Transcript Module 3

Module 3
Fundamentals of Nursing
1
Nursing as a Profession
 Criteria of a profession
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Extended education
Body of knowledge
Provides a specific service
Autonomy in decision-making and practice
Code of ethics
Professional organization and publication
Disciplinary course of action
2
Definition of a Profession
Discussion
 How do you define the term profession?
 What does the term professional mean to
you? What behaviors would you expect?
 How would you define
nursing?
3
Definitions
 Profession
 Type of occupation that meets certain criteria that
raise it above the level of an occupation
 Professional
 A person who belongs to and practices a profession
 Nursing
 The diagnosis and treatment of human responses to
actual or potential health problems (ANA, 1980)
4
Nursing Education Requirements
 Associate degree
 Diploma
 Baccalaureate degree
 Master’s degree
 Doctoral Degree
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Role of the Professional Nurse
 Provider of care
 Assists the patient physically and psychologically
 Communicator
 Communicates verbally and in writing to patients,
significant others, health professionals and the
community
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Role of the Professional Nurse
(continued)
 Teacher
 Assists patients to learn and perform at a level
necessary to restore, improve and maintain health
status
 Client Advocate
 Represents the patient’s needs/wishes to others; acts
to protect the patients by assisting them to exercise
their rights
7
Role of the Professional Nurse (continued)
 Counselor
 Assists patients to recognize and cope with stressful
problems, develop improved interpersonal
relationships and promote personal growth
 Change Agent
 Assists patients to make modifications in their own
behavior
8
Role of the Professional Nurse
(continued)
 Leader
 Influences others to work together to accomplish
specific goals
 Manager of Care
 Manages the care of individuals, families and
communities
9
Role of the Professional Nurse (continued)
 Member of the Discipline of Nursing
 Models and values nursing, commits to professional
growth, abides by the standards of practice and
legal/ethical principles, conducts research, and strives
to advance the profession of nursing.
10
Legal Basis for Nursing Practice
 Nurse Practice Act
 Provides laws that control the practice of nursing in
each state
 Mandates that, under the law, only licensed
professionals can practice nursing
 All states now have mandatory nurse practice acts
11
Legal Basis for Nursing Practice (continued)
 Standards of Practice
 Identify the minimal knowledge and conduct
expected from a professional practitioner based on
education and experience
 Nursing practice is guided by legal restrictions and
responsibilities regulated by state nurse practice acts
 General standards have been developed by the
American Nurses’ Association (ANA)
 Practice is also guided by professional obligations
12
Types of Law
 Statutory
– created by legislators at state and federal level
 Regulatory
– created by administrative groups (ex: Board of Registered
Nursing)
 Common
– used to resolve disputes between 2 persons based on principles
of justice, reason and common good
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Types of Law
(continued)
 Criminal law
 Public law that deals with the safety and welfare of
the public
 2 types include misdemeanors or felonies
14
Types of Law
(continued)
 Civil Law
 Protects the rights of individuals in situations which
generally involve harm to an individual or property
 Negligence is failure to use care that a reasonable
person would use under similar circumstances
 Malpractice is professional negligence, misconduct,
or unreasonable lack of skill resulting in injury or loss
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Types of Law
(continued)
 Good Samaritan Act
 Protects health practitioners against malpractice
claims for care provided in emergency situations
 Nurse is required to perform in a “reasonable and
prudent manner” and within accepted standards
16
Legal Infractions Terms
 Assault
 Unjustifiable threat or attempt to touch or injure
 Battery
 Any intentional touching or injury without consent
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Legal Issues Related to
Nursing Practice
 Review and discuss Legal Responsibilities of
the Nurse on Study Guide 3
 Review and discuss the Patient’s Bill of Rights
18
Legal Issues Related to Nursing
Practice
 Informed Consent
 Agreement to the performance of a
procedure/treatment based on knowledge of facts,
risks, alternatives
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Informed Consent continued
 Person giving consent must:
 Be of sound mind and physically competent and
legally an adult
 Consent must be voluntary
 Consent must be thoroughly understood
 Must be witnessed by an authorized person such as
the physician or a nurse
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Informed Consent
(continued)
 The physician is responsible for obtaining the
consent.
 The nurse may witness the signing of the
consent.
21
Consent of Minors
 Consent of Minors
 Minors 14 years of age and older must consent to
treatment along with their parent or guardian
 Emancipated minor
 Is a person age 14 or older, who has been granted the
status of adulthood by a court order or other formal
arrangement
 They can consent for treatment themselves
22
Potential Liability for Nurses
 See Study Guide 5 “Areas of Potential Liability
for Nurses”
 Choose several to discuss as a class
23
Restraints
 Restraints
 A device used to immobilize a patient or extremity
and restrain the level of activity
24
Restraints
 2 justifications for using restraints
 To protect patients from injuring themselves
 To protect others from the patient
25
Alternatives to Using Restraints
 Before restraining a patient, alternatives must
be used and documentation must state that
these were tried and failed
 Try to determine the cause(s) of the patient’s
behavior
 Eg: medication
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Alternatives to Using Restraints (continued)
 Physiological alternatives
 Reposition the patient
 Adjust medications to relieve pain
 Cover IV tubes to “hide” the tube
 Psychological alternatives
 Provide appropriate visual/auditory stimuli
 Increase visits from friends and family
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Alternatives to Using Restraints (continued)
 Environmental alternatives
 Put items within easy reach
 Place patient near the nurses’ station
 Hire private duty nurse to stay with patient
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Documentation of Restraint Use
 Follow facility policies which protect you and
them from legal actions
 Document the patient evaluation process
 Why restraint was needed
 List behaviors
 Alternatives tried
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Documentation of Restraints
(continued)
 Document the requirement for an order or
protocol authorizing the restraints
 Physician’s order must be time limited
 Verbal orders must be signed within time specified in
facility policy
 A PRN (as needed) order is never allowed
30
Documentation of Restraints
(continued)
 Document your on-going assessment and care
of the patient
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Nutrition
Hydration
Elimination
Special nursing services (ex: private duty nurse)
Follow policy regarding frequency/documentation of
on-going assessment
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Applying Restraints
 Follow the manufacturer’s instructions
 Apply to provide for as much movement as
possible
 Be careful that vest restraints are not put on
backwards
 Adjust the restraint so it is not so tight to
reduce circulation or cause pressure ulcers
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Applying Restraints
(continued)
 Tie the restraint to the bed frame, not the
bed rail
 Use a knot that will not tighten when pulled
(ex: clove hitch)
 Pad bony prominences when needed
33
Monitoring the Patient in Restraints
 Follow facility protocol
 Assess every 30 minutes
 Remove the restraint for 10 minutes at least
every 2 hours; assess for skin and neurological
impairment; perform range of motion
 Document restraint assessment on
appropriate restraint assessment tool provided
by the facility
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Types of Restraints
 Mitt restraint
 Belt restraint
 Jacket restraint
 Wrist or ankle restraint
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Using Restraints in Behavioral Health
 Strict time limits
 Adults: 4 hour limit
 Children age 9-17: 2 hour limit
 Children under age 8: 1 hour limit
36
Unusual Occurrence Incidents
 Also known as incident reports
 An incident is “any event that is not
consistent with the routine operation of a
healthcare unit or routine care of a patient”
(Perry and Potter 2005)
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Unusual Occurrence Incidents (continued)
 Examples:
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Accidental needle stick
Medication error
Patient or visitor fall
A physician’s order not being carried out by the nurse
Equipment malfunction
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Unusual Occurrence Incidents (continued)
 The report is a confidential record between the
observer of the incident and the agency Risk
Manager that documents the facts of the
incident
 It is an objective account of the occurrence and
does not include opinions, judgments or blame
39
Unusual Occurrence Incidents (continued)
 Complete a report even if there is no injury
 Never document in the nurses’ notes that an
incident report was completed.
40
Unusual Occurrence Incidents
 Class Discussion:
 Give some examples of incidents in which you
would complete a report.
41
Ethical Terms
(continued)
 Code of Ethics – a written list of
professional values and standards of conduct
which provide a framework for decisionmaking
 There are several codes of ethics that may be
adopted; in the U.S. the ANA Code of Ethics
is generally accepted (see study guide)
42
Ethical Issues in Nursing Practice
 Making ethical decisions is a common part of
every day nursing care
 Ethical decision-making is a skill that can be
learned
43
Ethical Terms
 Ethics – systematic study of what “ought” to
be done, the justification of what is right or
good
 Ethical Dilemma – situation that required a
choice between two equally favorable
alternatives
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Ethical Concepts That Apply to
Nursing Practice
 Define and discuss the following concepts from
the study guide
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Morals
Values
Autonomy
Beneficence
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Ethical Decision-Making Process
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Clearly identify the problem
Consider the causative factors,
variables, precipitating events
Explore various options for action
Select the most appropriate plan for
dealing with the ethical dilemma
Implement decided course of action
Evaluate results/consequences
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Ethical Decision-Making Activity
 Choose an ethical dilemma from the study
guide (Common Ethical Issues Involving
Nurses)
 Discuss your chosen dilemma using the 4 steps
for solving an ethical dilemma on the previous
slide.
47
Confidentiality
 Nurses are legally and ethically obligated to
keep information about patients confidential.
 The tort invasion of privacy protects the
patient’s right to be free from intrusion into
their private affairs.
 The ANA Code of Ethics also provides for a
patient’s privacy.
48
Confidentiality - HIPAA
 The American Health Insurance Portability
and Accountability Act (HIPAA) was passed
in 1996 and was required to be instituted in
April 2003
 Requires that patient health information be
available only to those with the right and need
to have this information
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Confidentiality
 Nurses role in maintaining confidentiality
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Don’t discuss information where others might overhear
Protect computer screen from being viewed by visitors
Protect patient charts from being viewed
Do not share your computer ID or password
Access/transmission of patient information via internet
requires strict scrutiny
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The Joint Commission’s
National Patient Safety Goals
 Introduced in 2003; updated annually
 Written by a group of experts who review all
of the sentinel events (unexpected
occurrences involving death or serious
physical or psychological injury)
 Experts define problem areas and advise The
Joint Commission on how to remedy these
problems
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National Patient Safety Goals for
Hospitals
 In 2007, there are 8 goals that hospitals must
follow
 Goal # 1: Improve the accuracy of patient
identification
 Use at least 2 patient identifiers
 Includes assigned ID number, social security number,
name, date of birth as options
 Follow organizational policy
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National Patient Safety Goals
(continued)
 Goal #2 Improve the effectiveness of
caregiver communications
 Includes guidelines for verbal orders
 Hospitals must develop a list of abbreviations,
symbols, and dose designations that are not to be
used
 Must develop guidelines regarding abnormal test
results and time for reporting
 Must create a standardized, consistent approach to
“hand-off ” communication
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National Patient Safety Goals
(continued)
 Goal # 3 Improve safety of using
medications
 Standardize and limit the number of drug
concentrations
 Identify and review look-alike/sound-alike drugs
 Create list of high-risk medications and have them
labeled
 Patient identification must be on all medication
containers
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National Patient Safety Goals
(continued)
 Goal # 7 Reduce the risk of healthcareassociated infections
 Proper handwashing
 Review infections leading to death or major
permanent loss of function while a patient
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National Patient Safety Goals
(continued)
 Goal # 8 Accurately and completely
reconcile medications across the
continuum of care
 Compare current medications with those ordered
when admitted
 Communicate complete list of meds to next provider
of service
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National Patient Safety Goals
(continued)
 Goal # 9 Reduce the risk of patient harm
resulting from falls
 Implement a fall reduction program
 Implement evaluation of the effectiveness of the
program
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National Patient Safety Goals
(continued)
 Goal # 13 Encourage patients’ active
involvement in their own care
 Encourage patients and their families to report
concerns about safety
 Teach about preventing infection by washing hands
 Encourage self-care
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National Patient Safety Goals
(continued)
 Goal # 15 Identify safety risks inherent in
your patient population
 Hospital should review all of its own sentinel events
and assess trouble spots in the care environment
 Complete assessment and follow-up on every patient
admitted for behavioral/emotional problems.
*According to The Joint Commission, suicide has
been the most frequently reported sentinel event in
staffed, round-the-clock facilities since The Joint
Commission began its reporting policy in 1996.
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Patient Falls
 Falls are the leading cause of accidents among
older adults
 Electronic devices are available to detect
patients attempting to get out of bed
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Fall Risk Assessment
 Identify clients at risk on admission and throughout
hospital stay
 Fall Risk Assessment Tools identify the risk level
based on the following:
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Physical condition
Mental status
Medications
Age
History of previous fall
Ambulatory devices used
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Nursing Interventions to Prevent Falls
 Identify clients at risk
 Implement fall prevention precautions
 Place items within easy reach of client
 Assist with ambulation; use ambulatory aids
 Teach client and family members of
precautions used in the hospital
 Non-skid footwear
 Use of handrails
62
Body Mechanics
 Safe and efficient body movements depend
upon balance and the interrelationship of the
center of gravity
63
Body Mechanics
 Review Summary of Guidelines and
Principles Related to Body Mechanics in the
study guide
64
Body Mechanics When Moving Patients
 Assess the situation; get help if needed
 Ensure patient safety by engaging locks and
brakes
 Bring the patient close to your center of
gravity
 Face in the direction of movement to prevent
spinal twisting
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Body Mechanics When Moving Patients
 Establish a broad base of support
 Lower your center of gravity by bending
your knees
 Tighten gluteal, abdominal, leg and arm
muscles
66
Applications of Cold and Heat
 Cold applications
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Cause vasoconstriction
Reduce blood supply
Remove oxygen, metabolites, and waste
Slow bacterial growth
Decreases inflammation
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Cold Applications
(continued)
 Dry cold: cold pack, ice bag, ice collar
 Moist cold: compress or sponge bath
68
Applications of Cold and Heat
 Heat applications
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Cause vasodilation
Increase blood supply
Brings oxygen, nutrients, antibodies and leukocytes
Increases inflammation
Helps rid body of waste (via polymorphonculear
levkacytes)
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Heat Applications
(continued)
 Dry heat: aqua pad, disposable heat pack,
electric pad (K-Pad)
 Moist heat: compress, soak, sitz bath
70
Nursing Care
Cold and Heat Applications
 Re-assess every 15 minutes after starting
treatment
 Evaluation: examine area to which cold or
heat was applied and document client
response on the medical record
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Medical vs. Surgical Asepsis
 Asepsis is the absence of pathogenic
microorganisms
 Medical asepsis - maintaining a patient and
the environment as free from pathogens as
possible
 Surgical asepsis - eliminating all
microorganisms, non-pathogenic and
pathogenic
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Surgical Asepsis Principles
 Use a sterile field for sterile materials
 Keep hands in front of you and above your
waist
 Edges of sterile containers are not sterile once
opened
 A dry field is necessary to maintain sterility
of the field
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Nosocomial Infections
 An infection acquired while a patient
 Caused by bacteria, viruses, fungi or parasites
 Patients are at high risk
 Multiple illnesses
 Elderly
 Lowered resistance
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Iatrogenic Infection
 An iatrogenic infection is a type of
nosocomial infection resulting from a
diagnostic or therapeutic procedure
 Example: a urinary tract infection (UTI) that
develops after a catheter insertion
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Chain of Infection
 6 links in the chain of infection
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Infectious agent
Reservoir
Portal of exit
Mode of transmission
Portal of entry
Susceptible host
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Nurses Role in Preventing Infection
 Infection does not occur or spread when one
of the links is broken
 Discuss ways in which health care
practitioners can break each link
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Medical Asepsis Principles
 Also known as clean technique
 Includes
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Handwashing
Standard precautions
Isolation technique
Cleaning/disinfecting of equipment
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Infection Control
 Standard precautions are the primary
strategies for prevention of infection
transmission
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Handwashing
Gloves
Mask, eye protection
Gown
79
Change in a Patient’s Condition
 The Nurse Practice Act requires that the nurse
observe and appropriately report a change in a
patient’s condition.
 Reporting should include
 assessment data including vital signs, behaviors of the
patient
 nursing interventions
 pertinent background information
 other related information (lab work, x-ray, etc.)
80
Change in Patient’s Condition
(continued)
 Changes might include:
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Sudden respiratory depression or difficulty
Change in cardiac status
Sudden unexpected pain
Sudden confusion
Critical change in vital signs
Anything out of the “expected behavior” of a patient
81
Therapeutic Communication
 Types of communication include
 Verbal
 Non verbal
 Active listening
82
Variables That Influence
Communication
 Perception
 Values/beliefs
 Culture
 Gender
 Age
 Developmental level
 Environmental factors
83
Characteristics of Therapeutic
Relationships
 Mutually determined goals
 Goal-directed toward meeting patient’s needs
 Provision of environment to maximize
patient’s potential for growth
 Patient learning new coping skills
 Predictable phases of the relationship
84
Essential Conditions for Therapeutic
Communication
 Rapport
 Trust
 Respect
 Empathy
 Genuineness
85
Cultural Considerations for Therapeutic
Communication
 It is important to review the characteristics
associated with a specific culture
 These include
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Personal space
Eye contact
Use of touch
Silence
86
Therapeutic Communication
Techniques
 Review the techniques listed in the study
guide. Practice using several of these with a
classmate.
 Review Blocks to Therapeutic
Communication in the study guide. Practice
using these with a classmate.
87
Assessment and Interventions for Safe
Fluid Therapy
 Measuring intake and output (I & O) is an
independent nursing function
 Patients on intravenous (IV) therapy or who
have a urinary catheter are automatically on I
&O
 I & O is used to determine the fluid and
electrolyte status
88
Intake and Output
 Intake includes
 All fluids taken my mouth
 All fluids taken by nasogastric and jejunostomy tubes
 All parenteral fluids (intravenous, blood)
89
Intake and Output
 Output includes
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Urine
Emesis (vomit)
Diarrhea
Gastric suction
T-tube drainage
Drainage from surgical wounds/other drainage tubes
90
Nursing Diagnoses for Fluid Volume
 Fluid Volume Deficit
 Dehydration
 Hypovolemia
 Fluid Volume Excess
 Hypervolemia
91
Nutrition
 5 food groups
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Breads, cereals, rice, pasta
Vegetables
Fruits
Milk, yogurt and cheese
Meat, poultry, fish, dried beans and peas, eggs, nuts
92
Culture and Nutrition
 Visit the web site listed in the patient study
guide to view and discuss food pyramids
from a variety of cultures
93
Common Therapeutic Diets
 Discuss foods that are and are not allowed on
the following diets
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Regular
Soft
Mechanical soft
Clear liquid vs. full liquid
No added salt (NAS)
High fiber
American Diabetes Association diets
94
Nutritional Assessment
 Gather baseline data
 Include client’s weight
 Identify specific nutritional deficits
 Establish nutritional needs
 Identify physical and psychosocial factors that
may influence nutritional needs
95
Nursing Diagnoses for Nutrition
 Body image disturbance
 Altered nutrition: less than body requirements
 Altered nutrition: more than body
requirements
 Self-care deficit: feeding
96
Nursing Interventions to Promote
Nutritional Well-Being
 Assist with food choices
 Refer to dietician if needed
 Provide comfortable environment
 Free of odors, noise
 Promote appealing food presentation
 Hot/cold food
 Offer to open containers
 Assist with feeding as needed
97
Enteral Tube Feedings
 Enteral feeding involves the delivery of
formula via a tube into the stomach or
jejunum
 Includes
 Nasogastric tube (NG tube)
 Gastric tube (G-tube)
 Jejunal tube (J-tube)
98
Nursing Care with Enteral Tubes
 Check for placement according to hospital
policy
 An x-ray is the only positive method for placement
 Assess bowel sounds
 Assess skin around insertion site
 Keep the head of the bed elevated for
continuous feedings and during intermittent
feedings to prevent aspiration
99
Nursing Care With Enteral Tubes
(continued)
 When delivering medications through a NG
or G tube:
 Dissolve the tablet in water
 Flush the tube before and after delivering the
medication
 Blood glucose monitoring is often done
during enteral feedings as the solutions can be
high in glucose
100
Total Parenteral Nutrition (TPN)
 A form of nutritional support in which
nutrients are given intravenously
 The patient must have a central venous access
system in place
101
TPN Complications
 Complications can be reduced by meticulous
care of the venous access device
 Prevent infection
 Prevent metabolic, electrolyte, fluid balance
complications
 Maintain parenteral system
102
Nursing Care of the Client on TPN
 Change tubing every 24 hours using strict
aseptic technique
 Assess for signs of infection
 Monitor blood glucose
 Daily weight
 Intake and output
103
Health Care of the Older Adult
 Older adults are 65-years-old and older
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65-74
75-84
85-99
100 +
young old
middle old
old-old (fastest growing subgroup)
elite old
104
Health Care of the Older Adult (continued)
 50% of hospitalized clients on med-surg units
are older than 65
 8% of elderly have 1 or more chronic
illnesses
 50% have 2 or more chronic illnesses
 5% live in institutional settings
105
Assessment Guidelines for Older Adults
 Adjust to physiologic changes
 Be familiar with sensory changes, changes in each body
system
 Adapt assessment techniques to diminishing
energy and ability
 Allow for frequent breaks if a lengthy assessment is
needed
106
Assessment Guidelines
(continued)
 In addition to physical assessment, the older adult
may need assessment of:
 Ability to perform ADL’s (Activities of Daily Living functional assessment)
 Network of support (family and friends)
 Health beliefs in nutrition, exercise, etc.
 Sleep patterns
 Living arrangements
 Financial assessment
 Self-esteem
 View of life and acceptance of death
107
Reminiscence/Life Review
 An adaptive function that allows them to
recall the past and assign meaning to these
experiences
 Can be a nursing intervention to encourage
self-esteem, increase communication skills,
and increase social interaction
108
Pain and the Older Adult
 May not report pain as feels it is a part of
aging
 85% of patients in nursing homes have pain
 Pain response: have similar pain tolerance as
young adults
109
Pain Assessment
 Use methods as with adults (pain scale)
 Don’t assume that if patient is busy or sleeping, they
don’t have pain; need to ask them
 If cognitive impairment is present, watch for nonverbal cues
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Agitation
Aggression
Wandering
Change in vital signs
Grimacing
110
Pain Management
 Ask what they usually use for pain and is it
working
 If acute pain, can use narcotics but may need
a decreased dose
111
Medications and the Older Adult
 25% of all prescriptions are written for people
older than 65
 Physiologic changes caused by aging affect the
activity and response of drugs
 Absorption, distribution, metabolism, excretion
112
Polypharmacy
 Many older adults are using multiple
medications, use multiple pharmacies, have
multiple physicians
 Multiple drugs may lead to adverse reactions
113
Polypharmacy
 Most common adverse reaction in the elderly
is confusion
 Confusion in the absence of disease is
not normal!!
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Nursing Interventions for
Polypharmacy
 Assess medications they are taking
 Encourage client to use one pharmacy for all
medications
 Encourage client to review with primary
caregiver all medications they are taking
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Medication Noncompliance in the
Older Adult
 May be non-compliant due to:




Not understanding how to take medication
Forgetful
Don’t like the side effects
Don’t have the money to purchase medications
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Nutrition and the Older Adult
 Risk of nutritional problems increases with age
 Energy needs decrease but nutrient needs
remain the same
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Causes of Malnutrition in the Older
Adult
 Loss of teeth
 Digestive system changes
 Loss/decrease of appetite
 Lactose intolerance
 Fixed income
 Lack of socialization during meals
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Nursing Interventions to Improve
Nutrition
 Small, frequent meals
 Assist with food choices
 Identify causes of decreased appetite
 Refer to dentist for teeth issues
 Refer to social services for financial problems
 Discuss ways to improve socialization during
meal time
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Goals for Older Adults
 Follow therapeutic plan of care
 Ensure transportation to MD visits
 Ensure primary physician is aware of all medications
currently taking
 Maximize independence in self-care activities
 Educate about resources to assist them with care if
needed
120
Goals
(continued)
 Maintenance of ability to communicate
 Educate about assistive devises such as hearing aids
 Assist with financial counseling to help pay for these
aids if needed
121
Goals
(continued)
 Maintenance of positive self-image
 Assist the patient to participate in appropriate social
activities to enhance the feeling of worth
 Encourage open expression of concerns such as
feelings of hopelessness
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Goals
(continued)
 Remain free of injury
 In the hospitalized patient
Perform fall risk assessment
Orient to surroundings and re-orient as
needed
Provide assistance with ADL’s
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Goals
(continued)
 Maintain bowel and bladder elimination
patterns
 Discuss nutrition to promote elimination
 Discuss use of medications if prescribed
 Urinary incontinence (loss of bladder control) is a
symptom, not a disease.
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Goals
(continued)
 Maintain adequate nutritional status
 When hospitalized






Intake and output
Daily weight
Dietary referral for preferences
Socialization
Assist with feeding
Liquid supplements as needed
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Goals
(continued)
 Maintain adequate fluid and electrolyte status





Place water within easy reach of the client
Offer fluids every 1-2 hours
Monitor electrolytes
Intake and output
Administer and monitor IV fluids if needed
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End-of-Life Issues
 Death and Dying
 Nurses must recognize influences on the dying
process





Legal
Ethical
Religious
Spiritual
Biological
 Provide sensitive, skilled and supportive care
127
End-of-Life Issues
(continued)
 Both the patient who is dying and the family
members grieve as they recognize the loss
 Nursing Diagnosis of Anticipatory Grieving
includes:
 Denial
worthlessness
 Anger
concentrate
 Feelings of guilt
 Inability to concentrate
128
End-of-Life Legal Issues
 Medical Directive to Physician (Living Will)
 Addresses only the withholding or withdrawal of
medical treatment that would artificially prolong life
 Becomes effective when the primary physician and
one other doctor say in writing that an individual is in
a terminal or irreversible condition and that death will
occur if life-sustaining medical care is not given
 Some states allow for personal instructions to be
added to this document
129
End-of-Life Legal Issues
(continued)
 Advanced Health Care Directive
 Used to be called Durable Power of Attorney
 An Advance Directive that allows an individual to appoint
representatives to make health care decisions if they become
incapacitated
 This document affects only health care and should not be
confused with granting power of attorney for other matters
 Becomes effective when the person becomes terminally ill or
incapacitated.
130
Nursing Responsibility for Advance
Directives
 Each state varies; nurses need to be aware of
requirements for their state
 Be prepared to answer questions from the
patient about these directives
 Ask if your patient has these and make sure
copies are placed in their charts
 Advance Directives must be honored
131
End-of-Life Issues
(continued)
 Artificial Nutrition and Hydration is another
important ethical and legal issue
 Feelings about withholding food and fluids are
emotionally charged and often have religious
connotations.
 U.S. Supreme Court has upheld the right of
patients to accept or reject the administration
of artificial nutrition and hydration.
132
End-of-Life Issues
(continued)
 Hospice Care
 Focuses on support and care of the dying person and
family
 Goal: to facilitate a peaceful and dignified death
 Based on holistic concepts
 Improve quality of life rather than cure
 Support patient and family
133
Hospice Care
(continued)
 Principles of hospice care can be carried out
in a variety of settings
 Home and hospital are the most common
settings
 Palliative care: differs from hospice in that the
client is not necessarily believed to be dying
134
Nursing Care of the Dying Patient
 Provide personal hygiene measures
 Relieve pain
 Essential for patient to maintain some quality in their
life
 Assist with movement, nutrition, hydration,
elimination
135
Nursing Care
(continued)
 Provide spiritual support
 Arrange access to individuals who can provide
spiritual care
 Facilitate prayer, meditation and discussion with
appropriate clergy or spiritual advisor
136
Nursing Care
(continued)
 Support patient’s family
 Use therapeutic communication to facilitate their
feelings
 Display empathy and caring
 Educate family on what is happening and what the
family can expect
 Encourage family members to participate in the
physical care of the patient
137
Do Not Resuscitate
 Also called DNR, No Code
 Must be written
 Must be reviewed regularly as per policy
 May have specific requests
 Example: may okay vasopressors and fluids but no
chest compressions or intubation
138
Photo Acknowledgement:
Unless noted otherwise, all photos and clip art
contained in this module were obtained from the
2003 Microsoft Office Clip Art Gallery.
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