Blood Seizure – Termination & Nursing Process

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


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