SAFE AND EFFECTIVE CARE ENVIROMENT: MANAGEMENT OF CARE y An RN can delegate activities with predictable outcomes, and activities

that involve standard, unchanging procedures, such as bathing, feeding, dressing, and transferring clients. Do not delegate an activity if the pt id unstable, if the outcome of the activity is not assured, or if the activity is complex or complicated.

The following problems indicate priority needs: y y y y y y y y Postoperative pts just out of surgery Pts whose status has deteriorated from their normal baseline Pts exhibiting signs of shock Pts with allergic reactions Pts with chest pain Postdiagnostic-procedure pts who require temp monitoring Pts who tell you they have unusual symptoms Pts with malfunctioning equipment or tubing

Ethical Practice y y y y y y y y Autonomy The right of individuals to make decisions for themselves Beneficence An RN s duty to do what is in the best interest of the pt Justice A fair, equitable, and appropriate treatment Nonmaleficence An RN s duty to do no harm Fidelity Keeping faithful to ethical principles and the ANA Code of Ethics for RNs Virtues Compassion, trustworthiness, integrity, and veracity (truthfulness) Confidentiality Maintaining the pts privacy by not disclosing personal info Accountability Responsibility for one s actions

Informed Consent y y y y Details of the procedure or treatment Risks and benefits of the procedure or treatment, including the potential for serious injury or death Alternative procedures or treatments Potential consequences of refusing the procedure or treatment

* Typically, the healthcare provider who is performing the procedure or providing the treatment is responsible for obtaining the pts informed consent. One of your roles in the process is to advocate for the pt by ensuring they have been provided the necessary info to make an informed decision. SAFE AND EFFECTIVE CARE ENVIROMENTS: SAFTEY AND INFECTION CONTROL

Record the facts of an incident in the medical record, but do not include a copy of the incident report or make a reference to its existence in the medical record.

Triage Pts in an Emergency: 1. Clear and open the airway 2. Assess for respiratory distress 3. Assess quality of breathing (rate, & color of skin, lips, and fingernails) & auscultate lungs 4. Check pulse 5. Assess for external bleeding 6. Take BP 7. Assess the level of consciousness and papillary response, and the weakness of paralysis of extremities Basic Principles of Surgical Asepsis: y y y y y y y y Every object used in a sterile field must be sterile If a sterile object touches an unsterile object, it is no longer sterile If a sterile object is out of view, or below waist level it is no longer sterile A sterile object can become unsterile through exposure to airborne microorganisms Fluids flow in the direction of gravity Moisture passing through a sterile objects flowing through a sterile object can draw microorganisms from unsterile surfaces above or below through capillary action The edges of a sterile field are unsterile The skin cannot be sterilized

Order to Administer PRBCs: 1. Verify the physician s order 2. Assess that the pt has a blood bank identification band 3. Explain the procedure to the pt 4. Obtain the pts VS 5. Prime the transfusion tubing with a 0.9% sodium chloride solution 6. Obtain the PRBCs from the blood bank according to hospital policy and perform a visual check of the blood (Must be administered within 30 minutes) 7. Perform bedside identification and blood product verification by two licensed professionals

HEALTH PROMOTION AND MAINTENANCE Category X Medications y y y y y y Birth control pills Accutane Some hyperlipidemia medications Warfarin (Coumadin) Ulcer drug (Cytoptec) Vaccines for Measles, Mumps, and Smallpox

* Pregnant teens require more PRO, Ca, and Phosphorus than pregnant adults, bc their bodies are still growing. Possible Danger Signs During Pregnancy: y y y y y y Vaginal bleeding Continuous headaches during the last 3 months Marked or sudden swelling of extremities during the last 3 months Dimness or blurring of vision during the last 3 months Severe, unrelenting abdominal pain Decreased fetal movement after 24 weeks

Cultural Differences during pregnancy: y y y Chinese Confucian value modesty and self control, so such women may remain stoic during pregnancy, asking few questions Mormon Pregnancy is viewed as a time of personal and family growth, as it creates a connection with eternity. Orthodox Jew Considered ritually impure after her water breaks, so her husband is unlikely to be in the delivery room. Instead, he prays in the waiting area

Postpartum Care and Education: y y Hemorrhage Report heavy clots or spurts of bleeding. Expect some blood in vaginal discharge for 3-6 weeks Infection or other illness Watch for a temp over 100.4; sudden increase in perineal pain; unusually heavy or foul smelling vaginal discharge; hot, tender, or red breast; dysuria; pain or swelling in the legs; chest pain or cough

Newborn Care and Education: y APGAR Appearance (color) Pulse (heart rate) Grimace (reflex irritability) Activity (muscle tone) Respiration (respiratory effort)

Warning Signs of Complications * Sunken or swollen soft spots on the head * Has a fever higher than 100.4 * Vomits more than once in 24 hrs * Is unable to keep down food or water * Is not breathing easily

Developmental Stages and Transitions: INFANTS: (1-12 months) y Expected Development o Physical May have swollen genitals and breasts, a misshapen head, milia on face; exhibits sucking, grasping reflexes; able to focus; learns to grasp with thumb and finger o Cognitive and Psychosocial Vocalizes sounds (coos); begins to respond selectively to words Deviations o Not rolling from tummy to side at 10 months o Not transferring toys from hand to hand at 9 months Special Needs o Parent-Infant bonding

Preschool Age Children (1 to 4 yrs) y Expected Development o Physical 0 Enjoys physical activities; has increasing bladder and bowel control; can manipulate small objects with hands; is able to dress and undress self; has refined coordination o Cognitive and Psychosocial - Becomes aware of limits: says no often; has a limited vocab of 500 to 3,000 words in 3 to 4 word sentences; believes that adults know everything; can use a pencil to draw shapes; is eager to learn; has a strong desire to please adults Deviations o Does not walk at 18 months o Does not speak at least 15 words o Does not imitate actions or words or follow simple instructions o Talks excessively about violence or other mature topics o Not interested in pretend play or other children Special Needs o Security and consistency of environment o Protection from harmful situations caused by natural curiosity o Some allowance for independence and playtime

School Age Children (5 to 12 yrs) y Expected Development o o y Deviations o o Special Needs o o Bed-wetting late into childhood Verbal or outward problems; important to discover at earliest stages Developing scoliosis Vision and hearing problems; important to discover at earliest stages Physical Able to do a series of motions to perform activities; such as skipping or jumping rope Cognitive and Psychosocial Able to follow directions; knows full name, age and address; tends to identify with parent of the same sex

Adolescents (13 to 18 yrs) y Expected Development o Physical Shows increased interest in personal attractiveness; develops secondary sexual characteristics o Cognitive and Psychosocial Struggles with sense of identity; forms strong peer allegiances; engages in risk-taking due to a sense of immortality Deviations o Persistent misbehavior, especially in school o Aggression Special Needs o Understanding of puberty s effect on disposition and personality

Adults (19 to 64 yrs) y Expected Development o Physical General slowing of physical functioning o Cognitive and Psychosocial General slowing of cognitive functioning; Erikson s stage of ego integrity vs despair; interpersonal relationships continue despite changes and losses Deviations o Despair can arise from remorse for what might have been Special Needs o Learning lessons of successfully retiring from the workplace o Keeping or losing long-term relationships

y y

Old Older Adults (85+) y Expected Development o Physical Continued decline of physical functioning o Cognitive and Psychosocial Continued decline of cognitive functioning: marked increase in changes and losses in relationships Deviations o Suicidal thoughts and behavior Special Needs o Acceptance of life s accomplishments and declines

y y

PHYSIOLOGICAL INTEGRITY: PHARMACOLOGICAL THERAPIES Blood and Blood Products y Procedure for Autologous Blood Donation: o Four to six weeks prior to surgery o Every 3 days if hemoglobin levels are satisfactory o Good for rare blood types, transfusion reactions, prevention of blood bourne disease transmission o Not good if client has an acute infection, a low hemoglobin count, or CV disease Various Blood Components o Whole Blood Not normally used; mainly situations of major hemorrhage o RBCs Anemia; blood loss o FFP Coagulation deficiency o Platelets Thrombocytopenia o Albumin Shock, blood loss, low protein levels due to surgery or liver failure o Cryoprecipitate Blood loss or immediately prior to an invasive procedure in clients with significant hypofibrinogemia Blood Administration Procedure 1. Verify client consent 2. Check client s baseline vital signs 3. Check physician s order, if one exist 4. Identify a stable vein, and then choose a needle with the proper gauge 5. Set up equipment 6. Obtain correct component from blood bank 7. Verify client identification and related information (use 2nd nurse to double check) 8. Hang blood 9. Begin transfusion at a slow rate (2 mL/min) 10. Monitor client VS 11. After 15 minutes, increase the rate of the infusion 12. Monitor client VS and lung sounds for one hour after transfusion is complete 13. Document all activities in the client s medical record

TPN o o o o o o o There is a risk of pneumothorax during catheter insertion Examine the insertion site during each shift for signs of infection Do not use the IV line for anything other than TPN Inspect the bad of solution for particles prior to hanging Monitor the client s glucose level Measure daily weight to determine/adjust fluid balance Monitor other lab results, such as electrolytes, protein, prealbumin/albumin, creatinine, lymphocytic count, and liver function

* Do not discontinue TPN abruptly. Possible complications include fluid overload, air embolism, infection/sepsis, hyperglycemia, and hypoglycemia.