Basics II

Intra-personal Communication

within the individual- thoughts influence perceptions, behaviors, self-concept

Inter-personal Communication

between two persons, allows problem solving, decision making and personal growth

Public Communication

interaction with large group, speaking at a lecture

Referent

stimulus motivates person to communicate with another

Sender (Encoder)

person who initiates interpersonal communication

Receiver (Decoder)

person who recieves the message and interprets the message

Channel

Means of conveying and recieving messages through any of the senses

Feedback or response

the message returned by the receiver, indicates if the meaning or the message was understood

Interpersonal variables

factors within both the senderand receiver that influence communication

Environment

setting for sender-receiver interaction

Most important Mode of Communication

Listening

Cultural Influence on Communication

Sociocultural background influence the way we communicate

Intimate Space

18 Inch area
Used when giving care

Personal Distance

18 inches to 4 feet
Sitting for an interview
Teaching a client

Social Distance

4 feet to 12 feet
Making rounds, support group

Public Distance

more than 4 feet
public speaking

Therapeutic Communication is:

Patient centered
Goal oriented

Empathy

Ability to understand and accept another person's reality

Sympathy

expression of one's own feelings about another's predicament

Autonomy

An ability to be self-directed

Mutuality

Involves sharing with another

Effects of NG Tube

Allows removal of gastric secretions
Introduction of solutions into stomach

Measure for NG Tube

Distance from tip of nose to earlobe to xiphoid process

Purposes of NG Tube

Decompression
Feeding
Compression
Lavage

Decompression

Removal of secretions and substances from GI tract

Common types of Decompression NG Tube

Salem Sump
Levin
Miller-Abbot (most-common)

Feeding (gavage)

Liquid nutritional supplements or feedings into the stomach

Types of Feeding

Duo
Dobhoff
Levin

Length of Use for Feeding Tube

Less than 1 month

Compression

Prevent internal esophageal or GI hemorrhage

Lavage

Irrigation of stomach in cases of active bleeding, poisoning or gastric dilation

Solution for Irrigating NG Tube

Normal Saline
20-30cc

PEG Tube

Percutaneous Endoscopic Gastrostomy
Surgically insertion into stomach or jejunum

Pupose of PEG Tube

allow for liquid feedings on long term basis
Bettter tolerated than NG tube

How do you confirm placement of a PEG tube?

by x-ray

Complications of PEG

Dislodgement
Infection
Distention

Care of client with PEG tube

Assess for abdominal complications
Signs of infection at insertion site

How do you asses for patency of a PEG tube?

Flushing with 30cc of water

If residual is greater than __cc, then ____

100cc, do not re-infuse and notify MD

Stop continuos feeding machine how long before?

30 minutes prior to procedure

Indications for IV's

Give meds too irritating for other route
Avoid discomfort of frequent injections
Maitain constant blood level of a med
Provide fluid and electrolyte replacement

Type of Insulin given IV

Regular Insulin

Hydrating Solutions

D/W, D/S, Norm Saline, LR

Blood Transfusions

Plasma, RBC's, Whole Blood
Platelets, Albumin

Total Parenteral Nutrition

Solution that provide calories and nutrients

Important Facts about TPN

Never stop abruptly (cause hypoglycemia)
Ordered per 24 hrs
Never used w/ peripheral IV's

Types of Infusions

Peripheral
Central
Continuous
Intermittent (Hep-lock)

How long are IV tubes good for?

72 hours

KVO

Keep vein open
TKO

Infiltration

IV fluids enter the SQ space around IV site

S/S of Infiltration

Swelling
Pallor (decreased circ at site)
IV flow rate decreases or stops
Coolness and discomfort

Treatment of Infiltration

D/C IV infusion
Re-insert IV into another site
Elevate extremity
Wrap extremity in warm towel for 20 mins

Phlebitis

Inflammation of the vien

Risk Factors associated with Phlebitis

Type of catheter material
Chem irritation from additives
Anatomical position of catheter

Major Risk associated with Phlebitis

Developing thrombophlebitis which can become an emboli

Prevention of Phlebitis

Removal and rotation of IV sites every 48-72 hours

S/S of phlebitis

Pain, Edema, Erythemia
Increased skin temperature
Redness traveling along path of vein

Treatment of Phlebitis

D/C IV line
Re-insert IV
Apply warm, moist heat

Delgation Authority for IVs

Maybe w/in SOP for LPN
Cannot be delegated to UAP

JACHO

Joint Comm. on Accred. of Health Care
agency that accredits hospitals

Client's Record

Provides a timeline
Establish a baseline
Legal document of client's health status

Documentation and Reporting must be...

Factual, Accurate, Complete, Current, Organized, Confidential, and Legible

Types of Reports

Change of shift, Telephone Reports, Transfer reports, Incident reports

Transfer Reports

Must talk to RN, not the unit clerk

Incident Reports

Any event not consistent w/ routine operations
Don't record in nurses notes
Nurse who witnesses event completes report

Problem Oriented Medical Record

Arranged according to problems a client has

Legal Guidelines for Charting

Do not chart opinions
Record only facts
Record legibly and in ink

How do you correct an error on a chart?

Single line through entry with initials

Address charting in which direction?

Head to toe
think logically & systematically

Incontinence

Involuntary loss of urine

Retention

unable to void although there is enough urine in bladder

Suppression

cannot void b/c bladder is empty

Diuresis

Increased urine formation

Polyuria

Excessive urine output

Oliguria

diminished capacity of urine
100-400cc per day

Anuria

less than 100cc per day

Gluycosuria

Glucose in urine
Must be above 180

Cystitis

inflamed or irritated bladder

Nocturia

frequency at night not result of increased intake

Dysuria

pain or burning on urination

Residual Urine

Retention in bladder after voiding
greater than 100ml
<100ml is normal

Enuresis

nighttime wetting after 5 yrs old
prevalent in boys

Primary Enuresis

Never been dry at night
Always wetting the bed

Secondary Enuresis

Aquired after being dry
Result of trauma

Hematuria

Blood in urine
Early sign of bladder infection

Capacity of bladder

600cc

Retention is ___cc to ___cc

1000-3000

Normal Volume of Urine

60-120 ml/hr

Polyuria more than ___ ml/day

2000 ml/day

Normal Color of Urine

Straw to Amber

Causes for Discoloration of Urine

Dark amber- dehydration
Red or pink- hematuria
Meds can discolor urine

Cloudy Urine

Pus from Infection

Foamy Urine

May contain protiens
Abnormal finding

Sweet Odor of Urine

Diabetes
Glucose in urine

Offensive Odor of Urine

Pyuria
Caused by bacteria

Specific Gravity Testing

Tells concentration of urine
Normal is 1.010-1.025

Protein in Urine

Not normally found
May be found after strenous excercise
up to 10 mg/ml

Blood in Urine

Up to two RBC's
Seen in truama & menstruating women

Complications in Pts with long-term foleys

Have to re-train bladder

Peristalsis

Reduced motility
Part of the aging process

Constipation

Symptom not a disease

Fecal Impaction

Results from unresolved constipation
Continuous oozing of diarrhea stools

Black Stool

Blood in upper GI

Bright Red Stool

Blood in lower GI

How does exercise affect bowels?

Improves GI motility

Cholinergic drugs

Increase contraction of bladder and improve emptying

Anticholinergic Drugs

Reduce incontinence

Ways to eliminate constipation

Prune juice, fresh fruit
Hot meals x 3 days
Increase exercise

Enema

Instillation of a solution into rectum and sigmoid colon

Puposes of Enemas

Promote defecation by stimulating peristalsis, temp relieve constipation, remove impacted feces

Types of enemas

Cleansing
Oil Retention
Harris Flush
Medicated Enemas

Safest type of Cleansing enema

Normal Saline- same osmotic pressure

Purpose of Oil Retention Enemas

lubricate rectum and soften feces

If order reads "enemas till clear"

repeat enemas till fluid is clear
Maximum of 3
Check with MD before giving more

Teaching is an _____

Interactive Process

Learning is the

acquisition of knowledge

Learning Need

Gap b/w the info a client knows and the info necessary to perform a specific function

Who sets the guidelines for client education?

JACHO

When teaching infants it is important to

Asses the learning needs of the parents

When teaching toddlers

Include parent participation, simple explanations, pictures

When teaching preschool age

use dolls or puppets to demopnstrate
Role playing

When teaching school age

Use different forms of play

When teaching adolescents

Use the problem solving method

Ectomy

removal of an organ or gland

Rrhaphy

suturing or stiching

Ostomy

providing an opening

Plasty

palstic repair

Scopy

looking into

Urgent surgery

prompt attention within 24 hours

Ablative Surgery

Removal of diseased body part
amputation, tonsils

Palliative Surgery

does not cure, reduce or relieve symptoms
tumor debulking

Serum creatinine/BUN blood levels

indicate renal function

Incentive Spirometer use

reduces collapse of alveoli

Consecutive coughs that help remove mucous more effectively than one forceful cough

Controlling cough

Purpose of SCD's and AE hoses

Promote venous return and prevents circulatory stasis
Reduce risk of thrombi

3 Elements of Informed Consent

Given voluntarily
Given by individual w/ full mental capacities
Info provided to allow for informed consent

All consents must be signed when?

prior to administration of sedatives

If sedatives are given before consent is signed?

Must wait 4 hours for sedation to wear off

When the nurse witnesses a client's signature of consent it means what?

The nurse is stating that this is indeed the signature of the client, not that the client understands the procedure

If consent can't be obtained by the pt in an emergency

Consent can be given by next of kin

For children under 18 years old

Consent given by parents or legal guardians

When consent is given over the telephone...

Need two persons to hear consent

Reasons for giving pre-op medications

Reduce client anxiety
Reduce amount of gen anesthesia
Reduce risk of nausea/vomiting

Benzodiazepines

Pre-anesthetic agent that reduces anxiety and provides sedation (Versed, Valium, Ativan)

Barbiturates

Provide sedation
(Seconal, Nembutal)

H2 Blocking Agents

Promote gastric emptying
(Reglan, Pepsid)

Antacids

Decrease gastric acidity

Anti-nausea agents

Reduce probability of aspiration

Anticholinergics

Dry secretions and decrease risk of aspiration
(Atropine)

Opiods

Decrease intraoperative anesthesia requirements
(Demerol, Morphine)

Principles of OR safety ensured by Nurse

Preoperative verification process
Marking operative site
Time-out before starting procedure

3 Classifications of Anethesia

Concious
Regional
General

Types of Regional Anesthesia

Local Anesthesia
Nerve Block
Epidural
Spinal

What type of pts would beneifit from a Nerve Block?

Pts w/ COPD, lung issues, heart issues

Pts with which anesthesia can't have HOB elevated after surgery?

Spinal anesthesia

3 Stages of General Anesthesia

Induction
Maintenance
Emergence

Highest priority of assessment in PACU?

Respiratory function

Client needs a score of __ on the Aldrete score before being discharged from PACU

8 out of 10

Aldrete Score assess what?

Activity, Respiratory, Circulation, Consciousness, O2 sat

Treatment for pts who are shivering

Oxygen

Do not remove OPA until...

Pt's gag reflex returns

Atelectasis

collapsed lung

Treatment for hypopharyngeal obstruction

jaw thrust

PARSAP

Post Anesthesia Recovery Score for Ambulatory Patients

Early signs of malignant hyperthermia

tachycardia, tachypnea, jaw muscle rigidity

For pts post abdominal surgery, keep NPO until when?

Bowel sounds return

Reduced glomerular function is what?

a normal physiological change associated with aging process

Post operative Complications

Shock
Thrombophlebitis, Pulm. Emboli
Urinary Retention

Primary Shock

Occurs at time of operation

Intermediate Shock

First few hours

Secondary Shock

Some time after operation

Steps to reduce risk of Thrombophlebitis or embolus

Leg exercises, OOB, wlaking, Anti-embolitic stockings, SCDs

Dehiscense

partial or complete separation of wound layers

Evisceration

Complete separation, intestines protrude

Most important nursing intervention for pts who are vomiting

prevent aspiration