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Delegation for effective task management. - answer A nurse is responsible for providing clear directions when a task is initially delegated and for periodic reassessment and evaluation of the outcome of the task. RNs must delegate tasks so that they can complete higher level tasks. RNs may delegate to other RNs, PNs or APs. PNs may delegate to other PNs or APs. Predictability of outcome: Is this routine, or is this new, is there potential for complications Potential for harm: Is the client stable? Risks? Aspiration, Bleeding Complexity of Care: Does the delegatee have the license to perform the task, and the training? Need for problem solving: Does this require the nursing process? Assessment skills or judgment Level of client interaction: Is there psychosocial support needed? TO PN - answer Monitoring findings Reinforcing client teaching Tracheostomy Care Suctioning NG tube patency Enteral Feedings Insert Catheter
Administering Meds TO AP - answer ADLs Bathing, Grooming, Dressing, Toliet Ambulating Feeding Positioning Routine tasks Bed making Specimen Collection, I and Os Vitals For stable clients Concepts of management—Strategies to identify solutions to community health problems - answer Planning Organizing: Controlling: Directing: Staffing: Planning: - answer What needs to be done, and who is going to do it Organizing: - answer Lines of authority, communications, and where decisions are made Directing: - answer Influences and motivates people to perform Controlling: - answer The evaluation of performance and unit goals to ensure outcomes are met Staffing: - answer Adequate staffing, and staffing mix
Emergent: - answer Highest priority, life threatening injuries but also have high survival rate once stable Urgent: - answer Second highest priority can wait 40-60 mins for treatment Nonurgent: - answer Minor injuries that are not life threatening and do not need immediate attention Expectant: - answer Lowest priority, expected to die, Comfort care, but not restorative care Determining Priority Care for a group of clients - answer Prioritizing Care for multiple home care clients - answer Life before limb Acute before Chronic Actual problems before potential problems Listen carefully to clients and don't assume Trends vs Transient findings Complications vs expected findings Prioritizing Care for post op clients - answer Airway, Breathing, Circulation, Disability, Examination/Exposure Maslow's Hierarchy - answer Physiological, Safety and Security, Love and Belonging, Self- esteem, Self-Actualization Speaking to a client who has a hearing Impairment - answer Learn the clients' preferred method of communications and make accommodations. Avoid covering your mouth
Sit and face the client Speak slowly and clearly Encourage the use of hearing devices Try lowering vocal pitch before increasing volume Do not shout Use brief sentences with simple words Minimize background noise Ask for a sign language interpreter if necessary Write down what clients do not understand Fractures: Care for a new Cast - answer Show the procedure on a doll Assist with crutches and use Assess for warmth Assess skin Apply ice for 24hrs Assess
Actual Loss - answer : Any loss of a values person, item or status Perceived loss: - answer Any loss that is not obvious to others Maturational or developmental loss: - answer Any loss expected of life. (Child leaving for college) Situational loss: - answer Any unanticipated loss caused by an external event (home loss by tornado) Anticipatory loss: - answer Experienced before the loss happens Stages of grief - answer Denial, Anger, Bargaining, Depression, Acceptance. Advance directives: - answer Legal documents that direct end of life issues Living Will: - answer Directive documents for medical treatment per the client's wishes Health Care Proxy/Durable Power attorney: - answer A document that appoints someone to make medical decisions when the client is no longer able to do son on his own behalf. Rest and Sleep—Promoting Sleep Factors that interfere with sleep - answer Illness: Can require more sleep or disrupt sleep Current life events: Traveling or work hours change Emotional stress: Anxiety, fear, grief Diet: Caffeine consumption, heavy meals before bedtime Exercise: Promotes sleep if at least 2 hours before bedtime
Fatigue: Exhausting or stressful work makes falling asleep difficult Sleep environment: Too light, wrong temp or too noisy Medications: Some can induce sleep, some can interfere Bedtime routine, Limit waking clients, Promote quiet, Help with hygiene, CPAP, Sleep products Limit alcohol, caffeine and nicotine at least 4 hours before bedtime. Limit fluids 2-4 hours before bed time Engage in muscle relaxation if anxious or stressed Narcolepsy - answer Exercise regularly, Eat small meals high in protein, Avoid sitting too long/warm environments /alcohol, Avoid accidents, driving or heights, Take naps when drowsy, Take stimulants Medication effecting urinary output Indications for use of diuretics - answer Management of blood pressure Excretion of edematous fluid related to heart failure, Kidney and Liver disease Prevention of kidney failure Emergency Response Plan - answer Facility Protocols: Appropriate client for discharge in event of community disaster First discharge or relocate ambulatory clients requiring minimal care. Next, make arrangements for continuation of care for clients who require some assistance which could be provided in the home or tertiary care facility Do not discharge or relocate clients who are unstable of require continuing nursing care and assessment unless they are in imminent danger. Discharge on the fact that some will likely be able to stay Handling Hazardous and Infectious materials
- Change PPE after contact with each client and between procedures with the same client, if in contact with large amounts of blood or blood fluids (compromising the PPE)
- Higher risk for loneliness explain the reason for isolation and provide sensory stimulation Airborne Precautions - answer 1. Private room
- Masks and respiratory protections (N95 for TB)
- Negative pressure airflow exchange of at least 6-12 exchanges per hour
- If splashing or spraying is possible wear full face protection
- answer Private room Droplet Precautions - answer 1. A private room or room with clients with the same disease a. Ensure that clients have their own equipment
- Masks for providers and visitors Contact Precautions - answer 1. A private room or room with the same illness
- Gloves and gown worn by caregivers, and visitors
- Disposal of infectious dressing material into a simple non porous bag without touching the outside of the bag. Vector based Transmission: - answer Animals or insect's transmission: Ticks ---Lyme disease, Mosquitoes--- West Nile and Malaria Post-Partum Physiological Adaptations Pertussis booster recommendations - answer This vaccine is recommended for women who have not previously received it. Administration prior to discharge or ASAP in the post-partum period is recommended
Skin infections/infestations Expected findings of pediculosis capitits - answer Intense itching, Small, red bumps on the scalp, Nits (White specks on the hair shaft) Use of restraints/ Safety Devices Client safety: Appropriate use of physical restraints - answer 1. Shortest duration necessary and only if less restrictive measures are not sufficient.
- They are for the physical protection of the client of the other clients and staff
- A client may voluntarily request temporary seclusion if environment is too stimulating
- Restraints can be either physical, vest, belt, mitts, or chemical such as sedatives
- The prescription must include the reason for the restraints, the type of restraints, the location, and how long to use and the type of behavior that warrants using restraints
- The prescription allows only 4hrs of restraints for an adult, 2 hrs for clients ages 9 to 17, and 1 hour for clients under the age of 9
- These prescriptions can be renewed for a max of 24 consecutive hours.
- Providers cannot write PRN prescriptions for restraints
- Explain the need for the restraints to the client and family, emphasizing that the restraints keep the client safe and are temporary
- Ask the client or guardian to sign a consent form
- Assess skin integrity, provide skin care every 2 hours
Client can swallow or sprinkle capsules on food Teach about diet and ways increase calorie intake With what type of foods should enzymes increase? - answer Increase dosage of enzymes when eating high fat foods When should clients take pancrelipase - answer WITH ALL MEALS AND SNACKS Can pancrelipase capsules be broken? - answer Yes, they can be swallowed or sprinkled in food Medication administration Diabetes Mellitus management: Teaching self-administration for insulin - answer Instruct the client to check the accuracy of the strips with the control solution provided Instruct the client to use the correct code number in the meter to match the strip bottle number Instruct the client to store strips in the closed container in a dry location Instruct the client to obtain an adequate blood sample when performing the test Keep a record of the SMBG, Date time, glucose, dose, food and other events Rotate Injection sites, Inject at a 90 degree angle, 45 degrees if the client is thin, Advise the client to eat at regular intervals, avoid alcohol intake, and adjust insulin to exercise and diet to avoid hypoglycemia
Medication Administration Self-medication administration: Error Reduction Eye Drop administration - answer Wait 5- minutes between eye drops Avoid touching the tip of the application bottle to the eye Always wash hands before and after use Place pressure on the inner corner of the eye Medication Administration Bipolar: Teaching about mood stabilizers - answer 1. Monitor plasma lithium levels during treatment, at least 5 days after starting and after any dosing changes until therapeutic level has been achieved then every 1 to 3 months
- Blood for monitoring should be obtained in the morning usually 12hrs after the last dose
- Maintenance level range is between 0.4 and 1.0, Greater than 1.5 can be toxicity
- Hemodialysis may be indicated for toxic lithium levels
- Monitor CBC, serum electrolytes, renal function tests, and thyroid function tests
- Advise clients to take lithium as prescribed
- Taking lithium with food can help decrease gastric distress
- Advise clients that effects take 7 to 14 days
- Encourage clients to adhere to lab appts
- Emphasize the high risk of toxicity due to the narrow therapeutic range
- Provide nutritional counseling, Stress the importance of adequate fluid and sodium intake
- Instruct clients to monitor for manifestations of toxicity and when to contact the provider
- Clients should withhold medication and seek medical attention if experiencing diarrhea, vomiting or excessive sweating
- Conditions that cause dehydration such as exercising in hot weather, or diarrhea, put client at risk for lithium toxicity
Fluid overload - answer Distended neck veins, increased blood pressure, tachycardia, SOB, crackles in the lungs, edema, additional finding varying with the IV solution Cellulitis - answer Pain. Warmth edema, induration, red streaking, fever, chills, malaise Catheter embolus - answer Missing catheter tip on removal, severe pain at the site with migration, absence of findings if no migration Pharmacological Pain Management Post-operative nursing care: Prevention of complications - answer Some complications of surgery are - answer 1. Hypovolemic shock
- Paralytic ileus
- Wound dehiscence or evisceration
- Deep vein thrombosis
- Airway obstruction
- Hypoxia
- answer Wound dehiscence or evisceration
- answer Deep vein thrombosis
- answer Airway obstruction
- answer Hypoxia Airway Obstruction - answer Swelling or spasm of the larynx or trachea, mucus in the airway or relaxation of the tongue into the nasopharynx Nursing Considerations: for airway obstruction - answer Monitor for choking, noisy irregular respirations, decreased ox stats, cyanosis Implement a head tilt, chin lift, to open the airway Keep emergency equipment at the bedside in the PACU Notify the anesthesiologist, elevate head of bed if not contraindicated, provide oxygen, and plan for reintubation with endotracheal tube Hypoxia - answer Decrease in ox stats Nursing Considerations: Monitor ox stat and admin ox as prescribed Encourage coughing and deep breathing to prevent atelectasis Position client with head of bed elevated and turn every 2hr to facilitate chest expansion Decrease in ox stats - answer Nursing Considerations: Monitor ox stat and admin ox as prescribed - answer
Administer IV Fluids and vasopressors as prescribed - answer Paralytic ileus - answer Can occur due to the absence of GI peristaltic activity caused by abdominal surgery or other physical trauma Nursing Considerations: for Paralytic Ileus - answer Monitor bowel sounds Encourage ambulation Advance the diet as tolerated when bowel sounds, or flatus are present The client can have an NG tube inserted to empty stomach contents Administer prokinetic agents such as metoclopramide as prescribed Wound dehiscence or evisceration Caused by spontaneous opening of the incisional wound Can progress to the protrusion of the internal organs through the incision Monitor for risk factors (Obesity, coughing, moving without splinting, poor nutritional status, diabetes mellitus, infection, hematoma, steroid use) If wound dehiscence or evisceration occurs, call for help, stay with the client, cover the wound with a sterile towel or dressing, do not attempt to reinsert organs, place in a low fowlers position with hips and knees bent monitor for shock, and notify the provider immediately
Causes for Deep vein thrombosis - answer Caused by dehydration, stress response that leads to hypercoagulability of the blood, immobility, obesity, trauma, malignancy, history of thrombosis, hormones, and use of indwelling venous catheter Nursing considerations: for DVT - answer Prophylactic measures include administration of low molecular weight heparin, low dose heparin or low dose warfarin, antiembolism stocking, pneumatic compression devices, range of motion, exercises, and early ambulation Avoid any form of pressure behind the knee with a pillow or blanket, which can cause constriction of blood vessels and decreased venous return Avoid dangling the client's legs for long periods of time Provide adequate hydration by administering IV fluids or encouraging increased oral fluid intake Health Promotion and Maintenance Priority Assessment: Membrane Rupture Ante/Intra/Post-Partum and newborn care Early Onset of Labor - answer Premature rupture of membranes (PROM): Spontaneous rupture of the amniotic membranes 1hr or more prior to the onset of true labor. Temperature elevation Increased maternal heart rate or FHR Foul smelling fluid or vaginal discharge Abdominal tenderness Assess for a prolapsed umbilical cord Abrupt FHR variable or prolonged deceleration Visible or palpable cord at the introitus A positive nitrating paper test (blue, pH6.5 to 7.5) or
