Professional Documents
Culture Documents
NOTES
By Danai
Harawa
2 HNN112 DANAI HARAWA
+ Behavioural signs
+ Clinical constraints
- Pressure Injuries
Pressure injuries are a result of low quality pressure area care. Pressure area
care is conducted for anyone who does not have the capability to reposition
themselves or when there is constant pressure on the body.
+ Blood Pressure
+ Respirations
+ Wound appearances
+ Ambulation description
Identify patient cues, cluster them and identify patient potential and actual
problems
+ Symptoms
+ Areas of Risks
+ Alteration in function
Perform a nursing handover using the ISBAR tool
I - Introduce yourself
+ Who you are
+ Why you’re calling them
+ Where you’re calling from
S - Situation
+ Short description of the situation and what has happened
B - Background
+ Do not be over detailed, keep it short and simple
+ History of the patient
A – Assessment
+ State what the problem is
+ State what you have already done (own interventions)
R – Request / Recommendation
+ Clarify what it is that you will want or need
+ What they should do
others increase it. For example, cardiac glycosides decrease the heart rate,
whereas adrenaline increases it.
Hypocalcaemia affects HR as loss of blood from the vascular system
normally increases HR. In adults, the loss of circulating volume results in an
adjustment of the HR to increase blood pressure as the body compensates
for the lost blood volume. Adults can usually lose up to 10% of their normal
circulating volume without adverse affects.
Stress affects HR as the sympathetic nervous stimulation increases the
overall activity of the heart. Stress increases the rate as well as the force of
the heartbeat. Fear and anxiety as well as the perception of severe pain
stimulate the sympathetic system.
Position changes affect HR as when a person is sitting or standing, blood
usually pools in dependent vessels of the venous system. Pooling results in a
transient decrease in the venous blood return to the heart and a subsequent
reduction in blood pressure and increase in HR.
Pathology can affect HR as certain diseases such as various heart conditions
or those that impair oxygenation can alter the resting pulse rate.
Infection Control
Define the terms microorganism and health care associated infections
+ Microorganisms are defined as an organism that can only be seen and
detected by a microscope.
+ Health care associated infections are defined as infections that are
contracted by a patient whilst awaiting medical treatment or care in a
clinical setting.
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any potential microorganisms that may be found upon the hands. There are 5
moments for hand hygiene
- Before touching the patient
- Before a procedure
- After a procedure
- After touching a patient
- After touching their belongings
+ Prevention of cross infection refers to minimising the possibility of
carrying any harmful pathogens to another susceptible host.
+ Disinfection and Sterilisation is the process of following a procedure with
chemicals to disinfect any potential microorganisms that may lie upon
equipment that is being used in the clinical setting.
+ Standard and Transmission based precautions means to follow any
procedures that may be required in order to prevent any microorganisms
passing from individual to individual. This may include wearing PPE when
entering a patient’s room.
Elimination
Identify the factors that influence elimination patterns
Urinary elimination
+ Frequency and Nocturia
Nocturia is when an individual wakes up more than once in the night to
void. In regards to frequency factors such as fluid intake can affect this
+ Urgency
A sudden strong desire to void it is common with those who have unstable
bladder contractions.
+ Dysuria
Voiding that is painful or difficult this is often to do with infections called a
UTI.
+ Enuresis
Involuntary urination in children beyond the age when voluntary bladder
control is normally acquired.
+ Urinary incontinence
When an individual cannot control their voiding.
Faecal elimination
+ Diet
+ Physical activity
+ Psychological factors
+ Defecation habits
+ Medications
+ Diagnostic procedures
+ Anaesthesia / Surgery
+ Pathological conditions
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+ Pain
+ Pregnancy
Distinguish between normal and abnormal urine and faeces
Characteristics of faeces
+ Colour – Normal: Brown
Abnormal: Grey, clay or white – absence of bile pigment
Black or tarry – Drug (iron), malaena (bleeding from UGI tract), diet high in
red meat and dark green vegetables (spinach) or licorice. Also certain
medications such as phenylbutazone, oxyphenbutazone or bismuth
compounds.
Red – Bleeding from lower GI tract (rectum) or some foods such as beetroot
or cocoa.
Pale tan – Malabsorption of fats, diet high in milk and milk products or low
in meat.
Green – Intestinal infection, ingestion of spinach or senna laxatives or rapid
transit times.
+ Consistency – Normal: Soft formed
Abnormal: Constipation (hard, dry, pebbles) – Dehydration, lack of fibre,
lack of fluids, lack of exercise, motility disorder (Hirschspruns disease),
endocrine disorders (hypothydroidism, diabetes mellitus), psychiatric
disorders (depression, anorexia nervosa, dementia), local pathology (tumors,
structure and fissure), drug induced (anticholinergics, antihistamines,
tranquillisers, opiates, antacids, laxative abuse)
Diarrhoea – Gastrointestinal infections, food or drug intolerance
(antibiotics), impaction with overflow, short bowel syndrome, inflammatory
bowel disorders (ulcerative colitis or Chrons disease) or radiation enteritis.
Encopresis (faecal incontinence) – Uncontrolled Diarrhoea from any cause,
neurogenic disorders (paraplegia, spinal bifida, caudal equine lesions),
cognitive deficits (dementia, Alzheimer’s disease)
+ Shape - Normal: Tubular as in the shape of the rectum
Abnormal: Narrow, pencil shaped or string like stool – Obstructive tumors
or strictures of the rectum or anus
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Characteristics of urine
+ Amount in 24 Hours (Adult) – Normal: 1200 – 1500ml
Abnormal: Under 1200ml / A large amount over intake – Urinary output
normally is approx. equal to fluid intake. Output of less than 30ml/hr may
indicate decreased blood flow to the kidneys and should be reported
immediately. For infants and children the minimum urine output is 1-2
ml/kg/hr
+ Colour – Normal: Straw, amber, transparent
Abnormal: Dark amber / cloudy / dark orange / red or dark brown / mucus
plugs / viscid / thick – Concentrated urine is darker in colour. Dilute urine
may almost appear clear or very pale yellow. Some foods and drugs may
colour urine. Red blood cells in the urine may be evident as pink, bright red
or rust brown urine. Menstrual bleed can also colour urine but should be
confused with hematuria. White blood cells, bacteria, pus or contaminats
such as postactiv fluid, sperm or vaginal discharge may cause cloudy urine
+ Odor – Normal: Faint aromatic
Abnormal: Offensive – Some foods such as asparagus, cause a musty odor.
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Infected urine can have a foetid odor and urine high in glucose has a sweet
odor.
+ Sterility – Normal: No
Abnormal: Microorganisms present – Urine in the bladder is sterile. Urine
specimens however may be contaminated by bacteria from the perineum
during collection.
+ PH – Normal: 4.5 – 8
Abnormal: Under 4.5 or over 8 – Freshly voided urine is normally somewhat
acidic. Alkaline urine may indicate a state of alkalosis, UTI, or a diet high in
fruits or vegetables. More acidic urine (low pH) is found in starvation, with
diarrhea or with a diet high in protein foods or cranberries.
+ Blood – Normal: Not present
Abnormal: Occult (microscopic) / Bright red – Blood may be present in the
urine of people who have UTI, kidney disease or bleeding from the urinary
tract. Specimens may also be contaminated from menstrual flow in the
female person.