Study Guide Exam 3 (2) - more notes PDF

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Study Guide Exam 3 Concepts: Health Policy, Quality improvement, safety, legal issues, Informaics, Clinical decision making, managing care  What is health policy? o Goal-directed decision making about health that is the result of an authorized and public decision-making process. o Includes those ac...

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Study Guide Exam 3 Concepts: Health Policy, Quality improvement, safety, legal issues, Informatics, Clinical decision making, managing care  What is health policy? o Goal-directed decision making about health that is the result of an authorized and public decision-making process. o Includes those actions, nonactions, directions and or guidance related to health that are decided by governments or other authorized entities.  What is the purpose and components (regulatory agencies) of health policy? Major attributes of health policy: 1. Decisions are made by authorized government institutions such as legislatures or courts or by government-authorized entities. 2. The decision-making process is subject to public review and public input. 3. Health policies address a public policy goal. Minor attributes of health policy include the following: 1. Health policies are subject to ongoing review by governing institutions and by the public. 2. Health policy goals change according to changes in political and social values, trends, and attitudes. o

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Legislatures:  Establish laws to serve some policy goal and authority to create laws.  Determines the appropriate funding for a legislative act and for providing oversight for policies that are administered by government agencies. Courts and Judiciary:  Court systems play an important role in the development of health policy because the federal and state courts are often the staging ground for determining rights in health policy disputes through judicial review.  Judiciary review can be addressed to widely varying concerns, including challenging unreasonable government action, supporting the establishment of newly created rights through legislation, and ensuring protections provided by health care law.8 Executive Branch:  The executive branch of federal and state governments is responsible for the carrying out of laws passed by legislatures.  Chief executives develop and implement institutional budgets, control the vast resources of the executive branch, and are usually able to use veto authority

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(constitutional right to reject a decision) to influence policy changes. Regulatory Agencies:  Regulatory agencies either can be a part of the executive branch or may be independent or semi-independent organizations. These agencies are established by legislatures to implement and enforce laws through a rule-making process. The rules developed by these agencies are made through public administrative processes and have the force of law. Health care is a highly regulated industry, so many health policies are established through administrative rule making by regulatory agencies. Decisions related to nursing licensure by state boards of nursing are an example of administrative rule making.  Center for Medicaid and Medicare services (CMS)  The joint commission  Occupational Safety and Health Administration  Other important regulatory agencies that ensure health care quality include the U.S. Food and Drug Administration, the U.S. Department of Justice, the Office of the Inspector General, and the U.S. Drug Enforcement Administration

 What is the quality improvement process in healthcare? o Quality health: the degree to which health services for individuals and populations increase the likely hood of desired health outcomes and are consistent with current professional knowledge. o Attributes of health care quality: 1. Safe 2. Effective 3. Timely 4. Patient centered 5. Efficient 6. Equitable

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Model for improvement: The first part consists of 3 fundamental questions: 1. What are we trying to accomplish? 2. How will we know that a change is an improvement? 3. What changes can we make that will result in improvement? The second part is the Plan Do Study Act: 1.

 How is informatics used in the healthcare system (and specific to nursing)? What are the benefits? o Critical thinking: application of knowledge and experience to identify patient problems and to direct clinical judgements and actions that result in positive patient outcomes o Clinical Reasoning: uses critical thinking, knowledge and experience to develop solutions to problems and make decisions in a clinical setting. o Problem solving: finding a solution to a problem o Decision Making: choosing a solution or answer from among different options; often considered a step in the problem-solving process. o Reasoning: logical thinking that links thoughts, ideas, and facts together in a meaningful way o Judgement: the result or decision related to the process of thinking and reasoning o Nursing Informatics: the specialty area of informatics that integrates nursing science with multiple information management and analytical sciences to identify, define, manage and communicate data, information, knowledge and wisdom in nursing practice

Benefits:. The ability to quickly review laboratory results or review a complete medication profile can help the nurse to choose appropriate interventions. o Use of health care IT has improved organization, communication (right data at the right time, and decision making; reduced duplicate orders, charting time, and paperwork; made medication administration safer; and enhanced information access and administrative functions. o Current initiatives in health care IT are focused on admission systems that capture demographic patient data and bed availability; the electronic health record, which moves the traditional paper patient chart online; computerized provider order entry; bar-code medication administration (BCMA: fewer med errors are made); and e-prescribing, telehealth, personal health records, and radiofrequency identification (RFID). o Decision support systems: safe practice alerts and reminders that improve the quality of care. o Electronic Medical record (EMR): documentation of a single episode of care. Ex. Outpatient visit or impatient stay; it also becomes a part of the EHR which is a longitudal record of care. o Listserv: automatically sends messages to multiple email addresses on a maliling list o Blog: social medium that has regular entries of commentary descriptions of event, or other material such as graphics or videos. o Data= Facts o Information= organized data o Knowledge= organized information that is meaningful o Wisdom= appropriate application of knowledge o Telehealth or Telemedicine: the use of the internet to link medical experts with other clinicians allowing remote consultations w/ clear video images and High-fidelty links  Nursing Informatics skills and roles: o Beginner skills: 1. Have computer information and web literacy 2. Fundamental skills in information management 3. The ability to identify and collect relevant data o Experienced skills: 1. Able to see data relationships and make judgements based on trends and patterns in data 2. Skilled in information management and the use of computer technology 3. Able to suggest areas for IT system improvement. o Specialist skills: 1. Focus on information needs for the practice of nursing o

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2. Integrate and applies information science, computer science and nursing science 3. Apply skills in critical thinking, data management, processing and system development Innovator Skills: 1. Conduct research and generate theory 2. Develop solutions and understand the interdependence of systems, disciplines, outcomes. Standardized nursing terminology: structured vocab that provides communication among nurses. Nursing minimum data set(NMDS): first attempt to standardize the collection of essential nursing data. International Classification for Nursing Practice (ICNP): standard that compares nursing practice locally, regionally, nationally and internationally.

 Concepts: Tissue Integrity, Infection, Inflammation Exemplars: Appendicitis (Perioperative Care), Pneumonia, Influenza, Pressure Ulcer, Wound Assessment and Care  Complete medication chart (antiinfectives, anticoagulants, narcotics, antiemetics, H2 receptor antagonists, gastric acid pump inhibitors, anticholinergics, benzodiazepams): o See medication chart:  Pressure Ulcers – risks for, assessments and interventions. o Description: 1. A pressure ulcer is an impairment of skin integrity. 2. A pressure ulcer can occur anywhere on the body; tissue damage results when the skin and underlying tissue are compressed between a bony prominence and an external surface for an extended period of time. 3. The tissue compression restricts blood flow to the skin, which can result in tissue ischemia (restriction of blood flow), inflammation, and necrosis (death of cells); once a pressure ulcer forms, it is difficult to heal. o

Risk factors: 1. Skin pressure 2. Skin shearing and friction 3. Immobility: spinal cord injury, advanced multiple sclerosis, tractions and restraints, diabetes 4. Malnutrition: unintended weight loss

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Incontinence: excessive moisture causes softening of the skin 6. Decreased sensory perception: dementia or brain injury. 7. 8. • Prolonged bedrest 9. • Immobility 10. • Incontinence 11. • Diabetes mellitus 12. • Inadequate nutrition or hydration 13. • Decreased sensory perception or cognitive problems 14. • Peripheral vascular disease

 Older adults are at higher risk for skin tears and pressure ulcers because of age-related skin changes. Flattening of cells at the dermal-epidermal junction predisposes older people to skin tears from mechanical shearing forces, such as tape removal and friction from tight restraints. Skin moisture and irritation from incontinence combined with friction over bony prominences can lead to skin destruction with loss of tissue integrity and pressure ulcer formation. Patients with cognitive impairments may not readily report discomfort from inadequate pressure relief. If pressure is unrelieved, tissue destruction progresses to full-thickness injury. Assess patients with cognitive impairments more frequently for loss of skin tissue integrity.  Preventing Pressure Ulcers  Positioning • Pad contact surfaces with foam, silicon gel, air pads, or other pressure-relieving pads. • Do not keep the head of the bed elevated above 30 degrees to prevent shearing. • Use a lift sheet to move a patient in the bed. Avoid dragging or sliding him or her. • When positioning a patient on his or her side, do not position directly on the trochanter. • Re-position an immobile patient at least every 2 hours while in bed and at least every 1 hour while sitting in a chair. Asses heal positioning every 4 hours. • Do not place a rubber ring or donut under the patient's sacral area. • When moving an immobile patient from a bed to another surface, use a designated slide board well lubricated with talc or use a mechanical lift. • Place pillows or foam wedges between two bony surfaces. • Keep the patient's skin directly off plastic surfaces. • Keep the patient's heels off the bed surface using bed pillow under ankles. Nutrition • Ensure a fluid intake between 2000 and 3000 mL/day. • Help the patient maintain an adequate intake of protein and calories. Skin Care • Perform a daily inspection of the patient's entire skin. • Document and report any manifestations of skin infection. • Use moisturizers daily on dry skin, and apply when skin is damp. • Keep moisture from prolonged contact with skin:

▪ Dry areas where two skin surfaces touch, such as the axillae and under the breasts. ▪ Place absorbent pads under areas where perspiration collects. ▪ Use moisture barriers on skin areas where wound drainage or incontinence occurs. • Do not massage bony prominences. • Humidify the room. Skin Cleaning • Clean the skin as soon as possible after soiling occurs and at routine intervals. • Use a mild, heavily fatted soap or gentle commercial cleanser for incontinence. • Use tepid rather than hot water. • In the perineal area, use a disposable cleaning cloth that contains a skin barrier agent. • While cleaning, use the minimum scrubbing force necessary to remove soil. • Gently pat rather than rub the skin dry. • Do not use powders or talcs directly on the perineum. • After cleansing, apply a commercial skin barrier to those areas in frequent contact with urine or feces Teach all nursing care personnel and family members not to massage reddened skin areas directly or use donut-shapped pillows for pressure relief Assessments and stages of pressure ulcers: Inspect the entire body, including the back of the head, for areas of skin tissue integrity loss or pressure. Give special attention to bony prominences (e.g., the heels, sacrum, elbows, knees, trochanters, posterior and anterior iliac spines) and areas with excessive moisture. Make sure tubing and other medical devices are not underneath the patient and producing a pressure point. Assess the patient's general appearance for issues related to skin health, such as the proportion of weight to height. Obese patients and thin patients are at increased risk for malnutrition and pressure ulcers. Check overall cleanliness of the skin, hair, and nails. Determine whether any loss of mobility or range of joint motion has occurred. Do not delegate this assessment to UAP. Stage 1: (intact)    

Skin is intact Area is red and does not blanch with external pressure Area may be painful, firm, soft, warmer, or cooler compared with adjacent tissue Darkly pigmented skin may not have visible blanching; color may differ from surrounding areas

Stage 2:  Skin is not intact  Partial-thickness skin loss of the dermis occurs  Presents as a shallow open ulcer or abrasion with a red-pink wound bed or as intact or open/ruptured serum-filled blister. Bruising not present Stage 3:  Full-thickness skin loss extends into the dermis and subcutaneous tissues, and slough may be present

 Subcutaneous tissue (fat) may be visible but bone, tendon or muscle are not exposed  Undermining and tunneling may or may not be present Stage 4:  Full-thickness skin loss is present with exposed bone, tendon, or muscle  Slough or eschar may be present  Undermining and tunneling may develop Unstagable/unclassified:  Full-thickness tissue loss in which the wound bed is covered by slough and/or eschar  The true depth, and therefore stage, of the wound cannot be determined until the slough and/or eschar is removed to visualize the wound bed  Exposed palpable muscle, tendon or bone Suspected deep tissue injury:  Ischemic subcutaneous tissue injury under intact skin or blood filled blister  Appears purple or maroon colored  May be painful, firm, or boggy, mushy, warmer or cooler.

Interventions: 1. Identify clients at risk for developing a pressure ulcer. 2. 2. Institute measures to prevent pressure ulcers, such as appropriate positioning, using pressure relief devices, ensuring adequate nutrition, and developing a plan for skin cleansing and care. 3. 3. Perform frequent skin assessments and monitor for an alteration in skin integrity (refer to Chapter 15 for more information on skin assessment). 4. 4. Keep the client’s skin dry and the sheets wrinkle-free; if the client is incontinent, check the client frequently and change pads or any items placed under the client immediately after they are soiled. 5. 5. Use creams and lotions to lubricate the skin and a barrier protection ointment for the incontinent client.

6. 6. Turn and reposition the immobile client every 2 hours or more frequently if necessary; provide active and passive range of motion exercises at least every 8 hours. 7. 7. If a pressure ulcer is present, record the location and size of the wound (length, width, depth in centimeters), monitor and record the type and amount of exudates (a culture of the exudate may be prescribed), and assess for undermining and tunneling. 8. 8. Serosanguineous exudate (blood-tinged amber fluid) is expected for the first 48 hours; purulent exudates indicate colonization of the wound with bacteria. 9. 9. Use agency protocols for skin assessment and management of a wound. 10. 10. Treatment may include wound dressings and debridement; skin grafting may be necessary •Wound Management of pressure ulcers: If ulcer is covered, remove old dressings/coverings daily (unless the dressing type is to remain in place until it loosens naturally). • Measure wound size at greatest length and width using a disposable paper tape measure or, for asymmetric ulcers, by tracing the wound onto a piece of plastic film or sheeting (plastic template) at least weekly or more often if the wound shows signs of deterioration. • Compare all subsequent measurements against the initial measurement. • Assess the ulcer for presence of necrotic tissue and amount of exudate. • Assess and document the condition of the skin surrounding the pressure ulcer in terms of color, temperature, texture, moisture, and appearance. • Remove or trim loose bits of tissue (may be done by a certified wound care specialist, physical therapist, advanced practice nurse, or other as specified by the agency and the state's nurse practice act). • Cleanse the ulcer with saline or a prescribed solution (after diluting it as per manufacturer's directions or prescriber's instructions). • Rinse and dry the ulcer surface. • In collaboration with the certified wound care specialist, select and apply the dressing materials most appropriate for the volume of wound drainage. • If possible, avoid positioning the patient on the pressure ulcer. • Re-position at least every 1 to 2 hours to prevent ulcer extension or generation of additional pressure ulcers. • Use prescribed pressure-relieving and pressure-reducing devices and techniques as described in Chart 27-2.  Wound care – assessments, interventions, and treatment modalities (such as dressings, drainage systems, irrigation, etc.) Wound assessment:

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Location, size, color , extent of tissue involvement, cell types in wound base and margins, exudate/drainage and characteristics, conditions of surrounding tissues, presence of foreign bodies, if it is a pressure sore, stage the wound A focused wound assessment includes an evaluation of the wound's location, size, and color; presence of drainage; condition of the wound edges; characteristics of the wound bed; and patient's response to the wound or wound treatment. Undermining The presence and location of undermining are determined by exploring the edge of the wound with a cotton-tipped applicator. The undermined area is part of the wound and is included in the treatment plan for the wound. Tunnels increase the actual size of the wound, are a part of the wound, and must be treated appropriately. Because wounds heal from the edges inward and from the bottom up, tunneled wounds usually are packed lightly with gauze or other dressing materials so that they can heal along with the rest of the wound, instead of prematurely closing, which would result in pockets of dead space. Such pockets can predispose the patient to the development of an abscess or infection.

Drainage: During wound assessment, note whether drainage is present, the amount of drainage, and its color, consistency, and odor. Serous drainage contains clear, watery fluid from plasma. Serosanguineous drainage is pink to pale red and contains a mix of serous fluid and red,

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bloody fluid. Sanguineous drainage usually indicates bleeding and is bright red. Purulent drainage usually is thick and indicates infection. It can be yellow, greenish, or beige. The amount of drainage (small, moderate, or large) from a wound is difficult to ascertain and is determined somewhat subjectively by evaluators. Usually, knowledge of the exact amount of drainage is not required. Increases in the amount of drainage and the presence of purulence or a foul odor can indicate infection or the presence of a fistula. In cases in which infection is suspected, the nurse can seek an order for a wound culture. Common organisms causing wound infections include Staphylococcus aureus and Streptococcus pyogenes. Infectious organisms are discussed in Chapter 26. An important point to remember is that the production of drainage req...