the most e ff ective way to break the chain of infection? When can alcohol-based hand gels be used for hand hygiene? When can they not be used?
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602 Evidence-Based Practice Ventilator-Associated Pneumonia in Acute Care Hospitals Clinical Question UNIT FOUR Skill 28.2 (continued) Do patients have a higher risk for ventilator-associated pneumonia (VAP) who receive mechanical ventilation (MV)? Evidence Patients who receive MV are at a higher risk for nosocomial pneumonia. VAP is a type of HAI. A patient is at risk for VAP if they are on MV for 13 to 51 per 1,000 ventilator days. A patient is also at risk for developing MRSA while on me- chanical ventilation. When the patient must be frequently
shed the uidelines 14.2 pro-
Clinical Skills and Care
8. Carefully replace the swab into the sterile tube. Contamina- tion of the swab or tube can lead to misdiagnosis and inappropriate treatment for the patient. 9. Crush the capsule in the end of the tube to provide a moist environment for the pathogens until the culture is done. 10. Label the tube according to facility policy. 11. Follow the Ending Implementation Steps located on the in- side back cover. Evaluation Steps 1. Ensure that an adequate specimen has been taken so that the culture will grow any pathogens present in the patient’s throat.
2. Evaluate the patient’s tolerance of the procedure. Did it cause gagging or throat discomfort? 3. Ensure that the throat culture tube is placed in the appropri- ate biohazard specimen bag with the requisition and taken to the laboratory.
Evidence-Based Practice boxes demonstrate the link between research and practice that underlies the best nursing care.
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Sample Documentation
ows are
10/10/22 1330 Throat culture obtained per order and delivered to the lab. Pharynx red with yellowish-white patches noted on tonsils bilaterally. Culture taken from these areas. C/o sore throat before and after procedure. Nurse’s signature and credentials
Skill 28.3 Assisting With Incentive Spirometry
Assessment Steps 1. Verify the health-care provider’s order for incentive spirome- try. Note: Some hospitals do not require a health-care provider’s order for this because it is considered a nursing or respiratory therapy order. Always follow your facility’s policy. 2. Determine the patient’s pain level, availability, and willing- ness to perform the procedure. It may be necessary to med- icate the patient for pain before beginning the procedure. Planning Steps 1. Obtain an incentive spirometer. 2. Plan for appropriate time for incentive spirometry; avoid mealtimes. Implementation Steps 1. Follow the Initial Implementation Steps located on the inside front cover. 2. Assist the patient to an upright position in the bed or chair to enlarge the rib cage and allow for maximum lung expansion. 3. Splint abdominal or chest incisions with a pillow to prevent pain during deep inhalation and exhalation. 4. Place the mouthpiece of the incentive spirometer between the patient’s lips to prevent air from escaping around it during inhalation. 5. Instruct the patient to take a deep breath through the mouth, then exhale through the nose. This helps the patient understand that the focus is on deep inhalation, not exhalation.
Step-by-step procedures for over 120 skills make every concept easy to grasp.
6. Show the patient how far the platform or balls moved. Identify the goal for the patient to work toward. Set the slide pointer to the goal volume on the spirometer. 7. Instruct the patient to repeat the inhalations 10 times every hour while awake to prevent respiratory complications of immobility such as pneumonia and atelectasis. 8. Follow the Ending Implementation Steps located on the inside back cover. Evaluation Steps 1. Ask the patient to demonstrate the use of the incentive spirometer without verbal cues to ensure that he or she understands how to correctly use it. 2. Check back frequently to be sure the patient is using the incentive spirometer as ordered.
Sample Documentation
10/10/22 1100 Assisted with incentive spirometry. Able to raise 2 out of 3 balls in unit. Instructed to repeat 10 times each hour. Nurse’s signature and credentials
CLINICAL JUDGMENT IN ACTION Scenario: You are a nursing student at a long-term care facility for basic nursing clinical experience. As you walk past a resident’s door, you see him getting up from a chair without his walker and taking a very unsteady step away from the chair. This is a situation where you must use your clinical judgment and act quickly. • What are the cues in this situation? • What is your hypothesis when you analyze these cues? • What action will you take? • How will you evaluate the effectiveness of your action?
Clinical Judgment in Action boxes ask you to consider the current situation, prioritize and describe the actions you would take, and explain why.
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