Fire Containment and Equipment Failure: A PIE Assessment Analysis for Nursing Care Planning.

it provides a clinical decision making approach for you to develop and implement an individualized plan of care An Apple PIE Assessment Analysis (nursing diagnosis) Planning Implementation Evaluation

institutional: fire-confine the fire by closing doors, equipment failure-watch out for the entire environment in the patients room (loose or frayed cords, objects on the floor blocking pts path), hazardous waste, biohazard, oxygen therapy worker: back injury-from lifting or moving patients, exposure to pathogen-needle sticks, radiation-X ray (limit exposure as much as possible), body fluids patient: medication, infection, seizures, bioterrorism-the use of biological agents (biological, chemical, radiological) to create fear and threat, procedure related accident, environment falls-64 years and older it's the leading cause of unintentional death, most costly and most preventable of patient injuries, most happen during the day

extremes of age, confusion, unsteady gait, improper footwear, medication, proprioception (awareness of position or posture), history of falling, vision, orthostatic hypotension, urinary incontinence

-developmental stages (adolescent, adult, school age child, elderly, infant, toddler preschooler) -lifestyle (drugs, fatigue, anxiety, meds, risk takers, work at dangerous job) -impaired mobility (muscle weakness, paralysis, poor coordination) -sensory or communication impairment (dementia, confusion, depression, altered concentration) -lack of safety awareness (keeping meds or poison away from children, reading expiration date on food products) -in the healthcare agency (medical errors): falls; patient inherent accidents other than falls-pt is primary reason for accident (self inflicted burns/cuts, fire setting, ingestion of foreign substances); procedure related accidents-caused by healthcare provider (med and fluid administration errors, improper application of external devices); equipment related accidents (malfunction, disrepair, misuse)

risk for falls-r/t (related to) altered mental status aeb (as evidenced by) orientated X 1 impaired physical mobility-r/t neuromuscular impairment aeb R leg paralysis sensory deficit activity tolerance

Short Measurable Attainable Reasonable Timely (specific, supported by assessment data, measurable, timely)

Assessment: gait unsteady, holds onto furniture, uncorrected eyesight, hard of hearing Diagnosis: impaired mobility R/T poor balance and sensory impairments AEB holding onto furniture when walking Outcome: patient will call for assistance w/ ambulation 100% of the time within 24 hours

***Anticipate and meet patients needs before being asked*** accomplished by hourly rounds -orient patient: talk them through what's going on, remind them of what's happening -use safety features: bed rails, call lights, night lights -keep environment clear of danger -consider placement of patient on unit: may place patient closer to nursing station -employ family support -order noninvasive alarm -document: everything that you've done to ensure the patient's safety

***LAST RESORT*** the optimal goal for all patients is a restraint-free environment, always consider and implement alternatives to restraints first -criteria for using restraints: danger to self or others (reduce risk of injury to others by the patient); reduce the risk of patient injury from falls; prevent interruption of therapy such as traction, IV infusions, nasogastric (NG) tube feeding or Foley catheterization; prevent patients who are confused or combative from removing life support equipment -physician order: this is required based on a face to face assessment of the patient -documentation: this is essential, must include the behaviors that necessitated the application of restraints (mental status-confused, forgetful, agitated, combative; mobility-unsteady, stumbling, R or L leg weakness), the procedure used in restraining, the condition of the body part restrained (circulation of hand), and the evaluation of the patient response -legal guidelines & institutional policy: for legal purposes know agency specific policy and procedures for appropriate use and monitoring of restraints, use of restraints must be clinically justified and part of the patient's prescribed medical Tx and plan of care

-make sure your assessment is patient centered and includes the patient's own perceptions of his or her risk factors, knowledge of how to adapt to such risks and previous experience w/ any accidents -consider possible threats to patient's safety including immediate environment and any individual risk factors, ask the patient specific questions related to safety (Exs of nursing assessment questions pg 372) -nursing history: includes data about a patients level of wellness to determine if any underlying conditions exist that pose threats to safety (pay attention to gait, balance and vision, review developmental status, see if the pt taking any meds undergoing a procedure that poses risk) -determine if any hazards exist in the immediate care environment (does the patient need help to walk? is the call bell within reach?), make sure equipment functions properly and is in good condition -assess patients risk factors for falling to determine specific needs for them and to develop targeted interventions to prevent falls -be alert to factors in your work environment that make it more likely for medical errors to occur, overwork and fatigue cause a great decrease in alertness and concentration leading to errors -be prepared to respond and care for a sudden influx of patients at the time of a community disaster, communication is key -when caring for a patient in the home, a home assessment is necessary, do a thorough hazard assessment, assess risk of food infection or poisoning (food prep and storage practices of pt) and patients hand washing practices, assess environmental comfort of patients home (when does pt heating and cooling system serviced)

Ex of nursing diagnosis: risk of injury pg 375 -gather data from your nursing assessment and analyze clusters of defining characteristics to identify relevant nursing diagnoses, include specific related or contributing factors to individualize your nursing care -nursing diagnoses for patient w/ safety risk include: risk for falls, impaired home maintenance, risk for injury, deficient knowledge, risk for poisoning, risk for suffocation, risk for trauma

-patients with actual or potential risks to safety require a nursing care plan w/ interventions that prevent and minimize threats to their safety, design your interventions to help a patient feel safe to move about and interact freely within the environment, the total plan of care addresses all aspects of patient needs and uses resources of the health care team and the community when appropriate -goals and outcomes: for each nursing diagnosis make sure they are measurable and realistic w/ consideration of the resources available to the patient -setting priorities: prioritize a patient's nursing diagnoses and interventions to provide safe and efficient care, plan individualized interventions based on the severity of risk factors and the patient's developmental stage, level of health, lifestyle and cultural needs, remember that the patient wants to maintain independence (keep it within their limits) -collaboration with the patient, family and other disciplines (social work, OT and PT) are an important part of a patient's plan of care

-direct your nursing interventions toward maintaining the patient's safety in all types of settings, health promotion and illness prevention measures should be implemented in the community setting, prevention is a priority in the acute care setting -health promotion: to promote an individual's health, it's necessary for the individual to be in a safe environment and practice a lifestyle that minimizes risk of injury; passive and active strategies aimed at health promotion-passive: public health and government legislative interventions (sanitation, clean water laws), active: those in which the individual is actively involved through changes in lifestyle (wearing seat belts, installing outdoor lighting) and participation in wellness programs -nurses participate in health promotion activities by supporting legislation, acting as positive role models and working in community based settings

-patient centered care requires a thorough evaluation of the patient's perspective related to safety and whether his or her expectations have been met -patient outcomes: evaluation involves monitoring the actual care delivered by the health care team based on the expected outcomes, for each nursing diagnosis measure whether the outcomes of care have been met, if you've met the patients goals the diagnosis is resolved and your nursing interventions were effective and appropriate, if not then you determine whether new safety risks to the patient have developed or whether previous risks remain -when patient outcomes aren't met ask questions such as "What factors led to your fall?" "What questions do you have about your safety?" "Has your health care provider recently changed you medications?"

hazards of immobility

decreased depth of breathing, may develop atelectasis -atelectasis: collapse of the alveoli, closing up of alveolar spaces, secretions block a bronchiole or a bronchus and the distal lung tissue (alveoli) collapse as the existing air is absorbed producing hypoventilation -hypostatic pneumonia: inflammation of the lung from stasis or pooling of secretions, result of accumulation of secretions in alveoli and bronchioles, bacteria grows in the mucus because the secretions are stagnant (you can hear crackles in the lungs) -decreased cough effort

-increased cardiac workload: the heart works harder and less efficient during periods of rest, cardiac output decreases which further decreases cardiac efficiency and increasing workload -orthostatic hypotension: pulse rate increases, pulse pressure decreases and BP drops as a person stands up from a laying position -deep vein thrombosis (DVT): blood pools in the extremities, coagulation occurs, thrombus breaks of and becomes an embolus which can lead to a pulmonary embolus -decreased venous return -interrupted circulation -edema

muscle effects: atrophy, loss of muscle mass, weakness skeletal effects: pain, contractures changes in bone density, potential for fractures-pathological, osteoporosis, calcium resorption (loss)-bone tissue becomes less dense or atrophied

-loss of appetite -decreased metabolic rate -reduced motility

urinary elimination changes -urinary stasis: because peristaltic contractions of the ureters are insufficient to overcome gravity (normally urine formed by the kidneys enters the bladder unaided by gravity) the renal pelvis fills before urine enters the ureters, holds on to extra debris increasing risk for UTIs & kidney stones -UTIs -renal calculi: calcium stones that lodge in the renal pelvis or pass through the ureters

-pressure ulcer: impairment of the skin as a result of prolonged ischemia in the tissues, due to being on only one side for too long, skin dies in that area -friction causes sheering of the skin (prevent friction when moving a patient) -excoriation/maceration: wearing of the skin, abrasion (dry); wearing of the skin/softening or breaking into pieces, occurs as a result of being wet for an extended period of time

-depression -decreased mental acuity (sharpness)

changes in mobility alter endocrine metabolism, calcium resorption (loss) and functioning of the GI system: decreases the metabolic rate, alters the metabolism of carbs, fats and proteins, causes fluid, electrolyte and calcium imbalances, causes GI disturbances such as decreased appetite and slowing of peristalsis (constipation)

impaired physical mobility, ineffective breathing patterns, impaired skin integrity

patient will use incentive spirometer q2h

-the nurse assess for and asks questions about the pt's degree of both mobility and immobility during physical examination -assessment of pt mobility focuses on ROM, gait, exercise and activity tolerance, and body alignment -when assessing ROM ask questions about and physically examine the pt for stiffness, pain, swelling, limited motion and unequal movement; assessment of ROM is important as a baseline measure to compare and evaluate whether loss in joint mobility has occurred -gait: describes a particular manner or style of walking, assess this allows you to draw conclusions about balance, posture, safety and ability to walk w/o assistance -assessment of the pt's energy level includes the physiological effects of exercise and activity tolerance; as activity begins monitor pt for sxs such as dyspnea, fatigue, chest pain, and/or a change in vital signs -body alignment: perform assessment w/ pt standing, sitting or lying down -assess pt for hazards of immobility by performing a head to toe physical assessment

the 2 diagnoses most directly related to mobility problems are: -impaired physical mobility: applies to the pt who has some limitation but isn't completely immobile -risk for disuse syndrome: applies to pt who is immobile and at risk for multisystem problems because of inactivity

-the goals focus on preventing problems of risks to body alignment and mobility -develop goals and expected outcomes to assist the pt in achieving his or her highest level of mobility and reducing the hazards of immobility -many times actual problems (pressure ulcers, disuse syndrome)are addressed only after they develop, so monitor the pt often reinforcing prevention techniques of impaired mobility to pt, other caregivers and nursing assistive personnel -collaborate w/ other health care team members (PT or OT) when it's essential to consider mobility needs

-examples of health promotion activities that address mobility and immobility include prevention of work related injury, fall prevention measures, exercise and early detection of scoliosis positioning techniques: -trochanter roll: prevents external rotation of the hips when the pt is in a supine position -supported Fowler's position: the head of the bed is elevated 45 to 60 degrees and the pt's knees are slightly elevated w/o pressure to restrict circulation in the lower legs -supine position: resting on your back facing up -prone position: lying on your stomach facing down -side lying (or lateral) position: pt rests on the side w/ the major portion of body weight on the dependent hip and shoulder, a 30 degree lateral position is recommended for pts at risk for pressure ulcers -sims's position: different from lateral position in the distrubution of pt's weight, pt places the weight on the anterior ileum, humerus and clavicle

-evaluate the effectiveness of specific interventions designed to promote body alignment, improve mobility and protect the pt from the hazards of immobility -evaluate the pt's and family's understanding of all teaching provided as well

-keep the phone number for reporting fires visible on the telephone at all times -know the fire drill and evacuation plan of the agency -know the location of all fire alarms, exits, extinguishers and oxygen shut offs -priorities in case of fire R-rescue and remove all patients in immediate danger A-activate the alarm, always do this before attempting to extinguish even a minor fire C-confine the fire by closing doors and windows and turning off oxygen and electrical equipment E-extinguish the fire using an appropriate extinguisher