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NCLEX Review Class 2: Safe, Effective Care Environment Client Needs • • • • Safe Effective Care Environment Health Promotion and Maintenance Psychosocial Integrity Physiological Integrity Safe Effective Care Environment • Management of Care 13-19% • Safety and Infection Control 8-14% Health Promotion and Maintenance 612% Psychosocial Integrity 6-12% Physiological Integrity • Basic Care and Comfort 6-12% • Pharmacological and Parenteral Therapies 13-19% • Reduction of Risk Potential 13-19% • Physiological Adaptation 11-17% Integrated Processes • Nursing Process • Caring – nurse provides hope, support and compassion to help achieve desired outcomes • Communication and Documentation • Teaching and Learning Safe Effective Care Environment • Management of Care Scope of Practice of Nursing Personnel • Baccalaureate prepared nurses equipped to care for individuals, families, groups & communities in both structured & unstructured health settings • Associate degree prepared nurses equipped to care for individuals in a structured health care environment RN’s cannot delegate • Initial assessment of patients • Evaluation of patient data • Nursing judgment • Patient/family education/evaluation • Nursing diagnosis/nursing care planning • Licensed practical/vocational nurses equipped to assist in implementing a defined plan of care & to perform procedures according to protocol. Assessment skills are directed at differentiating normal from abnormal. Competence is in caring for physiologically stable patients with predictable conditions. • Unlicensed assistive personnel have most limited scope of practice. They can assists in a variety of direct patient care activities such as bathing, transferring, ambulating, feeding, toileting, obtaining measurements such as vital signs, height, weight & I & O. Can also perform indirect activities such as housekeeping, transporting & stocking supplies The RN is very short staffed because two people did not show up for work. Of the following four clients, which one would the RN care for first? 1. A client just admitted with acute abdominal pain & possible cholecystitis. 2. A client with nephrotic syndrome with increasing edema; hourly urine checks & vital signs. 3. A confused client yelling because he is in soft restraints & cannot get out of bed. 4. A head-injury client (with an IV) who was just admitted to the unit. • 1. 2. 3. 4. The RN tells the LPN she is very busy & needs assistance. Which one of the following tasks cannot be delegated to an LPN? Checking the blood glucose level of a client & giving the appropriate insulin dose. Completing a peripheral vascular assessment that a nursing assistant identified as being different from the earlier assessment. Completing an initial health assessment on a newly admitted client. Completing client teaching for a client scheduled for discharge. Safety and Infection Control 8-14% • • • • • • • • • Accident Prevention Disaster Planning Emergency Response Plan Ergonomic Principles Error Prevention Handling Hazardous & Infectious Materials Home Safety Injury Prevention Medical and Surgical Asepsis • Reporting of Incident Event/Irregular Occurrence/Variance • Safe Use of Equipment • Security Plan • Standard/Transmission-Based/Other Precautions • Use of Restraints/Safety Devices Accident Prevention • Accident prevention interventions (Chapter 37 Potter & Perry) • Visual/Hearing deficits, other sensory/perceptual alterations. • Infant/child car seats • Factors that influence accident prevention (developmental stage, lifestyle) Disaster Planning • Disaster planning actions • Nursing role in disaster planning • Determine which client(s) to recommend for discharge in a disaster situation Emergency Response Plan • Prepare for and implement emergency response plans (internal/external disaster) Security Plan • Apply principles of triage and evacuation procedures/protocols • Participate in security plan activities • Review security plan with staff DISASTERS (Brunner Ch. ) • Know the agency’s disaster plan • Internal disasters are those in which the agency is in danger • External disasters occur in the community, and victims will be brought to the health care facility for care • When the health care facility is notified of a disaster, specific plans as specified in the agency policy must be carried out TRIAGE EMERGENCY DEPT. TRIAGE • Making tentative diagnosis and prioritizing each patient’s care • Brief eval. of pt’s airway, breathing, circulation – document chief complaint in pt’s own words • Determine is pt. needs immediate intervention, then transport for care. If they don’t, continue with more detailed assessment Emergency Dept. Triage Categories • Emergent • Urgent • Nonurgent • Delayed Emergent – need immediate attention • • • • Chest pain – cardiac complaints Cardiac arrest Trauma codes – MVA, penetrating injuries Airway compromise: foreign bodies, allergic reactions (respiratory distress) • Eye injuries • Falls/jumps more than 20 ft • • • • • • • Hemodynamic instability Hypo- or hyperglycemia Inhalation injuries Limb amputations Seizures/post-seizure states Stroke Head injuries URGENT – Problems that should be treated as soon as possible (1-2 hours) • • • • • • • Acute abdominal pain Acute headache Cellulitis Major laceration Obvious fracture Sexual assault Nonurgent complaint in pt with diabetes, cancer, hypertention, AIDS NONURGENT – Problems that need to be treated sometime today (not always in ER) • Common cold • Minor injury • Simple laceration • Sore throat • Sprains/strains • Toothache DELAYED – Conditions that don’t require ER care & can be seen at any time • • • • • • Exams Prescription refill Rash Request for work slip Suture removal Wound check DISASTER TRIAGE • Provides for rapid life saving stabilization (airway & breathing control) but no CPR • 4 Categories: Red – Immediate –highest priority Yellow – Delayed – serious, not life-threating Green – Minimal – lowest priority Black – Expectant – dead or unsalvageable • First, separate walking wounded from other victims to be tagged later (green) • Next, triage remaining victims using: R=respirations P=perfusion M=mentation • R – no respiratory effort – reposition & reassess – still no response – black tag. If breathing, check rate – if > 30/min – red tag. If needs airway maintenance, assign, may need to be done without cervical spine precautions. If < 30/min, move on to next part of assessment • P – check for presence of radial pulses. No pulse – red tag. Control bleeding if possible. If there is a pulse → next step • M – mental status. Pt. unconscious or conscious but unable to follow directions – red tag. If normal LOC & can follow directions – yellow tag Immediate – Red tag Injuries are life-threatening but survivable with minimal intervention Examples: sucking chest wounds, airway obstruction RT mech. cause, shock, hemothorax, tension pneumothorax, unstable chest abd wounds, incomplete amp. Open fx of long bones, 2/3 burns of 15-40% BSA Delayed – yellow tag Injuries significant & require medical care, but can wait hrs without threat to life/limb Examples: stable abd wounds without evidence of sign. Hemorrhage, soft tissue inj. Face wounds without airway problems, vascular inj. With ade. Circ., most fx. Most eye and CNS injuries Minimal – Green tag Injuries are minor and treatment can be delayed hours to days. Examples: upper extremity fx, minor burns, sprains, small lac. Behavioral disorders or psych. disturbances Expectant – Black tag Injuries are extensive & chances of survival are unlikely even with definitive care. Separate from others but not abandoned. Provide comfort measures. Examples: unresp pt. with penetrating head wounds, high SC injury, multiple wounds to many organs, sites, burns>60% BSA seizures or vomiting w/I 24hrs radiation exposure, profound shock with multiple wounds Prioritize in this order: • • • • Breathing Bleeding Broken bones Burns Hospital Evacuation in Disaster • A Ambulatory - Remove walking first (may help with others) • B Bed ridden • C Critically ill last • Objective in disaster plan – evacuate volumes of clients. Ergonomic Principles Prevention of injury to health care workers. Back injury common Principles of body mechanics – Ch. 36 Potter & Perry Chart page 934 Chart page 946 Error Prevention • • • • Check for client allergies Check for accuracy of client prescriptions Prevent errors by following agency policies Utilize client identification policies (Name and allergy bands) • Verify client identity prior to procedures Handling Hazardous/Infectious Materials • Control spread of infectious agents • Safe handling techniques • Identify biohazardous, flammable & infectious materials Infection notes • A pathogen cannot infect if you break even one of the six links in the chain of transmission • Clients at high risk for infection get prophylactic antibiotics before surgical procedures • The major sites for nosocomial infections are urinary & respiratory tracts, blood & wounds • All nosocomial infections that occur in hospitals must be tracked & recorded Home Safety • Home safety interventions • Evaluate client care environment for fire or environmental safety hazards • Involve client/family when recommending modifications (lighting, handrails, kitchen safety) (p. 1021 Potter & Perry) Injury Prevention • Injury Prevention interventions • Factors related to mental status may contribute to client’s potential for accident or injury ( confusion, altered thought processes, diagnosis) • Factors R/T allergy may contribute to client’s potential for injury (food, meds, vaccines, environmental factors. • Use protective equipment when using devices that can cause injury (Home disposal of syringes) • Protect individual from injury (from another ind., falls, environmental hazards, burns) • Remove fire hazards • Meds and treatments that contribute to accident or injury • Client allergies Safety notes • Know institution’s plan for fire drills & evacuation • Know emergency phone number for reporting fire • Know locations of all fire alarms, exits & extinguishers • PRC: first protect people, then report fire, then try to contain it • In a fire, never use an elevator • Turn off all oxygen supplies in the area of fire • In a fire, close all doors & windows • In a power failure, only certain electrical outlets access the emergency generators, know which ones they are Poison notes • Never induce vomiting for these poisons: lye, household cleaners, petroleum products, furniture polish • If it is suspected someone has taken poison, save any vomitus & take it with the victim to ER Medical & Surgical Asepsis • • • • Nursing procedures & psychomotor skills Assess client area for sources of infection Correct aseptic technique Employ methods to control/eliminate infectious agents (handwashing most effective preventer of infection) • Set up sterile field and use appropriate supplies • Correct techniques to apply & remove mask, gloves, gown, protective eyewear Reporting of Incident/Event/Irregular Occurrence/Variance • Complete report according to policy • Identify situations requiring completion of report (med error, fall) Safe Use of Equipment • Check equipment for safe functioning • Ensure safe equipment use (CPM device, oxygen, mobility aids, restraints) • Inspect equipment for safety hazards (frayed electrical cords, loose/missing parts) • Remove malfunctioning equipment from client area to appropriate personnel Standard/Transmission-Based Other Precautions • Apply infection control principles (handwashing, isolation, aseptic tech,) • Review with client and staff • Universal/standard precautions • Identify communicable diseases & modes of transmission (airborne, droplet, contact) • Protect spread through use of equipment • Protect immunocompromised clients • Report client with communicable disease • Correct handwashing technique Use of Restraints/Safety Devices • Apply knowledge of science in use of restraints ( maintain function) • Apply knowledge from social sciences when using restraints (respect dignity of older clients, older adult risk for hip fx) • Apply & maintain prescribed restraints, bed alarms, safety devices according to policy • Evaluate appropriateness of type of restraint used • Identify & use least restrictive safety device/restraint • Monitor client’s response to restraints • Use appropriate device procedure for client RESTRAINTS • Protective device used to limit the physical activity of a client or to immobilize a client or an extremity • Physical restraints – Restricts client movement through the application of a device • Chemical restraints – Medications given to inhibit a specific behavior or movement RESTRAINTS • IMPLEMENTATION – When restraints are necessary, the physician’s orders should state the type of restraint, specific client behaviors for which restraints are to be used, and identify a limited time frame for use – Physicians’ orders for restraints should be renewed within a specific time frame according to the agency’s policy RESTRAINTS • IMPLEMENTATION – Restraints are not to be ordered PRN – The reason for the restraints should be given to the client and the family, and their permission should be sought – Restraints should not interfere with any treatments or affect the client’s health problem – Use a half bow or clove hitch knot so that the restraint can be changed and released easily – Ensure that there is enough slack on the straps to assure some movement of the body part RESTRAINTS • IMPLEMENTATION – Secure restraint to the bed frame, not to the side rails – Assess skin integrity, neurovascular, and circulatory status every 30 minutes and release the restraint to permit muscle exercise and promote circulation – Continually assess the need for restraints RESTRAINTS • DOCUMENTATION – – – – Reason for restraint Method of restraint Date and time of application of restraint Duration of use of the restraint and client’s response – Release from restraint with periodic exercise and circulatory, neurovascular, and skin assessment – Assessment of continued need for restraint – Evaluation of the client’s response ALTERNATIVES TO RESTRAINTS • Orient client and family to surroundings • Explain all procedures and treatments to the client and family • Encourage family and friends to stay with client and utilize sitters for clients who need supervision • Assign confused and disoriented clients to rooms near the nurses’ station • Provide appropriate visual and auditory stimuli to client, such as clocks, calendars, television, and a radio ALTERNATIVES TO RESTRAINTS • Place familiar items near the client’s bedside, such as family pictures • Maintain toileting routines • Eliminate bothersome treatments, such as tube feedings, as soon as possible • Evaluate all medications that the client is receiving • Use relaxation techniques with the client • Institute exercise and ambulation schedules as the client’s condition allows