• Physiologic- increased heart and respiration rates, diaphoresis, voice tremors/pitch changes, palpitations, freq urination, insomnia, flushing or pallor, body aches and pain, elevated blood pressure, dilated pupils, trembling, twitching, n/v, diarrhea, fatigue and weakness, dry mouth, restlessness, faintness/dizziness, paresthesia, hot and cold flashes, anorexia,
• Pt states feelings of: apprehension, nervousness, loss of control, inability to relax, helplessness, lack of self-confidence, tension or being "keyed up", anticipation of misfortune
• Client exhibits: irritability, impatience, crying, startle reaction, withdrawal, self-deprecation, angry outburst, tendency to blame others, criticism of self and others, lack of initiative, poor eye contact
• Cognition: inability to concentrate, forgetfulness, orientation to past, hyper-attentiveness, diminished learning ability, lack of awareness of surroundings, rumination, blocking of thoughts (inability to remember), preoccupation, confusion
• Feeling of dread, fright, apprehension, and/or behaviors of: avoidance, narrowing of focus on danger, deficits in attention, performance, and control
• Verbal reports of panic, obsessions, behavioral acts: crying, compulsive mannerisms, hypervigilance, dysfunction immobility, escape, aggression, increased questioning, verbalization
• Visceral-somatic activity- shortness of breath, muscle tightness, fatigue/limb weakness, inc resp, trembling, palpitations, rapid pulse, inc BP, flush/pallor, sweating, paresthesia, anorexia, n/v, diarrhea/urge to defecate, dry mouth/throat, syncope, absentmindedness, pupil dilation, irritability, lack of concentration, insomnia, nightmares, pupil dilation, urinary freq/urgency
• Anxiety - Uneasy, apprehensive, cause not clear (can't pinpoint why they are anxious)
o Continue on and do what they are anxious about (the unknown)
• Fear - Clear cause, try to remove self from threat ("I'm afraid of snakes."); Identify cause
o If they were fearful about surgery—they would not have surgery and would leave hospital.
Very young and very old are at greater risk; older adults specific problems:
o Cardiovascular - reduced cardiac reserve because of age, tachycardia, atherosclerosis, arteriosclerosis
o Respiratory - decreased vital capacity, decreased elasticity, decreased energy, postural changes that keep them from expanding their lungs.
o Giving them anesthetics with all these problems—OA usually don't tolerate it well.
o Urinary - decreased blood flow to kidney from atherosclerosis, decreased ability to excrete toxins and medications
o Fluids/Electrolytes - dehydration common, bowel dysfunction which leads to fluid and electrolyte imbalances, poor nutrition worsens this, enemas (don't tolerate well)
o Neurologic - decreased sense of acuity and decreased reaction times (compounded with pain medications—don't tolerate/excrete/metabolism medications very well), anesthesia
• Review of History
• Vital Signs - Elevated with anxiety and monitor for changes
• Skin/Nails - O2 status, turgor, lesions
• Nutrition status (page 867 Table 37-1) - Labs, skin condition, weight loss or gain
o Labs - Albumin, Total protein, BUN
• Fluid Imbalance - Turgor (If they had any weight gain over a short period of time—such as overnight), overloaded (look for edema or puffiness around the eyes). or deficit
• Physical Exam of all the body systems - looking for underlying problems changes that could affect outcome and recovery (we need to a system by system exam)
• Medications - What medications, Rx, OTC, herbal? When was it last taken? Always encourage patient to bring home medications to hospital.
• Allergies - Always ask, especially latex allergy if going in for surgery (If they have a latex allergy they must take down operating room and supply it with non-latex allergy. Allergy to tropical fruits is a common precursor to latex allergy)
• Lab/Diagnostic Tests - we want to uncover any abnormalities before surgery and treat them. (this is a nursing responsibility to make sure they were done and what the results were so if there is an abnormality we can bring it to the doctor's attention). This can delay surgery—could need to treat problem before surgery.
-CBC (WBC, RBC, H&H- ugh & Hct)
-TxM (type and cross match for blood)
-U/A (protein, glucose, and WBC)
-Electrolytes (Na, K, Cl, Ca, Magnesium, and Phosphorus)
-FBS (fasting blood sugar)
-BUN (Blood urea nitrogen)/Creatine
-ALT, AST, LDH, and Bilirubin
-Albumin and T pro (total protein)
-PT, PTT, INR
-CXR (chest x-ray)
May do preps at home and come in very early, usually with consent/lab are already done.
• Enemas till clear, oral care, specific Rx (catheter, TED hose, IVs, medications), valuables secured, fingernail polished remove, hospital gown (underwear need to be taken off because elastic can cause complications), consent
• Surgery team will call to say they will come in thirty minutes.
• On call: Vital signs, void (if no catheter/have patient void first if about to administer pain medications because they could fall and cause injury to self)
• Purpose: to ensure all documents, studies were done and reviewed, they are consistent with team and pt's understanding of what is to happen and/or be done. Discrepancies (wrong name on chart/lab work not done), and/or missing information must be addressed before starting procedure.
• Process: Ongoing process of information gathering and verification. This begins with the decision to do a procedure, through all settings and interventions, up to and including the "time out" just before the start of the procedure.
• Preoperative Verification Process: correct person, procedure, /site:
o at the time the surgery/procedure is scheduled
o at the time of admission or entry to the facility
o anytime care is transferred to another caregiver
o with the patient involved, awake and aware, if possible
o before the pt. leaves the pre-op area or enters the procedure/surgical area
• Use of a pre-op checklist is useful to ensure the following are available and reviewed prior to the start of the procedure:
1. Relevant documentation (e.g. H&P, consent, etc)
2. Relevant images properly labeled and displayed.
3. Any required implants and special equipment.
• Purpose: To identify unambiguously the intended site of incision or insertion.
• Process: For procedures involving right/left distinction, multiple structures (such as fingers and toes), or multiple levels (spinal procedures), the intended site must be marked such that the mark will be visible after the patient has been prepped & draped.
• Marking the Site:
o Make the mark at or near the incision site. DO NOT mark any non-operative sites unless necessary for other aspects of care.
o Have the patient point to which part is being operated on and have them mark the area themselves.
o Make marks unambiguous (e.g. use initials or "YES", or a line representing the incision. An "X" may be ambiguous.)
o Position mark to be visible after the pt. is prepped and draped.
o Mark must be made using a marker that is permanent and will remain after the prep. Adhesive markers should NOT be use as the sole mark.
o Method and mark used should be consistent throughout facility.
o At a minimum, mark all structures involving laterality, multiple structures (fingers, toes), or levels (spine).
o The person performing the procedure should do the site marking
o Marking must take place with the patient involved, awake and aware, if possible.
o Final verification of the site mark must take place during the "time out" phase
o A defined procedure must be in place for pt's who refuse site marking.
1. Single organ cases (heart, c-section)
2. Interventional cases where the catheter/instrument site is not pre-determined (cardiac cath)
3. Teeth - indicate tooth name on documentation/dental radiograph or diagram
4. Premature infants - the mark may make a permanent tattoo
• Purpose: To conduct a final verification of the correct patient, procedure, site and, as applicable, implants.
• Process: Active communication among all members of the surgical/procedure team, consistently initiated by a designated member of the team, conducted in a "fail-safe" mode. This means the procedure is not started until any questions or concerns are resolved
• "Time out" immediately before starting the procedure:
o Must take place where the procedure takes place just before the start.
o Must involve entire operative team, use active communication, be documented, such as a checklist, and must, at the least, include:
♣ Correct patient identity
♣ Correct side and site.
♣ Agreement on the procedure to be done
♣ Correct patient position
♣ Availability of correct implants and any special equipment or requirements
• The organization should have processes and systems in place for reconciling differences in staff responses during the "time out"
• Procedures for non-OR settings including bedside procedures.
• Site marking must be done for any procedure that involves laterality, multiple structures or levels
• Verification, site marking, and "timeout" procedures should consistent throughout the facility, including the OR and other locations where invasive procedures are done.
• Exception: cases in which the individual doing the procedure is continuous attendance with the patient from the time of decision and consent from the pt. to the conduct of the procedure may be exempted from the sit marking requirement. A "time out" final verification still applies.
• Responses to pain can vary greatly.
• Initially the body reacts in a fight or flight mode.
• The signs and symptoms will be elevated vital signs, sweating, pallor, dilated pupils, increased rate and pitch of speech.
• The body then starts to adapt to the stress of the pain. Always remember—if they have had time to adapt the patient could exhibit the opposite signs and symptoms of what you would expect. We need to look for all these things because they are data cues (caremap boxes). Get quotes from them about what type of pain they are having, etc.
• The parasympathetic system takes over and tries to reverse many of the body's responses.
• The vital signs will return to relative normal range, skin will be dry and warm, pupil will constrict, speech slows, may become monotone, may be nausea and vomiting.
• The pain is still present in the body but the body is responding differently.
• COLDERR - Character, Onset, Location, Duration, Exacerbation (getting worse), Relief, Radiation
• COLDSPA - Character, Onset, Location, Duration, Severity, Pattern, Associated factors or how it affects the patient
• Vital signs - elevated, but body adapts, so can have pain and normal vital signs
• Skin color and moisture - Pallor, sweating then may be warm and dry as adapts
• Behavioral signs of pain
o Facial Expressions - Grimacing, stone-faced (mask of pain), biting lips, tight lips, frowning, eyes closed tight, squinting.
o Gestures - Tossing and turning, moaning, slow position changes, remains motionless, guarding, reflexive, jerking, rubbing, rhythmic movements, fetal position.
• For general discomfort the responses may be less intense or less noticeable.
• Character - Acute, Chronic, Procedural, Constant, Intermittent, Other
Also verbal, but off going nurse gives an organized report on tape (usually there are a list of things that need to be included (diagnosis, complications, assessment of dressings, pain medication, I&O, activity level, diet).
o It is concise, short, biases minimized, but can't question at the time which is a disadvantage.
• Documentation is basically a means of written communication (concise, not grammatically correct).
• Includes anything written or printed that is relied on as proof or evidence of interaction between healthcare professionals, patients, their families, and health care organizations.
• Remember that documentation is legal document.
• Also gives evidence that tests, treatments, meds, or teaching was done and/or the patient's responses (document simple things as teaching the patient to not cross their legs).
• Make sure to chart patient responses
-Remember, documentation is a legal record.
-Documents are kept for years and is used by lawyers in lawsuits, insurance companies to check on costs (use twenty 4x4 but only document it once then the insurance company will not pay for all of the supplies used), and by healthcare professionals to see the medical history and course of the patient's illness.
-Also, hospitals and accreditation bodies audit records to ensure standards are being kept and everyone is following safety systems and standards of practice.
*Write as a paragraph (in short phrases) chronologically, write everything seen, done, changes, and responses.
- 7:00 awake, in bed, color pink. Resp regular, unlabored, alert and oriented x3, talkative, assisted to BSC and back to bed. 250 mL cloudy, amber urine. Bed low, side-rails up x2. ---- S. Randol, RN
- 7:45 breakfast served, regular, NAS diet (ate 75%). Tolerated. -------------------- S. Randol, RN
*Flexible, used in an setting, thorough (best thing to have with you if you need to go to a court case in the future), explained fully
*Time consuming, hard to track problems or find a specific fact, hard to read hand written (legibility)
*Started because SOAP was confusing. Many institutions use this because it is easy to get reimbursed, very specific data.
Focus - Put symptom or dysfunction here, what patient said, S&S noted, nursing diagnosis
DAR (data, action, response) - Assessment "What was found?", Interventions "What was done?", Evaluation, "What occurred as a result?"
*Straight forward and simple, flexible, centers on nursing process, easy to find problems and communicate with other health care personnel.
*Doesn't tell a complete story because it only focuses on the problems, may need staff training to use, may need other types of charting to fill in the gaps such as narrative charting.
*Flow sheets, check of charting (check off as you go), designed to eliminate lengthy notes (Check off on your shift only what you assessed on your patient)
*Easy to use, quick. Doesn't repeat charting, can track trends easily, guidelines for use so therefore it is uniform.
*Use incorrectly, easy to check of wrong box, promotes, laziness (don't do own assessment, use last person's data to check of boxes), may omit assessing something not listed, leaves out details.
1. Ensure you have the correct chart, lab results, or other record with pt. ID on every page.
2. Always date and time each entry/page.
3. Document as soon as the interaction is over to ensure accuracy of data recall.
4. Sign each entry with your full legal name and professional credentials, or as per policy.
5. Do not leave space between entries or at the end of a line.
6. Document in chronological order, if you have a late entry or out of order entry, state why.
7. Use single line to cross out errors, then date, time, and sign/initial correction. NEVER erase, scratch out, or use correction fluid.
8. Never change another person's entry, or correct it.
9. Use quotation marks to indicate direct patient response statements.
10. Write legibly or print.
11. Use permanent ink pen (black preferably).
12. Document in complete, but concise manner by using a common language and only approved phrases and abbreviations.
13. Don't use pronouns or the word patient. You are writing about the patient. Specify exactly if you are writing about some else, re: family.
14. Always put a number before a decimal: 0.2" , not .2", and never put a decimal after a whole number 6", not 6.0".
1. Record all data that is pertinent in positives terms, occasionally negatives are acceptable.
2. Avoid judgmental or vague language e.g., good, bad, normal, abnormal, decreased, seems, appears to be, slightly, a little.
3. Avoid evaluative statements e.g., is uncooperative, instead give specific actions or statements, States "I'm not taking that medicine."
4. State time intervals specifically e.g., bid, every 4 hrs, instead of seldom, frequently, or occasionally.
5. Be specific with descriptions and measurements, e.g., mass 3cm x 5 cm instead of large mass.
6. Always record from head to toe, even if actual assessment was done out of this order.
7. Refer to findings using anatomical landmarks e.g., left upper quadrant abdomen or draw a picture.
8. Use face of the clock to describe findings in circular patterns ex., breast, rectum.
9. Document any change in the patients condition during a visit or from previous visits.
10. Describe what you observed, felt, heard, or smell, not what you do during an assessment. Ex: don't put: auscultated lungs and heart. Put findings: Lungs clear bil. on ausc. Heart sounds heard, S1 & S2, regular/strong.
• Remember (knowledge) - drawing out factual answers, testing recall and recognition choose, describe, define, identify, label, list, memorize, name, recite, recognize
• Understand (comprehension) - translating, interpreting, and extrapolating classify, defend, demonstrate, explain, express, give examples, illustrate, indicate, interrelate, interpret, infer, represent, select.
• Apply - knowing when and why to apply, recognizing patterns that are new or unfamiliar apply, explain, generalize, organize, paint, prepare, produce, select, show, sketch, solve, use
• Analyze - breaking down into parts, forms Analyze, categorize, classify, compare, differentiate, distinguish, identify, infer point out, select subdivide
• Evaluate - according to some set of criteria, and why appraise, judge, criticize, defend, compare
• Create (synthesis) - combining elements into a pattern not clearly there before. Combine, compose, construct, create, design, develop, formulate, hypothesize, invent, make, originate, produce, role play, plan
• Rank or prioritize needs - Do this with the patient and other significant persons, the other person may be the one to care for the patient at home.
• Set goals (long term) and objectives - Goals are long term, broad, vague. Objectives are observable and measurable in terms of behavior, use of behavior verbs (on moodle). The objectives will help the patient reach the long term goal .
• Select Teaching Strategies - Must sui the individual, but also the teacher. Need to know your learner's style and level of experience. May have a varied group and must have something for everyone.
• Strategies - Discussion, demonstration, one on one, group work, reading, movies, modeling, role playing, lecture (especially if teaching a larger group of people).
• Content - Again it needs to be geared to the level of th learner, try not to be too far over their heads, or too simple (could insult the patient).
• Sometime standardized content must be included, but pace can be altered.
• Evaluation - Trying to see if the patient learned something or not (if the strategies worked and objectives are met; seen through return demonstrations, etc.)
• Illness - No energy, feel bad
• Pain - No concentration (focused on pain)
• Emotions - Anger, denial, grief, need to deal with these first (self centered if they have these emotions
• Age - Developmental level in child is important and the decrease in sense of older aldults (therefore, it is always better to teach along with the caregiver of OA present just incase something is missed).
• Prognosis - Preoccupied with news whether good or bad, decreased concentration
• Biorhythms - Different readiness with teim of day (sharper in morning than evening, etc.), month
• Language/Culture - Difficulty communication
• Iatrogenic - Nurses ignore cues, condescending (nurse knows more than patient), hurried which deters a therapeutic relationship (patients might not ask questions if they feel you are rushed) (nurses are at fault and the patient is not learning from the nurse)
• People now have unrealistic expectations
• Stopped taking an active part in their own health
• In time of Hippocrates, medicine was a dual practice between physician and patient.
• The patient was the center of the healing process, now the physician is the center present day.
• Current medical practices and treatments are too expensive (meaning not everyone has access due to: finances or due to where they live).
• Not available to each person in the world.
• Conflict with traditional, cultural, folk beliefs, and religion.
• This changing (people are becoming more self-conscious and taking care of self).
• Modern medicine, conventional medicine has come to release that the value of incorporating rational therapies (such as folk remedies) into care.
• Also, modern medicine is changing the focus to preventative, health-centered care. Nurses have always been a key part in this aspect (even though we do a focal assessment, we always assess the patient as a whole).
• Worldwide only about 10 - 30% of health care given by modern, conventional means.
• 80 - 90% is given as self-care based on folk beliefs or is given in organized health care systems based on alternative practices.
Allopathy:Seek care when ill, very little emphasis on prevention Believe the main cause of illness is pathogens and imbalances. Tests are a common way to diagnose. Drugs, surgery, radiation are all common tools to treat the problem.
Holistic:Focuses more on prevention and health maintenance. Looks for balance of mental, emotional, spiritual, as well as, physical well-being (A person can be physically well but have emotional problems that could cause other physical illnesses; emotional stresses could cause immune problems/falls, etc. We need to look at the whole person, not just the illness itself.) Looks for alternatives to invasive therapies, or treatments used in conjunction with others.
• Created because consumers of complementary and alternative medicine (CAM) and health care practitioners (nurses, doctors, physical therapist) wanted to know whether available alternative medical options were safe and effective (evidence based research).
• Use of CAM is rising and is considered mainstream (more so becoming mainstream by the public rather than the medical community but it is increasing in medical field)
o Insurance coverage for acupuncture rose from 33% in 2002 to 47% in 2004.
• Many health plans offer a range of CAM therapies.
• Some cover acupuncture as an alternative to anesthesia for certain procedures.
• Cover chiropractic manipulation, massage therapy, and nutritional counseling as well as vitamins and aromatherapy.
• These programs may also include discounts for nutritional supplements, weight loss centers, and fitness clubs (you must have a doctor prescription for the insurance companies to pay for these).
• The number of people using CAM was 42% in 1997 in the United States.
• In 2002, the NCCAM reported 62% of Americans used CAM approaches, including megavitamins and prayer to meet their needs.
• Research has shown recently that the most popular supplement right now is omega 3/fish oils (prevents heart disease, raises good cholesterol, lowers bad cholesterol). People are taking these on their own and physicians are also prescribing them as well.
1. Biological Based Therapies - Herbs, diet, vitamins
2. Energy Therapies - Reiki (Japanese therapy), therapeutic touch (patient lays down and nurse would take their hands and hover them up and down the patient's body rearranging the energy in the patients body), blue-light therapy, electromacupuncture (uses energy fields).
a. These things have been shown to work and help patients. (power of suggestion?)
3. Manipulative and Body based Methods - Chiropractic, massage, acupressure, acupuncture
4. Mind Body Interventions - Meditation, yoga, music, art, prayer, journaling
5. Whole or Alternative Medical Systems - Ayurvedic, homeopathy, naturopathy, past-life therapy (these are things that incorporate all other domains, incorporating medicine).
• State Board of Nursing has looked at the scope of nursing practice in relation to alternative therapy.
• Many forms are within the scope of nursing as long as the nurse is sufficiently trained.
o Examples - hypnosis, massage therapy, touch therapies
• The nurse can use these therapies in patient care to relieve pain, improve coping, reduce stress, and increase the patient's overall well-being.
• In the clinic or hospital setting, the nurse needs to be aware of what therapies a patient is using.
• Need to ask during history, when giving meds, or when a patient is going to surgery, etc.
o Very important to know when a patient is going to surgery because many of herbal remedies can interfere during drugs given during surgery, anesthetics, blood thinners.
o Remember over 80% of the world's population uses herbs as their primary medicine and 50% of drugs today are derived from plants.
• As nurses, again, our role is not to judge decisions made by others.
o Don't put our views on a person/family; such as, family doesn't want to put feeding tube in on patient. What people don't realize is that feeding tubes are not always a good thing—by this point the GI tract is malfunctioning/deterioration of organs due to chronic disease, etc. therefore, it is doing the patient more harm than good.
• We have to realize that death is not always the worst that can happen.
• We are there to comfort, care for, ease the situation for everyone, and support patient and family.
• Physical care - keep them clean, well-groomed, give meds, minimize pain, care for any needs, keep the patient's lips moist (always talk to the patient like they are awake/alert—they are still people and we need to treat them like they are).
• Emotional care - empathy, allow patient or family to vent (will go through the stages of grief even before death occurs), allay anxiety, be there with them, be honest (do not give them false reassurance)
• Spiritual comfort - supports their religious/spiritual practices, facilitate access to clergy, participate if they desire.
• Family care - emotional support, allow to talk, be honest, be flexible, allow them to participate in care and decisions, treat the patient as a person, give patient and family with respect, give them a respite (meaning, tell them to go get a cup of coffee while the nurse stays in the room, the family needs to get out of the room)
o Patient Center Care - Patient decides on things, but the family is also included in this