Determine the attributes that help form the professional nurses’ identity.
Apply principles of professional identity and professionalism.
Scenario
As a nursing student, you have a vision of your core values and expectations as a professional nurse. In this assignment, create a plan to guide you as you form your professional identity.
Instructions
This formation will include the following:
Describe the meaning of nursing professionalism identity
Identify the most important professional identity characteristics/attributes
Explain how you will adapt these characteristics/attributes in the clinical setting
Reflect on your educational journey and describe how this shaped your professional identity.
Create your goals for continued professional identity formation during your career as a nurse.
Provide stated ideas with professional language and attribution for credible sources with correct APA citation, spelling, and grammar.
The purpose of this assignment is to apply the principles of pharmacology to support evidence-based prescribing practices for the management of common diseases of the endocrine system. This assignment allows students to use clinical practice guidelines to guide treatment decisions for common patient scenarios in the clinical setting.
Course Outcomes
This assignment enables the student to meet the following course outcomes:
· CO 1: Identify the most commonly prescribed agents in the major drug classes. (POs 1, 2)
· CO 2: Make appropriate evidence-based therapeutic treatment decisions for individual patients utilizing drugs from the major drug classes.(POs 1, 2)
· CO 3: Apply knowledge of pharmacokinetics, pharmacodynamics and pharmacogenomics in prescribing patient treatment. (POs 1, 2)
· CO 4: Distinguish internal and external environment factors affecting drug action, reaction, efficacy, and interaction. (POs 1, 2)
· CO 5: Identify client indicators of therapeutic, ineffective, adverse responses and side effects to drug therapy. (POs 1, 2)
Due Date
· The Late Assignment Policy applies to this assignment.
· The assignment title is due by Sunday 11:59 p.m. MT of Week 5.
Total Points Possible 110
Preparing the Assignment
· Follow these guidelines when completing each component of the assignment. Contact your course faculty if you have questions.
· There are three patient cases presented in this assignment. You are to use the following to answer the questions.
· When you click on the resource links, the links will open in a new window so you will be able to navigate between the resources and the quiz.
· Rosenthal, L., Burchum, J. (2021). Lehne’s pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants (2nd ed.). Elsevier.
You will be presented with a patient case and then a series of questions. This assignment is completed in a quiz format; however, it is not an exam and you are encouraged to use your textbook and course materials. There are 12 questions worth 9 points each and an attestation question worth 2 points for a total of 110 points.
· Review the case information and then answer each required question with a succinct, informative answer.
· Answers should be one to five sentences in length.
· Some questions may require a short one-sentence answer, whereas others require a five-sentence answer for a complete explanation.
· Consider the most common and obvious answer.
· A scholarly reference is required for answers where a source such as textbook or clinical practice guideline is used to develop your response.
· Feedback is provided immediately after completing this assignment only. The feedback provided is general and non-specific to protect the integrity of this assignment due to the unfortunate nature of answer sharing among many students.
Lockdown browser is not required and there are no keyed correct answers to review. Course faculty will post assignment feedback for your review in the gradebook when grading is complete. There is no time limit for this assignment. It needs to be completed in one sitting and should be completed at the time it is begun as your answers may not be saved to return to it later.
When you are ready to begin this assignment, click the “Take the Quiz” button near the bottom of this page.
26. Kang J, Cho YS, Jeong YJ, Kim SG, Yun S, Shim M. Development and validation of a measurement to
assess person-centered critical care nursing. J Korean Acad Nurs. 2018; 48:323–334. https://doi.org/
10.4040/jkan.2018.48.3.323 PMID: 29968688
27. Foà C, Cavalli L, Maltoni A, Tosello N, Sangilles C, Maron I, et al. Communications and relationships between patient and nurse in intensive care unit: knowledge, knowledge of the work, knowledge of the
emotional state. Acta Bio-med. 2016; 87:71–82.
28. Azoulay E, Herridge M. Understanding ICU staff burnout: the show must go on. Am J Respirat Crit Care
Med. 2011; 184:1099–1100.
29. Dithole K, Sibanda S, Moleki MM, Thupayagale-Tshweneagae G. Exploring communication challenges
between nurses and mechanically ventilated patients in the intensive care unit: a structured review.
Worldviews Evid Based Nurs. 2016; 13:197–206. https://doi.org/10.1111/wvn.12146 PMID: 26860230
30. Martinho CI, Rodrigues IT. Communication of mechanically ventilated patients in intensive care units.
Rev Bras Ter Intensiva. 2016; 28:132–140. https://doi.org/10.5935/0103-507X.20160027 PMID:
27410408
31. Song YG, Yun EK. Model for unplanned self extubation of ICU patients using system dynamics
approach. J Korean Acad Nurs. 2015; 45:280–292. https://doi.org/10.4040/jkan.2015.45.2.280 PMID:
25947190
32. Samuelson KA. Adult intensive care patients’ perception of endotracheal tube-related discomforts: a
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Psychiatric notes are a way to reflect on your practicum experiences and connect them to the didactic learning you gain from your NRNP courses. Focused SOAP notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.
For this Assignment, you will document information about a patient that you examined during the last three weeks, using the Focused SOAP Note Template provided. You will then use this note to develop and record a case presentation for this patient.
To Prepare
· Review this week’s Learning Resources and consider the insights they provide. Also review the Kaltura Media Uploader resource in the left-hand navigation of the classroom for help creating your self-recorded Kaltura video.
· Select a patient of any age (either a child or an adult) that you examined during the last 3 weeks.
· Create a Focused SOAP Note on this patient using the template provided in the Learning Resources. There is also a completed Focused SOAP Note Exemplar provided to serve as a guide to assignment expectations.
· PleaseNote:
· All SOAP notes must be signed, and each page must be initialed by your Preceptor. Note: Electronic signatures are not accepted.
· When you submit your note, you should include the complete focused SOAP note as a Word document and PDF/images of each page that is initialed and signed by your Preceptor.
· You must submit your SOAP note using SafeAssign. Note: If both files are not received by the due date, faculty will deduct points per the Walden Grading Policy.
· Then, based on your SOAP note of this patient, develop a video case study presentation. Take time to practice your presentation before you record.
· Include at least five scholarly resources to support your assessment, diagnosis, and treatment planning.
· Ensure that you have the appropriate lighting and equipment to record the presentation.
The Assignment
Record yourself presenting the complex case study for your clinical patient. In your presentation:
· Dress professionally and present yourself in a professional manner.
· Display your photo ID at the start of the video when you introduce yourself.
· Ensure that you do not include any information that violates the principles of HIPAA (i.e., don’t use the patient’s name or any other identifying information).
· Present the full complex case study. Include chief complaint; history of present illness; any pertinent past psychiatric, substance use, medical, social, family history; most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; and plan for treatment and management.
· Report normal diagnostic results as the name of the test and “normal” (rather than specific value). Abnormal results should be reported as a specific value.
· Be succinct in your presentation, and do not exceed 8 minutes. Specifically address the following for the patient, using your SOAP note as a guide:
·
· Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
· Objective: What observations did you make during the psychiatric assessment?
· Assessment: Discuss their mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses and why you chose them. List them from highest priority to lowest priority. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5 diagnostic criteria and supported by the patient’s symptoms.
· Plan: What was your plan for psychotherapy? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also be sure to include at least one health promotion activity and one patient education strategy.
· Reflection notes: What would you do differently with this patient if you could conduct the session again? If you are able to follow up with your patient, explain whether these interventions were successful and why or why not. If you were not able to conduct a follow up, discuss what your next intervention would be.
This information is also found in the Student Handbook.
Develop a personal philosophy focusing on the central concerns of nursing. The fundamental elements are to be included; others may be chosen if desired. Use at least two references to support your point of view. One reference must be research based from a nursing journal.
A philosophy of nursing is by its very nature, a very individualized, personal statement based on subjective life experiences and adoption of particular world views. As such, the grading of this project will rest solely on the “depth and breadth” of the philosophical inquiry guided by the questions. Total points possible for this project are 15. This is not a simple exercise. Put thought into this. It is your personal philosophy of nursing. Please answer the questions below: Personal Knowing 1. Examine your personal beliefs and baccalaureate nursing education.
(Write an overall introduction of your personal beliefs about being a baccalaureate prepared nurse). Ontological Questioning 2. To develop a personal philosophy of nursing: one must focus on the central concerns of the discipline. This would include, for example, the nature of human beings and the life process. From the perspective of nursing, attempt to answer the following questions which reflect the fundamental elements of nursing and any others you may choose to incorporate:
a. What is society – of whom is it composed, and what is the nature of the relationships among its constituents including self in the role of the nurse? Where do you, as a professional nurse, fit into the picture and landscape of community? b. What are your central beliefs about the individual person, and that individual’s potential? The individual’s ability to learn, change, and heal? The family? The community? Your role as a professional nurse in these processes and relationships? c. What constitutes the environment? How do human beings and the environment interact? What contextual importance does it have for the focus of the discipline of nursing. d. What is your view(s) of health? Is it a continuum? A unidirectional phenomenon? A state? A process? Achieved/maintained alone or in unison with others? e. How do illness and wellness relate to health? f. What is the central reason for the existence of nursing and your calling to it? g. Who is the recipient of your nursing call? h. How does self-discovery and knowledge development occur in nurse-client relationships.Empirical Knowing 3. From the perspective of a philosopher’s concern with knowledge, Epistemological attempt to answer the following questions that reflect the Questioning essential elements of the scientific discipline of nursing: a. What do you believe is the nursing process? b. From what cognitive base does the professional nurse operate? Critical thinking? Problem-solving methodology? c. How do you implement the nursing process as you define it? What is necessary in the application of knowledge? d. How is the theory base for nursing derived? e. What is the theoretical framework for the profession? Is there room for diversity of thought, or is unity conceptual? Ethical and Esthetic 4.From the philosopher’s concern with ethics and esthetics, attempt Knowing to answer the following questions reflecting the valuation elements of nursing:
a. What are the essential rights and responsibilities of the professional nurse? b. What are the essential rights and responsibilities of the recipient of nursing care? c. How do your beliefs about nursing guide the research, education, administration and practice components of your role as a professional nurse? d. What are the governing ethical principles in the delivery of nursing care and the conduct of nursing research? e. What are your beliefs about the educational requirements and the focus of education for the practice of the profession? f. What are your beliefs about the teaching-learning process? g. What do you believe is needed for your continued development of esthetic knowing or responsiveness in nurse-client interactions?
An ongoing challenge for advanced practice registered nurses (APRNs) has been changing state legislation that allow APRNs to practice to the fullest extent to which they were academically prepared. For this discussion question, contact the Board of Nursing (BON) in your state or access your BON online. Examine laws that govern APRNs in your state. Consider the following: do APRNs in your state have prescriptive authority; is there legislation in place that allows them to practice autonomously; and finally, if a bill has been passed and adopted, which legislator introduced the bill and who were the strongest advocates for the bill? Then post an initial response that addresses the following:
Explain how the lack of autonomy for APRNs impact patients in rural populations? As a health care professional in an advocacy role, what resources could you utilize to guide you in changing policies that impact APRNS in your state? Include in your discussion the type of stakeholders and collaborative partners you would seek to guide or assist you on this cause. initial 400 APA words, makeup 2 replies to 2 students 200 words each.
Florence Nightingale was a leader in nursing whose writings led to the foundation of many of our current nursing philosophies and theoretical models. Although there have been significant changes in our society and health care since her era, one can identify evidence of her writings and practice in current nursing practice.
For this assignment, read “Nightingale’s Environmental Theory” published by Margaret Hegge in Nursing Science Quarterly 26(3), 211-219. The article can be accessed on the D’Youville College Library website. In this article, Dr. Hegge describes the environmental theory from Nightingale’s experiences. In your writing, please address the following topics:
Introduction to the main topic of the paper.(Begin with “The purpose of this paper is to…..” and then discuss the main points of the paper)
Describe Nightingale’s Theory.
Explain the current (actual or potential) environmental problem faced by patients or communities. Be sure that the problem is within the past 5 years and show the impact of the environment on the health problem. Discuss political influences, policy issues, and legal influences on the problem. Examples of current environmental problems include: Covid 19, Flint Water Crisis, Air pollution etc.
Compare and contrast one other discipline (e.g., PT, OT, Pharmacy, Social Work, Nutrition etc.) with nursing in examining the problem.
Discuss stakeholders and resources involved in examining the problem
Discuss outcomes. How will you measure the success of the solutions you propose?.
General directions for submitting assignment:
Use subheadings for each topic following the grading rubric.
The paper should be detailed with evidence.
APA format should be used including a title page, and references. You will lose credit if you do not follow APA format. See the APA documents for how to format the title page
To access the article for the assignment, go to the D’Youville College Library website (click to access). (Links to an external site.)Once there, in Spartan Search:
Type “Nightingale’s Environmental Theory Hegge.”
Click “Full Text.”
Under “Tools” in the right column, click “Article as PDF.”
1. Mrs. T. calls the pediatrician’s office and asks whether she should give acetaminophen, aspirin, or ibuprofen to her child for a fever. Her son is 3 years old and weighs 40 lb. What should you suggest for her son, and what dosage?
2. Mr. Z. is starting therapy for gout and is now taking allopurinol. Discuss the teaching needs for this disease and medication, including dietary guidelines.
3. Rheumatoid arthritis has been diagnosed in Mrs. S., and she will be taking an NSAID as part of her therapy. What should be assessed before she starts this type of medication?
4. Mr. R. comes to the clinic complaining of hearing problems. He says he hears a “funny noise” all the time. During the assessment and history, you discover that he has been taking aspirin for joint pain for about 2 weeks. He cannot tell you how much but says he takes “three or four pills three or four times a day.” What is the proper dosage for aspirin? Is Mr. R. showing signs and symptoms of aspirin toxicity?
5. Mrs. R. calls the clinic to ask about her medications. She wants to use an OTC pain reliever for headaches, but she remembered that she needed to check with her physician because she is taking an oral anticoagulant. She has acetaminophen, ibuprofen, and aspirin products at home. What should you tell her?
Case Scenario
A.R. is a 66-year-old male patient who comes to the clinic today with complaints of a painful big toe. Upon examination, the nurse notes that the toe is very red and swollen at the joint. A.R. advises the nurse not to touch his toe because it hurts so badly that he “cannot even wear a sock.” The nurse notes a significant decrease in the mobility of the big toe as well. A.R. has a history of ulcers, and the nurse notes that he consumes “several” alcoholic beverages each day. The physician sends A.R. to the laboratory for a uric acid level, and the results demonstrate a significant elevation. The physician makes a diagnosis of gouty arthritis and gives A.R. a prescription for febuxostat (Uloric) and colchicine.
What is the mechanism of action of colchicine, and how will this drug help A.R.?
Answer:
Rationale:
What is the mechanism of action of febuxostat, and how will this drug help A.R.?
Answer:
Rationale:
What side effects of febuxostat will the nurse teach the patient about?
• One introducer stabilizing catheter guide • One screw-cap locking tip catheter • One 0.2-μm screw-cap locking tip catheter connector • One epidural flat filter • Topical skin antiseptic, as prescribed • Sterile towels • Sterile forceps • Sterile gauze, 4 × 4 pads • Face masks with eye shields • Sterile gloves and gowns • 20 mL normal saline solution • 5 to 10 mL local anesthetic as prescribed (e.g., 1% lidocaine; local infiltration) • 5 mL local anesthetic as prescribed to establish the block • Test dose (e.g., 3 mL 2% lidocaine with epinephrine, 1:200,000) • Gauze or transparent dressing to cover the epidural catheter entry site • Tape to secure the epidural catheter to the patient’s back and over the patient’s shoulder • Labels stating “Epidural only” and “Not for intravenous injection” • Pump for administering analgesia (e.g., volumetric pump, dedicated for epidural use with rate and volume
limited, which has the ability to be locked to prevent tampering and preferably is a color-coded [e.g., yellow] or patient-controlled epidural analgesia pump)
• Dedicated yellow-lined, epidural portless administration set • Prescribed medication analgesics and local anesthetic medications • Equipment for monitoring blood pressure, heart rate, and pulse oximetry
Additional equipment, to have available as needed, includes the following: • Ice or alcohol swabs for demonstrating level of block • Capnography equipment • Emergency medications (e.g., naloxone for respiratory depression, intravenous colloids, and a vasoconstrictor
such as ephedrine for hypotension and Intralipid, a 20% fat emulsion for local anesthetic toxicity) • Bag-valve-mask device and oxygen • Intubation equipment
Patient and Family Education • Review the principles of epidural use with the patient and family members. If the patient’s pain needs are not
met, an assessment of the therapy will be completed and the physician, advanced nurse practitioner, or other healthcare professional may change the dosage or therapy to meet those needs. If available, supply easy-to- read written information. Rationale: This information prepares the patient and family for what to expect and may reduce anxiety and preconceptions about epidural use.
• Explain to the patient and family that the insertion procedure can be uncomfortable but that a local anesthetic will be used to facilitate comfort. Rationale: Explanation promotes patient cooperation and comfort, facilitates insertion, and decreases anxiety and fear.
• During insertion and therapy, instruct the patient to immediately report adverse side effects, such as ringing in the ears, a metallic taste in the mouth, or numbness or tingling around the mouth, because these are signs indicative of local anesthetic toxicity.13,30,33 Rationale: Immediate reporting identifies side effects and impending serious complications.
• Review an appropriate pain rating scale with the patient. The physician, advanced practice nurse, or other healthcare professional and the patient need to establish a mutually agreeable pain level goal. Rationale: Review ensures that the patient understands the pain rating scale and enables the nurse to obtain a baseline assessment. Establishing a pain level goal allows the physician, advanced practice nurse, or other healthcare professional to know an acceptable goal for pain management.
• During insertion and therapy, instruct the patient to report changes in pain management (e.g., suboptimal analgesia), numbness of extremities, loss of motor function of lower extremities, acute onset of back pain, loss of bladder and bowel function, itching, and nausea and vomiting.4,13,14,17 Rationale: Education regarding adverse side effects allows for more rapid assessment and management of potential complications.
• If the epidural infusion is patient-controlled, ensure that patient and family understand that only the patient is to activate the medication release. Rationale: The patient should remain alert enough to administer his or her own dose. A safeguard to oversedation is that a patient cannot administer additional medication doses if he or she is sedated.
Patient Assessment and Preparation P a ti e nt Asse ssm e nt • Assess the patient for local infection and generalized sepsis. Rationale: Assessment decreases the risk for
epidural infection (e.g., epidural abscess).31 Septicemia and bacteremia are contraindications for epidural catheter placement.4,8,23,27
• Assess the patient’s concurrent anticoagulation therapy. Rationale: Heparin (unfractionated) or heparinoids (e.g., low-molecular-weight heparin) administered concurrently during epidural catheter placement increases the risk for epidural hematoma and paralysis. Care must be taken with insertion and removal of the epidural catheter when patients have received anticoagulation therapy. Anticoagulant and fibrinolytic medications may increase the risk for epidural hematoma and spinal cord damage and paralysis. If used, anticoagulants must be withheld before insertion and removal of the epidural catheter.21,25,26 Removal of the epidural catheter should be directed by the physician. According to Kleinman and Mikhail,13 aspirin or nonsteroidal antiinflammatory medications (NSAIDs) by themselves do not pose an increased risk for epidural hematoma, assuming the patient’s coagulation profile is within normal limits. Therefore aspirin or NSAIDs may be administered while the epidural catheter is in place.13 However, epidural hematomas have been associated with the concurrent administration of the NSAIDs, ketorolac, and anticoagulants.12,21 Assessment of sensory and motor function must be regularly performed during epidural analgesia for all patients.
• Obtain the patient’s vital signs. Rationale: Baseline data are provided. • Assess the patient’s pain. Rationale: Baseline data are provided. • Review the patient’s medication allergies. Rationale: This information may decrease the possibility of an allergic
reaction.
Patient Preparation • Ensure that the patient and family understand preprocedural information. Answer questions as they arise, and
reinforce information as needed. Rationale: Understanding of previously taught information is evaluated and reinforced.
• Verify that the patient is the correct patient using two identifiers. Rationale: Before performing a procedure, the nurse and team members should ensure the correct identification of the patient for the intended intervention.
• Ensure that informed consent has been obtained. Rationale: Informed consent protects the rights of the patient and makes a competent decision possible for the patient.
• Perform a preprocedure verification and time out including all team members. Rationale: This action ensures patient safety.
• Wash the patient’s back with soap and water and open the gown in the back. Rationale: This action cleanses the skin and allows easy access to the patient’s back.
• Consider nothing by mouth (NPO), especially if sedation or general anesthesia is to be used. Rationale: NPO status decreases the risk for vomiting and aspiration.
• Establish IV access, or ensure the patency of IV catheters, and administer IV fluids as prescribed before epidural catheter insertion. Rationale: IV access ensures that medications can be given quickly if needed. The administration of IV fluids may decrease hypotension that may occur during epidural infusions.4,13
• Reassure the patient. Rationale: Anxiety and fears may be reduced.
Procedure for Pain Management: Epidural Catheters (Assisting With Insertion and Initiating Continuous Infusion)
FIGURE 105-2 Patient positioned for catheter placement. This figure shows two positions patients can assume for the epidural catheter placement procedure. (From Pasero C, McCaffery M: Pain assessment and pharmacologic management, St. Louis, 2011, Elsevier.)
FIGURE 105-3 Dermatomes. Segmental dermatome distribution of spinal nerves to the front, back, and side of the body. Dermatomes are specific skin surface areas innervated by a single spinal nerve or group of spinal nerves. Dermatome assessment is done to determine the level of spinal anesthesia for surgical procedures and postoperative analgesia when epidural local anesthetics are used. C, Cervical segments; T, thoracic segments; L, lumber segments; S, sacral segments; CX, coccygeal segment. (From Patton KT, Thibodeau GA: Anatomy and physiology, ed 9, St. Louis, 2016, Elsevier.)
2. Physicians, advanced practice nurses, and other healthcare professionals should apply personal protective equipment (e.g., face masks with eye shields). All physicians, advanced practice nurses, and other healthcare professionals present during epidural insertion should wear a hat and mask. The individual performing the procedure should wear hat, mask, sterile gown, and gloves.
3. Obtain the prescribed epidural medication infusion from the pharmacy.
The medication should be prepared with aseptic technique by the pharmacy with laminar flow or prepared commercially to decrease the risk for an epidural infection.23,27,28
All epidural solutions are preservative-free to avoid neuronal injury.30
4. Connect the epidural tubing to the prepared epidural medication infusion and prime the tubing.
Removes air from the infusion system.
5. Ensure that the patient is in position for catheter placement. Assist with holding the patient in position (lateral decubitus knee-to-chest position or leaning over bedside table) and consider preprocedure analgesia or sedation, if necessary (Fig. 105-2).
Facilitates ease of insertion of the epidural catheter. Both positions open up the interspinous spaces, aiding in epidural catheter insertion (see Fig. 105-2).
Movement of the back may inhibit placement of the catheter.
6. Assist as needed with the antiseptic preparation of the intended insertion site. (Level C*)
Reduces the transmission of microorganisms into the epidural space.
The choice of povidone-iodine or chlorhexidine as an antiseptic agent for neurological procedures is controversial. Both should be allowed to dry completely. Studies suggest chlorhexidine is neurotoxic.10,18,24
7. Assist if needed with draping the patient with exposure only of the insertion site.
Aids in maintaining sterility.
8. Assist the physician or advanced practice nurse as needed as the epidural catheter is placed.
Provides needed assistance.
9. Monitor the patient as the physician or advanced practice nurse administers 2–3 mL of 1% lidocaine containing 1:200,000 epinephrine as a test dose.
To confirm proper placement of the epidural catheter
An immediate increase in heart rate indicates the catheter has inadvertently penetrated an epidural vein. If this occurs the physician, advanced practice nurse, or other healthcare professional inserting the catheter should
withdraw the catheter slightly or remove it and insert a new catheter.29
10. After the epidural catheter is inserted, assist as needed with application of a sterile, occlusive dressing.
Reduces the incidence of infection.
Use of a transparent dressing allows for ongoing assessment of the insertion site for infection, leakage, or dislodgment.
11. Secure the epidural filter to the patient’s shoulder with gauze padding.
Avoids disconnection between the epidural catheter and filter. Gauze padding prevents discomfort and skin pressure from the filter.
12. The physician or advanced practice nurse administers a bolus dose of medication.
Facilitates a therapeutic level of analgesia and confirms correct catheter position.9
If a local anesthetic is used for the bolus, monitor the blood pressure frequently, with assessment for possible hypotension. Some analgesia medications (e.g., morphine) may take up to 1 hour to be effective.13,14,30
13. Connect the prescribed medication infusion system.
Prepares the infusion system.
14. Initiate therapy:
A. Place the system in the epidural pump or PCEA pump and set the rate and volume to be infused.
No other solution or medication (e.g., antibiotic or total parenteral nutrition) should be given through the epidural catheter.33
Responses to epidural analgesia vary individually, and epidural analgesia is tailored according to individual responses.
B. Attach an “Epidural only” label to the epidural tubing. Use a portless system.4,33 (Level E*)
Inadvertent intravenous administration of some epidural solutions can cause serious adverse reactions, including hypotension and cardiovascular collapse.11,28
C. Lock the key pad on the epidural or PCEA pump.
This is an important safety feature.
15. Assess the effectiveness of the analgesia. Follow institutional standards for assessing pain.
Identifies the need for additional pain medication and interventions.
A. Determine the pain score. Tolerable pain scores should be reported at rest, and very little pain should be
experienced with deep breathing, coughing, and movement.
B. Assess the level of the epidural block with ice or an alcohol swab.6
The ideal epidural block should be just above and just below the surgical incision or the trauma site (see the dermatomes described in Fig. 105-3).
16. Remove and sterile equipment and discard used supplies in an appropriate receptacle.
Removes and safely discards used supplies.
17. *Level C: Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results. *Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations.
Procedure for Epidural Catheter (Bolus Dose Administration) Without a Continuous Infusion
3. Boldly label the epidural catheter used for intermittent bolus dosing (suggest color coding).4,33 (Level E*)
Reduces the risk for administration of medication into intravenous lines.
4. Verify the correct medication with the five rights of medication administration.
Before performing a procedure, the nurse should ensure that the correct medication is being administered.
5. Prepare the bolus dose as prescribed.
Use only preservative-free solution to dilute assuring a decreased risk of neuronal injury.4,13
Do not use multidose vials because they increase the risk for contamination and the risk for an epidural infection.4,14
6. Prepare and cleanse the epidural port with an antiseptic agent. (Level C*)
Do not use an alcohol-based preparation. Use aqueous chlorhexidine or povidone-iodine.
Preparations with alcohol are neurotoxic to the epidural space. The choice of povidone- iodine or chlorhexidine as an antiseptic agent is controversial. Both should be allowed to dry completely. Studies suggest chlorhexidine is neurotoxic.10,18,14
7. Use aseptic technique to administer the epidural bolus:
A. Connect an empty syringe to the catheter port.
Administers the medication for injection.
Follow state and institutional guidelines as to who is able to provide bolus doses.
B. Aspirate the epidural catheter, limited by the amount allowed by institutional policy. If blood is aspirated, do not reinject the aspirate. Do not inject the medication. Notify the physician or advanced practice nurse. If clear fluid is obtained, it may be CSF. Do not reinject the aspirate. Do not inject the medication. Notify the physician or advanced practice nurse.6,9,19,30
If blood is obtained, the epidural catheter may have migrated into an epidural vessel. An amount of only 1–2 mL of blood may be inconclusive because any blood from an epidural vein may have mixed with blood from the trauma of inserting the catheter. If more than 3 mL is aspirated, the catheter is most likely in an epidural vein.30
If 5 mL or more of CSF is obtained, the catheter may have migrated into the subarachnoid space.30
Administration of epidural medications into the epidural vein or into the subarachnoid space may result in increased sedation, respiratory depression, hypotension, and bradycardia.
C. Connect the syringe with the bolus medication to the catheter port.
Prepares for the injection.
D. Administer the medication slowly. Note: If excessive pressure occurs, assess for kinks in the catheter or reposition the patient.
Some resistance will be felt because the diameter of the epidural space is small and the epidural filter is in place.
Excessive pressure may be more pronounced if the epidural catheter is
placed at the lumbar dermatome as opposed to the thoracic dermatome.
If resistance continues to impair administration of a bolus dose, contact the physician or advanced practice nurse.
8. Assess the effectiveness of the medication. Follow institutional standards for assessing pain.
Identifies need for pain interventions. Pain should be relieved or decreased.
Report continued pain despite pain interventions.
9. Monitor vital signs. An epidural bolus may cause hypotension, bradycardia, respiratory depression, or increased sedation.11,28
Report untoward decreases in blood pressure, heart rate, respirations, oxygen saturation, and sedation.
10. Monitor for increased motor and or sensory block, and signs and symptoms of local toxicity related to the epidural medications.
Allows for the early identification of signs and symptoms of local anesthetic toxicity which include lightheadedness, tinnitus, metallic taste, visual disturbances, perioral numbness loss of consciousness, seizure, arrhythmia, and asystole.4
11. Remove and discard used supplies.
12. *Level C: Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results. *Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations.
Procedure for Assisting With Removal of the Epidural Catheter
2. Physicians, advanced practice nurses, and other healthcare professionals should apply personal protective gear (e.g., face masks with eye shields), and sterile gloves may be worn by the physician, advanced practice nurse, or other healthcare professional removing the catheter.
3. Assist the physician or advanced practice nurse as needed with removal of the catheter.
Facilitates catheter removal.
4. Assist if needed with applying a sterile occlusive dressing.
Reduces contamination by microorganisms.
5. Remove personal protective equipment and discard used supplies in an appropriate receptacle.
Removes and safely discards used supplies.
6. Assess neurological status, pain, and insertion site after removal of the epidural catheter.
Motor or sensory loss in the extremities may be an early warning sign of an epidural abscess or hematoma or may indicate an excessive dose of a local anesthetic.26,27
An epidural hematoma is a rare but serious complication; if undetected, it may result in permanent paralysis.14,16,22,32
Assess for a change in sensory or motor function in extremities, sudden onset of back pain with increasing motor weakness, and loss in bladder and bowel function.
A. Monitor sensory and motor status of lower extremities and ability to void up to 24 hours after removal of the catheter (see Fig. 105-3).2,8,14,16
Identifies potential adverse effects of epidural analgesia.
B. Monitor insertion site for drainage or infection.
Identifies adverse effects of epidural analgesia such as infection.
C. Continue to assess pain.
Identifies need for ongoing interventions to manage pain.
Expected Outcomes • The epidural catheter is inserted into the epidural space • Pain is decreased and maintained at a tolerable level • The patient experiences minimal sedation • The patient experiences minimal numbness and no motor loss in the limbs • Hemodynamically stable • No opioid-related respiratory depression or decreased respiratory blockade from local anesthetic affecting the
diaphragm or ancillary muscles required for inspiration and expiration
Unexpected Outcomes • Inability to insert the epidural catheter • Suboptimal pain relief13
• Oversedation or drowsiness11,28
• Opioid-induced respiratory depression or hypoxia11,28
• Hypotension14,19,30
• Motor blockade of limbs; lower extremity weakness13,19,30
• Sensory loss in the limbs13,19,30
• Patchy block (e.g., uneven pain relief)13
• Unilateral block (e.g., pain relief on the contralateral side of the body only)13
• Nausea and vomiting8,14,17,28
• Pruritus1,8,14,17,28
• Urinary retention1,8,14,16,28
• Accidental dural puncture into the subarachnoid space13,33
• Dural puncture headache13,33
• Epidural catheter tip migration into a vessel or adjacent structure13
• Redness or signs of skin breakdown at pressure area sites (e.g., sacrum, heels) from decreased sensation • High epidural block— epidural local anesthetic block above the thoracic fourth vertebrae (T4)14
• Total spinal blockade13
• Occlusion of epidural catheter13
• Accidental epidural catheter dislodgment13
• Dressing disruption exposing insertion site • Leakage from the epidural catheter insertion site13,33
• Cracked epidural filter • Local anesthetic toxicity13
• Anaphylaxis14
• Epidural hematoma8,25,26,28
• Epidural abscess8,25,27,28
• Local erythema or drainage at insertion site32
• Nerve or spinal cord injury13
• Accidental connection of the epidural solution to the intravenous fluids33
• Accidental connection of intravenous fluids to the epidural catheter. • Local anesthetic toxicity13,14
These conditions should be reported if they persist despite nursing interventions.
1. Assess the patient’s level of pain with use of a pain scale.9,14,30 The frequency of assessments is determined by institutional standards. Record the patient’s subjective level of pain, with use of the institution’s standard pain assessment tool.
Describes patient response to pain therapy. A low pain score is expected both at rest and during movement.
Analgesic goal is safe, steady pain control at a low level that is acceptable to the patient.
• Moderate to severe pain scores
2. Assess the patient’s level of sedation9,14,30 with use of the institution’s standard assessment scale and frequency standard.
Sedation precedes opioid-related respiratory depression. A sudden change in sedation scale may indicate that the epidural catheter has migrated into an epidural blood vessel or the intrathecal space.11
• Increasing sedation and drowsiness or sudden change in sedation scale
3. Assess respiratory rate the first 20 minutes after administration of the epidural medication, and/or bolus then every 1–2 hours and as needed (prn).11,14,28 (Level D*)
Provides data for diagnosis of respiratory depression.
• Increasing respiratory depression or sudden change in respiratory rate combined with increasing somnolence
4. Assess heart rate14,28 with vital signs every 2 hours, then every 4 hours when stable.
Tachycardia may indicate a condition such as shock. Bradycardia may indicate opioid overmedication and sympathetic blockade by the local anesthetic.13,19
• Change in heart rate
• Abnormal heart rate
• Abnormal cardiac rhythm
5. Assess blood pressure with vital signs every 2 hours, then every 4 hours when stable. If hypotension occurs:
A. Turn off the epidural infusion; notify the physician, advanced practice nurse, pain relief service.
B. Place the patient in a supine, flat position.
C. Administer IV fluids as prescribed or according to protocol.
D. Administer vasopressor medications as prescribed.14,28
Epidural solutions that contain a local anesthetic may cause peripheral and venous dilation, providing a “sympathectomy.”14 The hypotensive effect of a local anesthetic is most common when a patient’s fluid status is decreased. Epidural analgesia may not be the sole cause of hypotension but may reveal hypovolemia.
E. Use caution when raising patient from lying to sitting or sitting to standing positions.31
6. Monitor the infusion rate with vital signs. Ensure that the control panel is locked if using the volumetric infuser or ensure that the PCEA program is locked in via key or code access.
Ensures that the medication is administered safely.
7. Monitor oxygen saturation and end- tidal carbon dioxide if prescribed or continuously as per institutional policy.11,14 (Level E*)
Assesses oxygenation. A decrease in oxygen saturation is a late sign of opioid oversedation and should not be solely relied on to detect oversedation.
• Oxygen saturation <93% or a decreasing trend in oxygenation
• Note: Decreased oxygen saturation is a late sign of opioid oversedation and should not be solely relied on to detect oversedation .
8. Obtain the patient’s temperature11,14 every 4 hours; assess more often if febrile. (Level E*)
Fever may signify an epidural space infection or systemic infection that is a potential risk when an epidural catheter is in place.14,17,27,32
• Temperature >101.3°F (38.5°C)
9. Assess the epidural catheter site every 4 hours or according to established institutional standards.14,32
Identifies site complications and infection. An epidural abscess is a rare but serious complication. Patient recovery without neurological injury depends largely on early recognition.14,17,27,32
• Redness • Tenderness
or increasing diffuse back pain
• Pain or paresthesia during epidural injection induration
• Swelling or presence of exudate
10. Monitor ability to void and ability to completely empty bladder.1,8,14 (Level E*)
Provides data regarding urinary retention and possible early signs of epidural abscess or epidural hematoma.8,14,26,27,32
• Urinary retention
• Change in bladder function
• Lack of urination for >6–8 hours
11. Monitor for sensory and or motor loss (e.g., leg numbness or inability to bend knees) at least every 4 hours and prn (see Fig. 105-3).2,8,14,16 (Level E*)
Motor or sensory loss in the extremities may be an early warning sign of an epidural abscess or hematoma or may indicate an excessive dose of a local
anesthetic.26,27 An epidural hematoma is a rare but serious complication; if undetected, it may result in permanent paralysis.14,16,17,32
function in extremities
• Sudden onset of back pain with decreasing motor weakness
• Loss in bladder and bowel function (e.g., incontinence )
12. Assess for ringing in the ears, tingling around lips, or a metallic taste.5,13,14 (Level E*)
If a local anesthetic is used in the epidural solution, ringing in the ears, tingling around the lips, or a metallic taste may indicate impending local anesthetic toxicity.5,13,14
• Ringing in the ears, tingling around the lips, or a metallic taste
13. Monitor and check skin integrity of the sacrum and the heels every 2 hours and as needed. Change the patient’s position as needed.
If a local anesthetic is used in the epidural solution, check for pressure points and decubitus ulceration (patient may have sensory loss in lower limbs).13,19,30
• Altered skin integrity
• Increasing redness or blistering of the skin on the sacrum or heels
14. Change the epidural catheter insertion site dressing as prescribed or if soiled, wet, or loose. Call physician or advanced practice nurse if catheter site is exposed. Follow institutional standards.
Provides an opportunity to cleanse the area around the catheter and to assess for signs and symptoms of infection that may indicate early signs of an epidural abscess.14,27
• Swelling • Site pain • Redness • Leakage of
epidural solution or drainage
15. Assess for the presence of nausea or vomiting.8
Antiemetics may need to be administered; the medication may need adjustment (e.g., opiates may need to be decreased or stopped if nausea and vomiting are not well controlled).
• Unrelieved nausea and vomiting
• Note: Nausea and vomiting may be a sign of severe hypotension.
16. Assess for the presence of pruritus.2,8 Epidural opiates may cause itching. Medications such as antihistamines
may cause sedation and are ineffective for spinally mediated itching. Low-dose opioid antagonists may be necessary to relieve pruritus. Small doses of naloxone (e.g., 0.04 mg) are
effective for pruritus without reversing the analgesia.13,19
Diphenhydramine or hydroxyzine can also be effective for itching associated with dehydration but may cause increased sedation.13,19
17. Label the epidural pump and tubing33 and consider placing the epidural pump on one side of the patient’s bed and all other pumps on the other side of the bed. Consider the use of a different colored label for the epidural pump and the tubing to differentiate it from pumps and tubing for intravenous fluids and medications.
May aid in minimizing the risk for mistaking the epidural infusion for an IV infusion system. Cardiopulmonary arrest and seizures may occur if the epidural solution is infused intravenously.13
• Infusion of IV fluid into the epidural space
• Infusion of epidural solution into the IV
*Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations. *Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations.
Documentation Documentation should include the following: • Patient and family education • Completion of informed consent • Preprocedure verifications and time out • Any difficulties associated with insertion • Type of dressing used • Confirmation of epidural catheter placement (e.g., decrease in blood pressure, demonstrable block to ice; see
Fig. 105-3) • Site assessment • Preintervention and serial pain assessment, including levels of motor and sensory blockade (documented on an
appropriate flow chart at regular intervals; see Fig. 105-3) and effectiveness of interventions30
• Sedation score assessment • Vital signs and oxygen saturation11
• Epidural analgesic medication and medication concentration being infused and infusion rate per hour • Bolus dose administration and patient response after bolus dose, including effectiveness of pain relief • Occurrence of unexpected outcomes or side effects • Nursing interventions taken • Pump settings when programmed for PCEA • Medication concentrations, continuous infusion rate, bolus dose, lockout interval, limit for 1 or more hours
according to institutional standards • Pain assessment, interventions, and effectiveness
Group therapy can alleviate feelings of isolation and foster a supportive and collaborative environment for sharing difficult feelings in order to facilitate healing. For many people, being part of a group that has a shared understanding of a struggle provides a unique opportunity to gain understanding of their own experiences.
As you examine one of the group therapy demonstrations from this week’s Learning Resources, consider the role and efficacy of the leader and the reasons that specific therapeutic techniques were selected.
To prepare:
· Select one of the group therapy video demonstrations from this week’s required media Learning Resources.
The Assignment
In a 3- to 4-page paper, identify the video you selected and address the following:
· What group therapy techniques were demonstrated? How well do you believe these techniques were demonstrated?
· What evidence from the literature supports the techniques demonstrated?
· What did you notice that the therapist did well?
· Explain something that you would have handled differently.
· What is an insight that you gained from watching the therapist handle the group therapy?
· Now imagine you are leading your own group session. How would you go about handling a difficult situation with a disruptive group member? How would you elicit participation in your group? What would you anticipate finding in the different phases of group therapy? What do you see as the benefits and challenges of group therapy?
· Support your reasoning with at least three peer-reviewed, evidence-based sources, and explain why each of your supporting sources is considered scholarly. Attach the PDFs of your sources.
Submit your Assignment.
Reminder The School of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at http://writingcenter.waldenu.edu/57.htm). All papers submitted must use this formatting.
NB: THE VIDEO IS ON YOUTUBE. YOU CAN TYPE THE BELOW YOUTUBE CHANNEL TO GET THE VIDEO.
