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
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2
Q

Before the RN delegates any nursing intervention, additional factors should be considered:

A
  1. Stability of patient condition
  2. Complexity of activity to be delegated
  3. Potential for harm
  4. Predictability of the outcome
  5. Overall context of any other patient needs
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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
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4
Q

5 Rights of Delegation

A
  1. Right Task
  2. Right Circumstance
  3. Right Person
  4. Right Directions and Communication
  5. Right Supervision and Evaluation
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5
Q

TAPE Acronym

A
  • things RN cannot delegate
  • T: Teaching
  • A: Assessment
  • P: Planning
  • E: Evaluation
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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
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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
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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)
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9
Q

ABCS + D & E: Disability Assessment

A
  • neurological status/GCS
  • PERRLA
  • blood glucose (hypo/hyperglycemia)
  • check for drug causes
  • urine output
  • pain
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10
Q

ABCS + D & E: Exposure Assessment

A
  • check temperature
  • expose patient
  • head to toe skin assessment
  • consider DVT and causes
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11
Q

Maslow’s Hierarchy of Needs Order of Prioritization and Examples

A
  1. Physiologic Needs (food, water, warmth, shelter, TPN, fluids)
  2. Safety and Security (LOC)
  3. Belongingness and Affection (relationships, family support, therapeutic communication)
  4. Esteem and Self-Respect (accomplishment, respect)
  5. Self-Actualization (full potential, coping, creativeness)
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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
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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)
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14
Q

Spectrum of Stability

A
  1. life threatening; life altering
  2. unexpected outcome for disease process
  3. abnormal data (critical lab value, etc.)
  4. expected outcome for disease process; not life threatening
  5. normal data (consistent lab values, VS, ready for discharge, etc.)
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15
Q

3 Types of Prevention

A
  1. Primary: promote health
  2. Secondary: screening
  3. Tertiary: after a diagnosis has been made; maximize patient’s functioning
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