HNN122 - ILO\'s PDF

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HNN122 Unit notes
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ISBAR handover

Week 1 • define the terms discharge planning and peri-procedure management Discharge planning: the process of anticipating and planning what a patient needs after discharge for a smooth move from one level of care to another, is a crucial part of comprehensive health care and should be addresses in each care plan. - planning commences on admission Peri-procedure management: occurring soon before, during or soon after the performance of a medical procedure - includes all the preparation from physical, social, emotional or educational. - done prior to a procedure either in hospital or before admitted

Identify patient : name, age, gender Situation: symptoms, diagnosis, patient stability and level of concern Background: history, date of admission Assessment: what’s your impression, what had been done so far Response: what needs to be done, any plans and reviews

• discuss the role of the nurse in patient management related to peri-procedure management and discharge planning Role of the nurse Peri-procedure - assessment of pt to identify risk factors and determine the client’s sustainability for surgery - check and confirm patients operative consent - checking fasting status - shower, shave, remove makeup (skin preparation) - removal or jewellery or hearing aids - check identification: name tags - TED stockings - preoperative medications - pain relief education - provide psychological support - educate patient (preoperative education) - pain relief, bed exercises - ensure pt safety and provide pain relief - assessment of patient (vital signs) - identify potential and actual health problems - planning specific care based on the individuals needs - nursing activities include assessing patents sustainability for surgery, identify potential risk factors, educate pt on avoiding complications of surgery and anaesthesia, plan to meet pt’s needs for safe and sustained recovery Discharge planning - be aware of the patients needs - contact any family - ensure they an adequate environment on discharge - follow up any physic - clear discharge with all staff - considering patient safety as a priority! - assessing patient discharge readings - patient education! - ensuring planned support services are appropriate! 3 phases of peri-operative - preoperative phase: decision to have surgery is made. Including preparation, physical, social, emotional, education - intraoperative phase: administering an aesthetic, making surgical incision, performing the procedure and closing of the wound. Care taken in the operating room - postoperative phase: handover of pt details by operating room staff to PACU staff. Retiring of patient to ward or day procedure unit.

Consent - patient has been fully informed about the proposed procedure, as well as the risks of the procedure and the alternatives - patient has consented freely and voluntarily - patient has legal capacity to consent • identify potential and actual problems related to peri-procedure management and discharge planning - Knowledge deficit related to lack of education - anxiety - loss of control/independence - loss of function - pain - risk of embolism: related to immobility - risk of pressure area: related to immobility - risk of chest infection: due to smoking history - falls risk due to decreased mobility Surgery complications! - Respiratory: Atelectasis, pulmonary embolism, phenomena! - Circulatory: Hypovolemia, haemorrhage, hypovolemic shock, Thrombophlebitis , DVT - Urinary: urine retention, UTI - GIT: nausea and vomiting, diarrhoea, constipation, retention of gases, Paralytic ileum - Wound: infection, dehiscence, Evisceration - Psychological: anxiety, depression, disturbed body image, family, financial Examples: - Pneumonia: Inflammation of the alveoli - Atelectasis: A collapsed alveoli which is not ventilated - Pulmonary embolism: blood clot that has moved from the lungs and blocks a pulmonary artery, obstructing blood flow to a portion of the lung - Hypovolemia: inadequate circulating blood volume - Hemorrhage: Internal or external bleeding - Hypovolemic shock: inadequate tissue perfusion resulting from markedly reduced circulating blood volume - Thrombophlebitis: inflammation of the vein, usually of the legs and associated with a blood clot - Thrombus: blood clot attached to the wall of vein or artery - Embolus: foreign body or clot that has moved from it's site of formation to another area of the body - Urinary retention: inability to empty the bladder - UTI: inflammation of the bladder, uterus or urethra - Nausea and vomiting - Constipation: Infrequent or no stool passage - Tympanites: retention of gases within the intestines - Postoperative ileus: intestinal obstruction - Wound infection: inflammation and infection of incision or drain site - Would dehiscence: separation of a suture line before the incision heals - Wound evisceration: extrusion of internal organs and tissues through incision - Postoperative depression • implement nursing interventions for potential and actual problems related to peri-procedure management and discharge planning - Preoperative education - Physical preparation - Nutrition and fluids - Elimination - Hygiene

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Medications Rest and sleep Valuables Prostheses Special orders Skin preparation Safety protocols Vital signs Antiemboli stockings Sequential compression devices

• evaluate care related to peri-procedure management and discharge planning - check on patient - have their needs been met - has the wound healed - have any problems been addressed - does the patient have enough information for discharge - ensure patient is comfortable and not in any pain, and administer pain medication - educate patient on home care procedures if necessary - They verbalized key information presented - ensure vitals are normal - they demonstrated an ability to perform , leg exercises, deep breathing and coughing exercises • describe, perform and document patient assessment in a peri-procedural context **** patient document

Week 2 • define the terms medication, drug, pharmacology, pharmacokinetics and pharmacodynamics! Medication: is a substance administered for the diagnosis, cure, treatment or relief of a symptom or for prevention of disease. Drug: a chemical compound taken for disease prevention, diagnosis, cure or relief or to affect the structure or function of the body. Pharmacology: is the study of the effect of drugs on living organisms Pharmacodynamics: is the process by which a drug changes the body e.g. alters cell physiology. Pharmacokinetics: is the study of the absorption, distribution, biotransformation and excretion of drugs • describe the pharmacokinetics and pharmacodynamics of medications Pharmacodynamics: the effect the body has with the drug (the way the drug moves throughout the body) - The drug reacts with specific molecules and chemicals found in the body - Receptors located on or within the cell membrane chemically bind with the drug where the pharmacologic effects are either agonism or antagonism. - A drug that produces the same type of response as the physiological substance is called an agonist - A drug that inhibits cell function by occupying receptor sites is called an antagonist. Pharmacokinetics (what the drug does to the body (effect of drug on body) - Absorption: is the process by which a drug passes into the bloodstream - Distribution: is the transportation of a drug from the site of absorption to site of action - Biotransformation: is a process by which a drug is converted to a less active form - Excretion: is the process by which metabolites and drugs are eliminated from the body. Routes of admission Oral medication

- Pass through the GIT - into the blood stream- out of the blood stream - into the cell - Absorption of the drug is influences by; solubility, poor blood prow, GIT mobility - oral drugs are more slowly absorbed - higher dose of drugs means more side effects Inhalation - straight to lungs Intravenous - direct into blood circulation Intramuscular - to vascular skeletal muscle, absorbed into capillaries • describe principles of safe medication management Safety considerations - Assess the person's health status and obtain medication history - Determine is route of administration is appropriate - Take note of patients allergies Ten rights of medication administration 1. Right medications 2. Right dose 3. Right time 4. Right route 5. Right person 6. Right education 7. Right documentation 8. Right to refuse 9. Right assessment 10. Right evaluation Medication calculations Metric units - 1g = 1000mg - 1mg = 1000micrograms - 1L = 1000ml Tablets - No. of tablets required = strength required (dose prescribed)/stock strength (dose available) - **Units must be in the same unit of measurement in order to do this** - Convert mg to micrograms (1mg = 1000 micrograms) Liquids - Volume required = strength required/stock strength x volume Drug x weight (kg) - Dose required due to weight = strength required x weight Simple solutions - IV Rate = volume/time (in hrs) Infusions - Concentration = stock required (mg) / volume of solution(mls) - Rate = dosage (mg/hr) / concentration of stock!(mg/ml)

• discuss the role of the nurse in medication management

Post medication admission - Medications aren't left at the bedside unattended - Record the drug administered and time - Evaluate the patients response to the drug Responsibilities when collecting patent from PACU - Ensuring patient information is clarified during handover - Close monitoring after surgery observations every 15-30 minutes - Medication chart - Fluid chart - Presence and location of any drains - Medication administered in the recovery room - Estimated blood loss - Anaesthetic used • identify potential and actual problems related to medication management - allergies - ability to swallow medication - factors effecting absorption o medication such as vommiting or diarrhoea • implement nursing interventions for potential and actual problems related to medication management Routine Post Anaesthetic Observations (RPAO’s) - checking vital signs every 30mins for 4 hours - Neurovascular obs; colour, warmth, movement, sensation, pain - Pain assessment 0-10, PQRST or COLDSPA - Skin integrity - Check surgical site is dry and intact, ice - Drain check same time as obs - FBC, IVT Interventions - Compression stockings/TEDS - Encourage coughing/deep breathing - Monitor intake (IV fluid) and output (drainage) for fluid imbalance - Repositioning - Pressure areas assists if can't move e.g. heel pads - Call bell within reach - Orientate to environment • evaluate care related to medication management - Conduct appropriate follow up - Observe for desired effect - Note any adverse effects or side effects

- Relate to previous findings - report significant deviations to doctor • prepare, perform and document medication administration **** patient document • perform a nursing handover of a patient’s medication management using the ISBAR tool Post Anesthetic Care Unit PACU handover - respiratory status - cardiovascular status - assess of wound - IV therapy - Pain management on return to ward - Post of treatment orders: oxygen therapy, wound/dressing management, monitoring of drains, mobility restrictions, medications, IV therapy, nutrition, tests/referrals - Satisfactory PACU discharge criteria

Week 3 • define the term pain Pain: is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage • describe the pathophysiology of pain Acute vs chronic pain Acute pain: when pain only lasts through the expected recovery period, either sudden or slow onset and regardless of the intensity Chronic pain: is prolonged, usually reoccurring or permitting over 6 months or longer and interferes with functioning. Physiology of pain - Nociception is the sensory nervous system's response to certain harmful or potentially harmful stimuli. - Four elements of Nociception: 1. Transduction : release of biochemical mediators to stimuli 2. Transmission : travelling of the pain impulse 3. Modulation : body's way of substantiating the level of pain 4. Perception : a person becomes cogitatively aware of pain • describe principles of pain management - Reduce pain - Reduce synthetic nervous response - rising in vital signs - Reduce anxiety - Regularly screen all patient for pain - Follow the WHO analgesic ladder - Combined analgesia is more effective than a single modality - Minimising opioids does not need to mean no analgesia • discuss the role of the nurse in patient management related to altered comfort: pain - Assess and manage pain - Evaluate pain management - Educate patients - Ensure quality and safety • identify potential and actual problems related to altered comfort: pain

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impaired mobility Malnutrition Infection Constipation Pressure injuries Nausea Fatigue Activity intolerance Impaired breathing Self-care deficit Disturbed sleep Hopelessness Social isolation Sexual dysfunction Ineffective coping Spiritual distress

• implement nursing interventions for potential and actual problems related to altered comfort: pain Pharmacological - Medications - Allied health Non-pharmacological interventions - Relaxation therapy - imagery - Cold (wounds) and heat packs (achy) - Distraction - Acupuncture - Massage • assess a patient experiencing pain using appropriate validated clinical tools and scales - Numerical pain rating scale - 1-3 mild pain - 4-6 moderate pain - 7-10 severe pain - COLDERR - Access the character of the pain - Pain onset - Duration of the pain - Location of the pain - Exacerbating factors - Relieving factors - Radiation Tools to help assess pain - The McGill pain questionnaire - Numerical rating scare (rating 1-10) - The Wong-Baker Faces Tool - The visual analog scale • evaluate care related to altered comfort: pain - Severity and relief - Impact of pain on activity, sleep ad negative emotions - Side effects of treatment - Helpfulness of information about pain treatment decisions - Patient ability to participate in pain treatment decisions - Impact of non-pharmacological strategies

• demonstrate therapeutic use of medicines for pain management Analgesia: acts on nervous system to relief pain. Does not cure pain. Types of analgesia include; - Opioids: given to patients experiences moderate to severed pain - Medication examples: - morphine - paracetamol - Side effects: - Nauseas and vomiting - Drowsiness - Constipation - Respiratory depression - Non-Steroidal Anti-inflammatories (NSAIDs) or nonopiods: mild to moderate post operative pain - Medication examples - diclofenac - ibuprofen - paracetamol - Side effects - Nauseas and vomiting - Dyspepsia - GI ulceration - Bleeding Intramuscular injection - morphine and ondansetron - 23 gauge needle (blue) - 18 gauge drawing up needle - 90 degree insertion angle Subcutaneous injections - heparin - 25 gauge needle (orange) - 18 gauge drawing up needle - 45 degree insertion angle

• describe adjunct therapies for pain management Adjunct analgesia: given for chronic pain and long term duration of care - An adjuvant analgesic is a medication that is not primarily designed to control pain but can be used for this purpose. Some examples of adjuvant drugs are medications like antidepressants and anticonvulsants. They may also be called coanalgesics. - Medication example:

- Tricyclic antidepressants • describe, perform and document pain assessment **** patient document • prepare, perform and document medication administration for pain management **** patient document

Week 4 • define the terms hypoxia, tachypnoea, bradypnoea, orthopnoea, apnoea Hypoxia: deficiency in the amount of oxygen reaching the tissues. Tachypnoea: abnormally rapid breathing. Bradypnoea: Abnormally slow breathing Orthopnoea: is shortness of breath (dyspnea) that occurs when lying flat Apnoea: temporary cessation of breathing, especially during sleep. • describe the pathophysiology of altered breathing and oxygenation - primary function is for gas exchange - Respiration involves 3 processes; 1. Pulmonary ventilation or breathing: the movement of air between the atmosphere and the alveoli of the lungs as we inhale and exhale 2. Gas exchange: involves diffusion of oxygen and carbon dioxide between the alveoli and pulmonary capillaries 3. Transport of oxygen from the lungs to the tissues and carbon dioxide from the tissues to the lungs • describe the principles of respiratory management - determine adequacy of gas exchange - oxygenation of tissues - excretion of carbon dioxide - administration of supplemental oxygen; - treatment of pulmonary infection; - treatment of airways obstruction; - measures to limit pulmonary oedema; - mechanical respiratory support. • discuss the role of the nurse in patient management related to altered breathing and oxygenation - obtain health history - conduct a physical examination - maintain a patients airways - improve comfort and ease breathing - maintain or improve pulonart ventilation and oxygenation - improve ability to participate in physical activity - prevent risks associated with oxygenation problems - patient education • identify potential and actual problems related to altered breathing and oxygenation - Ineffective airway clearance - Ineffective breathing pattern - Impaired gas exchange - Activity intolerance • create nursing interventions for potential and actual problems related to altered breathing and oxygenation - Oxygen therapy and equipment - Raising bed head to promote effective breathing

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Deep breathing and coughing techniques Oral suctioning Assess need for bronchodilators skin and tissue breakdown

• evaluate care related to altered breathing and oxygenation - compete oxygen saturation to expected or norma levels - assessing appearance of breathing sounds, respiratory rate, rhythm and depth, pulse rate and rhythm, and skin colour - volume of secretion - complaints of pain or discomfort • describe, perform and document assessment of a patient’s breathing and oxygenation **** patient document • prepare, perform and document methods to assist with breathing and oxygenation including nebuliser and oxygen administration **** patient document

Week 5 • define the terms wound, standard precautions, aseptic technique Wound: an injury to any of the tissues of the body caused my physical means and interruptions of continuity. Standard precautions: are a set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin (including rashes), and mucous membranes. Aseptic technique: means using practices and procedures to prevent contamination from pathogens. It involves applying the strictest rules to minimize the risk of infection • describe the pathophysiological response to injury Phases of would healing 1. Homeostasis phase - Is the process of the wound being closes by clotting 2. Inflammatory phase - Inflammation is the first phase of wound healing - controls bleeding and prevents infection - Blood vessels are vasoconstrictor briefly and then vasodilator - After 24 hours, micro-phases arrive with the blood supple and stimulate the formation of epithelial bloods - Occurs before immune response - Eliminates extend of tissue damage - 5 sings of inflammation: Redness, swelling, heat, pain, loss of function 3. Proliferative phase - wound is rebuilt with new tissue made up of collagen and extracellular matrix. - Day 3 or 4 - Granulation occurs - Collagen produced and 'scaffold' the wound bed 4. Maturation phase - is when collagen is remodelled from type III to type I and the wound fully closes.! - Collagen compresses over the vessel - Scar formation - after 3 weeks ongoing for 6 months or longer Complications of wound healing 1. Haemorrhage - abnormal large amount of blood loss/bleeding from wound 2. Infection

- contamination of the wound surface with micro-organisms 3. Dehiscence with possible evisceration - total rupture of the a sutured would • discuss factors that may influence wound healing - Factors effecting healing include lifestyle factors, patient co-morbities and decreased mobility - D...