1
Cultural and Spiritual Nursing Care: Using a Medical Interpreter
Chapter 35
Advocacy
- Use only a facility-approved medical interpreter. Do not use the client's family or friends or a nondesignated employee.
- Inform the interpreter about the reason for and the type of questions that will be asked.
- Allow time for the interpreter and the family to be introduced and become acquainted.
- Ask one question at a time.
- Use lay terminology if possible, knowing that some words may not have an equivalent word in the client's language.
2
Legal Responsibilities: Continuity of Care
Chapter 4
Concepts of Management
- Nurses should use the formal chain of command to verbalize concerns related to assignment in light of current legal scope of practice, job description, and area of competence.
- Nurses should refuse to practice beyond the legal scope of practice.
- Nurses must ensure the clients understand their rights and protect their client's rights.
- Nurses are accountable for protecting the rights of clients.
- Nurses must ensure the clients understand their rights and protect their client's rights.
3
Admissions, Transfers, and Discharge: Initiating Discharge Planning
Chapter 9
Continuity of Care
- Discharge planning should begin on admission - unless it is long-term care.
- Assess whether or not the client will be able to return to his previous residence.
- Determine whether or not the client will need to have someone to assist him at home, and if he has that person.
- Assess the residence to see if the client will need adaptations or specific equipment.
- A client who is legally competent has the right to leave the facility at any time.
4
Information Technology: Correct Documentation
Chapter 5
Continuity of Care
- Subjective data can be documented as direct quotes, within quotation marks, or summarized and identified as the information of the client's statement.
- Objective data should be descriptive and should include what the nurse sees, hears, feels, and smells.
- Information and facts should be documents precisely - only abbreviations and symbols approved by the Joint Commission.
- Never pre-chart an assessment, intervention, or evaluation.
- Communicate documented information in a logical sequence.
5
Information Technology: End of Shift Report
Chapter 5
Continuity of Care
- Formats include face-to-face, audiotaping, or presentation during walking rounds in each client's room.
- A report should include significant objective information about the client's health problem.
- It should proceed in a logical sequence.
- There should be no gossip or personal opinions.
- Changes in medications, treatments, procedures, and discharge plans should be related.
6
Safe Medication Administration and Error Reduction: Documentation
Chapter 47
Reporting of Incident/Event/Irregular Occurrence/Variance
- Do not use od, qd, qod, or qhs. Write out words.
- So not write subq, write subcut.
- Do not write IN or IJ.
- Write out greater than or less than.
- Do not use / to indicate per, write out per.
7
Pharmacokinetics and Routes of Administration: Instructing Client to Self-Administer Insulin
Chapter 46
Safe Use of Equipment
- When drawing up regular and NPH insulin, inject air into NPH, inject air into regular, draw up regular, draw up NPH.
- Insulin is injected subcutaneously (also heparin).
- Inject into adequate fat bad (abdomen, upper hip, lateral upper arms, thighs).
- Clear insulin must be drawn up before cloudy insulin.
- Roll insulin between hands prior to administering.
8
Infection Control: Caring for a Client with Methicillin-Resistant Staphylococcus Aureus
Chapter 11
Standard Precautions/Transmission-Based Precautions/Surgical Asepsis
- Use a respirator for clients with TB.
- Rinse equipment first in running cold water, then in warm water with soap.
- Masks, eye protection, and face shields are required when care may cause splashing or spraying of body fluids.
- Avoid overuse of antimicrobials.
- Teach client about infection control measures at home, self-administration of medications, and any complications that need immediate attention.
9
Medical and Surgical Asepsis: Preparing a Sterile Field
Chapter 10
Standard Precautions/Transmission-Based Precautions/Surgical Asepsis
- Prolonged exposure to airborne micro-organisms can make sterile items nonsterile.
- Only sterile items may be in a sterile field.
- Consider any items held below waist or above the chest to be nonsterile.
- Outer wrappings and 1-inch edges of packaging that contains sterile items are not sterile.
- Do not reach across or turn your back on a sterile field.
10
Mobility and Immobility: Steps for Transferring a Client
Chapter 40
Mobility/Immobility
- First, determine how capable a client is of participating in the transfer.
- Explain the transfer process so the patient understands what will happen.
- Ensure all equipment is ready and functioning properly before beginning to move the patient.
- Maintain correct posture, use appropriate body mechanics and lifting techniques, and use assistive devices whenever possible.
- When moving patients from a bed to a wheelchair or a gurney, put all brakes in the locked position to prevent falls and injuries.
11
Pharmacokinetics and Routes of Administration: IM Injections
Chapter 46
Medication Administration
- Sites with high blood perfusion have rapid absorbtion. IM has risk for infection, though.
- IM injections are appropriate for irritating medications, solutions in oils, and aqeous suspensions.
- Use a needle size 18 to 27 gauge (usually 22 to 25), length 1 to 1.5 inches long, and injected at 90 degree angle.
- Volume injected is usually 1-3 ml; if a greater amount is required, it should be divided into two syringes.
- Most common sites include ventrogluteal, deltoid, and vastus lateralis (pediatric). Dorsogluteal is contraindicated.
12
Specimen Collection for Glucose Monitoring: Using Correct Technique
Chapter 52
Diagnostic Tests
- Outer edge of the fingertip is the most common site.
- Rotate sites to avoid ongoing tenderness.
- Cleanse the site with warm water and soap or antiseptic swab (not alcohol).
- Wipe away the first drop of blood.
- Hold finger in dependent position.
13
IV Therapy: Interventions to Promote Infusion
Chapter 49
Potential for Complications of Diagnostic Tests/Treatments/Procedures
- Infiltration - pallor, local swelling, decreased skin temperature, damp dressing, slowed rate of infusion. Stop infusion and remove catheter, elevate, restart infusion proximal to the site.
- Phlebitis - edema, throbbing, burning, increased skin temperature, red line up arm. Discontinue and remove catheter, apply warm compress, culture site.
- Fluid overload - JVD, increased BP, tachycardia, SOB, crackles, edema. Stop infusion and raise head of bed.
- Cellulitis - pain, warmth, edema, induration, red streaking, fever, malaise, chills. Discontinue and remove, elevate and apply warm compress, obtain specimen.
- Embolus - missing catheter tip, severe pain at side with migration. Place tourniquet high on extremity to limit venous flow, save the catheter, prepare for removal.
14
Fluid and Electrolyte Imbalances: Findings to Report
Chapter 57
Fluid and Electrolyte Imbalances
- Hyponatremia - coma, seizures, respiratory arrest. Hypernatremia - serious neuro, endocrine, and cardiac disturbances.
- Hypokalemia - PVCs, hyperthermia, hypotension, muscle weakness and cramping, parasthesias. Hyperkalemia - Cardiac arrhythmias and cardiac arrest.
- Hypocalcemia - painful muscle spasms, parasthesias, Chvosteks sign (facial twitching) and Trousseaus sign (blood pressure cuff). Hypercalcemia - decreased reflexes, bone pain, flank pain (renal calculi).
- Hypomagnesemia - hyperactive DTR, C and T signs, increased cardiovascular symptoms. Hypermagnesemia - diminished DTR, muscle paralysis, decreased cardiovascular signs.
- Dehydration indicates increased protein, BUN, electrolytes, and glucose.