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Cleansweep RN

An international code of ethics for nurses was first adopted by the International Council of Nurses (ICN) in 1953. It has been revised and reaffirmed at various times since, most recently with this review and revision completed in 2005. It is a guide for action based on social values and needs. The Code has served as the standard for nurses worldwide since it was first adopted in 1953. The new version, revised for the first time in 27 years, responds to the realities of nursing and health care in a changing society.

ELEMENTS OF THE CODE

1. Nurses and people

The nurse’s primary professional responsibility is to people requiring nursing care. In providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected. The nurse ensures that the individual receives sufficient information on which to base consent for care and related treatment. The nurse holds in confidence personal information and uses judgement in sharing this information. The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations. The nurse also shares responsibility to sustain and protect the natural environment from depletion, pollution, degradation and destruction.

2. Nurses and practice

The nurse carries personal responsibility and accountability for nursing practice, and for maintaining competence by continual learning. The nurse maintains a standard of personal health such that the ability to provide care is not compromised. The nurse uses judgement regarding individual competence when accepting and delegating responsibility. The nurse at all times maintains standards of personal conduct which reflect well on the profession and enhance public confidence. The nurse, in providing care, ensures that use of technology and scientific advances are compatible with the safety, dignity and rights of people.

3. Nurses and the profession

The nurse assumes the major role in determining and implementing acceptable standards of clinical nursing practice, management, research and education. The nurse is active in developing a core of research-based professional knowledge. The nurse, acting through the professional organisation, participates in creating and maintaining safe, equitable social and economic working conditions in nursing.

4. Nurses and co-workers

The nurse sustains a co-operative relationship with co-workers in nursing and other fields. The nurse takes appropriate action to safeguard individuals, families and communities when their health is endangered by a co-worker or any other person.

Cleansweep RN

Betty Newman was born in 1924 at Lowell, Ohio, United States of America. In 1947 she received RN Diploma from Peoples Hospital School of Nursing, Akron, Ohio. She then moved to California and gained experience as a hospital, staff, and head nurse; school nurse and industrial nurse; and as a clinical instructor in medical-surgical, critical care and communicable disease nursing. In 1957 Dr. Newman attended the University of California at Los Angeles (UCLA) with double major in psychology and public health. She received BS in nursing from UCLA. In 1966 she received Masters Degree in Mental Health, Public Health Consultation from UCLA. The Newman Systems Model was originally developed in 1970 at the University of California, Los Angeles, by Betty Newman, Ph.D., RN. The model was developed by Dr. Newman as a way to teach an introductory nursing course to nursing students. The goal of the model was to provide a holistic overview of the physiological, psychological, socio-cultural, and developmental aspects of human beings. Newman’s model focuses on the person as a complete system, the subparts of which are interrelated physiological, psychological, socio-cultural, spiritual, and developmental factors.

Newman's System Model

The large circle in the center is the focal point and includes the symbol for Maslow's hierarchy of needs: Physiological, socio-cultural, developmental, spiritual. The concentric circles around the center signify client (brown triangle with a circle on top), environment (blue clouds and yellow circle sunshine), health (red crosses), and nursing (pink hearts). The layers, usually represented by concentric circle, consist of the central core, lines of resistance, lines of normal defence, and lines of flexible defence. The basic core structure is comprised of survival mechanisms including: organ function, temperature control, genetic structure, response patterns, ego, and what Newman terms known and commonalities. Lines of resistance and two lines of defence protect this core. The person may in fact be an individual, a family, a group, or a community in Newman’s model. The person, with a core of basic structures, is seen as being in constant, dynamic interaction with the environment. Around the basic core structures are lines of defence and resistance. The person is seen as being in a state of constant change and-as an open system-in reciprocal interaction with the environment.


Elements of Newman’s Theory

Person - The person is a layered multidimensional being. Each layer consists of five person variables or subsystems: Physical/Physiological, Psychological, Socio-cultural, Developmental and Spiritual

Environment - The environment is seen to be the totality of the internal and external forces which surround a person and with which they interact at any given time. These forces include the intrapersonal, interpersonal and extra personal stressors which can affect the person's normal line of defence and so can affect the stability of the system.

  1. The internal environment exists within the client system.
  2. The external environment exists outside the client system.
  3. Newman also identified a created environment which is an environment that is created and developed unconsciously by the client and is symbolic of system wholeness.

Health - Newman sees health as being equated with wellness. She defines health/wellness as "the condition in which all parts and subparts (variables) are in harmony with the whole of the client (Newman, 1995)". As the person is in a constant interaction with the environment, the state of wellness (and by implication any other state) is in dynamic equilibrium, rather than in any kind of steady state. Newman proposes a wellness-illness continuum, with the person's position on that continuum being influenced by their interaction with the variables and the stressors they encounter. The client system moves toward illness and death when more energy is needed than is available. The client system moves toward wellness when more energy is available than is needed.

Nursing - Newman sees nursing as a unique profession that is concerned with all of the variables which influence the response a person might have to a stressor. The person is seen as a whole, and it is the task of nursing to address the whole person. Neuman defines nursing as actions which assist individuals, families and groups to maintain a maximum level of wellness, and the primary aim is stability of the patient/client system, through nursing interventions to reduce stressors. Neuman states that, because the nurse's perception will influence the care given, then not only must the patient/client's perceptions be assessed, but so must those of the caregiver (nurse). The role of the nurse is seen in terms of degrees of reaction to stressors, and the use of primary, secondary and tertiary interventions.

Newman's 3 stage nursing process:

  1. Nursing Diagnosis - based of necessity in a thorough assessment, and with consideration given to five variables in three stressor areas.
  2. Nursing Goals - these must be negotiated with the patient, and take account of patient's and nurse's perceptions of variance from wellness
  3. Nursing Outcomes - considered in relation to five variables, and achieved through primary, secondary and tertiary interventions.
Cleansweep RN

Lumbar puncture (spinal tap) is a diagnostic and at times therapeutic procedure that is performed in order to collect a sample of cerebrospinal fluid (CSF) for biochemical, microbiological, and cytological analysis, or occasionally as a treatment "therapeutic lumbar puncture" to relieve increased intracranial pressure. Although usually used for diagnostic purposes to rule out potential life-threatening conditions such as bacterial meningitis or subarachnoid hemorrhage, lumbar puncture is also sometimes performed for therapeutic reasons, such as the treatment of pseudotumor cerebri. CSF fluid analysis can also aid in the diagnosis of various other conditions, such as demyelinating diseases and carcinomatous meningitis.

Indications:

  • Suspicion of meningitis
  • Suspicion of subarachnoid hemorrhage
  • Suspicion of central nervous system diseases such as Guillain Barre Syndrome and carcinomatous meningitis
  • Therapeutic relief of pseudotumor cerebri

Contraindications:

    • Unequal pressures between the supratentorial and infratentorial compartments
    • Infected skin over the needle entry site
    • Relative contraindications to lumbar puncture are as follows:
      • Increased intracranial pressure
      • Coagulopathy
      • Brain abscess
    • Indications for brain CT scan prior to lumbar puncture include the following:
      • Patients who are older than 60 years
      • Patients who are immunocompromised
      • Patients with known CNS lesions
      • Patients who have had a seizure within 1 week of presentation
      • Patients with abnormal level of consciousness
      • Patients with focal findings on neurological examination
      • Patients with papilledema seen on physical examination with clinical suspicion of elevated ICP

Equipments:

  • Spinal or lumbar puncture tray
  • Sterile gloves
  • Antiseptic solution with skin swabs
  • Sterile drape
  • Lidocaine 1% without epinephrine
  • 3ml Syringe
  • Gauge 20 & 25 neddles
  • Spinal needles gauge 20 & 22
  • Three-way stopcock
  • Manometer
  • 4 plastic test tubes, numbered 1-4, with caps
  • Sterile dressing
  • 10 mL Syringe

Procedures:

  1. Explain the procedure, benefits, risks, complications, and alternative options to the patient or the patient's representative and obtain a signed informed consent
  2. Wearing nonsterile gloves, locate the L3-L4 interspace by palpating the right and left posterior superior iliac crests and moving the fingers medially toward the spine. Palpate that interspace (L3-L4) as well as one above (L2-L3) and one below (L4-L5) to find the widest space. Mark the entry site with a thumbnail or a marker. To help open the interlaminar spaces, the patient can be asked to practice pushing the entry site area out toward the practitioner.
  3. Open the spinal tray, change to sterile gloves, and prepare the equipment. Open the numbered plastic tubes and place them upright, assemble the stopcock on the manometer, and draw the lidocaine into the 10-mL syringe.
  4. Use the skin swabs and antiseptic solution to clean the skin in a circular fashion starting at the L3-L4 interspace and moving outward to include at least 1 interspace above and below. Just before applying the skin swabs, warn the patient that the solution is very cold, since this can be unnerving to the patient.
  5. Place a sterile drape below the patient and a fenestrated drape on the patient. Most spinal trays contain fenestrated drapes with an adhesive tape that keeps the drape in place.
  6. Use the 10-mL syringe to administer local anesthesia. Raise a skin wheal using the 25-ga needle and then switch to the longer 20-ga needle to anesthetize the deeper tissue. Insert the needle all the way to the hub, aspirate to confirm that the needle is not in a blood vessel, and then inject a small amount as the needle is withdrawn a few centimeters. Continue this process above, below, and to the sides very slightly (using the same puncture site).
  7. Stabilize the needle (20 or 22 ga) with the index fingers and advance it through the skin wheal using the thumbs. Orient the bevel parallel to the longitudinal dural fibers to increase the chances of the needle separating the fibers rather than cutting them (bevel facing up in the lateral recumbent position and facing to either side in the sitting position). Insert the needle at a slightly cephalad angle toward the umbilicus. Advance the needle slowly but smoothly. Occasionally, the practitioner feels a characteristic “pop” when the needle penetrates the dura. Otherwise, the stylet should be withdrawn after approximately 4-5 cm and observed for fluid return. If no fluid returns, replace the stylet, advance or withdraw the needle a few millimeters, and recheck for fluid return. Continue this process until fluid is successfully returned.
  8. To measure the opening pressure, the patient must be in the lateral recumbent position. After fluid returns from the needle, attach the manometer through the stopcock and note the height of the fluid column. The patient's legs should be straightened when measuring open pressure or a falsely elevated pressure will be obtained.
  9. Collect at least 10 drops of CSF in each of the 4 plastic tubes, starting with tube #1. The CSF that is in the manometer should be used (if possible) for tube #1.
  10. Replace the stylet and remove the needle. Clean off the skin preparatory solution. Apply a sterile dressing and place the patient in the supine position.

Complications:

  • Post–spinal puncture headache – This is the most common complication of lumbar puncture. It usually begins 24-48 hours after the procedure and is more common in young adults. The probable etiology is continued CSF leak from the puncture site. The headache is usually fronto-occipital and improves in the supine position.
  • Bloody tap – More than 50% of lumbar punctures have falsely present red blood cells in the CSF as a result of microtrauma caused by the spinal needle. This is an uncomplicated occurrence in healthy patients with a normal coagulation system.
  • Dry tap – Dry tap is usually a result of misplacement of the spinal needle. The most common mistake is a lateral displacement that can be easily corrected by complete withdrawal of the needle, reevaluation of the patient’s anatomy, and reinsertion in the correct place and angle.
  • Infection – Cellulitis, skin abscesses, epidural abscesses, spinal abscesses, or diskitis can result from a contaminated spinal needle.
  • Hemorrhage – Epidural, subdural, and subarachnoid hemorrhage are rare complications that might carry significant morbidity and mortality in coagulopathic patients.
  • Dysesthesia – Irritation of nerves or nerve roots by the spinal needle can cause different lower extremity dysesthesias. Withdrawing the needle without replacement of the stylet can cause aspiration of a nerve or arachnoid tissue into the epidural space. Always replace the stylet before moving the needle to prevent this complication.
  • Postdural puncture cerebral herniation – This is the most serious complication of a lumbar puncture. This is a very rare complication and debate exists in the literature regarding whether the lumbar puncture or the underlying disease process is the cause of the herniation.

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