Leadership

When prioritizing, remember the four orders:

1. Any immediate threats to safety (ABCs, Maslow) 2. Actual problems for which the client is requesting help 3. Actual or potential problems of which the client may not be aware 4. Actual or potential future problems

The nurse is preparing to delegate client care to all personnel on the medical surgical unit. What factors should the nurse examine when attempting to delegate client care?

A licensed nurse is responsible for providing clear directions when a task is initially delegated and for periodic reassessment and evaluation of the outcome of the task. ● RNs may delegate to other RNs, PNs, and APs. ◯ RNs must be knowledgeable about the applicable state nurse practice act and regulations regarding the use of PNs and APs. ◯ RNs must delegate tasks so that they can complete higher level tasks that only RNs can perform. This allows more efficient use of all members of the health care team. ● PNs may delegate to other PNs and APs Nurses can only delegate tasks appropriate for the skill and education level of the health care team member who is receiving the assignment. ● RNs cannot delegate the nursing process, client education, or tasks that require clinical judgment to PNs or AP.

To AP

Activities of daily living (ADLs) Bathing, Grooming, Dressing, Toileting, Ambulating, Feeding (without swallowing concerns), Positioning, Bed making Specimen Collection Intake and output Vital signs (stable clients)

Disaster Management Tips

Disaster is an event that causes human distress and anguish and demands resources that strain demand. Disasters can be main-made, naturally occurring and/or a combination of both. Role of the Community Health Nurse in Disaster Management includes risk assessments.

Upon admission to a healthcare facility, what are the nurse's responsibilities regarding a living will?

Living will ● A living will is a legal document that expresses the client's wishes regarding medical treatment in the event the client becomes incapacitated and is facing end of life issues. Types of treatments that are often addressed in a living will are those that have the capacity to prolong life. Examples of treatments that are addressed are cardiopulmonary resuscitation, mechanical ventilation, and feeding by artificial means. ● Living wills are legal in all states. However, state statutes and individual health care facility policies can vary. Nurses need to be familiar with their state statute and facility policies. ● Most state laws include provisions that health care providers who follow the health care directive in a living will are protected from liability. NURSING ROLE IN ADVANCE DIRECTIVES ● Providing written information regarding advance directives ● Documenting the client's advance directives status ● Ensuring that advance directives are current and reflective of the client's current decisions ● Recognizing that the client's choice takes priority when there is a conflict between the client and family, or between the client and the provider ● Informing all members of the health care team of the client's advance directives

Delegation Tips

Nurses need to delegate fittingly and review that clients receive safe, quality care by the assigned personnel. The delegating nurse reviews the following factors when assigning tasks and nursing activities: Individual client needs, facility policies, job descriptions, the specific state nurse practice act and professional standards. RNs are responsible for the supervision of client care tasks delegated to licensed practical nurses (LPNs) and to assistive personnel s (APs). The RN must be knowledgeable about the applicable state nurse practice act and regulations LPNs may delegate to other LPNs and AP.

A community health nurse is assigned to a rural and migrant health clinic. What are some issues facing this population and strategies for primary, secondary and tertiary prevention for this population? (Review the Community Health Review Module)

• Hazardous work environment • Poverty status • Inadequate housing • Limited availability of clean water and septic systems • Inadequate healthcare access • Continuity of care issues • Lack of insurance • Cultural and language barriers

List three (3) statements made by the client that will confirm they understand the medication sucralfate for Peptic Ulcer Disease.

-I will make this on an empty stomach at least one hour before meal -I will take it the same time each day -It may take 4-8 weeks for my ulcer to heal

A community health nurse is identifying barriers to health care in her client population. Identify six (6) barriers to health care in a disparaged population?

-Inadequate health care insurance -Inability to pay for health care services -Language barriers -Cultural barriers -Lack of health care providers in a community -Geographic isolation -Social isolation -Lack of communication tools (e.g., telephones) -Lack of personal or public transportation to health care facilities -Inconvenient hours -Attitudes of health care personnel toward clients of low socioeconomic status or those with different cultural/ethnic backgrounds -Eligibility requirements for state/federal assistance program

A nurse is caring for a client with a minor head injury. What are manifestations of increasing intracranial pressure that should be reported to the provider

-Pupils unequal -Confusion -Headache

The charge nurse takes a telephone order for morphine 50 mg IVP every 3 hours. After hanging up the phone, the nurse feels this order is not safe. List three (3) strategies to prevent errors of miscommunication when receiving telephone orders

-Repeat the order to the provider -Confirm order is right -Call the provider back if you think it is unsafe and do not admin the medication

The community health nurse is speaking to a men's civic group about health promotion for men. The question is posed regarding how and when to properly perform testicular self-examination (TSE). What would be the priority information to provide to the group?

-during a physical -possible prostate cancer? (age 45)

A registered nurse (RN) is preparing to delegate client care to a licensed practical nurse (LPN). Identify client care activities that are in the LPNs scope of practice.

A licensed nurse is responsible for providing clear directions when a task is initially delegated and for periodic reassessment and evaluation of the outcome of the task. ● RNs may delegate to other RNs, PNs, and APs. ◯ RNs must be knowledgeable about the applicable state nurse practice act and regulations regarding the use of PNs and APs. ◯ RNs must delegate tasks so that they can complete higher level tasks that only RNs can perform. This allows more efficient use of all members of the health care team. ● PNs may delegate to other PNs and APs TO PN Monitoring findings (as input to the rn 's ongoing assessment) reinforcing client teaching from a standard care plan Performing tracheostomy care Suctioning Checking ng tube patency administering enteral feedings inserting a urinary catheter a dministering medication (excluding i V medication in some states)

An elderly client is being discharged from the hospital to home following a long hospitalization. What are some community resources that the nurse should initiate referrals for this client?

A referral is a formal request for a service by another care provider. It is made so that the client can access the care identified by the provider or the consultant. ● The care can be provided in the acute setting or outside the facility. ● Clients being discharged from health care facilities to their home can still require nursing care. ● Discharge referrals are based on client needs in relation to actual and potential problems and can be facilitated with the assistance of social services, especially if there is a need for: ◯ Specialized equipment (cane, walker, wheelchair, grab bars in bathroom) ◯ Specialized therapists (physical, occupational, speech) ◯ Care providers (home health nurse, hospice nurse, home health aide) ● Knowledge of community and online resources is necessary to appropriately link the client with needed services. The nurse's role regarding referrals ● Begin discharge planning upon the client's admission. ● Evaluate client/family competencies in relation to home care prior to discharge. ● Involve the client and family in care planning. ● Collaborate with other health care professionals to ensure all health care needs are met and necessary referrals are made. ● Complete referral forms to ensure proper reimbursement for prescribed services.

A nurse is planning care for a client who practices Mormonism. What are spiritual rituals and observances a culturally competent nurse can be aware of?

Birth rituals: -Children are baptized at age 8 by immersion. Dietary rituals: -Those practicing Mormonism avoid alcohol, tobacco, and caffeine. Death rituals: -Last rites are given. -Communion is offered. -Burial is preferred

A nurse is preparing to participate in change of shift report. What should be included in this report and where should it be done?

Change of shift report ● Performed with the nurse who is assuming responsibility for the client's care. ● Describes the current health status of the client. ● Informs the next shift of pertinent client care information. ● Provides the oncoming nurse the opportunity to ask questions and clarify the plan of care. ● Should be given in a private area, such as a conference room or at the bedside, to protect client confidentiality

A nurse has administered the wrong medication to a client. What actions should the nurse take now?

Check on the patient to make sure nothing is going wrong with the client. The call the provider and report. ncident reports are records of unexpected or unusual incidents that affected a client, employee, volunteer, or visitor in a health care facility. ● Facilities can also refer to incident reports as unusual occurrence or quality variance reports. ● In most states, as long as proper safeguards are employed, incident reports cannot be subpoenaed by clients or used as evidence in lawsuits. Examples when an incident report should be filed ● Medication errors ● Procedure/treatment errors ● Equipment-related injuries/errors ● Needlestick injuries ● Client falls/injuries ● Visitor/volunteer injuries ● Threat made to client or staff ● Loss of property (dentures, jewelry, personal wheelcha

A nurse is caring for a client with human immunodeficiency virus (HIV) and is concerned about maintaining client confidentiality. What are the components of the HIPPA privacy rule that this nurse should uphold?

Clients have the right to privacy and confidentiality in relation to their health care information and medical recommendations. ● Nurses who disclose client information to an unauthorized person can be liable for invasion of privacy, defamation, or slander. ● The security and privacy rules of the Health Insurance Portability and Accountability Act (HIPAA) were enacted to protect the confidentiality of health care information and to give the client the right to control the release of information. Specific rights provided by the legislation include the following: ◯ The rights of clients to obtain a copy of their medical record and to submit requests to amend erroneous or incomplete information ◯ A requirement for health care and insurance providers to provide written information about how medical information is used and how it is shared with other entities (permission must be obtained before information is shared) ◯ The rights of clients to privacy and confidentiality NURSING ROLE IN CONFIDENTIALITY It is essential for nurses to be aware of the rights of clients in regard to privacy and confidentiality. Facility policies and procedures are established in order to ensure compliance with HIPAA regulations. It is essential that nurses know and adhere to the policies and procedures. HIPAA regulations also provide for penalties in the event of noncompliance with the regulations

A client is being transferred from the hospital to hospice care. Identify three (3) teaching points the nurse should discuss with the client and family about hospice care.

Commitment to delivering quality end of life care. They control pain and discomfort they help the whole family deal with the emotional, social and spiritual aspects of death and dying.

The nurse is providing discharge instructions to a client that has been prescribed ceftriaxone to take at home. What information should nurse provide regarding this medication? (Found in Pharmacology Review Module)

Do not use this medication if you are allergic to ceftriaxone, or to similar antibiotics, such as Ceftin, Cefzil, Keflex, Omnicef, and others. Before using ceftriaxone, tell your doctor if you have liver or kidney disease, diabetes, gallbladder disease, colitis or other stomach or intestinal disorder, if you are malnourished, or if you are allergic to penicillin. Use this medicine for the full prescribed length of time. Your symptoms may improve before the infection is completely cleared. Skipping doses may also increase your risk of further infection that is resistant to antibiotics. Ceftriaxone will not treat a viral infection such as the common cold or flu. Antibiotic medicines can cause diarrhea, which may be a sign of a new infection. If you have diarrhea that is watery or has blood in it, call your doctor. Do not use any medicine to stop the diarrhea unless your doctor has told you to.

A client's wife calls the charge nurse to the room and states she is very angry with the nursing staff because her husband is "not receiving adequate nursing care". What problem solving strategies should the charge nurse use in this situation?

Open communication among staff and between staff and clients can help defray the need for conflict resolution. ● When potential sources of conflict exist, the use of open communication and problem solving strategies are effective tools to de escalate the situation. Actions nurses can take to promote open communication and de escalate conflicts ● Use "I" statements, and remember to focus on the problem, not on personal differences. ● Listen carefully to what others are saying, and try to understand their perspective. ● Move a conflict that is escalating to a private location or postpone the discussion until a later time to give everyone a chance to regain control of their emotions. ● Share ground rules with participants. For example, everyone is to be treated with respect, only one person can speak at a time, and everyone should have a chance to speak.

To LPN's

Reinforcement of client teaching Monitoring client clinical manifestations after the initial RN assessment and evaluation Tracheostomy Care Suctioning Reviewing patency and placement of a nasogastric tube Enteral feeding administration Urinary Catheter insertion Medication administration (excluding intravenous medications - state specific)

Scenario #2 You receive report in the morning and are assigned the following clients. Prioritize the order in which you will assess these clients: A client requesting discharge instructions because his ride home is waiting. A client requesting pain medication. A client who had an episode of urinary incontinence, resulting in urine on the floor next to the bed. A client needing a dressing change for an infected wound.

Scenario #2 Key The order of care should be as follows: 1. A client who had an episode of urinary incontinence, resulting in urine on the floor next to the bed. 2. A client requesting pain medication. 3. A client needing a dressing change for an infected wound. 4. A client requesting discharge instructions because his ride home is waiting. Think Safety first!! The urine spill needs to be cleaned first to prevent an injury from someone slipping and falling. The pain medication should be given before completing the dressing change because the pain is acute, but the wound is already established. Once client care needs are addressed, then teaching can take place.

Scenario #3 You are the nurse on the day shift and the following events are occurring. Prioritize the order in which you would address these issues: The Emergency Department is full and wants to give you a report on a patient being transferred to you unit. A client is experiencing pallor, a heart rate of 42, and has a change in level of consciousness. Lunch trays need to be passed out to your clients. A family member of one of your client's has a question to ask you.

Scenario #3 Key The client experiencing pallor, a heart rate of 42, and changes in the level of consciousness needs to be seen 1st as these symptoms indicate an emergency situation! Remember—ABCs and Safety 1st!! The remaining tasks can be managed by collaboration and delegation: Ask another nurse to take report on the client being transferred from the Emergency Department. This nurse can also speak with the family that has the question to see if she can be of assistance while you deal with an emergency situation. Delegated the passing of the lunch trays to an Assistive Personnel.

Scenario #4 A trash can in a client's bathroom is smoldering from a lit cigarette being thrown away. Prioritize the following nursing Actions: Pull the fire alarm. Get the fire extinguisher, pull the pin, aim at the base of the fire and spray in a sweeping motion at the base of the fire. Remove the client and any visitors from the room. Close the door to the client's room.

Scenario #4 Key 1. Remove the client and any visitors from the room. 2. Pull the fire alarm. 3. Close the door to the client's room. 4. Get the fire extinguisher, pull the pin, aim at the base of the fire and spray in a sweeping motion at the base of the fire. Remember RACE! Rescue the client and any visitors Activate alarm Confine the fire Extinguish the fire

Scenario #5 The following clients arrive at the Emergency Department at the same time. Which order should be used when attending to these clients? An elderly client who fell at home and is reporting hip pain. An elderly client requesting a flu shot. A middle-aged client who is unable to stop the bleeding after cutting her finger while cleaning up broken glass. A young adult who was splashed in the face and chest with a chemical agent.

Scenario #5 Key The clients should be attending to in the following order: 1. The young adult who was splashed in the face and chest with a chemical agent should be seen 1st due to the risk for serious injury related to the chemical agent. 2. The elderly client who fell at home and is reporting hip pain should be seen 2nd because of the potential for severe internal bleeding if the femur is fractured. 3. The middle-aged client with the bleeding finger should be seen 3rd because the severity of bleeding is not as serious as the potential bleeding secondary to a fractured hip. 4. The elderly client requesting a flu shot should be seen last.

After signing an informed consent, the client states, "I can't go through with this, I will not have the surgery!" What is the nurse's responsibility in this situation?

Signing an informed consent form ● The form for informed consent must be signed by a competent adult. ◯ Emancipated minors (minors who are independent from their parents, such as a married minor) can provide informed consent for themselves. ● The person who signs the form must be capable of understanding the information provided by the health care professional who will be providing the service. The person must be able to fully communicate in return with the health care professional. ● When the person giving the informed consent is unable to communicate due to a language barrier or hearing impairment, a trained medical interpreter must be provided. Many health care agencies contract with professional interpreters who have additional skills in medical terminology to assist with providing information

A school health nurse is conducting tertiary education on family violence for displaced children. What education should be included?

TERTIARY PREVENTION ● Establish parameters for long term follow up and supervision. ● Make resources in the community available to survivors of violence (telephone numbers of crisis lines a nd shelters). ● If court systems are involved, work with parents while the child is out of the home (in foster care). ● Refer to mental health professionals for long term assistance. ● Provide grief counseling to families following the death of a family member to suicide or homicide. ● Develop support groups for caregivers and survivors of violence

Which of the following tasks can the RN delegate to an assistive personal? (Select all that apply)Take all vital signs on a patient receiving a blood transfusionAmbulate a client 4 h post-op laparoscopic appendectomyObtain all client's output totals on the nursing unitFeed a newly diagnosed stroke patient with dysphagiaPlace a patient on a bed pan following a spinal tap

TO AP Activities of daily living (a Dls) Bathing grooming Dressing Toileting ambulating Feeding (without swallowing precautions) Positioning routine tasks Bed making Specimen collection intake and output Vital signs (for stable clients

A nurse working in the emergency department has just received four (4) new clients. According to Maslow's Hierarchy how should the nurse prioritize care of these four clients?

The nurse should consider this hierarchy of human needs when prioritizing interventions. For example, the nurse should prioritize a client's: ● Need for airway, oxygenation (or breathing), circulation, and potential for disability over need for shelter. ● Need for a safe and secure environment over a need for socialization. PRIORITY INTERVENTIONS ● First: Airway ◯ Identify an airway concern (obstruction, stridor). ◯ Establish a patent airway if indicated. ◯ Recognize that 3 to 5 min without oxygen causes irreversible brain damage secondary to cerebral anoxia. ● Second: Breathing ◯ Assess the effectiveness of breathing (apnea, depressed respiratory rate). ◯ Intervene as appropriate (reposition, administer naloxone). ● Third: Circulation ◯ Identify circulation concern (hypotension, dysrhythmia, inadequate cardiac output, compartment syndrome). ◯ Institute appropriate actions to reverse or minimize circulatory alteration. ● Fourth: Disability ◯ Assess for current or evolving disability (neurological deficits, stroke in evolution). ◯ Implement actions to slow down development of disability. ● Fifth: Exposure ◯ Remove the client's clothing to allow for a complete assessment or resuscitation ◯ Implement measures to reduce the risk for hypothermia by providing warm blankets and IV solutions and using a heating device if needed

Scenario #1 You receive report in the morning and are assigned the following clients. Prioritize the order in which you will assess these clients: A client needing assistance with feeding due to hemiparesis. A client on a ventilator with a PRN order for tracheal suctioning. A client going to OR for an appendectomy at 0900. A client needing reinforcement of teaching regarding self-administration of insulin.

The order of care should be as follows: 1. A client on a ventilator with a PRN order for tracheal suctioning should be seen 1st—ABCs and Safety! 2. A client going to OR for an appendectomy at 0900 should be seen 2nd to ensure that the procedure is started on time. 3. A client needing assistance with feeding due to hemiparesis can be seen 3rd as hunger and thirst come before teaching according to Maslow's Hierarchy of Needs. 4. A client needing reinforcement of teaching regarding self-administration of insulin can be seen last.

List three (3) expected laboratory results the correlate with the diagnosis of Peptic Ulcer Disease.

WBC FOBT RBC

Risk assessment questions

What are the populations at risk within the community? ¨ Have there been previous disasters, natural or man-made? ¨ What size of an area or population is likely to be affected in a worst-case scenario? ¨ What is the community disaster plan? ¨ What kind of warning systems is in place? ¨ What types of disaster response teams are in place? ¨ What kinds of resource facilities are available in the event of a disaster? ¨ What type of evacuation measures will be needed? ¨ What type of environmental dangers may be involved?