Need to know in Patient Safety
Developmental levels
Mobility, sensory, and cognitive status
Lifestyle choices
Special risks found in health care setting
Patient Safety according to QSEN
Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.
Patient Safety according to IOM
New standard for quality care�care that is free of unintended injury from acts of commission or omission, in any setting in which it is delivered.
Patient Centered Care according to QSEN
Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient's preferences, values, and needs.
Purpose of the National Patient Safety Goals (TJC website)
The NPSGs were established to help accredited organizations address specific areas of concern in regards to patient safety.
Risks for Infant, Toddler, and Preschooler
Injuries, lead poisoning, accidents due to particular stage of growth--such as oral activity and children possibly ingesting dangerous substances or choking
Risks for the School-Age Child
Different environments outside of the home, such as school, school transportation, after school activities, etc. Strangers, sports activities, bicycle related injuries.
Risks for the Adolescent
greater independence and separate emotionally from family; tension associated with physical and psychological changes and peer pressures can lead to risk-taking behaviors like smoking or drugs; motor vehicle accidents
Risks for the Adult
lifestyle habits: alcohol/drug use, and smoking; stress leading to accidents or illnesses, such as headaches, gastrointestinal disorders, and infections
Risks for the Older Adult
physiological changes leading to greater fall risk and other types of accidents such as burns and car accidents
Risks within the Healthcare Setting
Medical errors: infection, bed sores, and failure to diagnose and treat in time; medication errors; falls, client-inherent accident; procedure-related accidents; equipment-related accidents
Inflammation
A protective reaction;
Can be caused by nonliving agents i.e. heat, trauma;
Always present with infection;
Infection occurs only through superimposed evasion of microorganisms;
It establishes an environment for healing
Infection
Involves invasion of tissue or cells by microorganisms (bacteria, fungi, or viruses)
Always has inflammation present
Often reveals altered lab values ( i.e. WBCs, positive cultures)
Infection and Inflammation
can be local, systemic, acute or chronic
Recognizing Infection
Local or systemic
Patient information, clinical appearance (objective and subjective)
Vital signs
Lab values
CBC (Complete Blood Count)
Culture reports
Recognizing Inflammation
Swelling
Redness--Hyperemia
Heat
Pain/Tenderness
Loss of Function
Functions of red blood cells (erythrocytes)
carry oxygen from the lungs to body tissues and transfer carbon dioxide from the tissues to the lungs. Oxygen transfer is accomplished via the hemoglobin contained in RBC's. Hemoglobin combines readily with oxygen and carbon dioxide.
Normal values white blood cells (leukocytes)
normally 5000 to 10,000/microliter, can rise up to 15,000 to 20,000/microliter and higher during inflammation, high white blood cell count can indicate infection
Functions of white blood cells
involved in cellular response of inflammation upon arrival at site; WBC pass through blood vessels and into the tissues; through phagocytosis, neutrophils and monocytes ingest and destroy microorganisms and other small particles
High red blood cell count (polycethemia)
increases in the RBC count occur at high altitudes because less atmospheric weight pushes air into the lungs, causing a decrease in the partial pressure of oxygen and hypoxia. With strenuous physical training, increased muscle mass demands more oxygen.
Normal values of red blood cells
4 to 6 million/microliter
Low red blood cell count (anemia)
can occur from either a decrease in the number of red blood cells, a decrease in the hemoglobin content, or both. Red blood cells live for approximately four months in the bloodstream
Normal levels of platelets
150,000 to 400,000/microliter
Functions of platelets (thrombocytes)
prevent bleeding
Chain of Infection
Infection occurs in a cycle that depends on the presence of:
Infectious agent or pathogen, Reservoir or source for pathogen growth, portal of exit from the reservoir, mode of transmission, portal of entry to a host, susceptible host
Infectious agent
microorganisms include bacteria, viruses, fungi, and protozoa; can cause disease when there is sufficient number, adequate virulence, ability to enter and survive the host, and susceptibility of the host
Reservoir
place where a pathogen can survive but may not multiply, may be in food, oxygen, and water; factors that affect bacteria growth are temperature, pH, and light (organisms can thrive in the dark)
Portal of Exit
for microorganisms to grow and multiply they must exit their host, portals of exits include blood, skin, and mucous membranes, respiratory tract, genitourinary tract, gastrointestinal tract, and transplacental (mother to fetus).
Modes of Transmission
the specific way a disease is transmitted, most common: (unwashed hands) direct (person-person), physical contact, indirect (susceptible host to inanimate object), droplet (large particles that travel up to 3 ft), airborne, vehicles, vector (mosquitos)
Portal of Entry
organism enter the body through the same routes they use for exiting
Susceptible Host
depends on the individual degree of resistance to a pathogen (immune response). Factors that influence susceptibility are age, nutritional status, presence of chronic disease, trauma, and smoking
pathogenicity
the ability of a pathogen to produce an infectious disease in an organism
localized infection
localized symptoms (wound infection) pain and tenderness and redness at the wound site
systemic infection
infection that affects the entire body instead of just a single organ or part, can become fatal if left untreated
inflammatory response
protective reaction that serves to neutralize pathogens and repair body cells
nursing actions that control or eliminate infections in the clinical setting
properly administering antibiotics, monitoring response to drug therapy, and using proper hand hygiene and standard precautions; supportive therapy would include proper nutrition and rest
Role of nurse in infection control
Assess patient's defense mechanisms: age, nutritional status, stress, disease process; susceptibility and knowledge of infections;
"Risk for Infection": lab data and clinical appearance;
Consult Infection Control Practitioner: clients with infection
Nursing Care Infection Control-wound care
Handwashing
Use gloves
Elevate foot
Aseptic technique for dressing change
Discard contaminated dressing, linens, etc. properly
Administer medications
Management of fever
Rest
Maintain glucose within normal range
Healthy diet
Teach infection control
Acute/Transient Pain
protective, has an identifiable cause, is of short duration, and has limited tissue damage and emotional response
Chronic/Persistent Pain
not protective and serves no purpose, lasts longer than anticipated, does not always have an identifiable cause, and leads to great personal suffering, can be cancerous or noncancerous)
Chronic/Episodic
pain that occurs sporadically over an extended duration of time, may last for hours, days, or weeks (migraine headaches)
Cancer pain
can be acute and/or chronic, sometimes nociceptive and/or neuropathic; usually due to tumor progression and its related pathological process, invasive procedures, toxicities or treatments, infection , and physical limitation--at actual site or referred
Inferred pain by pathological process
Nociceptive pain--somatic and visceral and neuropathic pain
Nociceptive Pain
Damage to bone, soft tissue, or internal organs
Usually responsive to nonopioids and/or opioids
Types of nociceptive pain: somatic pain and visceral pain
Somatic Pain
Arises from bone, joint, muscle, skin or connective tissue
Usually aching or throbbing in quality and is well localized
Visceral Pain
Arises from viscera, such as the GI tract and pancreas;
Described as squeezing, cramping pain, shooting;
May be due to obstruction of hollow viscous, which causes the cramping and poorly localized pain
Neuropathic Pain
Abnormal processing of sensory input by the peripheral or central nervous system;
Treatment usually includes adjuvant drugs;
A physical cause for reports of excruciating pain may not be evident on examination
Idiopathic Pain
chronic pain in the absence of an identifiable physical or psychological cause or pain perceived as excessive for the extent of an organic pathological condition
factors that influence pain
physiological factor: age, fatigue, genes, neurological function; social factors: attention, previous experience, family and social support; Spiritual factors; psychological factors: anxiety, coping style; Cultural Factors: meaning of pain, ethnicity
Pain Assessment
Factors influencing the pain experience:
Location
Intensity
Quality
Pattern
Aggravating/relieving factors
Medication history
Pharmacological Measures Nursing Responsibilities (pain management)
Assess pain
Determine when to administer analgesics
Select the appropriate analgesic
Evaluate effectiveness of analgesics
Monitor and manage medication side effects
Suggest changes
Consider the needs of special populations (mentally ill, cognitively impai
nursing role in pain management
Direct clinical care
Patient/family teaching
Education of colleagues
Identify system barriers
Factors Affecting Oxygenation
physiological, developmental, lifestyle, environmental
Physiological Factors affecting oxygenation
reduced oxygen carrying capacity, reduced inspired oxygen concentration, hypovolemia, higher metabolic rate, impaired chest wall movement-pregnancy, obesity, musculoskeletal abnormalities, trauma, neuromuscular diseases, central nervous system alterations
Developmental Factors affecting oxygenation
infants and toddlers (upper respiratory tract infection), school age children and adolescents (smoking-respiratory infections), young and middle age adults (lifestyle factors-affect cardiopulmonary health)
The older adult and oxygenation
trachea & large bronchi become enlarged from calcification of the airways; alveoli enlarge, reducing the surface area available for gas exchange; the number of cilia is reduced, causing a decrease in the effectiveness of the cough mechanism-which can caus
Lifestyle factors affecting oxygenation
habits such as cigarette smoking or unhealthy diets; nutrition, exercise, smoking, substance abuse, stress
environmental factors affecting oxygenation
pulmonary disease is higher in smoggy, urban areas than in rural areas; patient's workplace --occupational pollutants include asbestos, talcum powder, dust, and airborne fibers
Alterations in Respiratory Functioning
Atelectasis
Aspiration
Hyperventilation
Hypoventilation
Hypoxia
Atelectasis
collapse of alveoli which prevents normal exchange of oxygen and carbon dioxide
Aspiration
occurs when fluids are breathed into the lungs or airways leading to the lungs
Hyperventilation
a state of ventilation in excess of that required to eliminate the carbon dioxide produced by cellular metabolism
Hypoventilation
occurs when alveolar ventilation is inadequate to meet the body's oxygen demand or to eliminate sufficient carbon dioxide
Hypoxia
inadequate tissue oxygenation at the cellular level, results from a deficiency in oxygen delivery or oxygen utilization at the cellular level-life threatening condition
Signs and symptoms of Hypoxia
apprehension, inability to concentrate, declining level of consciousness, dizziness, and behavioral changes, increased pulse rate and increased rate and depth of respiration
Cyanosis
blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries-late sign of hypoxia
Objective nursing assessment as related to oxygenation
Inspection, Palpation, Percussion, Auscultation;
Laboratory and diagnostic tests
Hemoglobin
Pulse oximetry
Arterial blood gases
Arterial blood gas analysis
most effective way to evaluate acid-base balance and oxygenation, deviation from normal value will indicate that the client is experiencing an acid-base imbalance; measure of: pH, PaCO2, PaO2, oxygen saturation, and HCO3-
Inspection as related to oxygenation
Respiratory rate, rhythm, depth, breathing pattern
Skin color
Breathing posture
Muscles used in breathing
Clubbing of finger nails
Capillary refill
Level of consciousness
Diagnostic Tests as related to oxygenation
Hemoglobin Levels: 13.5-18g/dl males, 12-16g/dl female
Chest x-ray
Pulmonary function studies
Lung Scan
Bronchoscopy
Throat culture
Sputum specimens
Pulse oximetry
Pulse Oximetry
Non-invasive
Measures arterial oxygen saturation
SpO2 Normal is > 95%
Ensure accuracy: validate with patient heart rate
Ensure accuracy: determine patient's hemoglobin level
Continuous, intermittent, or during ambulation
pH
Normal arterial blood pH is 7.35 - 7.45; acidic is less than 7.35 and alkaloid is greater than 7.45
PaCO2
partial pressure of carbon dioxide in arterial blood and is a reflection of pulmonary ventilation; normal range is 35 - 45 mm Hg, hyperventilation occurs when the PaCO2 is less than 35mm Hg; hypoventilation occurs when the PaCO2 level is more than 45mm Hg
PaO2
partial pressure of oxygen in arterial blood; normal range is 80-100mm Hg; less than 60mm Hg leads to anaerobic metabolism, resulting in acidic production and metabolic acidosis; hyperventilation also causes a decrease in PaO2, or respiratory alkalosis
Oxygen Saturation
the point at which hemoglobin is saturated by O2, normal range is 95%-99%
nursing action for atelectasis
hypoventilation occurs so best action is to help improve tissue oxygenation, restoring ventilatory function, treating the atelectasis, and achieving acid base balance. use of incentive spirometer, deep breathing and coughing, pursed lip breathing
nursing action for hypoventilation
same as atelectasis, add diaphragmatic breathing-if possible, check on oxygen therapy
nursing action for aspiration
positioning to avoid aspiration, coughing to clear sputum/fluid, maintain a clear airway
nursing action for hyperventilation
oxygen therapy, diaphragmatic breathing to relax patient, incentive spirometer
nursing action for hypoxia
oxygen therapy, incentive spirometer, diaphragmatic breathing
general nursing actions in regards to oxygenation
Auscultate lung sounds
- Monitor RR, depth, rhythm
-Monitor vital signs
-Monitor O2 sat, ABGs
-Monitor mental status
-Position for best lung expansion, elevate HOB
-Reposition regularly
-Ambulate patient
-Provide oxygen
-Provide humidification
-Increase f
Principles of Oxygen Therapy
Oxygen should be treated as a drug
Expensive
Side Effects
Safety issues
Verify 6 Rights of medication
Factors that influence the quality and quantity of sleep
Physical Illness
Drugs/Medications
Lifestyle
Emotional Stress
Environment
Nutrition
Sensory Deprivation
hypersomnolence
sleep problems from inadequacies in either quantity or quality of nighttime sleep on a daily basis
insomnia
a symptom clients experience when they have chronic difficulty falling asleep, frequent awakenings from sleep, and/or short sleep or nonrestorative sleep (most common complaint)
sleep apnea
disorder characterized by the lack of airflow through the nose and mouth for periods of 10 seconds or longer during sleep; 3 types: central, obstructive, and mixed apnea
obstructive sleep apnea
occurs when muscles or structures of the oral cavity or throat relax during sleep; the upper airway becomes partially or completely blocked, diminishing (hypopnea) nasal airflow or stopping for as long as 30 seconds
central sleep apnea
involves dysfunction in the brain's respiratory control center, the impulse to breathe temporarily fails, and nasal airflow and chest wall movement cease
narcolepsy
dysfunction of mechanisms that regulate the sleep and wake states (may fall asleep uncontrollably at times)
sleep deprivation
result of dyssomnia, causes may be illness, emotional stress, medications, environmental substances, and variability in the timing of sleep due to shift work
parasomnias
sleep problems that are more common in children than in adults--may have link to SIDS, in older children: somnambulism, night terrors, nightmares, nocturnal enuresis, body rocking, and bruxism (tooth grinding)
measures to promote sleep
Adequate assessment
Plan activities to maximize time for rest and sleep
Provide comfort measures
Establish sleep environment
Patient education
interventions to promote sleep
Plan activities to maximize time for rest & sleep
Provide comfort measures
Establish sleep environment
Establish sleep routine
Avoid stimulants
Avoid exercise 2-3 hours before bedtime
Pharmacological approaches
sleep apnea treatment
Behavioral Therapy
-weight reduction
-avoidance of alcohol, tobacco, sleeping pills
-positional therapy
Physical or Mechanical Therapy
-dental appliance
-positive airway pressure device
nursing process
professional nurse's approach to identify, diagnose, and treat human responses to health and illness; 5 steps: assessment, diagnosis, planning, implementation, and evaluation
nursing assessment
deliberate and systematic collection of data to determine a client's current and past health status and functional status and to determine the client's present and past coping patterns
steps of the nursing assessment
1) collection and verification of data from a primary source, and secondary sources
2) the analysis of all data as a basis for developing nursing diagnoses, identifying collaborative problems, and developing a plan of individualized care
database
built during assessment, concerns the client's perceived needs, health problems, and responses to these problems
sources of data
client, family and significant others, health care team medical records, nurse's experience, other records and literature
subjective data
client's verbal description of their health problems, will include feelings perceptions, and self-report of symptoms
objective data
observations or measurements of a client's health status
nursing health history
data about the client's current level of wellness, including a review of body systems, family and health history, sociocultural history, spiritual health, and mental and emotional reactions to illness
data analysis
involves recognizing patterns or trends in the clustered data, comparing them with standards, and then coming to a reasoned conclusion about the client's responses to a health problem.
medical diagnosis
the identification of a disease condition based on a specific evaluation of physical signs, symptoms, the client's medical history, and the results of diagnostic tests and procedures
nursing diagnosis
clinical judgment about individual, family, or community responses to actual & potential health problems or life processes; statement describing the client's actual or potential response to a health problem that nurse is licensed and competent to treat.
collaborative problem
an actual potential physiological complication that nurses monitor to detect the onset of changes in a client's status
North American Nursing Diagnosis Association (NANDA)
established to develop, refine, and promote a taxonomy of nursing diagnostic terminology of general use for professional nurses
defining criteria
the clinical criteria or assessment findings that support an actual nursing diagnosis
clinical criteria
objective or subjective signs and symptoms, clusters of signs and symptoms, or risk factors that lead to a diagnostic conclusion
actual nursing diagnosis
describes human responses to health conditions or life processes that exist in an individual, family, or community--acute pain
risk diagnosis
describes human responses to health conditions/life processes that will possibly develop in a vulnerable individual, family, or community
health promotion nursing diagnosis
a clinical judgment of a person's, family's, or community's motivation and desire to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors, such as nutrition and exercise
diagnostic label
the name of the nursing diagnosis as approved by NANDA International, it describes the essence of a client's response to health conditions in as few words as possible
related factors
a condition or etiology identified from the client's assessment data, associated with the client's actual or potential response to the health problem and can change by using nursing interventions
etiology
the cause of a disease, and is alway within the domain of nursing practice and a condition that responds to nursing interventions
planning
3rd step of nursing process; a category of nursing behaviors in which a nurse sets client-centered goals and expected outcomes and plans nursing interventions
priority setting
the ordering of nursing diagnoses or client problems using notions of urgency and/or importance to establish a preferential order for nursing actions
goal
an aim, intent, or end; a broad statement that describes the desired change in a client's condition or behavior
expected outcomes
measurable criteria to evaluate goal achievement
client-centered goal
specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function
short-term goal
an objective behavior or response that you expect a client to achieve in a short time, usually less than a week
long-term goal
an objective behavior or response that you expect a client to achieve over a longer period; usually over several days, weeks, or months
guidelines for writing goals
client-centered
singular goal or outcome
observable
measurable
time-limited
mutual factors
realistic
types of interventions
independent nursing, dependent nursing, and collaborative interventions
independent nursing intervention
actions that a nurse initiates
dependent nursing intervention
physician initiated, actions that require an order from a physician or another health care professional
collaborative intervention
interdependent, therapies that require the combined knowledge, skill, and expertise of multiple health care professionals
nursing care plan
enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care
scientific rationale
the reason that you chose a specific nursing action, based on supporting evidence
implementation
4th step of nursing process; formally begins after the nurse develops a plan of care
nursing intervention
any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance client outcomes
Implementation skill of nursing process
cognitive skills: application of critical thinking to nursing process
interpersonal skills: effective for nursing action-developing a relationship
psychomotor skills: integration of cognitive and interpersonal skills
evaluation
last step of nursing process; used to determine if after application of the nursing process, the client's condition or well-being improved (used to determine if you met expected outcomes, not if nursing interventions were completed)
standard of care
minimum level of care accepted to ensure high quality of care to clients; defines the types of therapies typically administered to clients with defined problems or needs
Oxygen Saturation
Normal PaO2 80-100 mm Hg
Normal O2 saturation > 95%
(SaO2)
Compare to pulse oximetry reading
(SpO2)
Acid Base Imbalances
Normal pH 7.35-7.45
Acidosis <7.35
Alkalosis >7.45
Lungs regulate pH using CO2
Kidneys regulate pH using HCO3
Respiratory Acidosis
pH Below 7.35
PaCO2 Above 45
HCO3 Normal
Common Example: Hypoventilation
Respiratory Alkalosis
pH Above 7.45
PaCO2 Below 35
HCO3 Normal
Common Example: Hyperventilation