Nursing Foundations PDF

# Making an Occupied Bed ## Assessment * **Always** assess the patient's ROM and ability to reposition independently first. * If the patient is on aspiration precautions or tube feeding, the HOB cannot go lower than 30 degrees. * If the patient is prescribed an analgesic, it can be adminis...

# Making an Occupied Bed ## Assessment * **Always** assess the patient's ROM and ability to reposition independently first. * If the patient is on aspiration precautions or tube feeding, the HOB cannot go lower than 30 degrees. * If the patient is prescribed an analgesic, it can be administered 30-60 minutes before bedmaking. * **Important** to read the chart because it might not allow alignment with bed making. * During the procedure, inspect for skin irritation, pain, reduced ROM, dyspnea, or fatigue. ## Bed Linen Order 1. Flat sheet 2. Soaker pad 3. Top sheet 4. Blanket * They get discarded in a linen bag at the end of the bed. * If the mattress is soiled: wipe off the moisture with an antiseptic solution and dry thoroughly. ## Procedure **Minimizes risk of infection:** 1. Hand hygiene and explain the procedure to the patient. 2. Raise the bed to a comfortable working height (nurse safety) and lower the HOB to the prescribed height. 3. Lower the side rail on the side you are working on, loosen the top linen, gather and roll. Have the patient grab the side rail and roll onto their lateral side. 4. Roll the soiled linen under the patient, wipe the mattress if soiled and dry thoroughly. Place a new clean flat sheet with the seam facing down and soaker pad. Lift the side rail back up and move to the other side. 5. Have the patient roll back the other way and hold the opposing rail. Gather the soiled linen from the corners and roll with the previously gathered linen and discard in the linen bag. 6. Make the other side of the bed, place a clean pillowcase on the pillow and roll the patient back into a supine position. 7. Lower the bed height back, adjust HOB to prescription and provide the patient with a call light. ## Evaluation * Ask if the patient is comfortable after settling. ## Infection control * Soiled linen should never be placed on the ground, or rolled toward the uniform when changing the bed and the opening of the pillowcase should face away from the door. ## Unoccupied Bed Making Tips * Linen is first applied to one side and then the other. * Bottom sheet should be placed seam down and even with the bottom edge of the mattress to prevent skin irritation and pathogen transmission. * Drawsheet is placed over the bottom sheet if not fitted and provided. ## Reposition patients every 2 hours **a.** Supine pressure points: back of head, scapula, elbows, sacrum, heels. **b.** Lateral pressure points: side of head, ears, shoulder, medial and lateral knee, ankles. ## Positioning Patients in Bed **Alerts:** * Always assess the patient's level of consciousness, levels of pain, and ability to assist in repositioning. * Mechanical lifts are essential when a patient is unable to assist. * To prevent further injuries to patients with a spinal cord in recovery from neck, back, or spinal surgery, keep the spinal column in straight alignment, and move the patient as a unit. * When moving a patient always ensure, the bed is at a comfortable working height or the hip height of the shortest worker. * Stance should involve flexed hips and knees. * When physically moving the patient, the primary nurse counts "1,2,3" and the primary worker performs front to back weight transfer while the secondary worker performs back to front. We cannot transfer. * If prescribed an analgesic, it can be prescribed 30-60 minutes before positioning. ## Assisting Patients with Oral Nutrition ### Assessment * Check patients for the level of consciousness. * Are they nauseated? This puts the patient at risk for aspiration. * Identify dysphagia (loss of power to use or understand language from brain injury or disease). * Assess the level of independence by encouraging self-feeding. This will help determine what assistance is needed. ### Procedure * Help patients that cannot eat independently. * Identify food location on the plate, as if the plate was a clock. * Cut food into small bite-size pieces to prevent choking. * Provide fluids throughout the meal (do not let patients drink all their fluids prior to the meal). * Position the patient in Fowler's position with the chin down and place food on the stronger side of the mouth. * Use suction if there are signs of aspiration. * Check the oral cavity if a dependent patient eats without the nurse watching. ### Monitoring Intake & Output * Intakes: fluids, external feed tubes, medications, blood. * Outakes: urine, stool, vomit, drainage, gastric suction. * Weigh patients at the same time of day, on the same scale, and in comparable clothing. ### Assessment * Identify if the patient is on medications with fluid loss as a side effect/impacts fluid balance. * Look for signs and symptoms of dehydration and fluid overload. * Reduced turgor of skin = dehydration. ### Procedure 1. Explain to the patient why I/O has been prescribed. 2. Assess the patient's ability to self-monitor and record I/O. 3. Supply equipment i.e. urine hat. 4. Measure urine collection drainage, to be feeding, chest tube/wound drainage. 5. Provide the patient's caregiver with instructions. * 3 x 100 ml of ice = 150 ml of liquid. ### General Considerations * Create a friendly atmosphere. * Keep company. * Help as needed. * Be encouraging to participate. ### Documentation * Signs of aspiration or if the patient experiences difficulty swallowing/something feels stuck in the throat or if there needs to be a change is food preparation (i.e. can no longer handle minced and needs puree). ## Patient Bathing * **Partial bed bath** = washing face, hands, underarms, genital/perineal area. * Places that accumulate odor, discomfort, and moisture as those areas are susceptible to bacterial growth. * **Complete bed bath** = washing head to toe for patients who are totally dependent and require total hygiene care. * Observe verbal and non-verbal cues for exhaustion. * Monitor for signs of distress for patients that haven't been bathed for a long time as it can shock the body. * **Important** to assess skin integrity. Dry skin is predisposed to impairments. ### Bathing Guidelines: 1. Provide privacy by closing the door or curtain. 2. Maintain safety by keeping the side rails up while away from bedside. * **Important** for dependent, debilitated and unconscious patients. 3. Maintain warmth by partially covering the patient with a blanket to areas of the body not being washed and keep the bathroom warm, as wet skin loses warmth through convection. 4. Promote independence. 5. Anticipate needs. * If you need to leave to get more supplies, leave the call light with the parent. * Do not raise all 4 side rails up, as it is a constraint and lower and lock the bed to prevent falling if the patient tries to get out. ## Female and Male Perineal Care ### Female Genitalia **Alerts:** * Always perform hygiene from cleanest to less clean areas to reduce the risk of infection. * Wash from the pubis area to the rectum, to prevent contamination of the vagina and urethral meatus. * Avoid placing tension on an indwelling urinary catheter. ### Head to Toe Bath: Face → Arms → Hands → Chest → Abdomen → Legs → Feet ### Procedure: 1. Hand hygiene, apply clean gloves and place a basin of warm water and cleansing solution on the over-bed table. 2. Allow the patient to clean perineum on their own if they can. 3. Drape the patient appropriately with a bath blanket and tuck outer corners of the blanket around the patient's thighs to expose the perineum. 4. Wash and dry thighs. 5. Wash labia majora. Retract labia from the thigh with the non-dominant hand. Use the dominant hand to wash in the sink folds, wipe front to back and repeat on the opposite side with a separate wash cloth. 6. Separate labia, wash urethral meatus and vaginal cuticle front to back. Use a separate section of the wash cloth for each stroke and avoid tension on the indwelling catheter if present. 7. Rinse and any area thoroughly front to back. 8. Reposition the blanket over the patient and assume a comfortable position. 9. Dispose of gloves and perform hand hygiene. ### Evaluation * Document procedure and observations on patient participation and tolerance. Report alterations to skin integrity, break in suture line, increased wound secretion. ## Male Genitalia **Alerts:** * Can be positioned in a supine position unless it is contraindicated for the patient. * After male care for uncircumcised males, make sure the foreskin is in its natural position. * This is **important** for patients with decreased sensation in lower extremities. * Tightening the foreskin around the shaft of the penis causes local edema (swelling) and discomfort, can cause permanent urethral damage. ### Procedure Differences from Female: * Wash the tip of the penis at the urethral meatus first (to minimize introducing pathogens to the meatus) in a circular motion to retract foreskin, cleanse outwards until the penis is clean and discard the cloth. * Return foreskin to a natural position. * Have the patient abduct legs, take a new wash cloth and cleanse the shaft of the penis and scrotum, paying attention to underlying folds. ## Oral Hygiene **Essential to Prevent Mouth Infections & Bad Breath** * **Prevent Health Complications:** * Soft tissue infections * Tooth loss * Bacterial overgrowth * Lead to problems with eating and nutrition * Damage of heart valves ## Perineal Care * **Perineum** = between the anus and either the vaginal opening or the root of the penis. * **Close** to sites of fecal and urine excretion. * **Dim, damp, warm** = germs. * **Keeping the region clean prevents infections, skin irritation, and gets rid of unpleasant body odor.** ## Mouth Care for Unconscious Patients * If the patient has an impaired gag reflex, determine the suction apparatus needed at bedside to protect the airway from aspiration. * Never place fingers inside the patient's mouth when unconscious or debilitated as it can occlude the airway and their reflex may be to bite down. ### Procedure: 1. Hand hygiene, raise the bed to a comfortable working level and position the patient in a side lying position. 2. Place a towel underneath the patient's head and an emesis basin under the chin. 3. Remove dentures or partial plates. 4. Access the oral cavity when they are relaxed, if possible and clean the mouth with a moistened brush, apply toothpaste or solution and suction secretions, moisten the brush to clean the tongue and repeat. ### Document: * Appearance of the oral cavity, presence of gag reflex and the patient's response to the procedure and any unusual findings. ## Footcare **Alerts:** * Do not soak hands and feet of patients with diabetes mellitus, peripheral neuropathy or PVD because of the risk of maceration that makes the skin susceptible to infection. * When using water and solutions for hygiene care, be sure to check the temperature to prevent burn injury as patients with diabetes mellitus, peripheral neuropathy or spinal cord injury and reduced sensation. ### Assessment: * Pay attention between toes, feet and nails for dryness, inflammation, and cracking and inspect socks for fluid or blood stains. * Assess circulation. * Assess gait when walking and ask if they experience pain when walking and relieves when standing. ### Evaluation: * Identify any unexpected outcomes. * Provide patient education on infection prevention. ### Document: * Document procedure. * Report areas of discomfort, breaks in skin or ulcerations. ## Compression Stockings (Elastic) **Alert:** * The development of Deep vein thrombosis (DVT) is a mobility hazard. * **DVT** must be reported immediately. Skin discoloration is a sign. * Signs include: swelling in the affected leg (rarely seen in both), warm, cyanotic skin and pain in the leg that starts in the calf and can feel like cramping. * Stockings must be removed and reapplied at least once a day. * Toe circulation must be assessed to ensure it isn't too tight. ### Observe for contradictions to the use of stockings: 1. Dermatitis or open skin lesions 2. Recent skin graft to lower legs 3. Decreased arterial circulation in lower extremities * Antiembolic stocking increase disruption to a patient's skin integrity. * Obesity, pregnancy, and immobility are a vicious triad associated with venous stasis (blood pooling). ### Assessment: * Assess for contraindications. * Assess the condition of the patient's skin, circulation, palpate pedal pulses, note palpable veins. ### Procedure: 1. Measure patient's legs for proper stocking length. 2. Apply cornstarch to legs if appropriate to reduce moisture - moisture can cause skin breakdown. 3. Turn the elastic stocking inside out. 4. Slide the stocking smoothly up the patient's leg. 5. Instruct the patient to not roll stockings partially down to avoid wrinkles and to elevate legs while sitting. 6. Remove compression socks at least once per shift to check for skin irritation or breakdown. ### Evaluation: * Evaluate skin integrity and circulation. * Educate the patient and/or caregiver about elastic stocking. ### Documentation: * Document date and time of stocking application, stocking length and size. * Document the condition of lower extremities, patient education and response. ## Physical Restraints - **Vest & Jacket Restraints** - **Wrist Restraints** - **Mitt Restraints** - **Belt Restraints** - **Tray Tables or Lap Buddies** * 2 point * 3 & 4 point ## Restraints * **Chemical Restraints:** Medications * **Physical Restraints:** * Alarms or sensor pads * Wheelchair or bed belts * 5 point restraints (Sequlf) * Use the least amount of restraint when possible. * Offer alternatives if the family denies restraints, until it's the only option. ### Consent: * Need patient or family/caregiver consent. * If the family denies consent, they will be asked to sit with the patient until it is no longer an option and the doctor overrides their non-consent. ## Personal Protective Equipment ### Putting On PPE * Wash hands - gown - mask - goggles - gloves ### Taking Off PPE * Gloves - wash hands - gown - wash hands - goggles - wash hands - mask - wash hands. ## Hand Hygiene * If hands are visibly soiled, they need to be washed with soap and water. * Antiseptic can be used when hands are not soiled. ## Aspiration Precautions * Patients can aspirate on food, liquids, medications, saliva, and vomit. * Assess level of consciousness. * Identify obstructions or medication side effects that affect swallowing. * If there is suspicion of dysphagia or aspiration risk, place the patient on NPO until evaluated. * The patient may complain of food feeling stuck in their throat, or having to swallow multiple times, put on NPO. ## Precautions * Position the patient in Fowler's position when feeding. * Keep patients upright for 30-60 minutes after a meal. * Check pocketing of food or pills. * Oral hygiene after meals, clean dentures. * Position unconscious patients in the lateral position to prevent aspiration on vomit. * Avoid mixing different food textures, alginate liquids, and food and cut food into small bite-size pieces. ## Hand Off Report * Each patient uses SBAR. * **Situation:** patient's name, gender, age, chief concern of admission and admission. * **Background Information:** Allergies, emergency code status, medical and surgical histories, special needs as related to any physical challenges and immunizations. * **Assessment data:** Both subjective and objective made by the nurse during the shift. Emphasis on any recent changes. * **Recommendation:** Explanation of the priorities to which oncoming nurse must attend, including referrals, nursing orders, and care measures. ## Nursing Assessment, Diagnosing and Planning * **Assessment:** Collecting data pertinent to the patient's health. * **Primary Source:** Patient (Interview) = best source. * **Secondary Source:** Medical records, caregivers, or other health professionals. * **Tertiary Source:** Information outside the specific patient's frame of reference, i.e. textbooks or nursing experience. * **Subjective data:** Verbal descriptions of their health concerns, i.e. symptoms. * **Objective data:** Observations or measurements of a patient's health status i.e. signs, measurement of blood pressure. ### Collecting Data * **Interview** = organized conversation with the patient. 1. Introduce self, explain role. 2. Establish a caring therapeutic with the patient. 3. Obtain insight about the patient's concerns and worries. 4. Determine the patient's goals and expectations. 5. Obtain cues about which parts of the data collection to further investigate. ### Working Phase = Focused Questioning * **Open-ended questions:** Provide opportunity for patients to give more information - "What happened before you fell?" * **Close-ended questions:** Limited to when additional info is not needed - "How many times did you fall?" * **Reflective Questioning:** Confirm or clarify something the speaker already said - "You mentioned you were feeling dizzy 3 hours ago?" * **Leading Questions:** Directing the speaker to answer a specific way - "You are losing balance easily, right?" * **Active Listening:** Being attentive to what the patient is saying both verbally and nonverbally. It enhances trust and facilitates patient communication because it demonstrates acceptance and respect to the patient. * Sit facing the patient. * Open posture * Lean forward * Establish and maintain eye contact. * Relax. ### Physical Assessment * **Collect Objective data** * Using senses * Rash * Wheezes * **Validate Subjective Information** * Health History * **Develop Plan of Care** * **Evaluate Effectiveness of Intervention** * **Plan of Care** ## Diagnosis * **Diagnosis:** Analyzing assessment data to determine key issues and make clinical judgment in the form of a nursing diagnoses. * **Nursing Diagnosis:** A clinical judgment after assessment about the patient, family, or community responses to actual and potential health problems within the domain of nursing. Defines characteristics (signs and symptoms) that cluster in patterns and support clinical judgment. * **Acute pain** is a nursing diagnosis. * **Risk Nursing Diagnosis:** Describes human responses to health conditions that will possibly develop in vulnerable populations i.e. factors that contribute to developing a condition. * **Health Promotion Nursing Diagnosis:** Clinical judgment of a person, family, or community motivation and desire to increase well-being and actual human potential i.e. lifestyle behaviors related to nutrition and activity * **Wellness Nursing Diagnosis:** Describes levels of wellness in an individual, family, or community that can be enhanced. This is diagnosed once the individual has achieved optional health i.e. coping strategies after surviving cancer. ### Possible errors: * **Data Collection** - Inappropriate assessment steps, not validating data, interpretation errors. * **Developmental age:** Can cause conflicting or insufficient cues. * **Data Clustering** - Premature diagnosis based on some scans and symptoms. * **Delivering wrong interventions based on diagnosis interpretation.** ## Planning * **Planning:** Creation of a formal that prescribes strategies and alterations to attain the expected outcome. * Person-centered goals and expected outcomes. **Example** * **Nursing Diagnosis:** Acute pain related to pressure on spinal nerves. * **Goal:** Patient’s level of comfort will improve before surgery. * **Expected Outcome:** Patient will be able to turn without reported discomfort in 2 hours. * **Measurable Behavioral Response (i.e. perform hygiene independently):** * Short-term goal: Objective behaviors expected to achieve in less than a week or within hours in an acute setting. * Long-term goal * **Priority Setting:** Ranking diagnoses and patient problems using principles like urgency and chronological order. ## Implementation * Carrying out the plan. * Health teaching, promotion, providing medications, or other therapies. ## Evaluation * Do the interventions work? Monitor and adjust if needed. * Provide discharge plan that is realistic. ## Clinical Thinking * Uses knowledge and reasoning to make accurate clinical judgments and decisions. * **Evidence-Informed Knowledge:** Knowledge based on research or clinical expertise. Makes you a more informed critical thinking and improves patient outcomes. * **Clinical decision-making process:** Utilizing clinical thinking skills when making decisions for patients. ## Different Types of Nursing Roles * **Epidemiologist:** Involved in case finding, health teaching, tracking incident rates of an illness. * **Educator:** Provide their knowledge, skills and backgrounds to help prepare the next generation. * **Case Manager** Coordinate needed resources and services for a group of patients well being * **Caregiver:** Managing physical needs, preventing illness and treating health conditions. ## Patient Safety * **A patient safety incident:** An event or circumstance that could have or did result in unnecessary harm to the patient. * **Harmful Incident:** An incident that resulted in harm to the patient, also known as a preventable adverse event. * **Near Miss:** An incident that did not reach the patient. * **No Harm Incident:** An incident that reacted the patient, but didn't cause harm. * **Incident Reports:** * Incident Reporting, Unusual Occurrence Report, Variance Report. * Term to describe safety event reporting. * Safety event can occur when evidence-based best practice isn't followed. * Harm or potential harm to the client. ## Examples of Safety Events: - Accidental needlesticks. - Defective systems or equipment failure. - Falls - Medication errors (the #1 Cause of incidents) - Missing client belongings. - Hospital-acquired infections. ## Infection Control * **Infectious Agents:** Pathogens * Resident microorganisms are permanent residents on the skin that multiply without causing harm – not easily removed by hand washing. * Transient microorganisms attach to the skin when someone touches someone else or an object. * **Potential for disease relies on the following factors:** 1. Number of organisms 2. Virulence - ability to produce disease 3. Ability to enter and survive in the host 4. Host Susceptibility * **Reservoir:** Where the pathogen can survive: human body (most common), animals, insects, food, water, inanimate objects. * Pathogens love moist and warm environments. * Pathogens in the body but does not cause harm = Colonization. * Carriers = animal or human that shows no symptoms of the illness, but have the pathogens in the body. ## Mode of Transmission * The way microorganisms can be transmitted from reservoir to host - can be more than one. 1. **Contact Transmission: ** * Direct contact: skin to skin i.e. C. diff, MRSA, herpes. * Indirect contact: Object to host i.e. RSV, MRSA, diff. * Droplet: Large respiratory particles from the tract to the host i.e. flu. 2. **Airborne Transmission:** * Air-borne particles suspended in the air and host inhale i.e. TB, measles, varicella. 3. **Vehicle:** * Single contaminated source (i.e. E. coli) * Water, food, medications, intravenous fluid. 4. **Vector:** * Insects or pests infect host i.e. West Nile, Lyme. ## Patient Susceptibility * **Age:** Infants have immature defenses against infection, born with only the antibodies provided by the mother as they are unable to produce necessary immunoglobulin or WBCs. * Breastfed infants have greater immunity as they receive antibodies through the milk compared to bottle fed. * **Immunity Decreases with age** older people undergo alterations in structure of skin, urinary tract and lungs. * **Nutritional status:** Inadequate protein, carbs, and fats reduces the ability to defend against infection and impairs wound healing. * **Stress:** Continued stress leads to exhaustion and stored energy is depleted, and cannot fight infection. * Increased cortisol from chronic or intense stress = Decreased resistance to infection * **Disease process:** Patients with diseases that affect the immune system (i.e. leukemia or AIDS, chronic conditions i.e. diabetes, arthritis, and burn victims, are at risk for infection due to stress, poor nutrition, or skin damage.) * **Medical Therapies:** Some drugs or therapies compromise immunity (i.e. radiation destroys cancer cells but also healthy bone marrow and cells. ## Chain of Infection **Microorganism** (bacteria, virus, fungus, parasite) **Reservoir/Source** (human, animal, air, food, soil, water, habitat for organism to grow: equipment) **Port of Exit** (secretions (e.g. saliva), excretions (e.g. urine, feces)) **Modes of Transport** (contact, droplet, airborne, vector, fomites) **Port of Entry** (wound, oral, respiratory mucosa lining, open tract, urinary tract) **Susceptible Host** (very young & elderly, those with chronic disease, malnourished, immunocompromised)