Level II, Exam I transitions

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There are three types of management. Matrix

Combination of both types; this is most commonly seen.

Identify and evaluate priority actions for clients with IV therapy

Monitor the site for redness, pain, or swelling Teach PT not to pull on the port tubing Remember to always use an infusion pump if administering K

Condition: Metabolic Acidosis

Pathophysiology: -DKA, diarrhea, renal failure, shock Signs/Symptoms -Kussmaul respirations (compensatory hyperventilation) -Decreased BP -Muscle twitching -Headache, NVD -Confusion, increased drowsiness -Hyperkalemia Treatment -Treat root cause -Dialysis (if related to renal failure)

Examine the five elements of liability that constitute negligence.

1.) Duty to provide care as defined by a standard -Care that should be given or what a reasonable prudent nurse would do 2.) Breach of duty by failure to meet the standard -Failure to give standard of care that should have been given 3.) Foreseeability of harm -Knowledge that failing to give the proper standard of care may cause harm to the client 4.) Breach of duty has potential to cause harm (combination of 2 and 3) -Failure to meet standard has potential to cause harm (relationship must be provable) 5.) Harm occurs -Occurence of actual harm

Compare and contrast nursing delivery models and their relationship to the roles of healthcare members (Functional, Team, Total Care, Primary, Case Management, Patient-Centered, Collaborative, Pathways) Functional Nursing

Nurses/staff are assigned to groups of tasks; task focused rather than patient focused Pros: cost effective and efficient Cons: fragmented care, absence of a holistic view of patients

Condition: Hypercalcemia

Pathophysiology: -Malignancies, hyperparathyroidism, immobilization Signs/Symptoms -Increased BP, increased PT/Ptt -Acute psychotic behavior, reduced LOC -Deep bone/flank pain -Constipation -Polyuria, thirst, dehydration Treatment -Treat root cause -Give fluids to dilute serum Ca and promote excretion -Restrict dietary Ca intake -IV phosphate and lasix may be given -Calcitonin IM may be used

Discuss potential post-surgical and immobility complications and the nurse's role in preventing them (thromboemboli, pneumonia, atelectasis, wound infection, wound dehiscence, and evisceration) Wound Infection

An invasion of deep or superficial wound tissues by pathogenic microorganisms S/S include warmth, redness, tenderness around the incision; fever and chills, purulent drainage, usually occurs 3-6 days postoperative Increased risk for patients who are chronically obese, or immunosupressed

Differentiate between general and regional anesthesia and concious sedation (therapeutic procedures). GENERAL ANESTHESIA

A reversible loss of conciousness Induced by inhibiting nerve impulses of the CNS Goal is for patient not to feel or remember anything during the procedure Delivered via inhalation, IV, or balanced (combination) routes Four stages -Analgesia and sedation, relaxation: begins with inductin and ends with loss of conciousness --Patient feels drowsy/dizzy,has reduced sensation to pain, and is amnesic --Close OR doors and control traffic, dim lights, positino patient securely with belts, keep discussions about patient to minimum (patient hearing is exaggerated) -Excitement, delirium: begins with loss of conciousness and ends with relaxation, regular breathing, and loss of the eyelid reflex --Patient may have irregular breathing, increased muscle tone, and involuntary movement of the extremities --Avoid auditory and physical stimuli, protect the extremities, assist the anesthesiologist or CRNA with suctioning as needed, stay with the patient -Operative/surgical anesthesia: begins with the generalized muscle relaxation and ends with loss of reflexes and depression of vital functions --Patient cannot hear, their jaw is relaxed, breathing is quiet and regular, and sensation (i.e. to pain) are lost --Assist with intubation, place patient into operative position, prep/scrub patient's skin over the operative site as directed -Danger: begins with depression of vital functions and ends with respiratory failure, cardiac arrest, and possible death --Patient's respiratory muscles are paralyzed, apnea occurs, pupils are fixed and dialated --Prepare for and assist in treatment of cardiac and/or pulmonary arrest; document occurence in the patient chart Risk factors include: -History of malignant hyperthermia (including familial) -Cardiac or respiratory disease, smoking -Gastric contents (risk of aspiration) Complications include: -Malignant hyperthermia: not most common, but most serious -Overdose of anesthetic -Unrecognized hypoventilation -Intubation complications: throat irritation; most common

Explore the purpose of incident reports as well as proper handling and disposition of these reports.

AKA "unusual occurence reports" these are records made of unexpected/unusual incidents that affected a client, visitor, or volunteer in a healthcare facility. -In most states, they cannot be subpoenaed by clients or used as eidence in lawsuits -High reliability organizations/just culture/culture of safety is the goal; they focus on system failures, not finger pointing It is typically directed to the risk management department through the nurse's immediate manager after a 24 hour review by the manager When writing an incident report, the nurse should: -Describe all events objectively and avoid subjective comments -Never note in a patient's medical record that an incident report was filed -Report every unusual occurrence or incident

Examine personal use of organizational skills when providing client care (Maslow, Priority needs, Nursing process, Client preferences) Nursing Process

Assessment -Comes first when prioritizing -With life threatening conditions, may occur concurrently, be very focused or partial -Includes collecting, verifying, clustering/organizing data, and analyzing Diagnosis -High, medium, low priority -High priority: life threatening -Medium priority: unhealthy consequences -Low priority: makes no negative difference if not attended to Planning -Prioritize diagnoses and establish realistic goals -Consider patient preferences Implementation -Prioritize nursing interventions Evaluation -Determine effectiveness and success of planning/time management

Identify time savers and time wasters that support or interfere with good time management. Time Savers

Avoid "stacked desk" syndrome (keep workspace clear) Practice "no detourism" to organize the mind -Concentrate on one activity at a time -Undertake and complete one activity at a time -Complete the task correctly the first time Learn the art of "wastebasketry" aka the TRASH approach, or "do it, delegate it, or dumpt it" -T: Throw it away -R: Refer it to someone else -A: Act on it -S: Save it -H: Halt it (for example, stop junk mail from coming to you)

Examine various career paths that can promote career advancement through degree completion.

BSN: some specialty areas, some management, and admission into Master's programs MSN: educators, administrators, nurse practitioners, managers, most specialty areas CNL: clinical nurse leader; a leader in the health care delivery system with expertise in quality improvement and cost-effective resource utilization PhD: researchers, educators DNP: considered preparation for contemporary advanced nurse practitioners

Blood's inability to clot; may be internal or external (suture leak, nicked vessel, body's inability to clot) S/S are the same as hypovolemic shock: low BP, weak/rapid pulse, cool/clammy skin, rapid breathing, restlessness, reduced urine output Increased risl for patients with coagulation disorders Priority actions: -Apply pressure (n/a if blood is abdominal); STOP the bleeding -Increase IV vluids and page teh surgeon STAT

Explain the use of proper channels of communication for managing practice and client related issues (Chain of Command, SBAR, Reporting, Boundaries)

CHAIN OF COMMAND -Starting at the bottom and working your way to the top -Example: Staff RN>Charge Nurse>Head Nurse/Nurse Manager>Nursing Supervisor>Department Director>CNO SBAR -A communication tool used to report patient problems, conditions, concers, and to guide care --Situation: admitting and secondary diagnosis and the problem your patient is having --Background: pertinent medical history, previous lab tests and treatments, psychological issues, allergies, current code status --Assessment: significant finding from head to toe assessment, recent vital signs, current treatment measures, restrictions, recent lab results and diagnostics, pain level --Recommendation: suggest a plan of care and request orders and other relevant needs CUS -Developed by a DoD; can be a "STOP," seeks to improve patient safety --I am Concerned/I need Clarity --I am Uncertain/Uncomfortable --I have a Safety concern REPORTING -Can be oral, written, or electronic -Used at shift change -Establishes general goals -Aids in making assignments (determines who can perform, plans for continuity) -Provides central and evaluative information BOUNDARIES -It is important to maintain professional boundaries

Differentiate between assertive, passive, aggressive, and passive-aggressive communication. AGGRESSIVE COMMUNICATION

Claims basic rights in a way that violates others' well-being Commanding, dominant, superior attitude Makes accusation that blame or put down others Conveys dominance and inclination to start quarrels or fights An aggressive speaker: -Uses anger, guilt, or hurt -Wants their way excessively and/or immediately -Is honest to a fault; a bully

Collapse of alveoli caused by obstruction due to mucus plugs, hypoventilation, inadequate tidal volumes; alveoli are not able to expand and fill with air S/S may not be present, but may include elevated respiratory rate, dyspnea, fever, crackles over affected lung areas, productive cough Greater risk in patients with upper abdominal surgery who have pain during inspiration and repress deep breathing Priority actions include: -Incentive spirometry (measures lung capacity), TCDB (turn/cough/deep breath), broncoscopy -Assess breath sounds, respiratory effort, O2 sat, vital signs

Differentiate between assertive, passive, aggressive, and passive-aggressive communication. PASSIVE-AGGRESSIVE COMMUNICATION

Combines the worst communication styles May appear honest but undermines others Avoids direct confrontation A passive aggressive speaker: -Uses gossip, manipulation and other people to get what they want

Identify cautions that should be considered regarding computer-based communication

Computer-based communication lacks nonverbal cues It can often be retrievedeven after it's been deleted Clarification is important to ensure that the correct message is received

Discuss the relationship of decision making and problem solving to clinical judgement.

Decision making and problem solving go hand in hand and require clinical judgement Problem solving in nursing incorporates critical thinking, meaning we add creativity and professional judgement to the situation This maintains both the art and science of nursing The problem solving process is similar to the nursing process 1.) Data gathering (Assessment) 2.) Definition of the prooblem (Diagnosis) 3.) Identification of the alternative solutions (Planning) 4.) Implementation of plan (Implementation) 5.) Evaluation of solution (Evaluation)

Review guidelines for appropriate and effective delegation to other LPN/LVNs and unlicensed personnel.

Delegation is the transfer of responsibility for the performance of a task from one individual to another while retaining accountability for the outcome The nurse must delegate a task within the guidelines established by the scope/standards of practice as outline in the Nurse Practice Act Within that, a nurse may delegate a task based on -Potential for harm -Stability of the patient's condition -Complexity of the task -Predictability of the outcome -Abilities/competencies of the staff to whom the task is delegated The Five Rights of Delegation are: -Right Task: delegated tasks must conform to established guidelines -Right Person: one who is qualified and competent -Right Circumstance: task does not require independent nursing judgement -Right Communication/Direction: clear explanation about the task and outcomes, and when the delegatee should report back to the nurse -Right Supervision/Evaluation: feedback to assess and improve the process; evaluate patient outcomes

Describes care that is respecful and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions

Differentiate between assertive, passive, aggressive, and passive-aggressive communication. PASSIVE COMMUNICATION

Is influenced or acted upon without acting in return Avoids confrontation or conflict; is indirect, wants you to guess what they need Is dishonest by not being open A passive speaker: -Uses apologetic words with hidden meanings -Seems disconnected, fails to say what they mean -May sacrifice their own needs/wants because they feel unworthy

Condition: FLuid Volume Excess

Pathophysiology: -Latrogenic (treatment induced) or heart/liver/kidney failure; excessive use of salt or Na-containing fluids Sigs/Symptoms: -Weight gain (3+ lbs in 2-5 days) -Increased urinary output and edema -Increased venous pressure/engorgement -Increased respirations -Tachycardia, high BP -Enlarged liver or spleen -Low HCT, BUN, and Na values Treatment -Restrict fluid -Promote excretion -Administer diuretic -DC fluids -Daily restriction of Na -Monitor for changes -Elevate extremities

Compare and contrast the torts of false imprisonment, assault, battery, ethical/legal practice/invasion of privacy, and defamation. Intentional Torts

Direct violation of a person's legal rights; plaintiff does not have to prove that the nurse breached duty or was negligent; consequences include fines and damages but may be elevated to criminal charges A nurse should ask the patient's permission before initiating any procedure and should document permission granted, particularly for procedures of an invasive nature Assault: causing a person to fear that he or she will be touched without consent Battery: the unauthorized touching or the actual harmful oroffensive touching of a person and may rise to the level of a crime Defamation: libel (written, as in medical notes); or slander (spoken, as in talking about patients in public areas) False imprisonment: unlawful restraint or detention of another person against his or her wishes; nurse has no authority to detain a patient even if there is likelihood of harm or injury Invasion of privacy: person's private affairs (including health history or status) are made public without consent; nurse has a legal and ethical duty to maintain patient confidentiality Intentional emotional distress: nurse's behavior is so outrageous that it leads to the patient's emotional shock

Identify time savers and time wasters that support or interfere with good time management. Time Wasters

External -Telephone interruptions or drop-in visitors -Socilizing and social media Internal -Lack of self discipline -Failure to delegate -Procrastination/indecision -Perfectionism

Examine the process for obtaining licensure and requirements for renewal such as continuing education

Florence Nightingale started the first registry in 1860 to provide institutions and clients with the means to ascertain the skills and knowledge of graduate The process of licensure requires: -Application for initial licensure to one state -Proof of nursing program completion (transcript) -Criminal background check -Registration for and succesful completiong of NCLEX-RN -State verification of license 29 states require 10-30 hours of continuing education for license renewal

Formation of blood clots in deep veins, usually in legs (sometimes arms) and due to immobility S/S include "hot spot" on the leg; cramping, redness, warmth, or edema at site Great risk if patient is over 40 yo, obese, has a history of varicose veins, blood clots, or PE, or is ortho, urologic, OBGYN, or neurosurgery patient Priority actions: -Notify surgeon so scan can be performed for diagnosis -Anticoagulants, pain meds -Bed rest with elevated limb above heart level (don't want to dislodge it) -Early ambulation and antiembolitic stockings or devices for prevention -Heat PRN: do NOT rub or massage area -Monitor labs (clotting time); color, temp, pulses of extremity every 8 hours or as ordered; measure calf circumference every 8 hours (most likely to occur in calf) -Patient education

Review HIPAA regulations and their relationship to proper maintenance of medical records and client information.

HIPAA: Health Insurance Portability and Accountability Act of 1996 -Ensures confidentiality of a patient's medical records -Set guidelines for maintaining the privacy of health data Any institution that collects/stores protected health information (PHI) is required to: -Name a privacy officer, provide employee training, and implement HIPAA policies and procedures Access to PHI is only for those employees who need to know Violators will be subject to criminal penalties and civil monetary penalties

Examine personal use of organizational skills when providing client care (Maslow, Priority needs, Nursing process, Client preferences) Priority Needs

High Level -Life threatening --Require immediate attention; ABCs Intermediate Level -Important but not life threatening --Pain, mental status change, signs/symptoms of infection, other patient safety Low Level -Need to be addressed according to resources --Disease management education, other health issues Other factors that may impact priorities -Principles of infection control -Cognitive or mobility impairments -Family/caregiver presence

Differentiate between hypovolemia and dehydration

Hypovolemia: fluid volume defivit; when present alone, serum levels remain unchanged -Hypovolemia will activate all regulatory systems Dehydration: loss of water with elevated serum K levels

Determine how to effectively organize a clinical day.

Identify tasks, obligations, and activities (especially timed, as in meds) and write them down Prioritize according to importance Break down big tasks into more manageable tasks Work on the most important tasks first, and delegate when possible Cross tasks off as they're done Avoid accepting assignments beyond your capabilities Avoid the need to be perfect; control work interruptions Evaluate how effectively time was used

Examine personal use of organizational skills when providing client care (Maslow, Priority needs, Nursing process, Client preferences) Client Preferences

If the nurse and the patient have different goals in mind, the care plan may be inappropriate. It's important to look at the client from a holistic perspective

Inflammation of alveoli caused by infectious process S/S include fever, chills, productive cough, chest pain, purulent mucus, dyspnea Increased risk due to smoking or upper respiratory infection, immobilization

Examine the role that institutional policies and procedures play in establishing standards for client care.

Institutional policies and procedures establish the standard of practice for employees They give detailed information about how the nurse should respond to or provide care in specific situations while performing client care procedures Helps protect the nurse if that standard of care still results in injury Nurses must be familiar with and adhere to their institution's policies and procedures

Differentiate between general and regional anesthesia and concious sedation (therapeutic procedures). Moderate/Concious Sedation

Involves IV administration of sedatives/analgesics May be administered by MD, CRNA, and specially trained RNs Continually assess vitals (RN ensures that anesthesiologist is monitoring these) Unlike general anesthesia, patient can breathe on their own

Discuss strategies for soliciting accurate and reliable information from Internet sources and transforming that information into practice.

Is the website open access? -If anyone can add information, no matter how legitimate it looks, it's unreliable Who is the author? -Name, credentials, authority on the subject What is the website's affiliation? -.edu, .org, .gov, .mil are generally reliable; .com and .net are not What are the website's characteristics? -Objectivity: clear purpose, factual and primary information, reputable sponsor -Accuracy: look for documentation and references; compare sources -Currency: look for dates; compare last update with current literature -Usability: site should be well-designed, stable, easy to use; content should be error-free and readable by the intended audience

Describe the two main regulators of acid-base balance in the body.

Lungs: control CO2 and convert H2CO3 into carbonic acid -Respiratory buffer response --Metabolic acidosis: increased respirations to eliminate CO2 --Metabolic alkalosis: decreased respirations to retain CO2 Kidneys: excrete or retain bicarbonate (HCO3) -Acidosis excrete H+ through urine and retain bicarb -Alkalosis: retain H+ and excrete bicarb through urine

Identify the various levels of nursing management (upper, middle, lower) by differentiating between leadership and management. There is a difference between leadership and management.

MANAGEMENT -Assigned or appointed role -"Official" -Problem-oriented process -Focus is on meeting business or financial goals -Involves planning, organizing, directing, and controlling LEADERSHIP -Self-selected/assumed role -Typically self evident -It's a way of behaving, the ability to cause others to respond differently -A leader influences others to accomplish goals -It may be formal or informal; it's an important aspect of effective management -Three types of leaders include autocratic, democratic, and laissez-faire

Identify the responsibility of the nurse in relation to mandatory reporting

Mandatory reporting is required in the following situations: -Child abuse (in all 50 states plus DC) -Elder and vulnerable adults abuse -Unsafe/impaired peers: patient safety first; follow your facility's chain of command -Compliance breaches (i.e. Medicaid fraud or unlawful restraint) -Communicable diseases (to the CDC and state Department of Health) -Gun shot wounds -Near misses of Sentinel Events

Compare and contrast the torts of false imprisonment, assault, battery, ethical/legal practice/invasion of privacy, and defamation. Unintentional Torts

Negligence: conduct that falls below the standard of care; "Failure to use the degree of care that a reasonable person would use under the same or similar circumstances" Malpractice: professional negligence

Recognize alterations in the laboratory values of electrolytes, arterial pH, CO2, HCO3, and O2 indicative of respiratory and metabolic acidosis or alkalosis.

Normal lab values for Electrolytes: -Sodium (Na): 136-145 -Potassium (K): 3.5-5.0 -Calcium (Ca): 9.0-10.5 -Magnesium (Mg): 1.3-2.1 -Phosphorous (P): 3.0-4.5 Normal lab values for ABGs -pH: Acidosis < 7.35-7.45 < Alkalosis -CO2: Alkalosis < 35-45 < Acidosis -HCO3: Acidosis < 21-28 < Alkalosis Remeber ROME (Respiratory Opposite, Metabolic Equal)

Nurse assumes responsibility for a patient or group of patients during their entire hospital stay; developed in the 1960s; common in home nursing Pros: more individualized care, autonomy, and improved collaboration between nurses and health care providers, provides continuity Cons: sometimes cost, requires a strong working relationship with associate nurses

Nurse assumes total care for a patient or group of patients during the shift; oldest model of nursing, developed circa the Nightingale era Pros: holistic, continuity during assigned shift, high patient satisfaction Cons: cost prohibitive, shift-based focus, and lacks long-term continuity

Determine communication skills/strategies needed when interacting with clients, families, subordinates, and peers (Openness, Empathy, Supportiveness, Positiveness, and Equality)

OPENNESS -Feelings and thoughts are stated directly and honestly -No attempt is made to hide or disguise the real object of disagreement EMPATHY -Feeling what the other person is feeling; seeing the situation as they see it -Entails believing that the other person's feelings are valid, legitimate, and justified SUPPORTIVENESS -Feelings are expressed with spontaneity rather than with strategy -Requires flexibility and a willingness to change personal opinions and positions POSITIVENESS -Entails capitalizing on agreements and using them as a basis for approaching disagreements and impasses -Conflict is viewed as positive -Individuals express positive feelings for each other and the relationship EQUALITY -All participants in the process are equal; respect for individual differences is apparent -People are comfortable expressing themselves freely and openly OTHER POSITIVE COMMUNICATION STRATEGIES -Use "I" messages to reduce feelings of defensiveness -Establish eye contact to demonstrate undivided attention (but be culturally sensitive) -Keep promises; if unable, thoroughly explain why -Express empathy to fully understand the patient's feelings and needs -Use open communication, with open-ended questions and statements -Be aware of body language (use an open stance, lean in towards patient to listen) -The most important communication skill is listening

Occurs when a dislodged blood clot that lodges in a pulmonary artery S/S include dyspnea, chest pain, dysrhythmias, diaphoresis, cyanosis, anxiety, restlessness, complete blockage can result in sudden death Increased risk for patients who are immobilized, have circulatory or coagulation disorders, or who have pelvic or abdominal cancer surgeries

Condition: Hypomagnesemia

Pathophysiology -Alcoholism is the #1 cause; also diarrhea, fistulas, NG suction, and any small bowel disruption Signs/Symptoms -Increased BP and HR -Hyperactive DTRs -Delirium, psychosis, seizures -Laryngeal stridor -Positive C&T signs Treatment -Dietary changes to include: green leafy vegetables, nuts, seeds, legumes, whole grains, seafood, peanut butter -Mg may also be given orally or IV via infusion pump

Condition: Hypophosphatemia

Pathophysiology -Increased urinary excretion or decreased intestinal absorption; severe protein-calorie malnutrition, overabundance of simple carb intake, chronic alcoholism Signs/Symptoms -Seizures, respiratory failure -Increased risk of infection -Tissue hypoxia -Muscle weakness, paresthesias, leg cramps -Bone pain Treatment -Goal of treatment is prevention -Oral or IV replacement, use caution with IV

Condition: Hyperphosphatemia

Pathophysiology -Renal failure; also, increased intake, decreased output, shift from ICF to ECF Signs/Symptoms -Tachycardia -Skin nodules -Soft tissue calcification of heart (leading to MI/stroke), lungs, kidneys (renal failure) -S/S of hypocalcemia Treatment -Treat underlying disorder -Restrict dietary intake (dairy products, protein/meats/beans, nuts/seeds/whole grains) -Loop diuretics -Fluid replacement with NS -Dialysis -Calcitrol may be used to bind phosphorous in the GI tract

Condition: Hypermagnesemia

Pathophysiology -Usually caused by renal failure; also untreated DKA, Addison's disease, excessive use of antacids, laxatives, opiods or anticholinergics, and lithium toxicity Signs/Symptoms -Decreased BP and HR -Hypoactive DTRs -Cardiac arrest and coma -Depressed respirations -Flushing Treatment -Do not give Mg to PTs in renal failure -Loop diuretics, NaCl, or LRs can be given to encourage excretion -IV calcium gluconate can be used to reverse effects in emergency situations (always have available for pregnant women on Mg for PIH)

Condition: Hyperkalemia

Pathophysiology: -Decreased renal excretion, rapid administration of K, movement of potassium from ICF (intracellular fluid) to ECF (extracellular fluid) compartment Signs/Symptoms: -Low BP and dyrhythmias -Abdominal cramps, diarrhea -Decreased muscle strength; tingling and muscle twitchees -Flaccid paralysis -Irritability and anxiety -Cardiac arrest possible if >7 mEq/L Treatment: -EKG; continually monitor -Loop diuretics -Reduced dietary intake -Peritoneal or hemodialysis for renal failure -Kayexalate PO or enema -IV sodium bicarb in dangerously high situations

Condition: Hypokalemia

Pathophysiology: -Diarrhea, prolonged intestinal suctionng, recent ileostomy, intestinal tumors, unbalance diet Signs/Symptoms: -Irregular pulse, low BP -Cardiac dysrhythmias -Polyuria and renal issues -Paresthesias and leg cramps -Constipation Treatment: -Dietary changes to include: salt substitutes, bananas, cooked dried beans, fruit juice, milk, meat, eggs, baked potatoes, coffee, tea, cocoa -Oral or IV replacement (use great caution and constant heart monitoring)

Condition: Fluid Volume Deficit

Pathophysiology: -Diarrhea, vomiting, diuresis, hemorrhage or blood loss, burns, sweating, insufficient intake, fluid loss to the third space Signs/Symptoms: -Weight loss >5% -Decreased urinary output and thirst -Rapid pulse, low BP -Dry mucus membranse -High than normal HCT and BUN -Urine specific gravity >1.030 Treatment: -Replacement with isotonic then hypotonic fluids -Electrolyte replacement -Treat underlying -Note: Hypovolemia is always secondary to the total body Na

Condition: Hypernatremia

Pathophysiology: -Fluid deprivation, diabetes, IV hypertoonic fluids, heat stroke, hemodialysis malfunction, near drowning in sea water Signs/Symptoms: -Rapid pulse, high BP -Sticky mucus membranes -Thirst, edema, decreased LOC -Neuro (seizures, brain damage if falls below 110) -Circulatory overload Treatment: -Decrease Na intake -Promote Na excretion with diuretic -Monitor I&O and daily weight

Condition: Respiratory Alkalosis

Pathophysiology: -Hyperventilation, or mechanical ventilation set too high Signs/Symptoms -Deep, rapid breathing -Decreased/normal BP -Tachycardia -Numbness, tingling of extremities -Lethargy, confusion, dizziness, N/V, hypokalemia Treatment: -Treat root cause -Breath in paper bag -Monitor closely for respiratory muscle fatigue; respiratory failure may occur

Condition: Respiratory Acidosis

Pathophysiology: -Hypoventilation, drug overdose (opiods), chest trauma, pulmonary edema, airway obstruction Signs/Symptoms -Rapid, shallow respirations -Decreased BP -Dysrhythmias -Muscle weakness -Headache, dizziness -Hyperkalemia Treatment -Treat root cause -Supplemental O2 -Pulmonary hygiene -Increase ventilation -Provide hydration

Conditions: Hypocalcemia

Pathophysiology: -Primary and surgical hypoparathyroidism, renal failure, inadequate vit D consumption, madnesium deficit, alkalosis, alcohol abuse. Signs/Symptoms: -Hyperactive DTRs -Seizures -Numbness and tingling in the hands and feet -Impaired clotting time; decreased prothrombin -Positive C&T signs Treatment: -IV admin of calcium gluconate -During IV replacement, client must remain on bed rest and BP monitored due to postural hypotension -Rapid infusion can cause cardiac arrest -Use caution if client is on digitalis because Ca can cause digoxin toxicity

Condition: Metabolic Alkalosis

Pathophysiology: -Severe vomiting, excessive GI suctioning, diuretics, excessive sodium bicarbonate or antacids Signs/Symptoms -Compensatory hypoventilation -Tachycardia, dysrhythmias -Restlessness, lethargy -Confusion (decreased LOC, dizzy, irritable) -NVD -Tremors, muscle cramps, tingling of fingers/toes -Hypokalemia Treatment: -Treat root cause

Condition: Hyponatremia

Pathophysiology: -Vomiting, diarrhea, diaphoresis, use of diuretics, low Na diet, deficiency of aldosterone, replacement of water but not electrolytes Signs/Symptoms -Rapid pulse, low BP -Dry skin and mucosa -Muscle cramps -Neuro (seizures, convulsions) -Orthostatic hypotension Treatment -Increase dietary intake -Replace water intake with juice or boullion -Replace Na using NS (0.9%) or 3%

Differentiate between the various phases of the surgical experience (pre, peri, and postoperative) and identify the role of the nurse in each of these phases (Assessment, Safety, Teaching, Positioning) POSTOPERATIVE PHASE

Physical qualifiers for discharge -Stable vital signs, AAOx4 -Uncompromised pulmonary function -Pulse ox at 93-100% or baseline -Urine output of at least 30 mL/hr -No nausea/vomiting (or under control) -Minimal pain Other discharge requirements -Give verbal and written instructions and information about follow up care -Responsible adult should accompany the patient and d/c instructions given to them as well -Give patient copies of all instructions, information, and give written original prescriptions to them

List the responsibilities of the nurse when caring for a client in the immediate pre- and postoperative period (Physiological Integrity, Reduction of Risk Potential)

Physiological integrity (contributes to reduction of risk potential) Nurse responsibilities in the preoperative period include: -Use knowledge of physiology and behavioral principles to describe an accurate and complete preoperative assessment -Evaluate personal factors that increase the patient's risk for complications during and immediately after surgery -Evaluate laboratory values for changes that may affect the patient's response to drugs, anesthesia, and surgery -Apply antiembolic stockings, sequential compression boots, or other devices to reduce or prevent vascular complications Nurse responsibilities in the intraoperative period include -Assess patients for specific problems related to positioning during surgical procedures -Understand anatomical principles for modifying patient positioning and OR bed padding to prevent skin breakdown. promote comfort, and prevent positioning injury during surgical procedures -Coordinate appropriate care for the patients with malignant hyperthermia Nurse responsibilities in the postoperative period include: -Perform ongoing head-to-toe assessment of postoperative patient -Prioritize nursing interventions during first 24 hours -Monitor for complications of shock, respiratory depression, or impaired wound healing -Assess patient's level of pain and evaluate his/her responses to coordinated pain management strategies -Evaluate surgical incisions and wounds for complications -Collaborate with health care team members to perform emergency care procedures for dehiscence or evisceration

Examine personal use of organizational skills when providing client care (Maslow, Priority needs, Nursing process, Client preferences) Maslow's Hierarchy of Needs

Physiological: breathing, food, water, sex, sleep, homeostasis, excretion Safety: security of body, of employment, of resources, of morality, of family, of health, of property Love/Belonging: friendship, family, sexual intimacy Esteem: self-esteem, confidence, achievement, respect of others, respect by others Self Actualization: morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts

Identify time savers and time wasters that support or interfere with good time management. Planning

Planning is the most important step of time management; 1 minute of planning = >10 minutes of productivity. Plan and prioritize tasks based on: -Urgency of situation, demands of others -Closeness of deadlines and the existing timeframe -Degree of familiarity and easiness of the task -Amount of enjoyment involved -Size of the task and congruence with personal goals

Identify the various levels of nursing management (upper, middle, lower) by differentiating between leadership and management. Nurses also need to develop the following leadership skills:

Planning: concept maps, goal planning Organizing: gathering equipment/supplies, time management Directing/Leading: patient education; asking others (CNAs, etc.) for help Controlling: evaluations, care maps

Recognize the indications for administration of potassium supplements, Kayexalate, and sodium bicarbonate.

Potassium supplements -Given in the case of hypokalemia that is not resolved by dietary changes -Must be given via infusion pump with continuous cardiac monitoring Kayexalate -Given in the case of hyperkalemia -PO or enema (enema preferred) Sodium bicarbonate -Given in the case of hyperkalemia -IV infusion pump -Used in most urgent hyperkalemic situations as IV is the fastest route of administration

Predetermined multidisciplinary treatment plans (similar to CORE measures, but can be specific to the hospital or organization). Often used in a case management setting

Differentiate between assertive, passive, aggresive, and passive-aggressive communication. ASSERTIVE COMMUNICATION

Pronounces one's own basic rights without violating others States wants, needs, desires, and feelings with objective and direct comments Connotes style of positive declaration and confidence Incorporates active listening and reflective feedback Takes time and effort to develop, but is the preferred communication style for nurses An assertive speaker: -Is sure of the facts -Carefully considers the options -Exudes confidence

Protrusion of internal organs and tissues through incision occuring 6-8 days postoperative; develops following dehiscence Priority actions: -Notify MD STAT -Cover with a sterile dressing (gauze, NOT cotton ball or 4x4) or towel moistened with warm sterile saline -Hold by hand to keep tissues from "spilling" -Have patient flex knees and keep patient calm and quiet -Reassure patient and family

It is important to differentiate between responsibility, authority, and accountability.

RESPONSIBILITY: the duties and activities that an individual is employed to perform. AUTHORITY: the official power to act in areas in which an individual has been given and accepts responsibility. ACCOUNTABILITY: liability; individuas being answerable for their actions. Requires follow up and analysis of your past decisions.

Differentiate between general and regional anesthesia and concious sedation (therapeutic procedures). PACU Protocols

RN should monitor: -Vitals, pain, LOC/mental status, IV site, respirations, incision site, cardiac monitor, ROM/sensation Other RN duties -Provide warm blankets -Manage nausea/vomiting, BP, output -Keep HOB elevated if not contraindicated -Verbal stimulation (ensure that we can arouse them) -Initiate postoperative orders -Continual assessment

RN, LPN, and CNA are assigned to a group of patients Pros: high quality, team input Cons: lack of continuity, requires strong leadership, team leader typically is not able to spend much time with patients and it is still task focused

Requires an RN to maintain responsibility for patient care from admission to after discharge; RN is respinsible for acute care in the hospital and then follows the patient after discharge Pros: cost-effective, efficient in planning discharge, multidisciplinary collaboration, focus on patient's complex health needs

Risk factors: -Obesity, amputation, altered mental status, elderly, certain surgeries Potential complications: -Pneumonia -Thrombophlebitis -UTI or constipation -Decubitus -Contractures Treatment -ROM and turn every 2 hours -Pulmonary therapy, antithromboembolitic devices (TED hose) -Increase fluid intake; good nutrition (fiber, protein, vitamin C) -Good skin care and hygiene -Foam mattresses, padding of bony prominences

Review organizational resources and proper solicitation of these resources when issues are related to safe, ethical, and legal nursing practices arise. Resources available to nurses to assist with legal issues include the following:

Risk managers Human resources Compliance officer Privacy officer Supervisors/Organizational chart Advisory boards Medical directors Hospital attorney Security plan

There are three types of management. Centralized/Tall

Senior managers make decisions, those further down have little input.

Identify the various levels of nursing management (upper, middle, lower) by differentiating between leadership and management. Nurses need to develop the following leadership skills:

Technical Skills: clinical expertise and nursing knowledge People/Human Skills: ability to work effectively with people in a leadership role Conceptual Skills: Ability to understand the complexities of the overall organization, and see how your area of management fits in.

Discuss the legal and ethical issues related to ensuring informed consent.

The SURGEON obtains the informed consent, which should describe: -The treatment/procedure completely -Who will be participating in the treatment -Potential harm, pain, or discomfort -Alternative options -The right to refuse treatment The CLIENT gives informed consent; they must: -Give voluntary consent -Be competent and of legal age or be an emancipated minor, or the guardian/authorized person must give consent -Receive enough information to make a decision based on an understanding of expected The NURSE witnesses informed consent; they must: -Ensure that the surgeon gave the client the necessary information -Ensure the client understood the information -Have the client sign the document -Notify the surgeon if the client has any questions or concerns -Document; record use of interpreter, if used

Determine the focus of quality improvement and how it relates to safe, quality client care and promotes ethical and legal practice.

The focus of quality improvement is on providing care that is: -Safe: preventing injuries to patients from the care that is intended to help them -Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care -Effective: providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit -Efficient: preventing waste, including waste of equipment, supplies, ideas, and energy -Equitable providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions National Patient Safety Goals increase patient safety CORE Measures: standardized sets of valid, reliable, and evidence-based quality measures used by The Joint Commission to integrate performance measures into the accreditation process and overall quality improvement processes CMSs hospital/nursing home/home health/physician compare -Ex. Medicaid hospital compare quality of care TJC Sentinel Event reporting -Root cause analysis -Used to determine systems failures to prevet future occurrences Eliminate never events -Medicare and insurances won't pay for hospital-acquired infections

Discuss the role of health care providers in obtaining informed consent.

The health care provider has the duty to disclose the following information to a patient prior to a procedure: -The nature of the therapy or procedure -Expected benefits and outcomes -Potential risks -Any alternative tratments available The nurse's role is: -Have the client sign the consent forms -If nurse has reason to believe that the patient hasn't given informed consent, the provider should be immediately notified -In no case should the nurse ever attempt to convey the information required for informed consent

Determine how a state's nurse practice act determines the scope of practice of RNs, LPN/LVNs, and unlicensed personnel (purpose, limitations, mandatory requirements)

The main function of a state's NPA is to protect -Protects the health and safety of citizens -Protects the RNs license The NPA defines the scope of practice and limitations within which nurses operate -Defines the term "nurse" -Describes personal nursing functions -Lists standards of competent performance, as well as misconduct/prohibited practices -Explains grounds for disciplinary action and the fines/penalties the board may levy It also contains... -Licensure and renewal requirements -Mandatory continuing education guidelines, if applicable -Criminal background check requirements -Delegation guidelines -NLC (compact) rules (currently 24 states with more pending legislature) It is an example of "sunset legislation" meaning it must be reviewed and republished by a specified date

Discuss the staff nurse's responsibilty related to rejecting unsafe assignments.

The nurse is accountable for the outcomes of his/her actions in carrying out nursing duties Some states have mandatory staffing and overtime laws Follow the chain of command, use assertive communication Be clear as to your competencies and document

The partial or complete separation of wound edges; caused by malnutrition, obesity, preoperative radiation to surgical site, old age, poor circulation to tissue, unusual strain on suture line S/S are increased drainage and appearance of underlying tissues 6-9 days postoperative Priority actions: -Notify MD, but it's not urgent

Discuss how lifelong learning is necessary to maintin practice that is current and protects the welfare of clients.

The science of nursing is growing rapidly; therefore, there will always be new evidence for you to apply in practice To learn, you must be flexible and always open to new information With application of knowledge gained from additional clinical experiences, you will become better at forming assumptions, presenting ideas, and making valid conclusions With experience, you will be better able to anticipate each new patient's needs, and recognize problems when they develop

An organizational chart is:

The structure of communication and authority used by an organization or facility. The chart defines lines of communication, authority, responsibility, and supervision.

This is the phase in which surgery occurs Classification of procedures -Urgency: Is the surgery elective or urgent? -Degree of risk: How invasive is it? Do benefits outweigh risk? -Purpose: Why are we doing this? Can it wait, and if so, how long? Positioning -Supine (flat on back) -Lithotomy (supine with legs in air) -Trendelenburg (on back, legs tilting down at the knee) -Lateral (on the side) -Jacknife (hands and knees with arms out to the side) -Prone (on belly) Correct site/time out -Stop; make sure everyone knows each other and what they are doing -Applicable for all procedures, not just surgery

This is the phase in which the patient is prepared for surgery. Assessment should include: -Age, general health, family history -Existing drug/therapy use --Tobacco, alcohol, illicit substances --Current medications --Complementary/alternative therapies (herbal, holistic, etc) -Medical history --Lung/respiratory condition (hx of asthma, etc.) --Prior surgical procedures and how they were tolerated --Prior experience with anesthesia, pain control, nausea/vomiting --Blood donation --Allergies (especially latex) -Patient preparedness --Type of surgery planned --Knowledge about/understanding of surgery process --Adequacy of patient support system Safety -Understand patient needs and situation

There are three types of management. Decentralized/Flat

Those who are the most knowledgeable make the decisions; nurses are closely involved with patient care decisions.

Understand the importance of trust among nurses, clients, and interdisciplinary team members.

Trust is essential to effective communication -It requires openness on the part of the nurse -It demonstrates honesty, integrity, and dependability Trust is achieved by: -Communicating clearly in a language the laypersons can understand -Protecting confidentiality -Avoiding negative communication techniques -Being available to the individual

Determine the rolse of the nurse in establishing and maintaining a "do not resuscitate" or "allow natural death" status for a client.

Unless a DNR or AND is written, the nurse should initiate CPR when a client has no pulse or respirations DNR/AND should be placed in client's medical record Client's decision is respected in regard to the use of antibiotics, initiation of diagnostic tests, and provision of nutrition by artificial means The nurse is responsible for: -Providing written info regarding advanced directives -Documenting the client's advanced directive status -Ensuring advanced directives are curent and reflective of client's current care decisions -Informing all members of the healthcare team of the client's advanced directives

Identify the various levels of nursing management (upper, middle, lower) by differentiating between leadership and management. Within the three levels of nursing management, responsibility and authority increases with each level. Accountability, by contrast, remains equal and prominent in all three.

Upper level: Chief Nursing Officer (CNO), Director Middle level: Unit manager Lower level: Charge nurse

Peri-Operative Pharmacologic Interventions Medication: Agonists-Antagonists Opiods Examples: Pentazocine, Stadol, Nubain

Uses/Actions -Given as an opiod mixed with an opiod antagonist to decrease opiod abuse

Peri-Operative Pharmacological Interventions Medication: Serotonin Antagonists Examples: Ondansetron (Zofran), other "-setrons"

Uses/Actions -Given to decrease nausea/vomiting -Prevent serotonin from binding to 5-HT3 receptors and activating the nausea/vomiting centers Cautions/Interactions -Can cause headache -May induce bradycadia, hypotension, and vertigo

Peri-Operative Pharmacologic Interventions Medication: Opiod Antagonists Examples: Naloxone (Narcan), naltrexone HCl (Revia)

Uses/Actions -Given to reverse opiod effect and treat respiratory depression; used as an antidote for opiod overdoses Cautions/Interactions -They also cancel the pain-relieving benefits of opiods and can lead to withdrawal symptoms -Administer slowly

Peri-Operative Pharmacologic Interventions Medication Anticholinergics Examples Atropine

Uses/Actions: -Given before surgery to decrease salivary secretions and increase heart rate when bradycardia is present -Causes a decrease in GI motility, a decrease in salivation, dilation of pupils, increase in pulse rate

Peri-Operative Pharmacologic Interventions Medication: Antihistamines Examples: Benadryl (diphenhydramine), loratadine

Uses/Actions: -Given for itching, allergic reaction -Competes with histamine for H1 receptors, blocking histamine effects on bronchioles, GI tract and blood vessels

Peri-Operative Pharmacologic Interventions Medication: Dopamine Antagonists Examples: Metoclopramide HCl (Reglan)

Uses/Actions: -Given to decrease nausea/vomiting -Cholinergic agent; increases gastric emptying time

Peri-Operative Pharmacologic Interventions Medication: Opiod Agonists Examples: codeine, oxycontin, morphine, hydromorphone, fentanyl, methadone, meperidine)

Uses/Actions: -Used to control moderate to severe pain and are used before and after surgery -Bind to opiod pain receptors in the brain and block the release of substance P, decreasing pain sensation Cautions/Interactions -Side effects include constipation, nausea/vomiting, urinary retention, pruritis (itching), sedation, respiratory depression Other Info -Most potent of all analgesics -Most are similar to each other in pharmacologic effects, so patients don't need more than one -Can be administered oral, transdermal, or IV -There is no ceiling for a pure opiod agonist, but "opiod rotation" may become necessary with long term use

Differentiate between general and regional anesthesia and concious sedation (therapeutic procedures). Regional/Local Anesthesia

Various types -Epidural block: works from the waist down -Spinal block: starts higher up than the waist -Local conduction block: used for neck, shoulder pain Nurse's role -Assist anesthesia provider -Observe for breaks in sterile technique -Provide emotional support for patient; stay with patient, offer information and reassurance -Position patient comfortably and safely Complications include -Myocardial depression --Bradycardia, hypotension, cyanosis, edema -Anaphylaxis --Cardiac failure, allergic symptoms, abnormal vital signs -ANS blockade --Bradycardia, hypotension, nausea, vomiting -Cerebrospinal fluid (CSF) leakage --Headache

When a nurse and health care provider work together

Compare and contrast the torts of false imprisonment, assault, battery, ethical/legal practice/invasion of privacy, and defamation. Criminal Laws

Written to prevent harm to society and to provide punishment for crimes Felony: a crime of a serious nature )rape, theft, kidnap, murder) Misdemeanor: a lesser crime with a penalty of a fine or less than a year in prison

Compare and contrast the torts of false imprisonment, assault, battery, ethical/legal practice/invasion of privacy, and defamation. Civil Laws

Written to protect the rights of the individual in our society; encourage fair and equitable treatment among people

Level II, Exam I transitions

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