NURS221 Notes (LabLec) PDF

LECTURE 1: Infection Control and safe environments of care CRNA INFECTION AND PREVENTION CONTROL STANDARDS “Standards describe the minimum expectations that nurse be met by RN’s and NP’s who practice nursing in Alberta. They must meet or exceed all standards that apply to their practice.” Retrieved...

LECTURE 1: Infection Control and safe environments of care CRNA INFECTION AND PREVENTION CONTROL STANDARDS “Standards describe the minimum expectations that nurse be met by RN’s and NP’s who practice nursing in Alberta. They must meet or exceed all standards that apply to their practice.” Retrieved Sept. 3rd, 2024, from 1. Responsibility and accountability 2. Knowledge-based practice 3. Ethical practice 4. Service to the public INTERDEPENDENT SUBCULTURES OF PATIENT SAFETY CULTURE (Gregory et al. 2020, pp. 270) RIFL Reporting culture (report if something is unsafe) Informed culture Flexible culture (if issue is identified, workplace can be flexible and fix it) Learning culture (students are most involved here in terms of infection control) If all is healthy in an organization- you have a just culture. ALBERTA HEALTH SERVICES Infection Prevention & Control (IPC) is dedicated to preventing infections acquired within healthcare facilities. As a province-wide service, IPC works in close collaboration with: Population, Public and Indigenous Health Workplace Health and Safety (WHS) Linen and Environmental Services (LES) Capital Management Medical Device Reprocessing Other clinical and non-clinical programs In canada, 220,000 hospital infections/year Chain of Infection/Transmission (IRPMPS) 1. Infectious agent 2. Reservoir: a place within which microorgs can thrive and reproduce (ex. Someone with infection) 3. Portal of exit: Place of exit providing a way for a microorg to leave reservoir (ex. Resp tract when you sneeze/cough) 4. Means of transmission: method of transfer in which germs are carried from one place to another (ex. Dirty hands) - USE HAND HYGIENE HERE TO BREAK CHAIN - Contact transmission: healthcare hands most common form of transmission in hospital - Transmit by hand to patient via direct contact - Transmit by surface → hand → patient via indirect contact 5. Portal of entry: any type of opening that allows the microorg to enter host body & cause infection or colonization (ex. IVs, devices, catheters) 6. Susceptible host: person at risk of getting infection, decided by factors such as age, disease, nutritional status, immune fx (ex. Patients with weak immune system) Hand washing: 15-30 sec ABHR: preferred method because fast, better for your hand health - Used majority of times except: visibly soiled, diarrhea/vomiting patients, before food prep  - MORE EFFECTIVE THAN SOAP AND WATER - Minimum alcohol content: 60% Commonly missed areas when hand washing: fingertips, areas between fingers, thumbs Gloves: can be barrier to hand hygiene, use in conjunction with hand hygiene, ONLY WORN WHEN: - Risk of exposure to blood/body fluids - Patients on contact precautions - Performing invasive/sterile procedure Hand Hygiene needed when: - Before accessing/donning gloves - Immediately after dofting gloves - Removing gloves while caring for same patient during 4 moments: 4 moments: when risk of transmission via hands is highest 1. Before patient/patient environ. contact 2. Before clean/aseptic procedure - putting on (donning) personal protective equipment (PPE), including gloves; wound care; handling intravenous devices; insertion of central venous catheters; food handling; and/or preparing medications. 3. After body fluid exposure - Dofting after touching body fluids with gloves 4. After contact with patient/patient environ. Aseptic procedure: prevention of transfer of micro-organisms from the patient’s body surface to a normally sterile body site. Such practices are used when performing procedures that expose the patient’s normally sterile sites: (4) - intravascular system, spinal canal, subdural space, urinary tract ^portal of exit: PCRA: point of care risk assessment, always use respiratory etiquette and waste management ^ Modes of transmission: routine actions THE NURSING PROCESS Mr. Jaydon is an 87 year old male, admitted to the care facility 2 months ago. He has issues with urinary incontinence, mobilizes independently with a walker, and is underweight with a diminished appetite. What increases his risk for infection? Assessment: where did he come from? (another care setting with MRSA?), underweight with diminished appetite, older adult, urinary incontinence puts him at risk for skin integrity/what causes the incontinence, pressure sores from sitting too long? Nursing Diagnosis Planning Implementation Evaluation See below: Routine Practices: gloving, gowning, eyewear, N95  - Identify what you are about to come in contact with - Gloves: blood/body fluids, contaminated items - Gown/eyewear: splashes, droplets - COVID: N95 masks KEY MOMENTS OF HAND HYGIENE Gregory et al (2020, pp. 401) Before touching a patient Before clean/aseptic procedures After blood or body fluid exposure/ risk After touching a patient After touching a patient’s surroundings Principles of Asepsis: - All tools were previously sterilized - When in doubt, assume it’s dirty - Containers used to hold sterile tools are NOT sterile - Moisture causes contamination - Medical asepsis: clean technique - Surgical asepsis: no germs allowed ROUTINE PRACTICES & ADDITIONAL PRECAUTIONS (RPAP) - In addition to protective equipment: when in contact with disease (determined or yet to be determined) - put patients on additional precautions  Airborne: (-) pressure room, PPE, N95 Airborne & Contact: gown, gloves, N95 Contact: gown, gloves, mask & goggles for resp symptoms Contact & Droplet: gown, gloves, mask/face shield or goggles, N95 for flu A & B/aerosol Droplet: mask and goggles - Patient have own room/equipment/restroom - Hand hygiene before putting on equipment - If you need mask, you also need goggles INFECTION CONTROL QUESTIONS Can you identify the key moments one should perform hand hygiene? What do you make sure you do prior to doffing each item of PPE? - after doff gloves, hand hygiene,  doff gown, hand hygiene, eyewear, hand hygiene When are gowns donned? - when in contact with droplets Clean gloves? Assessing a patient’s pedal pulses. No (no open wound) Examining a scratch on the patients lower leg yes Assisting a patient to brush their teeth yes Assisting a patient to set up their meal tray no unless you are feeding them Throwing away the patients used tissues yes Walking a patient to the washroom no not for walking, unless you wipe them too Assisting a patient with cleansing their perineum after using the washroom YES LECTURE 2: ADLs & fundamentals of care framework Functional Ability According to Sargent; is defined as the cognitive, social, physical, and emotional ability to carry on the normal activities to live. represents a continuum from full function to lack of function, varies from person to person, and different points in time. Risk recognition is essential to the early identification of factors that affect function Developmental: ex. From infant to adult Physical Psychological Disease Social and cultural factors Physical environment: ex. Patient who can’t climb stairs but their home has stairs Research has repeatedly identified age, cognitive function, and level of depression as risks *** A sudden onset of functional decline is often indicative of acute illness or worsening of chronic disease. Which would be most difficult for you to lose? Feeding yourself Toileting independently Mobilizing Doing your own hygiene care Dressing yourself Making meals Shopping Managing your finances Cleaning/laundry 12 Activities of Daily Living (ADL’s) according to Roper-Logan-Tierney Model of Nursing Maintaining a safe environment Breathing Communication Mobilizing  Eating and drinking Toileting/eliminating Personal cleansing and dressing Maintaining body temperature Working and playing Sleeping Expressing sexuality Dying Instrumental Activities of Daily Living (IADL’s) Are activities necessary for independent living in the community - Things that go beyond basic ADLs Managing finances, banking and paying bills Shopping and preparing meals Managing medications Use communication devices (i.e. phone) Maintaining environment and personal items- cleaning, laundry Organizing and/or getting to and from places (driving) How is this assessed Subjective and objective data from patient, family, or observer Identification of difficulties with an underlying reasons for the deficit Perceptions, values, and goals are highly important. Ask what do they think would help? Tools such as the FIM (Functional Independence Measure) Katz Index of Activities of Daily Living, or the InterRAi (RAI-HC) tools may be used Ex. IYM: patient’s ability may fluctuate might change depending on time of day, level of illness, recent test Urgent if there is a significant change Lack of ADL function can lead to dependence, unsafe situation, poor quality of life Functional Independence Measure (FIM™) > functional status of a person based on the level of assistance her or she requires 1-7 score (7 being complete independence) 2 subscales in cognition and motor, score range of 18 to 126 Used at different times during admission 72hrs upon admission and 72 hrs within discharge Identify progress and areas in need of assistance The higher the score the more independent the patient on that task Used by a healthcare practitioner to assess and grade the functional status of a person based on the level of assistance her or she requires  Can be used to identify progress Katz Index of Independence in Activities of Daily Living - Targeted at chronically ill people and older adults - Only basic ADLs are included - Identify one Bathing Dressing Toileting Transferring Continence Feeding The Hartford Institute for Geriatric Nursing (2007) Each ADL category can be ranked from 0 to 6 - From dependent to highly independent interRAI - Broad range of physical, social, mental abilities - Strengths in areas that might be problematic - Determines care plans (right care, right place) ADL functioning Communication/hearing Depression Environment/home safety Health conditions IADL- self performance Mental functions Nutrition/hydration Physical abilities Reliance on healthcare services Social functioning Strengths Continence Dental status Disease diagnosis Falls Medication use Informal (family) support services Mood and behaviour Pain Preventative health measures Skin conditions Socio-demographic/background information Vision Assistive Devices  - Ex. Commode chair for toileting - Quality of life and mobility - Teach patient and family how to use it - Mobility Devices - Cane; Assists with balance and support, relieves pressure on wt. bearing joints. Should be used on unaffected side - Crutches; For partial or non weight bearing ambulation. Requires good balance and CV reserve, strong upper body strength. - Walker; Provides more support than cane or crutches, various models: no wheels, 2 or 4 wheels - Wheelchair; Provides full support, however needs to be able to tolerate seated position. Off pressuring pressure points important (moving around when sitting) You may need cushions, special transfers and changing positions - Transfer Belt; Used to safely mobilize, and transfer patients. Alberta Aids to Daily Living Program (AADL) Helps Albertans stay independent in there communities by paying for basic medical equipment and supplies. You are eligible if you are an Alberta resident with a valid AHCIP card, and you require assistance because of a long term disability, chronic illness, or terminal illness A clinical assessment by a health care professional is required (AADL authorizer) and needs are determined. AADL is a cost share program, 25% of the benefit cost to a max of $500 per individual or family per year. Those receiving income assistance do not pay cost sharing. Equipment and supply needs may include items such as: Wheelchairs Hospital beds Adaptive equipment Dressing change supplies Incontinence supplies Oxygen and devices Definition of Fundamental Care - Also called basic care “Fundamental care involves actions on the part of the nurse that respect and focus on a person’s essential needs to ensure their physical and psychosocial wellbeing. These needs are met by developing a positive and trusting relationship with the person being cared for as well as their family/carers.” Fundamentals of Care Framework Rests on the ability of the nurse to connect with the patient and through that connection be able to meet or help the patient themselves meet their fundamental care needs. Focus is on enabling the patient and the nurse to confidently and competently assess, plan, implement, and evaluate care around the fundamental care needs. Nursing contributes to the patients journey in facilitating the effective execution of basic needs in a way that is competent, respectful, personal and empathetic. Effective nursing care is achieved through conscious alignment of three core elements; establishing a relationship with the patient; being able to integrate the patients care needs; and ensuring that the wider health system or context is committed and responsive to core tasks. Fundamentals of Care Framework Context of care: advocate for resources LECTURE 3: Safety in mobility, fall risk management It’s Your Move Notes: Physical hazard: lifting/handling loads - to reduce, use equipment, body mech, Chemical hazard: administering chemo - to reduce, wear gloves Biological hazard: body fluids/blood - to reduce, wear PPE Psychological hazards: verbal abuse from patient - to reduce, use diff approaches, apply distraction tactics 6 checkpoints of body mech: - 3 for top: ears, shoulder, hips lined up - 3 for bottom: tighten stomach, push butt back, keep body weight over heel, move trunk over, bend at hip & not at waist - Elbows tucked in - Safe effective grip: palms up and neutral wrist - Comfort zone: stand elbows bent, tucked in, move hands from shoulder to hips - Weight transfer: shift body weight from from leg to back leg/side to side, use slide-roll (passive) instead of lift) 4 assessments for IYM: - Self, Environmental, observational  - Patient: medical, cognition, functional, communication, emotional/behavioral Types of Transfers: Independent: bears body weight - Cooperative, predictable, reliable in physical and mental performance - Can safely relocate themselves with/without assistive devices Minimum assist: bears weight through parts of body - Same as above plus: - May need physical/verbal cues - May need minimal assistance with equipment/personal items One person with belt: bears weight through parts of body - Cooperative, predictable, reliable in physical and mental performance - Maintain balance when walking/shuffling/pivoting - Requires 1 worker/hands on assistance - Belts: not used for lifting, used for directional pressure/momentum 2 person with belt: same as 1 person/belt but now it’s 2 ppl Sit stand: unable to stand for 15 sec but has partial weight bearing abilities through parts of body - May be unpredictable physically/mentally - Able to keep at least 1 arm outside harness - Must be 2 workers for lift machine Total lift: can't bear weight - May be unpredictable - May be unable to follow instructions (cognitive/physical disability) - May be uncooperative - May be unable to maintain sitting position Bed rest: confined to bed by doc’s order or nature of medical condition Max # of logos at a time = 2 In transition: used in selected areas or admission of clients was less than 24hrs ago - May be changed after each functional assessment, use regular logo as soon as patient is stabilized KEEPING THE PATIENT AND NURSE SAFE Nurses need to practice ergonomics to avoid injuries- such as maintaining proper body alignment, movements, and posture. Nurses must also consider the patient’s alignment, movements, and posture to ensure they are not at risk for injury. POSTURE, ALIGNMENT AND GAIT Posture alignment: the relationship between one body part and another along a horizontal or vertical line, and involves positioning where there is no excessive strain on any muscle, joint etc. Balance: achieved when the center of gravity is balanced over a stable base of support and is enhanced by using proper posture. Gait: The manner or style of walking and includes rhythm, cadence and speed. You can use balance to maintain proper body alignment and posture by widening your base of support, and bringing the center of gravity to the base of support. DEFINITION OF A FALL “an event that results in a person coming to rest inadvertently on the ground or floor or other lower level, with or without injury” and has been described as a “complex multifactorial phenomenon, a syndrome, and an indication of an emerging or worsening health condition.” FALLS AND FALL RISK According to Healthcare Exc ellence Canada falls can be classified as; Anticipatory Unanticipated Accidental Anticipatory falls can be prevented through screening, communication, and implementation of targeted prevention strategies. FALL PREVENTION IS A PRIORITY ALSO BECAUSE Of all types of injuries, falls are a leading cause of injury deaths, hospitalizations, permanent total or partial disabilities. Approx. 30% of persons over 65 in the community fall at least once per year, and it increases to 50% for those over 80 years. 95% of hip fractures are directly attributable to falls, and 20% ultimately prove fatal. Fall injuries can affect quality of life, decrease independence, and may also require alternative housing arrangements. For example after a fall a patient may become anxious, less confident, and afraid of falling again. This is in turn may result in them engaging in less physical activities resulting in deconditioning, muscle weakness and greater risk of falling. RISK FACTORS FOR A FALL Over 400 risk factors have been identified They may be modifiable (amenable to interventions) or non modifiable (i.e. age). Factors such as poor communication among team members can also put the patient at risk! AHS FALLS RISK MANAGEMENT POLICY PS-58 ELEMENTS Prevention Screening and assessment Intervention Data collection and measurement Evaluation Practice improvement ACCORDING TO RNAO BEST PRACTICE GUIDELINES ON FALLS; Universal fall precautions should be implemented which are interventions in health care settings that benefits everyone such as addressing environmental issues. All adults should be screened for risk of falls If a risk is identified, employ a combination of interventions tailored to the person and the health care setting. UNIVERSAL FALLS PRECAUTIONS The premise is that addressing environmental and situational falls risk factors in the health care setting will benefit everyone. Like routine practices – they are automatically applied for all people whether or not deemed a fall risk. Examples include; looking for and addressing trip hazards, adequate lighting, and caution signage. Can you think of at least 2 more? A VARIETY OF TOOLS EXIST TO IDENTIFY PATIENTS AT RISK These include; Functional Gait Assessment (FGA) Hendrich ll Fall Risk Model St. Thomas Assessment Tool (STRATISFY) Schmid Falls Assessment Tool SCHMID FALLS ASSESSMENT TOOL ( PATIENTS 65 AND OLDER) Mobility: (0) no gait disturbance, (1) ambulates or transfers with assistive devices (1) unsteady gain no assistance. (0) unable to ambulate Mentation: (0) alert, oriented x3, (1) periodic confusion or confusion at all times, (0) comatose at all times. Elimination: (0) independent (1) independent with frequency or diarrhea (1) needs assistance with toileting (1) incontinent Prior fall history (1) Yes before admission (2) yes during admission) (0) no, (1) unknown Current medications: (1) anticonvulsants,/tranquilizers or psychotropics/hypnotics 3 or above is at potential risk for falls, strategies should be implemented. INTERVENTIONS COULD INCLUDE: Use clear communication Educate patient and family re fall risk and prevention strategies Regular comfort rounds every 2-3 hours (which includes; toileting needs, hydration, position changes) Reminder to call for help when transferring, ambulating, and toileting Bed height at lowest level with walking device and call bell are within reach, Assess ability to use call bell Assess if using walking device correctly Appropriate non slip footwear for all transfers and when ambulating Clear barriers and clutter ADDITIONAL INTERVENTIONS Depends on patient’s unique needs and situation Such as - Sensory aids, such as eye wear, within easy reach to access prior to mobilizing. - A medication review - Dietary changes - Exercise program IF A PATIENT FALLS;  Assess for injuries; provide treatment Monitor for injuries that may not be immediately apparent (i.e. timing depends on setting as indicated in AHS monitoring schedule, post falls review). Determine factors that contributed to the fall (post fall assessment) Conduct further assessments; determine appropriate interventions Modify or add to care plan such as a referral for physical rehabilitation and/or to support psychological well- being AT MINIMUM Comprehensive head to toe physical exam Vital signs Physical assessment and monitoring VS ongoing (for 48 hours post) Neuro VS (GCS) and routine VS monitoring frequency are increased for: Head injury or if a head injury cannot be ruled out (unwitnessed fall) Falls from any height (off a step/ stairs) Patients at higher risk of neurological trauma (those on anticoagulants, anti-platelet therapy, those with hemophilia, or leukemia) AS A NURSING STUDENT IF YOU FIND SOMEONE OR WITNESS A FALL; Immediately go to resident and assess for Signs of Life – Airway, Breathing, Consciousness. If altered signs of life – Do you know the resident’s Goals of Care??? If appropriate, initiate CPR and call for help If awake and breathing with an open airway, reassure the resident and call for help! If you suspect a head injury, or the fall was unwitnessed, assume a head injury and gently immobilize the resident’s head and ask them to keep still until an assessment is completed. 5 WHY’S – DETERMINING ROOT CAUSE Why did Janet fall? She tripped Why did she trip? Her foot caught the edge of the chair Why did they catch the edge of the chair? The chair was too close to her bed Why was the chair to close to the bed? Someone did not put it back, and area was cluttered Why was area cluttered? Too many items in the area, had visitors that day and more chairs were brought in but not returned. LECTURE 4: Nutrition definition: the science of optimal cellular metabolism and its impact on health and science Malnutrition: condition caused by excess or deficient food energy/nutrition intake Calorie: a unit of energy BMI: body mass index, Ratio of patient’s body weight to height Carbs: compounds composed of carbon, hydrogen, and oxygen and major source of energy Waist circumference: an indicator of health risk where the waist is measured Nitrogen balance: Amount of nitrogen consumed equals the amount of nitrogen excreted over a specific period of time. Waist-hip ratio: waist circumference/hip circumference Glycemic index: ranking foods according to their potential for raising blood sugar relative to a standard food (white bread/glucose) - Low GI = good, controls blood glucose, appetite, cholesterol - High GI = bad, high insulin output, increase glycogen and fat storage Dietary reference intake: DRI: general term that includes 4 types of nutrition recommendations 1. Adequate intake (AI) 2. estimated average requirement (ER) 3. Recommended dietary allowance (RDA) 4. Tolerable upper intake level (UL) “As nurses, we must pay as much attention to our patients’ diets as to their illnesses, treatments, and therapies.… nurses must be aware of nutrients in whole foods to contribute accurately to the completion of nutrition assessments.” Tools to assess or screen; 24 hour dietary recall Food intake records (i.e. 3 day, 7 day etc.) Food frequency questionnaires Mini Nutritional Assessment (MNA) Mini Nutritional Assessment –Short Form (MNA SF) Malnutrition Universal Screening Tool Implementation strategies Inform the care team of your findings and concerns, physician, dietitian, etc. Discuss with care team the possibility of changing diet, texture change, small frequent meals, nutrient dense, higher protein, supplemental formulas etc. Monitor and encourage food and fluid intake Monitor weight Physical assessments i.e. oral cavity etc. Referral to a denturist 6 classes of nutrients: carbs, fat, protein (*wound healing), water, vitamins, minerals - Recommended 25-35g of fibre a day Special Diets Clear fluids: clear, low fibre fluids that are easily digested. (i.e. tea, broth) Full fluids: Low fibre diet of pureed fruit, soups and fluids that are easily digested. (i.e. ice cream, milk)  Pureed: Pureed foods, that are finely blended. Regular: Healthy diet (< 35 % Kcal of fat, < 7g saturated fat, 14 g fiber/1000 kcal, medium diet 1600-1800 kcal. Thickened fluids: for patients requiring thicker fluids for control of drinking to reduce aspiration. Dysphagia It is the difficulty swallowing and is defined in terms of impaired oral, pharyngeal, and or esophageal phases of swallowing Caused when there is a problem with swallowing that impacts the ability to protect one’s airway It is common in many health conditions, i.e. stroke Complications of Dysphagia Aspiration *can be silent Respiratory infections Dehydration Undernutrition/ Malnutrition Decreased quality of life Death It is important to identify those with dysphagia early (adults) Coughing and or choking when eating or drinking Drooling or poor management of oral secretions Pocketing of food in cheeks Facial weakness Gurgly, hoarse voice, or lots of throat clearing Multiple swallows for each bolus Decline in respiratory status Prolonged mealtimes Weight loss or malnutrition Recurring chest colds Pain with swallowing Increasing avoidance of multiple foods/liquids Dysphasia in Kids/babies: - Back arching - Breathing difficulty - Decreased response during feeding - Difficulty chewing food texturally appropriate for their age, refusing certain textures/types - Food falls out constantly when eating/crying - Congestion after meals, frequent resp illness, vomit, choke, pharyngeal residue, nasopharyngeal reflux Strategies to Manage Dysphagia Swallow assessment by a trained member of the interprofessional team; SLP, Dietition, OT, Physician Follow prescribed modified diet Use correct feeding technique and positioning Good oral hygiene care Monitoring nutrition and hydration (intake)  Always monitoring and reporting any signs and symptoms of concern! Modified Texture Diet Texture Appearance Pureed Soft, moist, smooth, without any lumps, no visible particles Minced Foods are minced, grated, or finely mashed to a size less than ¼ inch. The food is moist with no liquid separation. Small foods such as peas or corn may need to be pureed to be safe. - Yogurt, minced beef with gravy, pancakes in syrup, soft buns/cookies, - Nothing dry (english muffins/bagels) - Allow mixed thin liquids + solids Soft dysphagia Soft moist, must be fork tender, and mashable. Some foods need to be diced to a small size. - 1cm cubed or less - With a sauce so it’s less dry - Minced sandwich fillings, canned meat/fruit - Nothing dry, crumbly, sticky, gummy, fibery, large nuts/seeds Easy to chew Used for patients with chewing difficulties – softer textured foods, no hard foods. - Excludes dry crispy, stringy, tough skins/nuts/salads, raw hard veggies stuff Fluids Thickened As unable to manage thin fluids- thickening improves control and reduces risk of aspiration ◦ Mildly thick (consistency of nectar) ◦ Moderately thick (honey) ◦ Extremely thick (pudding) Oral Hygiene Highly important to overall health and wellbeing Promotes comfort, and stimulates appetite Important to prevent infection, maintain dental and gum health Done ideally 4 times per day- if only done once always should be before bed. Care is individualized as patient may have own teeth or dentures Oral assessment is important Referral may be needed to address oral issues, such as dental caries, or ill fitting dentures Clients at risk for oral health issues; NPO (nothing by mouth) Dehydrated Malnourished  Medical treatments and medications (chemo, radiation) Medical problems such as infection, diabetes, ulcers, lesions etc. Trauma or surgery in the area Unconscious or unable Brush the teeth with fluoride toothpaste twice a day—in the morning and at night—and floss at least once a day. Oral hygiene: Denture Care Oral care is important as can have plaque and debris buildup, irritate gums Must be handled with carefully as could break or be damaged Must remove at night to give gums a rest and avoid bacterial buildup Always stored in water to avoid warping Must use a denture brush when cleansing and cleansing solutions Ill fitting dentures can cause gum irritation and can be a choking hazard - Stand over a folded towel or bowl of water when you or your caregiver takes the dentures out. This way, if you drop them, they won't break. - Store them in lukewarm water or denture-cleaning liquid overnight. Don't put them in hot water, and don't let them dry out. - Clean your dentures to help prevent stains and help your mouth stay healthy. ○ Take your dentures out of your mouth, and rinse them to remove any loose food. ○ Use a brush designed for cleaning dentures, or use a toothbrush with soft bristles. Wet the brush, and gently brush every surface of your dentures with a denture cleanser such as Efferdent or Polident. Don't use toothpaste or a brush with hard bristles. They can scratch the dentures. You can use hand soap or mild dishwashing liquid, but don't use abrasive household cleaners or bleach. Supplemental formulas for adults - Ensure - Both vitamin rich - Don’t replace meals - Prescribed - Regular boost: 240 cals/10g protein/27 vitamins & minerals - High formulation boost: 20g protein + everything else - If on specialized diet; low protein, high calorie/ low sugar diet (diabetics), their formula will be different Questions! You are setting up a patient for their meal who has dysphagia, you will do which of the following? A. Ensure head of bed is elevated to 90% B. Ensure the height of bed is at the highest level C. Ensure that you have cut up her food to bite sized pieces *this might not be the diet they are prescribed D. Ensure she is using a straw when drinking her fluids *can choke when inhaling and swallowing at the same time Which of the following complies with a pureed diet? A. A popsicle B. A hamburger C. Mashed potatoes D. Peas and carrots LECTURE 5: Collaborative Communication documentation and reporting Documentation: any written or electronically generated info about a client that describes the care or services provided to that client… an essential part of nursing practice - Outlines the clients plan of care, interventions, and health services provided. - Promotes effective communication and safety - Provides informational continuity of care - Serves as a record of critical thinking and judgment - Describes the quality of care and standards of practice - Minimizes risk of errors if done effectively and accurately - Is a legal document that provides evidence of the care provided Group documentation: - needs/goals of the group, criteria for client participation - Nurse’s actions to help guide the group/meet their goal - Outcomes of group’s actions - Evaluation of group Types of Records ◦ Database (assessment information) ◦ Problem list ◦ Care Plans ◦ Progress notes (i.e. narrative records) ◦ Care maps / critical pathways ◦ Flow sheets, Graphic records ◦ Kardex ◦ Electronic Health Records CRNA states; ◦ “As part of the permanent client care record, clear, accurate, and comprehensive nursing documentation provides evidence that the registrant has met the expected requirements of documentation standards in their role in a particular practice setting.” Standards for Documentation - Standard 1: Accountability - Standard 2: Communication and safe provision of care - Standard 3: Security For example must include; ▪ All assessments, plan, interventions, evaluation ▪ Issues, concerns, outcomes, preferred goals ▪ Patient responses, relevant information ▪ Adverse event or outcome ▪ Instructions, patient/family teaching ▪ Communication with other care providers Registrants documentation must follow Standards as set out by CRNA Must be complete, accurate, objective, contemporous, organized, logical, sequential, while maintaining privacy, confidentiality, and adhere to regulations and legislation. Follow Guidelines ◦ Record all facts, accurately, thoroughly, and completely ◦ Correct errors promptly ( …Right Error M.B. Left lower leg… ) ◦ Include subjective data and objective data- indicate patients words in quotes. ◦ Avoid generalizations- “Slept well ” ” had a good day” ” ate well” be accurate and objective ◦ Chart contemporaneously ◦ Chart only for yourself (unless an emergency situation) ◦ Always begin with date, time (24 hr clock), and end with your name and designation ◦ Never “pre chart” ◦ Always protect your passwords, and follow electronic charting guidelines ◦ If writing by hand- ensure is legible, using permanent ink. ◦ Ensure correct spelling and wording-use only approved abbreviations ◦ Never leave blank spaces, if a blank space strike though the area. Narrative Documentation SOAP (Subjective- Objective-Assessment-Plan) PIE (Problem – Intervention-Evaluation) DAR (Data –Action-Response) - DAR Focus Charting 1030 At 0950 Patient stated he “tripped over shoe and fell on the floor”. Patient found lying on his bed. Denied pain and discomfort, and stated he did not hit his head but tripped near his bed and landed on his right side on the floor. Vital signs taken. T. 36. Radial P.86, 2 + regular, Resp. 18 regular and moderate depth, BP 120/80. No bruising or swelling noted on limbs or torso. Able to move limbs with ease with full range of motion. Fall reported to charge nurse, J. Still RN, who advised to monitor with neuro vital signs q 15 min. over next 2 hours, and begin post fall protocol. Patient advised to report any pain or change in how he feels, and stated he understood and would do so. ----------------------------------------------M.Bazin RN 1230 Patient stated he “feels fine”, and has noticed no change re pain or discomfort. NV signs taken q 15 for 2 hours, see graphic record. M.Bazin RN Health Records may be electronic: Advantages of Electronic Records; - Captures longitudinal information on the patients health - Continuous access to authorized users at any time - Can link to information resources such as medication information. - AHS phasing in Connect Care Privacy and Confidentiality ◦ The Code of Student Behaviour – University of Alberta ◦ Clinical Placement Agreement (AHS) ◦ Alberta Health Services Information Technology Confidentiality Agreement ◦ Covenant Health Agreement ◦ CNA Code of Ethics ◦ College of Registered Nurses of Alberta. (2022). Documentation standards Author. ◦ College of Registered Nurses of Alberta. (2023). Practice standards for regulated members. Author. ◦ College of Registered Nurses of Alberta. (2023). Privacy and management of health information standards. Author. Health Information Act (HIA) Provincial legislation including expectations for the collection, use, disclosure and security of health information Protects the privacy and confidentiality of individuals and their health information Requires that a person who performs a service or works for the agency understand privacy requirements that apply to their practice, and takes appropriate measures to safeguard health information(this includes nursing students!). Requires mandatory reporting when there is inappropriate access, disclosure or loss of individually identifying health information. Once reported the agency must to a risk of harm assessment to the individual who is the subject of the breach. Agencies may be required to notify the individual(s) of the reported incident. What does this mean for you? You need to familiarize yourself with the legislation and standards. ***Ensure you read the CRNA (2023) Privacy and Management of Health Information Standards document. You must protect and handle information in a secure manner, and dispose of it correctly. Gathering information must be done without photocopying, printing, or photographing Identifiable information must not leave the unit. Only access patient information relevant to your practice. Report any inappropriate access, disclosure, or loss of health information of patients receiving care. Participate in an incident debriefing to gather lessons learned for prevention of future incidents. Reporting Examples;  ◦ Change of shift Reports ◦ Transfer Reports ◦ Urgent Reports- such as SBAR, CHAT ◦ Incident Reports “Safe, effective clinical care depends on reliable, flawless communication between caregivers. Miscommunication is frequently identified as being a major contributor in sentinel or critical events.” Why does communication breakdown? ◦ Different communication styles ◦ High level of activity ◦ Frequent interruptions ◦ Complex healthcare environment ◦ Stress ◦ No standardization in organizing essential information SBAR - SBAR is a standard communication tool used to communicate critical situational information between healthcare providers. Used in a variety of situations (i.e. shift to shift, to physician, rounds, etc.) ◦Situation- who is calling, why and situation- or major concern. ◦Background- pertinent information, events leading up ◦Assessment-what do I think is the problem? Assessment of the situation ◦Recommendation (or request)-what do I recommend- what needs to be done. Identification Hello Dr. Bain, My name is Chad Micha RN on unit B at the Dorset Hospital Situation I am calling about patient Paul Todd. The main problem is pain, edema, warmth and redness to his right lower leg. He has no allergies Background Vital signs are stable. He has pain in his calf, rating it at 7/10, and his posterior right calf is red, warm, and edematous, skin is intact. He was given acetaminophen at 1420, which was ineffective for pain.  Assessment I am very worried about his situation and think the problem is a possible DVT in his right leg. Recommendation I think Paul needs to be seen right away. Are there any other tests you wish to order. Repeat back Can you tell my what I just said Social Media Guidelines “As regulated health professionals, nurses need to understand their professional and ethical obligation to protect the public and maintain conduct that reflects trustworthiness and integrity, including their online presence.” (CRNA, 2020, page 1) For example nurses need to ensure social media; ◦ Is client/ patient free ◦ Does not breach confidentiality ◦ Has no derogatory comments ◦ Credits thoughts and work of others ◦ Only posting authorized content ◦ Careful regarding personal views ◦ Information is evidence based- do not give health advise on line LECTURE 6: Hygiene: conditions or practices of cleanliness or care of the body are conductive to health and wellness Self care: refers to the person's ability to perform care functions in the following four areas: 1. Bathing 2. Feeding 3. Dressing 4. Toileting All without the help of others Hygiene care: - Regular bathing is essential to prompt healthy skin integrity - Very personal - requires intimate contact - Should be individualized to the patient - Practices are learned/may be influenced by many factors such as (_____) Begin with assessment What can the patient do independently? What will their medical/ condition allow? What are their preferences and normal practices? What are their needs related to hygiene? Who usually assists with their hygiene? What are their teaching needs?  What else would be important to do at this time Hygiene care in care settings: Scheduling hygiene care Early morning care bedpan, urinal or assistance to the bathroom, prep for diagnostic tests or early surgery, Washing hands and face, oral care. Prepare for breakfast. Morning Care (am care) Bathroom, shower or bed bath. Hair care, and shaving, oral care, foot/nail care, back massage, Dressing in clothes or changing gown, bed linen change, positioning, straighten bedside unit Afternoon care Washing hands and face (to refresh), oral care, elimination needs, checking bed linens, reposition if needed HS or evening care Washing face and hands, oral care, elimination needs, changing into a new gown or bed clothes, change linens, back massage. Straightening up area- to reduce clutter Bed Baths May be partial or complete depending on the needs and ability of the patient Always an opportunity to assess skin integrity and other systems (MSK) Is done i a structured way - and certain principles apply: LOOK BELOW Check for shortness of breath, skin integrity, if they need to pee If they have an IV, immobility or injury on one side, start on the unaffected side Don’t remove IV, just thread it through arm hole until it’s out of the way Fill basin ⅔ full, have patient test water temp 1. Eyes with washcloth 2. Wash face with/without soap 3. Wash arms DISTAL TO PROXIMAL DIRECTION 4. Wash 1 leg at a time, keep other one covered, distal to proximal wiping 5. Never soak feet for diabetics or impaired sensation patients 6. Peri care, change water, change gloves 7. Turn patient onto their side, wash from neck to butt When performing a bed bath Provide privacy (curtains closed) Maintain safety (side rails up) Maintain warmth (only expose areas being washed) Promote independence (encourage and assist where needed) Anticipate needs (be organized and have supplies ready) Ensure you are working safely (i.e. IYM principles- safe ht) Do a risk assessment and apply routine practices and infection control principles Cleanse from clean to dirty areas (change washcloth and water as needed – when cold or dirty) Use long strokes on limbs from distal to proximal Rinse and pat dry areas well Explain and communicate well throughout with the patient and family Bath in a bag (look like wet wipes) - Disposable - Convenient - No drying needed - No cleaning of equipment - Requires warming Safe bathing temp and frequency policy (38-43C) - AHS Policy # PS-47-01 (2022). - Standards are laid out to prevent harm to patients as a result of incorrect water temperature - Applies to all care settings – and applies to showers as well - Compliance is required among all staff including students - For 12 years and younger never over 38 degrees (36.7-38 is best practice - Safe temperature is identified prior to the patient entering the bath or shower - Continuing care homes- an opportunity for preferred bathing at least twice per week. Products to aid in maintaining skin integrity and hygiene care - Moisturizers - Moisture barrier creams - Cleansers and wipes - Pharmaceutical creams and powders - Incontinence products Moisturizers Cornerstone for dry skin (xerosis) Exerts effect by repairing the skin barrier, increasing water content of the skin, reducing water loss. Emollients are fatty acid containing lotions that replenish the oils on the skin surface Humectants are additives (i.e. alpha hydroxy acids, urea) that draw water from the deeper layers to the skin surface. Occlusives prevent water loss from the skin Considerations with the older adult and urinary function Decrease in Kidney’s ability to concentrate urine or reabsorb water Reduction in GFR Changes in vasopressin secretion- so may experience nocturia Functional capacity of bladder decreases Bladder contractility decreases- less efficient emptying Decrease sensation of thirst May experiences decreased muscle tone in perineal floor and anal sphincter Urinary Assessment Health history – symptoms, what is normal pattern of voiding – if needed complete a bladder and bowel diary symptoms, habits, medication use, diet, fluid intake and output, exercise and mobility, family& medical/surgical history, psychosocial, environment and use of aids etc. Physical assessment; flank pain, bladder position, skin and mucosa integrity, perineum Assessment of the urine; color, clarity, quantity (intake and output), odour Lab tests i.e. urine culture, urinalysis, specific gravity, blood work  Other diagnostic exams i.e. intravenous pyelogram, renal arteriogram Bowel Assessment Health History; symptoms, normal pattern- bladder and bowel diary, habits, medication use, diet, fluid intake and output, exercise and mobility, family & medical/surgical history, psychosocial, environment and use of aids. Physical assessment- oral cavity, abdominal assessment, skin integrity and rectal area. Assessment of stool – see Bristol Stool Chart, also identify color, shape, odor, and amount Lab tests; fecal specimen testing, blood work; serum electrolytes, CBC, etc. Other diagnostic test data; i.e. x-ray, colonoscopy, ultrasounds, CT scan, etc. Bladder/bowel Diary Amount and Bladder: Bowel Leaking and Urge? Type of Amount in Moveme (0=none, 5=very bad) Drink Container nt: Amount and reason for loss Pelvic Pain ( Time 0=no pain Type Urine Stool 10=very bad) (1 to 5) 7:00 am 350 mL Sm – cough, 2/5 8:15 am 1 cup milk 0 9:30 am 10:00 am 200 mL 10:30 am 1 cup tea 3 2 Red flags/urgent situations: Increase or decrease in urine output (less than 30 ml over an hour- report!) Increase or change (i.e. onset) of pain, distention Signs of infection and or septicemia Bloody stool or urine Reduced or no bowel sounds No bowel movements or movement of gas Diarrhea Care of those with incontinence: Important that patient skin integrity is maintained and kept clean and dry, Patient is safe, comfortable, while dignity and privacy are maintained A wide range of treatments; such as bladder retraining, timed voiding, prompted voiding, may be part of the care plan. There are a variety of incontinence products- may need to identify the best one for the patient. Peri-care Part of a complete or partial bath, and is also done when needed Highly personal and may be embarrassing Patients able to do their own care, are encouraged to do so  Routine practices and PPE must be applied It is important to use correct cleansing technique when wiping the perineal area i.e. for a male, female, catheterized, or post partum patient etc. Incontinence Products: When using be sure that patient is - Comfortable and has right size of brief - Skin is kept dry and protected - Dignity and privacy maintained Interventions to consider Report and document findings! Promote fluids – monitor intake and output Monitor vital signs regularly to identify any changes Monitor for other symptoms /changes i.e. N & V, chills, fever, malaise. Ensure safety when mobilizing - call bell within reach, determine what her functional ability and mobility status is (IYM), provide assistance quickly if needed. Utilize prescribed creams (if infection is present) or barrier cream in the perineal area and keep skin clean and dry Patient teaching, re hygiene, fluids, safety and mobility. Enhance nutritional intake General Nursing interventions: Report and document Encourage fluids (non caffeinated) Increase fiber in diet Pain management Increase mobility and exercise Ensure he is in appropriate position for bowel movement with privacy Monitor intake and output of urine and stools Patient teaching re fluids, pain management, diet and fiber, importance of mobility and exercise to reduce constipation. During a tub bath Mrs. Hicks asks for the water to be hotter. What does the nurse do? a) Turn on the tap and add more hot water b) Immediately remove Mrs. Hicks from the water as she must find it cold c) Explain you need to keep the temp. within the AHS policy guidelines **Never straight up add more hot water to bath **if they are cold, remove them from bath and give them a blanket (maybe they are more used to hotter baths for arthritis In caring for Mrs. Hicks which of the following is important? a) Regularly perform a skin assessment especially on dependent areas b) Pat dry the areas under her skin folds c) Ensure privacy and comfort during her bath d) All of the above You are performing a bed bath on your patient. You know that you may not use soap in which of the following areas? a) The perineum b) Under arm area c) The eye area (use clean washcloth, start bath at the cleanest area which is eye) d) The feet **use different washcloth for different parts of body LECTURE 7: minimizing complications due to immobility ACTIVITY TOLERANCE The type and amount of exercise or work that a person can perform without undue exertion or possible injury. It is important to assess the patients activity tolerance For some activity tolerance may be low, and even simple tasks may be difficult such as eating or sitting up UNDERLYING CAUSES ARE MANY AND VARIED SUCH AS: 4 general categories: - Postural abnormalities - Impaired Muscle Development - Damage to the CNS - Trauma BED REST An intervention that restricts patients to bed for therapeutic reasons: - To reduce physical activity and oxygen demands - To reduce pain - Promote safety (i.e. patient recovering from anaesthetic) - To encourage rest RISKS ASSOCIATED WITH DECONDITIONING Please refer to table (Vihos & McCutchan, 2019) posted on eclass this week. Metabolic Respiratory Circulatory Integumentary MSK GI How else can immobility and deconditioning affect the client? STRATEGIES TO REDUCE COMPLICATIONS Frequent assessments  Range of motion exercises, and physiotherapy (i.e. chest, incentive inspirometry) Positioning Nutrition, ensuring adequate intake of nutrients and fluids, and if a special diet is observed Skin care Equipment- i.e alternating pressure mattress, splinting, rolls, padding, stockings Entire team is involved due to complexity and risks. Range of Motion: - Important to keep joints flexible, maintain mobility and avoid contractures - Active or passive ROM - Make sure ROM exercises fit the patient’s unique situation Positioning - Body parts should be aligned and joints in neutral position to avoid strain - Foams and rolls may be used to assist with positioning - Reposition every 2 hours at least - Bed position changes can be implemented such as fowler’s and semi-fowlers Equipment - Depends on patient needs - Often determined with PT and OT - Can be walking aids, positioning aids, transfer devices or splints Nutrition - Must have nutritional status and needs addressed (ex. Potential of muscle loss) - Adequate hydration must be maintained to support GI/GU function - Peristalsis may diminish so constipation may be an issue - Appetite may decrease - Metabolic changes like Ca loss from bones may occur  System Nursing actions to consider for Mr. Edwards Skin integrity Frequent assessments, repositioning every 2 hours Keep skin areas dry and clean, apply skin barriers to perineum as needed MSK Active and passive ROM Application of splints to prevent joint contractures Reminders and frequent checks that he is not removing the should sling Follow IYM protocol for transfers Respiratory status Frequent respiratory system assessments Assist with removal of secretions- oral suctioning as needed Encourage deep breathing and coughing regularly throughout the day Positioning to facilitate maximum lung expansion Nutrition Assist with feeding- dysphagia precautions in place Ensure dietary needs are met and followed Encourage fluid intake throughout the day Monitor weight GI/GU Assess GI and GU system daily Monitor input and output, urine amount and quality Assess bowel activity daily for frequency and quality Circulatory Frequent circulatory assessments- BP, cardiac, PVS Application of compression stockings Active and passive ROM QUESTION! The health care aide indicates that Mr. Edwards has a reddened area on his sacral area, and says they will go back later to check on the area- what should you do? a) Advise them to report back with their findings b) Go and assess patient yourself c) Indicate that no one needs to reassess d) Ask them to massage the area to lessen the redness You notice that Mr. Edwards left ankle is stiffer than usual and is in a plantarflexion position. This is a concern as it may indicate which of the following is occurring? a) A Foot drop Position of the foot is in a pointed position - due to immobility and not splinting the patient - If transferring, inability to use that dropped foot b) Eversion of the ankle c) Inversion of the ankle d) Rotation of the knee LECTURE 9: Palliative care Refers to a philosophy and an approach to care. Aims to improve quality of life for persons facing life limiting illness and their families through the prevention and relief of suffering. It does this through early identification, assessment, and treatment of symptoms Palliative care extends across the trajectory of life limiting illness, including at the point of diagnosis, during treatment and at the end of life, as well as grief and bereavement support. Palliative care aims to Relieve suffering and improve the quality of living and dying Address the physical, psychological, social, spiritual (existential) and practice issues of persons and their families, and their associated expectations, needs, hopes and fears. Prepare persons and their families for self determined life closure and the dying process and help manage it. Help families cope with loss and grief during the illness and bereavement experience Treat all active issues, prevent new issues from occurring and promote opportunities for meaningful and valuable experiences, personal and spiritual growth, and self actualization. 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 the person’s prognosis and goals of care. - Holistic care that is intended to address physical, emotional, spiritual, social, and practical needs of individuals and their families and begins during the final active stages of dying, it continues until death and into family bereavement and care of the body. Advance care planning; a process of deliberation about future health care preferences. Goals of care designation (GCD); are medical orders that describe general and sometimes specific focus of a patient’s desired care approach, harmonized with what is medically appropriate to provide. 3 general categories, and 7 subcategories: Comfort Care Designations, Medical Care Designations, Resuscitative Care Designations Edmonton Symptom Assessment System- Revised (ESAS-r) Helps to assess nine common symptoms in palliative care patients Is one valuable part of a holistic assessment- but is not a complete assessment in itself. The goal of this took is to retrieve the patient’s perspective of symptoms which helps to direct treatment and assess for treatment effects. Patient rates the severity of each symptom on a scale of 0-10 on how they feel at the moment of completing the scale (now) Captures a point in time, and repeating the assessment will track the changes over time. Prefer the patient to rate by themselves, if they cannot but can still provide input, it can be completed with the assistance of a caregiver. If they cannot participate at all the caregiver completes it as objectively as possible Edmonton Symptom Assessment System- Revised (ESAS-r) 10 symptoms; each on scale of 1 to 10, (10 being the worst) Pain Tiredness Drowsiness Nausea Appetite Shortness of Breath Depression Anxiety Best Wellbeing Other problem (i.e. constipation) The FICA Spiritual History Tool F. Faith, belief, meaning: Determine whether or not the patient identifies with a particular belief system or spirituality at all. I. Importance and influence: Understand the importance of spirituality in the patient’s life and influence on health care decisions C. Community: Find out if the patient is part of a spiritual community, or if they rely on their community for support. A.Address/Action in Care: Learn how to address spiritual issues with regards to caring for the patient. Take a few minutes to determine a question you would ask a patient in each category. Signs of Approaching Death Less interest in eating and drinking Decreased urinary output May sleep more and begin to detach from environment May be confused, restless Decreased vision and hearing, difficulty with speech Secretions in throat may accumulate Irregular breathing with periods of no breathing Difficulty with temp control (feel cold and hot) Incontinence around time of death May tell you they see something or someone Limbs etc. may appear mottled. White rose program: Posted on the door or curtain A way of showing respect by creating a calm and quiet environment Need to explain and obtain consent prior to posting. Supporting Caregivers Caring for a family member can be emotionally, physically, economically, and spiritually exhausting. It is important for the nurse to provide empathy and support to the family as they care for their loved one. This is a time when they may be grieving and feeling pending loss. It is also important for the nurse to educate families regarding the type of symptoms the client may experience and the type of care that is necessary to meet the client’s needs. Care of the Family Ground yourself first Cultivate presence of mind Create an emotional space for grief Activate your listening skills What TO say What NOT to say What to do- Responding to grief Upon death the nurse; May be the one pronouncing death (see AHS & CRNA policies) Must care for the patient’s body (post mortem care) Notify the physician re death (ensure policies are followed) Provide care and support to the family  Support specific requests It is important that you examine your own attitudes and feelings regarding death, dying, and loss and respond to yourself with empathy and compassion- this will enable you to do the same for your patients When you invest emotions and energy in another person you will confront loss when the relationship ends- so expect to deal with grief from time to time in your career Develop self care strategies to protect against compassion fatigue Create a work environment that will lead to compassion satisfaction Identify a mentor whose work you admire and you can share ideas, and learn from Find a balance between work and play- take time to relax and enjoy, and be around supportive people. LECTURE 10: Medication Admin CRNA Standards - SAKE Standard 1: Safety Regulated members are responsible and accountable to provide safe medication management. Standard 2: Authority Regulated members follow current legislation, standards, and policies re medication management Standard 3: Knowledge Regulated members are knowledgeable about the medications they administer and those that their clients are taking, whether prescribed, over the counter, or natural health products. Standard 4: Ethics Regulated members follow the Code of Ethics for Registered Nurses and ethical principles in all aspects of medication management. Policies and Standards ► Faculty of Nursing Clinical Policies & Scope of Practice Guidelines for Undergraduate Nursing Students (on eclass, updated Dec. 2022) ► Patient Identification Policy (AHS, 2020) ► Do Not Use Abbreviations, Symbols, and Dose Designations for Medication Related Documentation Policy (AHS, 2023) ► Medication Reconciliation Policy (AHS, 2019) ► Controlled Substances (AHS, 2022) ► Independent Double Check (AHS, 2022) ► Medication Management Standards (CRNA, 2021) To name just a few! FON Clinical Policies and Scope of Practice for Undergraduate Nursing Students Students can perform activities with supervision (see levels of supervision) ► Which they have received formal theory and lab instruction and are deemed competent by the clinical instructor to perform the skills ► The agency allows them to perform ► The activity is within the scope of an RN ► Is not a specialized procedure (i.e. certification- chemotherapy meds.)  ► Most restrictive policy prevails (i.e. FON, or clinical agency) ► First time all skills must be supervised and then direct or indirect supervision each time after. *** Know which requires direct or indirect and what that means. The Medication Right’s Medication Dose Patient Route Time Frequency Site Gray Morris (2022, page 125-127) Reason Documentation Patient education Technique Approach Assessment Evaluation Refuse Medication Reconciliation (AHS policy PS-05) “Medication reconciliation means a structured process in which health care professionals partner with the patient, family, and caregiver for an accurate and complete transfer of medication information at transitions of care. The information is used to verify/validate the patient’s admission, transfer, referral, or discharge medication orders to reduce medication errors and adverse medication events at all points of care.” Consists of 3 steps; Step 1- Generate a Best Possible Medication History (BPMH) Step 2- Reconcile the BPMH at care transitions Step 3- Document and communicate the medication information Components of a Medication Order The order (which may be transcribed onto the MAR) should include the following components for each medication that is prescribed. Patient’s full name and unique identification number Date and time the order is written Medication name Dose Route Time and frequency of administration Signature of prescriber Example of medication orders ► Routine- when the medication should be given (q6h) ► PRN (with timing indicated) ► One time only doses ► STAT (immediately) ► Now (has to be given as soon as possible- not as urgent as a STAT order ) High Alert Medications According to the Institute for Safe Medications Practice https://ismpcanada.ca/resource/highalertlist/ “High alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error” Using the resource in the link name two high alert medication. Examples include: Anticoagulants, chemotherapy, neuropathic pain medication, insulin, opioids, parenteral nutrition KNOW that prior to administering any and all medications the 3 checks and 10 rights must be completed Compare the medication order with the MAR then; 3 checks for pouring medications 1. Compare the medication label to the MAR as you remove the drug from the storage area 2. Compare the medication label to the MAR as you prepare each drug (remove from container) 3. Compare the medication label to the MAR as you return the drug to the storage area Kilgour (2020 page 566) At bedside compare the medication label and patient identifiers to the MAR at the patient’s bedside before you administer each drug FON Clinical Polices & Scope of Practice Guidelines for Undergraduate Nursing Students (on eclass, pp 3) Independent Double Check Policy A consistent process for the activity of an independent double check prior to medication administration. Two (2) health professionals (student would be a 3rd) shall independently verify: ▪ The most current order or MAR ▪ Patient’s relevant lab values and or diagnostic results ▪ Medication dosage calculations (if required) ▪ The rights; patient, med, dose, time, route, reason, documentation, refusal, Infusion programming The first health care professional shall not communicate to the second until the second has finished verification, each will then share results. Discrepancies- a 3rd Health Care professional verifies prior to med admin. Documentation required. Co- signature Procedure Some medications require a co- signature from regulated health care professional (student is one signature, regulated health care professional the second). Medications requiring a co signature, direct observation of preparation, and initial direct observation of medication administration include: ► All IV medications ► Controlled substances ► High alert medications ► Pediatric fractional dosages (all routes) ► Other medication as determined by local/unit policy Distribution Systems ▪ Stock supply ▪ Unit dose ▪ Automated dispensing systems (or computer controlled dispensing systems) i.e. Pyxis med station Patient Identification AHS Policy PS-06 “Accurate patient identification reinforces the organizations ongoing commitment to patient safety. Two (2) or more patient identifiers shall be used to confirm the patient’s identity prior to a health service being provided, to confirm that the correct patient receives the intended health service.” Approved patient identifiers (see policy list 2.1). both the patient’s first and last name (considered one identifier) full date of birth (inclusive of day, month, and year); unique lifetime identifier (ULI); alberta residents only personal health number (PHN); everyone in canada medical record number (MRN); patient identification barcode patient address if the address is provided by the patient; Note: A room number is not considered the patient’s address a patient photograph if taken, managed, and stored in accordance with the requirements set out in the Patient Identification – Registration Standard facial recognition in accordance with Section 2.2 of this Policy offender record correctional administration (ORCA) number Medications routes addressed in N 221 ▪ Oral ▪ Topical ▪ Instillation (nasal, eye, ear, vaginal, and rectal) ▪ Inhalation Oral Route Easiest and most desirable way to administer Comes in many forms i.e. liquid, tablets, capsules, sustained release, buccal, sub lingual With each form and medication comes specific instructions! (i.e. cannot crush certain capsules, sustained release or enteric coated medications) Patient must be able to swallow well (prevent aspiration), have no contraindications (NPO), and no GI alterations that would prohibit intake (such as being on NG suction). Proper technique must be used in handling the medication- aseptic technique, hand hygiene, accurate pouring, and administering etc. Follow directions re no fluid intake after buccal or sub lingual tablets  Stay at the bedside and watch them consume the medication, never leave the medication unattended. Evaluate for therapeutic effects and for adverse effects Topical Medications applied to intact skin or mucous membranes Come in many forms such as pastes, lotions, ointments, or patches Can be local or systemic in effect, and maybe timed release Nurses must carefully follow the directions for example cleansing area prior to application, and where to apply Hand hygiene, wearing gloves and use of applicators is required. When documenting – note area that the topical medication was applied, and that old patch was removed. Never leave old patches in place! Instillation Nasal; sprays, drops, tampons Eyes; drops, ointments Ears; drops Vaginal; suppositories, foam, jellies, and creams Rectal; suppositories, enemas Carefully follow the specific instructions and procedure- such as positioning of the patient, and installation technique. Follow aseptic technique, & routine practices (hand hygiene and gloving) Inhalation Medications that are inhaled and penetrate the lung airways Rapid absorption May be metered dose inhalers (MDI’s) dry powdered inhalers (DPI’s), or slow stream inhalers Ensure the directions are followed well Patient education and monitoring essential. For the MDI and DPI, patient’s are given the device to administer the medication while the nurse observes. The patient needs adequate hand strength and dexterity, as well as the ability to follow directions. May need a spacer device for the MDI. Documentation Immediately after or as soon as possible after giving the medication, document on the dedicated form (MAR), as needs to be timely and accurate and include: Patient’s name, and ID #’s Order written out in full with dose, route, and frequency Prescriber’s name Date of start and stop (if applicable) Time administered Signature of who administered the medication Other- i.e. location of where applied patch On progress notes reason (i.e. pain), teaching, effectiveness, etc. Medication Administration Record Jane Smith ULI Prescriber: Dr. Bright Allergy Drug: No known drug allergies Allergy Food: Strawberries Allergy Other: No known other Start Scheduled DAY EVENING NIGHT Stop Medications Oct. 30, 2022 Erythromycin 0800 M. Bazin RN 1700 J. Hill RN Stop after 3 days. 250 mg po qid 1200 M. Bazin RN 2200 J. Hill RN Question? J. Meyers RN administered her patients medication Prednisone 5 mg po at 1700 hours and was finished her shift at 1900 hours. The next nurse, in reviewing the medications to be given later in the evening noticed that the prednisone medication was not signed off at 1700. What should the nurse do? a) Give the medication now as it was not given b) Contact the nurse to verify if it was missed c) Give the next dose at the usual time d) Give double the dose when it is next due. Questions 50 mg of a medication is to be given orally. The medication comes in a dose strength of 25 mg in 2 mL. How many mL’s should you give? 4mL Medication reconciliation is done in which of the following situations (name all)? a) When patient leaves the unit for an x ray b) When patient is admitted to the unit c) When patient is discharged from the unit Which of the following oral forms of a medication can be crushed? a) Capsules b) Enteric coated c) Tablets High alert meds: drug known to cause significant harm to human health when administered wrong Controlled sub: drug govt has categorized as having potential for abuse or addiction Adverse drug effect: patient injury after receiving wrong med or after not receiving the required med Medical reconciliation: a structured process in which health professionals partner with patient for an accurate and complete transfer of meds at transitions of care 3 checks: safety process designed to reduce errors, nurse verifies med against MAR & patient identity while preparing med LECTURE11: Oxygen therapy Fi02: fraction of inspired O2 Orthopnea: Condition in which 2+ pillows are required during sleep Hypoxemia: Decrease in O2 tension in the blood Hypoxia: Inadequate tissue oxygenation at the cellular level Nebulization: Process of adding moisture or meds to inspired air Incentive spirometry: Is used to promote deep breathing and prevent or treat atelectasis Oxygen Therapy Used to relieve or prevent tissue hypoxemia Is often used in conjunction with other interventions Requires a prescribers order Is treated like a medication- so all rights and checks apply Once initiated the patient needs to be continuously assessed Complications can arise and safety measures followed Oxygen supplied as: - Piped into the wall (tanks are in the basement) - Compressed gas cylinders - Oxygen concentrators - Picture to the right is a high flow venturi mask - Liquid oxygen systems Nasal cannula 1-6 L per minute Easy to use- patients can talk and eat without removal Can irritate skin i.e. behind ears, and cause drying of nasal with 4L or greater Can still be used for mouth breathers Simple Face Mask 6-10 L per minute (min. 6 L) Easy to apply but requires a tight fit Poor compliance as mask may be uncomfortable and must be removed when eating. Partial or Non Rebreathing mask with reservoir bags 6-10 L per minute Delivers the highest percentage of 02 with intubation or mechanical ventilation Valves must be secure and functioning Like simple mask cannot eat or drink with mask in place Reservoir bag must be kept inflated High flow venturi mask: Venturi mask 4-10 L per minute Flow rate needs to be set using meter on barrel Allows for more concise amounts Rickeard and Rodgers (2020, pp. 938, Table 33.3) L/min and Fi02 Oxygen Administration Device Flow Rate Oxygen percentage Fi02 Nasal Cannula 1L/min 24% (1-6L/min 2L/min 28% 3L/min 32% 6L/min 44% Simple mask 6-10L/min 40-60% Non rebreathing mask-reservoir 6-10L/min 60-100% Venturi mask 4-10L/min 24-55% Safety in Oxygen Therapy Oxygen is highly combustible- no open flames or products that are combustible (oils, petroleum jelly Inform everyone that oxygen is in the area (i.e. verbal reminder, signage) No smoking! Ensure all electrical equipment is functioning or correctly grounded- follow procedure and policy re checking patients items, to avoid sparks. Ensure you are up to date and knowledgeable re fire safety and procedures (i.e. evacuation, nearest extinguishers) Patient and family education re 02 safety- may require discharge teaching Ensure adequate portable oxygen supply should patient leave the unit (see AHS Portable Oxygen During Transfers policy). Oxygen Toxicity When too high a concentration of oxygen (> 50-60%) is administered for an extended period (longer than 24 hours). Causes an overproduction of free radicals. If not treated the free radicals can damage or kill cells. Signs and symptoms; substernal pain, paresthesia, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxia, atelectasis, and infiltrates. Prevention of O2 Toxicity The lowest amount of oxygen is used to obtain the necessary Pa02 level. If possible decrease or monitor the amount of time on higher oxygen levels Treat the underlying cause or why the 02 is needed (i.e. anemia, blood loss etc.) Monitor often for signs and symptoms and report immediately Determine interventions Patient and family teaching re safety and oxygen therapy, breathing techniques. Assessing and monitoring to ensure adequate oxygenation Respiratory assessments included in assessments Increase fluids, monitor intake and output Nutrition assessment, nutritious diet with adequate caloric intake Good oral hygiene care often May need assistance with airway clearance -oropharyngeal suctioning Breathing and coughing exercises, chest physio may be ordered, physiotherapy may be involved. Nebulization Nebulizer - oxygen or air driven - Disperses a medication which is inhaled - Creates a small mist - Often done prior to other interventions such as chest physio or deep breathing and coughing. Deep Breathing & Coughing Diaphragmatic Breathing- to strengthen the diaphragm during breathing. Pursed Lip Breathing- to prolong exhalation and increase airway pressure during expiration, thus reducing the amount of trapped air and the amount of airway resistance. Coughing- i.e. huff coughing Incentive spirometry (i.e. for post op patients). Encourages patients to increase their intake of air (deep breathing). Chest Physiotherapy Postural drainage Chest percussion Vibration Oropharyngeal & Nasopharyngeal Suctioning Clears the oral airway of secretions Prevents pooling of secretions Should never be done for longer than 10-15 seconds*** Requires clean technique and care of the catheter, wearing PPE Complications can occur! Signs of Hypoxemia Dyspnea Tachypnea ↓ LOC (level of consciousness) ↑ WOB (work of breathing) Agitation Confusion and disorientation Tachycardia/Bradycardia Cyanosis (late sign) If a patient is breathing room air, the Fi02 that they are breathing is which of the following? a. 16% b. 21% c. 28% d. 33% Which is true about the use of nasal cannula? Select all that apply; a) Can talk, cough, and eat without removing mask b) Can provide low to medium oxygen flow c) Higher flow rates may dry out nasal and pharyngeal mucosa d) Can only be used with nose breathers. Lecture 12/13: clinical judgement Critical Thinking ◦ Is a complex phenomenon that can be defined as a process and a set of skills ◦ Definitions emphasize the use of knowledge and reasoning to make accurate clinical judgements and decisions ◦ It requires purposeful and reflective reasoning to examine ideas, assumptions and beliefs, principles, conclusions, and actions within the context of the situation. ◦ The use of evidence informed knowledge makes for an informed critical thinker and improves patient outcomes. ◦ It not only requires cognitive skills but also a nurses habit (disposition) to ask questions, be informed, honesty in facing personal biases, and to be willing to be open and think differently about an issue. ◦ An interpretation or conclusion about a patient’s needs concerns, or health problems, and or the decision to take action (or not), use or modify approaches, or improvise new ones as deemed appropriate by the patient’s response” Tanner C. (2006 page 204) ◦ 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. Connor, J., et al. (2023, page 3336) Tanner’s Clinical Judgement Model; describes clinical decision making as judgment that includes critical and reflective thinking and action and the application of scientific and practical knowledge Clinical judgement includes 4 components: - Noticing (grasping the situation) - Interpreting or developing sufficient understanding of the situation to respond - Responding or deciding on which action to take  - Reflecting on or reviewing the actions taken and their outcomes Clinical Judgement Model: Caputi (2020) incorporates Tanner’s Model, in her model Noticing: Gather data ◦ What do I notice? ◦ What do I need to know? Interpreting: Make sense of information ◦ What does the information mean? Responding: Take action ◦ What will I do? Priorities? ◦ Carry out planned actions Reflecting: Evaluation and learning ◦ What was the effect of what I did and of my thinking Testable readings List: Infection control Woo, K., (2020). Principles of asepsis. In D. Gregory, C. Raymond, L. Patrick, & T. Stephen (Eds.), Fundamentals: Perspectives on the art and science of Canadian Nursing. (2nd ed. pp. 399-417, 422-427). Wolters Kluwer. Alberta Health Services Hand Hygiene module (completed in NURS 125/335 to be reviewed for NURS 221/330) Alberta Health Services (May 2021): ○ Hand Hygiene Policy ○ Hand Hygiene Procedure Alberta Health Services. Infection Prevention and Control: ○ Point of Care Risk Assessment (PCRA) (March 2020) ○ Routine Practices in Continuing Care (May 2023) College of Registered Nurses of Alberta (December 2022). Infection prevention and control standards. ADLs Hunter, K., (2021). Older adults. In T.C., Stephen & D.L. Skillen. Canadian nursing health assessment: A best practice approach (2nd ed. pp. 994-995). Kitson, A.L., (2018). The Fundamentals of Care Framework as a point of care nursing theory. Nursing Research, 67 (2), 99-107. Kitson, A., Conroy, T., Kuluski, K., Locock, L., & Lyons, R., (2013). Reclaiming and redefining the Fundamentals of Care: Nursing's response to meeting patients' basic human needs (Report No. 2) University of Adelaide, School of Nursing. D. Gregory, C. Raymond, L. Patrick, & T. Stephen (Eds.). Fundamentals: Perspectives on the art and science of Canadian nursing. (2nd ed.). Wolters Kluwer. ○ Activity and Exercise (pp 892-904) by Kostiuk, S., & Arvidson, S., (2020) ○ Client Hygiene (pp 800-806 [up to bathing an d skin care], 824-835 [up to oral care], 843- 846 [up to bed making]) by Tellier, C., & Lee, H., (2020) Osuji , J., & El Hussein, M., (2020). Principles and practices of rehabilitation. In M. El Hussein, & J., Osuji (Eds.) Brunner and Suddarth's Canadian textbook of medical -surgical nursing (4 ed.) pp. 177-180, 184-193). It’s Your Move Kostiuk, S., & Arvidson, S., (2020). Balancing activity and rest. In D. Gregory, C. Raymond, L. Patrick, & T. Stephen (Eds.) Fundamentals: Perspectives on the art and science of Canadian nursing. (2nd ed. pages 892-914). Wolters Kluwer. It’s your move videos Nutrition Alberta Health Services (2022). Learning about dentures. Alberta Health Services (2022). Dental Care for Older Adults. Alberta Health Services (2022). Nutrition guideline dysphagia. Alberta Health Services (2021). Oral Hygiene Policy DOCUMENT # HCS-212. Dental Hygiene Canada: The Canadian Dental Hygienists Association. (nd). Denture  Care pamphlet. Dental Hygiene Canada: The Canadian Dental Hygienists Association. (nd). Denture Care Advice for Caregivers pamphlet. Tellier, C., & Lee, H., (2020). Client hygiene. In D. Gregory, C. Raymond, L. Patrick, & T. Stephen. Fundamentals: Perspectives on the art and sciences of Canadian nursing (2nd ed. pages 835- 843 up to but not including eye care.) Wolters Kluwer. Wellington, C., & Patrick, L., (2020). Ensuring nutrition. In D. Gregory, C. Raymond, L. Patrick, & T. Stephen. Fundamentals: Perspectives on the art and sciences of Canadian nursing (2nd ed. pages 1003-1029, up to but not including Enteral Nutrition.) Wolters Kluwer. Communication/documentation/reporting Kilgour, K.N., (2020). Effective documentation. In D. Gregory, C. Raymond, L. Patrick, & T. Stephen (Eds.) Fundamentals: Perspectives on the art and science of Canadian nursing. (2nd ed. pp. 647-670) Wolters Kluwer. College of Registered Nurses of Alberta (2022). Documentation standards. College of Registered Nurses of Alberta (2020). Privacy and management of health information standards. College of Registered Nurses of Alberta (2021). Social Media and e-Professionalism: Guidelines for Nurses. Bathing/pericare Wolf, Z. R., & Czekanski, K. E. (2015). Bathing Disability and Bathing Persons with Dementia. Medsurg Nursing, 24(1), 9-22. D. Gregory, C. Raymond, L. Patrick, & T. Stephen (Eds.). Fundamentals: Perspectives on the art and science of Canadian nursing. (2nd ed.). Wolters Kluwer. ○ Client hygiene (pp 800-823) by Tellier, C., & Lee, H., (2020) ○ Supporting Elimination (pp 1051-1101) by McEwan, A., Dennison, S., & Patrick, L., (2020) Alberta Health Services. (2018). Safe bath temperatures policy. Health times. (2023). Aging skin and the importance of skin integrity assessment. Bathing and perineal skills (2011) Mosby's Nursing Skills. Elsevier. Retrieved from Films on Demand. Mosby's Nursing Skills. Bathing and Perineal Care Series: Performing a Complete or Partial Bed Bath. (16:01) Mosby's Nursing Skills. Bathing and Perineal Care Series: Performing Perineal Care for a Female Patient. (4:52) Mosby's Nursing Skills. Bathing and Perineal Care Series: Performing Perineal Care for a Male Patient. (4:19) D. Gregory, C. Raymond, L. Patrick, & T. Stephen (Eds.). Fundamentals: Perspectives on the art and science of Canadian nursing. (2nd ed.). Wolters Kluwer. ○ Bed Making (pp 846-852) by Tellier, C., & Lee, H., (2020) ○ Activity and Exercise (pp 892-914) by Kostiuk, S., & Arvidson, S., (2020) M. El Hussein, & J. Osuji (Eds.) Brunner and Suddarth's Canadian textbook of medical- surgical nursing (4th ed.). Wolters Kluwer.  ○ Principles and practices of rehabilitation (pp 180-184) by Osuji, J., El Hussein, M., (2020) End of Life care M. El Hussein, & J. Osuji. Brunner & Suddarth's Canadian textbook of medical-surgical nursing (4th ed.). Philadelphia, PA: Wolters Kluwer. ○ Hospice, palliative, and end-of-life care (pp 238-259) by Pooler, C. & Olson, K. (2020) Edmonton Symptom Assessment Scale User Guide FICA Spiritual Assessment Tool Med admin D. Gregory, C. Raymond, L. Patrick, & T. Stephen, Fundamentals: Perspectives on the art and science of Canadian nursing. (2nd ed.) Wolters Kluwer ○ Principles of medication administration (2020) (pp 553-597) by Kilgour, K.N. (2020) Killian, T., (2021). Gray Morris's Calculate with confidence (2nd Canadian Edition). Elsevier. ○ Complete or review chapters 1 through 15 Alberta Health Services ○ Policy PS-08 Do Not Use List of Abbreviations, Symbols, and Dose Designations for Mediation-Related Documentation (2023) ○ Patient Identity Verification Policy (2024). College of Registered Nurses of Alberta (2022). Medication management standards. Oxygen therapy D. Gregory, C. Raymond, L. Patrick, & T. Stephen, Fundamentals: Perspectives on the art and science of Canadian nursing. (2nd ed.) Wolters Kluwer ○ Oxygenation (2020) (pp 915-943, 951-954 up to and excluding endotracheal suctioning) by Rickeard, D., & Rodger, K.S. (2020) Alberta Health Services (2023) ○ Use of Portable Oxygen During Patient Transfers - Policy HCS-205 College of Registered Nurses of Alberta (2022). Medication management standards. Clinical Skills Essentials Collection (2021). Elsevier. Retrieved from Films on Demand: Ensuring oxygen safety Performing oropharyngeal suctioning Setting oxygen flow rates Clinical Judgement: Tanner, C. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204-211. i -