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158 Cards in this Set
- Front
- Back
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3 definitions of delegation: |
1. get work done through others 2. directing the performance of 1 or more people to accomplish a goal 3. transfer of responsibility for the performance of a task from one person to another. |
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ANA/NCSB definition of delegation |
The process for a nurse to direct another person to perform nursing tasks and activities. |
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List 4 reasons why a manager might delegate a task: |
1. they have other tasks to complete 2. someone else is more knowledgeable about the task 3. provide learning opportunity 4. contribute to professional development |
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2 methods of delegation: |
1. Direct 2: Indirects: actions determined by policy. |
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True or False, an RN cannot legally delegate to UAP or LPN. |
False: RN are legally authorized to delegate to UAP and LPN |
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What can the RN NOT delegate? |
Components of the nursing process (Assessment, planning, evaluation and judgment.) |
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What factors into the RN's decision to delegate? |
1. needs and condition of patient 2. potential for harm 3. stability of patient 4. task complexity 5. ability of the staff |
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LPN: Licensed Practical Nurse |
-1 year training in basic nursing skills -requires RN supervision -can perform many of same tasks as RNS with exceptions. |
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UAP= Unlicensed assistive personnel |
-Unlicensed -trained in supportive role -includes: orderlies, assistants, attendants, technicians. |
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TASKS THAT CANNOT BE DELEGATED!!! |
-Assessment/ progress evaluation -Analysis of assessment findings -Developing diagnoses -Creating care plan -providing education -communicating w/ other clinicians -delegating to others -documentation of assessments and interventions -administering blood products, IV push meds, and certain complex medications |
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Can an RN delegate: Documentation of assessments and interventions? |
No. |
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Can an RN delegate: Creating care plans? |
No. |
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Can an RN delegate: providing education? |
No. |
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Can an RN delegate: contributions to a care plan? |
Yes, from an LPN. |
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Can an RN delegate: administration of IV push meds? |
No. |
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Can an RN delegate: data gathering through observation and auscultation? |
Yes, an LPN can do these things. |
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Dressing changes |
LPN, RN, UAP |
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Obtaining Cultures |
LPN, RN, UAP |
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PO and some IV meds |
LPN, RN |
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Admin fluid |
LPN, RN |
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ADLs |
UAP, LPN, RN |
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Skin care |
LPN, RN |
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Respiratory support |
LPN, RN |
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When can RN delegate to UAP? |
-when patient is stable and circumstances are uncomplicated |
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4 requirements of UAP tasks: |
1. Routine 2. Simple 3. Repetitive 4. DO NOT require nursing judgment |
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Hygiene |
UAP, LPN, RN |
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Feeding |
UAP, LPN, RN |
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Ambulation |
UAP, LPN, RN |
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9 key steps to delegation: |
1. Plan ahead 2. ID skill/education requirement 3. Select capable personnel 4. Communication 5. Empower 6. Deadlines/Progress 7. Role model 8. Evaluate performance 9. Reward accomplishment |
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5 Rights of Delegation |
1. Right Task 2. Right Circumstance 3. Right Person (to right person for right person) 4. Right Direction/ Communication 5. Right Supervision |
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3 common delegation errors |
1. overdelegate 2. underdelegate 3. improperly delegate |
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4 P's of Prioritizing |
1. Purpose 2. Picture 3. Plan 4. Part |
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ABC of Nursing |
Airway Breathing Circulation |
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3 Levels of Priority Setting |
Level 1: Life threatening needs (ABC) Level 2: Immediately subsequent to level 1 -Safety -LOC -Acute pain -acute elimination problems -untreated medical issue -abnormal labs -risks Level 3: Long term issues, education, rest, coping |
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MASLOWS HIERARCHY OF NEEDS |
1. Physiologic needs- oxygen, food, sex, rest... 2. Safety & concern- safe, continuity, stability 3. Love & belonging- support 4. Self-esteem- privacy, self reliance, self worth 5. Self-actualization- growth, health, autonomy |
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Prioritizing: what is consequence of ignoring high priority? |
Life threatening |
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Prioritizing: what is consequence of ignoring medium priority? |
Unhealthy consequences |
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Prioritizing: what is consequence of ignoring low priority? |
Makes no difference if this goes unattended |
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4 C's of Intentional Direction |
Clear Concise Correct Complete |
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Percentage Water Weight: Adults |
60% |
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Percentage Water Weight: Older Adults |
45% to 55% |
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Percentage Water Weight: Infants |
70 to 80% |
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2/3 water in body is located as: |
Intracellular fluid (w/in cells) |
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1/3 water in body is located as: |
Extracellular fluid (space b/t cells and lymph) |
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Define plasma |
Extracellular fluid, liquid part of blood |
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Define Transcellular fluid |
Extracellular Fluid found in specialized cavities: cerebrospinal fluid, fluid in GI, peritoneal fluid. |
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Define Interstitial fluid: |
Extracellular fluid between cells |
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Define Ions |
Electrically charged particles |
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Define Cations |
Positively charged particles |
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3 examples of cations: |
1. Sodium (Na +) 2. Potassium (K+) 3. Calcium (Ca+) 4. Magnesium (Mg +) SOME PEOPLE CARRY MONEY |
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define anion |
negatively charged particle |
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3 examples of anions |
1. Bicarbonate (HCO3-) 2. Chloride (Cl-) 3. Phosphate (PO4-) BABIES CANT PAY |
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Prevalent cation in ICF: |
Potassium (K+) |
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Prevalent cation in ECF: |
Sodium (Na+) |
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Prevalent anion in ICF: |
Phosphate |
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Prevalent anion in ECF: |
Chloride (Cl-) |
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Define Diffusion |
Movement of molecules from high to low concentration. |
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Define facilitated diffusion |
Movement of molecule from high to low concentration w/out energy, USING SPECIFIC PROTEIN CARRIER. |
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Define active transport |
Molecules move AGAINST concentration gradient, required ENERGY. ie: Sodium potassium pump |
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Define Osmosis |
Movement of water between two compartments |
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Define osmotic pressure |
amount of pressure required to stop osmotic flow of water, determined by concentration of solutes |
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Hypotonic |
extracellular solution has lower concentration of solutes than intracellular solution. water diffuses into cell. Cells swell. |
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Isotonic |
extracellular and intracellular solutions have the same concentration of solutes. No change to cell. |
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Hypertonic solution |
Extracellular solution has higher concentration of solutes than Intracellular solution. Water diffuses out of cell. Cell shrinks. |
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Define Hydrostatic Pressure |
-Stems from the heart (BP in blood vessels)
-Force w/in a fluid compartment -Major pushing force -Pushes water out of vascular system at capillary level. |
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Define Oncotic Pressure |
Osmotic pressure (PULLING PRESSURE)exerted by colloids in solutions -Protein is major colloid -pulls fluid back into vascular space |
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Name an important colloid |
Albumin |
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3 ways to assess fluid shift in a patient: |
1. weight gain or loss 2. urine output 3. inspection: swelling, breathing, lungs |
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Define first spacing |
Normal distribution of fluid in ICF and ECF compartments |
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Define second spacing |
Abnormal accumulation of interstitial fluid (i.e. Edema) |
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Define third spacing |
Fluid accumulates (becomes trapped) in a portion of the body from which it is not easily exchanged w/ the rest of ECF |
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Ascites, burn associated edema, and peritonitis are examples of which fluid spacing? |
Third spacing |
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Edema (not trauma or burn related) is an example of which fluid spacing? |
Second spacing |
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5 factors to consider when looking out for fluid balance issues in older adults |
1. Kidneys: structural changes decrease ability to conserve water. 2. Sodium & water regulation: less efficient 3. Hormonal changes: decrease in ADH and ANP 4. Less subcutaneous tissue: increased loss of moisture. 5. Reduced thirst mechanism: decreased fluid intake. |
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Define ascites |
fluid in peritoneal cavity (bloated belly) |
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Isotonic IV Fluid |
0.9 % Normal saline Lactated Ringer -used w/ hypovolemia and hypotension |
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Hypotonic IV Fluid |
D5W, 0.45% 1/2 normal saline -osmo is less than blood -pulls water from intravascular to interstitial fluid spaces. -used for hyperglycemia |
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What type of solution is used to treat Hypovolemia and hypotension? |
Isotonic 0.9% normal saline LR |
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What type of solution is used to treat hyperglycemia? |
Hypotonic D5W, 0.45%, 1/2 NS |
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Hypertonic IV Solution |
-Osmolarity higher than blood -pulls fluid and electrolytes from intracellular and interstitial spaces to intravascular space -increases urine output, decreases edema (i.e. burns) -D5NS, D5(0.45%)1/2NS, D50W, D10W, 3%NS |
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What type of IV solution would you use to treat 3rd spacing issues? |
-hypertonic --D5NS, D5(0.45%)1/2NS, D50W, D10W, 3%NS |
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PICC Line |
Central line, inserted peripherally, enter into superior vena cava. use: 1 week to 6 months note: must flush with saline and heparin |
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Porta-Cath |
Inserted: inside chest wall Use: monts to years Note: always flush and pull back prior to putting anything through to check for blood return. |
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Sodium (Na+) Normal range: |
135-145 mEq/L |
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Sodium (Na+) Where is it found: |
Main cation in ECF |
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Sodium (Na+) What does it do? |
PRIMARY REGULATOR OF FLUIDS: Maintains concentration & volume of ECF and influences H2O distribution between ECF and ICF. |
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Sodium (Na+) Where does the body obtain it & how is it absorbed? |
In food, absorbed in GI tract |
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Potassium (K+) Normal levels: |
K+ 3.5 - 5 mEq/L |
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Potassium (K+) Where is it in the body?: |
K+ is most important intracellular electrolyte (98%%). |
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Potassium (K+)What does it do?: |
K+ regulates intracellular osmolality and promotes cell growth. |
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Potassium (K+) Where do we obtain it?: |
Diet is our source of K+: banana, baked potato, oranges, citrus/juices. |
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What are three general causes of hyperkalemia? |
1. Excess K intake 2. Shifts of K out of the cell 3. Failure to eliminate K |
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What happens to the EKG during Hyperkalemia? |
1. Tall peaked T waves 2. Prolonged P waves 3. Widening QRS 4. Ventricular fibrillation |
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Calcium Normal Levels: |
8.6 - 10.2 mg/dl |
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What 4 key roles does Calcium play in the body? |
Blood clotting Transmission of nerve impulses Myocardial contraction Muscle Contraction |
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What is the (general) total body content of Ca |
about 1,200g |
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What controls Ca balance in the body? |
Calcitonin and parathyroid hormone |
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What is Chvostek's sign and what is it a sign of? |
contraction of facial muscles in response to a light tap over the facial nerve in front of the ear. A sign of hypocalcemia. |
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What is Trousseau's sign and what it is a sign of? |
carpal spasm induced by inflating a BP cuff above systolic pressure for a few minutes: indicating hypocalcemia. |
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What are the EKG changes in hypocalcemia? |
Elongated ST segment Prolonged QT intervals Ventricular tachycardia |
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Normal values for Phosphate: |
2.4 - 4.4 mg/dl |
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Phosphate's essential functions include: |
1. Acid Base Buffering 2. ATP 3. Cellular uptake and use of glucose 4. (Muscle/RBC/Nervous system) |
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Normal values for Magnesium (Ma+) |
1.5 - 2.5 mEq/L |
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Where do you find Magnesium in the body? |
-50 to 60% is in the bone -it is also the second most abundant intracellular cation. |
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What does magnesium do? |
1. Coenzyme in metabolism of carbs and proteins 2. Role in normal Ca and K balance (helps break down Ca) |
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Normal blood pH |
7.35 to 7.45 |
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Normal PaCO2 |
35-45 mmHg |
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Normal HCO3 |
22 - 26 mEq/L |
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Respiratory Acidosis: |
Serum blood pH drops below 7.35 PaCo2 greater than 45mmHg Respiratory cause: retaining CO2 Metabolic cause: increase in bicarbonate |
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Respiratory Alkalosis |
Serum pH above 7.45 PaCO2 less than 35mmHg Respiratory cause: blowing off CO2 Metabolic cause: increase in bicarbonate |
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Metabolic Acidosis |
Serum pH less than 7.35 Bicarbonate less than 22mEq/L |
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Metabolic Alkalosis |
Serum pH greater than 7.45 Bicarbonate level greater than 26 mEq/L |
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Clinical manifestations of respiratory acidosis |
Hypoventilation, dyspnea, respiratory distress, shallow respirations, headache, restless, confusion |
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Clinical manifestations of respiratory alkalosis |
Hyperventilation, lightheaded, numb, tingling, muscle spasms, confusion, inability to concentrate, blurred vision, dysrhythmia, palpitation dry mouth. |
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Clinical manifestations of metabolic acidosis |
Headache, confusion, restless, lethargy, stupor, coma, Kussmaul respirations, flushed skin |
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Clinical manifestations of metabolic alkalosis |
Dizziness, lethargy, disorientation, seizures, coma, weakness, muscle twitching, muscle cramping |
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Pathophysiology of stroke: 2 basic factors: |
1. Anatomy of cerebral circulation 2. Regulation of cerebral blood flow |
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4 non modifiable stroke risk factors: |
1. gender 2. age 3. race 4. heredity/family history |
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10 modifiable stroke risk factors: |
1. hypertension 2. heart disease 3. metabolic syndrome 4. heavy alcohol consumption 5. poor diet 6. drug abuse 7. sleep apnea 8. obesity 9. physical inactivity 10. smoking |
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What is a TIA? What are the S/Sx and how to Tx? |
Transient Ischemic Attack: 2/3 people with TIA will develop stroke w/in 3 to 5 years. S/Sx: Vertigo, blurred vision, arm tingle, dysphagia, slurred speech, numbness, weakness, ataxia Treatments: Aspirin, clopidogrel (Plavix), and warfarin (Coumadin). |
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Name 3 types of stroke |
1. Thromotic- narrowing of artery blocks blood 2. Embolic- blood clot circulates in blood 3. Hemmorhagic- burst blood vessel, seep |
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What is the most common (61%) type of stroke? |
Thrombotic |
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2/3 of thrombotic stroke are associated with what 2 disorders? |
1. Diabetes mellitus 2. hypertension |
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This type of stroke has symptoms that develop slowly, can often be asymptomatic for the first 24 hours. |
Thrombotic stroke |
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What is a lacunar stroke? |
A Lacunar Stroke is a thrombotic stroke in which the occlusion is of a small penetrating artery and a cavity develops in the infarcted brain tissue. This typically happens in the basal ganglia, thalamus, internal capsule, or pons. |
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This type of stroke accounts for 24% of all strokes. |
Embolic Stroke |
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This type of stroke usually has a rapid onset of symptoms |
Embolic stroke |
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Name 6 heart conditions associated with Embolic stroke: |
1. atrial fibrillation 2. myocardial infarction 3. ineffective endocarditis 4. rheumatic heart disease 5. valvular prosthesis 6. atrial septal defects |
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This type os stroke accounts for 15% of all strokes. |
Hemorrhagic stroke |
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What is the #1 cause of hemorrhagic stroke? |
Hypertension. |
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What type of stroke is not associated with periods of activity? |
Embolic |
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What type of stroke commonly occurs during periods of activity? |
Hemorrhagic stroke |
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Symptoms of hemorrhagic stroke: |
1. neurological deficit 2. headache 3. nausea/vomiting 4. decreased LOC 5. hypertension |
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Unique symptoms of hemorrhagic stroke: |
Nausea and vomiting. |
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2 types of hemorrhagic stroke: |
1. Intracerebral hemorrhage 2. Subarachnoid hemorrhage |
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Common cause of subarachnoid hemorrhage? |
Cerebral aneurysm |
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Where does subarachnoid hemorrhage take place? |
Majority of aneurysms are in the Circle of Willis. intracranial bleeding into cerebrospinal fluid filled space between arachnoid and pia matter. |
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where does intracerebral hemorrhage take place? |
1/2 occur in Putamen and internal capsule, central white matter, thalamus, cerebellar hemispheres, and pons. |
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3 parts in nutrition assessment for stroke: |
1. Dysphagia 2. Assess gag reflex 3. aspiration precautions |
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2 types of aneurysm |
1. saccular/berry (20 -30mm) 2. fusiform atherosclerotic |
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Symptoms of aneurism |
focal neurologic deficits including:cranial nerve deficits -nausea, vomiting, seizures, stiff neck |
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Left brain damage: |
-paralyzed right side (hemiplegia) -impaired speech/language aphasias -impaired r/l discrimination -slow performance, cautious -aware of deficits, depression, anxiety -impaired comprehension related to language, math. |
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Right brain damage: |
Paralyzed left side- hemiplegia -left sided neglect -spatial/perceptual deficits -denies/minimizes problems -rapid performance/short attention span -impulsive, safety problem -impaired judgement -impaired time concepts |
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3 types of aphasia: |
1. Receptive: lose ability to understand language in written or spoken form. 2. Expressive: lose ability to produce language 3. Global: inability to communicate, loss of receptive and expressive. |
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Define dysarthria |
Disturbance in muscular control of speech: impairments involving: 1. pronunciation 2. articulation 3. phonation |
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4 spacial perceptual problems |
1. incorrect perception of self and illness 2. erroneous perception of self in space 3. inability to recognize an object by sight, touch, or hearing 4. inability to carry out learned sequential movements on command. |
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Define homonymous hemianopsia |
Blindness in the same half of the visual field of both eyes. |
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3 key areas to diagnosing strokes |
1. diagnose stroke extent & involvement: CT, MRI, PET 2. Cerebral blood flow: angiography, transcranial doppler 3. Cardiac: cardiac markers, chest exray |
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7 Stroke medication (treatment/prevention) options |
1. TPA 3 to 4.5 hrs 2. IV Heparin 3. SQ Lovenox (high dose treats, low does prevents) 4. aspirin 81 to 325 mg/day 5. clopidogrel (Plavix) 6. ticlopidine (Ticlid) 7. warfarin (Coumadin): goal 2.0 to 3.0 |
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3 Surgical interventions for stroke: |
1. Carotid endarterectomy 2. Angioplasty 3. Clipping/ coiling of aneurysm |
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2 medications taken to decrease cerebral enema in stroke: |
1. LASIX (fureosimide) (diuretic, prevents body from absorbing salt, passes it in urine) and 2. 2. 2. mannitol: forces urine production |
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4 anticoagulants given in acute stroke care: |
1. Heparin 2. warfarin (Coumadin) 3. acetylsalic acid (Aspirin) anti inflammatory) 4. clopidogrel (Plavix) |
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6 contraindications for tPA administration |
1. over 4.5 hours from onset of ischemic stoke symptoms 2. platelet count less than 100,000 3. SBP greater than 185, DBP greater than 110 4. CT reveals hemorrhagic stroke 5. Hx of GI bleed, stroke, TBI in past 3 mo 6. Hx of major surgery w/in 14 days |
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How to reverse bleed if PTT & INR are high? |
-give Plasma/platelets -give vitamin K (subs or IV) |
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In cases of acute stroke, IV antihypertensives are preferred. Give 2 examples: |
1. metoprolol (Lopressor) 2. nicardipine (Cardene) |
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What is TCDB |
Turn Cough Deep Breath |
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What is OOB? |
Out of Bed |
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How often should someone be repositioned? |
Every 1 to 2 hours |
