FUNDAMENTALS PATIENT CARE
notes by Kemi Peterside
Fundamentals Patient Care
notes by Kemi Peterside
THE NURSING PROCESS TERMS
the systematic guide to patient centered care with Subjective data - what patient says e.g
five sequential steps. nausea, pain, headache.
A - assessment Objective data - observed or measurable
D - diagnosis signs & symptoms e.g vitals, i/o, rash.
P - planning Maslow’s hierarchy of needs - a five tier
I - implementation model of human needs which states that
E - evaluation physical needs come before psychological
needs.
ASSESSMENT: gathering information and Primary source - patient
recognizing cues using subjective and objective Secondary source - patient’s family
data.
DIAGNOSIS: prioritizing needs and identifying
problems.
PLANNING: setting goals and outcomes using
SMART goals.
S -specific
M - measurable
A - attainable
R - realistic
T - timely
IMPLEMENTATION: taking actions and
teaching patients.
EVALUATION: reassess patient to see if goals were
met. MASLOW’S HIERARCHY OF NEEDS
CRITICAL JUDGEMENT & THINKING
Critical thinking - ability to think
systematically and logically.
Critical Judgement - outcome of critical thinking
and decision making which partly relies on
knowing the patient and the nurses experience.
- notes by Kemi Peterside
LEVELS OF CRITICAL THINKING TERMS
• basic Transformational leadership - staff
• complex involvement in patient care
• commitment Decentralized management - allows
COMPONENTS OF CRITICAL THINKING decisions to be made at the staff level.
• specific knowledge based Responsibility - duty to act
• experience Autonomy - freedom to act
• competence Authority - power to act
• attitude Accountability - owning the act
• standards Moral - value a person attaches to rights
COMPONENTS OF DIAGNOSIS Ethics - study of right or wrong in relation to
• actual problem a persons behavior
- nursing problem
- related to
- as evident by
e.g impaired gas exchange related to pulmonary NURSING STUDENT LEADERSHIP
fluid accumulation as evident by crackles on SKILLS
auscultation. - learning form previous mistakes
• potential problems - consulting with others
- risk for - communication
- related to
• health promotion CHARACTERISTICS OF A GOOD LEADER
- readiness for learning - role model for staff
- delegates work appropriately
PATIENT CENTERED CARE - effective communication
- adapting care as needed for individual change - show appreciation for a job done
- taking time to ensure patients understand - displays empathy
info about their health - shows appreciation to staff
- conveying respect for patient health & lifestyle - knowledgeable & empowers others
choices
DIRECT PATIENT CARE
offers hands on, face-to-face contact with
patients.
- notes by Kemi Peterside
THEORETICAL ETHICS
Deontology - uses rules to distinguish right from wrong
Utilitarianism - actions are right if they are useful or for the benefit of a majority
Beneficence - doing good to others
Non-maleficence - do no harm
Justice - all patients treated fairly & equally
CLINICAL CARE COORDINATION
STUDENT NURSE
decide: life decisions clinical decisions
prioritize: family, work, school patient needs
organize: family, work, school multiple priorities
resources: money, time, energy medical supplies
time: multiple deadlines multiple deadlines in a shift
evaluation: what works/doesn’t work. patient outcomes
LAWS IN NURSING PRACTICE
Statutory law: written laws enacted by the federal or state legislature.
Civil law: designed to monetarily compensate individuals for harm caused to them.
Criminal law: negligent nursing errors can result in criminal charges for assault, neglect,
or negligent homicide.
Battery: the intentional act of causing physical harm to someone
Assault: the intentional act of making someone fear that you will cause them harm
Tort: act or omission that gives rise to injury or harm to others
Living will: legal document used by patients for future health decisions
Power of attorney: grants in writing a particular agent the power to make healthcare decisions
on another's behalf
DNR: client requests no further measures to be takes to prolong life
DOA: legal document that names a proxy to make healthcare decisions for an individual who
is unable to do so themselves
- notes by Kemi Peterside
DELEGATION & SUPERVISION
RIGHTS OF DELEGATION
• right task: delegate tasks allowed by workplace policy or state laws
• right circumstance: know patient status
• right person: ensure assistant has right knowledge and level of skill
• right direction: communicate timeframe, goals, and when to report results
• right supervision: followup on delegated tasks
NURSE LPN CNA/UAP
IV push monitor. vitals
Blood transfusion administer medication ambulation
Nursing process (no titration) feeding
Central line can assess & teach I & O recording
Assessment/reassessment (long term patients, no bathing
Follow up tasks new admits or post op) position change
DO NOT DELEGATE
unstable patients (change in level of neuro status, new admits, post operative or procedure,
unstable labs)
teaching (initial or primary)
assessment (first, post operative, initial)
evaluation (lab values, pain)
- notes by Kemi Peterside
FLUIDS & ELECTROLYTES
Osmolarity: particles in a fluid contributing to it’s concentration
Diffusion: passive movement of particles down a concentration gradient
Active transport: use of energy to move across the cell membrane
Hydrostatic pressure: outward force against a surface
Osmotic pressure: inward pulling force toward a higher concentration
Hypertonic solution: high osmolarity
Hypotonic solution: low osmolarity
Isotonic solution: balanced osmolarity
Osmolarity imbalance: blood is too concentrated or dilute. High osmolarity needs hypotonic
fluid, low osmolarity needs hypertonic solution.
HOW FLUID MOVES TO CELL
Vascular system —> Capillary membrane —> Interstitial area —> Cell membrane
OSMOLARITY TESTS
- blood test —> 285 - 295 mmol/kg - urine specific gravity —> 1.005 - 1.030
- hematocrit & hemoglobin - sodium
CAUSES OF ELECTROLYTE IMBALANCE
- infection/ environment - medication side effects - organ failure
HOW TO CHECK FLUID VOLUME STATUS
- assess for jugular veins - assess lung sounds - check for edema
- input & output - weight - orthostatic vitals - blood pressure & pulse
- notes by Kemi Peterside
TYPES OF IV FLUIDS
- potassium chloride - dextrose 5% - 0.45 saline - 0.9 saline
- lactated ringer
IV RANGE -> gauge diameter flow rate age color
24 0.6 36 baby yellow
22 0.9 56 baby/child blue
20 1.1 80 child/adult pink
18 1.3 120 adult green
16 1.8 230 adult green
14 2.0 270 adult orange
SAFETY CONSIDERATIONS FOR CENTRAL VENOUS ACCESS
- sterile procedure - sterile dressing change - chest x-ray to verify placement
- education on signs & symptoms of infection - gauge disc to reduce infection risk
TRANSFUSION REACTIONS
* acute intravascular hemolytic: due to incompatibility.
SIGNS: blood in urine, low urine volume, shock, death, cardiac arrest, tachycardia,
hypotension
* febrile non hemolytic: antibodies attach white blood cells.
SIGNS: muscle pain, headache
* allergic reaction: antibodies attach plasma proteins.
SIGNS: hive, itching, flushing
* anaphylactic reaction: shortness of breath, cyanosis, shock, wheezing
- notes by Kemi Peterside
SLEEP & PAIN
Sleep is needed for restoration of body function. The body’s sleep sleep wake cycle is called the
circadian rhythm which is primarily controlled by the hypothalamus.
STAGES OF SLEEP
* N1: lightest level of sleep, lasts a few minutes, easily aroused.
* N2: relaxation process, brain activity continues to slow.
* N3: slow wave, deepest level of sleep, difficult to waken, low range of vitals.
* REM: stage of random eye movement, dream state, approximately 90 minutes after falling
asleep.
SLEEP CONDITIONS
Insomnia: sleep disorder, stress and depression contributes to insomnia
Sleep apnea: obstruction of airway making it difficult to sleep
Narcolepsy: sudden muscle weakness , people with thus condition can suddenly fall asleep at
any point and reach REM quickly, they are also a driving risk
Acute/chronic sleep deprivation: sleep disorder caused by illness, stress, medication, or
environmental disturbance
Parasomnia:often seen in kids, sleepwalking, bedwetting, sleep paralysis, and might terrors
LIFESPAN CONSIDERATIONS
Baby: 15-16 hrs sleep/day, 50% REM sleep
Toddlers: 12 hrs sleep/day, low REM sleep
Preschool: 9-12 hrs sleep/day, more daytime activities, parasomnia or sleep walking
Adolescent: 7 hrs sleep, poor sleep due to technology
- notes by Kemi Peterside
Young & middle adult: 6-9 hrs sleep/day, Low N3 sleep, insomnia
Older adults: take longer to fall asleep, low REM sleep
PAIN
Pain is subjective and differs per individual. Severe pain stimulates the vagus nerve which
leads to pallor, low heart rate, high blood pressure, irregular breathing.
TYPES OF PAIN
Acute pain: sudden and short term pain
Chronic pain: re occurring and long term pain
Visceral pain: pain that originates from the organs
Idiopathic pain: unknown cause of pain
Somatic pain: pain that originates from the skin, muscles, bones, and joints.
FACTORS INFLUENCING PAIN
- developmental stage - age - previous pain experience
- culture - environment - support system
- notes by Kemi Peterside
BOWEL ELIMINATION
FACTORS AFFECTING ELIMINATION
- age - diet - fluid intake - psychological factors - physical activity
- personal habits - positioning - pain - pregnancy - medications
- surgery & anesthesia
ASSESSMENT
- changes in appetite - weight gain or loss - last bowel movement - was it formed
- assess abdomen (inspect, auscultation, palpate)
CONDITIONS AFFECTING THE BOWELS
CONSTIPATION - unrelieved constipation can lead to impaction which results in intestinal
obstruction.
DIARRHEA - excess loss of fluids result in dehydration and electrolyte imbalance. Infants and
older adults are susceptible to complications.
C. DIFF - the most common health care infection. Patient to be on isolation to prevent spread.
BOWEL INCONTINENCE - inability to control the passage of gas & feces. Can lead to
incontinent associated dermatitis.
CROHN’s DISEASE - inflammatory bowel disease that affects the lining of the GI tract.
symptoms include stomatitis, weight loss, decreased appetite.
COLORECTAL CANCER - found in the intestine due to abnormal growth called polyps. Risk
factors include lack of physical activity, frequent constipation, lack of fiber in diet, obesity,
tobacco & alcohol use. Treated with surgery or chemotherapy.
- notes by Kemi Peterside
TREATMENT
• enema - promotes evacuation of feces from the colon. Includes tap water, saline, hypotonic,
and hypertonic enema.
• digital removal - stimulates vagus nerve which causes bradycardia.
BOWEL DIVERSIONS
Ileostomy - stoma made in the ileum causing liquid stool
Colostomy - stoma made in large intestine causing formed stool
CONSIDERATIONS
- food blockage avoid foods with indigestible fiber such as sweet corn, popcorn, raw mushrooms,
and cabbage.
- empty pouch when one third to one half full. Change pouch every 3-7 days
- consult wound, ostomy, and continence nurse (WOCN)
COMPLICATIONS - skin breakdown, infection
- notes by Kemi Peterside
PERIOPERATIVE NURSING
NURSING GOAL
- quality improvement and evidenced based practices - high quality care
- teamwork & collaboration - effective communication - cost containment
- advocacy for patient & family - timely assessment and interventions
RISK FACTORS FOR SURGERY COMPLICATIONS
- age - smoking - nutrition - obesity - immunosuppression
- fluid & electrolyte imbalance - postoperative nausea & vomiting
- obstructive sleep apnea - vein thromboembolism
PERIOPERATIVE PHASES
Pre operative phase - begins at decision to have surgery, assessment, risk factors, cultural
considerations, labs & diagnostic testing, communication preference, medication reconciliation,
allergies, smoking & drinking habits, pregnancy status, support after surgery, occupation.
Intraoperative phase - begins from admission to surgical department. Acute care, introduction
of anesthesia, positioning patient for surgery, documentation of intraoperative care.
Postoperative phase - patient is transported to PACU. Main focus is pain management, monitor
airway, transfer & neurological function & discharge planning.
- notes by Kemi Peterside
LOSS & GRIEF
LOSS
Loss: inevitable change that occurs with life. People respond to loss differently. It could be based
on their culture, spirituality, persona, beliefs, previous experiences. Degree of social support also
influences the way a person responds to death.
Actual loss: lost that can be physically seen (for example: objects, loss of body parts, loss of a
family member).
Necessary loss: losses that are necessary to bring about a change (for example: divorce, death of
a loved one).
Matriarchal loss: reaching adulthood and maturing (for example: a child not wanting to leave
their parents)
Situational loss: they are sudden and unpredictable (for example: automobile accidents,
effecting ADL’s).
Perceived loss: a loss that is not visible to others (for example: loss of a job).
GRIEF
Grief: a normal process someone goes through in response to loss, particularly the loss of
someone or something to which a person has formed a bond.
Mourning: the social expression of grief.
Bereavement: refers to the period of mourning and adjustment following the death of a loved
one. It encompasses the emotional, cognitive, physical, and social reactions to loss.
TYPES
normal (uncomplicated): normal expected reaction to loss, wide ranges of emotion, changes in
cognitive behavior.
- notes by Kemi Peterside
Anticipatory: anticipating something to happen, occurs before the loss
actually happens (Eg: child caring for parent with dementia)
Disenfranchised: when the person loses someone and they can’t talk to others about it.
Complicated: occurs when the grieving process goes past normal expectations.
Exaggerated: may display destructive behavior.
Delayed: postponed reaction to loss.
THEORIES OF GRIEF & MOURNING
KUBLER-ROSS STAGES OF DYING
Denial: unable to accept the fact they lost someone, psychological protection against lost
Anger: express of resistance.
Bargaining: postpone awareness of the loss, may start praying or ask for help
Depression: acceptance of the lost, suffering from the impact of loss.
Acceptance: final stage of grief, acceptance of situation.
OTHER THEORIES
Attachment theory
Grief task models by warden
Dual process model
Stages of dying
Rando’s R process model
ORGANIZATIONS THAT ASSIST WITH END OF LIFE CARE
End-of-life- nursing consortium (ELENC): provides nursing with basics and advanced
curriculum to care for patients and family members who are experiencing loss and grief.
American nurses association (ANA): set up scope of practice for palliative and hospice.
American society of pain management nurses: deals with pain end of life.
American association of critical care nurses: assists with end of life planning.
- notes by Kemi Peterside
FACTORS THAT INFLUENCE LOSS & GRIEF
Human development: maturity level
Personal relationships: influences grief response (Eg; grandchild-grandparent relationship)
Nature of loss: e.g Covid-19
Coping strategies
Socioeconomic loss: limited resources
Culture
Spiritual & religious beliefs
NURSING DIAGNOSIS
- Impaired family coping - death anxiety - pain - dysfunctional grief
- anticipatory
HEALTH PROMOTION
Palliative care: focuses on the prevention, relief and reduction of symptoms. Goal is to help
patient achieve the best possible quality of life.
PS: you don’t have to be dying to receive palliative care
Hospice care: focuses on the care of terminally ill patients. Goal is to manage pain, provide
comfort, and ensure quality of life while also prioritizing care according to patient’s wishes.
Therapeutic communication: establishes a caring and trusting relationship using open ended
questions which allows more insight on what patients are going through.
PHYSICAL CHANGES BEFORE DEATH
- increased period of sleeping/unresponsiveness - circulatory changes
- bowel/bladder incontinence - decreased/dark urine - restlessness
- confusion - disorientation - decreased intake of food/fluids - death rattling
- altered breathing pattern
- notes by Kemi Peterside
ROLE OF THE NURSE
- therapeutic communication - symptom management - psychosocial care
- spiritual e.g bringing in chaplains
CARE AFTER DEATH
- organ & tissue donation - autopsy - postmortem care
