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cswett
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Patient confidentiality
- •Restrict access
- •Ethical codes and legal responsibility
- •Adhere to policies and procedures to ensure privacy and confidentiality
- •Passwords required & should not be shared
- •Logged in?- don’t leave the computer terminal unattended
- •Do not leave client information displayed
- •Shared all unneeded computer-generated worksheets
- •Know the facility’s policy & procedure for correcting an entry error
- •Follow agency procedures for documenting sensitive material
- •Firewalls- protect server from unauthorized access
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Subjective Data
Objective Data
- Subjective Data - info obtained from what the client says - describes cleints perceptions of and experience with the problem
- - use quotes or summarize - subjective data is only incluses when it is important and relevant to the problem
Objective data - information that is measured or observed by the sences
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Medical vs Surgical Asepsis
- •Medical asepsis
- –Includes all practices intended to confine a specific microorganism to a specific area
- –Limits the number, growth, and transmission of microorganisms
- -Objects referred to as clean or dirty (soiled,
- contaminated)
- •Surgical asepsis
- –Sterile technique
- –Practices that keep an area or object free of all microorganisms
- –Practices that destroy all microorganisms and spores
- –Used for all procedures involving sterile areas of the body
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Body Mechanics
- •Proper alignment
- •Wide base of support
- •Avoid bending and twisting
- Squat to lift
- •Keep objects close when lifting
- •Raise beds
- •Pull rather than push
- •Push rather than lift
- •Get help
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Types of Wounds
- •Intentional- surgery
- •Unintentional- accidental trauma
- –Incision- surgery
- –Contusion- bruise from blunt instrument
- –Abrasion- surface scrape
- –Puncture- penetration of skin with sharp instrument
- –Laceration- tissues torn apart
- –Penetrating wound - penetration of skin & underlying tissues, bullet
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Exudate
- •Material such as fluid and cells that have escaped from blood vessels during inflammatory process
- •Deposited in tissue or on tissue surface
- •3 major types
- –Serous -
- •Mostly serum
- •Watery, clear of cells
- •E.g., fluid in a blister
- –Purulent-
- •Thicker
- •Presence of pus (suppuration)
- •Pus- WBCs, dead debris, bacteria
- •Color varies with organisms
- Sanguineous (hemorrhagic) -
- •Hemorrhagic
- •Large number of RBCs
- •Indicates severe damage to capillaries
- •Serosanguineous
- –Clear and blood-tinged drainage
- –Surgical incisions
- •Purosanguineous
- –Pus and blood
- –New infected wound
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Pressure Ulcers
any lesion caused by unrelieved pressure that results in damage to underlying tissue.
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Risk Factors for Pressure Ulcers
- •Friction & shearing- sheets, sliding down from Fowler’s
- position
- •Immobility
- •Inadequate nutrition
- •Fecal and urinary incontinence
- •Decreased mental status
- •Diminished sensation
- •Excessive body heat
- •Advanced age
- •Chronic mental conditions
- •Poor lifting and transferring techniques
- •Incorrect positioning
- •Hard support surfaces
- •Incorrect application of pressure-relieving devices
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Four Stages of Pressure Ulcer Formation
- •Stage I:
- –nonblanchable erythema signaling potential ulceration
- •Stage II:
- –partial-thickness skin loss involving epidermis and possibly dermis
- •Stage III: –full-thickness skin loss involving damage or
- necrosis of subcutaneous tissue
- •Stage IV: –full-thickness skin loss with tissue necrosis or
- damage to muscle, bone, or supporting structures
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Preventing Pressure Ulcers
- •Providing nutrition
- •Maintaining skin hygiene
- •Avoiding skin trauma
- •Providing supportive devices
- •Fluid intake- 2,500 ml
- •Protein, vitamins (A, C, B1, B5, zinc
- •Dietary consult
- •Weight/lab data monitoring
- •Nutritional supplements
- •Monitor weight/lab values
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Effects of Heat
- •Vasodilation
- •Increases capillary permeability
- •Increases cellular metabolism
- •Increases inflammation
- •Produces sedative effect
- •Indications for heat
- –Muscle spasms
- –Inflammation
- –Pain
- –Contracture
- –Joint stiffness
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Effects of Cold
- •Vasoconstriction
- •Decreases capillary permeability
- •Decreases cellular metabolism
- •Slows bacterial growth
- •Decreases inflammation
- •Local anesthetic effect
- •Indications for cold
- –Muscle spasms
- –Inflammation
- –Pain
- –Traumatic injury
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Hypoxia
Hypoxemia
Cyanosis
- Hypoxia - deficiency of O2 anywhere in the body
- Hypoxemia - deficiency of O2 in the blood
- Cyanosis can accompany hypoxemia - high unoxigenatied hemoglobin
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Signs of decreesed oxygenation and tissue perfusion
- Signs of Hypoxia:
- Rapid pulse
- Rapid, shallow respirations and dyspnea
- Increased restlessness or light-headedness
- Flaring of the nares
- Substernal or intercostal retractions
- Cyanosis
- anxious, tried, and drawn face
- orthopenic position
- appear fatigued and lethargic
- Clubbing of nails
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Pursed lip breathing and huff coughing
- •Removes secretions, then expectorate
- •Types:
- •Abdominal (diaphragmatic)
- –Deep full breathes with no effort
- •Purse-lipped
- –Controlled breathing - breathe in deeply through nose, purse lips & whoosh out - dont puff cheeks - count to 7 during exhalation
- –Prolongs exhalation & airway collapse - increases pressure in bronchi and minimizes collapse of smaller airways
- •Huff coughing- keeps airways open while moving secretions up & out
- -after bronchodilator - inhale deep & hold breath for few seconds
- -cough twice - first loosens - second moves mucus
- -inhale by sniffing - short rapid breaths to prevent mucous from moving back into smaller airways
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Promoting good breathing
- •Ensure a patent airway
- •Positioning
- •Encouraging deep breathing, coughing
- •Ensuring adequate hydration
- •Medications
- •Incentive spirometry
- •Chest PT
- •Postural drainage
- •Oxygen therapy
- •Artificial airways
- •Airway suctioning
- •Chest tubes
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Risk Factors for CAD
- •Non-modifiable risk factors
- –Heredity
- –Age
- –Gender
- •Modifiable risks
- –Elevated serum lipid levels-
- •diet high in saturated fats
- –Hypertension
- •Increases work of heart, increasing O2 demand
- •Causes enlarged heart
- •Causes endothelial damage of blood vessels which
- stimulates atherosclerosis
- –Cigarette smoking-
- •increases BP & narrows blood vessels
- –Diabetes
- •Accelerates athersclerosis
- –Obesity
- •Often has elevated lipid levels
- •Increases workload of heart
- –Sedentary lifestyle
- •Exercise benefits:
- –Increase HR & O2 supply
- –Heart muscle more efficient
- –Slows down athersclerosis
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