Exam 3 101 Fundamentals PDF

**Pr THORAX/LUNGS ASSESSMENT** - **[Thorax lung assessment:]** - **WHAT MUSCLES DO WE USE FOR BREATHING?** - 1.exteral intercostal muscles and diaphragm. - **WHEN WOULD YOU SEE ACCESSORY MUSCLES BEING USED AND WHY?** - 1.When a person is having a hard time breathing/during exercise an...

**Pr THORAX/LUNGS ASSESSMENT** - **[Thorax lung assessment:]** - **WHAT MUSCLES DO WE USE FOR BREATHING?** - 1.exteral intercostal muscles and diaphragm. - **WHEN WOULD YOU SEE ACCESSORY MUSCLES BEING USED AND WHY?** - 1.When a person is having a hard time breathing/during exercise and are lacking oxygen - 2\. you would use the following muscles: trapezius and sternomastoid muscles - **HOW DOES AIR TRAVEL THROUGH THE BODY?** - Oxygen trachea left and right bronchi bronchioles zee alveoli's "air sacs" they're surrounded by capillaries aka where gas exchange occurs?(o2 an c02 exchange)ie: see pic below. - **WHERE DOES GAS EXCHANGE OCCUR?** - Between alveoli and capillaries - *The process of inhalation inspiration*: we breath in then it travels thru the body until it gets to the alveoli sacs HERE O2 diffuses into the alveoli, they inflate & O2 moves into capillaries and get dispersed to the rest of the body\ When CO2 diffuses into the alveoli, they deflate and we breath out CO2 [ ]  [ ]  [ ] - **WHY DO THE BRONCHIOLES CONSTRICT AND GET INFLAMED DURING AN ASTHMA ATTACK?**: - sm bands **constrict aka:** broncho constriction on the outside **,** causing airway to narrow while the lining in the inside will be **inflamed** which **narrows** *it even more.* NOTE:\*\***ASTHMA is not COPD.** - **[2 BRANCHES OF COPD:]** [**1.CHRONIC BRONCHITIS**:] broncho constriction on the outside and inflammation n swelling in the inside[.] BUT THE Bronchi swell and become clogged/plugged with [ **mucus**] - **What IS THE MAIN DIFFRENCE BETWEEN CHRONIC BRONCHITIS AND ASTHMA ?** - Asthma does not produce mucus. **[2.EMPHYSEMA:]** destruction of alveoli; Alveoli expands and becomes hyperinflated. so they lose their elasticity and there's no recoil therefore they are now left overstretched. So, when you exhale CO2, it doesn't fully deflate. - [referred to as CO2 retainers:] [failure to remove co2 fully] - **WHAT IS IN THE INTRAPLEURAL SPACE?** - a thin fluid layer of interstitial fluid - **WHAT IS PLEURAL EFFUSION?** - excess fluid in intrapleural space effecting ability to breath - **HEMOTHORAX. :** **blood** in the interpleural space due to injury or trauma - **EMPYEMA.:** infection/ **puss** in the interpleural space - **PNEUMOTHORAX :** **air** in intrapleural space due to traumatic injury or puncture wound - **What can pneumothorax cause?** - collapse lung - **PLURAL EFFUSION:** **fluid** in the pleural space - **What happens if somebody has a collapsed lung?** - When someone has a collapsed lung, it means air from the outside gets inside the chest where it shouldn't be. Usually, the lungs have less air pressure inside, which helps them stay open. But if there's a hole---like from a stab or puncture---outside air rushes in and squishes the lung, making it collapse. When the lung is collapsed, it can't fill with air, so you won't hear breathing sounds on that side of the chest. - **What happens to the trachea if the lung has collapsed?** - Trachea could shift/deviate - **What kind of subjective data do we ask for respiratory?** 1. Any History of coughing? If yes ask the following questions\... - Productive/Non-productive: "are you bringing anything up with this cough? - Productive: mucus n phlem - Nonproductive: dry cough - Sputum Characteristics: greasy? Green? 2.Any Shortness of Breath? Any Chest Pain? 3.Any History of Smoking? 4.Is there Environmental exposure? 2^nd^ hand smoke? Casino smoke? - **What is the biggest risk factors for COPD?** - Smoking - **What would be an abnormal finding of the anterior posterior diameter of the chest? What can it lead to?** - AP = transverse diameter, its a 1:1 ratio = barrel chested - **What would be a normal finding of the anterior and posterior diameter of the chest?** - AP diameter the front to back should be less than\< transverse **Inspection "IPPA" DO NOT PERCUSS!** 1. Shape & Configuration (AP diameter the front to back should be less than\< transverse : how's the left n right ? do they match? 2. Level of Consciousness? Awake ? lethargic? "drowsy" 3. Position of the patient? sitting/supine? 4. Note use of accessory muscles? Aka like using other parts of the body to breath good 5. Location of trachea (deviation) 6. Skin color and condition (cyanosis) 7. Rate Normal = 12-20/ min (tachypnea) **What is the tripod position?** Hunched over position if someone is SOB. It allows the lungs to expand more to get more air /o2 into the lungs. **ABNORMAL CONFIGURATION OF THORAX** 1. **BARREL CHEST:** you see this if pt had yrs of COPD. 2. **SCOLIOSIS l**ateral deviation/curve of the spine; do this by asking them to bend over n touch toes 3. **KYPHOSIS :** Hunchback; posterior deviation of spine 4. **PECTUS EXCAVATUM:** caved in sternum: genetic; depending on the severity it could affect cardiac/respiratory function. 5. **PECTUS CARINATUM**: protruding sternum: genetic; depending on the severity it could affect cardiac/respiratory function. **Abnormal Respiratory Patterns** - **TACHYPNEA:** fast shallow breathing - **BRADYPNEA:** slow breathing - **HYPERVENTILATION:** Breathing fast but **DEEP** (blowing up too much CO2) if there's too much acid in the blood patient can become alkaline. - **CHEYNE-STOKES:** apnea, near to death breathing, regular and irregular breathing with episodes of apnea - **How are nurses able to tell in hospice care that a pt is near death and may have less than 24 hrs away?** - Change in respiration. irregular/ regular breathing pattern bc they can have episodes of apnea. - **If pt is hyperventilating what do you do?** - Find out what's causing them to hyperventilate ? **Palpation** 1. **Symmetric Expansion:** hand on "pos n antof lungs" ask pt to take a deep breath \* watch for separation and it should symmetrically expand.; or place hands underneath the nipples on anterior lungs and have pt inhale and exhale and thumbs should move equally. 2. **Tactile Fremitus :** Place both hands on chest.Ask patient to say \"99\"Feel the equal vibration of both lungs from vocalization. 3. **Note areas of tenderness:** the owww! 4. **Note lumps or masses:** note lumps  **Adventitious Lung Sounds: always use diaphragm** **[CRACKLES ]** - Non-musical, popping sound - Fine: roll hair between fingers by ear - Coarse: opening Velcro - Due to fluid, mucus or pus **[WHEEZING (]**[due to narrowing of airway)] - High pitched - Due to airway narrowing - Caused by **lower obstruction** **[STRIDOR]** ([due to narrowing of airway)] - High-pitched during inspiration - Due to obstruction of **upper airway (above trachehea)** [**RONCHI (**due to narrowing of airway)] - Low-pitched, snore-like - Due to airway narrowing and secretions - Combination of all. **Respiratory Conditions** - **What is COPD?** - chronic obstructive pulmonary disease (chronic bronchitis and emphysema) - **What is ATELECTASIS:? How do we prevent or tx this ?** - collapse of alveoli - incentive spirometer/deep breathing trea allows WHICH HELPS Aveoli to inflate/expand - **COPD: has 2 BRANCHES** 1. **CHRONIC BRONCHITIS** 2. **EMPHYSEMA** - **How does pneumonia cause pleural effusion?** - Excess fluid is building up in the alveoli in the lungs, fluid will seep out the capillaries into the intrapleural space & alveoli - **ASTHMA:** narrowing/constriction of airway. - **PLEURAL EFFUSION:** excess fluid @ intrapleural space cause by Heart failure \*most common), pneumonia - **How does left sided heart failure cause pleural effusion? (pulmonary congestion)** - Blood and excess fluid backs up into the lungs; too much fluid will seep out of capillaries into the alveoli/intrapleural space - **PNEUMOTHORAX:** punctured lung and lung collapses - **What do we look for if someone has pneumothorax/collapsed lung?** - Cyanosis, tachypnea, tracheal deviation, decreased breath sounds or no breath sounds - **WHAT DO WE LOOK FOR SOMEONE WHO HAS TUBERCULOSIS?** - Rust colored sputum, fever, night sweats - **What kind of PPE do you wear with someone who has TB? What type of room will they be in?** - N95 respirator - The patient will be in a negative pressure isolation room - **What is clubbing of the nails? What\'s a possible cause? And whos common to get this?** - Rounded distortion of the nail bed like a cave man\'s club; - Hypoxia - Common in pt who is a long term smoker and COPD **Abdomen Assessment** - Interview & Exam: - **What is IAPP for the abdomen/GI assessment?** - Inspection - Auscultation - Percussion - Palpation - **WHY DO WE HAVE PALPATION SAVED FOR LAST?** - Don\'t want to cause unnecessary pain or create bowel sounds - **How do we do percussion?** - Firmly press middle finger on skin - Tap hard on the bone of your finger - Hollow sound=tympany - **What organ is in the right lower quadrant?** -appendix - **What organs are in the right upper quadrant?** **-**liver, gallbladder, ascending & transverse colon - **What organs are in the left upper quadrant?** **-s**tomach, spleen, pancreas, transverse & descending colon - **What organs are in the left lower quadrant?** **-**descending colon, sigmoid colon - **What organs are in the epigastric region?** -liver, stomach, pancreas - **What organs are in the umbilical region?** -small intestine, transverse colon of large intestine - **What organ is in the hypogastric/suprapubic region?** -urinary bladder - **What kind of subjective data do we gather for abdomen assessment?** - **What objective data do we need to inspect for abdominal inspection?** - **What is a scaphoid abdomen?** \--Abdomen is caved in - **What is a rounded abdomen?** \- increased adipose tissue \- round abdomen - **What is a protuberant abdomen? (if they\'re pregnant just say pregnant)** **-**Abdominal distension - **What is peristalsis?** -movement of contents/feces through the intestines - **How does peristalsis work? What happens to water in fecal matter?** -Motility/waves move fecal material through colon -Water absorbed from feces into capillaries - **What is the colon absorbing from the fecal material?** **-**Water; watery fecal matter - **What\'s the fecal material going to be like in the ascending colon?** -watery fecal matter - **What\'s the stool going to be like in the sigmoid colon?** -Semi-solid mass - **What is happening during constipation?** **-**Feces stays in large intestine for extended time; water is getting absorbed too much - **What\'s happening during diarrhea? What is not getting absorbed?** -Feces is moving too quickly, due to water not being absorbed - **How does stool gain its form?** -Water is being absorbed as the fecal matter passes through the colon, it gets harder as it moves a long - **If a patient has a colostomy closer to the ascending colon, what will the output be like?** -watery stool - **If a patient has a colostomy closer to the sigmoid colon, what will the output be?** -Formed stool Auscultating bowel sounds : USE THE BELL! A. Listen for bowel sounds: air & fluid B. high pitched, gurgling, irregular sounds,grumling C. 5-30 per minute - **What will a HYPERACTIVE abdomen sound like?** **-**More than 30 bowel sounds per minute ; Constant gurgling, peristalsis is going too fast - What will a **HYPOACTIVE** abdomen sound like? -Less than 5 bowel sounds per minute ; peristalsis is going too slow - **What is the maximum amount of time we auscultate the abdomen if there are absent bowel sounds?** -5 minutes and say pt is having [absent] bowel sounds. - **When pt comes back from surgery what do you asses?** -bowel sounds. P.s don't give pt water then do not give It to them until you hear bowels sounds. - **What order do we auscultate the abdomen?** **-**RLQ, RUQ, LUQ, LLQ; right lower quadrant, right upper quadrant, left upper quadrant, left lower quadrant - **How do we auscultate for bruits in the arteries of the abdomen?** -place stethoscope @ the epigastric region/ aorta then to renal artery iliac artery---femoral artery. Percussion (abdomen) - **How do we percuss the abdomen?** -Use middle finger to tap knuckle on each quadrant in a circle - **What is tympany percussion?** - -A high pitched, hollow drum-like sound - **Why will we hear dullness when percussing the lower quadrants?** **-**Dullness is filled with fluid or masses/stools (bladder distention) - **What is HYPERRESONANCE?** -low-pitched, loud booming sound due to [too much air] in the abdomen - **How do we palpate the abdomen?** **-Screen for abdominal mass or tenderness** Palpation of abdomen A. Screen for abdominal mass or tenderness B. Light and Deep palaptions (2-3 inches) C. Keep area of pain for last (muscle rigidity) D. Were looking Rebound tenderness.. tenderness meaning discomfort pain. (Normal response is NO Pain) - **What abdominal area do we save for last when palpating?** **-**area of pain - **When doing light palpation, what should we be feeling or not feeling?** -We should be feeling for tenderness or masses; We aren\'t feeling for any organs - **What if nurse fells firmness in the super pubic region?** -well for one the bladder is there and it should be soft and if its firm you ask pt have you peed recently? - **What is MUSCLE RIGIDITY?** -stiffness seen with resistance to passive muscle stretching. - **What is rebound tenderness? What is a normal response to rebound?** -Pain on release of pressure; NO pain - **Who would you expect to have rebound tenderness in the right lower quadrant?** **-**Patient with peritoneal inflammation or appendicitis - **What is MCBURNEY\'S SIGN used to assess? What will be present when this area is palpated?** -To assess for appendicitis. Rebound tenderness and sharp pain is present when McBurney\'s point is palpated. - **What is Cullen\'s sign? What can cause this?** **-**Bluish periumbilical color -Internal GI/peritoneal cavity bleeding - **PERITONEAL:** abdominal - **CHOLECYSTITIS:** inflammation of the gallbladder due to bile not getting released into the stool - **WHAT IS MURPHY\'S SIGN:** Right upper quadrant pain of the gallbladder - **What happens to the stool if someone has cholecystitis?** **-**It doesn\'t give stool the brown color, it will be pale/clay color - **JAUNDICE:** yellow discoloration of the skin, due to the Gallbladder not excreting bile so it backs up into the liver, then leaks out into bloodstream into the tissues. - **What else does bile do besides give stool its brown color?** -It helps absorb fat from the stool - **Why is vitamin K important with preventing bloody stools?** -It\'s needed for forming prothrombin to make clotting factors for a blood clot - **PANCREATIS:** Inflammation of the pancreas there for the Patient will have epigastric pain through the back - **What causes pancreatitis?** **-**Pancreas secretes digestive enzymes, but sometimes they\'ll get activated in the pancreas instead of the GI. They\'ll start breaking down the pancreas. - Abnormal findings of abdomen: a. Enlarged organs b. Pulsations c. Hyper/hypoactive bowel sounds d. Distended bladder - abnormal pain findings of the abdomen: a. -Appendicitis RLQ (McBurney\'s point) b. -Bowel obstruction c. -Lower esophagus (GERD/MI) - **What does \"patient with pain at McBurney\'s point\" mean?** **-**Right Lower quadrant = appendicitis - **Where is the pain going to be at for a bowel obstruction?** -Left lower quadrant - **What are hemorrhoids?** **-s**tretched & distorted veins in the rectum, if they\'re strained they could open up & start bleeding - **What is coffee ground emesis? (vomiting) What can cause this?** -Partially digested blood that is vomited up; caused by a GI bleed **MUSKULOSKELETAL:** \-\-\--**Subjective Data: Do you have any limitations with daily activities?** "Questions you should ask" - **Joints**: pain? Stiffness? ROM - **Muscles:** pain? Cramping? Weakness? - **Bones:** pain? noticed any deformity? accidents/trauma? - **Functional Assessment (ADL's)** 1.Limitations in movement **Inspection : IPPA** 1. Color: even skin tone through out 2. Swelling: 3. Masses: 4. Deformities: **Palpation** - **Extremities (crepitous);** Always go from proximal to distal " shoulder to fingers." - Crepitous: crunch crunch; - **Joints (tenderness):** - **Temperature (heat):** - In arthritis if rheumatoid then their fingers will feel hot. **Range of Motion** - **Joint mobility:** - **Should not cause pain** - **AROM / PROM:** 1. Active range of motion exercise : Pt is actively doing I themselves "extremities" 2. Passive range of motion exercise : you're moving their extremities - **Muscle strength and hand grip:** have pt pull against, plantar and dorsi flexion, grip test **Grading Muscle Strength** - \- Have patient perform AROM while you provide resistance **Abnormal Findings** **Osteoporosis:** Loss of bone mass resulting in decreased ability to maintain structural integrity of the skeleton 1. Etiology: unknown 2. Associated with: aging 3. Increased risk of fractures 4. Kyphosis present **Treatment and Prevention: osteoporosis** **Biphosphonates "once a week medication"** 1. Inhibit "stop" bone resorption 2. **Common types:** Fosamax, Boniva, Actonel 3. **Side effect**: Esophageal ulcers 4. Oral 5. Recommend to take with cold water, instruct pt to sit upright "possibility of reflex", usually 30 mins -1 hr. **Calcitonin** 1. Inhibit bone resorption 2. **Common:** Miacalcin, Frotical (IM, SQ, Intranasal) 3. **Care of** IM, SQ, Nasal **Osteomalacia: lack vitamin D** - Softening of bone tissue due to inadequate mineralization of osteoid - Calcification **does not** occur - **Causes:** Vit D deficiency (lack of sunlight exposure, dietary intake, malabsorption in small bowel-Crohn's) - **Major treatment**: vitamin D - **At risk**: elders **Osteomyelitis: staph causes this** - Infection of the bone - **caused by** the invasion of microorganisms that stimulate the inflammatory response in bone tissue **Fractures** - **definition:** A break or disruption in the continuity of a bone **(complete/incomplete)** 1. complete: fracture goes thru the bone entirely 2. incomplete: halfway fracture - **can be**: Simple / Compound 1. simple: fracture but skin is intact 2. compound: fracture but breaks thru skin - **Types of fractures include:** 1. Comminuted: bone has several mini/multiple fracture 2. Displaced: when you have a complete fracture, but bone isn't aligned 3. Spiral: break/ crack runs in spiral shape. 4. Impacted: impact against bone on bone 5. Greenstick: bendable bones. +-----------------------------------+-----------------------------------+ | **Strains** | **Sprains** | +===================================+===================================+ | - Excessive stretching of a | - Excessive stretching of **a | | **muscle or tendon** | ligament** | +-----------------------------------+-----------------------------------+ | - **Classified according to | - **Classified according to | | severity:** first, second, | severity**: first-, second-, | | and third-degree strain.; | and third-degree sprain | +-----------------------------------+-----------------------------------+ **Management of Strains and Sprains: RICE "REST. ICE. COMPRESSION.ELEVATION** 1. Cold and heat applications 2. Activity limitations 3. Anti-inflammatory drugs 4. Muscle relaxants 5. Surgery **Osteoarthritis:** DEGENERATOIN OF **JOINTS.** - ***Most common*** type of arthritis - Weight-bearing joints and hands - Joint pain and loss of function, stiffnes - Progressive deterioration - **Typical:** middle-aged person, fat the runners; depends on activities - You will have hypertrophy of the bone joint - Start **[@ lower extremities. ]** **Clinical Manifestation** - Joint involvement - Pain worsens with activity / better with rest - Hypertrophy of bone joint (nodules) - 50% with hand involvement have: 1. **Heberden\'s nodes**: distal joint 2. **Bouchard's nodes**: proximal joint AKA : CRAKING OF KNUKLLES **Rheumatoid Arthritis** - Chronic, progressive, systemic inflammatory **autoimmune disease "Body is attacking itself"** primarily affecting the joints - Autoantibodies (rheumatoid factors) attack healthy tissue - Affects synovial tissue of any organ or body system -- thickened, inflammatory cells (erode cartilage and bone) - **Etiology:** unclear/ no treatment - usually start **[@ upper extremities]** - swan deformity. - is symmetrica **Clinical Manifestation** - Typically starts in UEs: ***upper extremities.*** - Joint deformity - **[Pattern:]** bilateral and symmetric "both hands at the same time - 25% of patients have subcutaneous **nodules.** - Soft tissue on surface of arm/fingers - Common deformities (next slide) **Treatment: no cure no treatment** 1. Pain management 2. Plasmapheresis: 3. Assistive devices **Comparison of OA and RA** **Ethical & Legal Considerations** **NURSING PROFESSIONAL VALUES** - **Altruism:** help ppl - **Autonomy** : make decisions - **Human Dignity**: holding standards. - **Integrity:** holding standards - **Social Justice**: equal treatment **LAWS VS ETHICS** +-----------------------------------+-----------------------------------+ | **Laws** | **Ethics** | +===================================+===================================+ | 1. Rules establishing society's | 1. Standards of behavior | | behavior | | | | 2. Based on moral values | | 2. Created and enforced by | | | government | 3. May or may not be penalized | | | | | 3. Breaking a law results in a | 4. Ex: steal,cheating | | penalty | | | | | | 4. Ex: murder | | +-----------------------------------+-----------------------------------+ **LAWS VS ETHICS** - An **illegal act is always unethical**, but **an unethical act is not necessarily illegal** **ETHICAL PRINCIPLES** - Definition: Standards of what is right or wrong (not always black or white) - **Include:** 1. **Autonomy:** make/respect decisions / respecting pts decision ; ex: pt wants to leave then let them leave. 2. **Beneficence**: doing good 3. **Fidelity:** keeping promise 4. **Justice**: fair equal treatment 5. **Nonmaleficence:** do no harm 6. **Veracity:** being honest - Nurses have a responsibility to be advocates, and to report ethical situations **TORTS: 2 types\ (WRONG COMMITTED AGAINST ANOTHER)** **1.Unintentional Negligence:** you didn't mean harm to pt but it happened **[2. Intentional:]** you wanted to hurt your pt - **Defamation:** talk bad; can be written= "liable" verbal= "slander" - **False imprisonment:** restraining someone's freedom of movement; can be a sedative/meds. Ex: some nurses will give pt sedatives, so they won't fall or wake up to go to bathroom. - **Ex:** pt with wheelchair, you put brakes when they don't need it "you are essentially restricting them from wheeling around." - **Invasion of privacy:** ex: close door / never talk bad abt pt/do not mention facilities, room \#''s - **Fraud: aka** "im a student nurse" - **Assault:** when you threaten to touch someone - **Battery:** when you touch someone **INFORMED CONSENT** **Includes:** 1. Explanation of treatment and expected results 2. Anticipated risks 3. Potential benefits 4. Possible alternatives 5. Answers to questions 6. Statement that consent can be withdrawn at any time **Informed Consent** - **Legal Responsibility** - Individual performing treatment (primary provider) - When **nurse witnesses signature**, means that there is reason to believe that the patient is informed about upcoming treatment and make sure it's the correct pt. - **Requirements** 1. Age 2. Competence 3. Voluntary 4. Cannot obtain it if intoxicated."ie: drugs alcohol" **ABUSE** - **Definition:** Action that causes harm to the patient - People most at risk are the very young and the elderly 1. Physical 2. Emotional 3. Financial - Report suspected abuse to immediately. **Neglect** - ***[Definition]***: Failing to do things that are necessary to meet the needs of the person -ex: don't give mends, don't clean them, ect **SIGNIFICANT HEALTH CARE ACTS** - **[Emergency Medical Treatment and Active Labor Law ]** - (E.M.T.A.L.A.0): mandates everyone will receive emergency treatment and be stabilized, once stables you send them to another facility. - **[Patient Safety and Quality Improvement Act: ]** - Ensures safe and quality care. ex: the surveys - **[Americans with Disabilities Act:]** - Ensures every individual will receive required care **Incident Reports** - **Definition:** Agency record of ***unusual occurrence (or accident***), and response - Report on any unexpected or unplanned occurrence that affects or potentially affects patient, family, staff - Purpose is for documentation and follow-up of incident - Analysis is basis for intervention - Internsl document **INCIDENT REPORTS -- COMMON SITUATIONS** 1. Medication errors (administer a med without an order) 2. Complications from treatment/procedure 3. Failure to report change in condition. 4. Falls 5. Break in aseptic technique. 6. Patient refuses treatment or refuses to sign consent. **HIPAA** 1. **[Health Insurance Portability and Accountability Act of 1996]** - Protects the privacy and security of a pt's health info - Fines up to \$250,000 and imprisonment - We cannot give out any type of info without prior consent (even to family) **WHAT NEVADA LAW GOVERNS NURSES**? - **[Nurse Practice Act]** - Delegation (LPNs/CNAs) - Meds, VS, IVs, Safe/Complex, T.O.s - Delegate Tasks not Nursing Process - Maintain accountability - **[5 Rights of Delegation ]** - Person - Task - Circumstance - Directions (communication) - Supervision **ADVANCE DIRECTIVES** - **Purpose:** communicate wishes regarding end-of-life care should patient become unable to do so - **[The Patient Self-Determination Act (PSDA]**) - 1.requires that all patients be asked if they have advance directives - 2.all pts must be informed of Advance Directives upon admission **2 TYPES OF ADVANCE DIRECTIVES:** - Living Will - **[Durable Power of Attorney for Health Care]**: " should anything happen to me this is what I want. **DO NOT RESUSCITATE ORDERS** 1. Unless there is a DNR order, the nurse should initiate CPR when a patient has no pulse or respirations 2. Order for a DNR must be placed in the patient's medical record 3. Provider consults the patient and the family prior to administering a DNR 4. Additional orders by the provider are based on the patient's individual needs and decisions and provide for comfort measures **NURSE'S RESPONSIBILITIES** 1. Provide written information regarding advance directives 2. Document patient's advance directives status 3. Ensure advance directives are current 4. Inform all members of the health care team of the patient's advance directives 5. Recognize that the patient's choice takes priority when there is a conflict between patient/family, or between patient/provider OTHER: **[Good Samaritan law] :** -reg person does the whole feels pulse, does cpr. Pt dies ; the reg person does not get sued -Nurse does cpr , pt dies : nurse gets sued -If you introduced yourself as an RN " you established a nurse pt relationship". **Documentation:** **Purpose of Records** 1. **Communication:** - Nursing Documentation (Care Plan) - Financial Reimbursement - Auditing / Monitoring - Legal Documentation **Common Methods of Recording** 1. **Narrative Documentation (physical assessments):** the nurses note. Assessment findings, what you did for pt, pt response. 2. **PIE:** problem, intervention, evaluation. "Focuses on one specific problem." 3. **DAR (Focus Charting**): Data , action, response. "Focuses on one specific problem" 4. **SOAP:** Subjective data, objective data, assessment/analysis, plan. "Not used by nurses." 5. **SOAPIE:** Subjective data, objective data, assessment/analysis, plan, intervention, evaluation. "Used by nurses" **Confidentiality** - All patient information is confidential. 1. Written 2. Computerized 3. Telephone 4. Verbal 5. Fax - Protecting patient information 1. Paper charts 2. Electronic records 3. Student clinical worksheets 4. Phone conversations (nurses station / public) 5. In public places **HIPAA** - **Health Insurance Portability and Accountability Act** 1. Patients have the right to see and copy record 2. Patient have the right to request restrictions - Health information can only be released for: 1. Treatment 2. Payment 3. Routine health care operations - Violation can result in penalties 1. \$250,000 fine 2. 10 years in prison **Guidelines for\ Quality Documentation** 1. Factual (state only the facts -- no assumptions) 2. Accurate 3. Complete 4. Timely Ex: 1.pt overheard telling son that he has used cocaine in the past 24 hrs: ACCEPTABLE 2.Pt appears anxious prior to surgical procedure. NOTACCEPTABLE 3\. Pt acting inappropriate while in PT. NOT ACCEPTABLE. "Your not a pt you don't know what good behavior is" **Documenting Guidelines\ (Paper Charting)** 1. Pen 2. Date and Time 3. Mistakes in entry 4. No white-out 5. No scribbling 6. Initials ("error") 7. No blank lines 8. Signature with credentials (J. Smith SN, CSN) **Initial Nursing Assessment** 1. Thorough and complete 2. Provides baseline 3. Sample narrative note for initial assessment (next slide) **Reporting** - ISBARR: 1. Situation-Background-Assessment-Recommendation 2. Gather all data before calling physician - Verbal Orders 1. R.B.V. 2. Read-Back-Verified Incident Reports: file when something happens that isn't expected to happen/ not part of pt med records. **Incident Reports -- Common Situations** - Medication errors - Complications from treatment/procedure - Failure to report change in condition - Falls - Break in aseptic technique - Patient refuses treatment Aims of Patient Education - Influence patient behavior to: 1. Promote health 2. Prevent illness/injury 3. Restore health 4. Facilitate coping - Help patient and family develop self-care abilities 1. Knowledge 2. Skills 3. Attitudes **Learning Domains** 1. Cognitive: knowledge 2. Psychomotor: skills 3. Affective: attitude **Factors Affecting Patient Learning** 1. Age 2. Health Issues 3. Support and Resources 4. Culture and Language 5. Literacy **Teaching-Learning Process\ (similar to Nursing Process)** 1. Assess (motivation, literacy, resources, etc.) 2. Identify actual learning needs (Analysis) 3. Develop (Planning) 4. Implement Teaching Plan 5. Evaluate the Learning **Assess** - What resources are available the patient? - What is the patient's learning readiness? - What is their motivation / health beliefs ? - Any language barriers? - Any cultural practices/beliefs? **Develop (Planniing)** - Contractual Agreement (Mutual Agreement) - Learning Outcomes: - Teaching Strategies: **Teaching Strategies** - Lecture - Discussion - Group Discussion - Demonstration/Return Demonstration - Discovery - Role Play - Printed/Audio-Visual Material **Planning Considerations** - Scheduling - Time Constraints - Group versus Individual Teaching - Formal versus Informal Teaching **Evaluate the Learning** - Cognitive - Psychomotor - Affective