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Computerized Charting, Emergency Assessment, Nursing Diagnosis and Nursing Process

Computerized Charting, Emergency Assessment, Nursing Diagnosis and Nursing Process. PN 103. Computers. M ainframe computers -data processing tasks -billing P hysician orders Pharmacy Laboratory D iagnostic imaging orders C entral supply requests C are planning

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Computerized Charting, Emergency Assessment, Nursing Diagnosis and Nursing Process

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  1. Computerized Charting,Emergency Assessment,Nursing Diagnosis andNursing Process PN 103

  2. Computers • Mainframe computers -data processing tasks -billing • Physician orders • Pharmacy • Laboratory • Diagnostic imaging orders • Central supply requests • Care planning • Documentation

  3. Computers • Bedside or handheld terminals for data entry.

  4. Computers • A password used to enter and sign off • Computer files should not be shared with another caregiver. • Never leave the computer terminal unattended after being logged on. • Follow the correct protocol for correcting errors. • Make sure that stored records have backup files.

  5. Computers • Do not leave information about a patient displayed on a monitor where others can see it. • Follow the agency’s confidentiality procedures for documenting sensitive materials. • Printouts of computerized records should be protected.

  6. Obtaining Medical Emergency Aid • The nurse: -ability to recognize the need for medical assistance -knowledge of how to obtain medical emergency aid -can mean the difference between life and death to an injured or ill person. -must be prepared to provide cardiopulmonary resuscitation (CPR) if needed until emergency medical assistance arrives

  7. Moral and Legal Responsibilities of the Nurse • Good Samaritan Laws • Protects health professionals from legal liability when providing emergency first aid • Follow a reasonable and prudent course of action • Victim must give verbal permission. -assumes that an unconscious person would give consent if he or she were able. Once first aid is initiated, the nurse has the moral and legal obligation to continue the aid until the victim can be cared for by someone with comparable or better training

  8. Triage • The medical screening of patients to determine their relative priority for treatment • Need to treat the most urgent symptoms or patients first • Critical thinking skills

  9. Shock • An abnormal condition of inadequate blood flow to the body’s peripheral tissues -life-threatening cellular dysfunction -hypotension -oliguria. -failure of the cardiovascular system to sufficient blood circulation to the body’s tissues -decreased metabolic waste removal. • To maintain circulatory homeostasis -a functioning heart to circulate blood -sufficient volume of blood.

  10. Shock • Classification of Shock • Severe blood loss • Intense pain • Extensive trauma; burns • Poisons • Emotional stress or intense emotions • Extremes of heat and cold • Electrical shock • Allergic reactions • Sudden or severe illness

  11. Shock • Assessment • Level of consciousness • Skin changes • Blood pressure • Pulse • Respirations • Urinary output • Neuromuscular changes • Gastrointestinal effects

  12. Shock • Nursing Interventions • Establish airway. • Control bleeding. • Reduce pain. • Position the victim flat with the head slightly lower than the rest of the body (elevate the feet and legs). • If victim is unconscious or is vomiting or bleeding around the nose or mouth, position on the side. • If victim is having breathing problems, elevate head and shoulders.

  13. A, Modified TrendelenburgB, If head, neck, or spinal injuries are suspected.C, Breathing problems

  14. Shock • Cover victim with a blanket or other covering to keep warm. • Do not give anything to eat or drink. • Relieve pain: support injury; avoid rough handling; adjust tight or uncomfortable clothes. • Do not give analgesics unless directed by a physician. • Provide emotional support and reassurance.

  15. Bleeding/Hemorrhage • Effects of Blood Loss • Decrease in oxygen supply to the body. • Blood pressure drops. • Heart pumps faster -compensates for the decreased volume and blood pressure. • Can result in shock and death.

  16. Bleeding/Hemorrhage • Types of Bleeding • Capillary • most common • damaged or broken capillaries • oozing of minor cuts, scratches, and abrasions • Venous • vein is severed or punctured • slow, even flow of dark red blood • embolism -if air enters the severed vein. • Arterial • Least common • usually protected by bones, fat, and other structures • Heavy spurting of bright red blood in the rhythm of the heartbeat

  17. Bleeding/Hemorrhage • Nursing Interventions • Direct pressure -apply direct pressure over the bleeding site. -raising the bleeding part of the body above the level of the heart -decreases the amount of blood flow -increase the body’s ability to clot at this site

  18. Bleeding/Hemorrhage • Indirect pressure • Indirect pressure may be applied to any of the pressure points situated along main arteries. • Application of a tourniquet -used only when the other methods have failed -the victim’s life is in danger. -can cause extensive damage to the body part.

  19. Bleeding/Hemorrhage • Internal Bleeding • Apotentially life-threatening situation. -fractures -knife/bullet wounds -crushing injuries -organ injuries -ruptured aneurysms. • Assessment • Signs and symptoms of shock • Vertigo • Hemoptysis or hematemesis • Melena • Hematuria

  20. Bleeding/Hemorrhage • A medical emergency. • Place on a flat surface with legs elevated. • Establish an airway. • Cold compress or ice is placed on the area of injury. • Maintain body temperature with blankets. • Assess vital signs. • Oxygen may be ordered by the physician

  21. Wounds and Trauma • Closed Wounds • Underlying tissue of the body is involved • Top layer of skin is not broken. • Ecchymoses (bruises)/contusions • Signs and symptoms -edema -pain and tenderness -discoloration -signs of internal bleeding -deformity -shock

  22. Wounds and Trauma • Nursing interventions • Small wound: -ice packs and elastic bandage • Large wound: -treat for shock -cold compresses and pressure bandage

  23. Wounds and Trauma • Nursing interventions • Small wound: ice packs and elastic bandage • Large wound: treat for shock; cold compresses and pressure bandage

  24. Wounds and Trauma • Open Wounds • Openings or breaks in the mucous membrane or skin • Always danger of bleeding or infection • Types • Abrasions • Puncture wounds • Incisions • Lacerations • Avulsions • Chest injuries

  25. Wounds and Trauma • Dressings and Bandages • Bleeding should be controlled before bandage is applied. • Use sterile material if possible; if not use, the cleanest material possible. • Dressing should never cover the entire wound. • Wounds should be bandaged firmly but not too tightly. • Bandage in alignment is desired. • Tips of fingers and toes should remain exposed if possible.

  26. Poisons • Assessment of Poisonings • Signs and symptoms may be delayed for hours. -respiratory distress -pain on swallowing -nausea/vomiting -unusual urine color -diarrhea -cardiac arrest. -seizures -abnormal eye movement -restlessness -delirium -agitation -color changes -signs of burns -skin irritation -shock -decreased level of consciousness -abnormal constriction or dilation of pupils

  27. Poisons • Ingested Poisons • Most common type of poisoning -especially in children. -household cleaning products -garden and garage supplies -drugs/medications -food -plants

  28. Poisons • Nursing interventions • Maintain airway. • Call the poison control center. • Dilute the poison by giving one or two glasses of water. • Induce vomiting if gag reflex is present and poison is not a corrosive. • Treat for shock and administer CPR if needed

  29. Poisons • Inhaled Poisons -carbon monoxide -carbon dioxide, -refrigeration gases -poisonous fumes from chlorine and other liquid chemical sprays • Nursing interventions • Remove victim from the dangerous area • Maintain airway; perform CPR if needed. • Victim should remain quiet and inactive while being transported to the nearest medical facility

  30. Poisons • Absorbed Poisons • Poisons, caustic chemicals, and poisonous plants -come in contact with the skin -burning -allergic responses -skin irritation -severe system reactions • Signs and symptoms -nausea/vomiting/diarrhea -CNS reactions -flushed skin -dilated pupils -cardiovascular abnormalities

  31. Poisons • Nursing interventions • Quickly remove the source of the irritation; -wash with soap and water. -baking soda -Burow’s solution -oatmeal. -calamine lotion/hydrocortisone cream -effective to relieve pruritus

  32. Poisons • Injected Poisons • Minor reactions to insect bites • Remove stinger • Wash with soap and water. • Apply cold packs; baking soda paste.

  33. Poisons • Severe reactions to insect bites • Urticaria • Wheezing • edema of the lips and tongue • generalized pruritus • respiratory arrest • Nursing interventions • Apply a wide constricting band proximal to the wound • keep affected part in dependent position; • transport to the hospital immediately

  34. Drug and Alcohol Emergencies • Alcohol • Mild intoxication signs and symptoms • -Nausea/vomiting/diarrhea • -lack of coordination • -poor muscle control • -flushing • -visual disturbances • -rapid mood swings • -erythema of the face and eyes • -lethargy • -slurred or inappropriate speech • -inappropriate behavior

  35. Drug and Alcohol Emergencies Serious intoxication signs and symptoms • Drowsiness to coma • rapid weak pulse • Depressed • labored breathing or respiratory arrest • loss of control of urinary and bowel functions, • Disorientation • Restlessness • hallucinations

  36. Drug and Alcohol Emergencies • Drugs • Signs and symptoms • Loss of reality orientation • Hallucinations • varying degrees of consciousness • slurred speech • extremes in mood swings • inappropriate behavior • Anxiety • flushed skin • Diaphoresis • lack of coordination • impaired judgment • increased or decreased pulse • pupils constricted or dilated • needle marks on the arms, legs, and neck

  37. Drug and Alcohol Emergencies • Nursing Interventions • Obtain information about the substance ingested. • Life-threatening situations are handled first. • Establish airway. • If unconscious, turn on the side. • Loosen clothing. • If fever is present, apply cool, wet compresses. • Protect the victim from injury during a seizure or hallucination. • Carefully assess mental status and vital signs frequently.

  38. Thermal and Cold Emergencies • Heat Injury • Heat exhaustion -most common type -results from prolonged perspiration -loss of large quantities of salt and water. • Observe for: -signs and symptoms of headache -vertigo -nausea -weakness -diaphoresis. -mental disorientation -brief loss of consciousness

  39. Thermal and Cold Emergencies • Nursing interventions • Cool the victim as quickly as possible -use cold, wet compresses and fan or air conditioner. • Have victim lie down with feet elevated. • If alert, give one-half glass of water every 15 minutes for 1 hour. • In the clinical setting, IV fluids are given.

  40. Thermal and Cold Emergencies • Heatstroke • more serious heat injury -death can result. • vigorous physical activity in a hot, humid environment. • body becomes overheated -the cooling mechanism of perspiration does not operate.

  41. Thermal and Cold Emergencies • Assessment: -rapidly rising body temperature -hot, dry, erythemic skin -no visible perspiration -pulse rapid initially and then slow -blood pressure falls -breathing deep and rapid -victim complains of headache, dry mouth, nausea, and vomiting

  42. Thermal and Cold Emergencies • Nursing interventions • Cool the victim as quickly as possible -use cold packs around the victim’s neck, under the arms, and around the ankles -cools the blood in the main arteries. • Establish and maintain an airway. • Monitor for chilling as the body temperature falls

  43. Thermal and Cold Emergencies • Exposure to Excessive Cold • Hypothermia • Lowering of the body temperature 95° F or below • Assessment • Uncontrollable shivering but ceases when body temperature drops below 90° F • Slurred speech • memory lapses • disorientation and poor judgment • uncoordinated gait • skin mottled and edematous • weak irregular pulse • decreased respiratory rate • loss of all reflexes

  44. Thermal and Cold Emergencies • Nursing interventions • Initiate CPR if necessary -must continue until the body is rewarmed. • Place victim in a supine position with the head lower than the feet. • Rewarm slowly -move to a warm area -remove wet clothing -wrap with warm blankets.

  45. Thermal and Cold Emergencies • Frostbite • Freezing and damage of body cells -ears, nose, fingers, and toes. • Assessment: -initially, skin takes on a red flush with numbness, -tingling, and pain; -progressively, the part becomes hard and loses all sensation -color turns to grayish white -if thawing occurs, may change to blue-purple or black; -edema may develop, followed by blisters.

  46. Thermal and Cold Emergencies • Nursing interventions • Treat for shock and hypothermia • establish and maintain an airway. • Warm part by immersion in warm water at 104 to 110° F for 20 to 45 minutes. • If tub is not available, may use a hot moist towel. • Be very careful not to rub the part. • The thawed part is wrapped in clean towels or bulky dressings and elevated.

  47. Bone, Joint, and Muscle Injuries • Fractures • A break in the continuity of a bone • Types of common fractures • Open or compound • Closed • Comminuted • Greenstick • Spiral • Impacted • Compressed • Depression

  48. Bone, Joint, and Muscle Injuries • Assessment -pain and tenderness and especially with movement. -deformity of the limb may be obvious -edema and discoloration of the area. -fragments of bone may be protruding through the skin. -crepitus -grating sound is heard when the affected part is moved. • X-ray can determine if a bone is fractured.

  49. Bone, Joint, and Muscle Injuries • Nursing interventions • Do not move unless he or she is in danger. • ABCs • Control bleeding • Immobilize the fracture -do not attempt to realign the bone. • Monitor circulation in the limb. • Apply ice or cold packs to the area

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