission. Surgical Asepsis: sterile technique, includes practices used to render and keep objects and areas free from microorganisms Vector: a living creature that transmits an infectious agent to a human, usually an insect Virulence: of the organism, or its ability to cause disease Virus: the smallest of all microorganisms, visible only with an electron microscope. Viruses cause many infections, including the common cold, hepatitis A, B, and C, and human immunodeficiency virus (HIV). Antibiotics have no effect on viruses. However, there are some antiviral medications that decrease the severity and duration of viral infections such as influenza. The exact antiviral prescribed varies depending on the strain of influenza most prevalent in a given season and does not replace annual immunization Learning Objectives: 1.)​ Explain the infection cycle to include infectious agent, reservoir, portal of exit and entry, transmission, and susceptible host -​ The infection cycle consist of 6 key components 1.)​ Infectious agent: the pathogen that causes the disease 2.)​ Reservoir: the place where the pathogen lives and multiplies [human, animals, water, surfaces] 3.)​ Portal of exit: how pathogens leave the reservoir 4.)​ Mode of transmission: the way the pathogen spreads [direct, airborne, contact, droplet, vector borne] 5.)​ Portal of entry: how the pathogen enters the new host 6.)​ Susceptible host: a person at risk for infection due to weak immunity, chronic illness, or open wound 2.)​ Discuss the nursing process related to patient-centered care and infection control -​ Assessment: gather patient history, risk factors, and signs of infection. Assess understanding of hygiene, wounds, and medical devices -​ Diagnosis: identify nursing diagnosis such as risk for infection or impaired skin integrity -​ Planning: develop individualized care plans including hygiene education, isolation precautions, and proper wound care -​ Implementation: perform hand hygiene, use PPE, administer antibiotics, maintain aseptic techniques, and educate the patient on infection prevention -​ Evaluation: Monitor for infection signs and assess patient adherence to hygiene practices (adjust care as needed) 3.)​ Describe evidence-based practice to include medical and surgical asepsis -​ Medical Asepsis: reduces microorganisms -​ Hand hygiene: use soap and water or alcohol based hand rubs per CDC guidelines -​ PPE use: wear gloves, masks, and gown as needed -​ Environmental cleaning: disinfect surfaces and equipment regularly -​ Standard and transmission based precautions: isolate infections -​ Surgical Asepsis: eliminates microorganisms -​ Sterile Field maintenance: only sterile items touch the sterile field -​ Proper hand asepsis: surgical hand scrubbing before procedures -​ Sterile PPE: use sterile gloves, gown, and mask in procedures -​ Aseptic wound care: clean wounds with sterile technique to prevent infection 4.)​ Describe teamwork and collaboration related to safe handling of hazardous and infectious materials -​ Clear communication: nurses, lab staff, and environmental services (must follow standardized protocols for handling biohazards and report spills of exposures immediately) -​ Use PPE: all team members wear appropriate gloves, gown, masks, and eye protection based on hazard level -​ Proper waste disposal: biohazard waste is disposed of in designated sharps containers or red biohazard bags to prevent contamination -​ Spill response and decontamination: teams follow facility protocols using appropriate disinfectants to clean hazardous spills safely -​ Training and compliance: regular team training ensures adherence to OSHA and CDC guidelines for infection control and hazardous material handling 5.)​ Explain the guidelines for standard and transmission-based precautions -​ Standard precautions: used for all patients to prevent infection transmission -​ Hand hygiene -​ PPE -​ Respiratory hygiene/cough etiquette -​ Safe injection practices -​ Cleaning and disinfecting -​ Transmission based precautions: used in addition to standard precautions based on mode of transmission  -​ Contact precautions: for infections transmitted by direct or indirect contact [MRSA and C. difficile] wear gloves and gown; limit patient transport -​ Droplet precautions: for infections that spread through large respiratory droplets [influenza and COVID] wear masks; patient should wear a mask during transport -​ Airborne precautions: for infections that spread by tiny airborne particles [TB and measles] use an N95 respirator; place patient in a negative pressure room (rooms that vent directly outside of facility) Additional Notes: An organism's potential to produce disease in a person depends on a variety of factors, including: -​ Number of organisms -​ Virulence of the organism, or its ability to cause disease -​ Competence of the person’s immune system -​ Length and intimacy (extent) of the contact between the person and the microorganism An infection progresses through the following phases: -​ Incubation period: interval between the pathogens invasion of the body and the appearance of symptoms of infection -​ Prodromal stage: most infectious during this stage -​ Full (acute) stage of illness: the presence of infection-specific signs and symptoms -​ Convalescent period: recovery period; signs and symptoms disappear, and the person returns to a healthy state The susceptibility of the host depends on various factors: -​ Integrity of skin and mucous membranes, which protect the body against microbial invasion -​ pH levels of the GI and GU tracts, as well as the skin, which help to ward off microbial invasion -​ Integrity and number of the body’s white blood cells, which provide resistance to certain pathogens -​ Age, sex, and heredity, which influence susceptibility—neonates and older adults appear to be more vulnerable to infection (see the accompanying box: Focus on the Older Adult) -​ Immunity, natural or acquired, which acts to resist infection -​ Level of fatigue, nutritional and general health status, the presence of pre existing illnesses, previous or current treatments, and certain medications, which play a part in the susceptibility of a potential host -​ Stress level, which if increased may adversely affect the body’s normal defense mechanisms -​ Use of invasive or indwelling medical devices, which provides exposure to and entry for more potential sources of disease-producing organisms, particularly in a patient whose defenses are already weakened by disease When to use alcohol based hand rubs: -​ Before direct contact with patients -​ After direct contact with patients -​ After contact with body fluids, mucous membranes, non intact skin, and wound dressings, if hands are not visibly soiled  -​ After removing gloves -​ Before inserting urinary catheters, peripheral vascular catheters, or invasive devices that do not require surgical placement -​ Before donning sterile gloves prior to an invasive procedure -​ When moving from a contaminated body site to a clean body site during patient care -​ After contact with objects (including equipment) located in the patients environment Various factors influence the choice of sterilization and disinfection methods, including the following: -​ Nature of organisms present: The CDC recommends that all supplies, linens, and equipment in a healthcare setting should be treated as if the patient were infectious. Some organisms are easily destroyed, whereas others can withstand certain common sterilization and disinfection methods. -​ Number of organisms present: The more organisms present on an item, the longer it takes to destroy them. -​ Type of equipment: Equipment with small lumens, crevices, or joints requires special care. Certain articles that may be damaged by various sterilization and disinfection methods require special handling. -​ Intended use of equipment: The need for medical or surgical asepsis influences the preparation and cleaning of equipment. In the home, it may be safe to use equipment and supplies that are clean, but most health care facilities use sterilized articles for patient care. -​ Available means for sterilization and disinfection: The choice of chemical or physical means of sterilization and disinfection depends on the nature and number of organisms, the type and intended use of the equipment, and the availability and practicality of the means. -​ Time: Time is a key factor when sterilizing or disinfecting articles. Failure to follow the recommended time periods is grossly negligent. Activity Key Terms: Active Exercise: the patient independently moves joints through their full range of motion (isotonic exercise). In active-assistive exercise, the nurse may provide minimal support and assistance if the patient cannot do the exercise independently Activities of Daily Living (ADLs): Eating, bathing, dressing, and toileting are examples of ADLs Aerobic Exercise: refers to sustained (often rhythmic) muscle movements that increase blood flow, heart rate, and metabolic demand for oxygen over time, promoting cardiovascular conditioning. Examples of aerobic activities include swimming, walking, jogging, cross-country skiing, aerobic dancing, bicycling, jumping rope, and racquetball Atrophy: leads to decreased muscle size Contractractures: permanent contraction of a muscle Ergonomics: the practice of designing equipment and work tasks to conform to the capability of the worker and provides a means for adjusting the work environment and work practices to prevent injuries (OSHA) Flaccidity: Decreased tone; results from disuse or neurologic impairments and is described as a weakness of the involved area Footdrop: If maintained for extended periods, plantar flexion can cause an alteration in the length of muscles, and the patient may develop a complication; In this position, the foot is unable to maintain itself in the perpendicular position, heel–toe gait is impossible, and the patient experiences extreme difficulty in walking Fracture: A break or crack in the bone Instrumental Activities of Daily Living (IADLs): Housekeeping, meal preparation, management of finances, and transportation are examples of IADLs Isokinetic Exercise: involves muscle contractions with resistance. The resistance is provided at a constant rate by an external device, which has a capacity for variable resistance. Examples include rehabilitative exercises for knee and elbow injuries and lifting weights Isometric Exercise: involves muscle contraction without shortening (i.e., there is no movement or only a minimum shortening of muscle fibers). Examples include contractions of the quadriceps and gluteal muscles, such as what occurs when holding a yoga pose Isotonic Exercise: involves muscle shortening and active movement. Examples include carrying out ADLs, independently performing range-of-motion exercises, and swimming, walking, jogging, and bicycling Orthopedics: refers to the correction or prevention of disorders of body structures used in locomotion Paralysis: The absence of strength secondary to nervous impairment Paresis: Impaired muscle strength or weakness Passive Exercise: the patient is unable to move independently, and the nurse moves the joint through its range of motion Range of Motion: the maximum degree of movement of which a joint is normally capable Safe Patient Handling and Mobility (SPHM): Ergonomics applied to activities associated with direct patient care is known as safe patient handling and mobility (SPHM). It is very important to incorporate safe patient handling and mobility interventions into nursing practice and patient care. Frequently, it is necessary to move patients who are weak or unable to move on their own Spasticity: increased tone that interferes with movement, is also caused by neurologic impairments and is often described as a stiffness, tightness, or pulling of the muscle Strength and Endurance Exercise: are components of a variety of muscle-building programs. Weight training, calisthenics, and specific isometric exercises can build both strength and endurance, increasing the power of the musculoskeletal system, and generally improving the whole body. They may or may not have aerobic benefit Stretching Exercise: involves movements that allow muscles and joints to be stretched gently through their full range of motion, increasing flexibility. Specific warm-up and cool-down exercises, Hatha yoga, and some forms of dance are examples Tonus: to describe the state of slight contraction—the usual state of skeletal muscles Learning Objectives: 1.)​ Describe the impact of exercise and immobility on physiologic and mental health functioning -​ Impact of exercise on health -​ Physiological: improves cardiovascular health, increases muscle strength, and enhances flexibility. Boosts immune functions and promotes healthy metabolism. Improves bone density and reduces risk of chronic diseases [diabetes & hypertension] -​ Mental Health: reduces stress, anxiety, and depression. Increases endorphin levels, improving mood and overall well being. Enhances cognitive function and sleep quality -​ Impact of Immobility on health -​ Physiological: leads to muscle atrophy, joint stiffness, and poor circulation. Increase risk of blood clots, pressure ulcers, and respiratory complications. Contributes to weight gain, metabolic dysfunction and weakened immune response -​ Mental Health: increases risk of depression, anxiety, and feeling of isolation. Reduces cognitive function and can cause sleep disturbances 2.)​ Discuss the nursing process related to patient-centered care and mobility status -​ Assessment: evaluate current mobility status. Assess for pain, weakness, or environmental barriers. Consider patient goals and preferences regarding mobility [assisted/independent/partial assist] -​ Diagnosis: common diagnosis may include impaired physical mobility, risk for injury, or activity intolerance -​ Planning: collaborate with patients to set realistic mobility goals. Plan physical therapy or assistive devices PRN. Address potential complications [pressure ulcers and falls] -​ Implementation: encourages safe mobility practices and educate the patient on mobility health and safety -​ Evaluation: monitor patients mobility progress and adjust care plan PRN. assess for complications 3.)​ Describe safe patient handling and movement techniques to include teamwork and ergonomics -​ Proper body mechanics: use leg muscles to lift, bend at knees, and keep load close to your body. Maintain a wide base of support and avoid twisting motions -​ Teamwork: collaborate with colleagues to move or reposition patients safely; use a lift team for heavy or high risk transfers, ensuring everyone know their role  -​ Use of equipment: utilize assistive devices to reduce strain. Ensure equipment is properly maintained and used according to guidelines -​ Ergonomics: position patients at comfortable heights for care to reduce strain. Plan patient movements ahead of time to avoid unnecessary lifting and bending -​ Patient Education: teach patients to assist in their own mobility when possible 4.)​ Discuss evidence-based practice related to ergonomics and assistive devices when providing safe patient-centered care -​ Ergonomics -​ Neutral body position: maintain alignment to reduce strain, stand at appropriate height, avoid twisting motions -​ Team coordination: used standardized protocols for lifting/transferring patients -​ Proper lifting techniques: use leg muscles, avoid bending/twisting to minimize back and musculoskeletal injuries -​ Assistive devices -​ Mechanical lift: use powered lifts or transfer devices to reduce manual lifting reducing worker injury risk -​ Transfer belts & slide sheets: use to help reposition patients reducing physical strain and risk of falls -​ Wheelchair, walkers, and canes: ensure they are appropriately sized and used correctly to promote mobility and independence -​ Height adjustable beds: minimizes care givers need to bend over during patient care reducing back strain Additional Notes: The excitability, contractility, extensibility, and elasticity of muscles enable them to perform four important functions for the body through contraction: -​ Motion: Skeletal muscle contractions pull on tendons and move the bones, creating movements as simple as extending the arm to as highly coordinated as swimming or skiing. -​ Maintenance of posture: Skeletal muscle contractions hold the body in stationary positions. -​ Support: Skeletal muscles support soft tissues in the abdominal wall and floor of the pelvic cavity. -​ Heat production: Skeletal muscle contractions produce heat and help maintain body temperature. Variables that can lead to patient handling injuries include the following: -​ Uncoordinated lifts -​ High exertion (force required to life, move or handle patient) while in an awkward posture -​ Assuming awkward and static postures -​ Manual lifting and transferring of patients without assistive devices -​ Lifting when fatigued -​ Repetitive movements such as lifting, transferring, and repositioning patients -​ Standing for long periods of time -​ Transferring patients from beds to stretchers and chairs, wheelchairs, or operating tables; repositioning patients in bed -​ Repetitive tasks  -​ Transferring/repositioning patients who have cognitive impairments, who are dependent/obese/overweight, or patients who are unable or unwilling to actively participate and promote their own movement Congenital or acquired postural abnormalities Nursing responsibilities: -​ Early detection of and referral for these problems -​ Exploration and selection of patient education, counseling, and support as treatment options -​ Careful attention to positioning, transfers, and exercise -​ Education of the patient and family/caregivers regarding safe self-care activities Problems with bone formation may include: -​ Congenital problems, such as achondroplasia, in which premature bone ossification (bone tissue formation) leads to dwarfism or osteogenesis imperfecta, which is characterized by excessively brittle bones and multiple fractures both at birth and later in life -​ Nutrition-related problems, such as vitamin D deficiency, which results in deformities of the growing skeleton (rickets) -​ Disease-related problems, such as Paget’s disease, in which excessive bone destruction and abnormal regeneration result in skeletal pain, deformities, and pathologic fractures -​ Age-related problems, such as osteoporosis, in which bone destruction exceeds bone formation and in which the resultant thin, porous bones fracture easily Nursing responsibilities for patients with problems of bone formation and muscle development and functioning: -​ Careful collaboration with the health care team to determine the motor capacities of the person -​ Patient and family/caregiver education aimed at developing optimal mobility -​ The ability to position, transfer, and exercise the patient safely, with attention to patient comfort Regular exercise results in cardiovascular conditioning and produces the following benefits: -​ Increased efficiency of the heart -​ Decreased heart rate and blood pressure -​ Increased blood flow to all body parts -​ Improved venous return -​ Increased venous return -​ Increased circulating fibrinolysin Improvements in pulmonary function include: -​ Improved alveolar ventilation -​ Decreased work of breathing -​ Improved diaphragmatic excursion Regular exercise produces the following benefits: -​ Increased muscle efficiency and flexibility -​ Increased coordination  -​ Reduced bone loss -​ Increased efficiency of nerve impulse transmission Exercise benefits on metabolic process include: -​ Increased triglyceride breakdown -​ Increased gastric motility -​ Increased production of body heat Exercise benefits on gastrointestinal system: -​ Appetite is increased -​ Intestinal tone is increased, which improves digestion and elimination -​ Weight may be controlled Exercise benefits on psychosocial include: -​ Increased energy, vitality, and general well being -​ Improved sleep -​ Improved appearance -​ Improved self-concept -​ Increased positive health behavior Risk related to exercise: -​ Precipitation of a cardiac event -​ Orthopedic discomfort and disability -​ Other health problems When a physical or psychological factor is believed to be affecting endurance, evaluate the following: -​ Vital signs while the patient is at rest -​ Ability to perform the activity (e.g., ambulation) -​ Patient’s response during and after the activity -​ Vital signs immediately after the activity -​ Vital signs after the patient has rested for 3 minutes Outcome Identification and Planning If the patient is not experiencing any mobility or activity problems, expected patient outcomes are directed toward the promotion of physical fitness. For example, the patient will: -​ Identify personal benefits of regular exercise -​ List support systems that will reinforce exercise efforts -​ Follow a program of regular physical exercise that improves cardiovascular function, endurance, flexibility, and strength Patients at risk for specific mobility or activity problems may require different expected outcomes. For example, the patient will: -​ Demonstrate correct body alignment -​ Demonstrate full range of joint motion -​ Demonstrate adequate muscle mass, tone, and strength to perform ADLs and/or IADLs Patients who are immobile require outcomes directed toward preventing complications related to inactivity and its effects on the body systems. For example, the patient will: -​ Be free from alterations in skin integrity -​ Show signs of adequate circulation -​ Maintain muscle mass, tone and strength Follow these recommended guidelines when moving and lifting patients: -​ Assess the patient. Know the patient’s medical diagnosis and health issues, capabilities, and any movement not allowed. Apply braces or any device the patient wears before helping from bed. -​ Assess the patient’s ability to assist with the planned movement. Encourage patients to assist in their own transfers. Encouraging patients to perform tasks that are within their capabilities promotes independence. It is important to eliminate or reduce unnecessary tasks to reduce the risk of injury and increase the patient’s self-esteem and mobility levels. -​ Assess the patient’s ability to understand instructions and cooperate with the staff to achieve the movement. Patient engagement during handling and mobility is an important factor in preventing adverse events -​ Ensure that enough staff are available and present to safely move the patient. -​ Assess the area for clutter, accessibility to the patient, and availability of devices. Remove any obstacles that may make moving and lifting inconvenient. -​ Use a screening or assessment tool to aid in patient assessment and decision making regarding safe patient handling and mobility (Arnold, 2019; VA Mobile Health, n.d.). Use of a standardized tool supports consistency and appropriate use of SPHM equipment to assist patients with the appropriate level of mobility Evaluate patient on: -​ General ease of movement and gait -​ Body alignment -​ Joint structure and function -​ Muscle mass, tone, and strength -​ Endurance Session 4 Comfort and Pain Management Key Terms: Acute Pain: Is generally rapid in onset and varies in intensity from mild severe. It is protective in nature. In other words, acute pain warns the person of tissue damage or organic disease and triggers autonomic responses such as increased heart rate, the fight or flight response, and increased blood pressure Addiction: Is a chronic relapsing brain disease characterized by compulsive drug seeking and use despite adverse consequences Adjuvant: Analgesics (anticonvulsants, antidepressants, multipurpose drugs) addition to primary pain relievers Analgesic: A pharmaceutical agent that relieves pain; function to reduce the person’s perception of pain and to alter the person's responses to discomfort Breakthrough Pain: a temporary flare-up of moderate to severe pain that occurs even when the patient is taking around the clock medication for persistent pain and has had well-controlled background pain Chronic Pain: Is maladaptive pain that persists or is recurrent for more than 3 months Cutaneous Pain: Superficial pain usually involves the skin or subcutaneous tissue (papercut) Endorphins: (an opioid neuromodulator) are produced at neural synapses at various points along the CNS pathway. They are powerful pain-blocking chemicals that have prolonged analgesic effects and produce euphoria Enkephalins: (an opioid neuromodulator) widespread throughout the brain and dorsal horn of the spinal cord, are considered less potent than endorphins. Thought to reduce pain sensation by inhibiting the release of substance P from the terminals of afferent neurons Exacerbation: The symptoms reappear or pain that is recurring and contains elements of both chronic and acute pain Gate Control Theory: Originally proposed by Melzack and Wall in 1965, provides the most practical model regarding the concept of pain. It describes the transmission of painful stimuli and recognizes a connection between pain and the projection of pain information to the brain. The theory states that small nerve fibers conduct excitatory pain stimuli toward the brain, exaggerating the effect of the arriving impulses through a positive feedback mechanism Intractable: When pain is resistant to therapy and persists despite a variety of interventions Modulation: The process by which the sensation of pain is inhibited or modified Neuromodulators: are endogenous opioid compounds, meaning they are naturally present, morphine-like chemical regulators in the spinal cord and brain. They appear to have analgesic activity and alter the perception of pain. These endogenous opioid compounds are believed to produce their analgesic effects by binding to specific opioid receptor sites throughout the CNS, blocking the release or production of pain-transmitting substances. Both pain and stress appear capable of activating the endogenous opiate system Neuropathic Pain: Pain caused by a lesion or disease of the peripheral or central somatosensory nervous system. The exact cause is unknown, but can originate either peripherally or centrally Neurotransmitters: Substances that either excite or inhibit target nerve cells Nociceptive Pain: Initiated by nociceptors that are activated by actual or threatened damage to non neural tissue and is representative of the normal pain process Nociceptors: (or peripheral receptors) respond selectively to mechanical, thermal, and chemical stimuli that are noxious; in addition when the threshold of perception for pain has been reached and when there is injured tissue, it is believed that the injured tissue releases chemicals that excite or activate nerve endings (Peripheral somatosensory nerve fibers that transduce and encode noxious stimuli) Opioid: Analgesics (all controlled substances, morphine, codeine, oxycodone, meperidine, hydromorphone, methadone) Pain Threshold: Is the “minimum intensity of a stimulus that is perceived as painful” Pain Tolerance: Level is the maximum intensity of a stimulus that produces pain a person is willing to accept in a given situation Perception: Of pain involves the sensory process that occurs when a stimulus for pain is present. It includes the person’s interpretation of the pain Phantom Pain: Does not have an identifiable physiologic or pathologic cause Physical Dependence: A phenomenon in which the body physiologically becomes accustomed to opioid therapy and suffers withdrawal symptoms if the opioid is suddenly removed, or the dose is rapidly decreased Placebo: Any sham medication or procedure that is designed and known to not be of any therapeutic clinical value Referred Pain: Pain can originate in one part of the body but be perceived in an area distant from its point of origin Remission: Disease is present, but the person does not experience pain Somatic Pain: Diffused or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue that occurs with a sprain causes deep somatic pain Tolerance: Occurs when the body becomes accustomed to the opioid and needs a larger dose for pain relief Transduction: Activation of pain receptors; it involves conversion of painful stimuli into electrical impulses that travel from the periphery to the spinal cord at the dorsal horn Transmission: Pain sensation from the site of injury or inflammation are conducted along pathways to the spinal cord and then on to higher centers. These pathways are clearly defined in certain areas but are still somewhat unclear in other areas Visceral Pain: poorly localized and originates in body organs in the thorax, cranium, and abdomen. One of the most common types of pain produced by disease, and occurs as organs stretch abnormally and become distended, ischemic, or inflamed Learning Objectives: 1.)​ Describe the physiology of the pain process. -​ Transduction: the process where noxious stimuli [injury,inflammation] are converted to electrical signals by sensory receptors activation of pain receptors -​ Transmission: the electrical signals travel along A-delta fibers [sharp localized pain] and C-fibers [dull aching pain] to the spinal cord and brain -​ Perception: The brain processes the pain signals creating the sensation of pain. This occurs in the somatosensory cortex, limbic system [emotional response] and frontal cortex [interpretation] interpretation of pain -​ Modulation: The brain and spinal cord regulate pain intensity through inhibitory pathways [endorphins, serotonin] or facilitate pain through neurochemicals like substance P [which enhances the transmission of pain signals to the brain contributing to pain sensation] -​ Locations of pain -​ Somatic: diffused or scattered/originates in tendons, ligaments, bones, blood vessels, and nerves -​ Visceral: occurs in organs [as organs stretch abnormally and become distended, ischemic, inflamed (most common type of pain produced by disease) -​ Cutaneous: superficial pain involving skin or subcutaneous tissue -​ Referred: pain that originates in another part of the body but is felt in another area 2.)​ Discuss components of a pain assessment and tools that can be utilized by the nurse, including the PQRST assessment tool. -​ P [provocation/palliation] what causes or relieves the pain? -​ Q [quality] how does the pain feel? -​ R [region/radiation] where is the pain, and does it spread? -​ S [severity] pain intensity, often rated on a scale of 0-10 -​ T [timing] when did it start, and is it constant or intermittent? -​ Other tools -​ Numeric rating scale [NRS]: 0-10 pain scale -​ Wong-baker facial scale: visual scale for children/nonverbal adults; patient must pick facial expression not the nurse looking and assuming -​ FLACC scale: used for infants or nonverbal patients [face, legs, activity, cry, consolability] -​ Visual analog scale [VAS]: patient marks pain intensity on a line 3.)​ Discuss the differences between physical dependence, tolerance, and addiction. -​ Physical dependence: is a physiological adaptation, leading to withdrawal symptoms if the drug is stopped. It does not imply compulsive drug seeking behavior, not necessarily an addiction -​ Tolerance: is when the body becomes less responsive to a drug overtime, requiring higher doses for the same effect. It can occur with or without dependence or addiction -​ Addiction: is a chronic disease involving compulsive use, loss of control and continued use despite harm or harmful consequences. It includes psychological and behavioral components, whereas dependence and tolerance are primarily physiological 4.)​ Identify barriers to effective pain management and identify ways to empower patients to participate in their own pain management plan. Barriers to effective pain management -​ Patient related -​ Fear of addiction or side effects -​ Misconceptions about pain reporting [“pain means weakness”] -​ Cultural or personal beliefs about pain tolerance -​ Provider related -​ Inadequate pain assessment skills -​ Bias or disbelief in patient-reported pain -​ Hesitation to prescribe opioids due to regulatory concerns -​ System related  -​ Limited access to medications or specialists -​ Insurance or financial barriers -​ Time constraints in healthcare settings ​ Ways to Empower Patients -​ Education: teach about pain management options, medication safety, and the importance of reporting pain -​ Encouraging communication: faster open discussions about pain, treatment preferences, and concerns -​ Non-pharmacologic strategies: encourage use of heat/cold therapy, relaxation techniques, and physical therapy -​ Shared decision making: involve patients in setting realistic pain relief goals and treatment plans 5.)​ Discuss evidence-based practice as it relates to use of pharmacologic and nonpharmacologic methods of pain relief. -​ Pharmacological methods -​ Opioids: effective for acute and severe pain but evidence supports cautions use due to addiction risk. Multimodal analgesia [combining different drug classes] is recommended to reduce opioid reliance -​ NSAIDs and Acetaminophen: strong evidence supports their use for mild to moderate pain especially in musculoskeletal and post surgical pain -​ Adjuvant medications: Antidepressants [amitriptyline] and anticonvulsants [gabapentin] are evidence based options for neuropathic pain -​ Non-pharmacological methods -​ Cognitive behavior therapy: research shows CBT helps manage chronic pain by altering pain perception and improving coping skills -​ Physical therapy and exercise: evidence supports movement based therapies for conditions like arthritis and back pain, reducing pain and improving function -​ Mind body interventions: meditation, acupuncture, and relaxation techniques are backed by studies for reducing chronic pain -​ Heat/cold therapy and massage: proven to provide temporary relief for muscle and joint pain -​ Best practice approach: research supports a multimodal approach combining pharmacological and nonpharmacological methods for better pain control, improved function, and reduced reliance on medications 6.)​ Discuss physiologic, behavioral, and affective responses to pain. -​ Physiologic responses (involuntary) -​ Increased heart rate, blood pressure, and respiratory rate -​ Sweating [diaphoresis] -​ Muscle tension and rigidity -​ Pupil dilation -​ Pallor or flushing -​ Behavioral responses (voluntary) -​ Guarding or protecting the painful area -​ Restlessness or reduced movement  -​ Facial expressions -​ Verbal expressions -​ Affective responses (emotional and psychological) -​ anxiety , depression, or irritability -​ Withdrawal from activities or social interactions -​ Fear or helplessness -​ Anger or frustration -​ Nursing Diagnosis/patient problem -​ Type of pain: acute [rapid onset], chronic [pain lasting 6 mo or longer] -​ Etiologic factors: what is the pain related to or cause -​ Behavioral, physiologic, affective response: defining characteristics -​ Other factors: affecting pain process 7.)​ List common side effects of opioids and assessment tools the nurse can use to assess for these side effects, including the Pasero Opioid-Induced Sedation Scale. -​ Common side effects of opioids -​ Respiratory depression: slowed, shallow breathing due to opioid effects on the brain stem. Can be life threatening if severe -​ Sedation and drowsiness: patients may feel excessively sleepy, have trouble staying awake or appear confused -​ Constipation: opioids slow gastrointestinal motility, leading to hard stools and difficulty passing bowel movements -​ Nausea and vomiting: often occurs due to opioid effects on the brains chemoreceptor trigger zone and slowed digestion -​ Hypotension: opioids cause vasodilation leading to lower blood pressure, dizziness, and risk of falls -​ Itching: often due to release of histamines -​ Urinary retention: opioids impair bladder muscle function/hard to urinate -​ Confusion/cognitive impairment: results in disorientation, poor concentration, or hallucinations especially in older adults -​ Assessment tools -​ Pasero opioid induced sedation scale -​ S: sleeping, easy to arouse -​ 1: awake, alert -​ 2: slightly drowsy easily aroused -​ 3: frequently drowsy, arousable, drifts off mid conversation [unacceptable requires intervention] -​ 4: somnolent minimal or no response to stimuli [unacceptable requires immediate intervention] -​ Respiratory rate monitoring -​ Assess for swallow, slow breathing Intramuscular > Subcutaneous > Dermal In a drug–drug interaction, the combined effect of two or more drugs acting simultaneously can produce several effects: -​ Additive effect—drugs with similar pharmacological actions; results in an increase in the overall effect -​ Synergistic effect—drugs with different sites or MOA; results in greater effects when taken together (one drug potentiates the other) -​ Antagonistic effect—combined drugs alter the overall sum effect or negate each other; results in an effect less than that of each drug alone -​ Interference—one drug interferes with the metabolism of another; leads to the buildup of a medication (that cannot be metabolized) and can result in toxicity or an ADR -​ Displacement—one drug binds to protein-binding sites and forces another drug to be displaced; results in the released drug becoming pharmacologically active and can lead to an increase in the effect of the unbound drug The medication order consist of seven parts:  1.)​ Patient's name and secondary identifier 2.)​ Date and time the order is written 3.)​ Name of drug to be administered 4.)​ Dosage of the drug 5.)​ Route by which the drug is to be administered 6.)​ Frequency of administration of the drug 7.)​ Signature of the prescribing provider The label should be read: -​ When the nurse reaches for the unit dose package or container -​ After retrieval from the drawer and compared with the eMAR/MAR, or compared with the eMAR/MAR immediately before pouring from a multidose container -​ Just before giving the unit dose medication to the patient, or when returning the multidose container Controlled substances information usually required: -​ Name of the patient receiving the controlled substance -​ Amount of the substance used -​ Hour the controlled substance was given -​ Name of the prescribing provider -​ Name of the nurse who administered the substance Techniques for administering medications to older people include the following: -​ Allow extra time to administer medications to older adults because their reflexes may be slowed and they may require additional explanation of the treatment regimen. -​ Older adults may have difficulty swallowing medications and may find it easier to take their medications when crushed or given in liquid form. Initiate swallowing by gently massaging the laryngeal prominence or the area just below the chin prominence. The pressure from the gentle massage creates the desire to swallow. A speech therapist may offer additional suggestions for patients who have difficulty swallowing, such as a chin-to-chest position to increase the strength of the swallow. -​ Reevaluation of the drug dosage is necessary with the older adult, especially when considering potential interactions and toxicities. Weight and age should be used as criteria for determining the dosage. -​ Assist the older adult to set up a schedule as a reminder to take medications as scheduled at home. Associate medication with activities (such as breakfast or a television show) and not a specific time. -​ Monitor the patient carefully for adverse effects that may result from the drug regimen. Encourage the patient to have all prescriptions filled at one pharmacy to facilitate appropriate management of the patient’s entire medication regimen. -​ Teach patients the names of drugs, rather than distinguishing them by color. Manufacturers may vary the colors of generic drugs, and the visual changes associated with aging may make it more difficult to identify medications by their color.  -​ Empower patients to take control of their health by providing education and ongoing support focused on adherence to the medication regimen. Choose the equipment needed for an injection based on the following criteria: -​ Route of administration: A longer needle is required for an intramuscular injection than for an intradermal or a subcutaneous injection. -​ Viscosity of the solution: Some medications are more viscous (thick) than others and require a needle with a large lumen to inject the drug. -​ Quantity to be administered: The larger the amount of medication to be injected, the larger the syringe needs to be. Smaller syringes should be used as needed for precise dosing because they provide smaller increments of measurement—never estimate a dose. -​ Body size: An obese person requires a longer needle to reach muscle tissue than does a thin person. A thin person or an older adult with decreased muscle mass requires a shorter needle. -​ Type of medication: There are special syringes for certain uses. An example is the insulin syringe used only to inject insulin. Omitted Drugs -​ The patient is to have a diagnostic test and is required to fast before the test. Oral drugs may be omitted, or their administration may be delayed, depending on the provider’s orders. -​ The problem for which the medication is intended no longer exists. For example, a laxative has been ordered for a patient. The patient has had a bowel movement and no longer needs the laxative. The laxative is then omitted. -​ The medication does not meet prescribed administration guidelines or the clinical judgment of the nurse necessitates follow up with the prescribing provider. For example, it is standard practice to hold certain cardiac drugs if the heart rate or blood pressure fall below a certain level; these parameters may or may not be included with the order itself. -​ The patient is suspected of having an allergy to the medication. Any suspected allergy should be reported to the primary care provider When a medication error occurs: 1.)​ Check the patient’s condition immediately when the error is noted. Observe the development of adverse effects related to the error. 2.)​ Notify the nurse manager and the primary care provider to discuss possible courses of action, depending on the patient’s condition. 3.)​ Report the incident using whatever method is appropriate for your institution. These may include an incident report, a quality-assurance report, a risk assessment/root cause analysis report, or a variance report. These forms—generally called special event, event, or unusual occurrence reports—require an objective, complete account of the medication error. Include the steps taken after the error was recognized. For legal reasons, describe the error fully and accurately. Medication errors are a common allegation in nursing liability cases. Do not document in the patient’s record the fact that an incident report was filed. Your institution is bound by state and national mandates to report certain incidents. Some of this reporting is voluntary and some is required. For example, reporting near-miss medication errors, where an error almost occurred, is voluntary in some instances, but sentinel events, where serious patient harm or death results from the error, require reporting