Intervent 1

• a reflective thinking process that involves collecting information, analyzing the adequacy and accuracy of the information, and carefully considering options for action
• Used in every aspect of nursing

a systematic problem-solving process that guides all nursing actions

• Assessment
• Nursing Dx
• Planning
• --planning outcomes
• --planning interventions
• Implementation
• Evaluation

• based on a pt's response to treatment of problem or disease
• Focuses on pt

• describes a disease, illness or injury
• purpose is to ID a pathology so appropriate med treatment can be given
• more narrowly focused than nursing dx

actions, based on clinical judgement and nursing knowledge, that nurses perform to achieve client outcomes

Comprised of 5 communication qualities:

• empathy
• respect
• genuineness
• concreteness
• confrontation

the desire to understand and be sensitive to the feelings, beliefs, and situation of another person

communicated by valuing the client and being flexible to meet the client's needs

the ability to respond honestly

• concreteness refers to answering questions in specific terms of what you mean
• message must be constructed and delivered in manner suitable fo client
• If client is unable to express thoughts clearly, you must be able to confront him/her to request clarification
• you must also be wiling to be confronted if you are unclear

• Narrative
• PIE
• SOAPIE
• Focus
• FACT system

• tells story in chronological way
• basically time line
• Always end w safety
• Benefits: especially useful when attempting to construct a timeline of events, such as cardiac arrest or emergency situation. 
• highlights critical thinking and captures true art of nursing

• Problem
• Intervention
• Evaluation
• *Tents to focus only on the listed problems and not client as a whole

• Subjective
• Objective
• Assessment
• Plan
• Interventions
• Evaluate
• *organized to specific pt problems

• uses assessment data to evaluate client care concerns, problems or strengths
• ID's necessary revisions to care plan
• Generally has 3 columns, one for each letter in DAR
• Data, Action, Response
• *attractive cause it addresses the client's concerns holistically

• Flowsheet
• Assessment
• Concise
• Time

• charting by exception
• preprinted, charing "normal" by marking a check, if "abnormal" then documented
• *includes only exceptions to the norm. eliminated need to chart normal findings

• more than a format
• a system of charting in which only significant findings or exceptions to standards and norms of care are charted

• for collaborative pts
• members of each discipline record findings on separately labeled section
• Benefit is you can easily find care provided by each discipline and results to labs and diagnostic tests

combines source-oriented and POR's

• Problem-oriented reports in collaborative pts 
• organized around pt problems
• no separate sections for each discipline
• makes it easy for all disciplines to monitor pt progress in shared notes

group of instructions stating a person's wishes regarding his healthcare if he were incapacitated or unable to make decisions

• type of advance directive:
• a document that provides specific instructions about the kinds of healthcare the person would wish or would wish not ro have in particular situations

• durable power of attorney or healthcare proxy
• type of advance directive
• exists when another person is ID's to make decisions for an individual regarding healthcare choices when he is unable to do so based on circumstances (irreversible coma, terminal illness

• potential complication
• cant be prevented with nursing interventions alone
• brings many different professions together to solve problem

the client outcomes you want to achieve through your nursing interventions

• healthcare-associated infection
• refers to infections associated w healthcare given in any setting
• will affect 1 out of 20 pts

refers more specifically to hospital-aquired infections

• local or systemic
• primary or secondary
• exogenous or endogenous
• acute or chronic

Local infections: infections that cause harm in limited region of body (ex: in upper respiratory tract, the urethra, single bone or joint)

Systemic infections: occur when pathogens invade to blood or lymph and spread throughout the body

the clinical presence of bacteria in the blood

symptomatic system infection spread via the blood

• Primary infection is first infection that occurs in pt
• Secondary infections follow primary infection. Common for immunocompromised pts. (Ex: frail client w pneumonia may develop herpes zoster ~ aka. shingles ~ related to stress of illness

the pathogen is acquired from the healthcare environment

pathogen arises form pt's normal flora, when some form of treatment (ex: chemo or antibiotics) causes normally harmless microbe to multiply and infect

• cause no symptoms for long periods of time, even decades
• Ex: TB, HIV

• Incubation
• prodromal stage
• illness
• decline
• convalescence

stage of infection btwn successful invasion of pathogen into body and first appearance of symptoms

• 2nd stage of infection
• characterized by first appearance of vague symptoms
• Ex: person infected w cold virus may experience a mild throat irritation
• *not all infections have this stage

• 3rd stage of infection
• marked by appearance of S/S characteristic of disease
• If pt immune defences and med treatments are ineffective, this stage ends in death

• 4th stage of infection
• stage pt immune defenses, along w med therapies, successfully reduce # of pathogenic microbes
• S/S begin to fade

• 5th stage of infection
• characterized by tissue repair and a return to health as remaining # of microbes approaches zero
• could take 1 day, or require a yr or more

• type of mode of transmission
• indirect contact
• a contaminated object that tranfers a pathogen

• Infectious agent ~ bacteria/pathogen
• resides in 
• Reservoir ~ source of infection. Ex: human body, food, water, surfaces, etc.
• until it finds 
• Portal of Exit ~ path infectious agent leaves reservoir  ex: body fluid, cough, direct contact
• and it's 
• Mode of Transmission ~ how it travels to susceptible host ex: either direct/indirect = droplet, fomite, vector 
• once landed, searches for 
• Portal of Entry ~ can be normal or abnormal body opening
• it now makes new home in 
• Susceptible Host

• primary
• secondary
• tertiary

• Non-specific
• Always first line of defense
• bacteria have to get past this to compromise
• *Ex: intact skin, GI tract, mouth

• non-specific
• involves phagocytosis, complement cascade, inflammation, fever

• the process by which phagocytes (specialized WBC) engulf and destroy pathogens
• Phagocytic WBC's include neutrophils, monocytes and eosinophils

• a process by which a set of blood proteins, called complement, triggers the release of chemicals that attach the cell membranes of pathogens, causing them to rupture
• Also signals basophils (WBC's) to release histamine, which prompts inflammation

• IS SPECIFIC
• specific immunity
• body creates antibodies against specific pathogens

occurs when body makes it's own antibodies or T cells to protect the body against a pathogen

means absence of contamination by disease causing microorganisms

• absence from contamination
• done by:
• regular hand-washing
• alcohol base sanitizer
• keeping environment clean

• creation of sterile environment
• more complex
• not needed for every pt
• Ex: NICU, operating room, bedside procedures

• MRSA
• VRE
• C-Diff

• Methicillin-resistant staphylococcus aureus
• lives on skin & in nose w/o causing probs
• If person does get "staph" infection, can't be killed by methicillian
• Can be fatal
• spread by skin to skin contact 
• living in crowded places risky

• Vancomycin-resistant enterococci
• normal residents in intestines and female genital tract
• most infections occur in hospital
• leading cause of healthcare-acquired bacteremia, surgical infections and UTI

• get it from lack of good bacteria in intestine
• spores can't be killed w alcohol based hand sanatizer
• only way to prevent contact transmission is hand washing w soap & water
• found in stool
• major symptom is diarrhea

• Tier 1 = standard precautions, apply to care of all pts
• Tier 2 = Transmission-based precautions
• Tier 3 = Isolation

• Standard precautions
• Use w all clients in all settings
• remember all body fluids, blood, ect may contain pathogens
• Include hand hygiene; use of gloves, gown, mask, eye protection or face shield (depending on expected exposure) and safe injection practices
• Practice respiratory hygiene and cough etiquette

• Use for pts known or suspected to be infected w infectious agents
• Used in addition to standard precautions
• 3 categories: Contact, Droplet, Airborne precautions

• wear non sterile gloves
• wear clean gown 
• Remove PPE and observe hand hygiene before leaving room
• use disposable equipment

• MRSA
• Scabies ~ Mite
• Herpes-Zoster (shingles) 
• Diarrhea

• keep droplet precautions outside pt room
• wear mask, donning on entry
• change PPE and preform hand hygiene btwn pts

• Flu
• Viral resp tract inf = RSV, rhinovirus (add contact)
• Pneumonia, scarlet fever
• Pertussis
• Strep
• Rubella
• Mumps

• keep airborne supplies outside pt room
• Don mask on entry, wear special fitted N-95 respirator if pt has TB or smallpox
• remove respirator/mask outside room after closing door

• Measles
• TB
• Chicken pox
• Shingles (Herpes zoster)
• Cough in pt w risk of tb

• used for clients w low WBC counts, those undergoing chemotherapy, or clients w large open wounds or weak immune systmes
• Includes following standard precautions, placing pt in private room, restricting visitors, wearing mask, etc.

• same thing as reverse isolation
• used on clients with low WBC counts, clients undergoing chemo, or clients w large open wounds or weak immune systems
• Follows standard precautions
• pt in private room
• restricting visitors
• wearing mask, gown, and gloves

• yellow discoloration of the skin which can be caused by accumulation of bile pigments and is symptom of certain diseases
• causes skin to be itchy and dry

• a light-skinned person may appear as pale skin w/o underlying pink tones
• in dark-skinned person, observe for ashen gray or yellow color

• redness of skin
• related to vasodilation and inflammation

• a bluish coloring of skin, caused by decreased peripheral circulation or decreased oxygenation of blood
• may be related to cardiac, pulmonary, or peripheral vascular problems

Can delegate to licenced and/or non licensed as long as it's within their scope of practise

• Delegate with clear & concise instructions
• provide specific time frame
• Follow up to ensure proper completion

• Protection - first line of defense
• Sensation
• Regulation -temp
• Secretion/excretion - secretes waste products
• Vitamin D formation - from ultraviolet light of sun

• Dampness
• Dehydration
• Nutritional status
• Insufficient circulation
• Skin diseases
• jaundice
• Lifestyle and personal choices

• Excessive perspiration and incontinence cause skin to be damp
• Skin breaks down more easily when damp, especially in skinfolds

• softening of skin from prolonged moisture
• makes epidermis more susceptible to injury
• especially in skin folds

• loss of superficial layers of skin
• ex: scratching and by digestive enzymes in feces

• Fluid loss and insufficient fluid intake can lead to dehydration
• this causes the skin to become dry and crack easily

• people who are very thin or very obese are more likely to experience skin irritation and injury
• Morbid obesity makes it difficult to reach all body areas, leading to development of odor and fungal conditions

• immobility, vascular disease, and overall inadequate nutritional status may compromise skin
• predisposes pt to local tissue death and ulceration when skin cells do not receive enuf oxygen

diseases such as impetigo (bacterial infection) and systemic diseases (like measles and chickenpox) cause lesions that create discomfort and require special hygiene care

• some people damage skin by exposure to uv rays because they want to tan
• skin tattoos or piercings create risk for systemic and local infection and scarring

• Rest is a condition in which the body is inactive or engaging mild activity, after which person feels refreshed
• Sleep is a cyclically occurring state of decreased motor activity and perception

• Schedule nursing care to avoid interrupting sleep
• create a restful environment
• promote comfort
• support bedtime rituals and routines
• Offer appropriate bedtime snacks or beverages
• Promote relaxation (guided imagery, music therapy, progressive muscle relaxation)
• Teach sleep hygiene
• Maintain pt safety
• medication

• sleepwalking
• sleeptalking
• bruxism
• night terrors
• REM sleep behavior disorders
• Nocturnal Enuresis

• sleepwalking
• occurs during stage 3 sleep, usually 2 hrs after person falls asleep

grinding and clinching of the teeth

• periodic interruption in breathing during sleep
• an absence of air flow through the nose or mouth during sleep

nocturnal enuresis = bedwetting

• occurs during NREM sleep
• usually doesn't interfere w rest but may disturb partner

sudden arousals in which person (often child) is physically active, often hallucinatory, and expresses a strong emotion such as terror

• are associated w REM (or dreaming period)
• the sleeper violently acts out the dream
• People have injured themselves and others waking