501 Exam 3

Formula Method

(Dose ordered x Quantity on hand)/ Dose on Hand = amount to administer

NIHSS

0 = No drift; limb holds 90 (or 45) degrees for full 10 / 5 seconds. 1 = Drift; limb holds 90 (or 45) degrees, but drifts down before full 10 / 5 seconds; does not hit bed or other support. 2 = Some effort against gravity; limb cannot get to or maintain (if cued) 90 (or 45) degrees, drifts down to bed, but has some effort against gravity. 3 = No effort against gravity; limb falls. 4 = No movement.

Muscle Strength Grading

0 = No movement 1 = Trace of muscle contraction 2 = Active movement without gravity 3 = Active movement against gravity 4 = Active movement against gravity / resistance 5 = Normal

Steps of EBP

0. Cultivate a spirit of inquiry. 1. Ask a clinical question in PICOT format. 2. Search for the most relevant evidence. 3. Critically appraise the evidence you gather. 4. Integrate all evidence with your clinical expertise and patient preferences and values. 5. Evaluate the outcomes 6. Share the outcomes with others.

Unit Conversions

1 kg (kilogram) = 2.2 lbs. (pounds) To convert pounds to kilograms: # of pounds/2.2 = # of kilograms

Memory

1. Registration: (immediate memory) involves the ability to receive information; relates to attention 2. Storage: (recent memory) involves recalling recently (seconds to minutes) received information. 3. Retrieval: involves recalling previously learned (long term: days, months, years) material.

Older Adults Demographics

12% of population is older adults (> 65) By 2030, older adults: Will comprise 18% of the population By 2050, older people: Will be more racially/ethnically diverse Minority elders will comprise 42% of the elderly population

HIPPA

1996 - purpose to make health insurance info "portable" 2003 - updates clarified and expanded privacy and security regulations

Needle Sticks

385,000 needlesticks to healthcare workers per year Estimated that half or more actual needlesticks may go unreported This is nearly a third fewer incidents (in non-surgical settings) than prior to the Needlestick Safety and Prevention Act of 2000

Rules of Rounding

> or = to 5 round up, <5 round down Never round up medication in tablet form 1.5 tablets remains as is; not 2 tablets Each step of calculation must be carried out to at least the hundredth place The final step or "final answer" is to be rounded to the Tenths if greater than 1 (1.56 = 1.6) Hundredths is less than 1 (0.422 = 0.42)

Stroke Scale

A clinical stroke assessment tool to evaluate and document neurological status in stroke patients. The stroke scale is valid for predicting lesion size and can serve as a measure of stroke severity. The NIHSS has been shown to be a predictor of both short and long term outcome of stroke patients.

Reducing errors

ASK - seek clarification IDENTIFY - key drug info KNOW - facility P&Ps SIX RIGHTS - every single time FOCUS - Avoid distractions INSTINCT - Trust your gut LISTEN - to your patient DOCUMENT - every thing TRANSPARENCY - if there is an error

Pharm Metabolism

Absorption Passage of medication molecules from the site of administration into the blood Distribution After a medication is absorbed, how it moves throughout the body. Metabolism (Metabolization) Occurs after a medication reaches its site of action Excretion Medications are excreted through: Kidneys, Liver Bowel Lungs Exocrine glands

Long term care settings

Acute Care NICHE ACE Geriatric ED Sub-acute Rehabilitation Long term care/Skilled nursing facility Home

Otic Meds

Adult-up Child-down

Neuro Considerations

Age Meaningful stimuli Amount of stimuli Social interaction Environmental factors Occupation, sports, hospitalization Cultural factors English as second language Health literacy

Impaired sensory perception

Altered sensory perception Excessive environmental stimuli Psychological stress Altered sensory reception, transmission, and/or integration/insufficient environmental stimuli Biochemical imbalances for sensory distortion (e.g., illusions, hallucinations); Electrolyte imbalance Biochemical imbalance

Guidelines and Standards

American Nurses Association (ANA) Principles for Nursing Documentation Code of Ethics National Committee for Quality Assurance (NCQA) The Joint Commission (TJC) Specialty organizations Policies and Procedures RUMC P&Ps

Sources of Evidence

Articles from nursing and health care literature Databases, research studies Quality Improvement and risk management data Standards of care Infection control data Benchmarking, retrospective, or concurrent chart reviews Clinicians' expertise

Motor Function

Assess for muscle size and tone bilaterally. Spasticity (Upper motor neuron injury) Rigidity/Flaccidity (Lower motor neuron injury) Assess gait and posture Look for involuntary movements. Assess muscle strength.

Sensory Function

Assess touch - soft and sharp. Assess temperature and vibration bilaterally. Proprioception - thumb or big toe are moved up and down. Patient able to state correct location without looking.

Stick prevention

BEFORE ENTERING ROOM LOOK at the device you will be using (in the package) and confirm how to use the safety device. If you are not 100% sure how to activate the safety device, ASK. By law, all needles (with very few exceptions) must have a safety device.

US health advantages

Cancer mortality • Stroke mortality • Control of blood pressure and cholesterol levels • Suicide • Elderly survival • Self-rated health

Comatose

Cannot be aroused; have no muscular, corneal, or gag reflex, and they may have no pupillary response to light.

Medication Names

Chemical—provides the exact description of medication's composition. N-acetyl-para-aminophenol Generic—the manufacturer who first develops the drug assigns the name, and it is then listed in the U.S. Pharmacopeia. Acetaminophen Trade—also known as brand or proprietary name. This is the name under which a manufacturer markets the medication. Tylenol, Panadol, Tempra

Pharm Basics

Classification, symptoms the medication relieves, desired effect Medication forms

EBP #2

Clinical Expertise

Purpose of Documentation

Communication Legal record of patient care Health care reimbursement Quality Improvement Research Nursing Education

Level 3 of evidence

Control trial - no randomization For example: convenience sample

TJC

Core measures are national standards of care and treatment processes for common conditions. These processes are proven to reduce complications and lead to better patient outcomes. Core measure compliance shows how often a hospital provides each recommended treatment for certain medical conditions.

Obtunded

Decreased alertness; slowed psychomotor responses. Decreased interest in their surroundings, slowed responses, and sleepiness.

Acute care considerations

Dehydration/Malnutrition Poly-pharmacy Pressure Ulcers Falls Health care acquired infections Urinary incontinence Sleep

Mentation

Depression in ambulatory care doubles cost of care across the board (Unutzer 2009) 16:1 ROI on delirium detection and treatment programs (Rubin 2013)

Med Administration Guidelines

Designate a "No Interruption Zone' Check expiration date & package integrity Prepare for 1 patient at a time Keep in original package or label Only give meds you have prepared Don't delegate Watch the patient take the meds Double check calculations Stop if the patient questions the med Don't hesitate to double/triple check the order

Topical Meds

Direct application on skin Insertion of medication in to a body cavity Installation of fluid in to body cavity Irrigation of a body cavity Spraying a medication into a body cavity

Confusion

Disoriented to time, place, or person, memory difficulty is common, has difficulty with commands, exhibits alteration in perception of stimuli, may be agitated

Needles

Disposable Stainless steel Three Parts Hub Shaft Bevel Length ¼ to 3 inches Gauge

Dimensional Analysis

Dose ordered x concentration on hand Allows for all math to be completed in one linear setup by matching up units to cancel out

The right:

Drug Dose Route Time (Frequency, Intervals, Time of Day, Facility Times) Patient Documentation

Evidence based practice

EBP is the integration of clinical expertise, patient values, and the best research evidence into the decision- making process for patient care

EMR

Electronic Medical Record (EMR) - Legal record that provides a vehicle for sharing information with members of the health care team - includes Personal Health Information (PHI)

Employee Engagement

Employee engagement in healthcare is higher than global norms Nurse engagement can be the difference between life and death Employee engagement in healthcare leads to lower operating costs Patient care from engaged employees is safer and more thorough Engagement and patient satisfaction scores are closely linked

Microsystems

Essential building blocks of health system and the larger organization; Small yet functional front-line units that provide health care to patients; Local environments where patients, providers, support staff, information, and process come together to meet patients health needs.

Eight (8) Common steps in quality improvement

Establish a clear and defined aim or purpose Review the literature Examine current resources available to facilitate quality improvement Map current processes Analyze root cause Select appropriate tools for process analysis Select measures and metrics (baseline and outcomes) Conduct rapid cycle review of the plan, data, interventions and outcomes

Effective Documents

Factual Accurate Current Organized Complete

Caregivers

Family (informal) caregivers may include spouses, adult children, neighbors, relatives, and friends Assist w/ patient care Provide emotional/social support Manage/coordinate health care services 43.5 million informal caregivers provide care to adult or child 39.8 million for 18 and older 15.7 for persons with ADRD Informal care services valued at $470 billion ADRD: $217.7 billion Individuals provide care for about 24.4 hours per week

Improve Quality

Focus on pt, being part of team, use of data

Infomantics

Health care Informatics is the "application of computer and information science in all basic and biomedical sciences to facilitate the acquisition, processing, interpretation, optimal use, and communication of health-related data. The focus is the patient and the process of care and the goal is to enhance the quality and efficiency of care provided.

Common Sensory Deficits

Hearing Deficits Presbycusis Cerumen accumulation Taste Deficit Xerostomia Neurological Deficits Peripheral Neuropathy Cerebrovascular accident

Cultural Considerations in neuro

Hearing impairment higher in whites Otitis media higher in Native American children Glaucoma is 3X higher in blacks Diabetic retinopathy higher in Hispanic Americans Macular degeneration higher in whites All sensory deficits are more common in Older Americans

Joint Commission Safety Goals

Identify patients correctly Improve staff communication Use medicines safely Use alarms safely Prevent infection Identify patient safety risks Prevent mistakes in surgery

PICO Case study

In adult patients with total hip replacements (P), how effective is PCA pain medication (I) compared to prn IM pain medication (C) in controlling post operative pain (O) during the perioperative and recovery time (T)?

EMR Includes

Includes but is not limited to: Admission data and physical assessment Ongoing assessments (flow sheets and progress/DAR notes) Medications, laboratory, procedures, and treatment Standardized care plans Acuity ratings Education Discharge summaries/teaching

US health disadvantages

Infant Mortality& Low Birth Weight • Injuries& Homicides • Adolescent Pregnancy& STIs • HIV and AIDS • Drug related deaths • Obesity and Diabetes • Cardiovascular disease • Chronic lung disease • Disability

Lifespan meds

Infant/Child Pharmacokinetics Weight and body surface area used in calculations Various delivery devices available ( e.g., syringe) Injection sites, needle and syringe sizes vary Immobilization Older Adult Pharmacokinetics Chronic conditions Injections sites, equipment varies Poly-pharmacy including OTCs

Parenteral

Intradermal - ID Subcutaneous - Sub Q Intramuscular - IM Intravenous IV (Term 2)

During stick:

Keep your eye on the needle at all times Act assertively...not hesitant...not careless Be prepared for "unexpected" patient movement

post stick:

Keep your eye on the needle at all times Your first priority is YOUR safety...the first action after removing the needle is to activate the safety device Activate the safety device using only one hand whenever possible Immediately discard the device THEN, take care of your patient (Band-Aid, etc.) Remember, sharps boxes are ONLY for sharps

Most important parts of neuro assessment

LOC and mentation

Types of Errors

Latent failure is removed from the practitioner; involves decisions affecting organizational policies, procedures, allocation of resources Active failure involves direct patient contact Organizational system failure is indirect and involves management, organizational culture, protocols/processes, transfer of knowledge, and external factors Technical failure is indirect failure of facilities or external resources

10 Successful Characteristics of High Performing Microsystems

Leadership Organizational Support Staff focus Education and Training Interdependence Patient focus Community and Market focus Performance Results Process Improvement Information and Information Technology

Level 6 and 7 of evidence

Level VI Single descriptive or qualitative study Level VII Expert opinion Handbooks, textbooks, fundamental but general knowledge

Neuro Assessment

Mental status Cranial nerves Motor system Sensory system Coordination Deep tendon reflexes

COVID goal

Mixed path • Building capacity to control transmission by continued social distancing, massive testing, and PPE for frontline workers • Investing in efforts to mitigate the impact of Covid-19 by rapidly finding treatments, increasing health care capacity, and further accelerating work on a vaccine.

Students sticks

Multiple studies show rates of 9-60% of nursing students have received a sharps injury, with 40-96% not being reported by the student! Usually due to unfamiliarity

Age friendly health systems

New initiative from Institute for Healthcare Improvement (IHI) and The John A. Hartford Foundation Aims: Create a healthcare system where every older adult, everyday: Gets the best care possible Experiences no healthcare-related harms Is satisfied with the healthcare Realizes optimal value Try This - Age-Friendly Health Systems: The 4 Ms

Med math guidelines

No trailing zero after a decimal point or a whole number 1 mg (not 1.0 mg) No naked decimal point 0.5 ml (not .5 ml) Use mg, ml, g, without a terminal period. Period could be mistaken as number 1 if written poorly. mg (not mg.) Numerical dose and unit of measure - Place adequate space between the dose and the unit of measure 10 mg (not 10mg) Use commas for dosing units at or above 1,000

Document Considerations

Nurses are legally and ethically obligated to keep client information confidential. Clients must give permission for info to be given to family, significant others Clients have the right to obtain their medical record. They must complete the HIPPA Privacy Rights Request Form. To have records sent to anyone who is not providing treatment, payment, or health care operations, client must sign an Authorization for Release of Patient Health Information Form.

Confusion Intervention

Nursing interventions SAFETY first Re-orient as needed Present reality concisely and briefly Explain reasons for confusion if known. Encourage use of glasses and/or hearing aids. Make sure they are clean/functional. Evaluate current medications

Mobility

Older adults who sustain a serious fall-related injury required an additional $13,316 in hospital operating cost and had an increased LOS of 6.3 days compared to controls (Wong 2011) 30+% reduction in direct, indirect, and total hospital costs among patients who receive care to improve mobility (Klein 2015)

Med Routes

Oral Topical/Mucosal Inhalation Parenteral

Barriers to quality improvement

Organizational Culture Miscommunication/misunderstanding Improper problem identification Inadequate constituency Unrealistic goals/plans Inadequate follow-up/evaluation

Med Orders

Patient's full name Date and time the order was written Medication name - correct spelling is a "must" Dosage Route of administration Time and frequency of administration Signature of health care provider

Oral Meds

Pill, capsule, tablet Buccal Sublingual Syrups/Suspension Sustained release (SR) or extended release

Alert and Oriented

Promptly and spontaneously states name, location (i.e., oriented to self, place, and time, or "oriented X3"). A normal sleep stage from which a person is easily awakened is also considered a normal level of consciousness. "Clouding of consciousness" is a term for a mild alteration of consciousness with alterations in attention and wakefulness.

EBP #3

Pt preference/values

5 P's of Microsystems

Purpose Patients Processes Professionals Patterns

(H)CAHPS

Purpose - Better understand patient experience with health care and develop scientifically valid and feasible strategies and tools to: Assess patient experience. Report survey results. Help organizations use the results to improve the quality of care. Communication with nurses Communication with doctors Responsiveness of hospital staff Pain management Communication about medicines Discharge information Individual measures Cleanliness of hospital environment Quietness of hospital environment Overall rating of hospital Willingness to recommend hospital

Incident Report

Purposes: Quality Improvement Risk management Examples: Unexpected death or outcome Injury to patient or visitors or staff Device failure Specimen labeling error HAPUs Burns Important to know: Should Include objective info Should not be used to assign blame - "Just Culture" Not a part of the legal EMR

Quality vs. safety

Quality has to do with efficient, effective, purposeful care that gets the job done at the right time for the right cost. Safety: lack of harm

Level 2 of Evidence

Randomized Control Trial *Gold standard for research Randomly assigns people to an experimental group or a control group. Controls for the influence of variables - only one population should be study at a time. The only difference is the outcome variable being studied.

Vital Signs and Neuro

Respirations The brain controls breathing so any problems with the brain can affect respirations. The rate, depth and pattern of breathing should be recorded. Temperature: indicates hypothalamus function Blood pressure and pulse: Elevated blood pressure, bradycardia and a fall in respiratory rate may be indicative of increased ICP. Level of consciousness would deteriorate before altered vital signs.

Safety Key terms

Safety event - an event, incident, or condition that may or may not result in direct harm to a patient Adverse event - a patient safety event that results in harm to a patient (Fall, Surgical Sight Infection, CLABSI, CAUTI, Pressure Injury) No harm event - a patient safety event that reaches the pt. but does not cause harm (Wrong medicine given, no adverse reaction) Close call - near miss or good catch - A pt. safety event that didn't reach the patient (Rocephin not compatible with LR; Sponge left in vagina) Hazardous (or unsafe conditions) - A circumstance other than a patient's own disease process or condition that increases the possibility of an Adverse Event (Violence directed toward patient or caregiver) Sentinel event - A sentinel event is a patient safety event not primarily related to the natural course of a patient's illness or underlying condition that reaches a patient and results in any of the following: death/permanent harm/ severe or temporary harm (Wrong breast removed; Difficult Intubation that lead to pt death)

Safety First

Scope of the problem. Human cost - 250,000 deaths by medical error in 2016 (BMJ, 2016) Economic Cost - $187.5 Billion to $250,000 History of patient safety and the origins of the blame culture. Need to speak up if they see something that is unsafe. Think about the difference between system failures, violations (cutting corners) and errors.

Mini mental status exam

Score Interpretation 30-24 Normal 23-18 Mild Cognitive Impairment 17-0 Severe Cognitive Impairment

Sensory Alterations

Sensory Deficits: A deficit in the normal function of sensory reception or perception. Sensory Deprivation: Occurs when a person receives an inadequate quality or quantity of stimulation (monotonous or meaningless stimuli) Sensory Overload: Multiple sensory stimuli that cannot be perceptually disregarded or selectively ignored

LEvel 4 of evidence

Single Nonexperimental Study Correlational Study - determines if two variables are/are not correlated Cohort Study - identifies two groups of patients (cohorts) prospectively where one received the exposure of interest Case Control - identifies patients (cases) who have the outcome of interest and a control group without the outcome (retrospectively)

Stuporous/Semi-Comatose

Sleep-like state (not unconscious); little/no spontaneous activity; only respond by grimacing or drawing away from painful stimuli

Lethargic

Sleepy. Shows excessive drowsiness and responds to stimuli only with incoherent mumbles or disorganized movements

Aphasia

Speak slowly. Allow sufficient time. Don't shout If receptive aphasia: simple and short questions, speak of familiar things and of interest to patient If expressive aphasia: Yes/no questions or blinking of eye, picture or communication board

Level 1 of Evidence

Systematic Review Meta-Analysis Practice Guidelines Produced by experts based on a review of the evidence and sets a standard of best practice - usually multi-disciplinary approach. Systematical developed guidelines based on the best evidence for patient care.

LEvel 5 of evidence

Systematic review of descriptive/qualitative studies Descriptive - data may be collected qualitatively - often through surveys, interviews and observation but analyzed quantitatively (%, averages, etc) Qualitative - more holistic and focused on exploring individual thoughts/ perspectives / experience

What do we measure to determine quality health care?

TJC Core Measures National Database of Nursing Quality Indicators (NDNQI) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Press-Ganey Employment Engagement Survey

Geriatric Sensory Changes

Taste Smell Vision Touch (Pain) Hearing

Safe Practice

The prevention of harm to patients (IOM, 2001) Errors are generally systems issues Systems should prevent errors Learn from errors Promotes a culture of safety AHRQ (2007) expands the definition: "Freedom from accidental or preventable injuries produced by care" QI/PI Continuous/Ongoing efforts to achieve measurable improvements in efficiency, effectiveness, performance, outcomes, accountability.....

Normal Aging: Sleep

Total increased sleep time, averaging 10 hours nightly Total decreased sleep time, averaging about 6.5 hours nightly Increased REM sleep Decreased time to fall asleep

Infusion rates

Total vol in mL/# of hours= mL per hour

Glasgow Coma Scale

Usually used after sports injuries, motor vehicle accidents or any injury resulting in potential head trauma Classification of brain injury Mild: GCS 13-15 Moderate: GCS 9-12 Severe: GCS 3-8

Brief Neural Assessment

Vital Signs Level of Consciousness (Mentation) Orientation Pupils Speech Movement Sensation

The 4 M's

What Matters: Knowing and acting on each patient's specific health goals and care preferences Medication: Optimizing medication use to reduce harm and burden, focused on medications affecting mobility, mentation, and what matters Mentation: Identifying and managing depression, dementia and delirium across care settings Mobility: Maintaining mobility and function and preventing complications of immobility

EMR 5 W's

Who: Right person What Requirements e.g., acceptable abbreviations Provider or patient conversations When Timely or follow up with correction ASAP Chart Lock Down Where Correct location of info Why If it wasn't documented, it wasn't done.

Systems analyst/Risk anticipator:

able to participate in systems review to improve quality of client care delivery and at the individual level to critically evaluate and anticipate risks to client safety with the aim of preventing medical error.

Information manager

able to use information systems and technology that put knowledge at the point of care to improve health care outcomes;

If pt can't follow commands, assess

assess only the pupils, eye opening, motor response, some of the cranial nerves

If pt can follow commands, assess

level of consciousness (LOC) pupils cranial nerves I through XII motor response sensation

Consciousness

most sensitive indicator of neurological change Defined as a state of general awareness of oneself and the environment. Estimated by observing how patients respond to certain stimuli. Changes in LOC are GLOBAL in nature

Covid policy changes

paid sick time; • access to safe quarantine; • moratorium on evictions, foreclosures and termination of public benefits; • immigrants and the homeless have safe access to testing and treatment • Food and other social support benefits

PICO/ PICOT

patient, intervention, compairison, outcome, time

Inadequate public health workforce

per capita spending on public health is less than 3% of total health care expenditures • 51,000 PH jobs lost in Great Recession of 2008 • Federal funds for state, local, and tribal public health preparedness cut from $940 million in 2002 to $675 million in 2019 • governmental public health workforce deficit of as many as 300,000 workers.

Healthy People 2030

provides science-based, 10-year national objectives for improving the health of all Americans. For 3 decades, Healthy People has established benchmarks and monitored progress over time in order to: •Encourage collaborations across communities and sectors. •Empower individuals toward making informed health decisions. •Measure the impact of prevention activities.

The Community Guide

resource to help you select interventions to improve health and prevent disease in your state, community. Reviews are designed to answer three questions: -What has worked for others and how well? -What might this intervention approach cost, and what am I likely to achieve through my investment? -What are the evidence gaps?

outcomes manager

synthesizes data, information and knowledge to evaluate and achieve optimal client outcomes.

Affordable Care Act

• Coverage • Expanded insurance opportunities/Medicaid • Quality • Penalties for readmissions • Cost • Value Based Payments • Unique Opportunities for Prevention • National Prevention Strategy