Understanding Ethics in Nursing: Key Concepts and Practices
School
Midlands Technical College**We aren't endorsed by this school
Course
NUR 134
Subject
Nursing
Date
Dec 12, 2024
Pages
23
Uploaded by adivlogs
Legal and EthicalDescribe what ethics is and what the key terms are involved with ethics. •Ethics: a conscious understanding about right and wrong behavior, or good vs evil•Ethics gradually develops starting in childhood•May be a code of professional conduct: nursing code of ethics•Morals: standards of right and wrong based on personal or community beliefs•Just because an action is legal, does not mean it is ethically or morally right•Types of Ethics•Bioethics: discipline focusing on ethical concerns for bioethical research science and medicine•Clinical ethics: focus on ethical concerns that arise during patient care•Nursing ethics: study of ethical concerns that arise during nursing practice•Ethical conduct: principles of bioethics•Autonomy: self determination; respect patient’s right to make decisions•Nonmaleficence: avoiding causing harm to patients•Beneficence: act of doing good; balance benefits against risks and harm•Justice: fairness; give each person his/her due•Fidelity: keep your promises•Veracity: truthfulness•Accountability: accepting responsibility for your actions•Privacy: right to be left alone•Confidentiality: maintaining HIPPA, not sharing patient informationExamine nursing practice that is consistent with the Code of Ethics of Nursing. •Nursing Code of Ethics: set of principles that reflect the goals, values, and obligation of nursing•The Ethical Standard for Nursing that includes primary goals, values, and obligations of nursing•Violations may have consequences•Nursing Standards of Practice•American Nurses Association Standards of Clinical Nursing Practice•Ethical obligations and duties of nurses•An expression of nursing’s own understanding of its commitment to society•Standards of professional performance•Standards of care•Patient’s Bill of Rights•Rights and responsibilities while receiving care in the healthcare setting•Bill of Rights for RNs•Enables nurses to provide safer patient care•Empowerment of nurses by making clear what is nonnegotiable in the workplace•Nurse patient ratioRecognize ethical issues as they arise in nursing practice •Ethical dilemma•Two conflicting courses of action•Usually around the beginning of life and the end of life•Ethical distress•The nurse is in conflict between the right thing to do and institutional or personal factors that may make it difficult to follow the correct course of action•Professional dilemma
Analyze ethical issues in nursing using case study situations. Formulate a plan for resolving ethical issues in nursing. •Use the nursing process to resolve ethical problems1.Assess the situation (gather data)•Recognize and describe the the situation and contextual factors that give rise to ethical problems•Views of the main people involved•Patient’s medical, nursing, and social situation•Legal, administrative staffconsiderations that are relevant2.Diagnose — Identify the problem•What is the issue? Clarify that it is ethical in nature.•What is the moral or ethical component involved?3.Plan•Identify options and weigh alternatives•Short and long term consequences•Use ethical reasoning and code of conduct to decide on a course of action4.Implement•Implement and compare the outcomes with what you hoped for5.Evaluate•What did you learn?•What changes need to be made at the organizational level?Discuss factors influencing values formation and clarification. •Values are beliefs about the worth of something, about what matters, that act as standards to direct one’s behavior and decisions•Influence beliefs about needs, health and health behaviors, and responses to illness•Formed throughout life based on environment, family, and cultural practices•Values in Nursing•Set the foundation for practice•Influence how nurses interact with patients and members of the healthcare team•It is important that individual values are not used to judge the patient’s value•As nurses we need to routinely monitor whether our values support excellent practice•Value system: an organization of values in which each is ranked along a continuum of importance•Values clarification involves understanding one’s own values•It is a process by which people come to understand their own values and value system•Allows the person to discover through feeling and analysis of behavior, what choices to make when alternatives are present•When nurses understand the values that motivate patients’ decisions and behaviors, they can tap into these values when teaching and counseling patients•Professional values include•Altruism: concern for the well being of others; doing things in the best interest of the patient•Autonomy: the right to self-determination; allowing patients to make decisions without influence•Human dignity: respect for the worth of individuals and populations; treating all patients equally•Integrity: acting in agreement with a code of ethics or standards of practice•Social justice: maintaining moral, legal, and humanistic principles; being fairIdentify legal aspects associated with standards of care. •Law: standard or rule of established and enforced by the gov to protect the rights of the public•Litigation: process of brining and trying a lawsuit•Standards of care: what a reasonable, practical, or competent nurse would or would not have done
Describe professional and legal regulation of nursing practice. •Nurse practice acts: defines legal scope of nursing practice, to protect the public•Scope of practice: things you are allowed to do with your medical license — differs by state•Ensures that nurses practice within these limits•Developed by each state (obtain from the state board of nursing)•Explains violations and discipline that may result•Standards of care: what a reasonable, practical, or competent nurse would or would not have done in a similar situation•Voluntary standards•Developed and implemented by the nursing profession•Not mandatory•Guidelines for peer review•American Nurses Association (ANA) Standards of Practice•Legal standards•Developed by legislature and implemented by state authority•Determine minimum standards for nurse education, licensing requirements•Decide whether a nurses license may be suspended or revoked•Credentialing: ensures professional competence•Accreditation: process of evaluation of educational nursing programs as having met specific standards•Legal: state approved accreditation - state boards of nursing, required•Voluntary: National League for Nursing Accrediting Commission or American Association of Colleges of Nursing - not a legal requirement•Licensure: based on laws passed by state legislature•Allows on individual to offer nursing skills to the public•Allows one to act with basic competence•Is not appealed without due process•Certification: confirms specialty knowledge, expertise, and clinical judgement•Advanced knowledge and skill proficiency•Requires additional testing•Advanced Practice NursesDiscuss the purpose of the Nurse Practice Act. •Nurse practice acts: defines legal scope of nursing practice•Ensures that nurses practice within these limits•Developed by each state (obtain from state board of nursing)•Explains violations and discipline that may result, if a nurse practices outside of their scope•Prevent untrained or unlicensed people from practicing nursingDiscuss ways of decreasing liability for nurses. •Must have these elements established to prove malpractice or negligence occurred•Duty: obligation to use due care defined by standards of care•Breach of duty: failure to meet standard of care•Causation: indicates that breach of duty causes injury•Damages: harm or injury resulting that occurs to patient•The nurses best legal safeguard against liability it always competent practice•Liability insurance can help protect a nurse during malpractice claims
Describe Legal Safeguards for the Nurse •Protect nurses from legal risks•Ensure safety for nurses and patients•Informed consent: required for admission, tx, and dx procedures•Must be written and signed by patient or legally responsible person•Exception in emergencies or inability to reach legally responsible person•Respect patient’s self determination and promoting their well being•Physician responsible for explaining any procedures; nurse may answer questions, reinforce information already given, and witness patient signature•Must include potential risks, consequences, and alternatives•Assess patient understanding of procedures before obtaining consent or initiating treatment•Be aware of internal and external factors that may affect the patient’s ability to be competent to give consent•Refusal to consent should always be documented•Whistle blowing: informs public of dangers and protects workers from retaliation•Contracts: exchanges of promises between two parties•Nurse contact with employer: usually written•Nurse contract with patient: usually implied•Collective bargaining: representatives of organized workers negotiate on behalf of employees•Establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality healthcare•Competent practice: maintaining adequate clinical abilities and education•Documentation: factual, accurate, complete•Adherence to policies and procedures•Patient education: legal duty of the nurse•Physician orders•Acting as patient advocate•Questioning inappropriate orders per patient situation or facility policies•Proper communication•Liability insurance: protect nurses facing licensure disciplinary action•Risk management: analyzes and prevent risks in healthcare setting•Incident, variance, or occurence reports•Used by healthcare facilities to document unusual occurrences that either result in, or have the potential to harm patients, visitors, or employees.•Used for quality improvement.•Helps to identify high risk patterns•Not used for disciplinary action•Should be completed by the individual who witnesses or is responsible for the event or injury.•Sentinel Events: unexpected occurrences involving death or serious injury or risk of injury.•Require immediate investigation and response•Never Events: Rare medical errors that should never happen.•Patient’s Bill of Rights: expectations, rights, and responsibilities while under care.•Good Samaritan Laws: Protects healthcare professionals from liability when they provide assistance to the public in emergency situations.•Care must not be given in a negligent manner.•Care must fall under scope of practice•Dependent upon each state.
Differentiate intentional torts and unintentional tort. •Crimes and torts are wrongful acts committed against another person or his/her property•Crime: punishable by the state•Tort: may be punished or receive actions in a civil court•Intentional Torts: the person committing the act is aware of the legal limits of their words or actsA.Assault: a threat or attempt to make bodily contact with someone without consentB.Battery: assault that is carried out or acted upon•Willful, angry, violent touching of another person’s body or clothes or anything attached to or held by another — Includes well intentioned acts•Nursing examples? Giving a patient a medication without their consentC.Defamation: individual makes derogatory remarks about another person to negatively impact their reputation, without good reason to believe they are true•Slander: oral defamation•Talking poorly about a patient to a coworker•Libel: written defamation•Writing false rumors in a patients chartD.Invasion of privacy: right to be left alone and have information maintained confidential•Health Insurance Portability and Accountability Act — Protects Patients’ Privacy RightsE.False imprisonment: unjustified custody or prevention of movement of another person without consent•Nursing examples? Using restraints without an order; 4 side rails upF.Fraud: purposeful misrepresentation that may cause loss or harm to an individual or property•Unintentional tort: negligence — nurse who fails to initiate proper precautions to prevent harmA.Negligence: performing an act that a practical person would not normally do in a similar situation•Failing to act in a way that a reasonable person WOULD act in a similar situation•Malpractice: professional negligence; failure to abide by the standard or care of one’s profession•Failure to follow standards of care, use equipment in a responsible manner, document, monitor and assess, communicate, and/or act as a patient advocateMobilityExplain the key terms in the textbook reading assignment. •Types of ExerciseA.Isotonic: muscle shortening and active movementB.Isometric: muscle contraction without shorteningC.Isokinetic: muscle contractions with resistanceD.Passive ROME.Active ROMF.Active Assistance ROM•Types of MobilityA.Flexion: the state of being bentB.Extension: the state of being in a straight lineC.Hyperextension: the state of exaggerated extension; often an angle of greater than 180D.Abduction: lateral movement of a body part away from the midline of the bodyE.Adduction: lateral movement of a body part towards the midline of the bodyF.Rotation: turning on an axis; the turning of a body part on the axis provided by its jointG.Circumduction: turning in a circular motion; combines abduction, adduction, extension, flexionH.Supination: supine position; lying on back, palm facing upwardsI.Pronation: prone position; lying on abdomen or palm facing downwards
Discuss the effects of exercise and immobility on the various body systems. A.Integumentary: pressure ulcers•Effects of exercise•Nourishes the cells•Improved tone, color and turgor from Increased circulation•Prevents prolonged pressure to a part•Immobility•Pressure from a bed or chair•Decreased blood flow to the skin: less O2 and nutrients = ischemia•Increased risk for skin breakdown and formation of pressure ulcersB.Psychological: depression, anxiety, forgetfulness, and confusion•Effects of exercise•Increases energy, vitality, feeling of well being •Improves sleep•Improves body image•Improves self-concept•Improves health behaviors•Relieves boredom•Enhances sense of control•Immobility•Powerlessness•Low self esteem•Loneliness•Depression•Disrupted sleep cycle•DisorientationC.Musculoskeletal: osteoporosis, muscle atrophy and weakness, and contractures•Effects of exercise•Improves coordination•Improves muscle mass, tone, strength — more efficient•Improves joint flexibility•Decreases fatigue•Immobility•Bone Demineralization: Osteoporosis•Muscle Weakness/Atrophy•Decrease in endurance-longer to recover•Decrease in Joint mobility and flexibility: can lead to contracturesD.Cardiovascular/perfusion: postural hypotension, cardiac muscle atrophy, orthostatic intolerance, and deep vein thrombosis•Effects of exercise•Increased cardiac output: decrease HR and BP•Increased fibrinolysis — substance that breaks up small clots•Improved venous return: increase blood flow and oxygenation•Immobility•Increased cardiac workload•Orthostatic hypotension•Thrombosis formation
E.Respiratory: respiratory tract infections, atelectasis, and pulmonary embolism•Effects of exercise•Improved gas exchange•Increased rate and depth of respirations•Improved diaphragm excursion•Quicker return to resting state•Decreased work of breathing•Immobility•Generalized muscle weakness•Stasis of secretions•Inflammation: hypostatic pneumonia•Atelectasis•Decreased lung expansion•Respiratory tract infectionsF.Gastrointestinal: constipation and fecal impaction•Effects of exercise•Increased tone and motility•Improves digestion•Improves elimination•Strengthens abdominals “6 pack”•Immobility•Weak gastrointestinal muscles•Decreased peristalsis/motility: constipation•Decreased defecation stimulus•Postponed/delayed defecationG.Urinary System Effects: calculi•Effects of exercise•Improved blood flow to the kidney•Improved waste excretion•Immobility•Kidney stones: bone demineralization —> calcium —> calculi formation•UTIs/Urinary Retention: decreased muscle tone —> urinary stasisH.Metabolic Effects: glucose intolerance•Effects of exercise•Metabolism and thermoregulation efficiency increased: GI, Cholesterol, Heat•Immobility•Less O2 demand: decrease in metabolic rate•Changes in fat/carb/protein metabolism•Decrease in appetite•Fluid and electrolyte imbalances•Catabolism: muscle wastingDetect signs and symptoms that indicate the complications of immobility. A.Integumentary assessment priorities•Perform daily skin and Braden assessment•Monitor hydration/nutrition•Inspect bony prominencesB.Psychological assessment priorities•Signs of depression/anxiety Suicidal thoughts•Signs of sleep disturbance Anger/getting upset
C.Musculoskeletal assessment priorities•Muscle tone, strength•ROM, pain•Endurance: V/S, SOB•Assistance requiredD.Cardio/Perfusion assessment priorities•Heart rate and rhythm, apical and peripheral pulses, capillary refill, BP•After activity, note changes in V/S and SOB•Edema in dependent areas, especially the sacrum•Calf redness, warmth, swelling and shininess, tendernessE.Respiratory assessment priorities•Lung sounds, note areas of diminished sounds in dependent lung fields•Chest symmetry, respiratory rate, rhythm, depth, pulse ox•Increased respiratory secretionsF.Gastrointestinal assessment priorities•Monitor intake of food and fluids•Weigh daily to evaluate fluid changes•Note frequency and consistency of stools, pattern of elimination•Assess bowel sounds•Ability to ambulateG.Urinary system assessment priorities•Note voiding pattern: time, frequency, amount, dysuria, flank pain•Note bladder distention. Use bladder scanner if available•Nore urine color, odor, cloudiness•Record intake and outputH.Metabolic assessment priorities•Monitor intake and output•Monitor labs: K+, Na, Glucose, proteinSelect factors that contribute to altered physical mobility and identify patients at risk for complications of immobility. •Perform Fall Risk Assessment Emotional State•Environmental factors Injured•Posture and Gait abilities Illness•Longer length of time immobile Patient with Dementia•Elderly or very young patient Patients recovery from surgery•The heart has to work harder when a patient is immobile•At risk for thrombosis formation due to decreased venous return•Common in lower extremities•Bedded is found because don’t want the clot to moveSelect appropriate health problems, behavioral outcomes and interventions for patients who need assistance with mobility and preventing complications of immobility. A. Integumentary•Nursing Diagnosis•Impaired skin integrity•Risk for pressure ulcer•Goals/Outcomes?•Patient will remain free of pressure ulcer development during their hospital stay•Patient will maintain a Braden score of >18 during hospital stay
•Interventions•Develop regularly time repositioning schedule for client- turn patient every 2 hours & float heels•Keep patient’s skin clean & dry•Use padding or appropriate pressure-reducing devices – specialty mattressesB. Psychological•Nursing Diagnosis•Impaired Social Interaction•Risk for loneliness•Hopelessness•Social Isolation•Goals/Outcomes?•The patient will maintain usual sleep pattern during hospitalization•The patient will participate in one group PT activity per day.•Interventions•Seek community program for client involvement that promote positive behaviors•Provide socialization•Utilize volunteers, family, staff•Promote independence •Promote normalcy •Encourage participation in unit activitiesC. Musculoskeletal•Nursing diagnosis•Impaired physical mobility•Activity intolerance•Sedentary lifestyle•Goals/outcomes?•Patient will participate in upper body morning ADLs by 12pm•Patient will perform active ROM upper body exercises 3x by 3pm•Interventions•Perform active/passive ROM 3-4x daily•Provide devices to maintain joint functionD. Cardio/Perfusion•Nursing diagnosis•Risk for decreased cardiac tissue perfusion•Decreased cardiac output•Risk for impaired cardiovascular function•Goal/outcomes?•Patient will demonstrate behaviors or lifestyle changes to maintain or maximize circulation: diet, exercise, no smoking — by discharge•Patient will not show signs of DVT while immobile during their hospital stay•Patient will transfer safely from bed to chair three times a day in weeks weeks•Change from lying to standing position safely without injury•Interventions•Administer anticoagulant medications such as antiplatelet agents, thrombolytics•Graduated Compression Stockings, Pneumatic Compression Devices, SCDs as ordered by MD•Encourage early activity (as tolerated) — ROM exercises•Isometric exercise•Positional changes like lying to standing•Bed to chair transfers•No pillow under the knees
E.Respiratory•Nursing diagnosis•Ineffective airway clearance•Impaired gas exchange•Ineffective breathing pattern•Goal/outcomes?•Patient will have patent airway during day of care — clear breath sounds on auscultation•Patient will have adequate gas exchange as evidenced by a pulse ox of greater than 93%•Interventions•Turn q2h to inflate lungs and move secretions•Humidity air•Provide 2000 ml of fluids daily•Instruct patient in use of incentive spirometer•Suction machine at bedside if patient is weak•What position would you assist patient in? Turning and standingF.Gastrointestinal•Nursing diagnosis•Constipation•Dysfunctional gastrointestinal motility•Goal/outcomes?•The patient will have a formed, semi-solid BM every 1-3 days during hospitalization•The patient will be free of signs of fecal impaction/constipation during hospitalization•Interventions•Collaborate with nutritionist to provide high fiber foods•Consult physician about bulk laxative, stool softener, or stimulant laxative if needed•Help to bathroom, use bedside commode, put bedpan on chair•Encourage fluid intake•Early mobility after surgeryG.Urinary system•Nursing diagnosis•Impaired urinary elimination•Urinary retention•Goal/outcomes?•The patient will be free of renal calculi during period of immobility•The patient will maintain usual voiding pattern – specify•The patient will be free of signs and symptoms of UTI during immobility•Interventions•Monitor intake and output. Encourage fluid intake of 1500- 2500 ml per day. Maintains renal function, prevents infection, and stone formation•Teach importance of keep perineal area clean & dry. Reduces risk of infection/skin breakdown•Bladder Scan for post void residual if retention suspectedH. Metabolic•Nursing diagnosis•Impaired nutrition: less than body requirements•Ineffective thermoregulation•Risk for electrolyte imbalance•Goal/outcomes?•Patient will maintain lab values within normal range during hospital admission•Patient will maintain and/or gain weight toward designated goal and be free from signs of malnutrition during hospital admission
•Interventions•Increase specific nutrients (protein, carbs) as needed, providing patient with preferred food and seasoning choices. To enhance intakeDescribe and demonstrate correct procedure for applying elastic stockings, transferring patients, positioning and turning patients, performing range of motion exercises and assisting patients with ambulation. A.Applying elastic stocking•Requires an MD order•Measure the patient’s legs to determine the proper size•Assess the skin condition and neuromuscular status of the legs•Do not massage the legs•Check the legs regularly for redness, blistering, and pain•Launder the stockings as necessary, at least every 3 daysB.Transferring patients•Transferring a patient from bed to chair•Baseline vital signs before attempting to transfer a patient•Assess the patient’s ability to bear weight to determine the appropriate method of transfer•If patient is unable to bear partial weight or full weight or who is uncooperative should be transferred using a full-body sling lift with two caregivers•Make sure wheels on bed and chair are lockedC.Positioning patients•Foam wedges and pillows —under calfs so heels float•Mattresses•Adjustable beds — elevate the head of the bed, less pressure•FootboardD.Turning patients•If the patient is unable to assist:•Full body sling•2 or more care givers•Make sure the bed is at the height of the care givers’ elbow•If patient cannot assist and >200 pounds use friction-reducing device and 3 caregivers•If patient cannot assist and < 200 pounds use friction-reducing device•If the patient can assist have additional caregiver on stand by for safety as needed.E.Performing range of motion exercises•Involve the patient•Set schedule•Start gradually and slowly•Exercised sequentially•Stretch the muscles and keep the joint flexible: move each joint until there is resistance•Support the extremity: return joint to its neutral positionF.Assisting patients with ambulation•Use a gait belt or a lift as neededDescribe and demonstrate correct body mechanics when assisting patients with mobility. •The use of proper body positions to provide protection from the stress of movement and activity, specifically in regards to structure, function, and position of the body•Illness prevention•Health Promotion
Evaluate appropriate safety precautions for patients with impaired physical mobility. •Assess the patient’s abilities•Obtain baseline vital signs•Use good body mechanics•Use appropriate assistive devices•Lock the wheels of the bed, wheelchair and stretcher•Appropriate footwear on•Use of gait belt•Clutter free environment•Alarms onUtilize criteria to evaluate patients’ response to nursing care that promotes mobility and prevents the complications of immobility. •Used each nurse-patient interaction to evaluate the patient in the following respects:•General ease of movement and gait•Body alignment•Joint structure and function•Muscle mass, tone, and strength•Endurance•An excellent time to assess these essential ingredients of well-being is when the patient is performing simple tasks such as, walking, dressing, eating, and undertaking hygiene measures,Compare and contrast musculoskeletal changes in aging patients. •Muscle strength•Respiratory capacity — decreased•Perfusion/circulation — decreased•Range of motion — decreased•Stability and Gait — decreasedEliminationExplain the key words in the textbook reading assignment. •Anuria: 24 hour urine output is less than 50ml•Bacteriuria: bacteria in the urine; infection•Dysuria: painful or difficult urination•Frequency: increased incidence of voiding•Glycosuria: presence of glucose in the urine•Hesitancy: difficult starting the urine stream or keeping it flowing•Micturition: process of emptying the bladder — also known as voiding•Nocturia: urination during the night that awakens the person•Oliguria: 24 hour urine output is less than 400ml•Peristalsis: contractions of the circular and longitudinal muscles of the intestine•Polyuria: excessive output of urine; diuretics•Proteinuria: protein in the urine•Pyuria: pus in the urine•Urgency: strong desire to void•Urinary incontinence: involuntary loss of urine•Urosepsis: when a UTI spreads to the kidneys and causes sepsis
Give examples of factors that contribute to or interfere with healthy elimination. Factors affecting UrinationA. Age•Infant/toddlers: void by reflex and no voluntary control until 18-24 months•Elderly population•Concentration of urine: diminished ability of the kidneys to concentrate urine may result in nocturia •Muscle tone and contractility decreased: increased frequency of urination/UTI•Health history/chronic conditions: interfere with voluntary control, may result in incontinenceB. Psychological/sociocultural•Personal/private act — bedpans may invoke embarrassment and anxiety•Stress: smaller amounts of urine, more frequent or difficult emptying the bladder completelyC.Food and Fluid Intake•Dehydration vs fluid overload•When the body is dehydrated the kidneys will reabsorb fluid and produce a more concentrated urine and the amount is decreased•Signs of dehydration: delayed skin turgor, dry mucous membranes, tachycardia•With fluid overload the kidneys excrete a large quantity of diluted urine — edema!•High Na+/salt intake: sodium and water reabsorption and retention, decreasing urine formation •Alcohol — diureticD. Pathological•Kidney disease/disorders•Congenital urinary tract abnormalities•Polycystic kidney disease•HTN•DM•Gout•UTIs•CalculiE.Medications•Diuretics: pale yellow urine•Nephrotoxic medications: capable of causing kidney damageF.Activity and Muscle Tone•Increased metabolism: optimal urine production and elimination•Immobility: decreased bladder and sphincter tone — poor urination control and urinary stasis•Pregnancy and menopause — decreased muscle toneFactors Affecting Bowel EliminationA. Age•Newborn/infant•Less secretion of digestive enzymes — Small stomach capacity•More rapid peristalsis•Voluntary control: 18-24 months•Elderly•Decrease in activity•Peristalsis declines — constipation is often a chronic problem•Constipation is often a side effect of medications, life habits, immobility, inadequate fluid intake, and lack of attention to urge to defecate•Impaired absorption•Nutrition/fluid: decreased fluid and fiber consumption lead to constipation
B. Diet•Food intake•Fiber — high fiber diets promote elimination•Gas producing•Food intolerance•Fluid intake•Fluids help to liquefy intestinal contents•Hot beveragesC. Medications•Elimination aides: laxatives•Side effects: may cause diarrhea or constipation depending on the medication•Anesthesia may cause constipationD. Pathological/Physiological•Diverticulitis•Crohns, Colitiis•IBS, Short Gut SyndromeE.Physical activity: regular exercise improves GI motility and muscle toneF.Prolonged Bedrest or Immobility: increases risk for constipationG.Personal habits/lifestyle: frequency, time, consideration, position, and place•Changes in these patterns may upset the persons routine and lead to constipationH.Pain: someone in pain may not want to use the bathroom or is unable to moveI.Pregnancy: may cause constipationJ.Psychological factors: stress, anxiety, chronically worryEvaluate elimination patterns and recognize abnormalities. •Micturition: the urge to void•The bladder normally holds 600 ml; urge to void occurs at about 250 ml•Normally painless•Voluntary control only during the act of voiding•Involuntary control = incontinence•Commons problems in urinary elimination1.UTI — An infection of the bladder and urethra commonly caused by E. coli•Can occur due to wiping back to front or may be a CAUTI•Sxs: pain, burning with urination, blood tinged urine, confusion in elderly2.Incontinence•Stress Incontinence: involuntary control in response to increased intra-abdominal pressure•Overdistention between voiding, weak pelvic muscles•Urge Incontinence: loss of urine soon after feeling the need to go•Increased risk with caffeine and alcohol consumption, fecal impaction, UTI. Ineffective habits•Mixed Incontinence: 2 or more types of Incontinence•Overflow Incontinence: caused by over distention and overflow•Functional Incontinence: inability to reach the toilet in time•Mobility deficits, altered environmental factor•Reflex Incontinence: no sensation of need to void•Total Incontinence: caused by anatomic abnormality3.Renal Calculi — Kidney Stone•A “pebble” made from waste molecules in urine (uric acid, calcium)•Sxs: reddish urine, urinary frequency, N/V, painful urination when passing stone along with sharp pain in the back/side•May cause a blockage: urinary obstruction
4.Urinary diversion: urinary flow is surgically diverted•Illeal Conduit•Urinary Reservoir•Ureterostomy/urostomy•Suprapubic Catheter5.Urinary retention•Retains urine after voiding — prostate may be enlarged•Sxs: feelings of pressure, discomfort, tenderness over the symphysis of the pubis; restlessness, and diaphoresis•Key assessment: absence of urinary output, but still have the urge to void — distended bladder•Retention with Overflow: pressure in the bladder builds so the external urethral sphincter is unable to hold back urine•Common Bowel Elimination Problems•Constipation: dry, hard stool that is difficult to pass•Caused by:•Decreased fiber in diet•Decreased fluid intake•Inactivity•Delaying defecation•Abuse of laxative•Changes in routine•Side effect from medication•Impaction: caused by hardened stool wedged in the rectum•Oozing of diarrhea stool: liquid stool seeping/passing around the blockage•Diarrhea: more than three stools a day that are loose or watery•Caused by abuse of laxative, emotional stress, intestinal infection, colon disease•Incontinence: involuntary passage of stool•Caused by•General decline in muscle tone•Cognitive impairment•Rectal sphincter abnormality•Dietary habits•Laxative abuse•Bowel Diversions•A surgically created opening (ostomy) in the abdominal wall for fecal elimination.•A part of the intestine/colon is brought to the surface to create a stoma•Hemorrhoids: caused by abnormally distended/swollen vein(s)•Sxs: painful BMs, may have blood in stool or when wiping that is bright red•FlatulenceAnalyze data and identify patients at risk for impaired elimination. •UTI risk factors: sexually active females, people who use diaphragms, post menopausal people, people with indwelling catheters, those with diabetes, older adults•Incontinent Risk Factors: recent pregnancy, weak pelvic muscles, kidney disease, immobility•Impaired Urinary Elimination: elderly, under 18 months, patients who are dehydrated or at risk for fluid overload, patients who have preexisting kidney diseases or disorders, impaired mobility•Impaired Bowel Elimination: elderly, patients under 24 months, low fiber intake, high intake of gas producing foods, ingesting food intolerances, dehydration, immobility, pain, stress, anxiety
Discuss the effects of impaired elimination on the body. •Urinary elimination alterations may cause fluid overload or dehydration•Bowel Elimination alterations can affect your•Hydration and nutrient: fluid and electrolyte imbalance•Skin integrity•Comfort•Self conceptDescribe, demonstrate, and document correct procedure to assist patients with elimination. •Bladder Scanner: nurses do not need an order to complete•Cystoscopy: nurses are responsible to obtain consent, provide sedation and analgesics•IV Pyelogram: radiographic examination of the kidney and ureter with contrast•Retrograde pyelogram: Pt is NPO, obtain pt hx including allergies•CT•Renal Biopsy•Ultrasound Examination•Catheterization•Follow proper sterile technique for insertion•Provide routine catheter care•Observe/report patient and urine for sxs of UTI•Removal of catheter•Assure balloon deflation•Uncomfortable-have patient take some deep breaths•Perineal care•Monitor output•*Instruct patient to increase fluid intake•*1st few voids post removal:•May have slight burning with urination•May experience some pink tinged urine- no gross blood or clots thoughUtilize the nursing process to contribute to the development of a plan of care/concept map for patients with altered elimination. 1.Assessment•Data collection for Urinary Elimination•Asses the patient’s urinary function: voiding patterns, habits, and difficulties•Assess the skin for color, texture, and turgor•Assessment of bladder and urethral meatus, if indicated•UA — clean voided, sterile specimen, or 24 hour specimen•Color: straw yellow, amber•Clarity: clear•Odor: aromatic•pH: 6 is desirable; may range from 4.6-8•Specific gravity: 1.005-1.030•Organic Constituents: urea, uric acid, creatine, hippuric acid, Indian, urene pigment, and N•Inorganic Constituents: ammonia, Na, Cl, K, Ca, and traces of iron•Intake and Output•Diagnostic Procedures•Intravenous Pyelogram: NPO, shellfish allergies, contraindicated for elevated BUN/Creatinine•Cystoscopy: liquids only before, encourage fluid intake after, swelling normal•Bladder Scan
•Data collection for Bowel Elimination•Changes in characteristics of stool or frequency may be the first sign of a problem•Volume: color and odor — brown, pungent•Consistency: soft, semisolid, formed•Constituents: bile, intestinal secretions, shed epithelial cells, bacteria, and inorganic material•Assess external anal area for lesions, ulcer, fissures, inflammation, external hemorrhoids•Assess the patients chewing ability and oral cavity•Assess patients mobility•Auscultate bowel sounds and inspect the abdomen•Significant findings: asymmetry, swelling, distention, or protrusion•Disconnect NG tube when auscultating •Stool specimen testing•Fecal occult: used to detect occult blood in the stool•Stool analysis/culture: obtained when an infection is suspected•Diagnostic Exams•Colonoscopy: NPO, bowel prep, flatulence normal, observe for signs of bowel perforation•EGD/Endoscopy: fasting, observe for signs of perforation•Barium Radiography — Upper GI: NPO, posttest laxative to prevent fecal impaction2.Interventions•Promoting and maintaining urination patterns•Goal is to maintain or restore optimal function, alleviate sx, prevent complications•Increase fluid intake•Monitor Intake and Output•Take to BR timely — maintain regular voiding habits “lets go to the bathroom”•Assist patients are in their normal voiding position•Provide privacy•Teach hygiene and infection control principles•Strengthen muscle tone•Treatment for Incontinence•Behavioral Techniques: bladder training, scheduled toileting, fluid/diet management•PT: pelvic floor muscle exercises and electric stimulation•Pharmacological: contract/reflex associated muscles•Mechanical devices: pessaries and urethral insert/plugs•Surgery: anterior repair, bladder sling, bottoms, urostomy, suprapubic catheter•Promoting regular bowel habits•Timing/retraining of elimination•Positioning during elimination•Privacy•Nutrition: increase fiber for constipation and fecal impaction•Fluids: increase fluids for constipation, diarrhea, fecal impaction•Exercise: increase for constipation•Cathartic/laxatives: overuse can cause harm•Wetting agent and stool softeners•Enema: loosen stool to promote elimination; order required•Impaction removal: requires a doctors order•Ostomy care: teach patient how to perform it•Maintain Skin Integrity: patients with diarrhea
Utilize criteria to evaluate patient response to nursing interventions that assist with elimination. •Nursing care is considered effective if the patient expresses satisfaction with the urinary function measures and is able to accomplish the following as it applies to their plan of care•Produce a sufficient quantity of urine to maintain fluid, electrolyte, and acid base balance•Empty the bladder at regular intervals without discomfort•Provide care for urinary diversion and know when to notify care team•Develop a plan to modify any factors that contribute to current urinary problems or may impair urinary functioning in the future•Promote urinary functioning as appropriate for the person•Nursing care is considered effective if the patient expresses satisfaction with the bowel elimination measures and is able to accomplish the following as it applies to their plan of care•Verbalize the relationships among bowel elimination and nutrition, fluid intake, exercise, and stress management•Develop a plan modify any factors that contribute to current bowel problems or may impair urinary functioning in the future•Promote bowel functioning as appropriate for the person•Provide care for bowel diversion and know when to notify healthcare teamDifferentiate the roles of the RN and the LPN in the care of patients with altered elimination. •RN: ADPIE the patients needs with altered urinary and bowel elimination pattern•LPN assists the RN with caring for patient with altered urinary and bowel elimination patternsIntake and OutputWhat is Intake? Output? •Intake is the measurement of all liquid gain or intake•Majority taken by mouth.•Foods items that turn to liquid at room temperature•Routes of fluid intake: PO, IV, Tube feeding (TF;enteral)•Output is the measurement of all routes of fluid loss or output•Routes of fluid loss•Urine: bedpan, urinal, disposable brief, catheter drainage bag•Liquid stool: diarrhea•emesis•drainage•suctioned secretions•excessive perspirationStudent should know conversions and be able to apply them •Intake and output should be recorded in ml•Convert all values to mlUnderstand what should be included when recording intake and output •Intake includes liquids•Puréed food is not recorded as intake. Only clear liquid foods are recorded in intake•Output includes emesis, wound drainage, urine, and diarrhea•Urinary output is normally equal to amount of fluid intake
Infection and InflammationExamine the infection cycle and evaluate methods to break the chain of infection. 1.Infectious Agent•Bacteria: most significant and most prevalent in hospital settings•Virus: smallest of all MOs•Fungi: plant like organisms present in air, soil, and water•Parasites: relies on host for nourishment•Potential to produce disease depends on?•The number of organisms•Virulence•Host’s immune system•Type of contacts•Colonization versus infection2.Reservoir: People, Animals, Fruit/veggies, Fingernails, Inanimate objects3.Portals of Exit: Respiratory, Gastrointestinal, Genitourinary tracts, Breaks in skin, Blood and tissue4.Mode of Transmission: direct or indirect contact, droplet, airborne, vehicles, vectors5.Portals of Entry: Respiratory tract, GI tract, Genitourinary tract, Breaks in skin, mucous membranes, Bloodstream6.Susceptible Host: the degree of resistance the host has to a pathogen•The infection cycle illustrates the chain of infection and precautions that can break it1.The chain of infection can be broken between the Infectious Agentand Reservoir•Hand hygiene•Sterilization•Antibiotics/antimicrobials2.The chain of infection can be broken between the Reservoirand Portal of Exit from Reservoir •Transmission based precautions•Sterilization or use of disposable supplies3.The chain of infection can be broken between the Portal of Exit from Reservoir and Means of Transmission •Dry intact dressing•Hand hygiene•Wear gloves if contact with body fluids will occur•Cover nose and mouth when sneezing4.The chain of infection can be broken between the Means of Transmissionand Portals of Entry•Hand hygiene•Use pesticides to eliminate vectors•Adequate refrigeration 5.The chain of infection can be broken between the Portals of Entryand Susceptible Host •Hand hygiene•Wear gloves•Use masks and appropriate PPE•Proper disposal of needles and sharps6.The chain of infection can be broken between the Susceptible Hostand Infectious Agent•Immunizations•Screen healthcare staff
Differentiate the stages and characteristics of infection. •Incubation Period: time between the pathogen’s invasion of the body and the appliance of symptoms of the infection — may last days to weeks•Prodromal Stage: nonspecific signs and symptoms like fatigue, malaise, low grade fever•Most contagious stage•Full Stage of Illness•Infection: specific signs and symptoms•Wound infection: swollen, deep red, feels hot, drainage increased and may be purulent, foul odor,•Symptoms may be localized or systemic•Length and severity depends on the illness•Convalescent Period: recovery from infection•Signs and symptoms disappear and the persons health returns•Previous health state may be changedDiscuss nosocomial infections (Health Care Acquired Infections) and the sites they usually occur. •Nosocomial infections or HAIs are infections that are acquired in a healthcare setting•Risk factors•Skin integrity•Age•Multiple illnesses•Invasive procedures/indwelling medical devices•Broad spectrum antibiotics•Poor aseptic technique•Multiple health care personnel•Extended length of hospitalization•Common HAIs•Catheter-associated urinary tract infection (CAUTI)•Surgical site infection (SSI)•Central line–associated bloodstream infection (CLABSI)•Ventilator-associated pneumonia (VAP)Identify factors that reduce the incidence of Health Care Acquired Infections. •Standard precautions•Medical asepsis•Surgical asepsisIntegrate standard precautions during patient care. •Wash hands•Assume all bodily fluid is contagious and all patients are contagiousDifferentiate the classifications of pathogens. •Multidrug - Reistant Organisms (MDRO)•Methicillin–resistant staphylococcus aureus (MRSA)•Vancomycin-resistant enterococcus (VRE)•Clostridium Difficile (C. Diff) — wash hands!•Prevent transmission by using Contact Precautions and medical asepsis
Explain the body’s normal defense against infection. •Body’s First Line of defense against infection•skin and mucous membranes•body’s normal flora in the GI tract•Inflammatory response: protective mechanism•Immune response•Antigen (foreign material) + Antibody (body’s response) = Antigen-Antibody reaction•This is what happens in the body when a vaccine is administered•Cell mediated immunity: increase in WBC to destroy foreign materialIdentify patients at risk for developing infections. •Factors that may place patients at risk for developing infections•Age, sex, race, heredity WBC•Skin integrity pH of GI & GU tract•Health status Immunization•Stress level Medical devices that are invasive or indwellingExplain the inflammatory response, including signs and symptoms. •The inflammatory response is a protective mechanisms•It is a localized attack to remove dead damaged tissue and to repair/replace tissue•Cardinal Signs and Symptoms: redness, heat, pain, swelling, loss of function•Vascular Inflammatory Response•Vasoconstriction to confine the area of injury and limit tissue damage•Vasodilation to floor the area and promote healing•Cellular Inflammatory Response•WBC moves to the area to consume cell debris and foreign material•Exudate is released: serosanguineous, serous, purulent, sanguineous•Damaged cells are either replaced or scar tissue formsUtilize the nursing process to assist in the development of a plan of care/concept map for the care of patients with infection and inflammation problems. •Outcome Identification for Infection Control•Demonstrate effective hand hygiene and good personal hygiene practices.•Identify the signs of an infection.•Maintain adequate nutritional intake.•Demonstrate proper disposal of soiled articles.•Use appropriate cleansing and disinfecting techniques.•Demonstrate an awareness of the necessity of proper immunizations.•Demonstrate stress-reduction techniques.•Assessment for Wounds•Inspection of wound appearance and drainage•Assess smell and pain•Psychological effects: anxiety, feat, impact on ADLs, change in body image•Assess for Wound Complications•Infection: Edges are not approximate, drainage, pain, redness•Hemorrhage: Heavy bloody drainage, not clotting•Dehiscence: excessive stress on healing wounds that causes separation of wound layers•Evisceration: separation of abdominal wound that results in protrusion of internal organs•Fistula formation: abnormal passage from organ to organ or from organ to outside of body
•Interventions to Promote Wound Healing•Hand hygiene•Ensure adequate blood supply and flow is present for circulation and oxygenation of the tissue•Proper nutrition: protein, vitamin C, zinc•Keep wound free of foreign material that may slow healing•Medication regimen adjustment: corticosteroid drugs and postoperative radiation therapy delay wound healing•Hot and Cold Treatment: therapy to bring about local or systemic change in body temperature•Effects of applying cold:•Constriction of peripheral blood vessels•Reduces muscle spasms•Promotes comfort•Reduces the release of serotonin, histamine, bradykinin•Alters tissue sensitivity•Prolonged exposure causes: Goosebumps, Shivering, Increased BP, Tissue damage•Effects of applying heat:•Dilates peripheral blood vessels•Increases tissue metabolism•Reduces blood viscosity and increases capillary permeability•Reduces muscle tension•Helps relieve pain•Prolonged exposure causes: Sweating, Increased HR, Decreased BP, Increased COApply transmission based precautions. •Contact precautions: hand hygiene, wear gloves and gown, use dedicated or disposable equipment, clean and disinfect reusable equipment like your stethoscope•For drug resistant organisms•Droplet Precautions: hand hygiene, wear mask and goggles•Airborne Precautions: hand hygiene, N95 mask, door to room must remain closed•Negative airflow isolation room•TB, rubeola, varicella•Donning: Gown, Mask, Goggles, Gloves•Doffing: Gloves, Goggles, Gown, Mask (alphabetical order)•Isolation room: private room that may have negative pressure airflow for airborne precautions•All equipment that come into the contact with the patient are considered contaminated•Dedicated equipment for these patients that remains in the patients room•Transportation to other areas of the hospital•Pt may need to wear surgical mask if on airborne or droplet precautions — pts do not wear N-95Evaluate the phases of wound healing and the types of repair. •Tissue RepairA.Primary Intention•Clean, surgical incision•Intentional woundB.Secondary Intention•Edges do not close, wound heals from the inside out•Large wounds, burns, pressure injuries, primary that became infectedC.Tertiary Intention•Delayed closure•Allows edema and infection to resolve, then suture closed
•Stages of Wound Healing: HIPM•Hemostasis: occurs immediately after initial injury•Involved blood vessels constrict and blood clotting begins•Platelets stimulate other cells to migrate to the injury to participate in other phases of healing•Vascular portion of the inflammatory process — bleeding•Inflammatory Phase: follows hemostasis and lasts about 2-3 days•WBCs move to the wound•Macrophages enter the wound area and remain for an extended period to ingest debris and release growth factors that attract fibroblasts to fill in the wound•The patient has a generalized body response: exudate, pain, heat, redness, swelling•Proliferation Phase: Fibroblastic, regenerative, connective tissue phase•New tissue is built to fill the wound space through the action of fibroblasts•Capillaries grow across the wound to ensure good blood flow•A thin layer of epithelial cells forms across the wound•Granulation tissue forms a foundation for scar tissue development•Maturation Phase: remodeling•Final stage of healing that begins about 3 weeks and continues for months and up to 2 years after injury•Collagen is remodeled and continues to be deposited•Scar tissue is avascular and becomes a flat thin line that does not sweat, grow hair, or tan