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?
Pre-interaction
Orientation
Working
Termination
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
– ASSESS PATIENT HEALTH STATUS
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:
Clarifying
Check that understanding is accurate
Restate an unclear message
Rephrase to clarify
Define the therapeutic communication technique of:
Focusing
Centers on key elements of concepts of message
Helpful when patient is vague or rambles
Define the therapeutic communication technique of:
Restating
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:
Reflection
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
Self-Disclosure
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)
Socioculture
Language
Gender
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
Sympathy
Arguing
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
INFECTION PHYSIOLOGY…….
SEE NOTECARDS FOR MED-SURG EXAM, PART ONE
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
Nutrition
Hygiene
Immunization
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:
Blood
Body fluids (except sweat)
Excretions
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
Cleaning
Disinfection/Sterilization
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?
Gown
Mask or Respirator
Eye wear
Gloves
What is order of removal of protective equipment for isolation?
Gloves
Goggles
Gown
Mask
Sterile field must have what size border?
1 inch
What are the vital signs?
Pulse
Pain
Temp
BP
Respiration
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
Communicated
Body Temp normal range
96.4-100.1
Body temp is affected by heat loss, what causes this?
Radiation
Conduction
Evaporation
Convection
What produces heat in the body?
Cellular Respiration
What is considered a fever?
Adult 102.2 ↑
Child 104
What is pyrexia?
FEVER
What is an Antipyretic?
Medication that brings down fever
Ex: Tylenol, NSAIDS
How is temp measured?
At the core or the surface by:
Electronic
Infrared
Digital
Disposable Chem Dot
What is pulse?
Palpable bounding of the blood flow in a peripheral artery
What are the locations for pulse?
Temporal
Carotid
Apical
Brachial
Radial
Ulnar
Femoral
Popliteal
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?
Hypertension
Hypotension
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
concussion
Infection
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
Incontinence?
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?
Compressor/ventilator
Recorder/ time keeper
Medication Administrator
Defibrillator
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?
Compressions:
– 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