Minimizing Immobility Complications in Patients PDF

Welcome, everybody, to our next lab lecture, which is minimizing complications due to immobility. This is most interesting, an area because we're getting into the more complex patients, and we need to start implementing and looking at all our previous concepts and how they will impact the patient in...

Welcome, everybody, to our next lab lecture, which is minimizing complications due to immobility. This is most interesting, an area because we're getting into the more complex patients, and we need to start implementing and looking at all our previous concepts and how they will impact the patient in this area. So, to begin, we're looking at learning outcomes, such as applying clinical reasoning and judgment to patients, exemplar related to immobility, identify complications that might arise due to immobility, discuss interventions that may reduce complications, and there are quite a number of interventions, and so I'm going to be just talking about a few. And in fact, you might have seen quite a few out in your clinical area already. And so we're going to address some of them. So the definition of immobility, according to, in your Gregory text, is Kostiak and Arvidson, is inability to move apart or all of the body to some degree. And so, you likely have already encountered patients who have some form or degree of immobility. Another concept that is highly interrelated is the activity intolerance. And so, it's an important concept to keep in mind. And the definition is that it's the amount and type of exercise or work that a person can perform without undue exertion or possible injury. So, it is important to assess the patient's activity intolerance or tolerance. And for some, activity tolerance may be very, very low. And even simple tasks may be difficult, such as eating or sitting up. And this may be, be on their way to recovery but in the meantime their activity tolerance is very low. It could be due to, as I mentioned, something going on such as a disease state. It could be due also fluctuate due to fatigue, mood, other things can impact it. So just to name a few. So mobility is on a continuum. So if you look at that and you were in your concept, you have already addressed this. So complete mobility to complete immobility. So your patients might be somewhere along the spectrum and it could also change depending on how they feel day-to-day or during the day. The causes are many and varied and some include Vyjos and McCutcheon talk about four general categories and they could be postural abnormalities. So these could be due to skeletal issues for example, such as osteoporosis, there could be kyphosis, something might be impacting them in this area. There could be impaired muscle development or impairment of the muscle. And And we're going to talk more about impairment of the muscle as we go along related to complications. And this could be, for example, muscular dystrophy, change to the CNS, so there could be or damage to the CNS. So that could be, for example, a cerebral vascular incident, such as a stroke. And one of the ones that also needs to be mentioned is trauma. So for example a motor vehicle collision and the patient has trauma related to their structure and they are immobilized or immobile. So one of the things we also should talk about is the concept or the intervention of bedrest and it's an intervention that restricts patients to bed for this therapeutic reasons. So, it could be temporary, and in often cases, it is not as used as often as it used to be. We know the value of mobility and moving the patient, and so it is not taken lightly. It's used to reduce physical activity and oxygen demands, to reduce pain, possibly, promote safety, patient recovering from anesthetic, they are not conscious enough to be able to move and so that brings to mind other patients who are unconscious, they are likely on bed rest and to encourage rest. So in some situations there might be a need for rest so that they can recover well. We also McCutcheon talk about muscle deconditioning and this will be something that we need to look at muscle deconditioning in due to the lack of activity can can be quite impacted when you're a person is not able to move. So, the person might not be on, maybe due to a number of reasons, might be immobile. And as such, reconditioning might be occurring. In fact, they talk about that physical, you can lose muscle strength up to 3% a day on bedrest. And this is for the average person height and weight without chronic illness regardless of age. So that's pretty significant and something that we would want to avoid. And so this is why it's so important we look at this area. So some of our patients though are immobile and may not be coming back from that. And so, knowing that, what do we know about what we have to do to decrease their risks from deconditioning? And even patients who might be temporarily immobile, we need to think about those as well. And they come under the systems of metabolic, respiratory, circulatory, intergumentary, so skin, MSK and GI. And so if you're looking at that, what other system do you think might be affected by immobility and deconditioning? So I'm thinking of your psychosocial and feelings of loss due to decreased independence and isolation as well as possible role change. So, think of how this might impact the patient might be far reaching. For example, they might not be able to work in their usual job, they might not be able to care for their children in their usual way. There can be any number of changes that might be highly impacting the patient. It also may, for example, a younger patient or a child, it can affect their developmental abilities. So they might not meet their developmental milestones in walking or other areas if they are immobile and even for a period of time. So we want to talk about strategies to reduce complications. So, frequent assessments, these patients are at high risk for a lot of things, so we need to prevent any of these things from occurring. So range of motion exercises and physiotherapy to address some of the activities that are impacted such as a respiratory and MSK positioning, highly important. patients may or may not be able to position themselves and nutrition. So this is going to also be impacted and we will have to address implementation strategies to address that. Skin care, so our patients' integumentary system is impacted so we need to implement areas for skin care. Use of equipment, so we're going to be using a lot of equipment and strategies to decrease any kind of defects, such as joint complications. And in this care, patient of this nature, we will need the entire team involved due to the complexity and the risks. So I'm not going to go over frequent assessments except to talk about them in relation to the implementation strategies. The first one I'm going to talk about is range of motion and it is clearly laid out in your Gregory text pages 894 to 896 and the exercises and the way you move the joint is laid out and you will have an opportunity to practice these exercises in lab this week. These exercises will be very familiar to you from your nursing 125 class and your MSK assessment so you will be able to see how you need to move the joint. Of course always whenever you're doing any kind of movement you never take it past the point of past the stretch or past the area of immobility that they can't go further than any kind of pain. So we're just bringing it to that motion. The reason we're doing this is immobility can lead to fluid stasis and shortening of the muscles, resulting in limited movement of the joint which impacts mobility and comfort and can be quite painful if the joint is inflexible. Flexibility of one's joints may decrease with age due to injury and certain diseases. So it already might be there. In addition, if the patient is immobile, they are at further risk. So there's two types. There is reactive. And so that is when the patient is doing it themselves. and you as the nurse your role might be just to encourage them to do the exercise or even to guide them in the exercise and then passive which is when the nurse or another member of the team such as physiotherapy might be doing it on the patient themselves. In this form you can see in this picture the patient is having their elbows supported and their joints supported while the nurse is likely flexing and extending the arm. So you support the joint while you're taking the patient through this movement. It also is important that the exercises fit the patient's situation. So it will be part of the team approach, so physical therapy will be involved and guide in terms of anyone's that might be contraindicated for the patient. And what the hope is, is that it will avoid such complications as joint contractures, which are quite devastating and can be either temporary or permanent. And that would be very problematic for the patient because they would not be able to it back to their previous function. So what happens is with disuse, atrophy, and shortening of the muscle fibers, a joint contracture can occur. And so we want to make sure that that doesn't, that the joint maintains its flexibility and movement so that this does not happen. and one that can be quite devastating for a patient is if a patient has foot drop and so that's permanently fixed in a plantar flexion position and so that the patient cannot dorsiflex and move their foot up and this will in fact highly affect their mobility and it can occur due to prolonged bed rest without splinting. So the patient's foot is kept in this position and they have then a difficulty moving their foot back up. So the other one that's highly important is positioning. And so you will have a chance to talk about positioning and practice positioning in your lab class this week. It is with patients who are in who are bed rest or immobile in bed you need to change their position every two hours if they're not able to do so and even if they are able to do so it's really important you explain to them why they should change their position because they might have a great favorite position that they want to always rest on. The body part should be aligned and joints in neutral position to avoid strain. Foams and rolls and cushions may be used or pillows to assist with the positioning. So for example, you can see in the side lying position, there is a pillow between the patients or supporting the upper leg and also the arm. And one also has to consider in this position the shoulder and the head. There are several positions that can be implemented, and these are just naming a few, such as the prone. And the prone is not often used, but it might be used to offload any kind of issues that are occurring on the back, such as any kind of pressure sores or injuries, a sideline, the supine position, and the sims. As well, to support this is also changing the bed position. So for example, we talked about the fowlers and semi- fowlers position, and they're outlined in your textbook, so be sure to look at those to see how you can use the bed to support the changing position. Equipment is a big intervention as well and may be ordered by the physician, the physiotherapist, occupational therapist. It has to be specially determined for the patient. But we also know that because the patient's limbs and joints need to be in a neutral position, there is have walking aids, cushions for the wheelchair, transfer devices, just to name a few. In fact, you might be even using special and larger pieces of equipment such as a bed that has a mattress that offsets and slightly changes the position of the patient using air. And so this can be highly helpful for patients, particularly those who aren't able to move on their own. Another might be nutrition. So we have to really address the patient's nutritional status and needs that need to be addressed. For example, any kind of nitrogen balance we need to offset that due to that which could cause a potential for muscle loss or is occurring due to muscle loss. And if we think about our patients they may be immobile or bedridden, and they may also have a number of other conditions occurring at the same time. That may be adding to the complexity. So for example, if they have an infection, we need to make sure that the patient is adequately hydrated and nutritional needs are met to support their GI-GU function as well. Peristalsis, as you can see from the V-host and McCutcheon graph that's on your E-class site, might be diminished, so constipation might be an issue, so we have to avoid that. Appetite might decrease, so they may not just feel have the appetite they usually have, so we need to look at how we can stimulate appetite. And there may be metabolic changes. So, for example, a metabolic change might be calcium loss, increased calcium loss from the bones, which then goes into the blood system and out through the kidneys. And they could be hypercalcemic. And also, this would impact them if they are not able to expel that calcium. They might have kidney stoves. So, we need to, it's really important that you know all of the complications that occur and that you implement strategies to avoid them. The other is, we were talking about the respiratory system, and so that is also highly important for the patient in terms of interventions, and one of the interventions we mentioned before was positioning. So positioning the patient so that they can have good respiratory expansion. When you are lying in a position for a period of time, secretions can pool. So respiratory secretions and we would want to avoid that because that would create complications related to atelectasis, which is a collapse of the alveoli as well as pneumonia. So we want to make sure that that is addressed. The other things we need to think about is this cardiovascular system. So we know that orthostatic hypotension can occur, that the cardiac system has to work harder in bed, and there can be a decreased cardiac output. So we need to ensure as well that no thrombus formation. So, with our equipment, something might need to occur related to any swelling or edema in the legs, such as TED stockings, things like that. So, I've just changed the slide to skincare, and this is a huge area for any patient who is immobile. And in this image from Viho Simakuchen, you can see the pressure points that one has to watch for related to the skin. So this might be an area of where a pressure injury could occur. So these are bony prominences, and they must be assessed often. So, for example, whenever you're transitioning or moving a patient, this is an opportunity to take a look at the area such as the back or the buttocks area to see if there's anything that may be evidence of any kind of change. So evidence might be a reddened area. So when this happens, then implementation strategies need to occur. So, before we were talking about repositioning every two hours, this is already something to try to promote and protect that area because of what is happening is the skin area is being damaged by compression of the capillaries, by constant pressure on that area. So by doing so, we need to offload. So using cushions, repositioning, adequate hydration, all of those things are going to be very important and assessment as well. So I have a scenario here. This is Jasper Edwards. He is a 72-year-old male who had a stroke seven years ago affecting his right side, so he has hemiparesis. He is able to weight bear on his left leg, uses his left arm to assist with dressing and eating. He does not follow directions well due to cognitive impairment and is sometimes found in his wheelchair trying to take off his right arm shoulder splint or sling. He has dysphagia and has difficulty clearing his secretions when he coughs and it takes him some time to do so. He He is on a puree diet and requires assistance with feeding as well as reminders to drink fluids which are thickened to honey texture. He has urinary and bowel incontinence and does not signal when he has had a bowel movement. He spends a long period of time in his wheelchair as well as in bed and he requires assistance with positioning. Identify areas of priority in Mr. Edwards' care. So if you can identify some areas that you can see that are already red flags for you and that need to be addressed, please take a moment to do so. So if we look at the systems, we can see that he has a number of things going on for him. that puts him at risk due to his immobility. So for example, he has skin integrity, he's not moving much. Also, if you look at the GIGU, he's incontinent, which can impact his skin integrity. His MSK system, so he has hemiparesis. So the other is if he's not moving, he will need to have his left shoulder supported because of subluxation can occur. So for example the arm is so heavy that they can't hold it up and so they need some kind of support and this can affect the joint. joint. So having that splint in place is really important. Also noting any kind of other issues in his MSK system, so for example how well are his joints in his left side as well as to make sure that there's no contractures forming. His respiratory status, so this is really important because he does have dysphagia, what kind of things do we need to put into place for that? dysphagia, what kind of things do we need to put into place for that? His nutritional status. So with dysphagia it may be taking him longer to eat and he He has to eat foods of honey texture. He's on a textured diet. Also he might have impact with his GIGU. So is he having any issues with peristalsis, constipation, hydration? What does he need to be attended to in those areas? His transfers will be important to monitor and make sure that you're following. He will need help with his transfers and also his circulatory system. So is he having issues with any kind of swelling in his extremities strategies, and does he need any support with that? So if we look at the tool that is on eClass for this week, it looks at some of the implementation strategies or actions that we can take. Here are some that you might consider for Mr. Edwards. And so, for example, frequent repositioning and reminders to reposition. You might even use special cushions or devices to help offset and promote repositioning. Keeping the skin areas dry and clean, apply skin barriers to the perineum if needed. And we talked about this in our elimination on Hygiene Care Lab, and so those need to be put into place, so all of the aspects related to incontinence. active and passive range of motion. So what can he do? Maybe he can do some activity himself independently with some guidance on his left side, but he needs some help with his right side. Application of splints to prevent joint contractures. So if he is not moving much in bed. He does he need any support with his left and right legs? What is it that his is important? Reminders and frequent checks that he's not removing his sling. It's removed protocols are to be put into place for his transfers and safety measures. Respiratory status. Frequent respiratory assessments. Assist with removal of secretions. So if he's having difficulty removing his oral secretions and they're just pooling there, maybe we need to implement some oral suctioning. Encouraging deep breathing and coughing. So he has a weak cough. So if we can encourage him to cough when he's needed regularly throughout the day. Again, positioning will help to facilitate maximum lungs expansion. So if he is lying in bed, we need to move him so that we can offset any kind of cooling. In our oxygen lab, there's going to be more strategies discussed and more areas that can be looked at more thoroughly. Nutrition, so he likely needs help with feeding, if he can feed himself with his left arm, so he can do so independently, but maybe he needs help with setup, also monitoring his dietary intake and making sure that it's being followed. So if he needs an increase in his protein, we need to identify that and encourage that encourage fluid intake throughout the day. Maybe that will also help with any dehydration. His secretions, we don't want them to become thickened and pool. We want them to be readily able to secrete them. So making sure he doesn't become dehydrated is important. Or that he loses weight. We want to make sure that he is able to maintain a good healthy weight. Okay. GI and GU. So assess his GI and GU system daily. Monitor his input and output, his urine amount and quality. Assess the bowel activity daily for frequency and quality as well. So he is at risk for constipation. So there might the other strategies that have to be put into place for that, but for example, we also like to look at his fiber intake and see if that needs to be increased or gradually increased. But monitoring his GI and GU because we know that peristalsis might be impacted. His circulation, so frequent circulatory assessments, BP, cardiac and peripheral vascular, so we're looking at his limbs and his circulation. Application of compression stockings if needed, if he's having any issues with circulation in his lower extremities. Active and passive range of motion will also help with this and for sure. So these are some of the strategies that may be implemented and any other unique strategies may be required. So we're just going to end on a couple of questions. going to end on a couple of questions. So questions. The health care aide indicates that Mr. Edwards has a bread and dairy on his sacral area and says that they will go back later to check on the area. What should you do? should you do? Advise them report back with their findings, go and assess yourself, indicate that no one needs to reassess, ask them to massage the area to lessen the redness. So actually what you need to do is you need to go and assess yourself. You are the licensed practitioner when you become an RN, but also as a student nurse the prudent thing to do is to go and assess yourself to take a deeper look at what's going on, and then identify what strategies need to be put into place. This might be the beginning of a pressure injury. And so this needs to be reported to the team. And more deeper dive into implementation strategies needs to occur. Of course, this needs to be reassessed and looked at. And you'd never massage the area, because of when you take this area and look into it what happens is as it's starting to red and what it means is that there is injury occurring in this area so massaging it could enhance or increase the injury so we wouldn't do that in this case. Advise them to report back later. No, this is an issue that needs to be dealt with immediately So we would not advise them to report back on their findings because as the nurse you would go ahead and have to assess yourself. nurse you would go ahead and have to assess yourself. So you notice that Mr. Edwards left ankle is stiffer than usual and is in a plantar flexion position. This is a concern as it may indicate which of the following is occurring? occurring? A a foot drop, B eversion of the ankle, C inversion of the ankle, D rotation of the knee. So the correct answer if you haven't determined it already is A a foot drop. So this is where the position of the foot is now becoming in a plantar flexion position and it can be due to immobility and not splinting the patient and putting them in a neutral upright position of their foot. The issue with this is that it can have a big impact on his mobility and if we are transferring him and using his left foot to transfer, this could impact that. He could maybe be in a position where he may not be able to use that foot. So that has to be reported and this will have to be addressed. So to prevent and to decrease this complication. So we've come to the end and so my suggestion is that you go through the complications more thoroughly than I have here and look at the chapter and the implementation strategies such as the range of motion techniques and maybe even practice them before you come out to lab this week. That would be really important. really important. You can practice them on somebody else. Anyways, I hope you have a great week and I look forward to seeing you again. Take care. Greetings everybody and welcome to our lab lecture for this week. Just a little service announcement before we get started that next week will be medication administration. So it's a good time to start that process of starting those readings and those activities early and do the practice mask so that you can identify any areas that you're having challenges with and determine if you need additional help. So if you do need additional help, bring it to your lab lecturer or your instructor in the lab and they can assist you with some of the calculations. So let's get started on this topic. This is a topic called End of Life Care. It's a huge topic and I'm going to be briefly addressing it, but you can imagine that there is a lot of reading, a lot of understanding in this area that needs to occur, and I will be addressing it as best I can, but there's more to do. One of the things that's really important to do in this topic area as nurses is to really look at what are your thoughts and reflect on that. Where are your thoughts and understandings coming from? How do you feel about that? And how will you feel looking after a patient who's at their end of life? This is an opportunity to, if you're having some challenging thoughts and feelings about it, to reach out and to start working on that. Maybe it's working with a mentor or somebody who is really experience that you admire as a nurse and they can assist you with that. So as we get started, one of the things we have are our outcomes and we're going to talk about symptom assessment of a palliative care patient and the tools that might be available, goals of care, personal directives, and patient-centered care at the end of life, explore feelings and beliefs related to implementing palliative and end-of-life care. And this one is the one where I just find difficult for us to actively do when we're doing a recorded lecture. So this is where I'm going to be asking you to do that self-study. Also in lab itself there may be an opportunity to explore some of those feelings and beliefs. We're also going to look at how caring for the palliative care client or the end-of-life client impacts the caregiver, formal, informal, and family and friends. So formal caregivers for those who are the health care providers, informal are the family and friends who might be providing caregiving help to that patient. So our patient is Jen Bay, a patient on your unit, has advanced cancer and is end of life. She has been experiencing pain, has lost a great deal of weight, and has no appetite and to not wish to eat. She is coherent and orientated, but sleeps long periods. Her husband and parents are at her bedside when they are distressed regarding her symptoms of pain and appetite. So take a moment and think of what the patient's needs are at this time and also what are the family's needs at this time. How can we best support them? So for example, one of the things that we're noticing is that the family is distressed regarding her symptoms of pain and loss of appetite. So it would really be important to talk to them about what's happening with that. How are we addressing them? And what kind of pain control is she having also explaining? That loss of appetite might be a natural process at this time and that the patient feeding and Eating at this time might be diminished So we need to review the policy, or sorry, the philosophy and an approach to care, which is palliative care. And this is a broad philosophy and approach to care, and it aims to improve quality of life for patients or persons facing life-limiting illness and their families through the prevention and relief of suffering. So you can almost see that this might be an approach that we would do in many, many situations. And it extends across the trajectory of life-limiting illnesses, including the point of diagnosis during treatment and at the end of life, as well as grief and bereavement support. So, it can be at many different stages and with a focus on providing symptom control and addressing wishes and needs of the patient. So here are some other aims of this cognitive care. So we're looking at relief suffering and improved quality of living and dying. Address all these aspects of the patient such as the physical, psychological, social and spiritual needs and practice issues and their families and their associated expectations, needs and hopes and fears. Prepare persons and their families for self-determined life closure in the dying process and help manage it, and help families cope with loss and grief during the illness and bereavement experience after. Free all active issues, prevent new issues from occurring, and promote opportunities for meaningful and valuable experiences, personal and spiritual growth, and self-actualization. And this information comes from the RNAO best practice guidelines, a palliative approach to care in the last 12 months of the life. And I put the resource at the end of the PowerPoint so that you can look it up if you'd like for more information. So end-of-life care is care for persons who are expected to die in the foreseeable future and for their families. It includes helping persons and their families prepare for death, ensuring comfort and supporting decision-making that is consistent with a person's prognosis and goals of care. It's holistic, so as you can see, it addresses physical, emotional, spiritual, social and practical needs of the individuals and their families, and begins during the final active stages of dying. It continues until death and after with bereavement of the family and care of the body. With this also comes advanced care planning, a process of deliberation about future health care preferences. One engages with this about current and future health scenarios relevant to their situation, information, reflecting on their values and wishes, and communicating these with the healthcare providers and members of their family, and documenting their decisions and naming an agent in a personal directive. So for example, naming an agent in there who will provide information and also speak on their behalf when they're not able to. So, the goals of care designation, which you've already probably talked about in 220, are medical orders that describe general and sometimes specific focus of the patient's desired care approach harmonized with what is medically appropriate. So, for example, this provides the care team direction on how the patient wants to proceed. There are three general categories and seven subcategories. The highest category is resuscitative care designation, which is where you would provide full support, resuscitation, and ICU support for the patient. And then the others related to comfort care, and so the C2 would be where a care is directed at preparation for imminent death, usually within hours or days, with maximal efforts directed at symptom control. And it also interesting in this category, transfer to another facility would not occur at this time. So the patient, Jen, may have already talked about her goals of care, and now we would look at what that would mean for the family. So here's just a little chart outlining what would be appropriate in terms of goals of care in a little click-to-lookout format. So you can see that C2 includes everything. C2 includes only symptom control, whereas R1 includes all other measures. So surgery, ICU admission, symptom control, all of those areas. So let us say that Jen had a designation, and now her designation is C2, so that our focus is on, because it's of imminent death, our focus is on symptom control. So it is important that we talk about some of the tools that might be out there to use to help with identifying and looking at symptoms that the patient might be experiencing. And one of the tools that's actually used and was created by the Edmonton Palliative Care Program was the Edmonton Symptom Assessment system and it's called revised because over the years what they've done is they've gathered more research on the tool and validity and adapted it accordingly so it's called ESASR. So, this tool is used in palliative and oncology areas, and it is focused on symptoms, and it is a tool that the patient may fill out themselves, or they may be receiving assistance to fill it out. but it's preferred that they rate themselves at that time, and it provides a capture of that moment for them. So how are they feeling on these areas? And it includes, and where the goal is that they want to be at. The rating is on a scale of zero to 10 on how they feel at the moment of completing the scale. So 10 would be the worst possible rating and how they are feeling. So the symptoms include pain, tiredness, so lack of energy, browsiness, so feeling sleepy, nausea, appetite, shortness of breath, so feeling very dyspaniac, not able to capture their breath, depression, so it's feeling sad, anxiety, feeling nervous, best well-being, and other problems. So there's a category there for other. So we've identified nine symptoms, but the tenth, the other problem is the tenth symptom. Here are some tools that are used. So the ESASR, as you can see the patient might circle a score and then it can be transcribed by the nurse onto this graphic record so that trends can be identified. So where are they at and how is it occurring? So if the goal is that they will be at no pain or one to two, we can see if they are staying within that format during the Now, it depends on the site and the location for the patient. So if they're an oncology patient who is coming in on an outpatient basis, they might be filling this out when they arrive at the clinic. Or if they're on an inpatient hospital unit, maybe it will be done every day. It depends on what the needs are of the patient and the policies of the site. Another tool that might be helpful at this time, as we know spirituality is an important part of the patient's being, and this is a spirituality, spiritual history tool called FICA. It is a way to organize the questions that we might ask the patient, and so it goes from F, which is faith, belief, and meaning, I, importance and influence, C is community, and A, address, action, and care. and A, address, action, and care. So if you were to take a few moments, what kind of questions would you ask under each of these categories? What would be, how would you frame those questions? So if you'd like to pause the video at this moment and write a few down to see what would be helpful, that would be ideal. So I have looked at the guide just to get a sense of how we could frame the questions. And so for AF, what we're trying to capture is what kind of faith do they have? What kind of things do they believe in? And what brings some meaning? So a question could be, do you consider yourself a spiritual person? Do you have spiritual practices and beliefs? And what gives your life meaning? So the patient might identify themselves as being not religious, but being very spiritual, and that certain things might give themselves meaning in their experiences. What importance for I does spirituality have and influence does it have in their life? So has it influenced how you take care of yourself? Does it impact your decisions? So basically, what kind of things are they believing in? So basically, what kind of things are they believing in? Community. Who is, oh, who are you connected to? So it might be a spiritual community, or it might be more of an informal group. And who do you rely on for support? A address, action, and care. So this would be, what would you like the health care team to address or support you in at this time? So, are there spiritual practices that you would like included in your care? And these, like I said, don't have to be formal religious practices. They might be meaningful to the person, such as, I would like to spend some time outdoors. I would like to make sure that I have access to my friends and family whenever I want. These might be some of their wishes, so it's really important we hear those so that we can help support them and enact them. So it's important that we as nurses are able to assess the patient and determine what's going on for them. And one of the things that we need to start looking for are any signs of approaching death or what we would call imminent death. and so I'm talking about an expected death here as you know with unexpected there are different ways to address that and it would be in a different way this are these are expected deaths and relate to the goals of care so this would be for example less interest in eating and drinking and this can be quite distressing for the family because they always think of eating and drinking as life and also comfort and so when they start to see the family member pull away from that they can see that if they don't eat or drink that things are sliding and becoming more difficult for the patient and they're worried about that. Decreased urinary output and this could be because the system is starting to fail or it could be because they're eating and drinking less. They will sleep or they may sleep more often and begin to detach from their environment. They may even become confused and restless because of oxygen demands or something going on, less circulation. This can be very distressing for the family and so we need to explain to them what's going on and there are in this what we're also doing is looking at medications that might help or lessen these issues. Decreased vision and hearing, difficulty with speech, and also it's important to let the family know that when they're talking it's important to keep talking to them, the patient might not be able to respond to them, maybe their only response is a movement or a hand grip, but it let them know that you're there and let them know that you care. Secretions in the throat may accumulate. So this is where it also can be very distressing for those around the patient because they see this as being very uncomfortable and distressing to the patient. It looks like they're struggling. And so this is something we need to talk about with the family. and also there's medications that can be given to decrease those secretions. Irregular breathing may occur with periods of no breathing, so chined stokes, ******* may be occurring and it may become longer. The periods of no breathing may increase. There may be difficulty with temp control, so the patient might be feeling hot or cold. So cold you may also notice that the limbs appear modeled and what we mean by modeled is they take on a bluish tone and they're especially in the dependent areas because of decreased circulation and pooling in these areas. Interestingly from Pooler and Olson they also may tell you they see something or someone and around time of death they may experience incontinence and so this is why it's important to have good padding on the bed and incontinence products. So letting the families know as they go along what to expect is really important. Sorry I turned it on to the other tools. The other is the white rose program so you might have already seen that. It's a program in Alberta Health Services where a white rose is posted on the door and it usually comes with a family as well. And this white rose signifies that somebody is in the course of passing and it's a show of respect by reminding everybody that the environment around should be calm and quiet and to respect the wishes of the family. You need to explain this to the family before you post this and obtain permission. So some families might not want others to know what's going on with their family member and they may not want this in their on their door. So it's always important as part of your care to support the family members. We know from our module that caring for a family member can be emotionally, physically and economically and spiritually exhausting. So we need to really watch out for them at this time, find out how they're doing. Important for the nurse to provide empathy and support as they are caring for their loved ones all through the palliative process and also through the grieving and feeling of impending loss. So there may be a feeling of impending loss and of course bereavement and loss after the passing. It is also important to educate families regarding the type of symptoms the client may experience and the type of care that is necessary necessary to meet them at that time. So for example one of the concerns the family may have is pain control even when the patient is not able to acknowledge or mention it at a time of imminent death and so you can assure them of what kind of pain control measures are being in place. So as mentioned there's a lot of things that we too find difficult and so it's an important time to remain calm and try to do our best. And according to the care of the family preparing to talk with families before and during the after death document, they talk about some communication techniques and things to be mindful of. And so ground yourself first, cultivate presence of mind, create an emotional space for grief, so ensuring that the patients and the families needs and grief can have that space, activate your listening skills, know what to say and what not to say. So this is not a time for platitudes such as they're in a better place, they're not having no pain but rather acknowledging their concerns with empathy and kindness and for example even maybe I'm so sorry to for your loss what to do related to responding to grief so listening to the family member and if the family member is wishing additional supports so other members of the team ensure they're there such as pastoral care. they're there such as pastoral care. So upon death the nurse may be the one pronouncing the death so there's AHS and CRNA policies related to this and there is a format for doing so. So prior to the death it would be determined and you'd know whether or not you are allowed to do this. And one of the things that we know is that it has to be an expected death in order for an RN to go ahead and do that, whereas an NP can pronounce an unexpected death as well. And also, what is the policy on your unit and area? on your unit and area? You will also, after, when you pronounce the death, according to the policy, what you do to, in order to pronounce to death, you need to do a physical exam on the patient. So you need to, for example, feel the carotid pulse, take an apical beat and determine that there is no, verify that there is no pulse or heartbeat. Then you look at respirations, for example. And so depending on what the policy also is of your areas, what other things do you need to do? So you need to make sure you document At the time as well, what time you pronounce death, who was there, what kind of symptoms you determined to verify the death, and what kind of needs of the patients and family are occurring at that time. So there might be special care strategies that have to happen based on their culture or religious beliefs that need to occur such as specific actions. You also will, depending on, take care of the patient's body, so provide post-mortem care. So this might be taking out any lines, washing the body, making it presentable, and preparing it to go down to the morgue. but prior to that you make it presentable for the family so they can view if more family members are coming to say their goodbyes. You give them enough time in order to do that. You also provide care and support to the family so find out how they're doing. If there's a family member that is on their own or appears to be struggling, what kind of support do they need? Do they need other people at their side, or do they need help getting home? So these are highly important. We also need to keep in mind, and this is another area for care of after death, of patients who are an unexpected death. So there's a specific protocol for that, and that would mean if it's a notifiable death, and you need to look at the list for no notifiable deaths, and so those are all unexpected and that would be what they mean by notifiable is that it go the medical examiner has to be contacted and also the person who pronounces the patient is the most responsible health care provider so that would be the physician or the nurse practitioner and there's a long list of what is required in terms of who are notifiable, what kind of patients are under that category. And so that would be anybody in occupation who's died within doing their occupation, anybody in a correctional facility, unexplained or unexpected death. So that could occur on your unit. Somebody who's had surgery in the last 10 days or has undergone anesthesia. Also for example somebody who has had improper or negligent treatment by any person or is a result of trauma, accident, suicide or poisoning. And so it's important, I'm not naming them all, but it's important that you kind of get a sense of that and so review and find out what that entails. So like I said if a patient is unexpected and has you have to notify your medical most responsible medical health professional that would be part of your care. There's also a protocol for calling the next of kin so that If it's an expected death, of course, that might be the nurse's role as well. So for you as a nurse, it's going to be important that you examine your own attitudes and feelings regarding death, dying, and loss, and respond to yourself with empathy and compassion. We need to know that also we invest a lot of emotions and energy into these persons that we're caring for, and sometimes we will feel a loss as well. and so it can be challenging. Develop self-care strategies to protect against compassion fatigue and create a work environment that will lead to compassion satisfaction. So for example what kind of strategies are in place at your work environment or that you've seen or need to be in place such as bereavement debrief. So is there something that we need to do and come together as a team in order to talk about how we're feeling, what we're feeling and how and maybe if we're struggling. we're struggling. Identify a mentor whose work you admire and you can share ideas and learn from. So how do they cope with this? What kind of strategies do they do? And how do they keep that compassion satisfaction going in their life? And how do they keep that compassion satisfaction going in their life? Find a balance between work and play. So this is really important to find that balance and avoid the burnout. So take time to relax and enjoy and reflect what is important for you and who. important for you and who. So we're at the end of the lecture so I'd like you to forward any questions my way and have a good week and please if you have anything that you'd like to chat about bring them forward because it is such an important topic. Thank you very much. Goodbye. Welcome everybody to our last two weeks, and I've merged the PowerPoint together as well as our discussion. So you can take your time taking a look at the scenarios that we have included here, and possibly even identify a few other learning activities that you would like to take the time to learn, and use this time to do so. Basically, we're talking about clinical judgment, and I know that you have an opportunity to talk about clinical judgment and critical thinking in other classes, such as your lecture classes in 220. I'm going to be talking about it as it applies to your clinical skills as well. and so it's always good to reinforce these things and have more discussion. So the conversation today will we will discuss appropriate clinical decision decision-making in relation to some scenarios that I've created. We're going to talk about some of the definitions and also the process and rationale for describe nursing interventions and expected outcomes related to clinical decision making. So this is one of the steps in clinical decision making, and so we won't get into a lot of detail with that. You have been overseeing and reviewing a lot of nursing interventions over the past 12 weeks, and so this is part of that. So what comes into play? So, if we're looking at the last 12 weeks, we have quite a number of topic areas that we have attended to throughout the weeks, and so all of these have built up your knowledge base. So, it's important that you review this information, especially as you move on to your next clinical placement in 225 so that you can really build up those skills in terms of drawing upon them for your and developing your clinical judgment. In order to talk about clinical judgment what we're going to talk about too is critical thinking. It's a complex phenomenon that can be defined as a knowledge and reasoning to make accurate clinical judgments and decisions. It requires purposeful and reflective reasoning to examine ideas, assumptions, beliefs and principles and conclusions and actions within the context of the situation. And the use of evidence informed knowledge makes for an informed critical thinker and improves patient outcomes. And so ultimately, what we want are improved patient outcomes and good clinical judgment. It not only requires cognitive skills, but also the nurse's habit and disposition to ask questions, be informed, honesty and facing personal biases, and be willing to be open and think differently about an issue. So these are important critical thinking skills. When a patient develops a new set of symptoms, asks you to provide comfort measures or requires a procedure, it is important to think critically and make prudent clinical judgments so that the patient receives or receives the best nursing care possible. So this is about quality nursing care and safe nursing care that we provide. One thing that we also know, and I'm just going to stop before I talk about clinical judgment and the definitions provided, is in one of the articles by Connor, the concept analysis, they talk about how it can be blurry in terms of what we're talking about in relation to clinical reasoning, clinical critical thinking, certain definitions. And so, what often is, is that some of those relate to the process of thinking. And then here, the, the definition, if I may point it out, talks more about a response. So for the first one from Tanner is an interpretation or conclusion about a patient's needs, concerns, concerns or health problems and or decision to take action or not, use or modify approaches or improve ones, new ones as deemed appropriate by the patient's response. So this is what she has included in her 2006 article. In Conner's article, Conner et al., they have done a concept analysis on clinical judgment and have determined the definition in their article as, clinical judgment is a reflective and reasoning process that draws upon all available data, is informed by an extensive knowledge base and results in the formation of a clinical conclusion. So that's how they have defined it. So in what we know is that Tanner has developed a clinical judgment model and describes clinical decision making as judgment that includes critical and reflective thinking and action and the application of scientific and practical knowledge. So in her model she includes four components and so basically four areas that need to be included and one of them is noticing or grasping the situation. The next one is interpreting or developing sufficient understanding of the situation to respond and then the third one is responding or deciding on which action to take and the fourth one is reflecting on or reviewing the actions taken and their outcomes. In this another model and this one is by Caputi, she incorporates the Tanner's model in her model and she has broken it down even further into making it more practical for students to really hone in on how to develop their clinical judgment and so she's included some elements such as questions. For example, noticing is about gathering data and asking the question, what do I notice? What do I need to know? Interpreting is making sense of the information. So this is the analysis. So where do I or what am I starting to see? What does the information mean? Responding is about taking action. What will I do? What are my priorities? So this is an important piece of this model is what is the priorities to carry out the planned activities as well. Reflecting evaluation and learning. What was the effect of what I did and at the end of my thinking? How did the outcome turn out? What would I have done differently? So I want to come back to the concept of priority setting. This is an important one because as we develop and identify more complexity in these situations, what we need to be able to do is identify what is the priority at this time and how do I respond to that priority. So here's a noticing. So, the documentation example, at 0800, a patient stated he is feeling very nauseous. 500 milligrams of daminohydrinate given PO by R. Stilson, RN. What are you noticing regarding the quality of the documentation? What are you noticing about the nurse's clinical judgment? So if you can take a moment to stop the video and take a second and write a few things down. So we're going to return and so what you might be noticing in terms of this situation is she's outlining what she did in terms of documentation. So I'm going to start with that. So she's writing at 1400 hours but she's documenting about something that happened at 0800. So that's kind of giving me a reason for pause. So I'm wondering about what's going on here. The patient stated he is feeling nauseous, very nauseous, and then how the nurse responded was to provide 50 milligrams of diaminahydronate given PO. So there's some concerns here and we kind of alluded to that in our previous medication and our other labs related to the identification of making sure that the right med for the right reason at the right time and if the patient is nauseous maybe of course they probably need something to relieve that nausea but is this what I'm not seeing here in the documentation is further information So I'm not feeling that I'm having any other symptom assessment as well. I'm wondering what jumps out at me is that there was something given PO for a person who's feeling very nauseous. So this kind of says to me, would this work? So are they going to throw it up? So, I would have liked to have seen more information, especially around the symptom assessment. I'd also wondered whether or not a different route would have been more appropriate for this patient. And then the other thing I would have liked to have seen in this documentation is information about how the patient responded and what else the nurse did. So this is very succinct and very does not include or is not would not meet the the principle of complete and also may not be the best clinical judgment. So this is what how we can notice that. So one of the things and you're probably you've noticed this model before. This model was presented in your assignment, your writing assignment, this term, and it is the clinical judgment measurement model and it is related to the NCLEX. This is about, this is presented here today so that you can see this type of model. It is used as a way to break down the steps. It has been identified and you can see how the nursing process is indicated here and noticed underneath. But it also includes similar processes that we just talked about in the other two models such as recognizing cues, analyzing the cues, forming a hypothesis, refining your hypothesis, generating solutions, taking action, and evaluating outcomes. Now the one interesting thing about this model is that it's actually a model used in the NCLEX, so the National Boards of Nursing exam, which also is an exam that you will be doing at the end of your BSCN program. And what they have done is they have indicated that they really are concerned about how nurses are making clinical decisions or judgments. And so they've broken down the steps to see at what level the nurse is in the exam and if they are indeed able to make sound decisions. So this is why they've created this model or this is an outcome of those conversations at the national level and then what they did is they broke down the steps. So it was very interesting because in addition this is something that Kapudi has also discussed and has been involved with in relation to thinking about the steps. So one of the things they know is that it's really important that nursing students be aware of these steps, that they practice the steps, and they build on this so that they become really good in terms of clinical thinking, clinical judgment, and areas that you can follow up on if you want to know more about the NCLEX exam and some areas that might be something that you'd like to practice on. Sometimes it's always helpful to have an understanding of this as you get into further further studies you will then you know that when we are developing exams for our program we are writing them in in the form of NCLEX questions so an application is the level that we are trying to get you to because that That is the level that, at least at that level, they will be at your exam time. And so, practicing the types of questions that they present are really helpful for you, but also gaining that understanding of what this is all about and what is clinical judgment and some of the frameworks that they have that they are including in that. And why is this important to my nursing practice? It's not just about the NCLEX though. This is about you being a strong practitioner and gaining that experience so that when you are practicing you can provide those sound judgments. So the rest of the video we'll be talking about certain aspects of these using the Kaputi format in relation to this. So I'm just presenting a scenario on Jack and you were doing your head to toe assessment on Jack, an 87 year old in your care, and he says he's having difficulty voiding. When asked he says that he is having a pain when urinating and his flow is a dremel and he feels like he is having to go all the time. He has noticed this since last night. We've got the vital signs there. We also have done a physical assessment on him, and you can see the results of the physical assessment. He has vowel sounds in all four quadrants, his bladder appears distended, and on very light palpation, he complains of discomfort over the symphysis pubis area. Dullness is heard over this area on percussion. So, take a moment and try to answer some of these questions that you have on your screen. So what I have done is I've yellowed out the noticing part. What is jumping out at you? So you have already taken health assessment. And also, you've taken elimination. And you know that these are unusual findings. So these are things that are jumping out to you. so he's having difficulty voiding, he's having pain when urinating, his flow is the dribble, and he feels like he is having to go all the time. He has noticed this since last night. The other things we're noticing in his vital signs, which may or may not be irrelevant, or relevant, is his pulse is slightly irregular. He also has a slightly higher than normal blood pressure, so that is important to notice. And he is blatter, of course, we've noticed here his physical assessment findings that we discussed before. his physical assessment findings that we discussed before. So what do I need to know? So when we're looking at this, we identified the things that are jumping out at us, or the areas of concern, and now we need to know some other things. So for example, what is his previous history and what other symptoms might he be having? So his previous history I would like to know in relation to his pulse. So what is this regular finding for him? Is this something that he has had for a while? Also what is his usual blood pressure? And in terms of this we also know that he has noticed this since last night, but one of the questions I'd want to know is, has he ever had this before? Or what is his history related to any kind of urinary issue? Has he had a history of this? What does this information mean? So this is what we want to find out. What does this mean? And so So in this, his bladder is full, his inability to urinate due to possible blockage. So this is an urgent priority that we need to respond to. And some of the things that we might be having to carry out to inform or gather more information is maybe a bladder scan or the other interventions might be to encourage him to try other measures to encourage urination. So, for example, maybe he needs to sit on the void on the toilet and take his time to see if he can relieve the pressure on his bladder. Is there anything else that would work for him? I would suggest an SBAR to his most responsible health care provider to let them know that you have some concerns and that this is an issue right now. And then, if, for example, they carry out the planned activities, when you, the most responsible healthcare provider came to see the patient, maybe catheterization was attempted, but maybe it was still blocked, or it was unsuccessful, and maybe urology had to be contacted for an urgent assessment. The blockage might have been confirmed and they then had to do a specialized catheterization on him with further testing to be done on his situation. So what is our reflecting on this situation? So after all is said and done, hopefully with this catheterization completed, urology involved, this and further testing will be done. When we were looking at this, we have attended to his urgent need and hopefully with a very good and positive outcome. What we also wanna talk about in our reflections is our actions. So did our actions fulfill what we needed to do? Was there anything we should have done differently? Was there something that was maybe missed that we could have included in our practice? How did we feel about this too? What were our concerns? concerns? Were we worried about anything? And what were we worried about the patients? So this might be also something we need to talk about in our reflections related to our emotional. So these are just a peek just an example of Jack. So let's go on to another one. So this is Miss Cook. Miss Cook is a 72 year old female who has advanced dementia and is unable to speak other than state occasional words. She has bladder and bowel incontinence and is immobile spending long periods of time in her wheelchair. On changing her incontinence brief first thing this morning you notice that she has excoriated red skin on her right decubitus area. What I should have said here is right hip area that's incorrect there. When cleansing the area she became very agitated. So take a moment and stop the video and answer the following questions. and answer the following questions. So coming back to this, what we are going to notice, sorry, is that she has a problem area or excoriated red and skin over her right hip. And based on our knowledge, we know that this is an in to us in to indicate potential pressure injury. And so we need to treat it and get help on and attend to this as soon as possible. So what is jumping out at you in relation to that. So some of the risks that we noticed as well is that the patient had advanced dementia and is unable to communicate her needs incontinent in mobile and sitting for long periods and of course as a result is at risk for many things such as skin breakdown so it appears that we are having an issue with skin breakdown over her right hip so what do you need to know for example the patient's history? What other areas might be involved as well? So does she have a history of pressure injuries or skin breakdown? What is the nature of her skin? her skin? Is it usually a issue quite underweight? Are there other risk factors that are putting her at risk? What kind of things can we do? Is there, for example, should we be doing maybe a further assessment somewhere? What does this information mean? This means that there is potential or there is actual pressure injury. So we need to have this treated. How are we going to respond? We need to communicate to the team and the most responsible healthcare provider involved in her care. We need to do some measures to prevent, to decrease and begin healing so that the skin integrity can be maintained and begin healing. But also we need to make sure we're doing measures to prevent any other areas from breaking down. So, for example, ensure offloading of the pressure injury area, so making sure that she's not putting any more pressure on that area, keeping area dry and clean. So because of her incontinence, we need to make sure that her brief is changed often and that is maybe we need to put some kind of skin lotion such as a berry or cream to prevent prevent skin breakdown. Is there any additional activities that we need to do? So for example does this warrant some kind of dressing that needs to be put on? I know I'm not going to get into detail about dressings here because you're going to be taking that in your next course in 225 with pressure injuries, but just know that there are a multitude of dressings that might be that one can apply for breakdowns in skin integrity and this might be warranted. So carry out the plant activities, so basically there's a lot of activities that might need to be done and some are not even included here. So for example, one of the things is looking at her nutritional status and her hydration, anything else that might boost her in terms of making her less vulnerable to any kind of skin integrity issue. So reflecting, so review of the events, what was the outcome? So the outcome hopefully will be that we are preventing any kind of further breakdown but also any kind of further not only in that area but in other areas that we are turning the situation around for for her and that she's on the way to healing this. So that is just one of the reflecting activities or questions that might be done. So here's a medication admin question and this one relates to just kind of a critical thinking question based on medication admin that we took two weeks ago and for example this is one related to a physician ordered a mild sedative for an anxious patient who is scheduled for a sigmoidoscopy in the morning. The order reads diazepam five milligrams orally at six o'clock times one dose. Identify a potential problem with the way it is written and then also what are your steps. So if we were to take those steps that we had talked about before, how is your response going to be? What is your action? So I'm going to get you to stop the video so that you can take a look at this and see what you can do for this. So if we look at this we have diazepam 5 milligrams given orally at 6 o'clock times one dose. So the issue here is if it is ordered we know that the patient is going in the morning. So is this, do they mean 6 o'clock at night or do they mean 0600 in the morning? So this verification has to be identified, otherwise we could have a potential medication error. So the response that you're going to do is, and the action you're going to take, is to clarify the order. And in doing so, you can then create a safe situation for your patient and clarity regarding the patient's care. So, you have done the action, you've contacted the person who's ordered the medication. And indeed, this is actually four, six o'clock in the morning, so it should read accordingly. And so, we have caught what could potentially be a near miss. This could be a near miss in terms of what if it was given at 1800 hours at night. So it's important that we're using our clinical judgement at all times in all situations. And this is an important one because you've already gotten some of this clinical judgement. You have gotten the information about the rights of medication in men and also what to do if you see something that doesn't meet the standards that you have or is not clear. So you have those steps in place. Here is another one that we can look at and this is Mr. James. Mr. James has been on oxygen at four liters via nasal cannula for the past 48 hours since returning from surgery. You take his vital signs and his temp, and you notice it's 37.4, his pulse is 86 and regular, his respirations are 18 and regular, his SPO2 is 98, his VP is 124 over 86, and the graphic records indicate that his SPO2 has been between 96 and 98 for the past 24 hours. He states he's feeling well and is using his spirometer hourly and doing his deep breathing and coughing exercises regularly with a non-productive cough. No adventitious sounds heard bilaterally. heard bilaterally. You refer back and you notice that the physician's order indicate oxygen to maintain spO2 above 94%. So what do you notice? So what do you notice? Take a and stop the video and answer the following questions. So in this situation, and I'm just going to see if I have, no I haven't, in this situation what you have noticed is that the vital signs seem to be very stable. The SPO2 is very good. He's had a very good SPO2 over the last 24 hours and And he seems to be doing very well in terms of his exercises and also his lung health. So what does that mean and what else do I need to know? So is there anything else that you need to know about his situation? Maybe there is. What makes sense here? What is your priorities? Well, one of the priorities is you may have noticed that the physician's order is for an SVO2 of above 94%, and he has been doing very well over 94% with his oxygen. And maybe the action that we might be able to take right now is to titrate him down. And so this might have started, maybe one could say we've noticed this and maybe it should have started a little while ago. But we can start it now. So remembering your titration sheet from Alberta Health Services, you're going to use that to inform your practice. And so what it says is that you're going to decrease it by one liter every hour and see how he does. Yes, so decrease it to three, see how he does if he's able to maintain his SPO2, and then decrease it to two, three, two, one, and then off. And so the other thing that you're going to do in that titration is, and some of the things you need to know, is what's his history in terms of oxygen consumption? What other healthcare situation, health issues does he have? and that might be complicated or complicating the situation. So when you carry out the plans, let's say they go ahead very well, and he is now off his oxygen and not requiring it, and he's even able to maintain his SpO2 saturation when he is up and walking and going to the washroom. and so he seems to be well on the way to recovery. So what is your reflection and evaluation of the situation? One of the things you might reflect upon and in this situation is and it may be prudent to do so is could this has been addressed earlier? So how did this, what might've been missed? What were your, were your actions effective, what, you know, this might be also a conversation to have with a team in terms of what you noticed. And maybe we need to look at this in future. And also how is his patient care. So this is one of the ways to reflect on this in terms of did I, did you do what you needed to do and was it the right actions to take. So we have Mr. Holiday. You enter Mr. Holiday's room to see how much he has eaten for lunch and see him struggling with his breathing. His face is ruber in color, so remember that is kind of like that reddish, bluish color. His hands are clutching at his throat. He is making sounds but unable to state words when you ask him if he can breathe. So this is in terms of priorities, this is an urgent priority, this is an emergency, and so what your urgent priority is, is to get him to be breathing. So he needs air entry. So it looks like he has airy with blockage, maybe he has aspirated something and he needs immediate attention. So what do you notice? You noticed all those signs and symptoms and what you need to do, what does this mean? It means he's in severe trouble. Your priority now is to get help and get him breathing. So then you're going to go and take action. So this would be when you're going to go behind him and do the Heimlich maneuver. So begin starting the Heimlich maneuver and of course why just before you did that you hit the emergency response button in the area. So go ahead and you hopefully see him respond to the Heimlich and discharge the object that he had choked on and then he is able to breeze well. Your team has come to your aid and they have already called the doctor to come and examine him to see how he's doing. So this might be one response to this situation. Another is that you might have tried the Heimlich and continue to try the Heimlich. Your team has responded and he's not responding. So then they go ahead and they continue to do so until he has passed out and then they continue you on with their plans. As you learned in your CPR course of what to do, as well as including the appropriate equipment that you have on hand in your site. So this is one of those situations that it is a high priority. It's an urgent situation that you need to identify quickly and respond quickly. So we have here Jen and Jen is you come into Jen's room on your shift change and she is coughing and states she has started feeling sick. She has had visitors and said one of them mentioned that they were under the weather. She is worried that she's caught something. worried that she's caught something. Her face appears flushed and she has what do I notice and what do I need to know? So go ahead and stop the video and do so. So what do I notice? So what do I notice? Well, Jen is showing symptoms. For example, a cough, she's stating that she is feeling sick. So maybe more information about what she means by feeling sick would be really helpful. What symptoms are she feeling? It appears that she also is flushed in the base and so she might be feverish and she is wrapped in a large bank blanket. So one might inquire if she's also feeling cold. So it would be vital to do her vital signs and further assessment. This situation might be that she has caught something and we need to identify this as a priority to find out what's going on for her. And the reason it's a priority too is that there might be a situation where she's around other patients and so we may need to isolate her until we know more. need to isolate her until we know more. So using our infectious diseases protocols that we talked about at the very beginning of the term, So, what kind of things do we need to do in terms of PPE? And also, what kind of things do we need to do in terms of isolation precautions? So drawing upon all that knowledge is going to be really vital. That is how you're going to respond and take action. You're going to let others know that this is a situation for your patient, and also you'll have to let the most responsible health care provider know that this is what is happening. In addition, find out the vital signs to find out if indeed the patient has a temperature. And if so, how is it to be treated? Is the patient to be given, is it high enough to warrant medication? And that will be from something that you'll ask the physician for. You'll also take a moment and also find out if the how her other symptoms are. So if she's wrapped herself in a blanket and she's flushed is and she has a cough. We need to find out in relation to that cough. Is it productive? productive? Is it is there something going on related to her chest? Is there sounds that we're hearing? So doing a respiratory assessment would be prudent. So you can see when you come into a situation, you may need to act quickly because other people might be involved. And so, for example, it's flu and cold season. And so one of the things we really are worried about is a flu outbreak on a unit. And so we would wanna make sure that our other, the patient, Jan, is safe, but also the other patients and the nurses on the unit or same. So upon reflection, you would want to find out were my actions effective and what happened with the patient's situation. So the other is it was interesting because one of the things we noticed here, the patient said that the patient had visitors and they were feeling under the weather. So, in addition to the actions, one of the actions might be a unit action, and is there signage up to encourage patients, visitors, and guests to not visit when they are feeling sick? Is it something we have to reinforce? So it could be more than just what's affecting the patient at the bedside. It could be something that has to change or be reflected on in terms of the system and the unit as well. So that is one of the things to think about. So one of the things I want to ask you about and knowing that clinical judgment is so important into your nursing practice is what activities can you think of may enhance critical thinking and clinical judgment. So if you have a moment take a guess or take some ideas and jot them down and see what you come up with. So stop the video and see if you can come up with a few really good suggestions. And maybe you already have a few in mind and so that they really help you with your critical thinking and your clinical judgment. and your clinical judgment. So I have a few here that I wanted to share with you. So when I was reading the articles on this, one of the things they really talk about, And especially Kapudi is talking about how it's important for students to know that clinical judgement is really an important skill to build and that one can build it up by doing certain activities. And so breaking down those steps and then becoming very cognizant of how we're looking at things. The other areas that we can do, so basically what she says is be deliberate and break down the steps. Think about your thinking and what are you, for example, what are you noticing? noticing? But also what are you noticing about your own thinking? There's activities you can do such as picking out the the idea so when you have a scenario really honing in on what you're noticing, comparing and contrasting activities, inconsistencies, knowing, seeing inconsistencies, looking at the relevant versus the irrelevant. So for example one of the irrelevance that I included in one of the scenarios was the irregular heartbeat and so that was maybe something that is not pertaining to the patient situation but also might be seen as relevant until we find out more information and then we can discount it. And also it's important to know what do I need to know. So taking the time to look at those steps and going forward. It's also really important that you engage and seek out as many activities as possible to build your knowledge and skills. So notice whenever you're looking at what are you drawing upon to inform your clinical judgment. So there's a lot of knowledge and you've reached you have read the chapter on critical thinking and so how do I develop my critical thinking knowing the patient according to Tanner is a really important part of your understanding of the pay of building your knowledge so for example when you're knowing the patient and you have engaged in that and you will know more that this is an unusual situation for the patient. For example, if the patient is starting to complain about some a new symptom, you know that this is something they've never complained about before. And so this is and it may make it more of a priority or inform your way to treat this situation. So the number one is knowing your patient and then also building up that big knowledge base that you need. So all of that reading that you're doing, all of those skills that you're practicing are extremely important. Talk to experienced nurses. Find out and watch them. See how they make clinical decisions. Listen and read stories, case studies, be involved with that. Hair mapping. Simulation is a really important one as well, and you're going to have more opportunities in doing so. These are just a few of the activities that we put into the program, but also you can do for yourself. For example, if you are seeking out or having trouble learning about a certain topic area, maybe you can go into and delve into it more. Practice identifying and setting priorities. So which is more urgent and less so? Priority setting is actually an important skill for nursing and one of the skills or one of the things that they will be testing you on the NCLEX exam. But for example, when you're on the unit, But it is important that you know which is more of a priority than others because it really helps with your organizational skills. Build your knowledge base, like I said. Also one of the areas to build your knowledge base on is what complications may occur and how to respond to them. So as we go further into your labs, for example in 225, you're going to be learning much more about the different um more lab skills and in that it's really important to pay attention to those complications. Incorporate reflection into your everyday practice. This is how you're going to build yourself as a practitioner. So notice um and really be thoughtful and reflective and critically reflect on what has happened and what kind of things you did or could have been done or you would like to learn more about. These might be things that might really be helpful. Ask questions, be open and self-directed, examine biases and be curious. So those come a little bit from the previous when we were talking about being a good critical thinker. So these are some of those elements that might help you along your way. So I'm just finishing up our our lab lecture. I'm hoping this these lab lectures were helpful to you and it's been my pleasure to be with you along this journey and I wish you all the best in your journey to come and keep up the good practice. Thank you so much and goodbye. Greetings everyone and welcome to Nursing 221, lab lecture on oxygen delivery devices and titration. So today's lab is a big one and we will continue on our lab lecture. This is the last major lab lecture until we get to the critical judgment, critical thinking and clinical judgment labs lectures that will be the last two. And so in those labs, I will put together opportunities to pull it all to put up put everything together and review some areas. So one of the things that I wanted to also mention about these lab lectures is it's highly important that you only you don't only use these lab lectures as your study tool. You need to make sure that you have a good solid knowledge base, so you need to do the readings because this is a way to very dive deeper into the content and I won't be providing all of the detail that you need in order to be a safe practitioner. So you, this is a supplement for sure, and will include some aspects that might be not in your readings, but certainly this is just a part of it. So our learning outcomes today discuss indications for oxygen therapy modalities, clinical reasoning and judgment related to oxygen therapy. discuss complications of oxygen administration and safety considerations, and discuss complications, discuss comfort and hygiene measures related to oxygen therapy. Review interventions to promote airway clearance and oxygenation, and identify a patient experiencing respiratory challenges distress, what we call respiratory distress, and determine appropriate nursing actions. The last one isn't in your lap guide, but I thought very important to add and always important to practice and to review. So one of the things that I have created here is a match the term to correct information so if you could pause the video and then look at the terms and find out which one matches with which and then I will give you the answer so if you could pause it now. Okay so I'm going to go ahead and give you the correct answers but FiO2 aligns with B, fraction of inspired oxygen and so it's also important to know what is room air and fraction of inspired oxygen and that is 21% and so what we are doing when we are providing oxygen therapy is that we are increasing that FiO2. Incentive spirometry is F which is used to promote deep breathing and prevent or treat atelectasis. Hypoxemia is number D, decrease in oxygen tension in the blood. So that is at the perfusion level. And hypoxia is C, inadequate tissue oxygenation at the cellular level. Orthopnea is A, a condition in which two plus pillows are required during sleep and this is often required for persons who are having problems with their oxygenation and breathing, their work of breathing. So nebulization is a treatment and it is number E or letter E, sorry, process of adding moisture or medications to inspired air. So, we'll talk further about that. So oxygen therapy, I'm not going to read all of this, but this is what the main points used to prevent or relieve tissue hypoxemia, is often used in conjunction with other interventions. So we also are involved with providing other interventions, and it requires a prescriber's order. But I want to know you to note that there is a program or a protocol that where and it is on one of the documents it's a professional practice notice and it's initiating oxygen therapy and when you can do this without an order, and it is on AHS website and it's dated 2023, and administering oxygen may, healthcare professional may initiate oxygen without a prescriber's order under the following conditions. When pulse oximetry is less than or equal to 90%, when no pulse oximetry is available and patients have signs and symptoms of hypoxia. So once that is initiated, you then the RN or other healthcare professional would not a student, I might add, is then to contact the most responsible healthcare practitioner involved in the care to obtain an order and a plan. time. So this is something that you need to know. So as you, you know, I say it requires the prescribers ordering and you might see in situations where it may indeed be started and then an order obtained after. It is treated like medication. And so all rights and checks apply. So you need to make sure that the equipment is labeled as well for the patients so that, And for example, nasal cannula equipment is not accidentally used by another. And that when you start it or you're using it that you know who the order is for when you're titrating it. Often initiated when once initiated, the patient needs to be continuously assessed. And by patient, I means the patient, but also the whole, the tubing and the monitor or the flow meter. So you need to make sure that you're constantly looking to make sure it's at the right flow meter level. We also need to know that complications can arise and safety measures must follow. So when in oxygen therapy, there are a lot of complications and we're gonna talk a little bit about oxygen toxicity, but also safety measures related to the use of oxygen itself. Jan Heigard, so I have a scenario for you, is a 72-year-old male who is a resident on your unit. He has COPD, and his secretions are tenacious, and he sometimes has difficulty clearing his throat and back of his mouth. Now, what I mean by tenacious is that's the word we use when we're talking about thick and sticky. So they're not easy to clear. So what we are having here is a problem with his airway. He coughs periodically, but his cough is weak. He is underweight and has a poor appetite. His vital signs are temp, 37.5, pulse, 92, respirations, 22, SPO2 is 86 and his BP is 136 over 84. You note he is using his accessory muscles when breathing at times and he is presently on room air. So what are you noticing about this situation and what comes to mind? So there are a lot of things going on. So if you could stop the video and write down your concerns or your what we would call your red flags that would be ideal. So one of the things that we have a big red flag here is if we go to the SPO2 and it is 86. So even for a person who has COPD this might not be within the patient and so this is a concern. It appears too that if he's using his accessory muscles when breathing he might be having difficulty maintaining that saturation and so his work of breathing is being used. He's using a lot of work for breathing and if he is already underweight and with a poor appetite we're talking about he's using a lot of calories to maintain this. His temperature is high, his pulse is high, and his BP might be his normal BP. We'd have to find out from his chart to find out what's going on. The concern as well is his airway and his clearance of his secretions. of his secretions. So they are tenacious and he has sometimes difficulty clearing his throat in we assist him with clearing the secretions because what we know is that when they start to pool, and if they're pooling in his chest, this is a good place for bacteria to grow. And I'm concerned because of his temp that we already may be having seen something like an exacerbation of an infection. So could something be going on? on? So we have orders here for him, and this is one way orders could be occurring for oxygen. So we would have, just like when we are doing medication orders, we would have his name, state of birth, Alberta health care number, or unique identifier, the date, we didn't indicate the time, but we should have the time, and we have the order for the amount. So two liters per minute and we have the way to deliver it. So per nasal cannula. So this is the flow amount per per minute and it is signed by Dr. Kelty. So the other way could be and it is more often used because what it's trying to do is target. It is a target range. So what we would like to see is more specific information. So oxygen per nasal cannula to keep SPO2 between 88 and 90 percent. So in this format, what the nurse has to do is titrate the oxygen to the amount to get to this range here and then keep it at that range. So this might be where they start at one, see how he responds and then increase it to two and see how he responds. If he's not responsive on that, we'd continue. However, we do know that he is a CO2 retainer so we also are keeping in mind his oxygen as CO2 drive and so we would if we are concerned regarding having to increase it all his healthcare provider. So there is the way so we are have the two ways and as I said you're more often to see it with the range with out there. So what you need to know is how is it supplies and how do you apply it. So we will be talking more about that in your labs this week and it's going to be an opportunity to actually work wall flow meters and the devices so that you can get the hang of it, but just know that it's piped into the wall from tanks in the basement so they have huge supply coming from the basement and lines in the hospital. The other ways that it can be provided is through compressed gas cylinders. So these ones are maybe oxygen tanks. So this would be a way we would, and a liquid gas system. These two might be ways that you will see, for example, a tank might be used in a patient being transferred, and so a special tank has to be ordered and brought up to the unit, and then it is then transferred from the wall to the tank. And there is a protocol in place or a policy in place called transfer. And so there is a transfer ticket that has to be completed for transfers. And so this is something done to be safe. And one of the things that's very concerning, whenever a patient is being transferred on oxygen, that they have to have the right device and also the right amount so that they don't inadvertently run out of oxygen midway or partially way through their transfer. So that is something that you might want to read up on because there is a document on Albury Health Services. So the oxygen concentrator, this is an interesting device. It is one that's used out in the community more often and it is used on electricity or a battery. A battery is when a patient is traveling somewhere, they're using it as a portable device and it's usually a little pack that they carry and their tubing is applied, their oxygen tubing is applied to it. It has a few more things to take care of than the other systems, such as having to change a filter, making sure that their battery is charged, and also that they are plugged in. So when there's periods of long power outages, this can be a concern. The other I just wanted to mention is the cylinders can be very bulky and very heavy and when they drop or crash these are the ones that actually you'd never want a spark to occur and they need to be recharged or refueled or on the unit, they'd have to go back down to be refilled. So there's modalities that the patient might be ordered for them. And it's important to know the difference between high flow and low flow modalities. So a low flow device is one where the room air is contributing to the patient's airflow. And so, we don't know for sure exactly how much they're getting, but they are getting low from the oxygen that is being provided. And so, it also depends on the patient's inspiration and expiration. So they're, in terms of how well it's been, how efficiently they're breathing. So there's some, we'll go into looking at more at the specific masks that provide that. The other is a low, high flow. And this is where it's more confined in terms of the, We are more defined in terms of how much the patient is getting. For example, in this Venturi mask, which is an example of a high-flow device, the dial goes to the FiO2 that has been required for the patient. And so they are getting the specific amount. So this would be more concise. The other ones that are out there, there are quite a number of other ones that are high flow such as the trach collar, face tents, and the other ones that might be mechanical. So we're not going to go into any of the trach supplies or the CPAPs or BiPAP machines or the ventilators in this as it's beyond the So, these are the nature of those two. So an example of a low flow is a nasal cannula. And you can see, and I'm taking this from a chart that is in your Gregory text, one to six liters per minute can be provided this way. Easy to use because patients can talk and eat without removal and drink, which is important. And so they are better at not desaturating, especially if the patient is one who gets quite breathless. So what I mean by desaturating is when they are off their oxygen or doing something like such as moving around or you know walking, their saturation levels decrease. The one thing that we have to be very careful when we're using this device is that it is use correctly so that the nasal prongs are in place and that they don't rub, especially on the ears or in the nares, because this can cause ulcerations. And also if it's coming in at four liters or greater, it is difficult because it can be very drying and so very drying to the nasal passages. So the patient might need some humidification, a bottle of humidifier sterile water attached to the flow meter and the air goes through the humidified air. The air flows through the water to provide humidified air. Now the other thing that can be used for some patients if they require it is water-based nasal ointment and that can be relieving for that. Then it can still be used, this nasal prongs can still be used by mouth breezers if they are doing, if they end up doing, being more mouth breather. But it's important to see if they can breathe through their nose. So simple face mask is another one and this is used periodically. This is 6 to 10 liters and it has to be at least 6 liters flow from the flow meter because if it's not, what happens is the CO2, it entraps the CO2 that the patient has breathed out and so what we need is to not have that occurring. It's easy to apply and requires for you know a good fit. Poor compliance often because it's uncomfortable and must be removed when eating and drinking and sometimes too when the patient is talking they find it difficult to talk with it on so they might feel that they need to do this. Now if you'll notice on this there's the oxygen tubing and also often there is air hole ports on the sides and this is where exhalation usually occurs through those ports however some they may draw in some air from the outside as well as air from the tubing. Too tight a fit as well can cause irritation and we also need to be aware of the type of elastic band if it's too tight on the face. So the next type is the partial or non-rebreathing mask with reservoir bags. And so this is one that provides also a higher amount of oxygen concentration. And it actually delivers the highest percentage of O2 without intubation or mechanical ventilation. It should be without in that word. And the valves must be secure and functioning if it is a non- rebreathing mask. And like simple masks, they can't eat or drink with mask in place. And the reservoir bag must be kept inflated. So when they're breathing in and out, which it shouldn't deflate fully. They need to keep it inflated. So that is the flow rate that will do that. So when the patient inhales, there is a valve right at the entry of the mask from the bag, the reservoir, we call this the reservoir bag, which is filled with oxygen. And the valve will open and then the patient can draw in the oxygen. When they exhale, the valve will close, so the O2 will not go into the bag. CO2 will not go into the bag. That is for a non- rebreathing mask. If it's a partial rebreathing mask, they don't have that valve there. So it means that part of their breath going, their exhalation will go back into that reservoir bag. So you can see that the non-rebreathing bag has a higher concentration of oxygen available. The other thing to notice is that you will have valves on the side of the mask. And if you can see here, I've got my pointer on that. And it is a little flesh colored, beige colored valve here. It will allow the patient to exhale and when the patient breathes in it will close so that they're not drawing in air from the outside. So room air. So this is the type of mask that you will see in lab this week. The other high flow device I briefly mentioned was the Venturi mask and it is 4 to 10 liters per minute. Flow rate needs to be set using the barrel on the meter barrel. So this is where we are going to be identifying the liters and the percentage of FiO2. So here's the percentage of FiO2 if it's that way. Allows for concise amounts and is, again, they have usually a little device on the side. this is sorry not this picture does not indicate a venturi mask this one does this device here again like the other rebreathing mask non-rebreathing mask allows the patient to exhale and then when they inhale they are only taking in from the from the device the oxygen from the device so I'm just pointing out this chart that is in your textbook. It also indicates a lot of the information that I've just talked about for each of the devices so that you can review it. And it is on page 938 in your Gregory 3. text, table 3 And so you can see where you're at in terms of the FIO2 and that the patient is receiving with each of these devices and whether or not you're using it correctly, for example. Okay, the important piece that we also need to talk about is safety in oxygen therapy. We know that oxygen therapy is highly combustible. No open flames or products that are combustible should be used, such as oils of petroleum jelly. You need to inform everyone in the environment that oxygen is in