Bedside Procedures, Safety, Delegation, Related Civil Law In Health care delivery Flashcards
Before approaching a client or for any procedures, what
the nurse would do?
Introduce self to client to reduce patient’s anxiety
Most important method used to protect each client
against microorganisms.
Handwashing (prevents spread of microorganism)
Hand washing required time for contaminated hands
* Hand washing uncontaminated hands
Hand wash for 2 minutes
* 20 seconds
Best antimicrobial agent to use in hand washing or
client’s skin.
Chlorhexedine gluconate (CHG) or Hibeclens
Inner cannula of tracheostomy is removed and cleansed
with hydrogen peroxide every? (frequency)
Every 2-4 hours
How do you use a Fire Extinguisher?
P- Pull the pin
A - Aim at the base of the fire
S- Squeeze the handle
S - Sweep side to side
Donning of Personal Protective equipment (PPE)
Place in order
Wear gown first, mask or respirator, goggles or face
shields, and gloves.
Removing of Personal Protective Equipment (PPE):
Place in order (drag and drop)
Remove the gloves first, then goggles, gown and mask
the last to remove.
Prime mechanism in preventing infection.
Good hand washing
Donning of gloves
The inside surface of the glove is touched first while
pulling it onto the hand.
Test (assessment) performed to a client who undergone
thyroidectomy.
Trousseau sign and Chovstek’s test
When opening a sterile package and to maintain its
sterility can be up to touch from
inch border?
1-inch (it is considered unsterile), if touched beyond an
inch of the folded sterile drape.
One guiding principle in handling and maintaining sterility
of sterile objects is by?
By holding sterile objects above the waist level.
A surgical mask can only be worn for how long?
20-30 minutes. When greater than 30 minutes, there will
be moisture build up making the mask ineffective
against maintaining sterility.
While client is in the hospital for vascular headache and
developed a bacterial pneumonia, this is called?
Nosocomial infection (hospital acquired infection)
Major sites of nosocomial infections
Respiratory tracts, urinary tracts, blood stream.
Surgical or traumatic wounds
Main cause of spread of infection
Lack of proper hand washing.
Catheterization of male client, how many inches to insert?
6-9 inches (15-23 cm)
Securing indwelling catheter in male client.
Catheter is taped to the abdomen to straighten the
angulation of the penoscrotal junction to reduce
pressure on the urethra.
Catheterization of female client, how may inches to
insert?
2-3 inches (5-7.5 cm)
(female urethral canal 3.0-4.0 cm)
Securing indwelling catheter in female client.
Catheter is taped to the thigh.
When discontinuing the NGT, instruct the client to?
Exhale to facilitate pulling the NGT with ease
When lubricating the NGT, you will not use
Oil-soluble such as petroleum jelly) instead use a
water-soluble (K-Y jelly), which is water soluble to
prevent risk of aspiration).
Vaginal suppository length of insertion
8-10 cm ( (3-4 inches) to the posterior wall of the vagina
Cleansing enema retained for (duration)
5-10 minutes
Oil retention enema retained for (duration)
At least 30 minutes to 2-3 hours
Height of the enema container from the bed
above the rectum:
18 inches (45 cm)
12 inches (30 cm)
Rationale for positioning client to the left with right leg
acutely flexed during enema administration.
Facilitates the flow if solution by gravity into the sigmoid
and descending colon (anatomically to the left side),
right leg flexed for adequate exposure of the anus.
Hypodermic needle size to administer heparin
Use gauge 25-26 needle - 5/8 mm (1/2 inch)
(when administered subcutaneously)
Discharge teaching for patient with xerostomia. (dry mouth)
Use hydrogen peroxide to cleanse mouth
Assessment in general
Inspection, Palpation. Percussion, Auscultation
Abdominal assessment
Inspection, Auscultation, Percussion, Palpation
Temperature in administration of pediatric enema
100 degrees (to avoid burning of rectal tissues)
Temperature of tepid sponge bath (TSB)
90 degrees (32°C)
Nursing diagnoses post liver biopsy
Bleeding and infection
Nurse alert: ensure patient’s safety from bleeding and
infection.
Nursing diagnoses post amniocentesis
Infection and premature rupture of membrane.
What to avoid when mixing the solution from a vial?
Rotating the vial between palms of the hands.
Do not shake the vial to avoid bubbles and foaming.
Safety in aspirating medication from an ampoule.
Aspirate medication using a filter needle to trap any
possible broken glass piece (possibly not visible by
eyes).
Gastrostomy height from the patient to cone syringe or
feeding source.
No more than 18 inches.
NGT feeding alert
Hold for residual volume of 50-100 ml (policy protocol),
Head of bed (HOB) - no less than 30 degrees,
Preferred elevation- semi-fowler’s position.
Rectal tube is gently administered
cm
3-4 inches (7-10 cm)
Rationale on why the foley catheter being secured
laterally to the thigh or to the lower abdomen
To prevent penoscrotal angle and prevent fistula
development.
BP cuff placement is correctly done of an8-month child
Approximately 2/3 of the length of the humerus.
A chemical spill to eye is best performed by?
Instilling sterile normal saline from the inner canthus to
the outer canthus.
Contraindications of enema in pregnant woman
Vaginal bleeding or premature labor, if the presenting
parties not engaged, or if there is other than a vertex
presentation.
How to manage a client on isolation and experiencing
social isolation
Keeping g client informed of the time as to what time the
nurse will return.
Comfort measure to a sickle cell client with joint pains
Apply heat to affected area, as ice has vasoconstricting
effect and will increase the pain due to hypoxemia to the cells.
Lumbar puncture indication?
Primarily to rule out meningitis and to diagnose Lyme
disease.
Non-pharmacological pain management
Positioning, elevation, promoting relaxation by using
slow, rhythmic breathing, purse-lip breathing).
Guided imagery.
Decreasing noxious stimuli (splinting abdominal incision
during coughing and deep breathing.
Application of cold or warm compresses.
Distraction by focusing patient’s attraction from his
painful Sensations.
Size of a needle to access AV fistula during dialysis.
14 to 16 gauge (needle is color coded as red and blue).
Prior to paracentesis, what to instruct client?
To void, to reduce the risk of inadvertent puncture of the
bladder.
What to monitor during and after paracentesis?
Hypotension
The trocar in paracentesis is located?
Midline below the umbilicus.
Test performed at the bedside when client is having TPN.
Check for glucose to monitor hyperglycemia.
Peak level (blood draw)
Blood sample should be collected 30 minutes after
administration of aminoglycosides (IM or IV).
Trough level (blood draw)
Blood sample should be collected prior to the next dose.
Humalog and pens are discarded after
Ten (10) days
Novolog pens are discarded after
Fourteen (14) days
Sites of insulin administration
Abdominal wall, thigh, upper arm subcutaneously
Insulin administration site is rotated to prevent.
Lipodystrophy
Insulin vial can be kept outside refrigerator.
28 days
Oral administration of drug is mar indicated when patient
iS.
Altered or decreased level of consciousness
Drugs absorbed through the skin are called.
Trans-dermal patch
(Birth control, Clonidine, Exelon, Nitroderm, & Fentanyl)
Intradermal injection is administered.
10-15 degree angle, using ½- inch long needle
26-gauge needle
When administering intramuscular iniection, the site with
highest risks.
Dorsogluteal
Gauge of hypodermic needle used in administering
subcutaneous injection
½ inch long needle and inserted at a 90-degree angle or
an inch-long at a 45-degree angle.
25-29 gauge hypodermic needle
Gauge of a needle to administer intramuscular injection.
1.5 inch long hypodermic needle
Maximum amount administered in IM injection.
3 ml
Proper way of administering topical medication
Apply thin layer of ointment or cream
Vaginal cream is applied by using an
Applicator
Suctioning is performed correctly
By applying suction catheter for no more than 10
seconds, as the catheter is withdrawn.
To perform hearing tests:
Weber’s test
(tuning fork)
- Hold the fork at its base and tap it lightly against the
heel of the palm. - Place the vibrating fork on top of client’s head or
middle of forehead. - Ask client where sound is heard (unilateral or
bilateral)
Rinne test
- Strike tuning fork against heel of the palm.
- Hold the vibrating fork with tines parallel to auricle
and their tips 1 inch (2cm) from external meatus. - Place stem of vibrating fork on bone of mastoid
process. - Ask the client to tell you if sound is louder by air
conduction or bone.
Reveals conduction hearing loss
Webers test / Tuning fork test
Client teaching on hearing aid use
Avoid use of aerosol near the hearing aid
(as it clog the receiver)
Drugs administered by Z-track.
Iron, Vistaril (hydroxyzine), Tigan (trimethobenzamide)
Rectal suppository is inserted into the rectum (length)
4 inches into the rectum.
Five rights of delegation
- Right task: by delegating to appropriate team
members (LVN/LPN, UAP/CAN) - Right circumstance: by determining the acuity and
to delegate to the level of caregiver skill. - Right person: Assess and verify the competency of
the caregiver. - Right direction/communication by keeping line of
communication open both written and oral on a timely
manner. - Right supervision/Evaluation (monitor performance,
intervene when necessary, clear documentation)
DELEGATION
RNs may delegate to LVNs/LPs under their directions
Medication administration except intravenous,
tracheostomy care suctioning, ostomy care,
urinary catheter insertion, patency checks for
nasogastric tube, enteral feeding administration,
suctioning, routine wound care dressing, continuity of
nursing assessment with input to the RNs.
RNs may delegate to UAP (CAN) under their
supervision
Bathing and dressing
Grooming and toileting
Feeding without risk for
aspiration such as:
stroke, neurological
disorders.
Activities of daily living
Ambulating
Positioning
Toileting
Bed making
Taking vital signs
Intake and output
Application of ophthalmic eye drops, gel, ointment
It should be instilled to the lower conjunctiva as capillary
beds are found for the medication to be absorbed.
Legal terminologies associated in nursing care.
Civil Law related to delivery of health care
Intentional torts
Assault is a threat or even an attempt to touch another
person without justification. (e.g.,” if you do not drink this
medication, I will insert an NGT”).
Battery is an intentional physical contact with a person
or object that the person is wearing or holding.
(e.g., he took his book and locked it.) The nurse
continued inserting the NGT when patient stated to stop.
**Failure to obtain consent is an intentional tort.
Unintentional torts
Liability, negligence, gross negligence, malpractice
(e.g., injury, harm caused to the client
failure to provide care, failure to deliver a standard of
care putting client at risk.
Is an intentional torts, refers to threatening or attempting
violence without physical contact.
Assault
Is an intentional torts, refers to physical contact in an
offensive manner.
Battery
Refers to acts of omission commission that result in
injury to the client.
Negligence
Is defamation by means of writing, print, or pictures.
Libel
Living Will (also referred as durable power of attorney)
Provides specific instructions about the medical
treatment in the event that client is unable to make
decision. For example, CPR, mechanical life supports).
What to do if there was a medication error?
Notify MD, complete an incident report, do not report in
the client’s chart. Incident report is used by the facility to
Prevent reoccurrence of the same event or problem.
When medication was given and not documented.
Error omission
When a client fell off bed and documented in a wrong
chart.
Error commission
During the first 24 hours after surgery, temperature is
routinely checked every (frequency)?
2 hours
After the 24 hour after surgery, temperature is routinely
checked every (frequency)?
8 hours
Patient teaching for a client with extreme food allergies.
To wear Medic-Alert bracelet and carry injectable
cartridge of Epipen.
Nursing alert when using latex gloves before any
procedure.
Assess for potential latex allergy.
Definition of HIPAA (1996)
Health Insurance Portability and Accountability
Is indicated to protect health and safety of patient while
preserving dignity, rights, and well-being.
It protects staff form injury.
Restraint
- Elbow restraints: used to prevent the child from
reaching the face as in post cleft lip repair. - Mummy restraints or papoose board restraints: used
infants and young children such as suturing or a
procedure. - Crib restraints: “bubble top” when physical
movements not contraindicated. Used to keep the child
from climbing out of a crib. - Clove-hitch restraints: Used to limit motion of arms
and legs.
Types of restraints in pediatrics
Types of adult restraints
Soft wrist restraints, vest and leather restraints
Restraints nurse alert
- If physician is not available, an RN may initiate
restraint use. However, physician must be notified
immediately. - It must be renewed every 24 hours as needed with
clinical indication. It must be removed if order is not
renewed. - Standing order or PRN restraint order is NOT valid.
Secure restraints to non-moving part of the bed frame or
gurney. - Restraints order must be justified (pulling lines, IV,
risk from falling).
Restraints documentation
- Restraint assessment is documented minimum of
every 2 hours (medical restraints). - Behavioral restraints fro severely aggressive or
destructive behavior is every 15 minutes. - Offer food, fluids, bathroom at least every 2 hours.
moving the unaffected leg onto a step. The affected leg
is always supported by crutches. Staff stays behind the
client when client has a walking belt.
Climbing stairs
A blood platelet disorder: low platelets,
uncontrollable bleeding, easy bruising
Platelet transfusion is not normally recommended and is
usually unsuccessful in raising a patient’s platelet count.
IP (Immune Thrombocytopenic Purpura)
This is because the underlying autoimmune mechanism
that destroyed the patient’s platelets to begin with will
also destroy donor platelets. An exception to this rule is
when a patient is bleeding profusely.
Is the result of a deficiency in clotting factor
The immune system destroys platelets
Is the result of a deficiency in clotting factor IX.
Christmas disease or class-B hemophilia
Use for mild cases of hemophilia A (DDAVP) can be
used to stimulate the production of clotting factor VIII
after a minor injury or dental procedure.
Desmopressin
Cryoprecipitate (made from the blood of a single donor)
and Lyophilized factor VIlI concentrate.
Hemophilia treatment
Time duration of blood transfusion
No more than 4 hours.
Pernicious anemia is treated with?
B12
Increased in BC mass and hemoglobin
Polycythemia vera
Drug therapy for Sickle Cell.
- Ibuprofen (Motrin) mild to moderate pain
- Opioid as Morphine Sulfate (moderate to severe)
- Broad spectrum antibiotic (chest infection)
- Hydrea (hydroxyurea) is an antineoplastic drug for
hematologic malignancies, antiretroviral against HIV as
it breaks down cells that are prone to sickle. - Procardia (nifedifine) used for priapism.
What specimen sample needs to be collected by a nurse
for a test ordered for Schilling test?
Urine sample (urine is collected over 24 hours after
taking B12 (oral and injectable B12)
If Schilling test has been ordered, the nurse is
anticipating that the test was ordered to rule out?
Pernicious anemia (Vitamin B12 deficiency)
VitaminB12 is a cyanocobalamin.
Immediate nursing intervention for transfusion reaction
Stop transfusion immediately and notify MD,
What do you send back to the blood bank if transfusion
reactions occur?
The blood bag used when transfusion occurred
Complete a transfusion reaction report
Collect urine sample to determine hemolysis of the
RBC.
Time duration of blood transfusion
Infuse as ordered, usually 2-4 hours. NO > 4 hours.
Solution contraindicated when transfusing blood
Dextrose solution (only 0.9% Normal Saline solution is
allowed).
Decrease in the number of circulating white blood cells )
the blood.
Leukopenia or leukocytopenia
Low WBC count may be due to.
Chemotherapy, radiation therapy, leukemia
Decrease in the number of circulating neutrophis-
granulocytes, the most abundant white blood cells.
Neutropenia
Blood transfusion
Blood can be transfused within how many hours?
No more than 4 hours. Do not allow blood to hang for
more than 4 hours.
Vital signs are checked prior to the start of infusion,
15 minutes after the blood has been started, every hour
until the completion of the blood transfusion.
High fever, sudden chills, headache, flushing,
hypotension, hives, itching, wheezing, shortness of
breath, lower back pain, and sense of impending doom.
Signs of transfusion reactions
When the blood is ready, when you can start transfusing
it?
Must be started within 30 minutes of arrival on the unit.
If blood is unable to get infused, return to blood to the
blood bank. Do not store in the unit refrigerator.
Do not take two (2) units or more at a time.
Nurse alert prior to administration of blood.
Double check the physician’s order and verify signed
consent.
Laboratory tests for anemia?
CBC (hemoglobin)
iron profile (serum iron, ferritin, total iron binding
capacity (TIBC).
Types of anemia
Iron deficiency anemia (microcytic, hypochromic)
Megaloblastic anemia (Pernicious)
Folic acid anemia
Aplastic anemia
