NUR 235 Week 2 (2).pdf

1 Week 2 Outline: Safety, Perfusion, and Gas Exchange A. Safety a. Maintain safety by promoting a culture of safety (a just culture where employ...

1 Week 2 Outline: Safety, Perfusion, and Gas Exchange A. Safety a. Maintain safety by promoting a culture of safety (a just culture where employees feel safe in reporting error without fear of punitive action), preventing all 3 levels of errors, and having systems in place that promote transparency (reporting mistakes and learning from them) b. Organizations: IOM/NAM, QSEN, IHI, IPEC i. QSEN goal: address the challenge of preparing future nurses to improve quality and safety ii. QSEN competencies: 1. patient centered care 2. quality improvement 3. teamwork and collaboration 4. Safety 5. evidence based practice 6. informatics c. 3 Types of Events: i. Near miss: a close call (ex: almost gave a patient 2000 mg acetaminophen instead of 1000 mg but you caught it in time) ii. Adverse event: an unexpected or undesired event or mistake (ex: gave 2000 mg acetaminophen instead of 1000 mg, but the patient was fine) iii. Sentinel event: a type of adverse event that causes serious harm or death (ex: gave 20 mg fentanyl IV instead of 20 mcg fentanyl IV and the patient died) d. Patient safety i. Healthcare workers are mandatory reporters of all types of abuse (physical, mental/emotional, sexual, social, financial, trafficking) 1. Signs of Abuse: a. Physical: injuries with inconsistent stories, bite marks, unexplained injuries, burns, pressure injuries, malnutrition b. Behavioral: depression, anxiety, sleeping issues, declining grades, declining work performance, social isolation ii. Factors that affect safety include age, mobility, cognitive and sensory awareness, emotional state, ability to communicate, and lifestyle and safety awareness.  2 iii. Ask about allergies! iv. Fall prevention 1. High risk patients for falls: a. Elderly b. Vision problems c. Weakness d. Urinary frequency e. Gait and balance problems (cerebral palsy, injury, multiple sclerosis) f. Cognitive dysfunction g. Adverse effects of medications (orthostatic hypotension, drowsiness) 2. Prevent falls a. Fall risk assessment b. Fall wristbands c. Instruct patient on call light d. Regular toileting e. Night lights f. Keep floor clear of clutter g. Grab bars and assistive devices h. Grippy socks i. Side table and personal items within reach j. Bed locked in lowest position k. Chair or bed sensors i. For clients who are sedated, unconscious, or otherwise compromised, keep the side rails up. ii. Avoid the use of full side rails for clients who are oriented enough to get out of bed or attempt to get out of bed without assistance. v. Seizure precautions 1. Before a seizure: a. Make sure rescue equipment is at the bedside, including oxygen, an oral airway, suction equipment, and padding for the side rails. b. Find any items that could cause injury during a seizure and remove them c. Assist with ambulation and transferring d. Educate family/caregivers 2. During a seizure: a. Stay with patient and call for help  3 b. Maintain airway patency and suction PRN c. Rescue meds d. Lower the client to the floor or bed, protect their head, remove nearby furniture, provide privacy, put them on one side with the head flexed slightly forward if possible, and loosen their clothing. e. Do not put anything in a patient’s mouth or restrain them during a seizure! f. Document the seizure vi. Seclusion and restraint 1. Can be physical (devices that restrict movement: vest, belt, mitt, limb) or chemical (sedatives, neuroleptic or psychotropic medications) 2. Least restrictive/least invasive 3. The provider must prescribe seclusion or restraints in writing, after a face-to-face assessment of the client only after ALL ELSE HAS FAILED a. Must include reason, type of restraints, location of the restraints, how long to use, and behavior of patient b. 4 hr of restraints for an adult, 2 hr for clients ages 9 to 17, and 1 hr for clients younger than 9 years of age. c. Can renew with a maximum of 24 consecutive hours. d. No PRN prescriptions for restraints. e. Nurses can place restraints in emergencies but must get a prescription ASAP 4. Nursing interventions: a. Assess skin integrity and provide skin care according to protocol (ex: Q2hrs) b. Pad bony prominences c. Secure/tie restraints to a part of the bed frame that can raise and lower when the bed controls are used. Do not secure/tie restraints to the side rails of the bed. If restraints with a buckle strap are not available, use a quick-release knot to tie the strap. d. Make sure the restraints are loose enough for range of motion and that there is enough room to fit two fingers e. Regularly determine the need to continue using the restraints f. Never leave a restrained patient alone! g. Offer food and water  4 h. Provide bathroom/hygiene means i. Monitor vitals j. Range-of-motion exercises k. Document 5. Do not use restraints for: a. Convenience of the staff b. Punishment for the client c. Clients who are extremely physically or mentally unstable d. Clients who cannot tolerate the decreased stimulation of a seclusion room vii. Fire safety 1. RACE: a. Rescue patients by moving patients to a safer location b. Alarm c. Contain/Confine the fire by closing doors and windows and turning off oxygen/electrical devices d. Extinguish the fire 2. PASS (fire extinguisher use): a. Pull pin b. Aim at base c. Squeeze handle d. Sweep extinguisher from side to side B. Gas Exchange a. Vertical chest landmarks: i. The midsternal line is through the center of the sternum. ii. The midclavicular line is through the midpoint of the clavicle. iii. The anterior axillary line is through the anterior axillary folds. iv. The midaxillary line is through the apex of the axillae. v. The posterior axillary line is through the posterior axillary fold. vi. The right and left scapular lines are through the inferior angle of the scapula. vii. The vertebral line is along the center of the spine.  5 b. Chest inspection i. Shape: AP diameter 1:2 ii. Symmetry: Symmetrical iii. ICS: No excessive intercostal (rib) retractions iv. Respiratory: 12-20 breaths/min, no accessory muscle use, even chest wall expansion, normal depth/effort/sound of respirations, no nasal flaring v. Cough: if productive, note sputum color and consistency vi. Trachea: midline vii. Abnormal findings: 1. Scoliosis: S or C shaped spine 2. Kyphosis: hunchback 3. Lordosis: lower back curves forwards  6 4. Barrel chest: Anteroposterior diameter is larger than transverse (common in COPD/emphysema) 5. Pectus carinatum: pigeon chest  7 6. Pectus excavatum: sunken chest c. Auscultation  8 i. Have patient sit upright or turn to side, take deep breaths through open mouth ii. Listen on skin not clothes! iii. Expected lung sounds: 1. Bronchial: Loud, high pitch, expiration > inspiration 2. Bronchovesicular: Medium pitch blowing, expiration = inspiration 3. Vesicular: soft, low breezy sounds, inspiration > expiration iv. Unexpected lung sounds 1. Crackles or rales: fine to coarse bubbly sounds not cleared with coughing 2. Wheezes: high pitched musical whistling, louder on expiration 3. Rhonchi: coarse, low pitched rumbling from fluid or mucus, can clear by coughing 4. Pleural friction rub: dry grating rubbing sound 5. No breath sounds: collapsed or removed lung v. Listen to lung sounds here! https://learn.practicalclinicalskills.com/lung-sounds C. Perfusion a. Heart sounds i. S1 (“lub”): closure of mitral and tricuspid valves, beginning of systole 1. Heard at heart’s apex (Points 4 and 5)  9 ii. S2 (“dub”): closure of aortic and pulmonic valves, beginning of diastole 1. Heard at aortic area (Points 1 and 2) iii. S3: rapid ventricular filling, may be normal in kids and young adults iv. S4: strong atrial contraction, may be normal in older and athletic adults and children v. Auscultation sites: All People Eat Three Meals (or APE To Man) 1. Aortic: 2nd ICS, right of sternum 2. Pulmonic: 2nd ICS, left of sternum 3. Erb’s point: 3rd ICS, left of sternum 4. Tricuspid: 4th ICS, left of sternum 5. Mitral (apical pulse or Point of Maximal Impulse): 5th ICS, left midclavicular line vi. Dysrhythmias: when heart doesn’t beat regularly vii. Gallops: extra heart sounds 1. Ventricular gallop: after S2, Kentucky 2. Atrial gallop: before S1, Tennessee viii. Murmurs: blowing or swishing sound when blood volume in the heart is increased or flow is altered. May be normal or related to regurgitation or stenosis (use bell of stethoscope to hear) 1. Systolic murmur: after S1 2. Diastolic murmur: after S2 ix. Bruits: blowing or swishing sound indicating obstructed flow (like atherosclerosis) 1. Can assess for bruits over carotid arteries, abdominal aorta, renal arteries, iliac arteries, and femoral arteries  10 b. Perfusion inspection and palpation i. Appropriate LOC ii. Normal SpO2 iii. Normal pulses 1. Equal bilaterally 2. Graded 2+ 3. Carotid: on either side of trachea a. Palpate one carotid artery at a time or your patient will pass out 4. Brachial: right above elbow 5. Radial: inner wrist thumb side 6. Posterior tibial: below inner ankle 7. Popliteal: back of knee 8. Dorsalis pedis: top of foot iv. Normal BP 1. No orthostatic hypotension (remember from week 1!) v. Cap refill