Anda di halaman 1dari 19

1

Nursing 1000 A
Chapter 10: Person Centered Care
What is Patient Centered Care?
Recognize the pt as the source of control and provide coordinated
care based on respecting the pts preferences, beliefs and needs
What the pt wants and needs
What the family wants
Its always about the pt
Principles include:
o Dignity and respect
Privacy
knock
Control
Ask permission before touching
Choice
Ask when would like to have meals
Humor
Make pt smile
Matter of factness
Give straight info
o Information sharing
Orientation at admission
Bedside report
Sharing of medical info
Discharge planning
o Participation
Involve family at bedside
Participation in plan of care during stay
Train family at bedside
Discharge planning
o Collaboration
Invite pts and family to become advisors
Assist with improving patient satisfaction

Expression of care
o Spiritual
Be aware of pts beliefs
o Presence
Be there for you pt
Physically present
2

Understanding
Be with your pt
Share onself
Ethics of Care
o Touch
Skin to skin
Eye contact
o Listening
Take in pt info
o Knowing
Understand the pt

Never have a conversation over the pt


Body language 60%
Tone of voice 30%
Words you chose 10%
Turn a negative into a positive
o Instead of I dont have time. I can help you in 5 mintes
3

Chapter 11: Assessing


Systematic way and a continuous collection of data
Data: how health functioning is enhanced by health promotion by illness/ injury
Database: includes all pt info collected by the nurse and other health care
professionals
Medical vs Nursing Assessment
o Medical target data pointing to pathologic conditions, look directly at issue
o Nursing focus on pts response to health problems, look at everything

Nursing assessment
o You look at the pt as a whole
o Your pt is the best source of info on them
Four types:
o Initial comprehensive
Performed on admittance to hospital
Performed to establish database for problem identification and
care planning
Performed by nurse to collect data on pts health
o Focused
Performed during initial assessment or ongoing data collection
To gather data about a problem already identified, or to
identify new or overlooked problems
Performed by nurse to collect specific data
o Emergency
Performed when a physiologic or psychological crisis happens
Life threatening problems
Performed by nurse
o Time lapsed
Compares pts current status to baseline data
Reassess health status and make necessary revisions
Performed by nurse

Objective Data
o Can be seen
o Elevated temp
Subjective Data
o Pt states it
o Pain, dizzy, anxious

Four Phases of nursing Interview


o Preparatory
Chart review
4

o Introduction
Introduce self and explain why your there
o Working
Collecting data, active listening
o Termination
Plan for the info
Always ask pt if have anything to add

Documentation of Data
o Give verbal report immediately whenever theres a critical change in
pt
o Use medical abbreviations
o Use pts own words when possible
5

Chapter 12: Diagnosing


Nursing diagnosis
o Describes pt problems nurses can treat independently
o Problem: what is unhealthy about the pt
o Etiology: factors maintaining unhealthy state, the cause
o Defining characteristics: subjective and objective data that signal the existence of
the problem
Medical Diagnosis
o Describes problems for which the physician directs the treatment
Collaborative Diagnosis
o Nursing and medical prescribed interventions

Types of Nursing Diagnosis


o Actual
Pt has
o Risk
High risk
o Possible
Pt may have
Could get
Need more info
o Wellness
o Syndrome
Cluster of nursing diagnosis that ae seen together
6

Chapter 13: Outcome Identification and Planning


Goals:
o Establish priorities
o Identify and write expected pt outcomes
o Communicate plan of care

Three Elements of Comprehensive Planning


o Initial
Happen on admission
Developed by nurse who performs nursing history and physical
assessment
Addresses each problem listed in nursing diagnosis
Identifies pt goals related to nursing care
o Ongoing
Keeps plan up to date
Develops more diagnosis
Makes outcomes more realistic and develops new outcomes
o Discharge
Carried out by nurse who worked most closely with pt
Begins when pt is admitted
Teaching and counseling is used

Prioritizing Nursing Diagnosis


o High
Great threat to pt well being
o Medium
Nonthreatening diagnosis
o Low
Diagnosis not specifically related to current health problem

Long term vs. Short term outcomes


o Long term
Takes time
Mobility
o Short term
Specific period of time
Medications

Categories of outcomes
o Cognitive
Increase in knowledge in intellectual behaviors
o Psychomotor
7

Pts achievement of learning a new skill


o Affective
Changes in pts beliefs, values and attitudes
8

Chapter 15: Evaluating


Has pt reached goal?
Actions based on pt response to plan of care

o Terminate
Get rid of when each expected outcome is achieved
o Modify
Edit if goals havent been achieved, difficult
o Continue
Continue if more time is needed

Four types of outcome


o Cognitive
Increase in pts knowledge
Ask pt to repeat info or apply knowledge
o Psychomotor
Pts achievement of new skills
Ask pt to demonstrate new skill
o Affective
Changes in pt values, beliefs, and attitudes
Observe pt behavior and conversation
o Physiologic
Physical changes in pt
Use physical assessment skill to collect and compare data
9

Chapter 23: Medical Asepsis


Medical asepsis
o Clean technique
o Gloves, hang hygiene
Surgical asepsis
o Sterile technique

Chain of Infection
o Infectious Agent
Can produce disease in humans
Bacteria
Most common in hospitals
Viruses
Smallest of all microorganism
Fungi
Plantlike in air, soil and water
o Reservoir
Where the pathogen can survve
Humans
Animals
Food
Insects
Need proper environment to survive
o Portal of Exit
Point of escape for the organism
Leave through:
Skin and mucous membranes
Blood
Respiratory tract
o Mode of Transmission
Contact
Direct
o Skin to skin
Indirect
o Contaminated object
Airborne
Droplets
Vehicle
Blood, food, water, inanimate objects
Vectors
Mosquitoes, ticks
o Portal of Entry
10

Enter through same routes they exit


o Susceptible Host
Degree of resistance
Immune system

Stages of infection
o Incubation
Invasion and symptoms
o Prodromal
Pt is most infectious, vague, nonspecific signs of disease
o Illness
Presence of specific signs and symptoms or disease
o Convalescence
recovery

Nosocomial Infection
o Transmitted by health care workers
o Hospital acquired infection
o 3 types:
Latrogenic
Exogenous
Endogenous

CDC guidelines
o Standard Precautions
All hospital pts
Blood, bodily fluids, non-intact skins
o Transmission- based
Suspected infection pts
Airborne, droplet, contact precautions

Hand Washing
o 15 seconds of vigorous washing
o Alcohol based antiseptics recommended when hands arent visibly soiled

Contact precautions
o Private room or room if pt has same infection
o Gown and gloves
o Disposable equipment

Droplet
o Private room or room with pt with same infection
o Wear mask
11

o Influenza, pneumonia, flu

Airborne
o TB, chickenpox, measles, ebola
o Private room
o Negative pressure
o Mask or respiratory protection device
N95 respirator
o Mask when pt is being transported
12

Chapter 24: Vital Signs


Five vital signs
o Temperature
F or C
Hypothalamus regulates core body temp
Shivering increases heat production
Sweating decreses heat loss
Goosebumps (vasoconstriction) decreases heat loss
Infants are vulnerable to temp
Highest in late afternoon
Lowest in early morning
Five routes
Oral
o 96.8-99.5 F
o Normal is 37.0C, 98.6 F
Rectal
o 37.5 C, 99.5 F
o Most accurate
Axillary
o 36.5 C, 97.7 F
Tympanic
o 37.5, 99,5
Temporal
o 34.4 C, 94.0 F

o Pulse
If pulse is irregular count for one full minute
60- 100 bpm
Radial
Count for 15 or 60 seconds
Apical
4th, 5th, or 6th, intercostal space, midclavicular line
Count for 30 or 60 seconds
1st sound
o Lub
o Atrioventricular valves close
2 sounds
nd

o Dub
o Semilunar valves close after ventricles empty
Tachycardia
o Greater than 100
Bradycardia
13

o Less than 60
Pulse deficit
Difference between apical and radial pulse

o Respirations
Inhale and exhale
12-20 per minutes
Tachypnea
Greater than 20
Bradypnea
Less than 20

o Blood Pressure
Systole/ diastole
Pulse pressure is S-D
Korotkoff sounds
Phase 1- soft tapping- systole
Phase 2- swishing or whooshing
Phase 3- distinct loud sounds
Phase 4- softer blower muffled sound that fades
Phase 5- last sound before silence- diastole
Normal
100-120/ 60-80
Hypotension
Less than 90/ less than 60
Hypertension
140+/90+

o Oxygen Saturation
Use pulse oximeter
95%-100%
Less than 70%, life threatening

o Pain
Rate on scale 0-10
0 being no pain
10 being the highest
Assess
14

Chapter 30: Hygiene


Early Morning Care
o Urinal or bedpan
o Washing face and hands
o Oral care

Morning Care
o Toileting
o Oral care
o Bathing
o Massage
o Hair care
o Dressing
o Repositioning
o Changing bed linens

Afternoon Care
o Offer assistance for toileting
o Offer pt w/ mobility

Hour of Sleep Care


o Assistance w/ toileting
o Massage
o Change soiled linen
o Reposition
o Call light within reach

PRN care
o Individual hygiene measures
o Oral care every 2 hours if indicated

Skin Problems
o Abrasion
Wearing away
o Dryness
Provide lotion
o Acne
Keep hair out of face
o Erythema
Redness

Bathing
15

o Cleansing bath
Always provide privacy
Place sheet over pt
Assist pts
Complete bed bath
Partial bed bath
Tub bath
Shower
o Therapeutic bath
Given for physical effects
Sooth irritated skin
Treat certain area
Perineum
Medication can be placed in water
o Ritualistic bath

Perineal and Vaginal Care


o Provide physical assessment
o Provide perineal care
Female always wipe front to back

Eyes
o Clean from inner to outer
o Lacrimal fluids wash the inner eye

Ears
o Are for hearing aids
o Minimal care
o Dont use qtips

Mouth
o Common problems
Halitosis
Bad breath
Gingivitis
o Brush teeth at 45 degree angle to gum line

Head and Hair


o Treat for infestations
o Groom and shampoo hair
o Assist with unwanted hair removal
o Brush hair daily
16

Nails and Feet


o Assess for color and shape
o Soak nails and feet
o Assist with cutting if not contraindicated
Most nurses never cut toe nails
o Provide diabetic foot care if indicated

Bed Making
o Dont shake soiled linen in air
o Make one side of bed at a time
o Unoccupied bed
Closed
Top sheet, blanket and bed spread are drawn up to top of bed and
under the pillows
Open
Top sheets are foled back
Easier for pt to get in bed
Usually open on admission

o Bed safety
Have bed at lowest position
Safe for pt
Bed controls are functioning
Call light works
Side rails are raised if indicated
Wheels are locked
17

Chapter 33: Activity and Immobility


Body Mechanics
o Body alignment and posture
o Balance
o Coordinated body movements
o Postural reflexes

Types of exercises
o Isotonic
Muscle shortening and active movement
jogging
o Isometric
Muscle contraction w/o shortening
o Isokinetic
Muscle contraction w/ resistance

Physical Assessment for Mobility


o Ease of movement and gait
o Alignment
o Joint structure and function
o Muscle mass, tone, strength
o Endurance

Positioning patients
o Every 2 hrs
o Can use:
Pillows
Adjustable beds
Bed side rails
Trapeze bars
Additional equipment

Range of Motion
o Active ROM
Done by yourself
o Active- Assistive ROM
Help with ROM
o Passive ROM
Dependent
Nurse/Nursing Assistant does it

Mechanical Aids for Walking


18

o Walker
Step with weak leg first
o Cane
Hold on non-affected side
o Braces
o Crutches
Four point
Three point
Two point
Swing to
Swing through
o Hoyer lifts
Used to move pt unable to walk
Never use alone
Always at least 2 people
19

Anda mungkin juga menyukai