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184 Cards in this Set
- Front
- Back
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Things to include when doing shift report... (7 things) |
-Change in the patient's condition -New medications -Complications -Dx procedures done during your shift -Procedures you did for your patient (Ex: gave Lasix for crackles) -Blood sugars -New admissions |
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Only time you will call the MD... (4 things) |
-Acute epiglottitis -Back pain (except for pancreatitis or 3rd trimester) -Eye pain -Change in the patient's conditions. *Don't call MD for something that is expected to be seen with an illness/disease |
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Which patients do pregnant nurses need to avoid? (5 things)
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-5th disease (Slapface/Parovirus B19) -Measles -Varciella -Internal radiation isotopes -Handling Chemo |
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Order to select Psych patients on the Psych ward. (3 things) |
1. Physiological 2. Change in psych behavior 3. Safety
*Drunks and Druggies are #1 but the above are to be chosen if not available. |
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Stress Related Conditions (8 things)
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1. Multiple Sclerosis 2. Lupus 3. Psoriasis 4. Addison's 5. Rheumatoid Arthritis 6. Raynaud's 7. Chron's 8. Asthma |
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Float Nurse Assignments... |
-Assign them a condition they would see on their own unit. -Give them the most stable patients -They DO NOT get cardiac pts or the borderline/antisocial pts. |
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OB floaters see... |
-Closed abd. surgeries -HTN -DM -Seizures -Drips -DVT
*Won't work with male patients |
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Med/Surg floaters see... |
-DM -DVT -HTN -Surgeries -Chronic conditions -Seizures |
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Who cannot be transferred from OB to M/S? |
NEVER transfer mom who: -Have delivered their baby -Are in labor -Have complications |
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Immunocompromised Patients |
-HIV+ -Cancer -Chemo -Organ Transplants -Steroids -Cushing's -Addison's -Radiation |
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What will kill the immunocompromised? |
-Infection (No oral polio/Varicella) -PCP (Danger ONLY to these pts.) |
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Progressive Neuro disease pts. will die respiratory so we need to have advanced directives |
-MS -ALS -Parkinson's -Huntington's chorea -Guillian Barre -Myasthenia Gravis -Scleroderma (hardens) |
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Infection Control--Airborne |
Are alone and in a private (-) pressure room |
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Infection Control--Droplet |
Watch the footage between beds and a mask is needed when within 3 ft of the patient |
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Infection Control--Contact |
Room alone or with another pt. with same condition. Gloves and gowns are needed. |
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INFECTED PATIENTS ARE ALLOWED TO LEAVE THEIR ROOM..BUT... |
THEY MUST WEAR OUT WHAT THE NURSE WEARS IN. |
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When do we need to isolate? |
-Night sweats, temp & cough (s/s of TB) -Headache & stiff neck (S/s of meningitis) -Rash or blisters (adult) on one side of body (S/s of shingles) -Any patient who presents with s/s of infection. |
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What pts. can be DC'd to make room for new admits? |
-Chronic/Stable -Those who are least likely to die. |
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With a med error, patient injury, or attempted suicide what are your actions? |
-Provide Care -Notify the Dr. |
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Patients on bleeding precautions |
-Coumadin/Heparin, Aspirin/NSAIDs -DIC -Hemophilia -Chemo -HIV -Problems with bone marrow -Cancer -Liver disease |
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Never send patients to surgery who are anti-coagulated.. |
-Low platelets -High PT/PTT -Those on Coumadin -Those on Heparin
*At risk of bleeding |
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What patient cannot be transferred? |
-Unstable -Pts with unknown diagnosis -Pts whose conditions are made worse by stress |
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How to transfer a peds pt. to med/surg ward |
First, identify the oldest child. Second, ask... -Can I catch what the child has? -Are they immunocompromised? -Do they need teaching?
*If no to all of these, they can go! |
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Pts. that require seizure precautions |
-Cirrhosis encephalopathy -PIH -DTs -ICP -CVA -Meningitis -Brain surgery -Head trauma |
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Who must remain in the hospital for 72 hours |
-MI -TURP (at risk for bleeding) -Hip (at risk for embolism) -Illeostomy (bowels will go into shock from manipulation) |
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Who cannot receive vaccinations? |
-Pts with a temp greater than 101 F -Pts on ABX |
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What to do for an acute exposure to any infection? (rusty nail, knife cut, dog bite) |
Immunoglobulins (boosts the immune system) |
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What to do for pt who is experiencing pain and/or discomfort? |
-Use a nursing intervention (before passing meds) -When in doubt, flush them out! |
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For hemorrhages... |
..always check the pts pulse NOT blood pressure |
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When output over a period of time is given... |
...always calculate to the hr. |
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Eliminate the adjectives from the question |
Ex: "NEWLY" licensed nurse |
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BUN is NOT a measure of kidney fxn... |
...ONLY serum creatinine will provide this info. |
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NEVER give medications with conflicting actions... |
Ex: Lasix & Vasopressors Digoxin & Epinephrine |
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Allergy Precautions |
-Egg--no flu or MMR vaccine -Iodine-- Dx procedures or as a cleaning sol. for foleys/or surgery -Yeast-- Hep. B vaccine -Latex/Rubber-- bananas, kiwi, chestnuts, avocados, strawberries |
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Never Massage... |
-Veins -Pressure ulcers -Z-track |
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Use Massage for... |
-Decreasing the pain of PVD -Claudication and to increase circulation -Fundus (Grapefruit) -Decrease neuropathy -After bleeding stops in a hemophiliac |
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What things are sterile in the home? |
-IV's -Dressings -Peritoneal Dialysis (watch for infection) |
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What things are non-sterile in the home? |
-Trach suctioning -Insulin injections -Foley, intermit & suprapubic caths. (wash with betadine)
*Won't get sick from your own bacteria. |
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Coumadin (blood thinner) |
-Normal PT- 12 seconds -1.5sec-2.5 sec (18-30 sec) -ANTIDOTE- vitamin K (Aquamephyton) *More than 30 sec, D/C and call the Dr. -Decrease green leafy vegs & multivitamins bc wont work as well |
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Heparin |
-Normal PTT-- 30 sec -30 sec x 1.5 =45sec -30sec x 2.5 = 75 sec -ANTIDOTE - Protamine Sulfate *More than 75 sec, D/C and call the Dr. |
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Checking Cardiac Status--Internal Jugular Veins |
To find out how much fluid someone has--a measurement of more than 3 cm. indicated increased venous pressure |
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Checking Cardiac Status--Palpation |
Use this to find the apical impulse. Ask them to hold breath to palpate easier while in a left lateral position. |
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Checking Cardiac Status--Auscultation |
-Diaphragm of the stethoscope to hear high pitched sounds like S1/S2, pericardial friction rubs, and aortic and mitral regurgitation murmurs. -Bell better to hear low-pitch sounds like S3/S4 and murmur of the mitral valve. |
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S1 (LUB) |
the start of systole and when the mitral and tricuspid valves close (louder than S2 at the apex) |
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S2 (DUB) |
start of diastole this is the closing of the aortic and pulmonic valves (louder than S1 at the base) |
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Cardiovascular tests--Holter monitoring |
Patient logs activities, stress, medication and any physical symptoms they experience bc certain activities can change your HR. |
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Nursing Action for an Air Embolus |
-Close open lumen to catheter if central line is in place -Place pt in LEFT side trendelenburg to keep embolus away from pulmonic valve. -Give patient 100% oxygen. |
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Venous Access Ports (med ports) |
Needs to be flushed at least once a month with heparin. |
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Superior Vena Cava Syndrome "Mother Superior is HEAD of the nunnery" |
Everything above the neck you will see s/s. Complications r/t having a med port. -feelings of fullness in the head, tightness around shirt collar, swelling in face and eyes, cyanotic lips, dyspnea, JVD, confusion -s/s improve when in upright position and worsen when lying down. |
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Putting on a cardiac monitor. (There will be no colored leads stated on NCLEX so know (+), (-)) |
Positive-- Below the left clavicle
Negative- Below the Right clavicle
Ground- at the lowest palpable rib, Left mid-clavicular. |
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Inderal |
do NOT give to asthma (wheezers) or diabetic pts (b/c can mask low blood sugar). |
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Inserting an Oropharyngeal Airway |
-Remember to rotate it 180 degrees downward into the arch shape after it passes the oral cavity and is near the posterior wall of the pharynx |
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Normal Ankle-Brachial Index |
0.97-1 -ankle systolic pressure divided by the brachial systolic pressure. -Nursing assistant can do this. |
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Blood flow through the heart valves.. |
Tissue Paper My Ass Tricuspid --> Pulmonic--> Mitral--> Aortic |
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Nitroglycerin Ointment |
Remember to squeeze the prescribed dose in a thin layer on a clean, ruled application paper.
Wear gloves and do not get on own skin. |
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Right Sided Heart Failure |
-Backs up the venous system
-Ascites, JVD, fatigue, edema...nausea and anorexia, liver enlargement (hepatomegaly), weight gain |
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Left Sided Heart Failure |
-Backs up into lungs
-dyspnea, cough, frothy sputum, crackles, fatigue, altered mental status, oliguria, |
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Transfusion Reactions. Happens in first 10-15 min or 50cc |
-Allergic-- Wheeze (obstruction), hives/rash, itching. -Febrile-- Contaminated blood, fever, chills -Hemolytic-- Incompatible blood, low back pain, this is the worse reaction as it will cause the kidneys to fail after a week. |
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Who can donate blood? |
-17 yo and weight at least 110 pounds. -Those with a BP less than 180/100 -Person who is not pregnant -Not on ABXs -Not HIV+ -Cancer free for at least 5 years |
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Effects of Alzheimer's on Memory |
-Amnesia-- memory loss -Aphasia-- not able to use words appropriately -Agnosia-- Does not know people and objects -Apraxia-- Use objects incorrectly |
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External Artery Compression Device |
If the pt reports severe pain, such as back, flank, or abd pain, this could be a sign of retroperitoneal bleeding or a pseudoaneurysm.
blew a hemorrhage..priority. |
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Respiratory Assessment |
Visually inspect to ensure the thorax is symmetrical and the front to back diameter is more than the side to side diameter. |
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Respiratory acidosis |
most common. COPD, pneumonia, bed rest, medicated.
Retaining too much CO2.
Tx: cough & deep breath to get rid of excess CO2 |
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Respiratory Alkalosis |
Panic attack, hyperventilating.
Blowing off CO2
Tx: breath into bag/cupped hands, or slow deep breathing. taking in CO2 that they are blowing out |
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Metabolic Acidosis |
seen with diabetes and renal failure |
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Metabolic alkalosis |
causes: prolonged vomiting, hypovolemia, diuretic use and hypokalemia
S/S: headache, lethargy, and tetany |
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Symptoms of Acidosis |
headache, sleepiness, confusion, SOB, arrhythmia, tachycardia, N/V, diarrhea, seizures, weakness |
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HYPOXIA (adults) |
Restlessness, irritability, tachycardia, tachypnea, anxiety |
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HYPOXIA (kids) |
inspiratory/expiratory grunting, difficulty eating, sternal retractions (abd. breathing), and nasal flaring. |
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Capnograph |
A test to measure the CO2 in every breath which provides information on the air exchange in the patient's alveoli. |
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Tracheostomy Suctioning |
Negative pressure is set to between 80 and 120 for suctioning. |
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Tracheostomy Care |
do NOT: -Apply oil or ointment around the stoma (at risk for pneumonia) -Use cut gauze under the tracheostomy tube flanges |
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Vent Alarms--Low pressure |
Indicates a problem with the machine.
Ex: tube disconnected from vent, vent is malfunctioning. |
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Vent Alarms--High pressure |
Caused by the patient interfering with the air flow
Ex: pt biting on tube, secretions in airway, condensation in large bore tubing, pt trying to talk. |
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ARDS (Select all that apply Q) |
-Medical emergency
S/S tachypnea, dyspnea, retractions, hypoxia, tachycardia, crackles, grunting, and use of accessory muscles.
X-ray will show nothing or white lung
Tx: PEEP to keep alveloli open. pneumothorax is a complication. |
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Cor Pulmonale |
Severe R sided heart failure
S/S: edema, JVD, and only able to breath if sitting up. |
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Pulmonary Emphysema (Select all that apply Q) |
S/S: increase CO2 retention >60, pursed lip breathing, increase mucus, Barrel chest, speech is short and jerky, digital clubbing. |
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Complication of Pulmonary Empysema |
Polycythemia: increase RBC from decreased 02 to compensate.
SE: increased bruising
Tx: increase fluids |
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Pursed-Lip Breathing |
Slow expiratory rate and help decrease retained carbon monoxide |
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Pneumothorax |
Air is trapped in the pleural cavity causing the lung to collapse
S/S: dyspnea, tachycardia, and decreased breath sounds
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Causes of Pneumothorax |
Ruptured bleb in a COPD pt, thoracentesis, trauma, placement of a central line, or secondary infection. |
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Chest Tube--Suction Control chamber |
Should have gentle continuous bubbling
Prob: too much bubbling...turn down the suction Prob: not enough bubbling...increase the suction |
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Chest Tube--Water Seal Chamber |
Should have intermittent bubbling
Prob: continuous bubbling...check connections for leak (usually at insertion site) Prob: No bubbling...Lung has re-expanded or the tubing is blocked. |
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Chest Tube--Collection Chamber |
Collects the drainage from the patient.
Prob: no change in drainage..check for kinks Prob: large amount drainage...Adults can have up to 100ml/hr, kids 30ml/hr when first inserted. |
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What is the nurse's action if the chest tube comes out? |
Place a gloved hand over the hole |
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What is the best way to see if the lung is expanded? |
Chest x-ray
nurse should listen to all lung fields also |
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Thoracotomy is an incision from the sternum to the back..what should the nurse watch for in the pt? |
Frozen shoulder.
This can be prevented by having the pt. do hand exercises and "walk the wall" |
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Pneumectomy |
removal of the lung
After surgery, the pt will lay on the surgical side and pillows will be used for positioning. allows the good lung to expand.
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If a pt has a deviated trach, it is treated first with... |
Chest tube insertion. |
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Nursing action for an ALS patient? |
Before eating, check the patient's gag reflex.
Will usually need a PEG tube because they become unable to eat and are at risk for aspiration. |
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Bell's Palsy |
At risk for corneal abrasions. Use drops or eye patches. Tape eyes shut at night.
Cranial nerve 7 is involved. |
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Giving eye drops |
Clean eye starting at inner canthus. Have pt tip head back slightly and look at ceiling. With non-dominate hand, pull lower lid down exposing conjunctival sac. instill the drops into the center of the conjunctival sac. Have pt. close eyes and move them around to help med cover eye. |
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water vs. oil medicated eye drops |
If both water and oil medications are ordered, the water goes in first. You much wait 5 minutes between orders. |
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What can happen if retinal detachment is not treated? |
if repair is not done, it could lead to vision loss and eventually blindness. |
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Post-op care for retinal detachment repair. |
No lifting heavier than 20 pounds.
No rubbing of the eye, coughing, or suctioning. |
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What to do after a cataract repair and patient is complaining of pain? |
Notify the doctor because a stitch may have come undone. |
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Cataract Prevention? |
everyone should wear sunglasses. |
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Glaucoma |
Presents with increased intraocular pressure and progressively looses vision.
Tx: Diamox to decrease production of fluid. Mannitol to decrease pain/pressure by drawing fluid out of eye.
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Meniere's Disease (My Ears Disease) |
S/S: vertigo, tinnitus, unilateral nerve deafness
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Who identifies hearing disorders and orders hearing aids? |
AUDIOlogist |
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Care for hearing aids |
Batteries need to be changed on a fixed scheduled, about every 6 months.
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How to Administer Ear Drops (know the order) |
Warm the drops Put on clean gloves Have pt. lie on side with bad ear up Straighten ear canal Hold med 1/2 in above ear Instill drops Massage behind ear to help into canal Place cotton in the ear |
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How to administer ear drops (CHILD) |
DOWN AND BACK |
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How to administer ear drops (ADULT) |
UP AND BACK |
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Stapedectomy |
Removal of the bones from the inner ear, Replace with artificial ones.
expect to have swelling and hearing noises for about 1year. sleep on non-surgical side. Sneeze with mouth open or it can pop the implant out. |
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Pain Control with a TENS Unit |
Do not use while sleeping, if pregnant, have a pacemaker, bladder stimulator, metal pins or plates, diabetes, or known heart disease.
Change electrodes every 72 hrs. Always start at the lowest setting. |
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Normal urine output (adults) |
60-75cc/hr. (total, 1440-1800cc)
minimum= 30cc/hr. <30cc/hr is abnormal except in Chronic renal failure patients. |
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Needle Biopsy of the Kidney |
Before test--no NSAIDS, aspirin, or Coumadin. check clotting studies.
Complication--bleeding/hemorrhage |
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After needle biopsy of the kidney |
Check VS (increased HR means hemorrhage). Increase fluids to keep the urine clear. Pt. is on bed rest for 24hrs. Patient can return to normal activities after 2 weeks. |
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Intravenous Pyelogram (IVP) |
before test--pt NPO for 8 hrs. laxative given to empty intestines for VISUALIZATION. check for iodine allergies.
Glomerulous are looked at during IVP. |
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Stress incontinence |
leak of urine during things such as exercise, lifting, coughing, sneezing...
Tx: behavioral techniques--bathroom Q2h, kegal exercises..
Tofranil & Premarin allow bladder muscles to relax and the neck muscles to tighten. |
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Urge Incontinence (Overactive bladder) |
Urine begins to flow as soon as the pt feels urge to go.
Tx: behavioral tech--limiting fluid intake/no drinking 2 hrs before bed.
Detrol & Ditropan decrease unwanted bladder contractions. |
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Overflow Incontinence |
Feeling that one needs to urinate but there is minimal output as soon as they are finished they again feel the need to urinate.
Tx: Intermitten cath (MS pts).
Duvoid- increases strength of bladder contractions & helps empty bladder |
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Functional Incontinence |
Something/Someone prevents pt from getting to bathroom before they urinate.
Tx: depends on situation..fix situation (ambulatory problem? fine motor?) |
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Suprapubic Catheter Care |
Clean technique
do NOT irrigate the catheter unless ordered and do NOT leave the catheter unsecured (tape to abdomen)
Watch for signs of infection |
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UTI (Cystitis) |
Get a culture before administering ABX.
Teach ways to prevent UTIs
Usually treated with sulfa ABX so check for allergies. Pyridium for pain/burning (Will turn urine orange. doesn't treat only relieves s/s) |
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Macrobid |
UTI tx
may cause diarrhea w/ mucus and pee to be brown.
Watch for signs of fever
Take with food or milk and shake well. |
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Kidney Stones (Renal Calculi) |
Males over 40 and those who are dehydrated are at greatest risk. Ask pt. if they are on diuretics.
Type will depend on intake/diet |
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Kidney Stones S/S |
Severe right upper quadrant pain, pale, diaphoretic, urination is frequent and painful.
Don't give morphine. all urine should be strained for calculi, check urine for color and odor. |
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Nephroscopy Tube |
A tube which is stuck into the kidney to drain urine.
Frequent dressing changes may be needed b/c urine will be coming out around the tube and need to avoid skin breakdown. |
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Major function of the Kidney |
Excretion of fluids--if there is kidney failure, there will be a decrease in output which will lead to edema, an increase in BP and headaches. |
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Kidneys release erythropoietin |
This stimulates bone marrow--if there is kidney failure and malfunctioning bone marrow it leads to decreased WBC, PLTs, RBC.
Epogen is given to help stimulate the bone marrow. |
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Kidneys--remove byproducts of digestion |
Urea and Creatinine--if there is kindey failure, there is an increase in BUN (this reflects the fluid and protein balance)
To determine renal fxn, look at serum creatinine (0.6-1.3) |
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Kidneys remove electrolytes |
W/ kidney failure, this can lead to increase Na, K, and other electrolytes which can result in muscle weakness and cardiac arrhythmia. |
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Glomerulonephritis S/S |
Hematuria (pink tingend/cola colored), proteinuria (foamy urine), increased BP, Edema, Oliguria |
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Glomerulonephritis--Treatment |
Bactrim (decrease u/o), stay away from things that can cause fluid build up Diet: increase protein (Ex: give a 5 yo a hamburger) |
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Nephrotic Syndrome |
Acute condition d/t excessive edema (anasarca), the pt is at risk for skin breakdown
S/S: massive protein loss in urine, hypoalbuminemia, edema, high cholesterol
Tx: diuretics, steroids, diet (increase protein & calories, decrease sodium) |
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Diet for Kidney patient |
WATER and POTASSIUM will KILL the kidney patient.
Protein is fine. 60g protein, 2g of sodium, 0g potassium, and restricted to 1000ml of water daily. |
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Amphojel |
A phosphate binder which will bind calcium with phosphate in the GI tract and remove it in the stool.
Used for End Stage Renal Disease pts who will also be on dialysis |
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What to do for a hypoglycemic patient that is diabetic and has ESRD? |
give them apple juice. |
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Example of Renal Diet: |
Protein: milk, eggs, meat Calories: cereals, bread, rice, pasta Vegs/Fruits: green beans, summer squash, cabbage, pears, grape fruit, blackberries, blueberries, boysenberries.
melons are high in potassium. milk is high in sodium (like eating a bag of potato chips) |
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Steal Syndrome |
Numbness, tingling, coldness, impaired motor function, decreased sensation, and check distal arterial pulses.
When dialysis fistula becomes "stiff"
Call Dr. the nurse is unable to do anything. |
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Peritoneal Dialysis |
Sterile procedure
Monitor the patients serum electrolytes, glucose, and lipid levels as ordered. Limit carbs b/c there are carbs in the dialysate. |
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What to expect after a TURP |
Brown clots in the urine for the first 8-24hrs.
Around 72 hrs output will be brown shreds (if red in color, may indicate hemorrhage)
Bladder spasms.
LPN/NA can't care for these patients for first 72 hrs bc nurse needs to ASSESS u/o. |
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Sildemafil (Viagra) |
Cannot be taken by those who are taking nitrates or alpha-blockers |
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Vardenafil (Levitra) |
Cannot be taken if using nitrates or alpha-blockers other than Flomax at a dose of 0.4mg/day. |
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Tadalafil (Cialis) |
Cannot take if taking nitrates or alpha-blockers. |
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Stop taking medications for erectile dysfunction if... |
Having eye problems (stop and notify Dr.)
Prolonged erection lasting more than 4 hrs (priapism). Not getting enough circulation to the penis. |
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After Vasectomy |
-Removal/cutting of the vas deferens
Sperm can live up to 6 weeks after procedure. Male is not considered to be sterile until he has 2 negative specimens which are one month apart. |
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Who is considered incompetent? |
Any pt who is under the influence of drugs/alcohol. (once pt begins to sober up, they can make their own decisions)
Demented patients
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Self Determination Act |
You decide what you want done when you can no longer speak for yourself. This can be changed at any time. ONLY YOU can change your advance directives. |
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American Disabilities Act (ADA) |
Employer must make reasonable accommodations (Elevator, ramps) |
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Organ Donation |
The next of kin will make the decision. Driver license has no bearing. |
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During a disaster, save the patients who are most likely to live. |
1st: Ambulatory pt 2nd: Bedridden 3rd: Critical Care (will stay b/c they cant be moved somewhere where there are not any plugs/equipment). Healthcare provider would have to stay back with these pts. during disaster.
Pt's who have pupils which are FIXED and DILATED are DEAD. |
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What is reported to the health department? (Gorillas Swing And Sign) |
Gonorrhea Syphilis TB (+AFB) Shigella |
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What is reported to the police? |
Dog bites Gunshot/knife wounds Suspected abuse of children/elders (can't defend themselves)
*Domestic violence b/w spouses isn't reported to the police. |
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Standard of Care |
What every nurse is expected to know.
Ex: patients should be turned every 2 hours |
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Neglect |
Failure to provide standard of care. If harm has come to the patient because of the nurse they can be sued for malpractice. When the case goes to court, it is called a tort. |
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Beneficence |
To do no harm.
Ex: the nurse is practicing beneficence when the armband is checked prior to administering medication. (if no arm band on children, ask the parent, not the child) |
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5 Rights for med. administration |
Right patient Right medication Right route Right dose Right time |
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Allergies |
Make sure you ask your patient about any known allergies and document what the patient reports. |
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Failure to observe |
liable if--your pts condition becomes worse and you didn't notice, if your pt suffers an injury while in your care, if you don't protect your pt who has known self-destructive behaviors. |
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Failure to intervene |
Protect your patient, Protect yourself! Intervene and document everything. |
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Failure to Protect |
protect patient from injuring themselves and from harm coming to the patient.
Ex: restraining pt without following policies, pt who got burnt while in the care of the facility, injuries r/t faulty equipment. |
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Abandonment |
Leaving a job without providing notive
Ex: Homecare--30 days written notice must be given before leaving the case. |
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Assault |
Acts which cause fear to the patient (no touching is needed) |
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Battery |
Any physical contact with the patient which will cause harm or is offensive |
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When does consent not need to be obtained? |
For emergencies When pt waives rights to be informed Telling pt could harm pt or prevent pt from receiving the Tx to save their life. Consent has already been received for the same type of procedure. |
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Nurse's job with obtaining consent. |
Nurse ONLY acts/signs as a witness and nothing more. Person giving info for consent (Dr/Surgeon) is responsible for everything else (giving information, alternate options, answering questions) |
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Breach of promise |
When an agreement is made between oneself and another and you fail to honor that agreement |
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Conversion |
the legal term for stealing
(ex: alcohol pads, soap/lotions, pens, lancets) |
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Defamation |
Communicating something to another person which hurts their reputation, character, financial well being, esteem, respect, and confidence of others in the person the communication may be: liable (written) or slander (spoken)
Women nurses are the biggest offenders. |
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Fraud |
intentionally giving misinformation |
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Infliction of emotional distress |
Extreme or outrageous conduct done to harm a person's peace of mind.
(Ex: sex with patient) |
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Invasion of privacy |
Inappropriate exposure to a person's body or condition.
Ex: calling support groups (unless u have permission), talking with lawyers, giving info over phone about pt (don't know who is on other end). |
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Incident Reports |
How to complete: -Simply state the facts do not add personal opinions. -Use the correct form -Do not mention the incident report in the patient's chart -NEVER copy an incident report (in NCLEX world) but in real life make a copy to cover your own ass. |
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Documenting Child Abuse |
Every state has a mandatory reporting law which requires suspected child abuse to be reported. |
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Documentation of Refusal of Treatment |
-Competent adults can refuse Tx/meds/Dx tests -When a pt. refuses, this needs to be documented -Make sure that pts who are refusing tx are informed of the consequences from this decision. (make sure you find out why the pt wants to refuse tx and document that also). |
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Documentation of Errors |
Never cover the error (whiteout/black marker). Draw single line through error, date/time/initial it. Include reason for the error (ex: mistaken entry).
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Good Samaritan Act |
If you do decide to help a victim, make sure you have your own private insurance to protect you. |
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When will the Good Samaritan Act NOT protect you? |
if actions are negligent and injury comes to the victim based on your negligence. Follow the nursing standard of care. Once you start care, can't leave victim unless trade off with another RN or someone higher up.
If you provide care and aren't licensed to provide that type of care. |
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Signs that the family is coping with their loss.. |
When they are reminiscing/telling stories about the person. It means they are starting to cope with the loss. Everyone deals with grief differently. |
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Latex Allergy |
Condoms, rubber bands, balloons, gloves, medical equipment.
May also be allergic to--avocados, bananas, chestnuts, kiwi, and strawberries.
Mylar balloons are safe for ppl with latex allergies. |
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Hyponatremia |
Sodium less than 135
S/S weakness, fatigue, abd cramps |
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Hypernatremia |
Sodium more than 145
S/S weakness, thirst, sick to stomach. |
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General Rule Regarding Electrolytes |
K and Na control muscles
Ca++ controls nerves
Watch out when you read muscle weakness (electrolyte imbalance) |
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Sign of Toxicity from Lasix? |
Patient has not U/O. |
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Hypovolemic Shock |
From LOSING too much fluid (bleeding or sweating) |
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Bloodborne Exposure (HIV) |
If results indicate the need for treatment, the postexposure prophylaxis (PEP) for HIV should be started within 1 hr of the exposure. |
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How to remove Personal Protective Equipment (PPE) |
Remove PPE in alphabetical order.. Gloves Goggles Gown Mask
All PPE should be removed at the door prior to leaving pts. room except with respirator (remove outside room) |
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Fecal Occult Blood test |
Instruct pt not to take NSAIDs like ibuprofen, red meat, vitamin C, colchicine, and iron for 3 days prior to test and during testing period
Blue colored result indicates blood in the stool. green means there is no presence of blood. |
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What is best way to wash hands? |
USE FRICTION |
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Setting up sterile field |
NEVER reach across or over the sterile field.
Remember, the outer 1 inch of the drape is not part of the sterile field and is the only area you can touch. |
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ABCD to Malignant Melanoma |
Asymmetry Border irregularity Color variation Diameter >6mm |
