Assignment RLE First Assignment.docx

7/25/2019 Assignment RLE First Assignment.docx

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Czarina Isabela

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nt in RLE



• The nursing process is a series of organized steps designed for nurses to provide excellent care. Learn

the five phases, including assessing, diagnosing, planning, implementing, and evaluating.

APIE ! Nursing Pro"ess Ste#

• ADPIE is an acronym that stands for assessment, diagnosis, planning, implementation and evaluation. T

ADPIE process helps medical professionals rememer the process and order of the steps they need to ta

to provide proper care for the individuals they are treating. This process is important as it provides a useand throughout frame"or! in patient care for developing critical thin!ing and prolem solving s!ills. follo"ing the ADPIE process medical professionals can improve the efficiency of their "or! and developmore accurate decisions in a timely manner.

PR$CESS $%ER%IE&

The purpose of ADPIE is to help improve an individuals mental, emotional and$or physical health throu

analysis, diagnosis and treatment. The ADPIE process allo"s medical professionals to identify potentprolems, develop solutions and monitor the results on an individual asis. If the process does not improthe individuals condition then the process should e reevaluated and the proper ad%ustments should

made in order to correct the issue.

&ere is an explanation detailing each step of the process'

ASSESS'ENT

Assessment is the first step of the ADPIE process.



During the assessment phase medical professionals "attempt to identify the prolem and estalish a data ase y intervie"ing the individual and$or fammemers, oserving their ehavior and performing examinations.

This step focuses heavily on collecting$recording davalidating information and listing any anormalities in the data.

Assessment data can e collecting in one of t"o "asu%ective or o%ective.



(u%ective data is data that can not e measured directly.

This can include veral information such as as!ing )uestiootaining veral feedac!, intervie"ing other individuals and collecting$gathering information on a patien

health history.

(u%ective data is often referred to as symptomatic as it can ne measured or oserved directly.



*%ective data is data that is measurale and can e seeheard, felt or smelt.

This can include performing an examination to measure

patients "eight, lood pressure, heart rate and ody temperature.

#ecause o%ective data is measurale they are often referredas signs.



During the assessment phase it is important to gather as mudata as possile and identify if the data is accurate, concise, consistent and clear.

*nce you+ve gathered enough accurate data you can form

conclusion aout the patients condition and move into the next phase, "hich is diagnosis.

IA(N$SIS

• The diagnosis phase of the process is the phase "here the medical professional develops a theory

hypothesis aout the individuals situation ased on the information that has een collected "hile performian assessment.

• hile nurses are unale to form a professional diagnosis they are ale to develop their critical thin!ing a

communicate their clinical %udgments to their team memers.

• In fact nurses have a standardized language for communicating their clinical %udgments, "hich com

from -A-DA international.• (ome examples of terms nurses may use include'

https://en.wikipedia.org/wiki/Nursing_process

http://www.nursetheory.com/registered-nurse/


http://www.nanda.org/


http://www.nanda.org/

https://en.wikipedia.org/wiki/Nursing_process



Activity intolerance

Anxiety

onstipation



Decreased cardiac output

/luid volume deficit

&ypothermia



(leep deficit

• The diagnostic process allo"s the medical professional to ma!e a determination aout the individual a

form an opinion on "hether it is an physiological, mental or emotional condition, or another situation that tindividual is dealing "ith.

• hile a professional diagnosis may not e given y a nurse these medical professionals are ale to iden

actual or potential medical $health ris!s.

• *nce a diagnosis has een performed any potential ris!s that may cause complications or harm to tindividual should e placed in order "ith the highest ris! listed as the top priority 0life1threatening2 and lo"ris!s eing addressed later in the list 0non life1threatening $ minor $ future "ell1eing2.

• As prolems are identified and corrected ne" prolems$priorities may need to e addressed so continuo

assessment of the individuals condition should e performed on a regular asis.

• After the prolems have een identified and prioritized the phase of the process is planning.

PLANNIN(

• Planning is the process of developing a plan and estalishing (3A4T goals in order to achieve a desir

outcome such as reducing pain or improving cardiovascular function.• (3A4T goals stand for specific, measurale, attainale, realistic$relevant and time restricted.

• (3A4T goals are developed to provide the individual "ith a focused set of activities that are designed

improve their condition.

• They also provide medical professionals "ith a plan in "hich they can measure and evaluate the individu

improvements.

• 5oals may e short1term or long1term, should e singular in nature and must focus on the individu

outcome.

• 6pon developing smart goals the medical professional should determine "hether or not the goals are

good fit for the individual and ale to e easily attained.

• In addition to creating (3A4T goals a care plan and intervention strategies should also e developed a

communicated to the team in order to maximize the success of the plan.

• A care plan should involve the steps and strategies that need to e ta!en in order to achieve the desir

goal.

• Intervention strategies are developed to help !eep the individual on trac! and may e communicated to t

individual and$or medical team or performed directly y a memer of the medical team as part of ttreatment.

• After the care plan, interventions and (3A4T goals have een estalished it needs to e implemented.

I'PLE'ENTATI$N



• The implementation phase of the process is the actionale part of the process "here the individual a

medical team implement the care plan, (3A4T goals and interventions so that the individual can achietheir goals and the process can e evaluated and measured.

• The implementation phase may e performed using a comination of direct care and indirect care.

• Direct care is care that is given directly to the patient in either a physical or veral manner.

• Direct care may include assisting the patient "ith moility, performing physical care and range of mot

exercises "ith the patient and assisting "ith daily living activities.

• It may also include coaching, counseling and providing feedac! to the individual.

• Indirect care is care that is given "hile a"ay from the patient.

• Indirect care may include monitoring $ supervising the medical staff, delegating responsiilities aadvocating on ehalf of the individuals you care for.

• hile implementing the care plan it is important for the medical professional to use critical %udgement a

)uestion procedures in the care plan in order to ensure that they appropriately meet the demands aconcerns of the individuals receiving the care.

• (teps or procedures that appear to e inappropriate, non1actionale or )uestionale should e )uestion

and reevaluated "ith the medical staff and the individual receiving the care plan in order to ensure it is saand aligns "ith the medical teams$individuals goals.

E%AL)ATI$N

• The last phase of the process is the evaluation phase.

• This is the part "here the medical professionals assess and evaluate the success of the planning a

implementation processes to ensure that the individual is ma!ing progress to"ards his$her goals andachieving the desired outcome.

• Evaluate if the process is "or!ing and identify "hat is ringing the individual closer to his$her goals.

• If the process is not "or!ing reassess it and determine "hether it needs to e modifying or eliminated.

• Evaluations should e performed throughout the ADPIE process on a regular asis in order to assess t

plan and ma!e ad%ustments "hen they need to e made.

• #y performing regular evaluations medical professionals can determine the appropriate course of actio

identify potential errors and ensure that the process is "or!ing as smoothly as possile.

.http'$$""".nursetheory.com$adp

• FDAR charting' Focus Data Action Response. /*6( &A4TI-51 descries the patient7s

perspective and focuses on documenting the patient7s current status, progress to"ards goals, andresponse to interventions.

*o"us – identifies the content or purpose of the narrative entry and is

separated from the ody of the notes in order to promote easy data retrieval and communication

ata 1 statements contain o%ective and$or su%ective information.

A"tion 8 statements that contain nursing interventions 0asic, perspective,independent2 past,

present or future.1 it also contains collaorative orders

Res#onse 8 Evident patient outcomes or response

I-/*43ATI*- /4*3 ALL T&4EE ATE5*4IE( 0DATA,ATI*-,4E(P*-(E2should e used onlas they are 4ELE9A-T or A9AILA#LE.&o"ever, all appropriate information should e included to

http://www.nursetheory.com/adpie/

http://www.nursetheory.com/adpie/



ensure complete documentation

Pur#ose o+ *AR ",arting

:2 To easily identify critical patient issues$concerns in the Progress -otes.;2 To facilitate communication among all disciplines.<2 To improve time efficiency "ith documentation.

=2 To provide concise entries that "ould not duplicate patient information already provided on flo"sheet$chec!list.hen is /DA4 necessary>2 To descrie a patient prolem$ focus$ concern from the care plan?2 To document an activity or treatment that "as carried out@2 To document a ne" findings2 To document an acute change in patient7s conditionB2 To identify the discipline ma!ing the entry as "ell as the topic of the note:C2 To descrie all specifics regarding patient$family teaching::2 To document a significant event or unusual episode in patient care

$C)'ENTATI$N $-S AN $NT-S

$-S1D* time and date all entries.1D* use flo"sheet$ chec!list. eep information on flo"sheet$chec!list current1D* chart as you ma!e oservations.1D* "rite your o"n oservations and sign your o"n name. (ign and initial every entry.1D* descrie patient7s ehavior and use direct patient )uotes "hen appropriate.1D* record exactly "hat happens to patient and care given.1D* e factual and complete.1D* dra" a single line thru an error. 3ar! this entry as error and1sign your name.F1D* use only approved areviations1D* use next availale line to chart.1D* document patient7s current status and response to medical care and treatments.1D* "rite legily. D* use in!. D* use accepted chart forms.

$NT-SD*-7T egin charting until you chec! the name and identifying numer on the patient7s chart on each

page.1D*-7T chart procedures or cares in advance.1D*-7T clutter notes "ith repetitive or fre)uently changing data already charted on the flo"sheet$chec!li1D*-7T ma!e or sign an entry for someone else.1D*-7T change and entry ecause someone tells you.1D*-7T lael a patient or sho" ias.

1D*-7T try to cover up a mista!e or incident y inaccuracy or omission.1D*-7T "hite outF or erase an error.1D*-7T thro" a"ay notes "ith an error on them.1D*-7T s)ueeze in a missed entry or leave spaceF for someone else "ho forgot to chart.1D*-7T "rite in the margin.1D*-7T use meaningless "ords and phrases, such as good dayFor no complaintsF11D*-7T use noteoo! paper or pencil.

(ENERAL ()IELINES1/ocus charting must e evident at least once every shift.1/ocus charting must e patient1oriented not nursing tas!1oriented.



1Indicate the date and time of entry in the first column.1(eparate the topic "ords for the ody of notes'a. /ocus note "ritten on the second column.. Data,Action and 4esponse on the third column.1(ign name for every time entry1Document only patient+s concern and$or plan of care e.g. healthteachingper shift.

http'$$allnurses.com$international1nursing$focus1charting1fdar1C=?;?.htm

T,e Surgi"al S"rub

The aim of surgical hand antisepsis is to remove deris and transient micro1organisms, to reduresident micro1organisms to a minimum and to inhiit rapid reound gro"th on the hands, nails aforearms of surgical personnel 0AfPP ;C::2. The follo"ing section outlines the surgical hand antisepprocedure.

:. Gour initial scru procedure should last > minutes.;. (use)uent procedures last < minutes.<. A cloc! should e provided for timing the scru procedure.=. If the scru practitioners hands or arms accidentally touch the taps, sin! or other unsterile o%ect durin

any phase of the scru cycle they are considered contaminated and the scru cycle must egin again

Please note that scrubbing areas other than the nails using the nail brush has shown to causeabrasions to the skin and should be avoided.

The purpose of surgical hand scru is to'

• 4emove deris and transient microorganisms from the nails, hands, and forearms

• 4educe the resident microial count to a minimum, and

• Inhiit rapid reound gro"th of microorganisms.:

Surgical Scrub Techniques

All sterile team memers should perform the hand and arm scru efore entering the surgical suite. The asicprinciple of the scru is to "ash the hands thoroughly, and then to "ash from a clean area 0the hand2 to a less clearea 0the arm2. A systematic approach to the scru is an efficient "ay to ensure proper techni)ue.

There are t"o methods of scru procedure. *ne is a numered stro!e method, in "hich a certain numer of rushstro!es are designated for each finger, palm, ac! of hand, and arm. The alternative method is the timed scru, aeach scru should last from three to five minutes, depending on facility protocol.

The procedure for the timed five minute scru consists of'

• 4emove all %e"elry 0rings, "atches, racelets2.

• ash hands and arms "ith anitmicroial soap. Excessively hot "ater is harder on the s!in, dries the s!in,

and is too uncomfortale to "ash "ith for the recommended amount of time. &o"ever, ecause cold "ate

prevents soap from lathering properly, soil and germs may not e "ashed a"ay.

Surgi"al s"rubbing/(o0nin 1 (lo2in

http://allnurses.com/international-nursing/focus-charting-fdar-804626.html

http://allnurses.com/international-nursing/focus-charting-fdar-804626.html



• lean suungual areas "ith a nail file.

• (tart timing. (cru each side of each finger, et"een the fingers, and the ac! and front of the hand for t"

minutes.

• Proceed to scru the arms, !eeping the hand higher than the arm at all times. This prevents acteria1laden

soap and "ater from contaminating the hand.

• ash each side of the arm to three inches aove the elo" for one minute.

• 4epeat the process on the other hand and arm, !eeping hands aove elo"s at all times. If the hand

touches anything except the rush at any time, the scru must e lengthened y one minute for the areathat has een contaminated.

• 4inse hands and arms y passing them through the "ater in one direction only, from fingertips to elo". D

not move the arm ac! and forth through the "ater.

• Proceed to the operating room suite holding hands aove elo"s.;

• If the hands and arms are grossly soiled, the scru time should e lengthened. &o"ever, vigorous scrui

that causes the s!in to ecome araded should e avoided.

• At all times during the scru procedure care should e ta!en not to splash "ater onto surgical attire.;

• *nce in the operating room suite, hands and arms should e dried using a sterile to"el and aseptic

techni)ue. Gou are no" ready to don your go"n and sterile gloves.

hen go"ning oneself, grasp the go"n firmly and ring it a"ay from the tale. It has already een folded so thatthe outside faces a"ay. &olding the go"n at the shoulders, allo" it to unfold gently. Do not sha!e the go"n.

Place hands inside the armholes and guide each arm through the sleeves y raising and spreading the arms. Donot allo" hands to slide outside the go"n cuff. The circulator "ill assist y pulling the go"n up over the shoulders

and tying it.

To glove, lay the glove palm do"n over the cuff of the go"n. The fingers of the glove face to"ard you. or!ingthrough the go"n sleeve, grasp the cuff of the glove and ring it over the open cuff of the sleeve. 6nroll the glovecuff so that it covers the sleeve cuff. Proceed "ith the opposite hand, using the same techni)ue. -ever allo" theare hand to contact the go"n cuff edge or outside of glove.

The scrued technologist or nurse go"ns the surgeon after he or she has performed the hand and arm scru.After handing the surgeon a to"el for drying, the technologist or nurse allo"s the go"n to unfold gently, ma!ingsure that there is enough room to prevent contamination y nonsterile e)uipment. To glove another person, therules of asepsis must e oserved. *ne person7s sterile hands should not touch the nonsterile surface of the perseing gloved.

• Pic! up the right glove and place the palm a"ay from you. (lide the fingers under the glove cuff and sprea

them so that a "ide opening is created. eep thums under the cuff.

• The surgeon "ill thrust his or her hand into the glove. Do not release the glove yet.

• 5ently release the cuff 0do not allo" the cuff to snap sharply2 "hile unrolling it over the "rist. Proceed "ith

the left glove, using the same techni)ue.

/ormal guidelines and recommended practices for hand "ashing have een pulished y professionalorganizations 0e.g., Association for Professionals in Infection ontrol 0API2, Association of peri*perative4egistered -urses, Inc. 0A*4-2. A*4- recommends the use of a traditional standardized anatomical timed scru





gives a false sense of security against acteria. 5loves provide an ideal environment for acterial gro"th, moisturand "armth, "hich ma!es good hand1scru techni)ues and aseptic go"ning and gloving an important part of thetotal infection prevention platform. It is important for healthcare management to help the personnel understand thecause$effect cycle of surgical scrus as they relate to infection prevention.

Gowning and Gloving

If you are the scru corpsman, you "ill have opened your sterile go"n and glove pac!ages in the operating roomefore eginning your hand scru. &aving completed the hand scru, ac! through the door holding your hands uto avoid touching anything "ith your hands and arms. 5o"ning techni)ue is sho"n in the steps of figure ;1=. Pic!

up the sterile to"el that has een "rapped "ith your go"n 0touching only the to"el2 and proceed as follo"s'

:. Dry one hand and arm, starting "ith the hand and ending at the elo", "ith one end of the to"el. Dry tother hand and arm "ith the opposite end of the to"el. Drop the to"el.

;. Pic! up the go"n in such a manner that hands touch only the inside surface at the nec! and shoulderseams.

<. Allo" the go"n to unfold do"n"ard in front of you.=. Locate the arm holes.>. Place oth hands in the sleeves.?. &old your arms out and slightly up as you slip your arms into the sleeves.@. Another person 0circulatory2 "ho is not scrued "ill pull your go"n onto you as you extend your hand

through the go"n cuffs.To gown and glove the surgeon, follow these steps

:. Pic! up a go"n from the sterile linen pac!. (tep ac! from the sterile field and let the go"n unfold in froof you. &old the go"n at the shoulder seams "ith the go"n sleeves facing you.

;. *ffer the go"n to the surgeon. *nce the surgeon+s arms are in the sleeves, let go of the go"n. #e carenot to touch anything ut the sterile go"n. The circulator "ill tie the go"n.

<. Pic! up the right glove. ith the thum of the glove facing the surgeon, place your fingers and thums oth hands in the cuff of the glove and stretch it out"ard, ma!ing a circle of the cuff. *ffer the glove tothe surgeon. #e careful that the surgeon+s are hand does not touch your gloved hands.

=. 4epeat the preceding step for the left glove

The principles of Sterile Technique are applied in various "ays. If the principle itself is understood theapplications of it ecome ovious. (trict aseptic techni)ue is needed at all times in the *perating 4oom.

Principles of (terile Techni)ue

:. All articles used in an operation have een sterilized previously.;. Persons "ho are sterile touch only sterile articles persons "ho are not sterile touch only unsterile

articles.<. (terile persons avoid leaning over an unsterile area non1sterile persons avoid reaching over a sterile

field. 6nsterile persons do not get closer than :; inches from a sterile field.=. If in dout aout the sterility of anything consider it not sterile. If a non1sterile person rushes close

consider yourself contaminated.>. 5o"ns are considered sterile only from the "aist to shoulder level in front and the sleeves to ; inches

aove the elo"s.:. eep hands in sight or aove "aist level a"ay from the face.;. Arms should never e folded.<. Articles dropped elo" "aist level are discarded.

Prin"i les o+



?. (terile persons !eep "ell "ithin the sterile area and follo" those rules from passing':. /ace to face or ac! to ac!.;. Turn ac! to a non1sterile person or "hen passing.<. /ace a sterile area "hen passing the area.=. As! a non1sterile person to step aside rather than trying to cro"d past him.>. (tep ac! a"ay from the sterile field to sneeze or cough.?. Turn head a"ay from sterile field to have perspiration mopped from ro".@. (tand ac! at a safe distance from the operating tale "hen draping the patient.. 3emers of the sterile team remain in the operating room if "aiting for the case.B. Do not "ander around the room or go out in the corridors.

@. (terile persons !eep contact "ith sterile areas to a minimum.:. Do not lean on the sterile tales or on the draped patient.;. Do not lean on the nurse+s mayo tray.

. -on1sterile persons J "hen you are oserving a case, please stay in the room until the case iscompleted. Do not "ander from room to room as traffic in the operating room should e !ept as aminimum. Patient privacy needs to e respected.

B. eep non1essential conversation to a minimum.:C. The circulating nurse is in charge of the room J if you have any )uestions, please refer them to her, th

supervisor or your instructor. As! circulating nurse "hen it is an appropriate time to as! )uestions so thexplanations$rationale can e given.

Sterile !e"bersSurgeon

The surgeon is in chargeF of the surgical team. &e or she is the person "ho performs the operation and directs thactivities of other memers of the surgical team. (urgeons usually specialize in the treatment of specific surgicalconditions, li!e orthopedics or cardiac surgery. #ecoming a surgeon involves = years of college, = years of medicaschool, then < to > years of specialized residency.Certified Surgical TechnologistThe surgical technologist is responsile for the preparation of the sterile supplies, e)uipment and instruments, theassists the surgeon in their use. The surgical technologist most fre)uently serves as instrument handler, setting upthe instruments, then passingF them to the surgeon. (urgical technologists also serve as second assistants,utilizing instruments to perform tas!s such as retracting incisions, cutting suture and manipulating tissue. ithadvanced training or education, some surgical technologists act as first assistants. This role may also e preformey another physician, a physician assistant or a registered nurse. #ecoming a surgical technologist involves : to ;years of college or specialized training.

#on Sterile !e"bersAnesthesiologistThe anesthesiologist is a physician "ho specializes in administering drugs to the patient so he or she is pain freeduring the operation. They monitor the patient+s response to anesthesia.Registered #urseThe 4egistered -urse role is generally that of the circulatorF. The circulator is responsile for the patient careduring the operation. &e or she assesses the patient, assists the anesthesiologist, completes operating roomrecords and dispenses items to the sterile team.

http'$$nurseslas.com$principles1of1sterile1techni)u

Preparing Your Patient for Surgery

Pre Intra Post

http://nurseslabs.com/principles-of-sterile-technique/

http://nurseslabs.com/principles-of-sterile-technique/



Preo#erati2e *asting

Patients are often told not to eat after midnight. The reason "hy, ho"ever, is not al"ays explained. Patients are noal"ays compliant they have reported they did Knot realize it "ould e a ig prolemK and had li)uids, gum, or can%ust prior to entering the admission area. The reasons for fasting should e explained to the patient. -ot only isthere an increased ris! of nausea and vomiting postoperatively, there is the ris! of regurgitation and pulmonaryaspiration, "hich can have very serious conse)uences. /asting criteria have ecome less strict over the past fe"years ho"ever, the possiility of the procedure occurring earlier should e ta!en into consideration "hen instructipatients

hen discussing fasting "ith the patient, it is also important to e very specific as to "hat Kclear li)uidsK and a KligmealK means. -onhuman mil! is similar to a solid in gastric emptying time. A light meal typically consists of toastand clear li)uids such as "ater, lac! coffee or tea, roth, or gelatin. /ried, fatty foods, or meat may also prolonggastric emptying time. The consumption of alcohol should e discussed at this time, as some patients have een!no"n to consider certain alcoholic everages as clear li)uids. They should e advised not to consume alcohol fo;= hours prior to their procedure. Patients often do not understand that che"ing gum and eating candy can alsocontriute to the stimulation of gastric acid secretion.?M

Although a procedure may e scheduled for late in the morning, or even in the afternoon, most often the patient "still e as!ed to have nothing y mouth after midnight. This is done for a fe" reasons. (ometimes, due toscheduling changes, the procedure may e scheduled earlier. A set time also minimizes confusion for some peopl

(ome institutions "ill allo" people to have li)uids until a specified time, "hich is communicated to the patient.hildren are often allo"ed to consume li)uids until the minimal allo"ale time

After Surger$

At the end of the procedure, the patient "ho has received sedation is a"a!ened and "ill usually move onto the

stretcher to leave the operating room and e transferred to the postanesthesia care unit 0PA62. If the patient has

received general anesthesia "ith intuation, the patient "ill e extuated and may re)uire assistance to move ont

the stretcher.

Patients "ho have een intuated or "ho have had an air"ay placed in the hypopharynx may experience a mild

sore throat for a couple of days. There is also a potential for postoperative nausea, especially if the patient has a!no"n history of postoperative nausea and vomiting. 3edication can e given to minimize this prolem. -ausea

may e due to the anesthesia or the specific surgical procedure 0eg, laparoscopic cholecystectomy, certain reast

procedures2.

Although every effort is made to ma!e the patient comfortale, there may e some pain or soreness "hen the

anesthetic reverses or "ears off. (ome patients elieve they "ill "a!e up after surgery and have no pain, and if

they are uncomfortale, they do not understand "hy. Each patient is different and reacts differently to anesthesia

"ell as the pain medication. 4egional spinal anesthetic may "ear off "hen the procedure is over or may last a

couple of hours longer. Patients should e reassured that medication "ill e given "hen pain arises, and pain "ill

e controlled. The surgeon "ill "rite a prescription for pain medication and leave it "ith "ritten postoperative

instructions for the patient and family. It is important to ma!e sure the patient has these prior to discharge.

3ost patients stay in the PA6 for approximately => minutes. hen a patient has met PA6 criteria for discharge

the patient "ill e discharged to a room, a step1do"n area to prepare for discharge from the facility, or directly to

home. It is re)uired that the patient have someone availale to transport him or her home 0the patient is not allo"e

to drive home follo"ing the procedure2. /or certain procedures and general anesthesia, patients "ill e as!ed to

have someone "ith them for at least the first ;= hours postoperatively

%ospital For"s

Doctors -otes



linical 3edical onsent /orm

5eneric 3edical 4ecords 4elease forms

3edical &istory /orm

Drug lassification chart

Discharge (ummary temple

-urses -otes

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Assignment RLE First Assignment.docx

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