Nursing Role Basics Flashcards
What is medication reconciliation
When a run compares current and past meds
When is medication reconciliation done?
At every transition in care
Ex: long term- hospital- long term
Floor- floor if new orders change
What is the purpose of medication reconciliation?
Omissions
Duplications
Dosing
Interactions
The 5 rights of delegation
Right person- consider experience Right task Right circumstances Right direction & communication Right supervision and evaluation
If a pt is unstable, should a rn delegate?
No
The rn should take which of the following pts
Unstable or potential to be unstable Blood transfusions Initial teaching Feelings- if unstable or post cva Initial plan of care Discharge
What tasks are an lpn allowed to do?
Trach suction Foley- insert and measure Dressings Culture / data collection Stable pts Re-I force teaching Contribute to nsg care plan Administers IVPB meds Monitors IV meds
Are lpn’s allowed to do sterile techniques?
Yes
What tasks are AP’s allowed to do?
ADL's VS's Feeding Bathing Ambulating Wt I/o's Safety Hygiene and grooming
What is the difference bx actual and potential problems?
Actual problems are problems occurring now and must be cared for/ assessed FIRST!
Mallows hierarchy of needs
Physiological Safety Love/belonging Esteem Self actualization
What are the ABCS?
Airway
Breathing
Circulation
Safety
What is the RN’s role in consent?
We act as the witness
Types of consent
General- procedures and txs
Implied- life or limb, pt incapacitated , lifesaving situations
Who is responsible for dosing med errors?
Pharmacy
Doctor and RN
What is negligence/
The omission to do something
What is malpractice
Failure of a professional person to act or do something
Disaster tagging
Black- brain matter, severe head trauma, dilated pupils
Red- Immediate priority, breathing/ airway obstruction
Yellow- can wait a few hours too see( ex: fracture)
Green- walking wounded, (ex: sprains, fractures, general injuries)
When is culturally competent care required?
Birth Death/ end if life Procedures Communication Meds- herbs Hygiene- shaving (particularly head)
Assessing cultural / religious preferences
Is it safe
Is it something you can do
In an emergent situation, if restraints are used, when does the order have to be signed?
Within 1 hour
How often must pt be released from restraints?
Q2H: ROM Bathroom Ambulate Perfusion check Tur and position
How often are VS’s taken when restraints are used?
Q 15 min
Seizure safety
Suction in room Padded side rails O2 Bed in lowest position Meds (anticonvulsants)
In-seizure protocol
Get pt into a safe position Clear the area Pt on their side Don't put anything into mouth Time seizure What did it look like?
Post seizure protocol
Re-orient pt
Clean pt if incontinent
Fire - RACE
Rescue
Alarm
Contain fire
Extinguish
What is brachytherapy
Sealed source of radiation
Visitor rules for Brachytherapy
30 mins per day
6 ft
No pregnancy / children
Nursing rules for brachytherapy
Wear dosimeter badge Cluster care Use long tongs of dislodged Linens don't leave pt room- scanned Distance from pt - 6 ft
When is trendelenburg C/I?
Brain swelling
Crutches
6” in front and sides
3 fingers under axillary
Wt should be bearing on hand bars, not axillary
What is the first question of gaits?
Is it wt bearing or not?
Which gait is non-wt bearing ?
3 pt gait
Which gaits are partial/ wt bearing ?
2 and 4 pt gaits
4 pt gait
Most stable
4 individual separate steps
2 pt gait
Wt bearing on both legs
What is the difference bx 2 and 4 pt gait?
2 pt- crutch and leg moved at the same time
Stair rules
Good leg goes up first
Bad leg goes down first
Canes
- held on strong side
- advance 6- 10” when walking
- bad leg steps toward the cane initially
What disinfectant kills viruses?
Bleach
NOT ALCOHOL
Bleach: water ratio
1:10
Semi-fowlers position
HOB > 30
Fowlers position
HOB > 45
High fowlers position
HOB > 90
Supine position
Lying on back with head and shoulders propped up slightly with a pillow
Prone position
Lying on abdomen with head turned to the side
Lateral position
Side lying
Sims position
Aka : semi prone
Lying on the left side with most wt anterior
Trendelenburg position
Head and body lowered with ft elevated
Modified trendelenburg
Supine with the legs elevated
Reverse trendelenburg
Head elevated with ft lowered
Dorsal recumbent position
Supine with knees flexed
What situations do we use standard precautions?
Body fluids
Non- intact skin
Mucous membranes
What situations do we use airborne precautions?
Measles
Varicella
TB
PPE needed for airborn precautions
Standard PPE and N95 mask
Negative pressure room
Situations for droplet precautions ?
Strep PNA Scarlet fever rubella Pertussis Mumps Meningococcal PNA/sepsis
Droplet precautions
Standard PPE
Same room as pt with same org
Situations for contact precautions
Wound drainage
Fecal incontinence
Bodily discharges
Rules for pt leaving the room on isolation
Contact- cover the wound
Droplet- pt wears mask
Airborn- pt wears surgical mask
Should you ever leave a pt alone?
NO
DO WE GIVE BOLUSES OF H2O THROUGH THE NGT?
NO
What is usually the earliest indicator that something is wrong?
Cardiac
Pt’s become a priority when they exhibit one or all of the following
D- disorientation
A- Airway
B- breathing
C- Circulation
When situation is not life threatening, what should the nurse do first?
ASSESS
Name some examples of situations in which the nurse needs to act immediately before assessing
Compartment syndrome
Life endangering situations
What are the 5 questions that should be asked when assessing priority patients (priority questions)
1- acute or chronic 2- expected s/s or unexpected? 3- treated or untreated 4- lab values- normal or abnormal? 5- time sensitive?
Which nurses get the most stable pts?
Floats
New grads
Fill ins
Which surgical patients get priority?
Consider recovery time
Do they require more than one form of assistance ?
What step is always last in priority?
Documentation
When do we notify the provider?
Critical situations
What should we did when a family expresses concern?
Screen the patient
What are the priority actions after a pt falls?
Consciousness and vitals
What is CAGE?
Screening for alcoholism
What is the screening for CAGE?
C- cut down
A- angry/ annoyed at others?
G- guilt
E- eye opener, need a fix when u first wake up
What is one positive aspect of organ donation?
Helps grieving process- especially if a child dies
How old does someone have to be to give informed consent?
17
Married
Pregnant
Emancipated
When does a pt first get ambulated after surgery
Next shift or next day
When should COPD pts rest?
In bx activities
Older patients are always at risk for what with meds?
Toxicity
What should be tried first before increasing or adding a pharm?
Non-pharm interventions
In order to increase muscle strength, have the pt do what?
Encourage gross motor mvmt
In order to increase coordination, encourage the pt to do what?
Encourage fine motor mvmt
Incident reports
- internal document only
- use only facts
- Do Not mention in patient chart
