Code of Ethics
Developed by the ANA, this document outlines rules for nurses about client privacy, nursing conduct, and nursing behaviors to protect clients and the profession.
PQRST
Provocation/Precipitating cause
Quality
Region (or Radiation): "Can you point to where you are having your pain?"
Severity(or Scale)
Timing
Assessment
Subjective: current complaint, history, medications, etc.
Objective: vital signs, intake & output of fluids, height/weight
What are the four most common HAI's?
1. Catheter-associated urinary tract infections (CAUTI)
2. Central line-associated bloodstream infections (CLABSI)
3. Surgical site infections
4. Ventilator-associated pneumonia
Gastrointestinal complications of immobility
Malnutrition, constipation, fecal impaction, GERD, heartburn.
Aspiration Precautions
Head of bed up
Thickened liquids
SLP for swallowing
Routine oral care
Chin to the chest when swallowing
Key Principles of the Code of Ethics
Advocacy
Responsibility
Accountability
Confidentiality
Numeric Rating Scale
The most frequently used pain scale is where the client is asked to rate the intensity of their pain on a scale from 0 to 10, with 0 being no pain and 10 being the worst pain the client can imagine.
Diagnosis
RN's clinical judgment about actual or potential health problems to help priortize and plan care.
Standard Precautions
Type of precautions used on all patients
Gloves
Tissue integrity risk factors for immobility
pressure injuries
Post-Op Complications for Infection
Increased pain
Severe redness
Swelling
Warm to touch
Drainage
Low BP
Increase respiration
Fever
Increased WBC
Integrity
The quality of being honest and having strong moral principles. (Think my ‘INtention is to always be honest)
Wong-Baker FACES Pain Rating Scale
Scale with facial expressions to indicates level of pain. Appropriate to use in children ages 3 and older.
Planning
Goals and outcomes formulated, personalized, to individuals unique needs
Contact Precautions
Precautions used when a client has an infectious agent that can be transmitted by direct or indirect contact with body secretions
Requires a minimum of gown and gloves before client interactions
Circulation risk factors for immobility
Deep vein thrombosis (DVT) occurs when a thrombus or blood clot develops in one or more of the deep veins, typically in the arms, pelvis, thighs, or lower legs. Immobile clients are at a greater risk for developing a DVT due to their increased blood viscosity and the atrophy of muscles that normally assist the body in pumping blood.
The most serious complication of DVT is a pulmonary embolism, which occurs when part of the thrombus breaks off and travels into the lungs via the bloodstream.
Ergonomics
Study of body mechanics concerning the demand and design of the work environment and the equipment used.
Autonomy
The right to make his or her own decisions
(think All by myself)
Face, Legs, Cry, Consolability (FLACC) scale
This scale is an observational pain measurement tool designed to be used with children 2 months to 7 years and clients who are cognitively disabled.
Implementation
Carrying out interventions outlined like cardiac monitor or oxygen, medication, and standard protocols
PPE Removal for Contact Precautions
Always remove PPE inside the client’s room if the client is prescribed contact precautions to avoid contaminating surfaces outside the client’s room.
Immobility for bone density
Resistance to extension of an extremity
What can the use of ergonomics increase and decrease?
Increase work satisfaction
Maximize productivity
Decrease the risk of injury and fatigue
AlTRUism
To do something, or take action, for the sake of benefiting someone else.
(think “It's TRUE I don’t expect anything in return when I help others”)
Practice Question: How do you determine pain in a patient who is cognitively disabled?
Use the Face, Legs, Activity, Cry, Consolability (FLACC) Scale.
Evaluation
Evaluate implementation to ensure desired outcome has been met: continous reassessment may be needed
Droplet Precautions
Don a mask when entering the room or coming into close contact with the client.
Respiratory risks with immobility
Atelectasis:
Partial or complete collapse of the lung, including airways and small sections of lung tissue.
Rapid, shallow breathing
Treatment: Deep breathing exercises 1 to 2 hours, bronchodilators
Examples of Ergonomic Practices and Equipment in Health Care
Modifiable workstations and chairs
Keyboards with wrist supports
Adjustable IV stands and poles
Height-adjustable beds
Two-person lifts/transfers
Client transfer devices
Shower chairs
Toilet seat risers
Side-opening garbage and linen containers
Elimination of uneven floor surfaces
Accountability
Responsible for all actions( think I am ‘accountable’ for my actions)
Nonverbal Pain Scale
Designed for clients who are unable to verbalize their pain level. This is for client who may be unconscious.
Determining Client Priority
Airway
Breathing
Circulation
The client that may deteriorate very quickly
Airborne Precautions
Used when a client has an infectious agent that can be transmitted through the air. You should don an N95 mask or a high-level respirator when entering the room of a client.
Client should be placed in a negative pressure air room (also called an Airborne Infection Isolation Room)
Orthostatic Hypotension
A decrease in blood pressure that occurs upon standing, especially from a lying or sitting position. A significant drop in blood pressure is caused by a change in position.
Fecal Occult Blood Test
A fecal occult blood test (FOBT) checks the stool for the presence of blood.
Test: Uses two drops(samples) one on 'A' and 'B' of square.
30 seconds for results
Nursing Managers
Nurse managers are responsible for their staff and unit functioning well. Their responsibilities include hiring, orienting, scheduling, evaluating, problem-solving, managing budget needs such as supplies and staffing, ensuring workplace staff and client satisfaction, and providing oversight of the safety, care, and positive outcomes of the clients on the unit.
CRIES Scale
The Crying, Requires oxygen, Increased vital signs, Expression, Sleeplessness (CRIES) Scale is an observational scale used for infants who were born at 38 weeks of gestation or greater.
Adult BP
Expected: Systolic 90 to 119
Diastolic 60 to 79mm Hg
A nurse is caring for a patient who has airborne precautions. What PPE should they don?
N95 mask
No assistance
The client can stand, march or step in place, and walk without any help.
The three layers of skin
Epidermis compromised of epithelial cells
Dermis
Subcutaneous
Nursing Educator
provides health care information to clients or teaches nursing students
Adult Pulse
Expected: 60 to 100 bpm
Minimal assist
The client can rise from a seated position and sustain a steady stand.
Use a gait belt and ambulation assistive device.
Nurse researcher
develops evidence-based information for nursing practice
Adult Temp
96.8°F (36°C).-100.4°F (38°C)
Moderate assist
The client can maintain a seated position and has some upper extremity strength but lacks enough lower extremity strength to transfer safely.
Case managers
coordinates care for the client with all team members
Maximum assist
The client cannot bear weight, assist, or maintain a seated position. Use a total mechanical lift or sling.
Nurse leader
manages and motivates a group toward achieving a common goal.
The nurse is preparing to conduct a mobility assessment for a client. What are the six steps?
Extend arm to shake hands with client’s farther upper extremity
Instruct the client to sit on the edge of the bed for at least 2 minutes
Instruct client to extend one leg, flex ankle, and point toes.
Request the client to stand at the bedside for at least 5 seconds.
Request the client to walk or march in place.
Ask the client to take a few steps forward and then backward.
What is a change agent?
A change agent sees a need and takes action to make a change.
Assistive Devices
Gait belt
Cane
Walker
Crutches
Slide board
Pivot disc
Mechanical sit-to-stand lift
Advocacy
Speaking up for clients' needs when clients are unable to speak for themselves, and supporting clients to make choices for their health.