Core Concepts for Local RN Examination Suctioning Technique STERILE Technique CATHETER SIZE Infant = #5 #8 Child = #8 #10 Adult

lt = #12 #18 POSITION Conscious = SEMI FOWLERS Unconscious = LATERAL LENGTH OF INSERTION measure distance from tip of NOSE to tip of EARLOBE (13 cm or 5 in) OXYGENATE BEFORE suctioning BETWEEN suction ATTEMPTS at the COMPLETION of the procedure LUBRICATE CATHETER TIP STERILE NSS or H20 H20 SOLUBLE LUBRICANT (K Y Jelly) Key Points ROTATE when withdrawing catheter APPLY suction while WITHDRAWING INTERMITTENT SUCTION NO suction while INSERTING Apply suction 5 10 sec Suction attempt 10 15 sec Interval 20 30 sec Duration 5 min EFFECTIVENESS CLEAR BREATH SOUNDS Suctioning At Home

CLEAN Technique Care of Suction Catheter Inside surface Flush by suctioning BOILED or DISTILLED H2O followed by suctioning of AIR Outside surface Wipe with ALCOHOL or HYDROGEN PEROXIDE Care of Suction Catheter Allow to DRY Store in CLEAN DRY area Use within 24 hours ONLY Bathing Categories Cleansing Baths Therapeutic Baths Cleansing Baths Complete Bed Bath ENTIRE body Partial or Abbreviated Bath only ODOR producing parts of the body Key Points 43 C 46 C or 110 F - 115 F Bed comfortable working height Client move NEAR you Side rail LOWER on your side Eyes wash using WATER only wipe from INNER to OUTER canthus Extremities use LONG FIRM strokes from DISTAL to PROXIMAL Increased VENOUS return Back assist to PRONE or SIDE LYING facing away from you Therapeutic Baths Colloidal antipruritus Medicated Tars psoriasis and eczema Saline widely disseminated lesions Sodium Bicarbonate cooling Starch soothing

Key Points Adult 37.7 C 46 C or 100 F - 115 F Child and Infant 40.5 C or 105 F Duration 20 30 minutes Special Oral Care Indication UNCONSCIOUS client USE Normal Saline AVOID Hydrogen peroxide Lemon glycerine swab Mineral oil Nurses Priority Assess GAG reflex Position Side lying with HOB lowered Key Points Rinse mouth by drawing 10 ml of WATER or ALCOHOL FREE mouthwash into syringe Inject it gently into EACH side of mouth Clean oral tissues with FOAM swab or GAUZE pad moistened with NSS Use SEPARATE applicators for EACH area of mouth Clean oral tissues in ORDERLY progression Cheek Roof of mouth Base of mouth Tongue Lubricate lips with PETROLEUM JELLY If client is on O2 therapy, use WATER BASED lubricant instead Levels of Prevention Primary Prevention PRE PATHOGENESIS Health Promotion not disease oriented Health Protection illness or injury specific HEALTH EDUCATION IMMUNIZATION Risk Assessment

Environmental Sanitation Family Planning Marriage Counseling Secondary Prevention PATHOGENESIS Early Diagnosis Prompt Treatment Health Maintenance Case Finding Health Checkups Assessment Order and Treatment Screening Surveys and Procedures Tertiary Prevention POST PATHOGENESIS Referral Rehabilitation Reinforcement to prevent further complication Making Referrals Active Program of Rehabilitation Teaching Clients with CHRONIC Disorders Cancer Screening Guidelines TSE 13 y/o Pap Smear 18 y/o or when sexually active Pelvic Examination 18 y/o BSE 20 y/o CBE 20 y/o Mammogram Low risk 35 39 y/o High risk 30 y/o DRE 40 y/o Guaiac Test 50 y/o Sigmoidoscopy 50 y/o Rehabilitation To improve QUALITY of life

 CLIENT is primary rehabilitator Begins on ADMISSION Documentation Systems Source Oriented Record Traditional Client Record Each person has separate section in clients record Narrative Charting Problem Oriented Record Data are arranged according to clients problems 4 Basic Components a. Database b. Problem List c. Plan of Care d. Progress Notes Focus Charting Focuses on client needs Three columns are used for recording: a. Date and Time b. Focus c. Progress Notes Charting by Exception only EXCEPTIONS to rule are documented ABNORMAL FINDINGS Faxing Information Secure CONSENT CHECK 3 times a. Before dialing b. After dialing c. Before SENDING Key Points Access to record is RESTRICTED to health professionals involved in giving care

Hospital is rightful OWNER of clients record Clients record is INADMISSIBLE as evidence when client OBJECTS COMPLETE CHARTING is best defense against malpractice Nursing care NOT recorded is NOT provided

Change of Shift Report Purpose To provide continuity of care Tool Kardex Basis Clients health care needs Telephone Order Only RNs should take telephone orders VERIFY Repeat it back to physician Countersign within 24 hours Physical Assessment General Guidelines PSYCHOLOGICAL PREPARATION Room WARM enough EMPTY THE BLADDER Comfort Provide privacy Draping Adequate lighting Ready the equipment at the bedside Expose ONLY body areas to be examined Avoid Hypothermia Special Considerations Convenient TIME HEAD TO TOE Inspection, Palpation, Auscultation, Percussion I P A P Plan SEVERAL ASSESSMENT times Elderly Start from the LEAST INVASIVE Infant/Child Methods INSPECTION Visual Examination Sense of Sight PALPATION Tactile Examination

Sense of Touch Types Light/Superficial gentle pressure less than 1 cm deep Deep increased pressure more than 1 cm deep Parts of the Hand FINGERTIPS Pulsation FINGER PADS Shape Moisture Consistency Texture PALMAR Aspect Vibration DORSAL Aspect Temperature General Guidelines Hands Clean Warm Fingernails SHORT Areas of Tenderness Palpated LAST Superficial Palpation Done FIRST AUSCULTATION process of LISTENING to sounds produced within the body Sense of Hearing Types DIRECT Unaided EAR INDIRECT Stethoscope Parts of a Stethoscope DIAPHRAGM HIGH frequency Breath sounds

Bowel sounds Friction rubs BELL LOW frequency S3 and S4 Bruits Venous hums PERCUSSION act of STRIKING BODY Sense of Hearing Sense of Touch Types of Sounds Quality Location FLATNESS very dull muscle bone DULLNESS thud like heart liver spleen RESONANCE hollow NORMAL Lung HYPER booming EMPHYSEMIC Lung RESONANCE TYMPANY drum like air filled stomach Key Points FLATNESS Most DENSE Least AIR TYMPANY Least DENSE Greatest AIR Key Points Chest SITTING position Back STANDING position Palpation of thyroid gland Stand BEHIND client Ophthalmoscope DARKEN room Vaginal speculum Pour WARM water Abdominal Assessment

General Guidelines VOID before the assessment O = Zero Degree HOB WARM the HANDS and the STETHOSCOPE SUPINE with knees flexed Correct Sequence IAPP Inspection Auscultation Percussion Palpation RLQ RUQ LUQ LLQ Isolation Precautions 2 Tiers of Precautions Standard Precautions Transmission based Precautions Standard All patients regardless of diagnosis or presumed infection Prevent Nosocomial Infection Transmission based Patients who are cases or suspects of a highly transmissible infection Types of Transmission based Airborne Precautions droplet nuclei less than 5 microns remain in the air travel more than 3 feet Requirements Negative pressure room Frequent hand washing Particulate or N95 mask Indications Measles Tuberculosis

Varicella Droplet Precautions particle droplets greater than 5 microns dont remain in the air travel less than or up to 3 feet Requirements Private room Frequent hand washing Mask when working within 3 feet of the client Indications Diphtheria Influenza HI type B German Measles Meningitis Mumps Pertussis Pharyngitis Strep throat Pneumonia Contact Precautions direct contact clients skin indirect contact contaminated articles Indications Dysentery Enteritis C. difficile Food borne Hepatitis Herpes simplex virus Scabies Cohorting Preschooler SAME AGE Roommate School Age SAME SEX Roommate Hand Washing most effective way to prevent spread of infection Preparation Fingernails are kept short

Assess hands for skin breaks Remove all jewelry Requirements Running water WARM Soap Liquid: 2 4 ml/ 1 tsp Tissue paper Key Points 10 15 seconds CIRCULAR movement FRICTION Medical Hand Washing Hold hands LOWER THAN elbows Surgical Hand Washing Hold hands HIGHER THAN elbows Medications Guidelines 1. YOU are responsible for your own action 2. If client VOMITS after taking oral medication, REPORT to nurse in charge or doctor 3. When medication is OMITTED, record fact and reason 4. When medication ERROR is made, ASSESS client and REPORT to nurse in charge or doctor 5. Administer ONLY medication personally prepared 6. Do NOT leave medications at bedside Identify the Client 1st Check clients identification bracelet nd 2 Ask client to state his/her name rd 3 Ask another nurse to identify client Key Point Do NOT ask client by stating his/her name Therapeutic Nurse Client Relationship Preinteraction Nurses SELF AWARENESS Planning for FIRST INTERACTION with client Reviewing client data Orientation

TRUST building ROLE CLARIFICATION Upholding clients rights SELF DISCLOSURE TERMINATION Setting CONTRACT Maintaining CONFIDENTIALITY Working Facilitating BEHAVIOR CHANGE EXPLORATION Working through RESISTANCE PROBLEM IDENTIFICATION Transference and Counter transference Termination Recapitulating GOALS and OBJECTIVES achieved REFERRALS Reinforcing NEW ADAPTIVE BEHAVIOR Delegation YOU Delegate Stable clients Standard procedures Do NOT Delegate Care of invasive lines Assessment Patient teaching Triage Administration of medication Insertion of IV and NGT Nursing process Nursing Care Modalities Functional Nursing Task Oriented Approach MANY Patients FEW Nurses Total Care or Case Nursing Holistic Approach

Ratio is 1:1 FEW Patients MANY Nurses Team Nursing Group Approach Decentralized Heart is Team Conference Primary Nursing Comprehensive Approach Admission to Discharge 24/7 Model Ratio is 1:4 6 (Small Group) Secondary Nurse Take over when Primary Nurse is OFF DUTY Head Nurse Quality Control Expert Informed Consent Types Express written or verbal agreement Implied nonverbal agreement Prerequisite for: Surgical procedures Entrance into a body cavity Radiological procedures Anesthesia administration General Guidelines 1. Purposes 2. What client can expect to feel or experience 3. Intended benefits 4. Possible risks or negative outcomes 5. Advantages or disadvantages of possible alternatives Elements Voluntariness Information Capacity Legal Age (over 18 y/o) Oriented Conscious

Exceptions Minors Unconscious Mentally incompetent Emancipated Minors 4 Ms Married minor Minor who has a child Minor in military service Minor whos living away from home Roles Physician Consent Taker Nurse Witness or Advocate Patient Decision Maker Key Points In emergency NO consent is needed IMPLIED consent applies PATERNALISM applies Two physicians may sign Routine procedures are covered by consent signed at admission MOST nursing interventions rely on ORALLY expressed consent or IMPLIED consent If client refused to sign consent form, have client fill out RELEASE form If client refused to sign release form, have it noted in clients chart In ELECTIVE sterilization, husband and wife must consent When sterilization is medically necessary, wifes consent is enough If client has questions and nurse has doubts about clients understanding, NOTIFY physician Consent is obtained BEFORE administering preanesthetic medication Incident Report WHAT? Unusual Occurrence Report hospital record of accident or unusual occurrence

Purposes 1. To make ALL facts available to hospital personnel 2. To contribute to STATISTICAL data 3. To help hospital personnel PREVENT future incidents or accidents Content 1. Clients name, initials and hospital or ID number 2. Date, time and place of incident 3. Facts of incident 4. Clients account of incident 5. Witnesses to incident 6. Any equipment and medication Key Points IR should be COMPLETED within 24 hours FACTS of incident should be noted in clients record IR is NOT part of clients record Do NOT record in clients record that IR has been completed because facts are already documented in chart ANYONE who identifies that incident occurred should complete IR IR is reviewed by hospital risk management committee When accident occurs, you should first ASSESS client Triage Triage System of client evaluation to establish priorities and assign appropriate treatment or personnel Determination of Priority Emergency situations GREATEST RISK receives priority Major disasters classification based on principles to benefit the LARGEST number those requiring highly specialized care may be given MINIMAL or NO care those requiring minimal care to save their lives should be treated FIRST

Categories Emergent Life threatening Be seen IMMEDIATELY Urgent Serious but NOT life - threatening Be seen within 1 hour Non Urgent Episodic illness Be addressed within 24 hours Fast Track Require simple FIRST AID or basic PRIMARY CARE Color Coded Tagging System Immediate Red Life threatening injuries 1st Priority Delayed Yellow Significant injuries 2nd Priority Minimal Green Minor injuries 3rd Priority Expectant Black Extensive injuries 4th Priority