Management Flashcards
RN role
assess analyze interpret critical thinking provide education offer counsel and support
LPN/LVN role
ASSIST with implementation of define care plan
provide care for stable clients with predictable outcome
collect date for assessment and report to RN
asepsis and dressing changes
CNA/UAP role
provide basic care vitals ADLs topical care med and OTC meds measuring and documenting intake and output blood sugar check or 12 lead ECG
they may not delegate an assigned task to another UAP
when delegating assignment
give the most stable patient
LPN: can reteach
RN: assess evaluate teach
CNA: cannot
anyone returning should be given to RN
if the answers have sxs then that is a clue whether they are stable patients or not
- see which one is the most acute
advanced directives
includes a living will and durable power of attorney
nurses and other members of health care team are required to:
- assess clients knowledge of advance directives and their status
- provide info and assistance in developing directives
- plan care that incorporates clients decision making
durable power of attorney
names a person to make health care decisions if client is unstable to do so
can make decisions of :
- wehn to admit or discharge
- types of treatmet or meds client can receive
- has access to all health care records
DNR
not to perform: - CPR - life saving measures such as: hemodialysis intubation emergency meds
healthcare proxy can verablly cancel DNR at any time
informed consent
cannot delegate to nurse
- they are only responsible for witnessing and co-signing clients signature
nonmaleficence
protect clients safety
autonomy
right to make deicisions for themselves, including living wills
maslows hierarchy
from priority to less priority:
- physiolocal needs
- safety needs
- social needs
- esteem needs
- self actualization
prioritzation
- BLS guidelines
- ABC
- Maslows hierarchy
- nursing process
- acute or chronic
- suddent onset or rapid worsening of SOB or pain - new onset sxs that doesn’t make sense with diagnosis
1st degree heart block
PR internvals greater than 0.2 seconds
regular P waves and R waves
P wave accompanying QRS complex
2nd degree heart block type 1 (Mobitz 1)
Pr intervals are progressively lengthening then all of a sudden theres no QRS complex
this is a cycle
2nd degree heart block type 2 (Mobitz 2)
theres no pattern in type 2
R waves is irregular
missing QRS complex randomly
temporary pacing is needed immediately
3rd degree - complete heart block
P wave will NOT accompany QRS complez
P and R waves are regular
cranial nerve II
optic nerve
- confrontation usual field test
- snellen chart for visual acuity
cranial III, IV, VI
3: oculomotor
4: trochlear
6: abducens
watch for nystagmus
reactive to light the pupils
cranial nerve V
trigeminal nerve
bite down and feel the masseter muscle and temporal muscle
open mouth against resistance
cranial nerve VII
facial nerve
close their eyes, smile, frown, puff out cheek
cranial nerve VIII
vestibulocochlear nerve
test hearing by occluding one ear and whispering 2 words
cranial nerve IX and X
IX: glossopharyngeal
X: vagus
swallow and say “ah”
cranial nerve XI
accessory nerve
move head from side to side, up, down, shrug against resistance
cranial nerve XII
hypoglossal
have patient stick tongue out and move it side to side
