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MCCNursing111

Fall2016

PersonalLectureNotes

!READFIRST!
Disclaimer!
These notes were taken for personal use and are subject to error, incomplete information, spelling
errors,misunderstoodconcepts,andnonstandardabbreviations.Alwaysconsultyourtextbooksand
instructorsforclarificationofunclearmaterialandspecificlabvalues.Theauthorofthispublication
takesnoresponsibilityforpossibleerrorscontainedwithinthisdocument.Byviewingbeyondthispage,
youhaveagreed toverifythrough otherpublished sources and withcurrent faculty, allinformation
containedwithin.MayGodhavemercyonyoursoul.

NUR111
Week1
September6,2016
*Clinicalweek19104ONLYat07:30(forthe1st2weeksofclass)
Alwayscheckblackboarddaily
SkillslabinCLL(1stfloor)
SecondweekclinicalBRINGfulloutlineforfurtherorganization
Dopreconfbeforeclass
Informalwritingassignisduethisweek
Academicadvisorisyourclinicalinstructor
ChaonofCO:
clinfacult
Tina

Skilllablabhoursarepostedondoors
MakefriendswithSNAlookinstudentlounge
Mathtestadninweeks9,12,14

Nursingprocess5steps(onblackboardalso)
assessment1collectdatafrom1or2source
diagnosispatientproblem(nurdiagnosishandbookAckley)
Planningpriorities,
implementationbasedonnursesclinjudgement
Evaluationandrepeat


7partsofwellnessmodel:
Withyouinthecenter
emotional
physical
social/cultural
environmental
occu
spiritual
Intellectual

FamlilyandculturalbelifesandpracticesisHUGEinfluenc

*Leveelsofprevention:
Priprevent
secon
tert

LookatHealthyPeople2020forextra

Florencenightingalenurse(Lister,JSnow)

*Reviewmicroterminology
Asepsis
Medical:
cleantechnique
reducingthenumberofpathogens

Surgical:

*rememberthepatientisthemostimportantpart,whatsbestforthepatient?
theyneedtounderstand,knowtherational
HealthPromotion:
NYSmandatoryInfectionTraining($30)every4yearsiscoveredinclassS6505b
TONIGHT:

studygroup
testeachother
*NYSmandatorypacket(whenlinkisavailable,answerthe6questions),Duebyweek3

NUR111
Week2
September13,2016
*onexamsofttherewillbeapracticetestwith100possibleattempts.Thisisusedtotestresident
softwareafteranycomputerupdates.
SNAmeeting9104wed.16:0017:00
Mathinthisnursingprogramisdimensionalanalysisnotratios
*asepsisquizonblackboard(problemsgettingittoblackboardbutprobablyavailabletoday)
elements..

Safety,activity,mobilitylecture
Thinkabout:falls,movement,medicationmistakes,pressureulcers,
safetyfreedomfrompsych,andphysicalinjury
ThinkfromMazlowsperspective
(inclass)Josiekingstory.JosiekingpatientsafetyfoundationJohnsHopkinshosp
*knowaboutthemajorgoverningbodiesthatworkwithnursingandhealthcare(ANA,IOM,JCAHO,nat.
patientsafetygoals)
Childrenunder5injuriesaretheleadingcausesofdeath
Schoolagehome,environmental,contactsports,attemptscomplexmotoractivities
Adolescentdriving,needtobeaccepted,relationshipissues,substanceabuse,mentalhealth
Adultslifestylehabits,smoking,drinking,obesity
Olderadultsphysiologicchanges,osteoporosis,decreasedmuscle.85%ofeldershavenotprepared
theirhomeforaging!
Conductsafetyassessmentofpatientshome(homecare)
Poisoncontrol(www.aapcc.org)911,18002221222
*knowelectricalsafety,plugsafety,electricandwater,routingwires,overheating

Hospitalcentered
Falls,pathogens,malfunctioningequipment,medengenderingoverwatch,medicationerrors,MSDS
Otherthings

Fire,nosmoking,(mostfirescausedfromelectricoranesthesia),knowRACE,extinguishers,staycalm
Fallassessmentforms/tools,assessandreassess.Assessconfusion,medications,drugs/ETOH,clutter
NursingprocessADPIE
Planninghaveameasurableplanforthepatient
Implementtheplanstoreachthegoalandreassesstheneedforanymodificationoftheplan

Lackofsafetyinthehospitalisabigproblem

Huddlesaboutsafety
JACOinitiatedaspeakupcampaignforpatientreporting
neverevents

Thecultureofsafety
Rootcauseofsafetyissues(rootcauseanalysis)
CUSPcomprehensiveunitbasedprogram
Incidentreporting(Quantrose)anassessmentofhowtheincidenthappenedandhowtocorrectitin
thefuture,meantnottobepunitive
Restraintsusingrestraintsaremoredangerousthanfallsasthenewtrend.
Alwaysassesseachpatient,assessmedicationrestraintsvsotheroptions
*readtextforoptionsotherthanphysicalrestraints
Restrainedpatientscanleadtopooroutcomes
Maintainpatientrightsanddignitywhenemployingrestraintsandreassessforsafety
**testeachotherabouttheunitterms**REVIEWINSTUDYGROUP
AgoalofmovementistopreformADLs
WhenassessingADLsworkwiththepatienttodeveloprealisticandattainablegoalsforselfcareand
living
Baseofsupport(centerofgravity)importantinbalanceandavoidingselfinjury
**lookatmathPPTsonblackboard

STRESSandCOPING
Stressorscausesstressandcausesacertainresponse

Stressorscanbeinternal,external,situational,maturational,sociocultural
Internalstresscanbeanxiety,..
Maturationalthroughoutalifespanandchangedependingonage;

Childbullying,peers,school
Teenagersappearance,hormonalchanges,sex,grades,career,bodyimagechanges
Adultsfamily,money,career,

Sociocultural

War
Poverty
Physicalhandicaps
Homelessness
Religionandrace

Stressstimulatesasympathetic/adrenergicresponse(pupilsdilate,parastalsisdecreasesm,bloodsugar
goesup

P.775potterandPerrystress
Mildanxietymayenhanceawarenessandlearning
Moderate
Severegreatlyreducedfunctioning,onlyfocusesonafewdetails,unabletofocus,notincontrol
Panicmorephysicalsymptomsrequiringimmediate,sometimesphysicalremovalfromthestimulation

GASgeneraladaptationsyndrome

A3stageresponse
1alarm
2resistance
3exhaustion,canleadtodeath

P.780782generalguidelinestominimizeanxietyandstresshealthpromotion

Steps:
identifystress
Verbalize
Identiftstrengths

Recognizepositive..

Nursing111Lecture
Week3
09202016
Nursepracticeactgovernshownursespractice(maybedifferentin
eachstate).Ensuresweallpracticeataminimumstandard.
Controlledpracticeactmedswithahighabusepotentialare
regulatedtopreventabuseandtheft.Outlineshowordersare
placed,research,lawenforcement.
diversionofnarcoticstheftbyahealthcareworker.
Nursingimplications

Tells,assessment,NursingDx,teaching,nursingoutcomes
i.e.:assessforskinrash,assessforGIbleeding,

6RightsofMedicationAdministration:
RightMedication
RightDose
RightPatient
RightRoute
RightTime
RightDocumentation

Pharmacokineticshowamedisabsorbed,distributed,andeliminated
*pillisquickerthantransdermal?
HTNdecreasesbloodflowandthereforedecreasesdrugdistribution
Fatsol.S.watersol.Medicationsfatsol.Isretainedbetter/storedintheSQtissue
BBBfatsolubleonlycanpassthroughtheBBB
Albumenisthemainbindingproteinformanymedications,albumenlevelscandictateamountofbound
medication

Metabolism:

liverisprimarymet.Site
diseasesmaydecreasethemetabolismwhichcouldleadtoaccumulationandtoxicity

Excretion:

age

ProviderDxandRxwritesorders
Pharmacymixes,evaluatesanddistributesmedications.Willalsomonitorpatient
Nursegivesandmonitorspatient,evaluateseverythingusereferencestoassistinevaluation
Patientcompliance,abilitytotakemedications,reportbackresponse/adverseRxn


Patientteaching:

names
dose
whentotake
adverseRxn
foodinteractions
adverseeffects
whotocall
storage

dosage,routeandfrequencyismostoftenmissedpartsofthemed.Order

**Inbackofclinicalsectionwhatmustbedocumentedforapatientrefusalofdocumentation**
removeandhaveonhandforclassesP.167

MedicationCalculationLecture
**week#9medicationexam
A. providerorder
Writtenby:(MD,PA,NP)
Properlywritten
Accuracy(dose,route,freq,spec.considerations
Availdose
Wherecanthemedsbefound?
Readlabelcarefully!
c.

Medicationcalcformula.Pickonewayofcalculationanduseitalways

studyin2006dimensionalanaly.Higheraccuracythanothersystems

**Doallmathonpaper/calculator(notinyourhead)

**dontleavelabelsoffofcalculations

Lecture09272016
Week4
Startedexam07:34ended08:13
Used7%powerfor1stnursingexam
Thingstododifferentfornextexam:

Opentop(questionwindow)wider
RememberIhaveanonlinecalculator
Getcomfortableearplugs
Sitinbackofroom
Clickoncontinuewithoutdisablingantiviruswhenaskedinthebeginningoftheexam
(Idid)butrememberAdderallbeforeexam(1/2hr45minbefore)(09:00feltfulleffect)
Q:dowegetourscrappaperbackduringreview?
Q:willthereeverbeselectallthatapply
Willsettingtheonscreentimerhelpstayontrack?
Remembertokeepscreenbrightnessawayfromfullbrightness
RememberstudentloginisMnumber
DoesExamSoftgiveyouyourscoreattheend?
Signinforclassonsheetbeforeexam

ReviewrationalesforanswerstounderstandhowtobestanswerNCLAXtypequestions/
wording

Fornextweek:

**filloutbasicnutritionneeds(pink)packet

MCC5k

satOct.8

signupinJennysofficetovolunteer

Nextweeknutritioninconferencepickuphandout(pink)infrontoronblackboardfordiscussion/
watchvideosupersize
Professionalcommunication
Protectspatientsafety,rights,legally(ifyoudidntdocument..
arelevantaccountofcare
MARpronouncedmar..

Components:
admissionsnote
orders
Hx/exam
progressnotes
criticalpathways
variance
problemlist(assumingitsupdatedcorrectly,alotofcutpastedone)
patientcaresummery
dischargesummaryforms
Kardex
Fluiddocument
updatedasordersareentered
usuallyelectronic
usedduringhandoff
Flowsheets
Visualizetrending
documentingtrendsandgoalprogress
ifthereisabnormaldata,documentandwritenote,assessment,planandresponse/interventions
Confidentiality
HIPPA
protectatallcosts
patientpermissiontoresearchanduseascontinuingED
HIM(healthinformationmanagement)departmenttoobtainfullchart
allelectronicaccessistraceable
EMRelectronicmedicalrecord
Standardsofcare
JACOwatchdogaccreditingbody
institutionshavetheirownstandardsandpolicies

Timelydocumentation,possiblyforgetting,poorcare
documentwithinthecontextofthenursingprocess(ADPIE)
Documentation
vitalsigns
comprehensive
providescontinuityofcare,alwayswatchingthepatientgoodhandoff,helpsunderstandingofwhere
patienthasbeenandtheirgoals.
supportsutilizationreimbursementandbilling
mustbefactualandobjective
directpatientobservations
Accuracy:

crossoutcorrectly(singlelinethrough,ERROR,date,initial)

avoidunnecessarywords,beconcise,onlyapprovedabbreviations(sheetsomewherein
packet?)

completewithadditionalobjectivedata

remembertobetimelysoyoudontforgetorcausepotentialpatientharm

Organization:ADPIE,logicalorder,clear,tothepointwithoutextrainformation

Thinkinalinearmanor

Examplesofnote:
assessmentwhatitappears
Dxitsrelatedtoswollencalf
Plan:notifyprovider,elevate,sch.Ultrasound
Impression:whatdidwedoactually
Evaluation:effectofpainmedshowispatientfeeling,vitals

DocumentintheformatOkdwithyourfacility

EMRelectronicmedicalrecord
HERElectronichealthrecord

leadstothedevelopmentofnursinginformaticsnursinginformaticscanspeakbothRNandIT
language(forresearchanddatapulls)
SOAPIEverycommonlyseen,separateinsignificantdatafromrelevantdata
Avoidrepetition
Focuscharting
data,assessment,response

Chartingbyexception:
onlydocumentabnormalities
reducesamountofdocumentation
promotesconsistencyindocumentation

Handoff
providescontinuityandsafety
mustdevelopaflow/style
SBAR

Teleorverbalorders:

Writeorder,sayback
Usuallyemergentorafterhours

Incidentreport:

WriteASAP
Writtenbythepersoninvolved
Witnesses/involved
Equipmentinvolved
**DONOTmentionincidentreportinmedicalrecord

Communicatewithpatient/family:
introduceandidentifyyourself
askpatienthowtheywanttobeaddressed

useunderstandableterminology,explain
useopenendedquestions
provideprivacy
askforpermissiontotalk(tofamily/friends)
avoidpolitics

Nursing111Lecture
Week5

10042016
**seejennyaboutvolunteeringat5K,
**bringAckleystolecturefromnowon

NursingDx:
Nausea

Anunpleasantfeeling,mayresultinvomiting
Foodaversion
Gagging
Inc.salivation
Sourtasteinmouth

Avoidmovement
Distractions
Odorfreesetting
LimitPOintake
Smallmeals
Inc.fluids
Blandfoods
Lowstress
Crackersonhand
Antiemetics

Tx:

Nutritionimbalance,lessthanabodyrequires:

Caloricintakedoesntincludesubstancesthatsupportbodygrowthandsupport
Elderly,adolescents,poorlydesigned/faddiets

Definingcharacteristics:

Cramping
Aversiontofood
Abdominalpain
Bodyweight20%underideal
Hairloss
Capillaryfragility
Misconceptions
Poormuscletone

Overweight:

excessiveweightforageandgender
Under2yoa>95percentile
Children218BMI>85%butunder95%orkg/m2
AdultBMI>25kg/m2

Riskforoverweight:

Excessivefatintakeforageandgender

Riskfactors:

AdultBMIapproaching25kg/m2
ChildrenBMiapproaching85%,consumptionofexcessivesweets/sweetenedbeverages
Eatingdisorders

MyPlate
USDA.org

Balancedcalorieswithphysicalactivitytomanageweight
Consumemoreofcertainfoods(healthyfoods),limitlowqualitybeef,limitfillers
Limitsodium<99mg/day,lowsugar
Wholegrains,fatfree/dairyfreeproducts
Balanceyourcalories(www.mayoclinic.org/healthylifestyle/nutritionandhealthy
eating/indepth/calorie...)

CalculateBMR

Howdowesucceed?

Eatslower
Payattentiontoyourfood(noTV/computer/nodrivingandeating)
Listentobodyclues
Payattentiontoyourenvironment,eatingisasocialactivity
Useasmallerplate
Aglassofcoldwaterbeforeameal
Apportionsmalleramounts
Share

Plantotakehomeaportionofthefood

Eatmoreof:

Vegetables
Fryits
Wholegrains,brownrice,(fiber)
Fatfreemilkor1%(childrenandwomenneedmilk/calcium)

Thingstoeatlessof:

Sugars,salts,solidfats(atroomtemperature/Crisco/lard)
Lookforsodium>2300
Readthelabel
Increasewaterintake
Unsweeteneddrinks

Lookathealthypeople2020forfurther
Table451P&P

Promotethrough:
Education
Healthpromotion
Rolemodels

Readingfoodlabels:

Howtomakehealthychoices
Howtopromotehealthinyourpatents
RequiredbytheFDA
Empowersconsumers
Providesguidelines
Whereisthelable?
Whatdoesitcontain(servingsize,nutritionalvalue)?
(caloriesfromfatsisgoingaway2016)
(avg.fibercontentis3grams)
Basedona2000caldiet

Beawareof:

Servingsize
Sodium,sugar,
Limitfatto5678GMsaday
Checkcaloriesperserving
Getenoughfiber,vitamins,minerals,othernutrients
Checkforallergies

Informationisbasedona2000cal./daydiet

CHANGEStolabels:

Newaddedsugarsmustbeidentified
Naisadjustedtoa2,300dailyvalue
KandDwillberequired(AandCwillbeoptional)

Terms:

Caloriefree(<5calperserving)
Sugarfree(<0.5GMS)
Reduced(<25%oforiginal)

*whentheseitemsareremovedsugarorsaltisaddedtomakeupforlackoftaste

Highfiber(>5GRMfiber)
Goodfiberis2.5to4.9GMS

NUR11110112016
Week6
NANDAI(Ackleys)

Nursingprocess:

Systematic
5steps(ADPIE)
Criticalthinkingandthenursingprocessissimilar(nursingprocesscentersaroundcritical
thinking)

Thisisanationalpracticestandardandthefoundationofcriticalthinking

Weneverstopassessing,itsacontinuousprocessthatbuildsonitsself
awrongassessmentwillbogdownthecontinuingcircle
gaininfoaboutthepatientscurrentandpastHx
usuallynursingpaperworkwillguideyouthroughtheassessment
Subjectiveexactlywhattheysaid
Primarysourcepatient
secondaryfamily/caregivers,otherhealthcareprofessionals
Professionalliterature

Datacollectionmethods:
interviewstructurednursecontrolled,setthetone
openendedquestions(usually)
Statesofinterview:

Openingbuildrapport
Bodycomm.Datacollection
Closing

EXAM:

Inspect,Palp,percuss,ausc
Organizedata(electronic,paper)(basedonMaslows)


Validatedata:

Doublecheck
Dontassume
Dontmakeamedicaldiagnose

AmedicalDiagnosis:
Etiologytheprobablecauseoftheproblem

Comparedatawithexpectedfindings
isdataabnormal?
whatistheabnormalitycausedby?

Dataclustering:
afterassessment
organizedata
lookforpatterns
makeinference..helpfultoanursingdiagnosis

Includethepatientintheplan
DoesClusterdatasupportyourDx?
Isitanursing,medical,orcollaborativeproblem(section3Ackleyswillhelpwiththis
**etiologymustbewithinthedomainofnursing*NOTAMEDICALDIAGNOSIS*

AnursingDxisabasisforselectinganursinginterventiontoachieveanoutcomewhichtheRN
isaccountabilityfor

CollaborativeDxstartwithpotentialcomplications(foundinsection2ofAckleys)
Etiology(theR/Tphrase)theprobablecause,inthedomainofnursingpractice

NUR11110182016
WEEK7

Functionofwaterinthebody:

Regulatestemp
Lubricatesjoints
Lessburdenonthekidneyandliverthrough
flushingofwasteproducts
CarriesOxygenandwaste
Dissolvesmineralsandnutrientstobecarried
tothebody
Preventsconstipation
Protectsbodyorgans
Moistensmucusmembranes

ImportantValues:
Normaloutput4080ml/hr
(min.30ml/hr)
+
K 3.55mEq
Na+135145mEq
Cl95105mEq
HCT3550%
pH7.357.45
specificgravityofurine1.0101.025

Fluidcompartments:

IntracellularInsidethecell(mediumforcellularmetabolism)
ExtracellularOutsidethecell(transportsystemfornutrientsandwaste
Interstitialfluidsbetweenthecellsofthebodyandthebloodvessels
Transcellularfluidsfluidsthatsurroundorgans(CSF,pluralfluid,synovialfluid)

Electrolytes:

Particlesinasolution
Inwater(solvent)
Breaksupintoseparatelychargedions
MeasuredinmEq/L(thecapacityofthecationstocombinewithanionstoformamolecule

Definition:

CationpositivelychargedelectrolyteNa+,K+,H+
AnionNegativelychargedelectrolyteCl,O

Functionofelectrolytes:

Regulateswaterdistribution
Transmitnerveimpulses
Acid/basebalance

Majorelectrolytesincompartments:
intracellularion:

**K+:functionskeletal,cardiac,smoothmuscleactivity,sourcebananas,figs,oranges,IV
fluids/medications

Deficitsseeninuseofdiuretics
Cancausemusclecramping,

Mainextracellularelectrolyte:

SodiumNa+
Functionregulateswaterlevels
Source:processedfoodtablesalt,IV

Fluid/electrolytemovement

Betweencompartments,acrosssemipermeablemembrane
Constantmotion
Equilibrium,homeostasis

Movement:
1stwayosmosis(osmosis=water)watermovestomaintaintherelativebalanceinthecompartments
2ndwaydiffusion(diffusion=electrolytes)electrolytesmovefromhightolow

Watchthesciguys:scienceathome,SF1SE14:thenakedeggosmosis(playingwitheggs,vinegar,and
cornsyrup)

Reninangiotensinaldosteronesystem(anadaptivemechanism)

Factorsaffectingfluid/electrolytes:
age
gender
environmenttemperature
lifestyle
illness
medications(laxatives,diuretics)
Nursingfluidmanagement:
Identifyrisks:

MedHxacute/chronic
Medications
Developmentalage
Socioeconomic/environmental

Functionallevelsurinaryhabits,anychanges?
Usualfood/fluidintake(elderlydrinklesstoavoidincontinence..espwomen)
Balance=IO

Monitorintake,output,

Intake:

Useinml
Measureateyelevel
Flatsurface
Atthebottomofthemeniscus(beaccurate)

*recordonlyoftheinitialvolumeoficechips
CounttubefeedsPLUSflushes
Includeliquidsgivenwithmeds

Output:

Trendhourly,Qshift,Qday
Norm4080ml/hr,(min30ml/hr)
Outputincludes:tubes,drains,wounddrainage,liq.feces,urine

Weights:

Trendsinlongtermfluidstatus
Balancescale
Sametimeoftheday
Sameclothes
Samescale

(morningisthebesttimetoweighapatient)
Labvalues:

K+
Na+
Cl
HCT

3.55.0mEq
135145mEq
95105mEq
3550%(volumeofRBCsinplasma0

Lessfluidvol=higherHCT,morefluid=lowerHCT

ABG:

pH

7.357.45

acidosisvs.alkalosis

specificgravitymeasureofsolutesinurine

1.0101.025sg

(highersg=dehydration)

Nursingprocessfluidandelectrolytes
NursingDx:
Excessfluidvolume:

Def.increasedisotonicfluidretention

Definingcharacteristicsassessmentdata

Adventitious(abnormal)lungsounds(crackles),interstitialedema
Edema
JVD
AlterationinB/P
Alteredmentalstatus
Alteredresp.pattern
Alteredspecificgravity
Anxiety

Definingcharacteristics:

Dyspnea
DecreaseinHCT
Electrolyteimbalance
IexceedO
Weightgain(significantweightgainis(>510lbsinaweek)

(remembertohavemorethan1definingcharacteristicforyournursingdiagnosis)

Assesslungsoundstolistenforpulm.Edema
Lookforperipheraledemanote1+to4+pitting

Assessat:dorsalpedal,behindankle,shin
holdfor5seconds
Estimatedepthoffingerprint

Measuredindepthofanickel

1+=1nickel
2+=2nickels
3+=
4+=

JVD:

(positionofpatientwhenassessing???)

Planning:

Setpatientgoalsoroutcomes.Whatisyourplanforpatientwithexcessfluid?
Dec.edema
Clearlungs
Labswnl
DecreasedJVD
Weightloss
NormalI&O
**Patientteaching

Interventions:

Monitoranxiety(2*toSOB)
MonitorRR
Monitorchangeinresp.rate
Monitorchangeinlungsounds
Monitorweights
Mon.I&O
MonchangesinJVD,edema
Monitorlabs

Somepatients:

Onfluidrestriction,explaintopatient
Deficientfluidvolume:

Defi.Dec.intravascular,interstitial,orintracellular

Def.characteristics:

Alteredms
Decurine
Dryskin/mucusmembranes

Incheartrate
IncHCT
Suddenweightloss
Urinedark
Thirst
Week

(loosing1%ofweightduetofluidlosscanbesymptomatic)
Planning:

Setpatientgoals:
Normalurine
Vswnl
Elasticskinturgor
Orientedx3
**patientteaching

Interventions:

EncouragePOintake(givereasoning),teachwhatfluidstodrink

IVfluids

Monitorvs
Orthostatic
MonitorI&O,mweights,labs,
FoleyPRN
Trendsover24hrs

Skinturgor:

**handsareNOTthebestarea(chest,shins)

Assessment/riskfactors:

Activefluidloss
Barriertoaccessfluids
Comp.regulationsystem
Excessivefluidlossvianormalroutes
Ageextremes
Factorsaffectingfluidneeds
Fluidlossthrough(abnormalrouts)
Insuff.Knowledgeaboutfluidneeds

Ptsmostlikelyfordeficits:

Confused
Coma

Bedridden
Infants/elderly

Prevention:

Teachwarningsigns(weakness,thirst,dryskin,drymucosa,inc.weight

Interventions:

(sameandaboveDx)

Fluidshifts:
3rdspacing:

Abdomen(ascites)
Intotissues
Lookswollenbutactuallyfluiddeficient

Document:

Assessmentdata:
Dxtest
I&O
Weights
Lungs
Edema
*patientresponse(aftereachintervention/medicationgiven)
*patientteaching

Nursing111Lecture
10252016
WEEK8
URINEELMINATION:

Maintainsfluid/electrolytebalance

Isaclosed,sterilesystem
Anatomy:
Kidneys,ureters,bladder
**Bladderholds400600ml
**micturition(voiding,urination)
Bladderhasstretchreceptorswhichsendsmessagetospinestimulating
(importantinpatientswithspinalcorddisruptionandmaycauseretentionduetonospinalcord
stimulation.Therefore,catheterizationcanbeimportant)
Privacycanbeveryimportanttosomepeople(shybladder),beawareandrespectful
Theveryyoungandelderlymayhaveadditionalproblemsaffectingappropriateurination

Factorsaffectingurination:
gender,religious,privacy,fluidintake,meds,ingestion
Physiologic:

DM,arthritis,spinalcordinjury,prostateenlargement,diagnostics(endoscopyofbladder,
catheterizationespeciallylongterm>1Mo.Youloosethenaturalurge/sensationtosensethe
needtourinate),hypnoticsandsedatives,anesthesia(loosethesensationatapointofthe
spinalcord

Nursingassessment:
Subjective:
patterns
dysuria
urgency
frequency
nocturia2xormorepernight(sleepdisruption)
enuresis(bedwettinginanabnormaldevelopmentalpoint)
incontinence(isitnew?acuteincont.maybeduetoaninfection)orbecauseofchildbirth.Kegels
canbeencouragedtohelpstrengthenthemuscledinvolved


ASSESSMENT:
shouldbealightstrawcolor
faintaroma
clear(notturbid)
15002500mlina24hrperiod
urineismadeoupof94%waterand4%solids(na,Cl,)
DXTEST:
microscopicanalys.
acetones(ketones)=0
Albumin/protein=0
RBC/redcolor=0(maybenormalinmenstruation)
Glucose=0
WBC=05%
Casts==0
SG=1.0101.025
pH=4.58(alk.IscommonwithUTIs,acidicurine=metabolicdisease)

**KNOWNORMALSFORABOVE

Diuresislargeamtofurine
Oliguria<500ml/24hrsor<30ml/hr
Anuria<100ml/24,
hematuriabloodintheurine

Physicalexam:
femalesbettheclitvagina
males

Assessfor:swelling,discharge,discomfort
distensionlookjustabovethepubicsymp.,palpation/percussion
Trackml/hrofurine
assessretentionandretentionwithoverflow(dribblingincontinenceorurinaryfrequency)treatby
usingleaseinvasiveinterventionsfirst.
useofBladderScan
Catheterization:

Riskofinfectionishigh
Requiressteriletechnique
Normalresiduals=0afewmls(afterthepatienturinatesandiscatheterized)ifthereisahigh
residual,noteandcontactprovider

NURSINGDIAGNOSIS:
Functionallyurinaryincontinence:
r/talteredcognitive,alteredenviron,impairedvision,neuromuscular,
definingchar:
completelyempties..
earlymorningincontinence
Planning:
patientwillusebathroom
eliminateincontinence
suggestpsycheval.
accesstoatoilet(onthesameflooraspatient)
**GOALS=SMART**
Interventions:
reassessment
assessmental/physical
bladderdiary
medreview
providetoilet
OTreferral

appropriateclothing
bladdertraining
Skincare
undergarments(optionsexpense,embarrassing,smell)
cath.
patientteaching

Evaluate:

DOCUMENT!

NURSINGDIAGNOSIS:
URINARYRETENTION:
r/tblockage,highureteraltol.

Assessment:
absentoutput
dribblingvoid
distension
overflowincontinence

Planning:(goals)
demon.Consistentabilitytovoid
residual<200250ml
befreeofUTIs

Nursinginterventions:
PMH

painassessment
physicalassessment
recog.RetentionasAMEDICALEMERGENCYCALLMD
reviewmeds
attemptnoninvasivetechniques
insertcath.UsingCDCCAUTIrecommendations

Goalofmanylongtermcarefacl.Istoreduce/eliminateurinarycatheters

UMBRELLADx:
impairedurinaryelimination:
adysfunctioninurineelimination

CDCrecommendations:
useonlyforappropriateindications
leaveinonlyaslongasneeded
ensureonlytrainedpersonnelinsertsandmaintainscath.
changemonthly
useaseptictechnique
useclosedsystem
maintainurineflow(gravity,bagbelowthebladder)
practicehandhygieneandstandardprecautions(followCDCguidelines)

UTIinfections:
EDUCATION:

Drinkfluids(upto2500ml/appropriateoutput~2400ml)
Voidwhenurgeisfelt
Propercareavoidharshsoaps,powders,syntheticunderwire(yogapants,tightjeans)

KnowS/s:

Frequency
Urgency
Dysuria

IfDxwithaUTIfinishALLABX

Careforindwellingcath:

Dailyperinealcare
Maintenanceofclosedsystem
Aseptictechnique

B0WELELIMINATION
Defecationisnormal
Largeintestine
absorptionofwaterandnutrients,secretion,elimination
Factorsaffecting:
age
diet
regulardietaryintake
foodintolerance
Fluidintake
2500ml/day

Nursing111
11012016
WEEK9

OXYGEN
4phasesofrespiration:(mustallbeintacttomaintainlife)
pulmonaryvent.
Alveolar./capillarygasexchange
transportofgasses
peripheralcapillarygasexchange

Inspirationanactiveprocess
Expirationpassiveprocess

Requirements:
unobstructedairway
IntactCNS
Intactbrainstem
Abilitychestcavitytoexpandandcontract
Abilityoflungstoexpandandcontract

Diffusion(def)amovementofgasesfromhighcons.Tolowcons.

Movementofgaseslungstoheart,hearttotissue

Requiresintactcardiovascularsystem

OxygenistransportedonthehemoglobinintheRBCs,CO2transportedonRBCsANDINTHEPLASMA

Peripheralcapillarygasexchange:
diffusionmovementofgasfromhightolowconcentration

Regulatorysystems:
NURALCONTROL:
brainstempons/medullaoblong.
cerebralcortex(C3,C5)
CHEMICALCONTROL:
chemoreceptors9medula,aorta,carotidarteries

Factorsaffectingrespirations:
stressfight/flight
Environmentaltitude,occ.Hazards
Lifestyleexercise,smoking
Healthstatus/diseaselungs,nervoussystem(COPD)
Medications(opiates,
Age
infants

children

elderly

Affectinggastransport:
effectivepump
adequateperipheralvasc.
adequateplasma
normalRBCs(size,shape,number,)
oxygencarryingcapacity

diet(Fe)
Infants:
infants3060RRM
Child>1yr22RRM
matureimmunesystem
increasedriskforresp.illness
Elderly:
dec.lungelasticity
shallowresps
agingcardiovascular.System,inefficientpump
environmentalhazardsthatdegradesystems
dec.immuneresponseriskforresp.illness

Generalassessment
Reportrestlessnessorconfusion
reportabnormalbreathingpatterns
report:cough,sputum,chestpain
cardiacsymptoms:fatigue,weakness,lightheadedness
medHx:Resp.,Neuro,Card
Environment
Medications
Lifestyle:activevs.sedentary
Diet:Feintake

Diet:
DietandFe
Significance:formationofHgb
SourcesofFe:organmeats./redmeat(highestlevels),seafood,oats,prunes,rasins,kidneybeans,
chickpeas


Absorptionof:Vit.C(increasesFe),Calcium(decreasesFe)

PopulationthatrequireincreasedFe;
lessthan10MO
pregnancy
lactation
menstruation
Deficiency:
vegetarians

Breathingpatterns:(objectivedata)
eupneanormal
tachypnearapid
bradypneaslow
orthopneaposition,situp
Cheynestokesdeeptoshallowrespswithperiodsofapnea
dyspneadifficulty
Useofaccessorymuscles

Pulseoximetry
Breathsounds:
normalclear
abnormaladventitious
Lungsecretions:
normal
absentorsmallamount
clear

Oxygensat.
anestimationofHgbOxygensaturation
normal92100%

Skincolor:
indicatesoxygenationstatus
normal=pink

Generalassessment:
Dxtests:
RBC
normal3.55.0million/cu.mm
Hgb
Norm1212g/100ml
Hct
3550%

Chestassessment:
symmetrical
prominentclavical
A/P1/3tooftransversediameter
presenceofpect.Perinetum/excovicum,barrel,

Abnormal:
**Hypoxia
**mentalstatus(earlysign)
**restlessness(earlysign)
tachypnea
dyspnea

lightheadedness
tachycardia
cyanosis(latesign)
Areastoassesscyanosis:
nailbeds
circumoral
sublingual
conjunctiva
earlobes
*buccalmucosa
*lips
*palms/souls
(*moreeasyindarkskinnedindivid.)

Cough:acompensatorymech.Tocleartheairway
subjectivedataoccurrence,triggers,productive/non
Objective:

Sputum:
color
amount
odor
consistency
blood?

Nursingdiagnosis:(*knowthesediagnosis)(seeblueBasicOxygenationneedshandout
*Ineffectiveairwayclearance:
inabilitytoclearsecretionsorobstructionsfromtherespiratory
R/T:


definingcharacteristics:absentcough,adventitiouslungsounds,cyanosis,difficultyverbalizing,
Interventions:auscultate,monitorresps,monitorABG,elevateHOB,incentivespirometer,meds

*Ineffectivebreathingpattern:
inspiration/expirationsthatdonotprovideadequate.

Generalassessment:
monitor
RR
breathpattern
breathsounds
cough

Optimizebreathing
position
fowlers
leanforward
pursedlipbreathing
pushfluids
humidifiedOxygen

Meds:(knowbold!!)
**guifeisen
**Dextromethorphan
forcoughwithoutproduction/coughsuppressiononly

Cardiovascularsystem:
promotefluidintake

inc.fluid,dec.bloodviscosity
O2asordered
**avoidpetroleumjellywithOxygen
**avoidsmoking.

Monitorskincolorforcyanosis
monitorRBC,Hgb,HCT

2typesofFe:
Fegluconate
Fesulfate(morelikelytocauseconstipationandGIupset)
Avoidcalcium
Takewithvit.C

InsurepatientiscomfortabletodecreaseO2demands
(withoutanMDorder)
treats/sthatinc.O2demands
assistinADLs
moderateactivity
restperiods

RESTANDSLEEPLECTURE:
Restisimportanttorecovery,repair,recoveryfromillness
GOALS:
reducenoisefromstaff,otherpatients,machinesandalarms
strangesounds
patientdoesnotfeelwellifyoudontfeelwellyoudontsleepwell
stress

unfamiliarsurroundings

Nursing111
11082016
WEEK10
**FORTHISWEEK:
MedcartonWednesday(time)
ISBARforclinical
nursingprocesspaper(part1)forclinical(P.Puffer),onlyfirstpart,nottheoutcomesyet

Implementation:
4thstep

Continuousprocess(cyclical,doesntstop)
actual/potentialhealthproblems=NursingDx
Evidencebasedpractice:(Def)basedonresearchandevidence(clinicaldecisionmakingbasedon..)
EBmedicinerequirespatientbuyin
ExofEBmed.:handhygiene,CAUTIprotocol,fallprecautions,siderailsdown(becauseEBresearch
showsmoreinjuriesreportedwithrailsup)
**asevidencechangessomustthepractice

Stepsinimplementation:
assess
reassess
needforassistance?
Implementationnursingstrategies(woundcaredry/barrierpro.)


Fornursingprocesspaper:
(P.Puffer),onlyfirstpart,nottheoutcomesyet

partiallymetmeans,thepatientisworkingonit,maynotneedtochangependingreassessmentlater

reviewAckleys:

Nursing111Lecture
Week11
11152016
Woundcare
Ingeneral,sterileglovedwoundcareisnotdoneasmuchasinclass(catheterplacementisALWAYS
donesterile).

VACwounddressingintermittentvacuumtopromotehealing

RNsroleinwoundcareis:assessment(!always),changedressings(withorders),stagingwound**is
withinscopeofpractice**
localvs.systemicinfections
iatrogenicinfectionstopbybreakingthechainofinfection,washhands,PPE,
EBPevidencebasedpracticepracticebasedonwellformedscientificstudiesandproof.

stage34ulcersmaynotbereimbursedbyinsurancebecausetheyarepreventable

defenseagainstinfection

(normal)humanflorahelpsmaintainthebodythrougha*symbioticrelationship

nonspecific
3systemsofdefense

Innateimmunity:

1skin,mucus,secretions

2macrophages,NKcells,inflammatoryresponse

Adaptiveimmunity
3lymphocytesBandTcells,antigenspecific,memory

Inflammationprocess
rapidvasodilationoccurserythemaincreasedbloodflownearthesite
tissuedamagereleaseofchemicals
edemaaccumulationoffluid

painfrompressurebuildup
WBCsarrive(leukocytosis)
(phagocytosis)

inflammatoryexudate:
**serousvs.sanguineousorpurulentvs.serosanguineous
tissuerepair:
granulationtissuefragile,healingtissuegranulationtissuehealsfromthebottomupandoutsidein.
astissuehealstissueisformeddifferentlyfromnativetissue(keyloids)
Specificdefense:
immuneresponseslow,calledwhennonspecificmethodsarenotenough
***askJackeyaboutconceptmaps
extremesinagesaremoresusceptible

healthyadultstendtogetmorevirusesvs.bacteriapossiblybecausebetterhygiene,immunity,
Riskfactors:
age,heredity,stress,medications(chemo),nutrition,disease(AIDS,Cancer),therapies(chemo)
Increasedcortisone(stress)inthesystem=decreasedimmuneresponse

Nursingprocess:
Assessment:

askquestionspainscale,time,onset,change,duration,patientsobservations,ADLs?

Objective:

observationsphysicalassessment,**LABDATA,

**WBC500090005to9(MCCvalues)
remembertodoanassessmentbeforecallingaprovider
CBCwithDiff:
(focusedonthedifferential)
nutro

basal
eos
mono
lymp

C&S:(urine)
e.coliiscommon

Woundculture:

Bloodculture:
bacteriaintheblood

NursingDx:
SMART,TEA

Woundhealing:
**primaryintentioncleanwoundmargins,approximation,littletissueloss,littlescaring,littleinfection

**secondaryintensionjaggedmargins,infection,*leftopen,healsfromthebottomupwith
granulationformulation,scarringismoreextensive

reviewfactorsthatinfluencewoundhealing:
circulationisneededforwoundstoheal
KNOW:
abrasions
lacerations
puncture

Contusionecchymosis,
Incision
Review:
woundcultureSTEPS

SkinIntegrity:
epidermallayer
dermallayerinner,tensilestrength,collagen,
frictionvs.shearinjuries
macerationmoisttissueinjury(avoidmoisturizerbetweentoesindiabetics)
reactivehyperemiauseofaTKtofirstblanchandthenflushwhentheTKisremoved
Riskfactors:
impairedsensoryperception,DM,spinalinjury,ALOC(sedation,coma,anesthesia)

Classificationofpressureulcers:

Lookingatsize,depth,appearance.Oncestageditremainsthatstagethroughoutrecovery

Stage1nonblanchable,warm,red,
State2fullthickness,open,sloughing,blistering,
Stage3SQlayersarevisible,undermining/tunneling,
State4bone/tendon/muscleisvisible
unstageableunabletoseefullstrataofwound

Treatmentdependson:
depth,whatcausedit,color,appearance,
slough=bacteria
red=granulation/healing
black=necrosis

NursingDx:
impairedskin..vs.tissue

preventioniskey
reducerisknursesjob
moisture=breakdown

Managementofwound:
usuallyneedanorder(MD/surg.Maywanttopreform1stchange)
moisturepromotesepithelialmigrationandhealing
debridementremovalofnonviabletissue

autolyticdigestescars

wettodrydressing

surgicaldeb.

irrigation

chemicaldeb.(Dankins,maggots)

**Knowwhatdressingyouwoulduseonwhichwounds

Nursing111
Week12
11222016
BASICNEEDS:SEXUALITY
TowardthebottomofMaslows
physiological,psych,culturalfactorsinfluencing
difficulttodefine,individualexpression
nouniversalnormal
consentingadultsiskeyinthedefinitionofsexuality
*crucialtoapersonsidentity
sexandreligionarethe2subjectsthatnurseshaveaproblemtalkingabout
involvesawiderangeofneedsanddesires,mustbewithinyourrealmofknowledge
sex.Healthypeopleincludes

knowledge

abletoexpressfullsexualpleasure

tomakeautonomousdecisions

*experiencesexualpleasure

capableofsexualexpressionthroughcomm.Love,emotion

abletoaccesshealthcareforpreventionofSTD

abletomakefreereproductivechoices

Componentsofsexhealth:
howonevaluesselfasasexualbeing
abilitytocontributeinarelationship

bodyimage
*centralpartofselfconcept
continuouschange
bodyperception
canbealtered:changeswithlifeevents(trauma,disease,age)

Componentsofsexhealth
genderidentity
onesimageofmale/female
morethanbiologic:inc.soc.Andcultural
maynotconformtoonesbio.Sex/anatomy
Componentsofsexualbehavior
GNDERROLEBEHAV.
perceivesgender
appropriatebehavior
outwardexpressionofmalenessorfemaleness..

Sexualpromotion
ED
responsiblesexbehavior
STDs
contraception

Importanttotellyoungchildrenaboutappropriatesexualparts
tofacilitatefutureconversations
protectagainstabuse
followsontoSTDprevention,andcontraception
Sexdevelopmentthroughthelifecycle:
childprefersoneparentoveranother

sexualityinfluencedbyculture
religioninfluencesvalues

ethics

guidelines

sexualexpression

meds,illness,diseasecaninfluencesexuality(sideeffectsofmeds,unabletoperformduetoillness)
BeforeobtainingaptssexualHxclarifyyourowncanhelptheRNunderstand

everyoneshouldhavesometypeofsexualhistory
screenforSTD
reviewillnessesandmedsthatmayeffectsex
evaluatesexproblems
Shouldinclude:
sexualactive?
areyouunhappywithsexualfunction?
experiencingandsexdifficulties?
hassexactivityadverselyimpactedyourpartner?
peopleindom.ViolenceWANTyoutoask
anySTDconcerns
birthcontrol
selfexams

Mustbenonjudgmental:
askquestions
reviewSx
startgeneral
somepeoplecomplainabout
askhasanyoneeverspokentoyouabout..
PLISSITallRNsshouldbeabletofunctionatthe1st3levels
Ppermission
Lilimitedinformation
SSspecificsuggestions(mostbecomfortable)
ITintensivetherapy(byaspecialist/practitioner)

Inappropriatebehavior:
exposing
sexjokes
offeringsex
askingforpericare
Dontbeafraidtoconfront,saystoporthatthatbehaviorifnotacceptable

SELFCONCEPT:
Defourownviewofourselves,
ifyoudontcareaboutyourselfhowcanyoucareaboutothers
youmusttreatothers
*Alwayssubjective
itsalwaysevolvingchangeswithlifestages,events,socialmedia,TV,radio,religion,relationships
Selfconcept:
basedinindividuality,age,race/culture,gender,sexuality
strongpersonalitymakesiteasiertohelpotherswiththeirs

Bodyimage:
doIlooklikeeveryoneelse?
isthereadeficitorpartsmissing
appearance
culture./society
canverybasedonlocation,socialstrata,economics,school,family,background,
Physically:
ifapersonhasapos.bodyimageislikelytotakecareofthemselves
Roleperformance:
howyoucarryoutyourrole
whatsocietyexpects

abilitytoperformthatrole,newjob,school,illness,coworker(clearexpectationsareneededto
progressthroughtheprocess)
Selfesteem:
individualjudgement,emotionalappraisal,selfworth
isgreatlyinfluencedbypos./neg.views
wehavetoknowhowwearedaytoday(howourptsaredaytoday)
offersupporttoanyonewhoneedsit
positivereinforcement,eventoself,canimproveselfesteem
behonestwithself,knowandfollowbeliefs
takeresponsibilityforactions
thiscreatesstability
identifyneedforgrowthandworktowardagoal

Apos.Selfesteem:
betterabletomaintainrelationships
resistspsychillness/physical
adaptandacceptchangesandadapt
Factorsthatalterselfconcept:
anyrealorperceivedchange
individualperception
changethatoccursphysically,spiritually,emotionally,sex,culture,health
crisis
Identitystressors:(biginadolescence)
roleperformance:roleambiguity,roleoverload,roleconflict,rolestrain
bodyimagestressor:Affect,appearance,health,functionorstructure,internalchanges
Selfesteemstressors:
failuretoadaptcanleadtocrisisandlowselfconcept

HowcantheRNchangethepatientsselfconcept

ther.Communication
selfawareness
personalselfconcept
withpatients:usepos.andmatteroffact,buildtrust,beawareoffacial/bodylanguage
AsRN:prevent,identifyearly,implementTxforstressors

Basicneeds:
Perceptualalterations
6senses:

Whatinfluences:
ageextremesin
meaningfulstimuluswhattypeofinteractions
Amounttoomuchortoolittleisnotgood
socialinteractionhowfrequently
Environsound,light,occupation
cultural

Meaningfulstimuli:
providesinfoaboutenvironment
necessaryfordevelopment
reducessensorydeprivation
ex:TV,music,pets,clocks,calendar,pics,people(someareimportantfororientation)
(alackofstimuliaffectsthepersonsabilitytoreactappropriately)

Nursesrole:
identifysens.Alterations

alterenvironmenttopromotesafety
assistpt.tointeractwithenvironment(getglasses,getdentures,getcallbell,TVwithremote,orientto
room)
Assessmenttodeterminewhoisatrisk:
elderly,sick,thoseinanonstimulatingenvironment,hearing/visionloss,

Hx:
family,Pt,friend
identifydeficits,leveloffunction,meds?,
SensoryalterationHx:
(495)
assessforptawareness
Mentalstatus:
LOC
memory
appearance
emotions
cognitiveabilities
Physicalexam:
testallsenses
yourobservations,followcommands
anyassistivedevices?
(patientwilltrytohidethingsfromyou)

Abletoselfcare
ADLs
abilitytocompletetasksbills,meds,driving
Healthpromotion:
dailyroutine

healthscreenings
gotodoctor
Environmentalhazards:
wheredotheylive
housesetup
safetyrisks
meaningfulstimuli
Work
Communicationmethods:
writtenlanguage
hearingdeficit
reading
alternatemethods?
Socialsupport:
family
mealsonwheels
friends
dotheyfeelsupported?
**review

careofhearingaid

Sensorydeficitvision

Contactlenscare(P.844)4014

Nursing111
Week13
11292016
ENTERp.7
IV,def.
fluidandormedicationsdelivereddirectlytotheintervascularspace
fast(dangerous)

IVcatheter:
selecttheappropriateequipment
Centralvsperipheralcannulation:
centralgoesdirectlytotheheart
peripheraltakesmoretimetoreachtheheart
needleisremovedandthecatheteristakenout(remindpatientaboutthis)
selectappropriateIVbagsize,fluid,admin.Set,catheter
selectifyoucanusegravity(leastamountofmechanics,butalsohasdrawbacks)vs.IVpump
IVflowsfromhigherpressuretolowerpressure(venouspressure)
considerviscosityesp.inadministeringblood
18GAislargerthana22GA
thehigherthebagisabovetheheartthehighertheinfusionpressure(thehighertheflowrate)
thelargerthevein/catheterthefastertheflow
lowerviscosityflowsfaster

ProposeofIV:
forfluidreplacement/electrolytes/blood
restorationtherapy(TPN)(ashorttermtherapy,usuallyusedwithpatientswhoneedtogivegutarest)
IVdrugadministration(muchfaster,rapidaccesstocirculatorysystem)(mustreassessoften)
Intracellular
incells

Extracellular
inthebloodvessels
Interstitialfluid
outsidethebloodvessels
(CSF/synovial/)

WhenadministeringIVfluids(esp.rapidly)watchforfluidoverload/edema)
Osmosisdef.
movementofwater
Diffusiondef.
movementofelectrolytes
movementof
Osmolalitydef.
concentrationofsolutesinasolution
Tonicitydef.
howtheconcentrationofanIVeffectshowosmosisanddiffusion

Isotonicsolutions:
balancedsolution,staysinthevascularspace(bed)
usedtoreplacefluiddeficits
watchforfluidoverload,edema,SOB,
useforDx:lowB/P

Hypertonicsolutions:(D5,LR)
pulledfluid/electrolytesINTOtheintervascularspace)
higherosmolalitythanblood
usedtodec.edemaandexpandvascularvolume

Hypotonicsolutions:(1/2NS,0.45%NaCl)
(ifyouseeanunusualorderforIVormedsaskprovidertoconfirm)dutyofnurse

**musthaveordertoD/CandIV

IVsusedforshorttermfluidreplacement(oralreplacementisbetterinlongterm)
Isotonic
fluidandelectrolytes

Hypotonic

Hypertonic(notusedasmuch)
lesssolutethanplasma
plasmafl.Levelisgreaterthanthecells
fluidmovesintothecells
usedtoTxcellulardehydration

Commonabbreviations:(p.8)
NS=normalsaline0.9%
D5W=5%Dextroseinwater
LR=closesttoplasma,Na,Ca,Cl,lactate
D5
1/2NS
D5LR

ComplicationsofIvtherapy:
infiltrationinadvertentadmin.Ofanonvesicant(nonblistering)sol.Intothesurroundingtissue
swelling/blanchingatsite

dec.IVflow
pain
(90%ofadmittedpatientsreceiveanIV)

Phlebitis:
inflammationofavein
increasedriskforbloodstreaminfection
Asses
pain/warmth
linearpatternofredness
**(ifanIVinfiltratesyoumayreplacetheIVbecausetheIVorderstillstands)

Circulatoryoverload:
fluidaccumulatesfasterthanthecirc.Systemcantransport,filterandexcrete
Assess:
peripheralEdema
dyspnea
JVD
rales
increasedheartrate
elevatedB/P

Infection:
Assess
drainagefromIVsite
warm/rednessatsite
fever(concomitantwithIVsitechange)

Bestpractices:

correctIVsol.
Correctflowrate
dateandtimehung(max.24hours)
patencyofthetubing(kinkedtubing)
AssessIVsite:
infection
infiltration
phlebitis
bleeding
monitorlabs(esp.ifadministeringmeds)
*changeIVevery3days(agencydependent)**96hourscontinuous,24hoursifIVisbrokenatany
time)newresearchcoming.

Bestpractices:
maintainaclosedsystem
keepairout(**<270mlmax)
aseptictech.
scrubthehub

Patientteaching:
purposeofIV
careofsite/equipment
abnormalitiestowatchfor
tellfamilydonttouchthepump(silencingalarm/restartingpump)

Infiltration:Phlebitis:
changeIVsite
applywarmcompresses
(canbedonewithexistingMDorder)


Infection:
changeIV
culturesite(MDorder)
Antibiotics(MDorder)

Circulatoryoverload:
dec.IVratetoKVO
interventionstoimproveO2
anticipateMDorderingdiuretics

CommonIVmeds:
Insulin
Heparin
Opioids
IVK+
neuromusc.Blockade
chemomeds.
Oxytocicmeds(maternitymedicationstoinducelabor)
(usuallyawarninglabelonpackage)highalertmedications(*alwaysuseapumpforthese)
Monitorlabvalues:
heparin
insulin
monitorforintendedandunintendedsideeffects

Potassium:
Alwaysdilute
neverIVP
ISavesicant

monitorserumK+levels(norm3.55)
**neveraddtoanexistingIVinfusionbag(ratiowillbeoff)

Documentation:
assessment
site
Pt.response
adverseRXN
typeoffluid
flowrate
volumeinf.
Typeofivdevice(gravityvspump)
dressingchanges?(marktime/dateondressing)
(followfacilityspec.protocols)

Elderly/peds:
physiol.Assessment
IVequipmentneeded
ageappropriatepsych,.Support
(inelderlycirculatoryproblems/renalfunct.)

Nursing111
Week14
Lecture12062016

CultureandHeritage
Culturecarehealthcarethatisculturallysensitive,appropriate,competent
Takesintoaccountthesettinginwhichthepatientlivesandhishealthcareproblems
Musthaveabasicknowledgeofthecultureyoureworkingwith
Mustbeculturallyappropriate

Ifapatientrequestsaspecifictypeofcaregiverstaffmanagershouldassess

Thereasonbehindtherequest.Thepatientcanmaketherequestbutitmaynot

Begrantedjustbecauseofpreference.

Cultureisshared
cult.Iscommunicatedbygroupsofpeople
dynamic,adaptive,everchanging
changesslowlyinresponsetogroupneeds
adaptivenatureallowsthegroup/culturetosurvive
Beliefsandpractices
magicoreligious:

health/illnesscontrolledbysupernaturalforces

biomedical

lifeabdprocessescontrolledbyabiochemicalprocessandcanbemanipulatedbyman

Holistic

balanceandharmony(3Dpatient)maintainedinforcesofnature

(apatientwhocantconsentfortreatment./refusalmustbetreatedbyacceptedmedicalpracticesfthe
patientcouldbeharmed)

Whoistheauthorityfigure?
children(seen/notheard?)

elders(keepersofwisdom?)
genderroles(canthespousebeinvolved?)
values(whosvaluesareinvolved?)
addressingthepatientcorrectly(Mr.,Mrs,patientpreference)
Communication:
Verbal
speed
silence
voice
useofinterpreters
Nonverbal:
touch
eyecontact
facialexpression
posture
space:intimate=11/2feet,personal=11/24feet,social412,public12+
EdwardTHallproxemics(studyofdistance)
Culturalassessment:
staplefood
foodprep
remedies
Sexualviews

Beproactive
Assessyourself
7stepstoculturalcompetency:

Culturalsensitiveinteractions:

Heritageassessmenttool:

ManagingCare

CRITICALTHINKING
criticalthinkingispartofthenursesday,allday
itsactive,purposefulorganized,cognitive,
CriticalThinkingisanactive,purposeful,organizedcognitiveprocessusedtocarefullyexamine
onesthinkingandthethinkingofotherindividuals.
CriticalThinking

ISNOT
Automaticresponses
Unclearcomments
Uninformedresponses
Irrationalstatements
Assumptions
Learnedovernight
Beingacritic
Takingresponsesatfacevalue

IS
Lookingatthewholepicture
Beingaware
Evaluation
Drawingconclusions
ThecoreofeverygoodRN
Continuousprocess
Beingopenminded
Looksateachpatientasbeingunique
Isaboutwhatis

TalkwithyourclassmatesandcomeupwithanexampleofISandISNOTcriticalthinkingthis
semester:

ClinicalDecisionMakinginvolvescriticalthinking..butISNOTthesamething.Whataresome
differencesandsimilarities?

CDMvs.Crit.Thinking:
CDM=problemsolvingbasedonexperienceandknowingthept.well,
confident
independentthought
fairtoeverypatient
accountableaskifyoudontknow,beresponsible
dontlabelpatients(uncooperative,drugseeking)
Crit.Thinking,Differences:

Differences

Similarities

CharacteristicsorAttitudesofACriticalThinker
1. Confident:

2. Independentthinker

3. Fair:

4. Accountable:

Otherattitudesincluderisktaking,disciplined,persevere,creative,curious,possessintegrity,
truthseeking,openminded,analytical,systematic,inquisitive,matureandhumble.

GeneralCriticalThinkingandDecisionMakingProcess

ScientificMethod

ProblemSolving

DecisionMaking

Basedonevidence,research,methodical*alwaysusethis

CompareandContrasttheNursingProcessandCriticalThinkingSeeVennDiagram(Iwillgive
youinclassbutisalsoonBb)andcompletethisonyourowntime

LetsWorkOnThoseCriticalThinkingSkills..SeehandoutforScenarios(giveninclass)

DescribetheVariousFunctionsoftheRN

Autonomy/Accountability

Communicator

Caregiver

Advocate

Educator

Communicator

Manager

Candoalotwithoutorders,(oralcare,barrier
cream,*Oxygenbecauseitsneeded
immediately*,

Helpmanagediseases,comforts,spiritualhelp,

Speakforthepatientiftheycant,takechargeand
offer/getresources

Teachpatient/familynecessaryteachings(meds,
breathing,when/howtowalk)

Othernurses,NA,LPN

ManagingPatientCare
**VitalInformationforNCLEX
NotJustBeingANurseManager
whatcanIdelegate?
whataremypriorities?
ManagingPatientEncompassesTheFollowing:
1.
2.
3.
4.
5.
6.

Useoforganizationalresources
UsingresourcestoprovidepatientcarePT,nutrition
Usingtimeproductivelygetasmuchdone
Settingpriorities
Collaboratingwithhealthcareteam
Usingyourleadershipskillstomanageothersontheteam

CompareandContrastLeaderandManager
Whocanbenurseleader?Whocanbeanursemanager?Canyoubebothatsametime?
Whoisinchargeoftheclinicalunit?

CharacteristicsofanEffectiveLeaderP.280(212)

Characteristic

Howisthisaccomplishedbythemanager?

EffectiveCommunicator

Consistentinmanaging
conflicts
Knowledgeableand
Competent

RoleModel

ParticipatoryApproach

Showsappreciation

Delegatesappropriately

GuidesStaff

Displaysempathy,
understanding

Motivatesandempowers

Proactiveandflexible

Focusesonteam
development

ListfromPotterandPerrycombinesmanagerandleaderattributesDOYOUAGREE??

FourFunctionsofaManagergiveanexampleofeachfunction
Planning:staffing
Organizingptcare
Directingstaff
Coordinating

HowdoesthestaffRNfunctionasaManager?Examples?
Planning
Organizing
Directing
Coordinating

LetstalkaboutDelegationandAssigning

**ANA(AmericanNursesAssociation)andNCSBN(NationalCouncilofStateBoardsofNursing)
bothdefineddelegationastheprocessforanursetodirectanotherpersontoperformnursing
tasksandactivities.NCSBNdescribesthisasthenursetransferringauthoritywhileANAcallsthis
atransferofresponsibility.Both**meanthataregisterednurse(RN)candirectanother
individualtodosomethingthatthatpersonwouldnotnormallybeallowedtodo.**Bothstress
thatthenurseretainsaccountabilityforthedelegation.Effectivedelegationshouldresultin:
1.
2.
3.
4.
5.

Achievementofquality,safepatientcare
Improvedefficiency
Increasedproductivity
Empoweredstaff
Skilldevelopmentofothers

**LOOKATNYSSCOPEOFPRACTICEOVERBREAK**
whatisassessment?
datacollection?
whatcanbedelegated?(youassumetheskillsaredonerightbywhoever)
whocandowhat(LPN,tech,)
**delegatevs.assign:

Assign:

Delegate:

FiveRightsofDelegation
RightsofDelegation

Examples

RightTask

RightCircumstances
Istheoutcomepredictable?

RightPerson

RightDirection

RightSupervision

SomeimportantnotesaboutthesetermsandNYStrytolookitup.Where???
DELGATIONVSASSIGNMENT

EffectiveDelegation

1. Assessknowledge

2. Assessskills

3. Matchtasks

4. Communicateclearly

Listenattentively

Providefeedback

ThisiscrucialcontenttoknowforNCLEXdolotsofpracticequestions!!

ADMISSION,DISCHARGE,TRANSFERINGAPATIENT:
wehavepatienttrust,morecontactthananyoneelse
dischargeplanningstartsonadmission
requirescollaboration
involvesfamily/patient/HIPAA(becarefulonwhoyougivewhatinfoto,whoelseisaround)
inemergencyroomHIPAAcangobeyondnormallimitationsbecauseofalackofinfo
andimmediateneedforinfotoTx.Youcanreceiveinformationfromanyonewithout
consentbutcannotgiveinfowithoutconsent.Cangetverbalconsentofwitnessed(ifno
signedconsentifavailable)
usetherapeuticcommunicationintalkingwithpatient:
activelistening
payattention
smile
showempathy*notsympathy

professionalism
ViewRSAshorts(youtubevideos

lookforduringadmission:
biodata
CC
HPI
PMH
All.
Imm.
Meds
FamHx
supportsystem
disabilities
dischargeneeds
Modificationofproc.
agesupportsystem,precautions(young/old)
levelofwellnessperceivedvs.actualwellness(whattheywillseekhelpfor?)

understandwhattheybelieveandeducatethem

cultureimpactonillness,beliefsandpractices
Contagioncheck:
haveyoubeenoutofthecountry?

immunizations?
cough,fever,

Transfer:
becauseofchangeinptconditionneedinghigher/lowerlevelofcare

RNresponsibilities:

collaborative

advocateforthepatient

identifyresources

helptoreduceptandfamilystress

Transfertips:
transport
report
dressed
meds/items(*makesureallitemsgowiththepatient)
sendchart(*originalMOLSTform)
phonereport
Receivetransfer:
obtainchart

Professionaltelephone:
clearly
statename,title,facility,unit
nosidebarconversations
quiet
repeatback
facts(professional)

Receivingtelephonereport:
doc.Dateandtime
nameandcredentials
accurate
signnotewithnameandcredentials

Dischargeplanning:
onadmission
smoothtransition
insurecontinuityofcare
coordinationofservices
Dischargeplanning:
whywasD/cs
ongoingassessment

dischargeneeds
supportperson
teaching
d/cinstructions

D/Cinstructions
meds
medsreconciliation(whatmedswereputonandtakenoffduringadmission)
Txandproc.
activityandrestrictions
dietandactivity
healthpromo
whentocallMD

AMAdischarge:
askwhytheyarerefusing
notifyRNsupervisor/MD
patientsignsappropriateforms
assistptwithdischarge

12132016
Week15
Nursing111

SpiritualityandReligion:
Faith
tobelieveinsomething/someone
providesstrength
givesmeaningtolife
(mayincludevalues,language,rituals)

Religion:
community
organizedsystemofbeliefsandpractices
guidance

Spirituality:
partofbeinghumanthatseeksmeaningthroughinterintraandtranspersonalconnection
reflectionofinnerexperience
asenseofbalanceandpurpose

Characteristics:
Meaninghavingpurpose,canmakesenseoflife
valueshavingcherishedbeliefsandstandards
transcendenceappreciatingadimensionthatisbeyondyourself
connectionrelatingtoothers,nature,ultimateother
Becomingreflection,allowinglifetounfoldandknowingwhoyouare

Factorsaffectingspirit.

pastexperience
culture
perceivedimportance/value
lifestyle
family
availablesupport
environment
society
Spiritualneeds:
meaningandpurpose
trust
respect/value
meaningoflife
creativity
belongingtoacommunity
hope
forgiveness
dignity
values
connectionwithGod
vision
Preparationandacceptancefordeath

Notforgivingcauseslongtermproblems,movetowardforgivenessifatallpossible

NursingHxcommonopenendedquestions:
arethereanyreligiouspracticesimportanttoyou?
howwillbeingsickinterferewithyourreligiouspractices?
howisyourfaithhelpfultoyou?T.Turner(thesis)

howmightIsupportyou?
visitfromspiritualcouncilor
whatareyoursourcesofstrength?

Dontpushyourbeliefsonthepatientorpersuadethemtochangetheirbeliefs

Cuestospiritualpreferences:
presenceofreligiousobjects

Commonpractices:
holidays
sacredwritings
symbols
praying/meditation
diet
healing
dress
birth/death

Assessspiritualwellbeing:
senseofinnerpeace
compassion
reverenceforlife
generosity
capacityforunconditionallove
gratitude
humor
wisdome

abilitytotranscendself
appreciatebothunityanddiversity

Spiritualdistress:*(nursingDx)
expresslackofhope
refuseinteraction
suddenchangeinspiritualpractice
expressabandonment
callforordenyspiritualleaders

Spiritualdistress/(riskfor):

Interventions:
presence,justbeingthere,beingavailable,allowthepatienttoexpressthemselves
offersupport
assistincreatingaquietenvironmentandprivacy
adjustnursingcarearoundspiritualneeds
referraltospiritualcouncilor(staywithinyourrealm)

Cluestospiritualdistress:
depressed
crying

Nursing112precourseupdate:

Lavenderpacketbooksfornextsemester
Yellowpacketcommonmedsfor112(importantformedpass)**MUSTBEFILLEDINFORCLASS**
Whitepacketreadingassignmentsforweek12(muchfromPotter&Perry
Singlewhitesheetfirst2weeksofclinical(oncampus),includeswhatsdue,when,howtoprepare
**Nursing112welcome01182017Room8100**
Checkemailatleastdaily

Lossandgrieving:
4types:
1situationalsudden,
2Actualmayberecognizedbyothers,apersonmaynolongerexperience
3perceiveddefinedbypersonexperiancing
4anticipatory,potential

Sourcesofloss:
lossofaspectofself(limb)
lossofexternalobjects(car,clothing)
separationoffamiliarenvironment(moving,changeinschool,job)
lossoflovedones(childrenmoveout,lossoffriendship,death)

Chronicillness:
frequentlyseeninelderly
incidencetriples>45
people>65haveatleast1chronicillness
whathaveyouseenthissemester?

Factorseffectingloss:
age/developmentallevel
meaningofloss/significance
culturalyourcustomsandbeliefs
spiritualcanbesupportiveandguiding
copingstrategies
socioeconomicstatusmiddleandupperclassesgenerallyhavemoreresourcestodealwithissues(a
joballowingtimeoff,moneyforburial,
supportsystemhowwedealwithloss
natureoflossordeath

Grief=emotionalresponse:
aunique,personalresponse

(quoteVickiHarrison)

Behavioralresponseknownasmourning,theactionsanindividualgoesthrough,highlyvariable
Bereavement=subjective

4thingstolookat:
stateofawareness

closedawareness,Pt.,isunawareofimpendingdeath

familymaylackunderstanding

providermaynothavetoldtheprognosis

Mutualpretenseeveryoneknows,noonewantstotalkaboutit

pt.maynottalktoprotectfamily

maysensediscomfortfromhealthcareworkers

Openawarenesseveryoneknowsandistalkingaboutit

noteveryonecancopewiththis(familyandnursingstaff)

providesopportunitytofinalizeaffairs

Video:AwalktorememberJamiessick(YouTube)

NursingHistory:
relationships
supportsystem
natureofloss
lifegoals(met?Change?)
griefpatternshowdoYOUdealwithit?
selfcareselfcareofthefamilymember,areyoueating/sleeping?..takeabreakandgetcoffee,is
familytalkingaboutit?,ispatienttakingmeds?
hopegivescomfort,planningforthefuture,
cultural/spiritualbeliefsspecificafterdeathcare?,spec.prayersbefore/afterdeath?

Copingstrategies:

Physicalassessment:
(stressresponse)adrenergicresponse
Emotionalresponse:
crying
changeinappetite
sleep
concentration
verbalizeloss

ElizabethKublerRoss:stagesofgrieving
Grief
Denial
Anger

Depression
Bargaining
Acceptance

ThelastsongJonah2010(YouTube)

Normalgrieving:
common,universalreaction
guilt
disbelief
hopeless
noenergy
crying
inabilitytoconcentrate
Complicatedgrief:abnormalafter1year,effectsthepersonslife
leavingbedroomsetup
avoidsmemorial
guiltm,dec.selfesteem
conciderssuicide
minoreventstriggersgrief

Maybedueto:
complicatedrelationship
multipledeaths
failuretogrieve
lackofsupportsystem
pastmentalhealthissues

NursingDx:Grieving:

anormalcomplexprocess

Complicatedgrieving:
adisorderresultinginfunctionalimpairmentaffectingjob,family,relationships.
mayhavethoughtsofsuicide
lackofmaintenanceofbasiclifeneeds
decreaseddailylifefunctions
Nursinginterventions:
bepresent
usetherapeuticcomm.
evaluate
supportgriefprocess
educatefamilyonhowtocare(emptyfoley..)
offercondolences(hug,holdhand,)
offertimetohavefamilyreflect
allowtimetoofferselftofamily/patient
identifycomm.Resources
Careforyourself
whendoYOUneedcounseling
tellingthefamilyandPt.thatitsOKtodie(**thisisOKtodo)
offercounseling/spiritualcounc.asappropriate

PalliativeCare:
Allencompassing:
acutecare
Hospice
..
CarewithgoaltoreliefofSx,pain,stress,regardlessofDx(givenatthesametimeascurativecare)

(notacurebutsupportandcomfort)
customizabletotheindividualpatient

Hospice:
addressqualityoflifewithregardstocomfortandsupport
itdoesntmeangivinguphope
notjustforpatientsbutforthefamily
meetphysical/psychologicalneedtomaintain
providehighqualitycare
providedeathwithdignity
respectPt.asaperson
gttoknowthePt.
includethePt.inalldecisions
whatsimportanttothepatient?
music,pet,arttherapy?
Pettherapyisimportantforallinvolved(family,Pt.staff)

Meetthephysiologicneedsofthepatient:
managepain
personalhygene
resp.distress
nutritionaskwhattheywant,favoritefood/beer?,suckonfoodiftheycantchew
positioningcomfort
elimination
(deathrattlesecretioninthroatduetodecreasedgag/swallowresponse)treatthisforfamily
applymakeup/jewelryifrequested

WhatstheRNsrole?:
support

holdhand
makeprocesseasier
aguideforthepatientandfamily
dontbeinarushwithPtorfamily
whatcanyoudoforthefamilytomakethencomfortable?
facilitatemourning
educateandletthemknow..
facilitatecopingstrategies
listentoPt.,family

Howdowefeel:
identifypersonalfeelings
dontimpostourbeliefsonothers
providecompassion
care/closure
identifyhope

S/Sofimpendingdeath:
decreaseinfood/drink
restlessness
inc.sleepiness
changeinrespirations
Imdying
progressivelylongerapneas
alterationsinresp.pattern
Osign(mouthopen)
incontinence
bloodinurine,changeinappearance
changeinvitalsigns

swelling
mottlinginextremities
cyanosis
dec.temperature
inc.rigidity
lackofpupillaryresponse(afterdeath)

ClinicalS/S:
Heartrate(apicalpulse)
Respirations
noresponsetostimuli
nopupilresponse

Changes:
Algormortis
bodytemp
Lvormortis
poolingofblood
Rigormortis
stiffening

Postmortemcare:
honorrituals
removetubesanddrains
bathe
changelinens
ensureproperID
documentallcare(timeyoufoundthem,providernamenotified,whowasinattendance,care
provided)

familywillgiveclueswhenitsoktoremovedeceased

Organdonation:
callandreferdonornetwork
ruleoutsmayincludeadvancedage/infections

Advanceddirectives:
legaldocuments
patientspreferences(speakintermspatientwillunderstand)
provideeducationonwhatisavailabletoPt.

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