Blood Seizure – Termination & Nursing Process

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Blood Seizure – Termination & Nursing Process

In this chapter we discuss blood seizure, termination and nursing process.

What are the four phases of the Helping (Nurse-Patient) Relationship?





Describe the PRE-INTERACTION phase of the Helping Relationship.

This takes place before meeting the patient:

– Review available data, history
– Talk to other caregivers who have info about patient
– Anticipate health concerns or issues that arise
– Identify a location or setting that fosters comfortable, private interaction
– Plan enough time for initial interaction

Describe the ORIENTATION phase of the Helping Relationship.

When nurse and patient first meet and get to know one another:

– Set the tone for the relationship by adopting a warm, empathetic, caring manner
– Recognize relationship is tentative
– Expect patient to test your competence and commitment
– Closely observe
– Begin to make inference and form judgements about messages and behaviors

Describe the WORKING phase of the Helping Relationship.

When nurse and patient work together to solve problems and accomplish goals. TEACHING occurs.

– Encourage pt. to express feelings about health
– encourage pt. w/ self exploration
– Provide information
– Help pt. set goals
– Take action to meet said goals
– Use therapeutic comm
– Use appropriate self-disclosure & confrontation

Describe the TERMINATION phase of the Helping Relationship.

Ending of the relationship

– Remind pt. that termination is near
– Evaluate goal achievement with pt.
– Reminisce about relationship with pt.
– Separate from the pt. by relinquishing responsibility for care
– Achieve a smooth transition for pt. to other caregivers

Acronym used for successful communication in the workplace to promote teamwork and safety.

S – situation
B – background
A – assessment
R – Recommendation

Characteristics of communication within Caring/Working Relationships:

Professionalism – appearance, demeanor, behavior

Courtesy – hello, good-bye, knock on doors, please, thank you…

Use of Names – Always introduce yourself

Confidentiality – HIPPA

Trust – always honest!

Acceptance & Respect – Non-judgmental attitudes

Availability – “Anything else I can get you?

Socializing – don’t socialize with pt. and don’t socialize with colleagues where pt’s can hear

What is therapeutic communication techniques?

Specific responses that encourage the expression of feeling and ideas and convey acceptance and respect.

Define the therapeutic communication technique of:
Active Listening

Being attentive to what patient is saying both verbally and nonverbally.

** Use SOLER to facilitate attentive listening

Define acronym SOLER

S – Sit facing the patient

O – Open posture

L – Lean toward the patient

E – Establish & maintain eye contact

R – Relax

Define the therapeutic communication technique of:
Sharing Observations

Observations/perceptions can help start a conversation, but need to be careful not to anger patient or make assumptions.

Define the therapeutic communication technique of:
Sharing Humor

Important but often underused resource in nursing interactions. It is a coping strategy that adds perspective and helps adjust to stress.

Define the therapeutic communication technique of:
Using Silence

Allow patient to break the silence, particularly when he/she has initiated it.

Particularly useful when people are confronted with decisions that require thought.

Define the therapeutic communication technique of:
Providing Information

To help patient understand, but do not preach

Define the therapeutic communication technique of:

Check that understanding is accurate
Restate an unclear message
Rephrase to clarify

Define the therapeutic communication technique of:

Centers on key elements of concepts of message

Helpful when patient is vague or rambles

Define the therapeutic communication technique of:

or Paraphrasing
this sends feedback that lets the patient know nurse is actively involved

Define the therapeutic communication technique of:
Open-ended Questions

Asking relevant questions allows patient to fully respond

Define the therapeutic communication technique of:

Summarizing a concise review of key aspects of interaction. Especially helpful in termination phase

Other techniques of therapeutic communication are:

Sharing empathy
Sharing hope
Use of Touch
Sharing feelings
Confrontation (with sensitivity after trust is established)

What physical and emotional factors must a nurse assess through communication?

Developmental –
age, physiological status (pain, hunger, weakness)




How can you communicate with non-english speaking patient?

Translator or translator phone

What are some non-theraputic communication characteristics?

Inattentive listening
use of medical jargon
Being defensive

How does the nurse demonstrate caring in communication?

Become sensitive to self & others

Promote and accept expression of pos & neg feelings

Develop helping trust relationships

Instill faith & hope

Promote interpersonal teaching & learning

Provide supportive environment

Assist with gratification of human needs

Allow for spiritual expression

What are the Zones of Touch?

Social zone

Consent zone

Vulnerable zone

Intimate zone

Social zone of touch is

Hands, arms, shoulders, back

Permission not needed

Consent zone of touch is

Mouth, wrists, feet

Permission needed

Vulnerable zone of touch is

Face, neck, front of body

Special care needed

Intimate zone of touch is

Genitalia, rectum

Great sensitivity needed

Zones of Personal Space

Intimate – 0-18″

Personal – 18″ – 4′

Social – 4 -12 ft

Public – > 12 ft

What is Intimate zone of personal space?

Holding crying infant

Performing physical assessment

Bathing, grooming, dressing, feeding, and toileting a patient

Changing patient dressing

What is Personal Zone of personal space?

Sitting at a patient’s bedside

Taking patient history

Teaching patient

Exchanging info at shift change

What is Social Zone of personal space?

Making rounds with physician

Sitting at the head of a conference table

Teaching a class for patients with diabetes

Conducting family support

What is public zone of personal space?

Speaking at a community forum

Testifying at a legislative hearing

Lecturing to a class of students


to review vocabulary and basic understanding.

THEN… proceed in this set of flashcards for the Nursing Care of Infections

Nursing process for Infection: Assessment

Assess all risk factors:
age, nutrition, diagnostic procedures (IV, catheters), occupation, high-risk behaviors, travel history, trauma, stress

Nutritional Status
– reduction in protein impairs healing

Lab Data
– WBC count (5000-10000 norm)
– Cultures
– ESR (up to 15 for men and 20 for women)
– Iron level 60-90g/100mL
– Differentials

Chronic or serious infections/diseases/disorders
– COPD → pneumonia
– heart failure → skin breakdown
– diabetes → venous stasis ulcers

* diabetes patients at risk for chronic infections

Nursing process of Infection: Diagnosis

⊗ Disturbed body image = look bad, smell bad, etc

⊗ Risk for fall

⊗ Risk for infection = lab results (WBC 5,000-10,000/mm³), review current meds

⊗ Identify potential sites of infection = IV, catheter

⊗ Imbalanced nutrition = protein needed for healing

⊗ Acute pain

⊗ Impaired skin integrity or tissue integrity

⊗ Social isolation

Nursing process of Infection: Planning

Goals & Outcomes

Setting priorities
→ Treatment is always a priority

Collaborative care

Nursing process of Infection: Implementation

Health promotion – break chain of infection




Adequate rest and regular exercise

Nursing process for Infection: Evaluation

Measure the success of infection prevention

Measure the patient and family adherence to discharge plans

Wound status and healing

** did your patient get better or worse? Did your patient get an infection at hospital?

Standard precautions taken with ALL patients protect health care workers from:


Body fluids (except sweat)


Non-intact skin

** These precautions began in the 80’s as a result of HIV/AIDS

It is required to wash hands with water and soap when:

Hands are visibly dirty
When soiled with blood or other body fluids
Before eating
After toileting
Exposure to spore-forming organisms (c-diff, bacillus anthracis)

Use of alcohol-based waterless antiseptic agent for routinely decontaminating hands for following situations:

Hands NOT visibly soiled

Before/after/between direct patient contact

After contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressing

When moving from contaminated to a clean body site during patient care

After contact with inanimate surfaces or objects in the patients room

Before caring for patients with sever neutropenia or other forms of immunosuppression

Before putting on sterile gloves to insert invasive devices

After removing sterile gloves

Nursing process for Infection: Implementation in Acute Care Settings

Use standard precautions

Control or eliminate infectious agents



Control or eliminate reservoirs

Control of portals of exit

Control of transmission

hand hygiene

Isolation & barrier protection

Protective equipment

Proper removal of PPE

Role of infection prevent & control

Prep for sterile procedures

Restorative/long-term care

What is order of preparing to enter room on isolation?

Mask or Respirator
Eye wear

What is order of removal of protective equipment for isolation?


Sterile field must have what size border?

1 inch

What are the vital signs?

Pulse Ox

When do you take vitals?

When they first enter

Appropriate intervals during stay

Just before they leave

Why must you know the baseline vitals for a patient?

Any changes in vital signs can help the nurse immensely

What are guidelines to measuring vital signs?

Must get baseline by taking when first enter

Measure correctly

Understood & interpreted


Body Temp normal range


Body temp is affected by heat loss, what causes this?





What produces heat in the body?

Cellular Respiration

What is considered a fever?

Adult 102.2 ↑

Child 104

What is pyrexia?


What is an Antipyretic?

Medication that brings down fever
Ex: Tylenol, NSAIDS

How is temp measured?

At the core or the surface by:

Disposable Chem Dot

What is pulse?

Palpable bounding of the blood flow in a peripheral artery

What are the locations for pulse?

Posterior tibia
Dorsalis pedis

What is Tachycardia

Pulse faster than 100 bpm

What is Bradycardia

Pulse slower than 60 bpm

What is Blood Pressure

Ability of the peripheral blood vessels to constrict and dilate that depends on cardiac output, PV resistance, blood volume, blood viscosity, and artery elasticity

What are the blood pressure variations?

Orthostatic hypotension

Orthostatic Hypotension

Looking for a drop in blood pressure during a rise in heart rate when person changes from lying to sitting to standing.

What is the Systolic Pressure?

Ventricular contraction that forces the blood into the aorta

What is the Diastolic Pressure

Minimal pressure exerted against the arterial wall

* Pulse pressure is the difference between systolic and diastolic pressures

Korotkoff sounds of BP

There are 5 phases, we listen for phase 1 (systolic) and then for phase 4 into phase 5 (diastolic)

phase 1 – sharp thump

phase 2 – blowing or whooshing sounds

phase 3 – crisp intense tapping

phase 4 – softer blowing sound that fades

phase 5 – silence

What is respiration?

the mechanism the body uses to exchange gases among the atmosphere, blood and cells

What is normal respiration rate?

12-20 per minute

Define Eupnea

Normal breathing

What is ventilation?

Physical act of breathing in and breathing out

What is Pulse Oximetry

Looking at hemoglobin molecule to determine how saturated it is with oxygen.

What is a weakness of Pulse Ox measure?

CO can fake out the pulse oximeter because blood will be saturated with CO, not O₂, but oximeter thinks that it is O₂

What is apnea?

Absence of breathing

How do we naturally release CO₂?

Sign or yawn up to 15 times an hour

What is Chain-Stokes Respiration?

Rhythm of acceleration of respirations followed by deceleration then followed by apnea.

Why can pulse ox be an indicator of iron deficiency anemia?

Patient doesn’t have enough red blood cells to carry enough O₂ to meet metabolic needs

What is a seizure?

Uncontrolled electrical neuronal discharges from the brain that interrupts normal brain function.

What causes seizures?

Brain tumor
Brain trauma
Metabolic disorders
Withdraw from alcohol
Idiopathic (no known cause)

How do you assess a seizure?

Was seizure seen

Precipitating factors

Where did it start

How did it progress

Type of movement in extremities

Gaze deviation

Mental status
How long did seizure last?

Mental status after seizure?

Motor weakness after seizure

Any injury from seizure

Another term for a seizure?

Irritable focus -or- Foci

What is Postictal Phase?

Altered state of consciousness that a person enters after experiencing a seizure.

It usually lasts between 5 and 30 min, and is characterized by drowsiness, confusion, nausea, hypertension, headache or migraine and other disorienting symptoms.

Nursing Diagnosis for Seizures

⊗ Risk for injury

⊗ Risk for aspiration – breathing fluid into lungs

⊗ Ineffective airway clearance related to relaxation of tongue and gag reflex secondary to muscle innervation

⊗ Anxiety

⊗ High risk of ineffective therapeutic regimen related to insufficient knowledge

Nursing plan for Seizures

Assess and detect signs of seizure

Implement seizure precautions

Medications as ordered

Assess history, serum drug levels, compliance with drug regimen

Nursing Interventions Before Seizures

How to call for help

Place pads on side rails

Bed in low position

Access to O₂ & suction

Nursing Interventions during a seizure

Attempt to turn patient on side

Maintain airway

Place O₂ on patient

Suction mouth as needed

Do not attempt to insert anything into mouth

Do not restrain

Monitor pulse ox

Assess type & length of seizure

Administer meds as ordered

Nursing Evaluation for seizures

Identify criteria and standards

Collect data

interpret findings

document & notify

Revise plan, if needed
– are the taking any meds?
– if so, is the dosage correct?

What are the different roles during a CODE?


Recorder/ time keeper

Medication Administrator


Traffic Controller

Code Blue

Check for responsiveness

Assess for breathing 5-10 sec

Activate code blue

check pulse for 5-10 sec

If not pulse, begin CPR

What does CAB represent?

– compress at least 2 inches
– 100 per min
– complete chest recoil
– correct hand placement

Airway – head tilt, chin lift

Breathing – 2 breaths every 10 seconds

What is ACLS?

Advanced Cardiac Life Support
– manual defib
– cardiac drugs
– advanced airway
– lab values