Delegation/Prioritization Flashcards
1
Q
RN may delegate what tasks to UAP?
A
- basic care activities
- bathing
- grooming
- ambulation
- feeding (unless extreme aspiration risk)
- mouth care
- toileting
- VS
- I/O (but not IV fluid intake)
- weight
- dressing
- transfers
- post mortem care
2
Q
Before the RN delegates any nursing intervention, additional factors should be considered:
A
- Stability of patient condition
- Complexity of activity to be delegated
- Potential for harm
- Predictability of the outcome
- Overall context of any other patient needs
3
Q
RN may NOT delegate what tasks to UAP?
A
- assessment
- discharge planning
- health education
- care planning
- triage
- interpretation of patient data
- care of invasive lines
- administering parenteral medications
4
Q
5 Rights of Delegation
A
- Right Task
- Right Circumstance
- Right Person
- Right Directions and Communication
- Right Supervision and Evaluation
5
Q
TAPE Acronym
A
- things RN cannot delegate
- T: Teaching
- A: Assessment
- P: Planning
- E: Evaluation
6
Q
ABCS: Airway Assessment and Interventions
A
- PATENCY
- Assessment: foreign body, chest movement, talking, cyanosis, obstruction, fluids, edema , LOC
- Interventions: maneuvers to remove foreign body (suction), oxygenation, intubate/trach
7
Q
ABCS: Breathing Assessment and Interventions
A
- OXYGENATION
- Assessment: RR, breathing workload, bilateral breath sounds, good airway entry, SPO2
- Interventions: oxygenation device, noninvasive ventilation, ambu. bag/BMV
8
Q
ABCS: Circulation Assessment and Interventions
A
- PERFUSION
- Assessment: pulses, cap refill, skin temp, skin color, BP (hypotension), HR/cardiac rhythm, LOC
Interventions: address causes, fluids, pressers (last resort)
9
Q
ABCS + D & E: Disability Assessment
A
- neurological status/GCS
- PERRLA
- blood glucose (hypo/hyperglycemia)
- check for drug causes
- urine output
- pain
10
Q
ABCS + D & E: Exposure Assessment
A
- check temperature
- expose patient
- head to toe skin assessment
- consider DVT and causes
11
Q
Maslow’s Hierarchy of Needs Order of Prioritization and Examples
A
- Physiologic Needs (food, water, warmth, shelter, TPN, fluids)
- Safety and Security (LOC)
- Belongingness and Affection (relationships, family support, therapeutic communication)
- Esteem and Self-Respect (accomplishment, respect)
- Self-Actualization (full potential, coping, creativeness)
12
Q
ADPIE
A
- A: Assess (know patient baseline)
- D: Diagnosis (nursing diagnosis)
- P: Planning (choose and prioritize interventions r/t SMART goals)
- I: Implement
- E: Evaluate
13
Q
SMART Goals
A
- S: Specific (well defined, who, what, where, why)
- M: Measurable (criteria to quantify progress)
- A: Achievable (attainable goals)
- R: Relevant (overall goal objective)
- T: Time-bound (deadline, gives sense of urgency)
14
Q
Spectrum of Stability
A
- life threatening; life altering
- unexpected outcome for disease process
- abnormal data (critical lab value, etc.)
- expected outcome for disease process; not life threatening
- normal data (consistent lab values, VS, ready for discharge, etc.)
15
Q
3 Types of Prevention
A
- Primary: promote health
- Secondary: screening
- Tertiary: after a diagnosis has been made; maximize patient’s functioning