Introduction to Healthcare Role and responsibilities of the PCT Types of Agencies Acute care — hospitals Long term care/ hospice Rehab centers — self care goal Mental Health facility
Goal — provide care for ill/injured, prevent disease, promote health, facilitate education and research Health care profession Person who is trained/ certified to provide holistic care and ensures that pt’s receives
highest level of care with resources available
Define the members of the healthcare team — provide direct patient care + role of PCT Physician — writes medical orders for care of each pt Nursing Personnel - Gives nursing care to pt — Nursing Assistants — Assist nurse in carrying out nursing care and services Ancillary Staff — assist nurse in services for pt (non medical)
Nursing Team — composed off nurse + PCT at minimum
care to patient based on physician orders
Strive to deliver holistic care based on nursing care plan
Nursing Process- bolded is PCT rolAssessment / Observation — gather/ Examine information and discuss with pt
insecure skin, abnormal vitals, level of assistance for basic needs 2) Diagnosis — Based on assessment + determines pt’s problems 3) Planning — Develop interventions and goals 4) Implementation — Carry out intervention Performing preventative skin care measures, measure/apply elastic stockings 5) Evaluation — Check if intervention is effective Report effectiveness of intervention
Nurses delegate based off of the 5 rights and PCT’s accept based off of the 5 rights Right task — have I been trained and is it in job description Right Circumstance — can I do this and keep the pt safe Right Person — Do I have any reservations / am I confident Right Direction — Was I given clear direction Right Supervision — Will the nurse be available for questions
Tasks Beyond PCT scope Giving meds/ oxygen Receiving verbal orders Diagnosing an illness and prescribing treatment Performing sterile techniques Inserting or removing tubes Foley catheter insertion
Reasons for Declining Tasks Outside of scope of practice or illegal/ can harm patient Nurse unavailable to supervise Dont have the proper equipment Unclear instructions Haven’t been trained
PCT Responsibilities Physical needs of pt (hygiene, safety, comfort, etc) Emotional needs of pt Observe and communicate abnormal findings or changes Get supplies + equipment Maintain environment Document / transport / apply restraints Ensure nutrition is delivered Report malfunctioning equipment Comply with safety precautions Vital Signs Glucose testing Moniter I & O Preventative Skin Care measures Post mortem care
Review the qualities of a strong work ethic Punctuality Reliability Cooperativeness - work as part of a team , make effort to get along with employees, dont wait for them to ask you Accountability — accept responsibility for your actions, accept criticism and admit to your mistakes Conscientiousness - Asks for clarifications, seeks help, admit when u dont know how to do something Honesty — tell the truth when recording vitals, access tot patient valuables
Empathy Desire to learn Courtesy and Respectfulness — treat with respect, address by their preference
Define the terms work ethic and professional attitude Professional— positive attitude + passionate — committed to doing then job to best of abilities at all times Work Ethic — Attitude towards work and willingness to volunteer, desire to learn and improve
Describe the professional appearance and behaviors Wrinkle free clothes Closed Toed shoes Well groomed hair No face / mouth jewelry … minimal lobe jewelry Clean nails… no artificial Subtle makeup, ligt scents, covered tattoos
Discuss the legal and ethics of the patient care technician Patient bill of rights - has he right to considerate / respectful care, info about Dx, privacy, confidentiality, refuse treatment Negligent — unintentional acts that lead to patient harm Criminal law an abuse — physical, emotional, sexual Risk factors — depend on someone else … elder abuuse and child abuse Physical abuse — injury to body… Neglect - failure to provide for ptt’s needs Phsychological abuse — threatening someone with harm or abandonment Isolating someone
Medical Abbreviation and Terminology 24 Hour Clock — 2400 = 12:00 AM , 1200 = 12:00 PM
Directional Terms Anterior (ventral) — toward the front of the body Posterior (dorsal) — toward the back of the body Lateral — Toward the outside of the body (pinky) Medial — Toward the midline of the body Proximal — Body part closest to the center/ point of origin Neck proximal to head Distal — Body part farthest from center/ point of origin Foot distal to head Positional Terms - HOB = Head of Bed Fowlers Low Fowlers — HOB = 30 degrees Standard Fowlers - HOB = 45 degrees Semi - Fowlers - HOB = 60 degrees High Fowlers - HOB = 90 degrees Prone - laying on stomach Supine - laying on back Trendelenberg - laying on back, head below feet Reverse trendelenberg - Laying on back, feet below head Sims position - Used mainly for bowel issues and getting enemas — laying on stomach, left arm bend and right leg bent
Medical Abbreviations Disease Hypertension - HTN Cerebral Vascular Accident - CVA Myocardial Infarction - MI Diabetes Mellitus - DM Degenerative Joint Disease (Osteoarthritis) - DJD Gastro - Esophageal Disease - GERD
Diagnostic
Urinalysis - UA
Culture and Sensitivity - C & S
Chest C- Ray - CXR
Patient Care
Blood Pressure - BP
Short of Breath - SOB
Sequential Compression Device - SCD’s
Do Not Resuscitate -DNR
Intake and Output - I & O
Hard of Hearing - HOH
Blood Glucose Monitor - BGM
When Necessary / pro re data (prn)
Each, every - q
Diagnosis - Dx
History - Hx
Treatment - Tx
Diets
Regular Diet - Reg
Diet as tolerated - DA
Clear Liquid - cl liq
Full Liquid - fl liq
Nothing by Mouth - NPO
Activity
Bed Rest - BR
Ambulate - Amb
Out of bed - OOB
Bathroom Privileges - BRP
Bedside Commode - BSC
As desired - ad lib
Frequency
Twice a day - bid
Three times a dat - tid
Four times a day - qid
bedtime - hs
before meals - ac
after meals - pc Medical Terminology Abbreviation Structure — Middle part — Main part — central meaning of term i.e. thermo = heat ex. Broncho — lungs, cardia/cardio — heart, colo — colon, gastro — stomach, hepato — liver , nephro — kidney , neuro — nerve, phleb — vein , sepsis — infection Prefix — adds meaning to main part i.e. Brady — slow ex. Dys- difficulty, a- without/ lack of , Brady - slow, tacky - fast, hypo - decreased, hyper - excessive, epi- over, peri - around Suffix — Modifies meaning of term - Ology — study of — cardiology — study of the heart ex. -algia - pain, -ology - study of, -pnea - breath, -ectomy - excision, -itis - inflammation, -phagia - swallow, -scopy - examination with scope, -stomy - creation of an opening
Charting—> date, time, initials or signature — use 24 hour clock
Skin Care of Our Patients – we use multiple products to prevent skin breakdown from incontinence
Male Urinary Containement Device – Condom Catheter Fecal Conainment Device – Dlexi – Seal (By MD orders) and Fecal Management System Absorbant Pads – air permeable Proper Choice of Bed, mattress and overlays
Bath in Bag Put washcloths in bath in bag 12-16, fill with warm tap water and no soap… cannot putt used washcloth back in Used for bathing
HibiClens – Use full strength on wet washcloth bc diluting decreases effictiveness of antibacterial Rinse from skin after using for washing Don’t use on face or genitalia unless medically instructed
Gentle Rain Antibacterial Soap – Use for foley catheter care, for face, and for genitals, and shampoo
Baza Perineal Lotion and Odor Control – Perineal care after gentle rain is used NOT for foley catheter care Spray on cloth, then apply Deoderizer
Sween 24 – Moisturizing Lotion For dry scaly skin… apply once daily (can do more)_… best after bath and can use on lips Should not be cakey
Critic Aid Clear Barrier Ointment Used for incontinent (urine or stool) Prevents and protects against mild/ moderate reddened areas Rub in until clear… thin layer… avoid clumping
Sensi Care Clear – Barrier Ointment Only at SHY and MWH – replaces critic aid clear
Critic Aid Paste – Barrier Paste Incontinent with liquid stool, use on excoriated denuded skin (loss of outer layr of skin( and moist weepy skin Thin layer… cclean area twice daily or as directed
Skin Prep – Protective Skin Wipe Apply to bony promineneces that are beginning to become red to prevent uclers
InterDry— Used on patients with folds of skin … if the skin in between folds is moist and red, apply this film to wick moisture and prevent furher skin death… Don’t use with powder or paste Allow two inches to leave the fold Don’t rinse
Pressure Injury Prevention Idenify patient at risk based on – skin breakdown , medical/ skin condition, nutritional status, age, incontinenecce, immobility, etc
Incontinence and Moisuture management – hourly rounding , offer bedpantt regularly, answer call lights quickly, use absorbant pads and skin barrier cream
Incontinent and moisture management – use containment devices when possible (external catheters and fecal containment devices ) – avoid plastic
Moisturizing cream and barrier oinment is preventaive – clear thin layer
Communicate to nurse– frequency, size, color, consistency, odor, skin condition
Friction and Shearing – When skin pulled in opposite directitons Prevent by elevating head of bed to 30 degrees or less, elevate food bed, use lift sheet to readjust
Nutrition – assist with meals, offer waer when turning pt, tell nurse if poor intake
Immobility – major contributor o pressure injury, ambulae as directed, complete range of motion checks, bring to chair as ordered, use chair cushion if indicated
Age – pt ^ 65 increased risk for pressure injury because skin gets thinnger
Preventative – apply moisturizer after bathing, apply barrier cream to buttocks and perineum, use lift sheet to reposition , avoid grabbing arms and legs
Pressure Reduction - Reposition every 2 hours, 30 degree side lying position, limit chair sitting, reposition in char every hour Elevatet heels off bed surgavce using heel lift or pillows Prevent skin skin contact
Specialty Beds Low Air Loss Saphire Altternate Appropriate for incontinent/moisture/pressure injury patients Fluid Immersioon / Low Air Loss Platinum
Use star seting for immersion with air flow Biariatric Low air Loss mattress Mighty Turn Designed to prevent and treat pressure injuries in bariatric pt’s Air Fluidized TTherapy (envella) Pressure redistribution PT needs to be repositioned
Pressure Injuries Stage 1- raised and red Stage 2- read and first alyer of skin gone Stage 3 – Deeper, more re Stage 4 – super deep, down past the fat later Untreatable – Black, necrotized
Deep Tissue pressure Injury – dark red / blue … injury internal
Ostomy Care Chheck every 2-4 hrs… make sure well adhered and no lifting, make sure no twisting or kinking of tube – empty when 1/3 full After cleaning, wipe outside and inside bottom with toilet paper/ wipe Encourage pt to assist Notify nurse if leaking occurs Goal is for patient to be able to do it themselves… patient independence Observation is key
Infection Prevention – prevention, monitoring, management Infectious Agent – Bacteria (MRSA, VRE, C Diff), Viruses (Influenza, HIV, Hep C), Fungi (Mucor) Reservoirs – Organisms live but don’t grow Humans, animals / insects / environment / medical equipment Portals of Exit—Broken skin, skin/mucous membrane, respiratory tract, GI tract, blood Route of Transmission – Contact, Droplets, Airborne Particles, Vectors, Vehicles Portal of Entry – Broken Skin, respiratory tract, skin / mucous membrane, catheters and tubes Susceptible Host—Anyone, more so immunocompromised, age, lifestyle, disease history Most important prevention is hand hygiene 5 moments of hand hygiene Before touching pt Before aseptic procedure After Body fluid exposure After touching pt After touching pt surroundings PPE- Glove, gowns, mask/eye shield Order is gown, mask, eye protection, face protection, gloves Doffing – gown and gloves, face shield, goggles, mask, wash hands
Environmental Cleaning – env is reservoir, disinfect Cleaning comes before disinfection – Cleaning – remove organics, scrub Disinfecting – disinfecting cannot occur before cleaning, kills bacteria, protects everyone
Bleach – effective against bacteria, virus and spores in 3 minutes
Hydrogen Peroxide – effective against bacteria, viruses, NON-SPORES in.1 minute
Use WITH bleach
Purple PDI – specialized for cardiac leads – 2 minutesClean reusable medical equipment (RME) major reservoir – before and after patient use
Infection Prevention – Blood Borne Pathogens (BBP’s) – in blood and cause disease, HIV, Hep B, Hep C Blood, cerebrospinal, synovial, amniotic, pleural, pericardial etc fluid Saliva, urine, breast milk contaminated with blood Exposre – coming in contact with blood or bodily fluids of another person
Types of exposure – punctures, non intact skin, bites, splashes
If exposed, wash/flush immediately, report to employee health, if closed ED
Standard Precautions – treat all bodily fluids as potentially infectious Work area restrictions – don’t eat or drink in work area, don’t apply cosmetics or contacts at work area Sharps Sffety– don’t recap needles, don’t break needles, use sharps container, change container when ¾ full
Soiled Linene handling – when touching soiled linen, use PPE (gloves) Place in leak proof blue bags Wash hands after handling
Labels and Signage – Biohazard == use PPE, caution
Isolation signage – contact
Yellow – MRSA, VRE, CRE
Brown – C. Diff, norovirus
Contact requires gown and gloves
Isolation signage – droplet
Used for influenza, meningitis and mumps
Requires a mask
Isolation signage review – airborne
TB, R/O TB, Measles
Requires N95 and PAPE
Combination Isolation
Droplet/Contact (Respiratory Virus, R/O) AND Airborne/Contact (Chickenpox)
Gown, Gloves, and Appropriate mask
Infection Control Risk Assessment (ICRA) – control air flow, protect patients, diff levels of isolation Specimen Collection - urine, feces, sputum Preparation – review, type collected, volme needed, procedure, collect material, storage and handing Processing – use gloves, label, dispose properly
Urine Specimens—either UA (Urinalysis) or C & S (Urine Culture and Sensitivity) Urinalysis (UA) – yellow cap, pointed bottom – best in the morning most [] Pour urine from pedpan, commode or urinal into specimen cup (as long as not contaminated) Seal and fill the yellow tube Send to lab Don’t use urine longer han 2 hours old Send at least 15cc of urine Culture and Sensitivity (C&S) – do clean catch or midstream specimen
Sterile collection – straight cath Indwelling catheter sample – foley cath Clean genitals prior to sample collection For clean catch, need the swabs to clean Clean Catch Female – wash hands, separate skin folds around urinary opening, use towelettes to swipe frnt to back on both sides and down the middle – new towelette for each side Begin to urinate in toilet then place cup underneath stream to catch which keeping skin folds apart Clean Catch Male – wash hands, if uncircumcised pull back foreskin to expose the head, use towelettes to clean tip and clean in circular motion Begin to urinate into toilet, and place specimen into urine stream to collect urine
Filling Urine Specimen Tubes – Dont send blue cup specimen cup to lab, peel back sticker and just press the tube onto the blue cap to fill For the grey tubes for C & S, invert 6-7 times to get the powder at the bottom dissolved into the sample Label tubes in presence of patient and discard extra urine, put sharp top into sharps
Nurses need to straight cath the get the specimen but if the catheter is already present PCT can get the sample from a port Sterilize the port and place the adaptor on, then attach the tubes that you want the specimen in Never obtain a specimen from the bag 24 hour Urine collection—collect all urine in a 24 hour period in one of the orange jugs and keep on ice—restart test is pee no saved or if urine contaminated with feces
Stool Specimen – send in sterile container, about 10 cc or walnut sized … don’t send if mixed with urine
Clostridium Difficile—distinct smell, report back to the nurse if you smell this when cleaning a patient Lots off diarrhea Associated with prolonged antibiotic use Transmitted through touched surfaces and then touch mouth Typically watery, green, seedy Sputum Specimen – Mucus form respiratory, have pts pi to get oout saliva, ttake a deep cough and spit what comes form the respiratory tract Best sample first thing in the morning Have pt rinse with clear water, deep breaths, cough deeply and expectorate into the sterile cup, send too lab asap
Nasal Swab for MRSA- Done on admission
Labeling… name should be clslse to lid, to change time, strike through, change and initial
All speciens should be in biohazard bags
Preventing Falls Increase risk of fall – altered mental state, visual/ auditory difficltty, pain, history of falling, meds, change in BP, muscle weakness, foot problems , bathroom issues
Hospital Hazards – slow response to call light, not leaving call bell near pt, bed not lowered
All patient considered fall risk- level depends on nurse discrenssion based on Does pt need assistance to walk / stand Does pt have history of falls Harm risk faccotrs?
Universal – no to all three questions
Level 1 – yes to one question
Level 2- yes tto 2 + questions Maintain safe exit on patients strong side / closest to Bathroom Level 1 – follow all universal precautions + yellow arm band Low bed suite, room location, perimeter mattress cover, helmet, hip protector, sitter Level 2—Bed alarm, chair alarm, bedside commonde, elevated toilet seat, personal alarm, lab belt , accommpany pt to br
Assisting pt to ambulate – sit before stand, non slip socks, assist to stand, support while ambulating
If fall occurs—pt sagety firsrt, don’t leave— call for help— check circulation, airway, and breathing – control bleeding, LOCC, vitals, assist to bed , notify RN , complete incident report Risk master ncident report located in patient chart
Basic Body Mechanics Good posture is balanced upright position … don’t hypercurve in either direcition
Power position – knees flexed, hips fflexed, back in neutral
When lifting, keep back straight …. Keep head and shoulders upright and
Avoid twisting motion
Equipment to prevent back injury – Draw sheets – move patients in bed – place under patient and coordinate witht partner Trapezes – allows patient to help in the process – pt can self mobilize Patran Sheet – reduces friction for moving patient from flat surface to another Mechanical lifts
Before Moving patient – how much assist needed, equipment available, lines/ dains to consider, reposition funitue Involve the patient, tell tthem how they will be involved
Moving patient in bed — 2 people and draw sheet – prep bed by locking and adjusting height, have pt bend knees and push down with feet, work from side of bed
Turning a patient in bed – 2 people o based on size and complexity—prep bed, corss pt arms and bend knees … turn p towards you – one hand on shoulder, other on hips
Bed to carrier – 2+ people depending on size, prep bed and carier, use slide board or sheet – pt lift head and cross arms… communicate
Bed to chair—2+ people – prep bed and chair, sit pt at edge of bed, have pt scoot to edge with feet on dfloow.. have pt use their arms to push form bed Stanf and Pivot with pt towards their stronger side Bend knees when lowering pt
If pt falls, stay close to pt but don’t try to catch them, get help
Always leave pt in sage position with call bell in reach… put important items close to them, don’t move unless there is adequente staff
Druring Transfer—feet apart, knees flexed, back straight Get good grip—arms around pt with close contact … gentle but firm, create handles, block patients feet / knees, encourage pt to participate
Hibacleans—bathing head to do (not face) includes perineal Use sweet 24 moisturizer on right after
If redness noticed on bony prominences i..e shoulder blades put on skin prep to prevent skin breakdown
Inner dry - cloth material used to wick away moisture in skin folds/ for larger patients and used if there is redness between folds…replace as needed
Gentle rain, soap for face (also shampoo)
Oncology patients and those with sensitive skin use electrical razor and keep the head of the razor
Regular skin, hair down shave face with regular razor using shaving cream
Cannot cute nails
TED HOSE & SCD’s – compression devices – compression stocking more on cardiac (fluid accumulation) and SCD’s for post – surgical to help prevent blood clots
Thrombophlebitis- – inflammation and pain caused by a clot forming – look for this sign as indicator of blood clot formation
Dep vein thrombosis – when blood clot forms – embolus when It breaks of
Stroke if it gets stuck in the brain Myocardial Infarction if it gets stuck in the heart Pulmonary Embolism when get stuck in pulmonary artery (going to lungs)
Thrombo-Embolus Deterrent (TED) – Stockings (don’t need in bed but apply when laying in bed) MD orders how high they want it to be, ranging from upper thigh, to ankle Sizing – calf circumference (widest part) X distance from bend of knee to bottom of heel Thigh high, also need measurement of thigh circumference (widest part) Must be removed + pt. bathed daily + every 8 hrs. for skin inspection (put sween 24) Document application, removal, refusal, intact Sometimes accompanied with diuretics to remove fluid… be wary of frequent urination May need to resize because the pt is losing fluid
Sequential Compression Devices (SCD’s)- Prevents blood from pooling Sleeves on legs connected to hoses and a pump 2 fingers should be able to fit between sleep and leg Apply starting at ankle Confirm with pt. they feel the compression Need to remove SCD’s when is on their feet out of bed, then reapply Remove daily for bathing + every 8 hours for skin inspection Document (application, removal, refusal, intact) Obtain everything from central supply
Constant Observation – Sitter Role and Providing Patient Safety +@ Risk for Suicide/Homicide
Do suicide assessment of every pt. admitted into the hospital
Sitting with patient Ask why—what to look for
Identify thoughts, plan, means (access to item to carry out), ability (capacity to carry out) Antidepressants, lack of social support, giving away possessions, hopelessness
Assessment, Communication, & Environment When pt. with psychiatrist— Minimize distractions and interruptions Eye contact, close to pt. Sensitive, empathetic, respectful
2 levels of patient observation Constant Observation (CO) Continuous observation Stay within view of pt. Make sure their hands are visible at all time Continues in bathroom Used for pt. at risk of harming self or others Special Constant Observation Stay within arms distance Hands must be visible SCO continues in bathroom and medical testing Actively trying to hurt / kill themselves
Types of Care Attendants Safety Care Attendant / Sitter Patient Care Constant Observation ADL’s Bed Making Comfort Measures No physician orders needed to initiate / discontinue Psychiatric Care Attendant / Sitter Constant Observation / Special Constant Observation Suicidal / homicidal Direct eyesight and within arms-length Don’t turn back on pt. Initiated by RN, ordered by physician Discontinued by physician
Safe Environment – must remove all contraband items Have pt. undress completely and only have the gown on Only cordless razors allowed/ No disposable razors Make sure windows are locked Possibly finger food only meals so no silverware, otherwise plastic Visitors leave belongings at nursing station Homicidal – constant observation and remain between patient and room exit so you have safe exit
Review of Responsibility Accompany the patient, even for bathroom CO – visualized at all times SCO – visualized and within arm’s reach at all times Stay with pt. at all times Can’t leave until relief is available Coordinate with peers No radios, headphones, cellphones
Vital Signs Temperature Red is for rectal Oral temp, put under the tongue Contraindication for rectal thermometer is recent surgery in that region or hemhorroids Axillary (under armpit) – right in the middle of armpit… not as reliable Avg is 97.7 F or 36.5 C
Pulse 60 – 100 bpm Radial Pulse – right below thumb Apical – heart easiest with stethoscope What are we looking for ? Rate – 60 -100 bpm Force – strength of pulse (strong, full, bounding vs. weak, thready) Rhythm – regular vs. irregular Palpation – Fingers on radial, 30 seconds, multiply by 2 [if pulse irregular count 1 min] >= 100 tachycardia – let nurse know <= 60 bradycardia – let nurse know Rhythm irregular – let nurse know Feeble, weak, thready – let nurse know
Respirations Inpiration + Exhalation = 1 respiation 12 – 20 per minute (adult) If normal, count 30 sec * 2 Don’t tell them you’re going to watch them – do while you are taking a pulse If abnormal do for complete minute Notify nurse if discoloration to blue of skin, lips, nail beds… chest pain… respiratory noises… struggling to breath
Blood Pressure Systolic (First) [contraction] vs. Diastolic (second) [filling] Males higher than females Age, gender, stress, pain, exercise, diet affect blood pressure Document where in the body we took the blood pressure, and in what position the patient was in when the blood pressure was taken Systolic Pressure >140 or < 100, let nurse know Diastolic Pressure > 90 or < 60, let nurse know Hypertension – systolic > 140 or diastolic > 90 Hypotension – systolic < 90 or diastolic < 60 Adult, check at upper arm at brachial artery – cannot do if there is a mastectomy or an IV…pink wrist band indicates you cannot use that limb – in this case us popliteal Popliteal artery (thigh cuff) systolic 10-40 higher than brachial
Stethoscope – rotate the side towards the side you will be using Sphygmomanometer – Cuff goes about an inch above the brachial artery .. put the stethoscope underneath it Pump 30 above their average Orthostatic BP – have lie down (check bp and pulse)… move to sitting position (check bp and pulse)… move to standing (check bp and pulse) Do on bare arm No caffeine or smoking within 20 minutes of bp, both feet on the floor
Order Temp, Pulse, Respirations, BP
Height / Weight New admission – check weight… ask for height Take off shoes.. zero out scale… check weight every 7 days unless otherwise specified (same time every day… before breakfast) If pt cant stand use bed scale… zero out and emove excess linen
Normals Less than 36 C or > 37.5 Pulse rate < 60 or >100 Repsirations <12 or > 20
Restraint and Seclusion Can be physical or chemical (more for physically violent patients)
Exclusions Orthopedic devices, surgical dressings, protective helmets, handcuffs (from jail), siderails during transport, IV arm boards
2 types of restraints Non violent restraint – due to behavior changes caused by medical conditions
Violent Restraint – when patient is at risk of hurting themselves or others, requires MD ordersRestraint is not disciplinary measure or coercion / substitute for pt. care Start with least restrictive and work up but keep them on for as long as possible
See if pt. behavior is caused by underlying issue, try to address underlying before restraints
Seek alternative methods – ask family members to sit in and keep them calm, move patient closer to nurses station, diversion i.e. movies, personal items from home, sitter
If restraint…assess much more often Release and reapply restraint Check color, sensation, movement oof extremities Asses skin integrity Readiness for restrain discontinuation Ambulate the patient
Documentation Vital Signs Release of restraint and reapplication Toileting Turning/ repositioning Intake Alternatives tried Must be timed correctly
Least Restictive Full side rails ( all 4) Mitts (only when tied down) Waist belt Vest Soft Limb Chair with locked tray Canopy bed Seclusion Hard Limbs
Glucometer CBS / BGM Action Range ~ less than 70 (Hypoglycemia), geater than 140 (Hyperglycemia)) Critical Values (Capillary blood sugar) ~ less than 50, greater than 500
Condition C, ccritical condition
Use the clear key device to scan the bracelet
Need to calibrate.. use lo and hi ontrols… scan in those two bottle The two dates on the controls is manufacturers exporation date and the date placed on it by the fst person tthat opened it (90 days from opening) Either surpass manfaccterer expiration of 90 days from first open, they have expired Scan the barccode of the testcode for quality control (also has expiration date)
Test every 24 hours or whenever we are prompted to do it
If bottles are expired, don’t use thehm, just throw them away
Open test string by tearing with blue side facing you, noth on the right Inset the piano keys into the device port Gently invert bottle several times Reove cap, wipe dry with dry gauze and apply solution to test strip (Dry off before capping) Apply solutteion to test string, hwhen there s beeping, stop the If fails once, retry, if itt fails a second time, get a new bottle of solution, it if fails a third time, talk to Point of Care (POC) department and don’t use meter
Universal Precautions Everyone doing POC test must adhere to infection control policies with universal precaution Hand hygiene and gloves for this procedure
Scan strip Insertt Strip Get pattients finger ready – clean finger with alcohol wipe and allow dry Uncap lancet Press firmly to outer fingertip Gentle press to get finger to bleed Discard first drop by wiping with gauze
Applying blood sample –touch tip to drop of blood.. keep going until beep Cannot apply blood multiple times to the teststrip – have to get a new sample
If you think there is an issue with the sample, use code 7 which is a procedure error
There will be an arrow that displays if its above or below the accepted values
If patient is not yet registered and doesn’t have a bracelet, get blood sugar by making their patient ID all 0’s – let POC know via phone call or email
Lancet goes into the sharps container + the tissue with blood goes into biohazard
If wireless transmission isn’t working, put the device on the dock and this allows for wireless transmission
After quality control, docking is also required
Bleach device between uses
Cardiac Monitoring and Leads More accurate placement = more defined and interpretable is the EKG
Change electrodes after a bath, every 24 hours
If hairy, shave the area – always run by RN before shaving (immunocompromised or blood thinners)
Dry prep (abrading) – rub with back of plastic backing – no alcohol prep prio to placing electrode
Snow over grass, smoke over fire, chocolate is near my hear
Battteries die very quickly, change regularly
Replace battery – red alarm – 10 min to replace battery
When pt is back from test or bath, reconnect immediately
7- questions 12 abbreviations (highlighted) 10 med term (highlighted) 3 reproting vital signs… find the abnormal 10 T/F 35 MC
Emergency Procedures Know where the crash cart is – red
Condition A – Arrest – heart stopped beating / stopped breathing Needs CPR
Condition C – Critical – deteriorating clinical condition – condition changing and without intervention, may arrest
Respiratory – Difficulty breathing (sudden onset)
(>30) || (< 10)
More O2 requirements
Hemoptysis - Bleeding in upper airway
Cardiovascular – Chest Pain
Hypotension – sustained Systolic BP <90 mmHg
Hypertension – sustained Systolic BP > 200 mmHg
Tachycardia – New onset sustained >120 bpm
Bradycardia – New onset sustained <50 bpm
Cyanosis – Blue tint
Neurological
Seizures
Change in responsiveness, consciousness, speech
Unexplained weakness or paralysis
New onset of delirium
Bleeding
Hematemesis – vomiting fresh blood
Hematochezia – fresh blood from rectum
High fever > 40 C
Pregnancy
Heavy vaginal bleeding
Urge to push
Gush of fluid from vagina
Severe Abdominal and Back Pain
Crowning Condition A or C tasks Bring the crash cart Assist with placing the backboard Give nurse cardiac monitor pads Assemble bag mask and suction Bring equipment to room
Condition F / Fire R- rescue A - alarm C - contain E – extinguish
Condition M (Dr. Strong @ Mercy) When person becomes violent / you feel unsafe Calls when security
Condition L Patient is lost Pt. may be disoriented + left the unit without authorization Wander risk patients should wear lime green gowns When found, need to call off the search
Condition O – often stems from a condition C Obstetrics
Condition I – infant abduction
Disaster Codes Internal – power failure External – mass casualty
Post-mortem care – need to wash the body after death and most patient wanna view the body so make sure it is presentable
Determine if pt needs autopsy before sending to the morgue
When autopsy required tubes stay in … if no autopsy, remove all of the tubes
Helping the hospitalized elderly patient stay safe 85 and older projected to double Hazards of Hospitalization – delirium, falls, dehydration + malnutrition, infection, pressure ulcers, loss of muscle mass
Delirium – onset in the hospital
Preventative measures of delirium Mentally stimulate the patient… talk to them Ambulate the patient Try to not wake patients up Make sure to provide hearing and seeing aids – do teach back to make sure they know what you are asking them… can you repeat back to me what I instructed you to do… ask them if there is an ear that they are more comfortable with it Keep them hydrated and nourished
Communicating with patients with dementia Identify yourself Be calm and patient Act in unhurried manner Eliminate outside noise!! Redirect if agitated Unclutter the rooms If agitated, stop what you’re doing, and try again later
Elder Abuse – any thoughts that abuse is occurring, go to the RN Physical Neglect Psychological Financial Sexual
Late Life Depression – Don’t ignore the pt. comments Loss, illness, finances, alcohol, isolation Often deny feeling depressed
Nasal Canula – 1L – 6L Low Resistance Nasal Canula (Dark Green) – 1 L – 15 L Simple Face Mask – 5L – 12L Non- rebreathing Mask – Indlated Bag Aerosol Face Mask – gives oxygen and aerosolizes some medication Aerosol Trach Mask – same as face mask but through tracheostomy Nebulizer Top Large Bore tubing
Pulse Oximetry – used to measure oxygen saturation in the blood—probe needs to be on the finger for at least a minute
ADT sensor… put probe on any of the fingers (most put on index finger) Place the sensor on the dominant hand on 3rd or 4th finger
Medical Gas Safety – turn off cylinder valve when tank not in use, Do not use O2 with petroleum based, transport tanks in the appropriate device
2 O2 tank holder— < 500 psi goes into the red storage and > 500 goes into green storage
Spirometer—deep breathing device that helps to reverse the effects of anesthesia by popping out the lower lobes of the lungs – ordered by the physician – pt. needs to breath slowly
Normal outputt — 1500 ml / 3 pints – refer to as voiding
Immpacting Factors Age -less efficient, decreased nephrons, decreased muscle tone - men = prostate enlargement Dietary Salt – increase salt, increase fluid retention, decreased urine ooutput Disease – Diabetes and hyppertension affect kidney – can cause kidney failure Drugs – Diureticc can increase urinatiton (lasix)
Normal Urination – pale yello (sttraw colored / amber) w/ out particles Observe for color, clarity, odor, amount, and particles Report pain / burning complaints/ odor
Cannot get out of bed - bedpan – women use for voiding and bowel… men use urinals for voiding Altetrnative is the fracture pans – used for those who just had surgery, casts, in traction etc
Urinal use - men stand or sitt or lie in bed May need to hold in place Men need tot let us know after theyre used the urinal
Bedside commodes (BSC) Use for thos uunable to walk to the bathroom Allows for normal excretion positon and minimizes the risk of a fall Make sure to lock the wheels, can also put commode over actual toilet to simply raise it up
Urinary Incontinence - loss of bladder control Practice good skin care with dry garments and linens to prevent skin damage / degredattion To remedy incontinence, bladder trainng may be needed or a catheter to prevent free urination into environment Use citric aid clear moisture barrier ointmentt and briefs if no catheter is inserted
Urinary Catheters Straight catheter – inserted to remove urine and is removed immediately after urine is removed Indwelling / foley is left in the bladder for continuing expulsion of urine Indications:: before/ during / after surgery, too weak to leave bed to urinate, close urinary output monitering, protect wounds from urine
Drainage bag – can be attathched to leg, must never touch the floor, keep lower than patients bladder (gravity) If bag disconected from cather and inform nurse, and wipe both ends witth alcohol and reconnect Drainage bags need to be regularly emptied and easured
End of every shhift When bag is getting full Prior to sending pt. for a test
Condom Catheter– incontinent men – slides over the penis Wash penis with soap and water, dry, apply and leave aboutt 1/2 - 1 inch of area between tip of tthe catheter and tip of the penis
Perineal Care – Female – cleanse front tot back Males – uncircumsized – retract foreskin and cleanse area witth soap and water
Urinary Tract Infection More common in femalles.. often in patients with indwelling catheters Burning, cramping with urination, change in appearance of urine
Renal Failure – kidneys dont filter blood, patients need dialysis Fistula needs to be surgically inserted to allow for dialusis
For renal failure pay close attention to Intake and Otput Dont do BP on arm where access for dialysis is Skin care Assist mobility Moniter intake / nutrition
Bladder training – patients given regular schedyle for urination and they try to hold until that time
Factors affecting – privacy, habits, age, diet, exerccise, fluids, drugs
Normal… vaired frequency, brown, soft + formed + moist, normal odor
Observe for bleeding orr foul smell associated with C diff Report color, amount, consistency, presence of blood, odor, shape, frequency , pai
Constipation – passage of hard dry stool – feces moove slowly through the bowel, prevented/ relieved by dietary change, drugs and enema
Fecal Impaction – Finger / digittal exam used to check for impaction – sometimes mass can be removed with a gloved finger
Diarrhea – diet and drugs used to recitify, clean more frequently and practive good skin care Need to replace fluid lost from diarrhea Skin breakdown is a major risk here Make sure to moniter vital signs as changes to vitals can occur
Fecal Incontinence– inabilitty to control defecation
Bowel Training, help with eliminattiono every 2 - 3 hours, make sure tto check frequenly and practice good skin care
Flatulence – if havent passed gas, distending of abdomen occurs To relieve–> exercise, walking, mmoving in bed, left side lying position Doctor may order enema
Bowel Training –> to gain control of bowel movements and develop regular patterns
##Enemas –> doctors order–> relieves constipattion, fecal impaction, flatulence Cant give enemas that contaian drugs Tap water enema– water from faucet saline is salt and watter Soapsuds enema – castile soap and water Oil retention enema – mineral, olive, or cottonseed oil
Cleansing enema Clean bowel of feces, relieves constipation + impaction
Small volume often irritates thte rectum
Oil Retention, clears constipation and impaction – lubricates
Amount of fluid depends on physician orders
Fluid impermeable pad underneath the patient + cover patient with a blanket , put patient in sims position
Should be room temp or tepid
Inser tip 2 -4 inches ino rectum
Hold enema in place while rectum is fillig
Goal is to retain for 15 minues, try o have patients retained… if cannot allow to expel into bedpan or make sure that the bathroom is open for the patient to use
Observe for color + blood
Pouch over the hole to collect stool and faltulanec
Pouch has an adhesice back … pouch is emptid when stool is present … pouch changed 3-7 days and when there is a leak
Opening in colon – collects feces from colon
Cerner is used for charting – use badge to access
Batth, moutth care, back care, peri care refusal, nottify nurse and document
OOB, ambulate, tolerance How much assistance
Call bell within reach, side rails up, adequent lighting, safe bed exit
Brief changes, incontinence, foley care
Turn + reposition Skin prep, ointment, barriier cream + lotion Incontinence Care Notify nurse of abnormal findings
Chart as soon as completetd Notify nurse of abnormalities
Transmit to eRecords
Weight in Kilograms … daily weights are most common , routine weights every 7 days Type of weight, type of scale, height on admission
% of meal pt. ate Abnormal food ocnsumption – less han 50% consumed Not eating supplements or snacks, lett nurse know
Chart totals at end of shhift Nurses do IV and tube feedings, not us
Black ballpoint pen … dont erase or use whitteout.. cross out and initial
Hospital Approved abbreviation
Need to write everything down or have a printout that can be given to the next PCT so they know what has been done
Also make a master list of everything that you have to do and cross off as you go
Att beginning of the shift, you will get your assignment
Sit with other PCT and go through the sheet Level of care needed, hygeine needs Bowel and bladder care habits
Delegated tasks, tests/ procedures, A x O *3, drains and dressings, O2 requirements , restraints, discharges, fall risk alarms
Prioritize glucose or more urgent patients
Minimum intake is 8 ounces of water a day
Intake – all fluids ttaken in (including jello and ice cream) Includes – in by mouth, tuube feedings, IV, fluids in drainage ttube
Measuring Intake – use graduated cup to measure water inake Measure immediately afer patient is finished with their meal tray Have pattient and family assist by writing down intake
1 ml = 1 cc 1 tspn = 5 cc 1 ounce = 30 cc 1 pint = 500 cc 1 quart = 1000 cc 1 gallon = 4000 cc
Ice chips equivalent to hald of their volume
All fluids leaving thte body Diarrhea, emesis, ileostomy, colostomy, urine, ouutput from drains, nasogastric tube Measured in mls
Explain to pt. that all output needs to be saved Give collection devices Label collection devices properly Change them daily
Measure using urinal or hat for urine Empty frains and indwelling / folet catheters every 8 hours and empty into graduated cyllinder
Inadequate bodily fluids… possibly a result of inadequate intake, diarrhea, vomiting Less able to feel thirst, kidney problems, difficulty pouring themselves a drink, confusion
Signs and Symptoms Dry mucouus membrane, weakness, confusion, lethargy, rapid pulse, low bloodpressre, dark urine, excessive thirst Ecourage fluids – offer frequent drirnk… possibly thicker liquuids if tthey have difficulty swallowing NPO – nothing by moouth
Swelling do to fluid accumulation
Too muchh in not eough out
PCT responsibility, elevate extremeties, apply elastic hose + stocking, assist patinet to bathroom frequently
Poor nutrition can be an attributing factor to surgical site infection, catheter associated tract infection, and pressure ulcers
Nutritional Risk Screening –> poor appetite, weight loss, skin breakdown, tube feeding Yes to any of the above requires consult with dietitian
Types of Diets – regular, NPO, therapeutic, consistency modified Regular – no special restrictions, anything from menu NPO– nothing by mouth Therapeutic – dependent on hhealth condition.. ordered by MD i.e. low sodium Consistency Modified – Dental (easy to chew) thickened liquids (nectar, honey, pudding consistency) Clear Liquids – fluids you can see through, juices with no pulp Full Liquids – things between clear liquids and solid food Jello, things that melt i.e. ice cream Fluid Restriction – max fluid intake, strictly monitored
Pt. with dysphagia (difficulty swallowing) – feed in upright position, follow all feeding instructions, go at the pt.s pace , watch adams apple rise and fall
Check with nurse before providing snacks
If ate less tthan 50% report to nurse
Tubue feed, elevate bed to 30-45degrees
Ideally eat sitting in chair, otherwise elevatte bed… high fowlers is best
Chart refusal of meals
Goal is protect the skin.. first layer of defense to infection
Older may resist hygeine due to disability, dementia, etc be adaptive
Good opportunity to stimulate the patient by talking to them
Bathing methohd depends on persons ability – respect individuals preference for time of bathign
Use a bathbag with washcloths and warm water
Complete bath bad – unconscious, paralyzed, casts/ traction, weak from surgery Encourage pt to do as much as possible, head to toe, cleanest area to dirtiest area Use hibiclens + sween 24
Skin Prep – apply it to bony regions when they look a little red, applying skin prep to prevent ulcer prevention
Interdry– antimicroobial + maceration / moisture protectioon 0— used for obese patient … strip that wicks moisture… keep like2 inches out of the fold
Partial Bath –sett up and instrucct patient… pefform teach bacl … asl patient ot wash and rinse areas and PCT helps with areas that they canot fo
Shower and tub baths – as able
Gather and set up equipment May have to brush the pt. teeth if they are unable to do so themselves Determine degree of assistance required For unconscious – sponge swaps to apply cleaning agent and lubricate the lips Weak patients – try to prevent choking / aspiration by putting them on one side with head turned to the side Use only small amount of fluid to clean mouth and dont insert dentures Keep moouth open with tongue blade
Denture Care – cleaned as often as natural teeth, don’t use hot water
Cleaning of genital and anal areas Prevents infectiton and odors
Done during the bath and after soiling… dont use hibiclens – gentle rain
Report any signs of breakdown, dischharge, unsual odor to the nurse
Make sure to record that the bath was given
Use Baza perineal lotion and odor coontrol, dont use for foley , spray on cloth not directly on patient
Patients shouold doo as much as possible
Dont braid without consent, never cut
Dont shampoo unless nurse instructs
Shaving is done with safety razors… cannot be used on those with healing problems of oin anticoagulant
Never trim toenails, call the podiatrist
#Skin care
Condom Catheter
Fecal Containment devices
Absorbant Pads
add washclothhs with warm water, use to bath
All over antibacterial soap (except for perineal )
Use for the peritoneal region and as shampoo
##Baza Perineal Lotion and Odor Control
Use instead of sween 24 afftter gentle rain on peritoneal region
##Sween 24
Use as an all over moisturizor except for peritoneal region
prevention / protectino used when we see mild redness at an area
Make sure nott clumpy
Indicated for incontinent patients
Used for incontinent of liquid stool patients
USed when skin is moist and weepy with deteriorating skin
Thin layer
Clean twice daily and reappy
Used for between people folds if it is red and irritated…
Rejects go in green bin, dirty linen goes in blue bag
Cannot give medication Cannot adjust oxygen Cannot take verbal or telephone orders Cannot diagnose or treat a patient
Accidentally throwing away the patientts hearing aid –> Negligence Yellow bracelet (fall risk) –> leaves person in the bathroom to go to a code… you come back and theyre on the floor –> negligence–> not intentional butt still happened
BID, TID, QID, ac, pc, hs, OOB, BRP, HOB, CBS, BGM, NPO, SCD, DNR, UA, NKA, C & S, HOH (Hard of hearing)
Yellow topped tube
Grey topped tube
Use a specimen cup
Just know how to do it
NPO going to surgery at x time… at what time are they NPO
Matching section – review but shouldnt be too bad just process of elimination
There is a highlighted anatomy outline
Just key functions … nohing too specific
High fowlers is the best feeding positiions Aim for getting oout of bed twice a day for meals
##Aspiration vs. PNA Nutrittional Consideration Aspiration – fluid or particulates fall back into the lungs Pneumonaia – fill up withh fluid / pus … alveoli will up with fluid and exdate… decrease gas exchange Deeding patients Body Positions Liquid Foods Clear Fluids (pulpy juices and dairy products)
Constipation – slow and dry but comes out Impaction –blockage in the intestines – possibly just a smear of liquidy indicates impaction
Measure calf circumfrence and knee length
smear is not a regular bowel movement or even a bowel movement in general
##feed patient in semi tot high fowlwers (hob 60-90 degrees) tend to their hand hugiene before after eating Eating less than 50% let the nurst know Less than 50% puts at risk for skin breakdown and pressure injury
Immobility Improper nutrition Incontinence Age Weight
Heels Coccyx Anywhere that digs in
Only purple products allowed for perineal area, sween 24 is not meant for perineal, used crittic aid on peritoneal to prevent breakdown, not sween 24
Critic aid paste is also for perineal once redness is already there
Cracked heels – sween 24
Full Fluids