Computerized Charting,Emergency Assessment,Nursing Diagnosis andNursing Process

PN 103

Computers Mainframe computers -data processing tasks -billing Physician orders Pharmacy Laboratory Diagnostic imaging orders Central supply requests Care planning Documentation

Computers Bedside or handheld terminals for data

entry.

Computers A password used to enter and sign off Computer files should not be shared with

another caregiver. Never leave the computer terminal

unattended after being logged on. Follow the correct protocol for correcting

errors. Make sure that stored records have

backup files.

Computers Do not leave information about a patient

displayed on a monitor where others can see it.

Follow the agency’s confidentiality procedures for documenting sensitive materials.

Printouts of computerized records should be protected.

Obtaining Medical Emergency Aid

The nurse:

-ability to recognize the need for medical

assistance

-knowledge of how to obtain medical

emergency aid

-can mean the difference between life and

death to an injured or ill person.

-must be prepared to provide cardiopulmonary

resuscitation (CPR) if needed until emergency

medical assistance arrives

Moral and Legal Responsibilities of the Nurse

Good Samaritan Laws Protects health professionals from legal liability

when providing emergency first aid Follow a reasonable and prudent course of

action Victim must give verbal permission. -assumes that an unconscious person would give consent if he or she were able. Once first aid is initiated, the nurse has the moral and legal obligation to continue the aid until the victim can be cared for by someone with comparable or better training

Triage The medical screening of patients to

determine their relative priority for treatment

Need to treat the most urgent symptoms or patients first

Critical thinking skills

Shock An abnormal condition of inadequate blood flow to

the body’s peripheral tissues -life-threatening cellular dysfunction -hypotension -oliguria. -failure of the cardiovascular system to sufficient blood circulation to the body’s tissues -decreased metabolic waste removal. To maintain circulatory homeostasis -a functioning heart to circulate blood -sufficient volume of blood.

Shock Classification of Shock

Severe blood loss Intense pain Extensive trauma; burns Poisons Emotional stress or intense emotions Extremes of heat and cold Electrical shock Allergic reactions Sudden or severe illness

Shock Assessment

Level of consciousness Skin changes Blood pressure Pulse Respirations Urinary output Neuromuscular changes Gastrointestinal effects

Shock Nursing Interventions

Establish airway. Control bleeding. Reduce pain. Position the victim flat with the head slightly lower

than the rest of the body (elevate the feet and legs).

If victim is unconscious or is vomiting or bleeding around the nose or mouth, position on the side.

If victim is having breathing problems, elevate head and shoulders.

A, Modified TrendelenburgB, If head, neck, or spinal injuries are suspected.C, Breathing problems

Shock Cover victim with a blanket or other

covering to keep warm. Do not give anything to eat or drink. Relieve pain: support injury; avoid rough

handling; adjust tight or uncomfortable clothes.

Do not give analgesics unless directed by a physician.

Provide emotional support and reassurance.

Bleeding/Hemorrhage Effects of Blood Loss

Decrease in oxygen supply to the body. Blood pressure drops. Heart pumps faster -compensates for the decreased volume and blood pressure. Can result in shock and death.

Bleeding/Hemorrhage Types of Bleeding

Capillary most common damaged or broken capillaries oozing of minor cuts, scratches, and abrasions

Venous vein is severed or punctured slow, even flow of dark red blood embolism -if air enters the severed vein.

Arterial Least common usually protected by bones, fat, and other structures Heavy spurting of bright red blood in the rhythm of the

heartbeat

Bleeding/Hemorrhage Nursing Interventions

Direct pressure -apply direct pressure over the bleeding site. -raising the bleeding part of the body above the level of the heart -decreases the amount of blood flow -increase the body’s ability to clot at this site

Bleeding/Hemorrhage Indirect pressure

Indirect pressure may be applied to any of the pressure points situated along main arteries.

Application of a tourniquet -used only when the other methods have failed -the victim’s life is in danger. -can cause extensive damage to the body part.

Bleeding/Hemorrhage Internal Bleeding

A potentially life-threatening situation. -fractures -knife/bullet wounds -crushing injuries -organ injuries -ruptured aneurysms. Assessment

Signs and symptoms of shock Vertigo Hemoptysis or hematemesis Melena Hematuria

Bleeding/Hemorrhage A medical emergency. Place on a flat surface with legs elevated. Establish an airway. Cold compress or ice is placed on the area

of injury. Maintain body temperature with blankets. Assess vital signs. Oxygen may be ordered by the physician

Wounds and Trauma Closed Wounds

Underlying tissue of the body is involved Top layer of skin is not broken. Ecchymoses (bruises)/contusions Signs and symptoms

-edema -pain and tenderness -discoloration -signs of internal bleeding-deformity -shock

Wounds and Trauma Nursing interventions

Small wound: -ice packs and elastic bandage Large wound: -treat for shock -cold compresses and pressure bandage

Wounds and Trauma Nursing interventions

Small wound: ice packs and elastic bandage Large wound: treat for shock; cold

compresses and pressure bandage

Wounds and Trauma Open Wounds

Openings or breaks in the mucous membrane or skin

Always danger of bleeding or infection Types

Abrasions Puncture wounds Incisions Lacerations Avulsions Chest injuries

Wounds and Trauma Dressings and Bandages

Bleeding should be controlled before bandage is applied.

Use sterile material if possible; if not use, the cleanest material possible.

Dressing should never cover the entire wound. Wounds should be bandaged firmly but not too

tightly. Bandage in alignment is desired. Tips of fingers and toes should remain exposed

if possible.

Poisons Assessment of Poisonings

Signs and symptoms may be delayed for hours. -respiratory distress -pain on swallowing -nausea/vomiting -unusual urine color -diarrhea -cardiac arrest. -seizures -abnormal eye movement -restlessness -delirium -agitation -color changes -signs of burns -skin irritation-shock

-decreased level of consciousness

-abnormal constriction or dilation of pupils

Poisons Ingested Poisons

Most common type of poisoning -especially in children. -household cleaning products -garden and garage supplies -drugs/medications -food -plants

Poisons Nursing interventions

Maintain airway. Call the poison control center.

Dilute the poison by giving one or two glasses of water.

Induce vomiting if gag reflex is present and poison is not a corrosive.

Treat for shock and administer CPR if needed

Poisons Inhaled Poisons

-carbon monoxide -carbon dioxide, -refrigeration gases -poisonous fumes from chlorine and other liquid chemical sprays Nursing interventions Remove victim from the dangerous area Maintain airway; perform CPR if needed. Victim should remain quiet and inactive while

being transported to the nearest medical facility

Poisons Absorbed Poisons

Poisons, caustic chemicals, and poisonous plants -come in contact with the skin -burning -allergic responses -skin irritation -severe system reactions

Signs and symptoms -nausea/vomiting/diarrhea -CNS reactions -flushed skin -dilated pupils-cardiovascular abnormalities

Poisons Nursing interventions

Quickly remove the source of the irritation; -wash with soap and water. -baking soda -Burow’s solution -oatmeal. -calamine lotion/hydrocortisone cream -effective to relieve pruritus

Poisons Injected Poisons

Minor reactions to insect bites Remove stinger Wash with soap and water. Apply cold packs; baking soda paste.

Poisons Severe reactions to insect bites

Urticaria Wheezing edema of the lips and tongue generalized pruritus respiratory arrest Nursing interventions

Apply a wide constricting band proximal to the wound

keep affected part in dependent position; transport to the hospital immediately

Drug and Alcohol Emergencies Alcohol

Mild intoxication signs and symptoms -Nausea/vomiting/diarrhea -lack of coordination -poor muscle control -flushing -visual disturbances -rapid mood swings -erythema of the face and eyes -lethargy -slurred or inappropriate speech -inappropriate behavior

Drug and Alcohol EmergenciesSerious intoxication signs and symptoms Drowsiness to coma rapid weak pulse Depressed labored breathing or respiratory arrest loss of control of urinary and bowel

functions, Disorientation Restlessness hallucinations

Drug and Alcohol Emergencies Drugs

Signs and symptoms Loss of reality orientation Hallucinations varying degrees of consciousness slurred speech extremes in mood swings inappropriate behavior Anxiety flushed skin Diaphoresis lack of coordination impaired judgment increased or decreased pulse pupils constricted or dilated needle marks on the arms, legs, and neck

Drug and Alcohol Emergencies Nursing Interventions

Obtain information about the substance ingested. Life-threatening situations are handled first. Establish airway. If unconscious, turn on the side. Loosen clothing. If fever is present, apply cool, wet compresses. Protect the victim from injury during a seizure or

hallucination. Carefully assess mental status and vital signs

frequently.

Thermal and Cold Emergencies Heat Injury

Heat exhaustion -most common type -results from prolonged perspiration -loss of large quantities of salt and water. Observe for: -signs and symptoms of headache -vertigo -nausea -weakness -diaphoresis. -mental disorientation -brief loss of consciousness

Thermal and Cold Emergencies Nursing interventions

Cool the victim as quickly as possible -use cold, wet compresses and fan or air conditioner. Have victim lie down with feet elevated. If alert, give one-half glass of water every 15

minutes for 1 hour. In the clinical setting, IV fluids are given.

Thermal and Cold Emergencies Heatstroke

more serious heat injury -death can result. vigorous physical activity in a hot, humid

environment. body becomes overheated -the cooling mechanism of perspiration does not operate.

Thermal and Cold Emergencies Assessment: -rapidly rising body temperature -hot, dry, erythemic skin -no visible perspiration -pulse rapid initially and then slow -blood pressure falls -breathing deep and rapid -victim complains of headache, dry mouth, nausea, and vomiting

Thermal and Cold Emergencies Nursing interventions

Cool the victim as quickly as possible -use cold packs around the victim’s neck, under the arms, and around the ankles -cools the blood in the main arteries. Establish and maintain an airway. Monitor for chilling as the body temperature

falls

Thermal and Cold Emergencies Exposure to Excessive Cold

Hypothermia Lowering of the body temperature 95° F or below Assessment

Uncontrollable shivering but ceases when body temperature drops below 90° F

Slurred speech memory lapses disorientation and poor judgment uncoordinated gait skin mottled and edematous weak irregular pulse decreased respiratory rate loss of all reflexes

Thermal and Cold Emergencies Nursing interventions

Initiate CPR if necessary -must continue until the body is rewarmed. Place victim in a supine position with the head

lower than the feet. Rewarm slowly -move to a warm area -remove wet clothing -wrap with warm blankets.

Thermal and Cold Emergencies Frostbite

Freezing and damage of body cells -ears, nose, fingers, and toes. Assessment: -initially, skin takes on a red flush with numbness, -tingling, and pain; -progressively, the part becomes hard and loses all sensation -color turns to grayish white -if thawing occurs, may change to blue-purple or black; -edema may develop, followed by blisters.

Thermal and Cold Emergencies Nursing interventions

Treat for shock and hypothermia establish and maintain an airway. Warm part by immersion in warm water at 104

to 110° F for 20 to 45 minutes. If tub is not available, may use a hot moist

towel. Be very careful not to rub the part. The thawed part is wrapped in clean towels or

bulky dressings and elevated.

Bone, Joint, and Muscle Injuries Fractures

A break in the continuity of a bone Types of common fractures

Open or compound Closed Comminuted Greenstick Spiral Impacted Compressed Depression

Bone, Joint, and Muscle Injuries Assessment

-pain and tenderness and especially with movement. -deformity of the limb may be obvious -edema and discoloration of the area. -fragments of bone may be protruding through the skin. -crepitus -grating sound is heard when the affected part is moved. X-ray can determine if a bone is fractured.

Bone, Joint, and Muscle Injuries Nursing interventions

Do not move unless he or she is in danger. ABCs Control bleeding Immobilize the fracture -do not attempt to realign the bone. Monitor circulation in the limb. Apply ice or cold packs to the area

Bone, Joint, and Muscle Injuries Dislocations

Occurs in joints -results from a blow or fall Assessment: -complaints of pain and edema -deformity of the part -part may be rigid -victim is unable to move it. Nursing interventions: -never attempt to reduce a dislocation -splint the joint -apply ice or cold packs

Bone, Joint, and Muscle Injuries Strains and Sprains

Strains -injuries to muscle tissue from stretching/tearing -due to overexertion. Sprains -injuries to joints resulting from stretched/torn ligaments -due to twisting of the joint beyond the normal range of motion.

Bone, Joint, and Muscle Injuries Assessment

Strains: -spasms of the muscle -acute pain -stiffness -weakness on movement -back pain radiating down the leg; -discoloration Sprains: -pain or tenderness around a joint discoloration -immobility of the joint -rapid and marked edema

Bone, Joint, and Muscle Injuries Nursing Interventions

RICE Rest the affected extremity Ice should be applied to the part Compression with a compression bandage Elevation above the level of the heart

Bone, Joint, and Muscle Injuries Spinal Cord Injuries

Assessment Assess for paralysis. Test for sensation. Assess for abrasions and ecchymosis on the

back. Nursing interventions

Take spinal cord precautions. Maintain airway; keep head in a neutral

position.

Burn Injuries SuperficialBurns

-outer layer of the skin -sunburns -burns from contact with hot objects Nursing interventions

Cooled immediately -soaking in cold water or applying cold compresses. -sterile dressing should be placed over the burn to prevent infection.

Burn Injuries Partial-Thickness Burns

Entire first layer of skin (epidermis) as well as some of the underlying tissue (dermis).

-severe sunburn -scalding liquids -direct flame -chemical substances. Assessment

Deep erythema of the skin Mottled skin with blister formation. Weeping of fluid through the skin surface Intense pain.

Burn Injuries Full-Thickness Burns

Destruction of the skin and underlying tissue -fat, muscle, and bone. -thick and leathery -black or dark brown, cherry red, or dry and milky white colors. The victim may not complain of pain -nerve endings may be severed. Wounds weep a great deal of fluid and blood. Causes: -direct flame -explosions -gasoline or oil fires

Burn Injuries Nursing interventions

Establish airway. Assess respiratory and cardiac function. Remove all of victim’s clothing, shoes, and

jewelry. Administer CPR if necessary. Treat for shock. Cool the burn with cool compresses for partial-

thickness burns. Avoid touching the burn with anything but

sterile dressings.

The Nursing Process Nursing defined “Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (ANA, 2003)

The Nursing Process Nursing process

Organizational framework for the practice of nursing

Problem solving Six phases ANA Nursing Scope and Standards of

Practice

The Nursing Process

Assessment The nurse collects information and

analyzes data about the patient Review/physical examination -ALL body systems -Cognitive -Psychosocial -Emotional -Cultural -Spiritual components

Assessment Focused assessment -patient is critically ill -disoriented -unable to respond

Assessment Subjective

Verbal statements provided by the patient Objective

Observable and measurable signs Can be recorded

Assessment Primary Source

Patient Most accurate

Secondary Sources When the patient is unable to supply

information, secondary sources are used -Family members -Significant other -Medical records -Diagnostic procedures -Nursing literature

Assessment Interview

Biographical data Reason patient is seeking health care History of present illness Past health history Environmental history Psychosocial history

Physical Exam Head-to-toe format

Assessment Related cues are grouped together. -focused on health concerns (or problems) that need support and assistance. -identification of nursing diagnoses

“c/o thirst, dry skin, dry oral mucous membranes, increased body temperature and decreased urine output.”Deficient fluid volume related to dehydration as evidenced by thirst, dry skin, and decreased urine output.

Diagnosing Identify the type and cause of a health

condition. “A clinical judgment about the patient’s

response to actual or potential health conditions or needs. Diagnoses provide the basis for determination of a plan of care to achieve expected outcome”

Diagnosing Problem

Any health care condition that requires: -diagnostic -therapeutic -educational actions Deviations from the population norms Change in the patient’s usual health status Deviations from normal patterns of growth Any dysfunctional behavior

Diagnosing Nursing Diagnosis

North American Nursing Diagnosis Association International (NANDA-I)

A clinical judgment about an individual, family, or community response

-actual or potential health problems or life processes Basis for selection of nursing interventions -achieve outcomes for which the nurse is accountable -legally identify/prescribe the primary interventions -treat or prevent problems

Diagnosing Components of a Nursing Diagnosis

Nursing Diagnosis Title/Label Concise name for the identified health

problem Adjectives add meaning to the nursing

diagnosis -imbalanced, impaired, etc.

Diagnosing Definition

Presents a clear, precise description of the problem

Helps to identify the difference between similar diagnoses

Diagnosing Contributing/Etiologic/Related Factors and

Risk Factors Involved in the development of a problem -the focus for nursing interventions -“related to” in the actual nursing diagnosis -increase the susceptibility of a patient to a problem

Diagnosing Defining Characteristics

Cues that tell how the diagnosis is manifested

-or “as evidenced by” Clinical cues, signs, and symptoms that

furnish evidence that a problem exists Written as “as evidenced by” in the nursing

diagnosis statement

Diagnosing Actual Nursing Diagnosis

-a condition that is currently present -cues from nursing assessment indicate problem exists Usually represent by a three-part statement:

The nursing diagnosis label from NANDA-I “Problem” The contributing/etiologic/related factor “Cause” The specific cues, signs, and symptoms from the

patient’s assessment “Signs/Symptoms”

Diagnosing Connecting phrases are used to join the

three parts of the statement “Related to” links the first and second parts. “As evidenced by” joins the second and

third parts.

Diagnosing Risk Nursing Diagnosis

-an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation -risk factors are present that are known to

contribute to the development of the problem Written in a TWO-part statement:

The nursing diagnosis label from NANDA-I The risk factor

“Related to” connects the two statements

Diagnosing Used when a problem is considered

FEASIBLE Additional data must be gathered to

confirm or rule out the problem Written in a TWO-part statement:

The nursing diagnosis label from NANDA-I The contributing/etiologic/risk factor

“Related to” connects the two statements

Diagnosing Syndrome Nursing Diagnosis

Cluster of actual or risk nursing diagnoses are predicted to be present in certain circumstances

Current syndrome diagnoses: -post-trauma syndrome -rape-trauma syndrome -risk for disuse syndrome -impaired environmental interpretation syndrome -relocation stress syndrome These are one-part statements

Diagnosing Wellness Nursing Diagnosis

-in transition from a specific level of wellness to a higher level of wellness Written in a one-part statement -“readiness for enhanced” are used in a wellness nursing diagnosis

Other Types of Health Problems Collaborative Problems

-physiologic complications that nurses monitor to detect onset or changes in status Nurses manage problems using physician-

prescribed and nurse-prescribed interventions to minimize the complications of the event

-Potential complication: hypoglycemia

Other Types of Health Problems Medical Diagnosis

The identification of a disease or condition through a scientific evaluation of physical signs, symptoms, history, laboratory tests, and procedures

-Physicians are licensed to make medical diagnoses. Example: Congestive heart failure

Planning Priorities of care Writes desired patient outcomes Selects and converts nursing interventions

into nursing orders Communicates the plan of care. What can be done to lessen or solve an

actual problem Prevent a risk problem from becoming an

actual problem. Interventions will be effective.

Planning Priority Setting

Ranked in order of importance for the patient’s life and health.

1. Life-threatening and health-threatening 2. Physiologic needs 3. Safety and security -actual problems may be ranked before risk problems. -as some problems are resolved, new ones can be addressed.

Planning Establishing Desired Patient Outcomes

Predicts the condition of the patient following nursing interventions.

-statement that indicates the degree of wellness desired, expected, or possible for the patient to achieve.

Planning Outcome: -specific -measurable behavior -exhibit in a given time frame following the intervention. Goal: -A statement about the purpose to which an effort is directed.

Planning Establishing Desired Patient Outcomes

-They guide the selection of nursing interventions. -Establishes the measuring standard that is used to evaluate the effectiveness of the nursing interventions

Planning A Well-Written Patient-Centered

Goal/Desired Outcome Statement: “patient” as the subject of the

statement a measurable verb specific realistic time frame -for patient reevaluation

Nursing Interventions Activities that should promote the

achievement of the desired patient outcome

-resolve a nursing diagnosis -monitor for the development of a risk problem -carry out a physician order

Nursing Interventions Physician-prescribed interventions

-ordered by a physician for a nurse or other health care provider to perform -medications -wound care -diagnostic tests Nursing judgment still used Assessing, teaching, and validating the

safety of physician orders expected of nursing practice

Selecting Nursing Interventions

Nurse-prescribed interventions Actions the nurse can legally order or begin

independently -providing a back massage -turning patient every 2 hours -monitoring for complications The nurse should consider: -contributing/etiologic/related factors -risk factors -patient-centered goal/desired outcome -nursing diagnosis label

Writing Nursing Orders

It is often necessary to convert these into more specific, instructional statements

Writing Nursing Orders Nursing orders should include

Date Signature of the nurse responsible for the

plan of care Subject (who will carry out the activity) Action verb Qualifying details

Communicating the Nursing Care Plan

Written nursing care plan is the product of the nursing process.

-written guidelines promotes the continuity of patient care. -formats vary among institutions. -may be prepared for each patient -standardized for a group of patients -computerized

Implementation The established plan is put into action to

promote achievement of the outcome. -ongoing activities of data collection -prioritization -performance of nursing interventions -documentation. -nurse- and physician-prescribed therapy -documentation is a vital component -“If it was not charted, it was not done”

Evaluation Have the established outcomes have been

achieved? Review the goals/desired patient outcomes

that were established in the planning phase. Reassess the patient’s actual response to

the nursing intervention. Compare the actual outcome with the

desired outcome Where the patient-centered goals/desired

patient outcome achieved?

Evaluation One of three decisions:

The outcome was achieved. The outcome was not achieved. The outcome was partially achieved.

Modifications: -if the outcome has been achieved -partially achieved -not achieved.

NANDA, NIC, NOC The NANDA-I Has Formed a Relationship With

Two Other Groups. Nursing Intervention Classification (NIC) -standardize the language used to organize and describe interventions Nursing Sensitive Outcome Classification (NOC) -standardized system to name and measure the results of patient outcomesNANDA-I, NIC, and NOC -standardizing the language of nursing.

Role of the Licensed Practical Nurse

Varies from state to state

-review the state’s nurse practice act. Provide direct bedside nursing care. The LPN’s direct care position allows the

LPN to closely observe, prioritize, intervene, and evaluate the care provided to and for the patient

Role of the Licensed Practical Nurse Assessment

Observe and report significant cues to the charge nurse or physician.

Diagnosis Assist with the determination of accurate

nursing diagnoses. Gather data to confirm or eliminate

problems.

Role of the Licensed Practical Nurse

Planning Assist with setting priorities. Suggest interventions. Assist with the development of realistic

patient-centered desired patient outcomes. Implementation

Assist with the establishment of priorities. Carry out physician and nursing orders. Evaluate the effectiveness of nursing

activities

Role of the Licensed Practical Nurse

Evaluation Assist with reevaluation of the patient’s

health state after nursing interventions. Suggest alternative nursing interventions

when necessary