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44 Cards in this Set
- Front
- Back
- 3rd side (hint)
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Scope of Med Surg Nurse
Main Goal |
Promote health, prevent illness/injury
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Scope of Med Surg Nurse
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Assessment, nurisng diagnosis, intervention, evaluation
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Nursing Diagnosis
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Identify Problem
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Prioritizing
A,B,C,D, E |
A- Airway & Spine
B- Breathing C- Circulation (b/p, hr) D- Disablity E- Exposure |
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Institute for Healthcare Improvement (IHI)
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*Prevent CVC infection
*Prevent Surgery infections ***Interventions to save lives |
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Hospital National Patient Safety Goals (NPSGs)
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Improve patient safety
* Identify correct patient * Improve staff communication |
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The Joint Commission (TJC)
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Accredits Hospitals
* Requires hosp to create culture safety |
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Medical Harm
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Anything leading to patient injury or harm
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Rapid Response Team (RRT)
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Intervenes for people beginning at clinical level
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IOM Core Competencies for Health Professionals
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Provide patient centered care
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Nurse Management, reduce health disparities
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* Nurse self assessment
* Patient assessment * Nursing Implementation * Advocacy |
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Cultural Factors Affection Health and Health Care
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* Personal Space
* Touch * Nutrition * Immigrants * Medications * Psychologic Factors |
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Communication (SBAR)
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HOW YOU COMMUNICATE
*S- Situation *B- Background *A- Assessment *R- Recommendation |
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Communication (PACE)
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Use for patient Reporting
*P- Patient Problem *A- Assessment/action *C- contining/changes *E- Evaluation |
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Delegation Examples
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*Turning and positioning (ADLs)
*Vital Signs, I&O measurements *LPN ONLY- administer meds |
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5 Rights to Delegation
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* Right Task
* Right circumstances * Right Person * Right Communication * Right Supervision |
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Evidence Based Practice (EBP)
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Intergration of the best current evidence to make decisions about patient care
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National Council of State Boards of Nursing (NCSBN)
(9 key areas of improvement) |
1) medication admin
2) clear communication of assessment 3) attentiveness/pt surveillance 4) clinical reasonaing/judgement 5) prevetion of errors 6) intervention 7) interpreting orders 8) Professional/ Advocacy 9) Mandatory reporting |
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Pain
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Believe the patient level is what they say it is.
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Definition of Pain
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Unpleasant sensory/emotional experience
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Reasons Why Patients reluctant to report Pain
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* Desire to be a "good" patient
* Fear of Addiction |
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Pain Scales
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* Simple Descriptive
* Numeric Pain * Visual Analog * Pain Relief Visual Analog * Percent Relief |
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Acute Pain
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Acts as warning Sign, activates sympathetic nervous System
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Acute Pain Responses
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* Increased HR
* Increased BP * Increased Resp Rate * Dialated Pupils * Sweating |
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Nonverbal Acute Pain Responses
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* inability to concentrate
* restless * facial grimicing * increased or new confusion |
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Chronic Pain
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* More than 3 months
* Onset is gradual * Hard to pinpoint * Usually depressed |
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Diabetic Neuropathy
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If pain not transmitted to the brain, person feels no pain
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Nociceptive Pain
Somatic |
Skin
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Nociceptive Pain
Visceral |
Organs
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Neuropathic Pain
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* Nerve Injury
* Burning, shooting, stabbing pain |
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PQRST (pain assessment)
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*P- precipitating or pallative (what caused to start)
*Q- Quality or quantity *R- Region or radiation *S- Severity Scale *T- Timing |
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Pain Location
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* localized
* Projected * Radiating * Referred |
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Non Pharm Methods of Pain Intervention
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*prayer
*Imagery *Mediatation *Music *pet therapy *Heat/Cold application |
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Non Opiods
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Mild Pain relieve
* Tylenol * NSAIDS ***Side effects: GI bleed, liver & kidney dysfunction |
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WHO Analgesic Ladder
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*Level 1 (1-3)- Use non opiods
*Level 2 (4-6)- Use weak opiods alone or with adjuvant drug *Level 3 (7-10)- Use strong opiods |
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ADJUVANTS
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SSRI
Anti-epileptic Muscle relaxers Local anasethetics |
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Invastion Techniques for Chronic Pain
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*When nothing else works
** nerve block ** spinal cord stimulation |
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Considerations for Older adults
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**Start low and slow
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Opiods
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Moderate to severe pain
* morphine * oxycodone * Loratab |
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Side Effects & Tx of Opiods
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* Nausea/Vomiting
* Constipation * Resp Depression (12&lower) *Sedation *Physical Dependence |
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Sedation Scale
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1- awake & alert
2- slighty drowsy, easy to arouse 3- always drowsy, but arousable 4- somnolent, little or no response to stimuli |
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Opiod- Drug Alert
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Give every 12 hours, never crush, or break. Swallow whole rather than chew
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Opiod- Critical Rescue
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*determine how easily the patient is aroused
*Stop med if not easily aroused *Assess first dose response * monitor resp rate and depth especially while sleeping |
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Opiod Antogonist- Drug Alert
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*Administer slow until resp increase to eight or more/minute
*Continue to monitor- resp depression may recur. |
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