NSE 111 Final.pdf

Week 1 ' Introduction to course and approach to care Client Centered Care - the focus is on the client - the client is taking part of their care plan as a partnership - maintain their dignity, independence, preferences, privacy and safety at all times Approach to Care 1. Dignity: feeling worthy and...

Week 1 ' Introduction to course and approach to care Client Centered Care - the focus is on the client - the client is taking part of their care plan as a partnership - maintain their dignity, independence, preferences, privacy and safety at all times Approach to Care 1. Dignity: feeling worthy and respected 2. Independence: encourage them to do what they can on their own 3. Preferences: allow them to make choices of what they’d like 4. Privacy: ensure to provide privacy of care to the patients 5. Safety: they are kept safe from harm —> Partner —> Empathy —> Respect Nursing Process - a clinical decision to making approach to care - assists nurses to identify health related concerns and to attain health outcomes Assessment - involves the collection of data to fully understand the patient’s needs Diagnoses - the analysis to determine key issues to make a judgement. Outcomes or goals for the patient Planning - creating of the plan that identifies strategies Implementation - carrying out the plan Evaluation - determining if the plan was successful Clinical Judgment Overview ADPIE ↳ Recognizeae b ↳ Prioritize hypothesis ↳ Generate solutions ↳ Action Taking ↳ Evaluate outcomes CNO Standards of Nurses of Ontario Accountability - each nurse is accountable for ensuring his/her practice meet the conduct of legislative requirements and standards of the profession - are responsible for their actions and consequences of those actions - advocating and promoting the best care possible to the patient College Continuing Competence - continually improves his/her competence by participating in the Quality Assurance program - the ability to use his/her knowledge, skills, judgment, values and beliefs to perform a given role - investing time, effort and other resources to improve knowledge Ethics - understands and promotes values and beliefs in the ethics standards - promoting the values of clients well-being, ensuring fairness, maintaining commitments and privacy and confidentiality - identifying personal values and ensuring they do not conflict with professional practices Knowledge - basic education and knowledge relevant to her/his practice - RN’s and NP’s study longer and achieve greater knowledge in clinical practice, decision-making and critical thinking - basic education by pursing ongoing learning through their careers - being informed with different nursing relationship Knowledge application - improves application of professional knowledge - applies knowledge to practice nursing frameworks, theories and/or processes - planning approaches to care of patient Leadership - providing and facilitating care - respect, trust, integrity, shared vision, learning, participation, good communication skills. All have opportunities for leadership - role-modelling professional values, beliefs and attributes Relationships - maintains respectful, collaborative and professional relationships - nurse-client relationship and professional relationships with colleagues - Therapeutic Nurse-Client relationships: appropriate use of power, demonstrates empathy and caring for all Professional Relationships - professional relationships are based on trust, respect, and improved client care - demonstrating knowledge of respect for each other’s roles, knowledge, expertise and unique contribution CNO - The College of Nurses of Ontario - RNs, RPNs, NPs - self-regulation profession: can put the interest of the public ahead of their own professional interests. Knowledge and expertise to regulate themselves CNO fulfill its role by: 1. Establish requirements for entry to practice 2. Articulate and promote practice standards 3. Administer its quality assurance program 4. Enforce standards of practice and conduct STEPS TO PERFORM NURSE CLINICAL JUDGMENT Assessment: Recognizing Cues - gather accurate info - identify cues - what is relevant? - what is immediate concern? Diagnose: analyze data or cues - clients conditions and consistent cues? - why are the cues a concern? - what would be established as a significant concern? - Prioritize Hypothesis: which explanations are most/least likely? Planning: Generate Solutions - identify expected outcomes - what are the desirable outcomes? - what interventions can achieve these outcomes? Implementation: Take action - address the highest priorities - which interventions is most appropriate? - how should it be accomplished (performed requested, administered) Week 3 Hygienic Environment, Bed Making BED MAKING 1. Examine the client’s need for safe, comfortable and hygienic environment 2. Perform nursing skills and knowledge related to occupied and unoccupied bed making including equipment (i.e. linen) 3. Explain how to incorporate infection prevention and control practices during bed making 4. Identify and explain the basic bed positions that may be used for client care CLEAN, COMFORTABLE, DRY BED… - promotes patient comfort - reduces spread of microorganisms - prevents skin breakdown and pressure ulcers ENVIRONMENTAL FACTORS THAT MAY PREVENT CLIENTS COMFORT - noises - odours - lights MAKING THE BED GIVES NURSES THE OPPORTUNITY TO: - assess patients status: pain, mobility, ability to assist, assessment of skin - assess for dropped medication, food particles, wetness - promote patient dignity and privacy - continue to develop the Therapeutic NCR BED MAKING - Bedmaking: unoccupied, have patient sit up in chair while bed is made; if not possible do occupied bed - collect necessary equipment - proper disposal of soiled linen - optional drawsheet- used to lift & reposition patient; place under torso to distribute most of the pt’s body weight over the sheet - maintain pt safety & body alignment during bedmaking and turning BODY MECHANICS - widen stance - increase balance by bringing centre of gravity closer to base of support - bend knees & flex hips till person is squatting with back aligned & trunk erect Some principles: - wider base of support > greater stability of the nurse - lower centre of gravity > greater stability of the nurse - facing the direction of movement prevents abnormal twisting of the spine - put bed height to working height when making it and lowest when finished - balanced between arms & legs reduces the risk of back injury - when friction is reduced between the objects, less force is required to move - maintain good body mechanics reduces fatigue of the muscle groups - alternating periods of rest and activity helps to reduce fatigue WHAT LINENS WILL YOU NEED IN LAB? - 1 spread (colour) - 1 top sheet (white flat) - 1 drawsheet (white flat) - 1 bottom sheet (white flat) - 1 lifter (padded) - 1-2 pillow cases - hand sanitizer HIGH FOWLER’S —> 60-90 degrees SUPPORTED FOWLER’S/ FOWLER’S/LOW FOWLER’S/SEMIFOWLER’S - HOB 45degrees- 60degrees - knees slighting elevated SUPINE/DORSAL RECUMBENT POSITION - client rests on back (good standing alignment) - Trochanter rolls, hand rolls & pillows used to enhance comfort - foot support to prevent plantar flexion (foot drop) DORSAL RECUMBANT LATERAL/SIDE-LYING SIM’S POSITION PRONE POSITION, HEAD SUPPORTED WITH PILLOW MOVING A CLIENT - to move clients who has slid down in bed from a fowler’s position - client is moved up in a bed to maintain good body alignment and comfort - move a client from one side of the bed to another - bed bath, changing linens etc. WATCH VIDEOS FOR POSITIONING AND BED MAKING Week 4- Principles of Body Mechanics - when you can lift safely and are in the correct position (i.e., in front of you), you make sure that you continue to follow the rules WHEN IS IT SAFELY TO MANUALLY LIFT A PATIENT? - 35lb. (16kg) maximum patient is cooperative and unlikely to move suddenly - less when task is performed under less than ideal conditions (lifting w/ extended arms; near the floor; trunk twister; in a restricted space; working more than 8 hrs) - patients can be unpredictable: - muscle spasms, resistant sometimes - patient movement during lift can create loads within the lifter’s spine greater than those created by slow, smooth lifting - when weight exceeds 16kg TRANSFER TECHNIQUES CLINICAL JUDGMENT OVERVIEW NURSING DIAGNOSES/HYPOTHESIS - activity intolerance - ineffective breathing pattern - risk for disuse syndrome - impaired physical mobility - impaired skin integrity - social isolation PLAN/GENERATE SUPPLIES AND EQUIPMENT USING SAFE TRANSFER TECHNIQUES 1. Assisting cooperative patient who can partially bear weight 2. Stand opposite patients hips. Turn diagonally so you can face patient and far corner head of bed. Using centre of gravity. Reduce twisting of nurse’s body. Place feet apart with foot closes to bed in front of other ASSISTING A CLIENT FROM BED TO CHAIR - assess client’s activity tolerance, strength, coordination, balance & coordination - evaluating environment for safety, e.g., brakes on bed and w/c - client wear supportive, non-slip shoes - dangling is important, the longer the immobilization the longer the Ned to dangle (monitor) - if patient’s dizziness lasts >1 min upright return: - to supine and take blood pressure PERSON TRANSFER 1. Nurse provides support @ waist (transfer belt) 2. Nurse flexes hips and knees, aligning knees with client’s knees 3. Nurse flexes hips while easing client into chair ASSESSMENT: AMBULATION When clients mobility restricts ability to walk: - activity tolerance - orthostatic hypotension- tolerates upright position or not - level of pain - coordination - baseline vital signs - which side needs help? Which side does cane go on PLANNING CLIENT FOR AMBULATION 1. Clear away obstacles/barriers 2. Have rest point close by e.g., wheelchair in case 3. Nonskid shoes 4. Transfer belt 5. Dangle before getting up >60 seconds dizzy, postpone AMBULATION 6. Support them on the weaker side, one hand at small of back AMBULATION OF CLIENT W/ HEMIPLEGIA/HEMIPARESIS - neglect on one side scan all visual before transferring - nurse with ANY doubt about their ability to ambulate a client alone should always request help - client wear a gait/transfer belt, nurse support at client’s waist - nurse stands at client’s affected (weak) side - walker is NOT a safe option ASSISTIVE DEVICES FOR WALKING Walkers - step> move forward> step Canes 1. Single-straight leg- used on stronger side of body, cane forward w/ body weight on both legs. Weaker leg is moved forward to cane- stronger leg advanced past the cane (always 2 points of support on flow at all times) 2. Quad Cane- provides most support FALL RISK ASSESSMENT - assessment of pt’s fall risk - client ability to move independently, and other factors - a score of 5 or more is high risk USED WHEN: 1. An admission to facility 2. After a fall, to determine why it occurred. Once a fall happens, they are at risk for falling again POSITIONING DEVICES - pillows - foot boards/foot boots: prevent foot drop. Keep for in dorsiflexion - trochanter rolls: prevents external rotation of the hip - sandbags - hand rolls: prevents contractures - hand-wrist splints - trapeze bar - side rails - bed boards - wedge pillow - elbow splints: prevents arm contractures TO REPOSITION PATIENT TO BED CAUSES OF IMPAIRED MOBILITY - postural abnormalities - congenital - acquired - disorders of bones, joints, muscles - injury - disease - CNS damage - musculoskeletal trauma - muscle atrophy - illness - surgery - injuries - pain - aging CARE - prescribed restriction of movement (bed rest order) - reduce physical activity - reduce pain, esp post-op - chance to rest Physical restriction because of external devices (traction, cast) PSYCHOSOCIAL EFFECTS OF IMMOBILITY - Social interaction - social isolation - sensory deprivation - loss of independence - role changes LEADS TO… - emotional & behavioural changes - sensory altercations - changes in coping - withdrawal and depression due to changed role, selfconcept RESPIRATORY CHANGES WITH IMMOBILITY - decreased respiratory movement - pooling of respiratory secretions - atelectasis - hypostatic pneumonia CARDIOVASCULAR CHANGES WITH IMMOBILITY - cardio workload is increased by immobility - orthostatic hypotension - decreased autonomic responses - venous vasodilatation & stasis - dependent edema - thrombus formation METABOLIC CHANGES WITH IMMOBILITY - basal metabolic rate - impaired immunity - protein intake and breakdown - decreased GI motility - calcium resorption MOBILITY NEGATIVE NITROGEN BALANCE - > nitrogen is excreted than ingested in protein the body is in negative nitrogen balance: - weight loss METABOLIC CHANGES GASTROINTESTINAL - decreased muscle mass - weakness SYSTEM - interferes with wound - constipation healing & restoring muscle - fecal impaction: pseudo diarrhea mass when mobility returns - blocks normal propulsion of liquid and gas - increased intraluminal pressure - intestinal function, dehydration, absorption ceases, electrolyte disturbance worsens URINARY ELIMINATION CHANGES WITH IMMOBILITY - urinary stasis - renal calculi - urinary retention/residual bladder - dehydration - hygiene - urinary tract infection MUSCULOSKELETAL CHANGES WITH IMMOBILITY - disuse atrophy - endurance decreases - disuse osteoporosis - impaired calcium metabolism; hypercalcemia - joint pain contracture (e.g., footdrop) SKELETAL EFFECTS - bone resorption occurs when weight bearing bones become inactive - calcium is released (lost) from bones and they become less dense - client is put on risk for pathological fractures CONTRACTURES ** An irreversible contracture further decreases the person’s mobility because it make moving the involved muscles difficult or impossible - wrist drop contracture - multiple contractures - plantar flexion contracture SKIN- BREAK DOWN - age, skin is less resistant barrier HIGH RISKS - sensory perception - moisture ++ - activity - mobility - poor nutrition - mechanics of pressure, friction, shearing cause skin breakdown THE BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK - Six specific risk subscales that preventative care addresses: —> sensory perception —> moisture —> activity —> mobility —> nutrition —> friction and shear - the lower the score, the higher the risk for pressure ulcer development - TOTAL SCORE OF 18 the cut-off for onset of pressure ulcer. Anything lower increases the risk. HOW DOES A PRESSURE ULCER FORM? - pressure slows the blood flow which leads to tissue death - poor sensory perception, moisture, inactivity, nutrition, friction/ shear, can add to the problem PATHOGENESIS OF PRESSURE ULCER - ischemia develops when the pressure on the skin is greater than the pressure inside the blood vessels to the skin THREE PRESSURE RELATED FACTORS 1) pressure intensity 2) pressure duration 3) tissue tolerance FRICTION - force of two surfaces moving across one anther such as mechanical force - force occurs in a direction to oppose movement - must be overcome when nurses turns, transfers, moves client up in bed - greater the surface area of the object to be moved How can you reduce friction? - get client to assist in moving - if unable to assist, place client arms across chest to and friction - Bend knees to surface area and friction surface area SHEARING FORCE - parallel to the skin and results from gravity pushing down on the body and resistance (friction) - combination of friction & pressure when applied to the skin—> damage blood vessels and tissue - occurs in fowlers position PREVENTION OF PRESSURE ULCERS Nutrition - encourage to eat and drink - assist with eating and drinking - feed those who are unable Positioning - encourage frequent small shifts - keep head of bed at 30 degrees or less - heels elevated supported by pillows under leg - use a pillow to keep knees and heels from rubbing together - turning schedule for residents who cannot move themselves NUTRITION - protein, carbohydrate, fat, minerals and vitamins - prelbumin, albumin, Hb and zinc—> proteins and nutritional supps are necessary - vitamin A: decrease side effects of steroids - vitamin C: synthesis of collagen - minerals zing and copper BODY PRESSURE AREAS NURSES INTERVENTIONS FOR CLIENT WITH LIMITED MOBILITY? 1. Respiratory- Deep Breathe & Cough 1- 2 hrs should inhale deeply x3 and cough on 3rd exhalation 2. Leg circulation - calf pumps and ankle rotations; compression socks 3. ROM - during bathing and 2-3 times more/day; splints 4. Fluids - 1100-1400 non-caffeinated mls/day; monitor I&O 5. Nutrition - protein, fibre, vitamin B&C, Zinc 6. Integumentary **turn 1-2hr, not 2-3 hrs; reposition; use Braden Scale 7. Psychological support - encourage ADLs, orient, encourage visitors, watch for delirium/ depression Avoid: pressure, friction, shearing & maceration Valsalva maneuver-eg during pushing in bed or defecation RANGE OF MOTION (ROM) What is it? - movement available at a joint in 1 of essentially 3 planes Sagittal, frontal & transverse - active or passive - assessing: stiffness, swelling, pain, limited movement, unequal movement - benefits: reduce hazards of immobility THREE TYPES OF ROM 1. Active: client moves his/her joints unassisted 2. Passive: nurse moves each joint for clients, unable to do themselves ….3. Somewhere between active and passive - elicits cooperation & assistance - start slowly with smooth/ease - flex joint; larger to smaller joints - work from head to toes - ROM to each joint x5 - assess client of any pain/fatigue - leave joint in correct alignment when done JOINT MOVEMENT Flexion: decreasing angle of the joint Abduction: movement of the bone away from the midline of the body Internal rotation: rotation of joint inward Dorsiflexion: flexion of toes and foot upward Pronation: movement of body part so front/ventral surface faces downward Extension: increasing the angle of the joint Adduction: movement of the bone toward the midline of the body External rotation: rotation of joint outward Plantar flexion: bending of toes and foot downward Supination: movement of body part so front/ventral surface faces upward Search for Meaning PIECES Physical -delirium , pain Intellectial-8 As communication , Emotional-anxiety depression Capabilities Environmental social - activities of - - noise personality Stop and Stop Think Observe Plan daily , fear living stimulation , , culture GO , life story Week 7 Supporting Personal Hygiene and Grooming Objectives Why is hygiene important to a person? What are the risks of not performing hygiene? What kind of situations make hygiene maintenance challenging? How does the nurse enable and assist a client’s hygiene? Factors Influencing Hygiene Practices Social groups: family customs, developmental stage Personal Preferences: (perhaps patient want to wear makeup? Body Image: What makes you want to wash you hair everyday? Socio-economic status: What if you were homeless? Health beliefs and motivation: used to believe that baths made you vulnerable to quite sick Cultural variables: different countries? Physical condition: what if you had terrible arthritis Risks for Unmet Hygiene Needs - tracheostomies, drains, dressings - skin integrity - chewing and swallowing difficulty - language deficits - sedation, mental illness, dementia - reduced physical energy, ROM, diminished vision - hands-inflammation, decreased dexterity - feet-ability to walk/weight bear, poor fitting shoes - environment-bathing obstacles Privacy & Confidentiality - close curtains, close door - maintain dignity of client - minimize the time the patient is unclothed and only expose part of the body that is being washed - use a do not disturb sign if available Infection Control - determine PPE required (or additional precautions when required) - ensure wash basin belongs to client, is sanitized (sanitize the basin after each use) - eyes-use different part of wash cloth and move from inner to outer canthus of eyes - always move cleanest part of body to dirtiest (face first, peri care last) - move fronts to back and cleanse meatus first when beginning peri-care Safety in providing Hygiene - infection control - body mechanics - rails and beds safety - client ability and risks - energy requirements: nurse’s and client’s - water temperature and product use - skin integrity Special Needs: when the client has Dementia or Cognitive Impairment - use distraction and negotiation instead of demands (e.g., give the patient a washcloth to keep hands occupied) - minimize noise in the bathing area or play the patient’s favourite music softly in the background - set priorities regarding which body parts need bathing and which parts can be deferred (e.g., separate hair washing from bathing) Cleaning Baths Complete bed bath - nurse washes the entire body Self-help bed bath - clients able to bath themselves, with assistance for washing back Partial bed bath - face, hands, axillae, perineal area, and back - Bag bath - Tub bath - Shower Clinical Judgment Overview Identify Techniques Reflecting Critical Thinking - assess-ability to assist and preferences what type of bath - assess-communication, comfort, mobility, fatigue - assess-skin-which pressure points? - safety: bed height, rails, partner’s position-watch your body mechanics- when is bed raised? Lowered? How is your energy conserved if working along or with another “nurse”? - HH and gloves: when performed/changed? - Bed blanket - Basin and water-assess preference - use 1 not 2 towels-place where? - mitt cloth: how will drag effect be minimized? - eyes and face-steps to cleanings: how is infection control minimized? - bath blanket: how repositioned throughout bath? How is privacy and warmth maintained? - direction of washcloth-over eyes? Limbs? Torso? Genitalperineum? Nursing Diagnosis Examples: - fatigue - ineffective health maintenance - impaired physical mobility - self-care deficit, bathing and hygiene, dressing and grooming, toileting - risk for impaired skin integrity Hygienic Care Use a sensitive and effective approach - eyes - ears - perineal-genial area - teeth and oral area Ongoing Assessment of Client - assisting with bathing is an excellent opportunity to also assess the client’s physical status: ROM, strength, grasp, coordination - include ROM when possible- not any discomfort, pain, or limitations - need for partial or complete bath - emotional response to bathing - document any changes from baseline Perineal-Genital Care Assess: - irritation, excoriation, inflammation, swelling - excessive discharge - odour, pain, or discomfort - urinary or fecal incontinence - recent rectal or perineal surgery - indwelling catheter - preferences Perineal-Genital Care: females Wipe from area of least to greatest contamination (pubis towards rectum) • Dorsal recumbent position 1. Spread labia with one hand 2. Start at urethra first* wipe downwards 3. Use separate corners of washcloth for each wipe 4. Wash folds between labia Minora then labia Majora 5. Dry area well in the same order —> wash and dry upper/inner thigh Perineal-Genital Care: Males - inspect the meatus for any discharge, inflammation or lesions. 1. Cleanse the urethral meatus tip first 2. Wash and dry penis using firm strokes 3. If uncircumcised, retract foreskin to cleanse and then replace foreskin to prevent constriction 4. Wash and dry scrotum too 5. Wash and dry upper/inner thigh area Grooming: Undressing a Client - RUF: Remove from the unaffected side first - easier if sitting up or if in bed in supine position - avoid overexposure/ensure privacy - may need to undo buttons, zippers, snaps, or ties for client - removing pants: remove foot wear first; if in bed ideally, place in supine and ask client to lift hips - if IV present: remove from non IV arm first Dressing a Client - DAF: Dress affected side first - easier if lying supine - a voice overexposure/ensure privacy - put socks on before pants - if IV present: dress the IV arm first Oral Hygiene: What to Assess - self-care ability - hygiene practices - eating habits and diet - cognitive ability - cultural factors - physical limitations - environment - personal health equipment - health/disease - client expectations What do you assess about the mouth? - colour - hydration - lips - breath - infection - inflammation - lesions/fissures/ulcers - missing or loose teeth - risk for aspiration - discoloured teeth coated tongue - receding gums Oral Hygiene Interventions/Health Promotion - dental check-ups - brush-how often? - what if edentulous? - types of toothpaste and brush - mouthwash - dexterity issues - plaque forming foods? - chewing gum - hydration Oral Hygiene and Special Needs - upper body strength and dexterity issues - edentulous - dementia/cognitive impairment - chemotherapy and radiation, medication side effects - dysphagia - unconscious - presence of mouth tubes, oxygen, mouth breathing - bleeds easily Swallowing Problems: Oral Care Tips Positioning - in a supine position (back) at about 45-60 degree angle or - lying on their side with towel placed on pillow (this allow fluids to pool in the cheeks rather than being at risk of aspirating them) Check the Mouth - look inside to remove debris around teeth - use propping devices when necessary but make sure there are no loose or broken teeth - may not be able to spit very well or clear their throat - place resident’s chin in neutral position to help prevent choking or aspiration - depending on the severity of the dysphagia or swallowing problem, the resident may require the use of: - suctioning as necessary - a suction-type toothbrush (can’t use toothpastes as it blocks the suctioning) Toothbrush with Water or Mouthwash - regular soft toothbrush should be dipped into water or mouthwash to brush teeth, clean tongue and gums - gently massage gums and palate - never use sponges or toothettes-note that this is not recommended for the unconscious patient - preferable to not use toothpastes - select a non-foaming toothpaste - water is used for flushing the suction toothbrush if needed - make sure debris and liquid is cleaned out of the mouth, may need to use a thin cloth such as a J-cloth - apply non petroleum lip balm Performing Mouth Care for the Unconscious Client or Debilitated Patient Skill Unconscious/Debilitated person can NOT swallow salivary secretions from mouth - increased risk of aspiration pneumonia (gram negative bacteria) - risk for dry inflamed oral mucosa - protect airway (absent gag reflex) - position for oral care: Sims’ - head turned well toward the side towards nurse - bedside suction necessary - insert padded tongue blade back molars when client is relaxed - toothbrush at 45 degree angle - use chlorhexidine solution - monitor respirations - moisten lips Safety implication when Caring for someone’s mouth - the mouth has the highest and most variety of pathogens than any other office of the body - the spatter that can occur when brushing or cleaning someone else’s mouth has the potential to enter the eyes or nasal opening of the provider - being bitten by the patient would present the same situation as any needle stick injury for the HCP Week 8 Assisting with Elimination Objectives What make elimination challenging? What are the risks of not elimination normally? How does the nurse enable and assist a client’s elimination? Important Factors for the Nurse to Consider in Providing Elimination Care - build and develop the TNCR - Sensitivity to the client’s routine - provides Privacy, Dignity, Comfort - applies infection control Practices - uses proper body mechanics General Types of Elimination Related Assistance - bathroom-commode - bedpan - incontinence brief - condom catheter - indwelling catheter - peri-care Factors Influencing Urination - disease conditions - medication - physiological factors - surgical procedures - bowel patterns - mobility - environment - fluid balance - psycho-social factors - habits Urinary Assessment: Analyze Cues - Knowledge in… physiology of fluid balance anatomy and physiology of normal using production and urination pathophysiology of selected urinary alterations caring for patient with alteration in urinary elimination caring for patient at risk or urinary infection Assessment Urinary Elimination Characteristics of Urine Colour - pale, straw coloured to amber - maybe altered by medication and food • more concentrated, stronger the colour • Sweet or fruit odours from acetone or acetoacetic acid Clarity - normal transparent • cloud if: renal disease, high proteins • Thick and cloud: result of bacteria Odour - characteristic odour. Ammonia odour Nursing Process: Assessment Urine Testing: - random specimen, clean-voided, catheter specimen, timed - urine collection in children - urinalysis - specific gravity - urine culture • voiding regularly every 3 to 4 hours (400 to 500mL) Worsening of lower urinary tract symptoms • tobacco • Alcohol • Caffeine, coffee, tea and chocolate • Carbonated beverages • Artificial sweeteners Assess Intake and Output - avg fluid intake is about 2200ml to 2700ml per day - oral intake account for 1100 to 1400ml, and solid foods for about 800ml to 1000ml - when monitoring client’s intake and output, all fluids consumptions are recorded on an intake and output record • fluid intake of 1500 to 2000mL promotes continence Assess Intake and Urine Output - when monitoring urine output, consider what are some recognizing cues one should report? Urine Collection- Mid-stream (Clean-Voided) Urine Specimen Assess the patient - when patient last voided - level of awareness or developmental stage - mobility, balance and physical limitation - understanding related to purpose of test and method of collection - provide fluid to drink a 1/2 hour before collection unless contraindicated, (such as fluid restriction), if patient does not feel urge to void Nursing Process/CJM: Planning, Setting Priorities Goals and Outcomes - ex. “Patient will void within 8hrs after catheter removal” - ex. “Patient’s bladder will not be distended on palpating” - setting priorities - continuity of care Common symptoms to a nursing diagnosis: • frequency • Urgency • Nocturia Nursing Process/CJM: Implementation/Taking Actions Restorative Care - Lifestyle modification - pelvic floor muscle exercises and training - bladder training - prompted voiding, timed toileting, and habit retraining - intermittent self-catheterization - pharmacological strategies - patient education - fluid intake - promoting regular micturition - offer toileting upon awakening, before and after meals, before bedtime - stimulation of reflex - position of male-standing - avoiding food or fluids that can irritate bladder mucosa - promoting complete bladder emptying (every 3-4hrs) - prevention infection: hygiene and acidifying urine Factors Affecting Normal Bowel Elimination - diet - fluid intake - physical activity - personal bowel elimination habits - privacy - age related changes Normal Adult Urine Output • 1500 to 1600mL/day Assessment: Nursing History - Elimination pattern - characteristics of stool - routines - use of medications or enemas - patient’s cognitive capacity - changes in appetite - diet and fluid intake - history of surgery or illnesses • Defecation: knees higher than hips, lean forward and put elbows on your knees bulge out your abdomen straighten your spine Specimen Collection - fecal sample for Occult Blood is one type of fecal specimen Key Principles Related to Bowel Elimination - process of defecation - factors affecting normal bowel elimination - diet - fluid intake - physical activity - personal bowel elimination habits - privacy Week 9 Key Takeaways - Canada’s Food Guide 2019 is evidence- informed - is developed for individuals who are two years of age and older and for those who do not have specific dietary requirements Main Guidelines: - nutritious foods are the foundation for healthy eating; - processed or prepared foods and beverages that contribute to excess sodium, free sugars, or saturated fat should not be consumed regularly - food skills and food literacy are needed to navigate the complex food environment and support healthy eating Cultural Aspects of Care CFG adapted for First Nations & Inuit Canadian Chinese/Immigrant Considerations. Translated to 10 languages Culture & Nutrition: Food Patterns - developed habits & culture as children - culture/religion influence meaning of food not related to nutrition - food connects to good OR bad feelings-associated - balance foods—> HOT (warmth, strength, and reassurance) vs COLD (weakness, menace)- not spiciness—> Temperature - WET vs DRY—> balance NURSING PRACTICE CONSIDERATIONS: - meaning for certain foods to client - cold illnesses/conditions vs Hot illness/conditions- require different foods lactose intolerance Canada’s Dietary Guidelines & Food Guide 2019 Guideline 1 & Considerations Nutritious foods are the foundation for healthy eating - vegetables, fruit, whole grains, and proteins foods should be consumed regularly. Among proteins foods, consume plant-based more often NOTE: protein foods include legumes, nuts, seeds, tofu, fortifies soy beverage, fish, shellfish, eggs, poultry, lean red meat including wild game, lower fat milk, lower fat yogurts, lower fat kefir, and cheeses lower in fat and sodium - foods that contain mostly unsaturated fat should replace foods that contain mostly saturated fat - water should be the beverage of choice - encourage nutritious foods to consume regularly cane be fresh, frozen, canned, or dried Cultural Preferences and Food traditions - nutritious foods can reflect cultural and food traditions - eating with others can bring enjoyment to healthy eating and can foster connections between generations and cultures - traditional food improves diet quality among indigenous peoples Energy balance - energy needs are individual and depend on a number of factors, including levels of physical activity - some fad diets can be restrictive and post nutritional risks Environmental Impact - food choices can have an impact on the environment Guideline 2 Processed or prepared foods and beverages that contribute to excess sodium, free sugars, or saturated fat undermine healthy eating and should not be consumed regularly Sugary drinks, confectioneries and sugars substitutes - sugary drinks, confectioneries and sugar substitutes - sugar substitutes do not need to be consumed to reduce the intake of free sugars Publicly funded institutions - foods and beverages offered in publicly funded institutions should align with Canada’s Dietary Guidelines Alcohol - there are health risks associate with alcohol consumption Guideline 3 Food skills are needed o navigate the complex food environment and support healthy eating - cooking and food preparation using nutritious foods should be promoted as a practical way to support healthy eating - food label should be promoted as a took to help Canadians make informed food choices Food skills and food literacy - food skills are important life skills - food literacy includes food skills and the broader environmental context - cultural food practices should be celebrated - food skills should be considered within the social, cultural, and historical context of indigenous peoples Food skills and opportunities to learn and share - food skills can be taught, learned, and shared in a variety of settings Food skills and food waste - food skills may help decrease household food waste Balanced Nutrition- Health & Scientific Information - adequate in calcium and vitamin D may reduce risk of osteoporosis - low in saturate fat and trans fat may reduce the risk of heart disease - rich in vegetable and fruit may reduce the risk of some types of cancer - physical activity 30-60min per day (adults); 90min per day (children & youth) - vitamin & mineral supplements - salt: limit levels - alcohol: no more than 5% of total intake - Caffeine: no more than 2 cups per day (adult) Nutrition Across the Lifespan INFANTS - rapid growth: high protein, vitamin, mineral & energy - infant doubles birth weight at 4-5 months and triples it at 1 year - energy intake of approx 108kcal/kg of body weight needed in 1st half of infancy and 98 kcal/kg in the second half - commercial formulas & human breast milk provide approx 20kcal/ 30mL - breastfeeding: immunological & allergy protection; economical, convenient, mother/infant to interact. Recommend for the first 6 months - breastfed infants need supplemental vitamin D - cow’s milk should not be before 9-12 months: causes GI bleeding, too concentrated for kidneys, increases risk of milk product allergies, and is poor source or iron and vitamins C and E - No honey: botulism toxin TODDLER/PRESCHOOLER Solids are introduced to meet the infant’s nutrient needs, specifically iron, zinc, and vitamin A - puréed smooth foods - physical readiness to handle different forms of food - new food should be introduced one at a time, early in the day, at 2 days intervals, 7 days apart if allergies - introduce new foods before milk or other foods to avoid infant rejection - growth rate slows during toddler years to 3 years - less kilocalories: increased proteins needed - appetite may decrease - strong food preferences? Picky eaters - small, frequent meals consisting of breakfast, lunch, dinner & 3 snacks - calcium and phosphorus: bone growth - whole milk until 2 years of age: ensure adequate intake of fatty acids for brain and neurological development - vitamin D supplementation - watch for milk anemia: too much milk- no iron - NO bottle sleeping: TOOTH DECAY CHILDREN 3-12yrs Preschooler (3-5yrs old) - dietary requirements - eat more: nutrient density is more than quantity - encourage healthy eating - small stomachs: frequent eating School-aged children (6-12yrs) - decline in energy requirements - gains 3 to 5 kg in weight and 6cm in height per year until puberty - better appetites: varied food intake - need for proteins & vitamins A & C - caution: fail to eat breakfast, unsupervised food intake- high amounts of fat, sugar, salt —> childhood obesity—> risk type 2 diabetes, sleep apnea, CV disease, gallbladder & liver disease, cancer, hypertension, osteoarthritis & hypercholesterolemia Adolescence - energy needs increase; greater metabolic demands - daily requirement of protein increases - calcium & vitamin D are essential for rapid bone growth - girls need a continuous source of iron to replace menstrual blood losses - boys also need adequate iron for muscle development - iodine supports increased thyroid activity (iodized table salt) - B-complex vitamins support increase metabolic activity - concern: body image/appearance, desire for independence, and fat diets - snacks: 25% of teenagers’ total intake: fast food: excess weight gain (fat content/sodium intakes in excess) - eating disorders: anorexia nervosa/bulimia nervous a - health promotion initiatives: in schools - sports: exercise YOUNG and MIDDLE-AGED ADULTS - growth period ends - nutrients for energy, maintenance and repair - obesity may become a problem: decreased physical exercise/frequent dining out - women who use oral contraceptives need extra vitamins - continue to need Iron & Calcium Pregnancy - nutrition influences birth/survival infants - calcium, vitamin D, Folic acid, water Lactating - 500kcal per day - additional vitamins A & C - intake of water-soluble vitamins (B and C) to ensure adequate levels in breast milk - caffeine, alcohol, and drugs are excreted in great milk & avoided Older Adults > 65yrs - decreased need for energy- metabolic rate slows - vitamin and mineral requirements remain unchanged - income is significant- fixed income - home-delivered or congregate meal services - health status: therapeutic diets- physical symptoms- lack of teeth/ dentures, risk for drug-nutrition interactions - thirst sensation diminish: inadequate fluid intake or dehydration - meats may be avoided because of the cost or difficulty to chew - cheese, eggs, and peanut butter are self high-protein alternatives - cream soups and meat-based vegetable soups are nutrient-dense sources of protein (commercial soups and packaged meats contain high salt) - milk protect against osteoporosis (a decrease of bone-mass density) - vitamin and mineral supplement AGING CHANGES - changes in the teeth and gums - decreased or thicker saliva production - decreased bite force - weaker gag/cough reflex - smell, taste & touch can be reduced/distorted - decreased esophageal and colonic peristalsis - decreased thirst sensation > dehydration risk - decreased energy needs (slowed metabolism), but same vitamin and mineral requirements - diet should contain choices from all food groups and may require vitamin and mineral supp - fixed income-costs of foods - health-possibly therapeutic diet, difficulty eating due to symptoms, and missing teeth or missing/poor fitting dentures - difficulty chewing textures - risk for drug nutrient interactions Nutrition: Nursing Process- assessment Nurses must recognize signs of poor nutrition and intervene ASSESS: 1. Physical status 2. Food intake 3. Weight changes 4. Response to therapies A Nutrition- risk assessment tool 1. Have you lost weight in the past 6 months without trying 2. Have you been eating less than usual for more than a week? ** YES indicates a nutritional risk Diet History: FASTCHECK Continued Promoting Appetite: eating - environment that promotes comfort - elimination unpleasant odour - provide oral hygiene as needed to remove disagreeable tastes - some medication affect dietary & nutrient intake; eg. Insulin, glucocorticoids, & thyroid hormones affect metabolism - some medications can affect taste - some psychotropic medications affect appetite- nausea & alter taste - assist client to patient select foods - social time- dining room - consider culture & religious preferences Feeding Assistance and Dysphagia The loss of the ability to feed oneself… - often the last activity of daily living to be lost due to illness (acute or chronic/injury) - the inability to feed one’s self impacts all aspects of one’s personhood - the impact of not being able to feed one self has emotional, social and physical sequela - challenges include ensuring feeding is safe, nourishing, ethical, and enjoyable Normal Swallowing Dysphagia: impaired swallowing Is the impairment of any part of the swallowing process, increases the risk of aspiration. - dysphagia and aspiration are associated with the development of aspiration pneumonia What is Aspiration? The misdirection of oropharyngeal secretions or gastric contents into the larynx and lower respiratory tract. Complications of Untreated Dysphagia inconvenient… life less enjoyable embarrassing….. over time can lead to CAUTIONS Fast transit of thin liquids (water, coffee, tea, juice) create risks of aspiration for those with: - poor motor skills who cannot contain fluids in their mouth; - slow/irregular pharyngeal response; - compromised airway protection; - reduced cognitive awareness Aspiration of an overly thickened fluid: can increase the risk of pneumonia and may be difficult to clear from the airway Essential that fluids be modified to appropriate consistency & each patient’s swallowing capacity Dysphagia Diets Specific diets are prescribed by a therapist as consistency of food & liquids related to patient’s oral motor control SOLID FOODS: modify textures from regular to mechanically altered (minced) to puréed (homogenous & cohesive-pudding like) LIQUIDS: create a consistency/viscosity that matches patient’s capacity for swallowing from nectar/honey like to milk shake consistency to apple sauce- to pudding and finally mash potato consistency - use of straws as prescribed by therapists Person at Risk: decreased level of alertness; decreased gag or cough reflexes Warning signs/symptoms of Dysphagia - avoids certain textures - coughing and/or choking during eating/drinking - change in voice tone or quality after eating; sounds wet or hoards when eating/drinking - abnormal movements of the mouth, tongue or lips - leakage of liquid/food - slow, weak imprecise, inconsistent, or uncoordinated speech - abnormal gag reflex or gagging - delayed swallowing - incomplete swallowing or pocketing of food or medications; pills get stuck in throat - regurgitation - drooling - voice upper respiratory infection VUR - pneumonia - silent aspiration Symptoms of Aspiration Pneumonia in Older Adults - elevated respiratory rate - fever - cough - chills - pleuritic chest pain - crackles (rales) - delirium, increased confusion, or falls Nursing Diagnoses - risk for aspiration - constipation - diarrhea - imbalanced nutrition: less than/more than body requirements - feeding self-care deficit Planning - goals and outcomes, ex. 1. Patients daily nutritional intake meets the minimum DRIs 2. Patient loses 250 g (1/2 lb) per week ** very unlikely that weight loss is the goal when the client has dysphagia - setting priorities - continuity of care Implementation: Acute Care - advancing diets - promoting appetite ** FOCUS IN NSE 111 - assisting patients with feeding** - enteral tube feeding - parenteral nutrition Feeding Strategies - safety: suction equipment - sitting in the most upright high-fowlers during and at least 30min after meal - sensory needs: e.g, glasses, hearing aids, dentures - feeder sits at eye level with person within their line of vision - describe the tray contents if visually impaired - place small bite of food on the stronger side of the mouth if hemiplegia - spoon rocking motion not tongue-metal or iced spoon is best - offer sips in between. Allow for 5-10 secs. Feed 1/2 - 1tsp bite at a time. Observe for 2 swallows between bites/sips. If not swallowed then offer empty spoon to stimulate swallow - minimize distractions but make enjoyable, offer choices, go at client’s pace-no spoon hovering. Eliminate bad doors - prioritize nutrient dense foods first, but must be agreeable - provide culturally appropriate foods - **observe for drooling, coughing, hoarse voice, choking, gagging, pouching and signs of swallowing difficulty-stop feeding - keep upright x 30 mins post meal - **Provide oral care post meal Multidisciplinary Management of Dysphagia Improve Physiology of Patient’s Swallow - medication - iced spoons - downward pressure on tongue - place food in unaffected side of mouth - upright position: during & 30min. After meal Redirect Bolus Flow - chin down position: direct bolus flow away from airway entrance - double or repeat swallow: to clear any remaining bolus from unprotected airway Dietary Modification Alter consistency of food and liquids related to patient’s oral motor control. SOLIDS: modify textures from regular to mechanically altered (minced) to puréed (homogenous & cohesive- pudding like) LIQUIDS: create a consistency/viscosity that matches patient’s capacity for swallowing from nectar/honey like to milk shake consistency to apple sauce- to pudding and finally mash potato consistency Evaluation: To measure the effectiveness of nutritional interventions To ascertain if patient has med goals and outcomes To amend nursing interventions More specifically… - how did the client tolerate the feeding? How much eaten? - any symptoms of dysphagia? Pocketing? Fatigue? - enjoy the meal? - able to sit 30 min post meal? - food preferences met? DIET PROGRESSION AND THERAPEUTIC DIETS Clear liquid: limited to broth, bouillon, coffee, tea, carb. Bevs, clear fruit juices, gelatin, or popsicles Thickened liquid: all liquids thickened to appropriate consistency (nectar honey, or pudding) Full Liquid: clear- or thickened-liquid diet can be added smooth textured dairy products, custards, refined cooked cereals, vegetable juice, puréed veg, or any fruit juices Puréed: this diet includes all of the above with addition of scrambled eggs, puréed meats, vegetables, fruits, or mashed potatoes and gravy Mechanical soft: includes all of the above pulse ground or finely diced meats, flaked fish, cottage cheese, rise, potatoes, pancakes, light breads, booked vegetables, cooked or canned fruits, bananas, soups, or peanut butter Soft or Low residue: low fibre, easily digested foods, such as pastas, casseroles Week 10 Safety in Health Care Setting What is the nurse’s role in patient safety? - assess patient and environment for safety hazards - plan and intervene appropriately to maintain safe environment - provide safe care, health promotion Building a ‘Culture of Safety’ - Emphasis on communicating effectively by acknowledging errors, and getting timely help to decrease errors: reflect upon mistakes, know/prevent conditions that lead to unsafe practices, develop competencies for safe practice. - need leadership, staffing models, collaborative and reflective practice - prevention/reduction of unsafe acts in the health care system - use of ‘best practices’ and practice guidelines make for better patient safety: fewer falls, fewer pressure sores, sleep/fatigue policies, fewer medication errors etc - patient safety is the reduction and mitigation of unsafe acts within the health care system, as well as through the use of best practices shown to lead to optimal patient safety What is considered an ‘Incident’? - patient safety incident (or adverse event) is an even that could have resulted, or did result in unnecessary harm to a patient - incidents include.. 1. Harmful incident 2. Near miss 3. No-harm Risks to Patient Safety - developmental risk occurs throughout life Categories of Risk within Health Care 1) falls: up to 90% for all ages of all reported incidents in hospital (*often from patients attempt to get out of bed to use toilet) 2) Procedure related accidents: occur during therapy (surgical, medication, fluid administration, break-in sterility errors) 3) equipment related accidents: malfunction or misuse of equipment, or from electrical hazards Fall Risk Assessment Tool: To determine specific needs, target interventions, to prevent falls (family members are important resource for fall risk info!!!) - Heinrich II Fall Risk Model: looks at client’s ability to move independently, and other factors that increase risk for falls. A score of 5 or more= High Risk When is the Tool Used? 1- on admission to facility-explain call bell for help out of bed 2- after a fall, to determine why it occurred. Once a fall happens, there is increased risk for falling again Safety Alert! Mechanical Lifting Devices - always follow organizational policy when using - do not use them by yourself - student nurses should always work with qualified personnel when using mechanical devices Medications (Year 2 onward) - follow procedures for administering to prevent errors - check patient ID, rights of medications Practice aseptic techniques (medical/surgical) to prevent infection Assessing and Maintaining a Safe Complete Health History: - assess gait, strength, balance, vision, exposure to environmental hazards, medications when increase risk (diuretics) Assessing Client’s Home Environment - inspect the home: lighting, walkways, risk for food infection, poisoning, heating/cooling system, assess for lead in paint plumbing Assessing Health Care Environment - in hospital, assess barriers to ambulation, call bell available? Risk for medical errors, nurse fatigue= errors - Check pt ID band before all medication administration and/or procedures-do not rely on your memory of pt - assess risk falls, medication errors Developmental Assessment and Interventions to Promote Safety Infants, Toddles, Preschoolers - “back to sleep” - safety locks - prevent accidental drowning or poisoning - car seat School-age - road safety - safe internet use, stranger safety - bicycle safety - sports safety gear Adolescent’s - self-esteem - body piercing/tattoo infections - sex education - effects of use of alcohol, drugs, substances - driving safety Adults - postpartum depression - lifestyle: nutrition, stress, alcohol Older Adults - falls - medication errors - burns and scalds - driving safety and MVAs - road safety WHIMIS: Workplace Hazardous Materials Information System - sets standards for control of hazardous substances in workplaces across Canada. Hazardous: any product/material that could cause physical/medical problems 3 Elements: - Worker Education Programs: how anyone can read the labels - cautionary labelling of products: display product’s physical/health hazards, safety/first aid measures, & identify the types of hazard that product presents - Material Safety Data Sheets (MSDS): give detailed information about the substance, any health hazards imposed, precautions for safe handling/use, steps to take if substance released or spilled What are Restraints? Are physical, chemical or environmental measures used to control the physical or behavioural activity of a person or a portion of their body Use of Restrains Must Meet the Following 4 Objectives: 1. Reduce the risk of client injury 2. Prevent the interruption of therapy, such as traction, IV infusion, NG tube feeding, or Foley catherization 3. Prevent the confused or combative client from removing therapeutic treatment/ life-support equipment 4. Reduct the risk of injury to others by the client Physical Restraint Devices used to limit body movement: - belt restraint - mitten - elbow restraint - mummy restraint - table fixed to a chair that cannot be opened by the client - bedrail that cannot be opened by the client, - jacket* - seat belt that fastens behind a chair What are the complication of physical restraints? - nerve damage - pressure ulcers - constipation - pneumonia - incontinence - urinary retention - contractures - circulatory impairments - fear, anger increased agitation, depression, humiliation, decreased self-esteem - muscle atrophy - skin tears - strangulation - asphyxiation - death Environmental Restraints Controls- clients mobility - secure unit or garden - seclusion - time out room - locked units - locked elevators Chemical Restraint: Medication used, not to treat illness, but to intentionally inhibit a particular behaviour or movement What puts a person at risk of being restrained? A person who may hurt themselves or others because they just forget to ask for help or have: - an illness or injury to the brain, severe cognitive impairment - physical impairment - confusion - a habit of falling or wandering to where it is not safe - fall-injury risk - diagnosis or presence of psychiatric disorder (e.g., alcohol withdrawal) - fears about getting a treatment like a needle that is necessary - presence of medical devices in cognitively impaired patients Alternatives to Restraints - encourage the person to do the things they enjoy such as cards, Tv or music - walk with the person - help the person to get to the bathroom at regular times - make the person’s room safe by lowering the bed to its lowest level - make sure there is enough light - place object and furniture in the same place - have a friend of family member visit to sit with the person when they are restless, confused, upset or afraid - use an alarm that tells others when the person moves from a chair or bed - Volunteers/sitters - Bed alarms/ chair alarms - bed at lowest point (as low as 12inches off the ground) - mattress on floor next to bed - patient room located close to nursing station - locked nursing units - exit door alarms ANSWER THESE: Why is the restoration applied? Can the restraint be removed? When temporarily? When permanently? What are the alternatives? How is safety addressed here? How is dignity/agitation minimized? What can YOU Expect if a Restraint becomes Necessary? - know agency policy - can alternative be tried? - a written order from you doctor is needed unless it’s an emergency - a patient, (and with consent their family or substitute decision maker), must be involved in a discussion and told about the use of any restraint - if unable to provide consent, the person’s family or subtitle decision maker must provide consent unless it is an emergency and the restraint is needed to prevent harm - the restraint should be used for the shortest possible time and as soon as it is safe, be removed - the least restrictive form of a restraint should be used - the healthcare team caring for the person in a restraint must: - what the person closely to ensure their safety (check facility policy to define “closely” in minutes) - assess all skin areas in contact with restraint - look for the earliest and safest time to take off the restraint, and - frequently offer the person who is restrained help with activities such as eating and going to the bathroom, ROM exercises What are the Unexpected Outcomes and Related Nursing Interventions? Recording and Reporting - record behaviours that place patient at risk for injury - describe restraint alternatives attempted and patient’s response - record patient’s and family’s understanding of and consent to restraint application - record type and location of the restraint and time applied - record time of assessments related to orientation, oxygenation, skin integrity, circulation, and positioning - Describe the patient’s response when restraints were removed Week 11: Understanding the CNO’s Quality Assurance Program CNO Mission: Clearly set out the role of the organization Regulating nursing in the public’s interest Both the VISION and the MISSION guide the planing and choices of the College’s Council and staff as they carry out their regulatory, governance and administrative functions. Overview of The College’s Quality Assurance Programs (QA): Principle that lifelong learning is essential to continuing competence. Nurses in every practice setting demonstrate their commitment to continually improving their nursing practice by engaging in Practice Reflection, and by setting and achieving learning goals. The following components: - self- assessment - peer feedback - practice assessments - coaching support - learning plan - quality assurance - monitors participation and compliance ** Peer Feedback and Coaching support are part of QA Reflective Practice - looking back on experiences in a new way - contemplating your actions and decision in order to learn from them - learning from experience - integrating experiential (personal), empirical, ethical and the aesthetic knowing… to are more effectively for your clients Process of Reflective Practice LEARN FRAMEWORK Look back Elaborate Analyze Revise New Perspective Look Back - recall and briefly outline a clinical event that is meaningful to you as a student nurse - be clear and concise - as a ‘look back’ you hint at the situation, only elaborate in the next part… Elaborate (what happened) Objective Recall Provide comprehensive/concise description of event - who was involved in the event? Remember confidentiality - do not use actual names of people or places - what was said by you are by others? - what was done by you and other? Subjective Recall Explore the meaning of event to self and other - what did you think? - what did you feel (emotions)? - what were your intuitions (gut feelings)? - how did you think others were feeling? - what are your values &/or beliefs in relation to the event? - from where do these values & beliefs arise? Analysis - identify one significant issue related to your role (i.e. actions, behaviours, thoughts) in the event - identify potential factors contributing to your role in the event and consider what was appropriate or inappropriate with you role in the event and why - describe how your thinking may have changed as a result of this event Assumption Recognition and Analysis - what has been taken for granted in this situation? - which beliefs/values are shaping me assumptions? - what assumptions contributed to the problem in this situation?