Nursing practice notes PDF

Preview

Summary

Download Nursing practice notes PDF

Description

Nursing practice notes Clinical reasoning Nursing process o

Evidence based

o

Goal directed and person centred (holistic)

o

Focused on problem solving and decision making

o

Interpersonal and collaborative

Nursing process

To…

Purpose…

How…

Assessing

Collect, organise, validate and document data

To establish a database of the patient’s responses to healthcare concerns or illness and their ability to manage health care needs

Distinguish relevant from irrelevant Be alert for assumptions   

Diagnosing

Analyse data; identify health problems, risks and strengths

To identify patient strengths and health problems that may be prevented or resolved

Identify problems, risks, strengths Identify individual’s priorities Consider resources – persons, family, MDT  

Planning

Prioritise problems; set goals; identify nursing interventions; develop a nursing care plan

To identify an individualised care plan that specifies patient goals/desired outcomes and related nursing interventions

Have I collected the data well? How reliable are my sources? What biases do I have that might make me miss important information?

Do I know the normal range of this data? What other problems may this data represent?

Consider factors impacting on the individual’s behaviour such as culture or

motivation Identify interventions known to be best practice and based on evidence Collaborate with MDT 



 



Implementing

Provide nursing care; reassess; promote

wellness and rehabilitation; document cares

To assist the patient to meet desired goals, promote wellness, prevent illness and facilitate coping with altered functioning

Work alongside the individual to establish goals, outcomes and timeframes Therapeutic relationships and collaboration Apply knowledge to perform interventions Reassess – consider the consequences of care 



Evaluating

Collect data and compare with desired outcomes; draw conclusions;

review nursing actions in achieving

2

To determine whether to continue, modify or conclude the nursing care plan

What do I want to achieve with this person? What is the most important problem to solve? What is the persons goal? What worked in similar situations in the past? What interventions will be effective? Are they current best practice?

Are there any safety issues I have overlooked? What is the best method of applying these interventions?

Reflect on the care Validate the outcome Determine if plan has been effective

goals, continue, modify or cease patient care plan





What data indicates the goals are being met? What are the responses to the interventions?

Why do we need to make decisions? o

An ability to make decisions based on evidence and knowledge separates the registered nurse from other nursing levels

o

Clinical judgement concerns the ability to make distinctions between different conditions and situations

o

Decision making is the ability to arrive at an appropriate course of action -

Check vital signs

-

Administer analgesia

-

Reposition and offer heat pack

-

Emergency response

-

Liaise with MO and arrange for an X-ray

-

Perform an ECG

Becoming a reflective practitioner The importance of becoming a reflective practitioner o

look back over the work you have done and consider how you can improve -

a university assessment

-

the first time you showered a person with dementia

-

facilitator feedback on areas for development in the final weeks of clinical placement

o

observe, listen and respond to feedback

o

seek to expand you knowledge

o

develop positive interpersonal relationships

Reflection o

3

usually begins with a description of what has happened. This ‘sets the scene’. It is important

at the stage to identify exactly what the key elements are – what makes this an incident worthy of reflection? This starting point relates to a low or superficial level of reflection Reflect on process and new learning contemplate: o

what else do you need to know?

o

Who can help you?

o

What have you learnt?

o

Would you do things differently next time?

Critical reflection o

What strategies should you adapt in the future?

o

How can you manage better next time?

Gibbs reflective cycle Description o what happened Feelings o what were you thinking and feeling? Evaluation o what was good and bad about the experience? Analysis

4

o what else can you make of the situation? Conclusion o what else could you have done? Action plan o if it rose again what would you do?

The chain of infection o

cycle of infection

Infectious agent/aetiological agent Any microorganisms that can cause disease such as bacteria, virus, parasite or fungus. Reasons that the organism will cause an infection are virulence (severity of the microorganism and its ability to multiply and grow), invasiveness (ability to enter tissue), and pathogenicity (ability to cause disease)

Reservoir The place where the microorganism resides, thrives and reproduces e.g. food, water, toilet seat, human faeces, respiratory secretions, plants. E.g. mosquito is a reservoir as it carries the malaria parasite but is unaffected by it.

Portal of exit The place where the organism leaves the reservoir, such as the respiratory tract (nose, mouth), intestinal tract (rectum), urinary tract, or blood and other bodily fluids

Mode of transmission How an organism transfers from one carrier to another by either; o

o

5

Direct transmission (direct contact between infectious hosts and susceptible host) - Touching, biting, kissing, sexual interaction - Droplet; sneezing, coughing, spitting, singing, talking Indirect transmission (which involves and intermediate carrier like and environment surface or piece of medical equipment) - Vehicle-borne transmission | objects, handkerchiefs, toys, clothes, cooking or eating utensils and surgical instruments or dressings - Vector-borne transmission | an animal or flying or crawling insects

-

Airborne transmission | droplet or dust by air currents into the respiratory tract

Portal of entry The opening where an infectious disease enters the hosts body such as mucus membranes (muscle that lines internal organs), open wounds (breaks in the skin), or tubes inserted in body cavities like urinary catheters or feeding tubes.

Susceptible host A person who is at risk for developing an infection from the disease. Factors making a person more susceptible include age (young people and elderly people are generally more at risk), underlying chronic diseases such as diabetes or asthma, conditions that weaken the immune system like HIV, certain types of medication, invasive devices like feeding tubes, and malnutrition. To break the chain...

Standard and additional (transmission-based) precautions Standard precautions

6

o

First-line approach to infection prevention and control

o

Work practices required to achieve a basic level of infection control for the treatment and care of all patients.

o

Decreases the risk of transmitting unidentified pathogens -

Patient to patient

-

Staff member to patient

-

Patient to staff member

Hand hygiene Most effective infection control measure. The 5 moments of hand hygiene; 1. Before touching the patient 2. Before a procedure 3. After a procedure or body fluid exposure risk 4. After touching patient 5. After touching patient’s surroundings Non-clinical situations for hand hygiene; Before o o o o After

Starting/leaving work Eating/handling of food/drink (whether own or patients) Using computer keyboard in a clinical area Hands becoming visibly soiled

o o o o o o o

Eating/handling food (whether own or patients) Visiting the toilet Using a computer keyboard in a clinical area Being in patient-care areas during outbreaks of infection Removing gloves Handling laundry/equipment/waste Blowing/wiping/touching nose and mouth

PPE Gloves o

7

Protect the hands when nurses are likely to handle any body substances; blood, urine, faeces, sputum, non-skin contact

o o

Reduces the likelihood of nurses transmitting their own endogenous micro-organisms to individuals receiving care Gloves reduce the possibility of nurse’s hands transmitting micro-organisms from an individual or a fomite to another person

Glove type Non-sterile gloves

Sterile gloves

Synthetic gloves, e.g. nitrile or polyvinyl chloride (PVC)

Required for  Potential exposure to blood, body substances, secretions or excretions.  Contact with non-intact skin or mucous membranes  Potential exposure to blood, body substances, secretions or excretions.  Contact with susceptible sites or clinical devices requiring that sterile conditions be maintained  Procedures involving a high risk of exposure to blood borne viruses or where high barrier protection is required

Clinical examples  Emptying urinary drainage bags  Nasogastric aspiration  Vaginal examinations  Management of minor cuts or abrasions  Surgical aseptic non-touch technique  Complex dressings  Dressing changed for central venous line  Insertion sites  Clinical care of acute surgical wound and drainage sites  Preparing or administering cytotoxic medications

Gowns/apron characteristics Worn when in close contact with individuals, materials or equipment that mat lead to contamination of skin, uniforms or other clothing with infectious agents or risk of contamination with blood, body substances, secretions or excretions. Gown type Characteristics  Single use Plastic apron  Plastic  Impervious to fluids  Disposable  Protects clothing from contamination of droplets or sprays  Worn when there is a low risk that your clothing or body parts will be exposed to blood or body substances (so low risk procedures)  Worn during contact precautions when contact with persons or their environment is likely Gowns  Single use  Disposable  Worn to protect your skin and clothing from blood, body substances, secretions or excretions during procedures and care activities associated with splashing or sprays of blood or body substances  Worn when there is close contact with the person, when equipment or materials mat contaminate your skin or uniform, or to protect the person from the microbes you carry  Single use Long-sleeved gown  Fluid resistant (full body gown)  Long sleeved, closed fronted and elastic knit cuffs (tucked under your o

8

Sterile gown

gloves)  Worn during procedures where there will be contact between your skin and a person’s broken skin  Worn during extensive skin to skin contact (e.g. repositioning a person with extensive burns)  Worn during contact with or splashing from uncontaminated blood or body substances (vomiting, uncontrolled diarrhoea)  Operative procedures  Worn when handling cytotoxic agents (chemo)  Sterile pre-packaged gowns  Worn for procedures requiring aseptic fields

Face masks Reduce the transmission risk of droplet and airborne routes by splatters of body substances masks are recommended to be worn; - by those close to the individual if the infection is transmitted by large particles (droplets). Usually transmitted by close contact and generally travel short distances (1m) - by all persons entering the room if the infection is transmitted by small-particles. Small particles remain suspended in the air and travel greater distances by air. Mask type Characteristics Required for Surgical masks  pleated face  procedures generating  2-3 polypropylene layers splashes or sprays of large  filtration via mechanical blood droplets, body impaction substances, secretions,  fluid resistant excretions or hazardous medications or chemicals  procedures requiring surgical ANTT to protect the person from exposure to infectious microorganisms carried into your nose and mouth  routine care of people requiring droplet precautions P2 respirator (N95)  Raised dome or duckbill  routine care of people requiring airborne  4-5 layers  filtration via mechanical precautions impaction and electrostatic  bronchoscopy or other high risk procedures in a person of capture unknown infectious status  procedures involving particle aeroionisation containing specific pathogens o o

Eyewear o

used in situations where bodily substances may splatter the face

Procedure or care activity Routine care

9

Examples  assessing vital signs  physical assessment

Required face and eye protection  not required unless caring for a person on droplet

precautions (surgical mask) or airborne precautions (P2 respirator  emptying urinary drainage bags  surgical masks Procedures generating  administering intravenous  protective eyewear/fullsplashes or sprays cytotoxic medications length face shield  intubation  protective eyewear Procedures involving  nasopharyngeal suctioning  surgical masks or if respiratory tract and required P2 respirator mouth P2 respirator masks have a duckbill and are sturdier than surgical masks offering greater protection from airborne and droplet infection as well as contact from splashes or sprays

Environmental cleaning disinfecting o

chemical preparation used on inanimate objects which destroys bacteria

sterilizing o

a process that destroys all micro-organisms. E.g. moist heat, gas, boiling water and radiation

Aseptic non-touch technique o

is a specific type of aseptic technique with a unique theory and practice framework. ANTT protects individuals during invasive clinical procedures by utilising infection-prevention measures to minimise the introduction of sufficient quantities of microorganisms to cause an infection by hands into susceptible sites, surfaces or equipment

Handling and disposal of sharps o

into the correct bin

Respiratory hygiene and etiquette o

covering sneezes and coughs prevent infected individuals from dispersing respiratory secretions into the air. Ensure to wash hands with soap after coughing, sneezing and using tissues, or after contact with respiratory secretions or articles contaminated with these secretions

Handling of waste and linen o

into the correct bin

Reprocessing/cleaning of reusable/shared equipment Sterilizing and disinfecting

Transmission based precautions Contact

Droplet

In addition to standard precautions

In addition to standard precautions

10

Airborne In addition to standard precautions

Before entering the room o put on apron or gown o perform hand hygiene and put on gloves leaving the room o discard gloves and apron o clean patient-related equipment o perform hand hygiene

Before entering the room o perform hand hygiene o put on a surgical mask leaving the room o discard mask o clean patient-related equipment o perform hand hygiene Keep door closed at all times!!

When workers hands or clothes are contaminated, patient care devices are shared between individuals, infectious individuals have contact with others, or environmental surfaces are not appropriately decontaminated.

When health care workers hands When health care workers or others become contaminated with inhale small particles containing respiratory droplets and transferred infectious agents to susceptible mucosal surfaces. E.g. coughing, sneezing or talking

Before entering the room o put on a p2 mask/respirator o perform fit check o food services speak to nurse leaving the room o discard mask o clean patient related equipment o perform hand hygiene Keep door closed at all times!!

Occupational exposure to microorganisms

Assessment techniques and normal ranges Types of data

Subjective data  Apparent only to the person affected  Symptoms – described by the patient … includes feelings, beliefs, perceptions, stress  E.g. “I have a pain in my stomach and its making me feel sick”

11

Objective data  Detectable by an observer can be measured or tested against a standard  Signs – seen, felt, heard, smelled, measured  E.g. on palpitation the abdomen is firm and slightly distended. Pulse and blood pressure elevated compared to baseline data

Vital signs Pule rate o

60 to 100 bpm

Respiration rate o

12 to 20 bpm

Oxygen saturation o

95% - 100%

Temperature o

36 – 37.5

Blood pressure o

120/80

o

4 – 8 mmol/L

BGL

Urine analysis Urinalysis strips

o pH o specific gravity o glucose o ketone bodies o blood o protein o nitrites o leukocytes o bilirubin o urbilinogen Stool analysis

12

Pressure injury o

13

A localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, shear and/or friction, or a combination of these factors

Falls risks

Stage 1

Non-blanchable erythema  Intact skin with persistent nonblanchable redness of a localised area usually over a bony prominence  The area may be painful, firm, soft/boggy, warmed or cooler compared to adjacent tissue

Stage 2

Partial thickness skin loss  Partial thickness loss of dermis presenting as a shallow, open wound with a red-pink wound bed  May also present as an intact or open/ruptured serum-filled blister  Presents as a shiny or dry, shallow ulcer without slough

Stage 3

Full thickness skin loss  Full thickness tissue loss; subcutaneous fat may be visible but bone, tendon or muscle are not exposed  Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunnelling

Stage 4

Full thickness tissue loss  Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed

14

Fluid balance o

On separate

Activities of daily living o

Activities that individuals need to manage and live at home, any difficulties experienced in the basic activities of eating, grooming, dressing, elimination and mobility can cause the individual going to a nursing home etc.

o

Instrumental activities of daily living: any difficulties experienced in food preparation, shopping, transportation, housekeeping, laundry, and the ability to use the telephone, handle finances and manage medications -

Walking, or otherwise getting around the home or outside. The technical...