Criteria 2: Current Clinical Knowledge & Clinical Problem Solving Flashcards
As a Registered Nurse, you will be working in a teamwork environment.
Within a month of commencing work, you will be responsible for a number
of patients.
Halfway through your shift, you realised you do not have time to complete
your work? What would you do?
As a RN I understand that time management and team work is important. This allows for safe patient care, that is holistic. Each patient deserves care that is tailored to there needs. Duty of care.
Apply time management strategies, time management list
Priority setting/ most important to lest, work through list
Appropriate delegation
Advise NUM, preceptor, team members, educator
Ask for help
Hand over uncomplicated tasks to the next shift
Documentation
Reflect on what you can improve next time
PRORITATSATION QUESTION
- Each patient I have a duty of care. No patient is more imporatant that another. Deserve PCC (Mccormack n McCance). May have competing priorities..
Prioritisation & delegation skills
Assess patients & prioritise care according to assessment
Asks other staff for help
Identifies teamwork is important
Identify risks/ possible difficulties
Follow up with appropriate staff/ Dr etc
Communications concerns to others
Documents all care
Reflect on what you can improve next time
A patient you are caring for has fallen in the bathroom. Their IV cannula has
dislodged and is bleeding from the site.
How would you manage this situation?
Call for assistance Assess the patient Standard precautions - PPE: blood spill Moving safely policy adhered to: no lifting OH&S principles: water on the floor? OH&S principles Privacy/dignity issues Appropriate medical review Incident notification Documentation
When answering a call to the bathroom, a patient directs you to a person
lying on the floor who is bleeding from the head.
What would you do in this situation?
Safety for self and others Call for help DR ABC Assess patient Observations including neurological assessment Infection Control principles including PPE Incident notification Maintain privacy and dignity Documentation Reassure other patients OH&S Manual Handling Informs relevant staff ie DR
EXAMPLE - ICU
You walk into one of your allocated patient rooms and find a patient
unresponsive.
What would you do in this situation?
Assess patient DR ABC A - clear airway using head tilt/chin lift or jaw thrust. Nasopharyngeal airway or oropharyngeal airway. B - the effort of breathing, RR and skin colour. Oxygen; bag value mask 10-15 l (1-12 BMP) CPR if required (100-120 BMP) Maintain pts privacy and dignity Observations & Oxygen Documentation Reassure other patients Informs relevant staff ie DR
You are looking after a patient who is becoming increasingly paranoid that
staff on the ward are trying to harm them.
How would you deal with this patient
Who becomes paranoid ? MH, Dementia, Delirium.
Assess patient, review history and progress notes
Policies/procedures
Consult with senior staff
Safety self, patient and others
Notify medical officer
Communication, diversional therapy etc
Document
Don’t ignore continually engage the pt and seek outcome
If available contact CNC or CNS in MH to help develop strategies of
management
EXAMPLE : SAGU
While checking a dose of antibiotics for your patient, you calculate that the
dose is twice the recommended amount. When you check the patients
chart, you notice the same medication dose was given 6 hours ago.
What would you do in this situation?
Assess the pt, vital signs
Recheck orders on medication chart
Double check calculation and ask second nurse to check again
Consult with nurse who looked after pt on previous shift / DR looking after the
patient
Let staff know that the order is double the normal dose
If incorrect: contact Dr to re-chart drug
Inform NUM/ team leader
Incident notification
Do NOT give the drug until order confirmed
Document in patient notes
At the beginning of your shift, you are looking after a patient who was
admitted with an overdose. When you go to introduce yourself she is not in
her bed or anywhere to be seen.
What would you do?
Check the entire ward area.
Consult with nurse who looked after the patient on previous shift to see if they
know where the patient is and ask RN when last saw the patient
Check whether patient has gone for a procedure/test, or gone for a walk
Inform Team leader, NUM & MO
Call security –description of patient
Call next of kin
Incident notification and other Documentation
Team Leader may need to notify police if patient is a risk to self or others or if not
at home and does not return
Assess how it happened to decrease the risk of it happening again
You are caring for a patient with a history of self harm. They are on close
observations and have asked you to take them to the shop.
What would you do?
Discuss with patient Policies/procedures Consult with other staff Safety of self, patient, others Know own limits Set boundaries Inform other staff of plan and actions
Seizure
Assess patient + call for help
DR ABC
A - clear airway using head tilt/chin lift or jaw thrust. Nasopharyngeal airway or oropharyngeal airway.
B - the effort of breathing, RR and skin colour. Oxygen
C (circulation) - HR (brady, tachy), pulse, BP.
D - AVPU, Pupil size ; change my indicate raised ICP. ECG
E - wounds, infection? can be cause
F - fluid overload, enough fluid
G - bgl e.g. hypoglycemia
Anti-epileptic medication
VItals
Maintain pts privacy and dignity
Documentation
Reassure other patients
Informs relevant staff ie DR
- blood FBC, ELFT
- Drug results
- review HX
- CT + MRI
- Head to toe
Chest pain
Assess pt. Call for help PQRST ECG Asprin 300 mg Bloods - troponin Analgesia - standing orders GTN DRABC if unresponsive
Maintain pts privacy and dignity Documentation Reassure other patients Informs relevant staff ie DR frequent observaitons
- thrombalise if appropriate
Respiratory Arrest
- Assess patient; vital signs; Sp02 aim above 95%
- Call for help
- Assess reason for RA: airway and breathing,? is it blocked clear airway using head tilt/chin lift or jaw thrust. Nasopharyngeal airway or oropharyngeal airway. Intubation? Suction?
- apply supplementary oxygen
- sit upright
Unresponsive = CPR
Maintain pts privacy and dignity
Documentation
Reassure other patients
Informs relevant staff ie DR - chest x-ray
- Bloods
- fluid management