Cultural and Spiritual Nursing Care: Using a Medical Interpreter

Chapter 35

Advocacy

1. Use only a facility-approved medical interpreter. Do not use the client's family or friends or a nondesignated employee.
2. Inform the interpreter about the reason for and the type of questions that will be asked.
3. Allow time for the interpreter and the family to be introduced and become acquainted.
4. Ask one question at a time.
5. Use lay terminology if possible, knowing that some words may not have an equivalent word in the client's language.

Legal Responsibilities: Continuity of Care

Chapter 4

Concepts of Management

1. Nurses should use the formal chain of command to verbalize concerns related to assignment in light of current legal scope of practice, job description, and area of competence.
2. Nurses should refuse to practice beyond the legal scope of practice.
3. Nurses must ensure the clients understand their rights and protect their client's rights.
4. Nurses are accountable for protecting the rights of clients.
5. Nurses must ensure the clients understand their rights and protect their client's rights.

Admissions, Transfers, and Discharge: Initiating Discharge Planning

Chapter 9

Continuity of Care

1. Discharge planning should begin on admission - unless it is long-term care.
2. Assess whether or not the client will be able to return to his previous residence.
3. Determine whether or not the client will need to have someone to assist him at home, and if he has that person.
4. Assess the residence to see if the client will need adaptations or specific equipment.
5. A client who is legally competent has the right to leave the facility at any time.

Information Technology: Correct Documentation

Chapter 5

Continuity of Care

1. Subjective data can be documented as direct quotes, within quotation marks, or summarized and identified as the information of the client's statement.
2. Objective data should be descriptive and should include what the nurse sees, hears, feels, and smells.
3. Information and facts should be documents precisely - only abbreviations and symbols approved by the Joint Commission.
4. Never pre-chart an assessment, intervention, or evaluation.
5. Communicate documented information in a logical sequence.

Information Technology: End of Shift Report

Chapter 5

Continuity of Care

1. Formats include face-to-face, audiotaping, or presentation during walking rounds in each client's room.
2. A report should include significant objective information about the client's health problem.
3. It should proceed in a logical sequence.
4. There should be no gossip or personal opinions.
5. Changes in medications, treatments, procedures, and discharge plans should be related.

Safe Medication Administration and Error Reduction: Documentation

Chapter 47

Reporting of Incident/Event/Irregular Occurrence/Variance

1. Do not use od, qd, qod, or qhs. Write out words.
2. So not write subq, write subcut.
3. Do not write IN or IJ.
4. Write out greater than or less than.
5. Do not use / to indicate per, write out per.

Pharmacokinetics and Routes of Administration: Instructing Client to Self-Administer Insulin

Chapter 46

Safe Use of Equipment

1. When drawing up regular and NPH insulin, inject air into NPH, inject air into regular, draw up regular, draw up NPH.
2. Insulin is injected subcutaneously (also heparin).
3. Inject into adequate fat bad (abdomen, upper hip, lateral upper arms, thighs).
4. Clear insulin must be drawn up before cloudy insulin.
5. Roll insulin between hands prior to administering.

Infection Control: Caring for a Client with Methicillin-Resistant Staphylococcus Aureus

Chapter 11

Standard Precautions/Transmission-Based Precautions/Surgical Asepsis

1. Use a respirator for clients with TB.
2. Rinse equipment first in running cold water, then in warm water with soap.
3. Masks, eye protection, and face shields are required when care may cause splashing or spraying of body fluids.
4. Avoid overuse of antimicrobials.
5. Teach client about infection control measures at home, self-administration of medications, and any complications that need immediate attention.

Medical and Surgical Asepsis: Preparing a Sterile Field

Chapter 10

Standard Precautions/Transmission-Based Precautions/Surgical Asepsis

1. Prolonged exposure to airborne micro-organisms can make sterile items nonsterile.
2. Only sterile items may be in a sterile field.
3. Consider any items held below waist or above the chest to be nonsterile.
4. Outer wrappings and 1-inch edges of packaging that contains sterile items are not sterile.
5. Do not reach across or turn your back on a sterile field.

Mobility and Immobility: Steps for Transferring a Client

Chapter 40

Mobility/Immobility

1. First, determine how capable a client is of participating in the transfer.
2. Explain the transfer process so the patient understands what will happen.
3. Ensure all equipment is ready and functioning properly before beginning to move the patient.
4. Maintain correct posture, use appropriate body mechanics and lifting techniques, and use assistive devices whenever possible.
5. When moving patients from a bed to a wheelchair or a gurney, put all brakes in the locked position to prevent falls and injuries.

Pharmacokinetics and Routes of Administration: IM Injections

Chapter 46

Medication Administration

1. Sites with high blood perfusion have rapid absorbtion. IM has risk for infection, though.
2. IM injections are appropriate for irritating medications, solutions in oils, and aqeous suspensions.
3. Use a needle size 18 to 27 gauge (usually 22 to 25), length 1 to 1.5 inches long, and injected at 90 degree angle.
4. Volume injected is usually 1-3 ml; if a greater amount is required, it should be divided into two syringes.
5. Most common sites include ventrogluteal, deltoid, and vastus lateralis (pediatric). Dorsogluteal is contraindicated.

Specimen Collection for Glucose Monitoring: Using Correct Technique

Chapter 52

Diagnostic Tests

1. Outer edge of the fingertip is the most common site.
2. Rotate sites to avoid ongoing tenderness.
3. Cleanse the site with warm water and soap or antiseptic swab (not alcohol).
4. Wipe away the first drop of blood.
5. Hold finger in dependent position.

IV Therapy: Interventions to Promote Infusion

Chapter 49

Potential for Complications of Diagnostic Tests/Treatments/Procedures

1. Infiltration - pallor, local swelling, decreased skin temperature, damp dressing, slowed rate of infusion. Stop infusion and remove catheter, elevate, restart infusion proximal to the site.
2. Phlebitis - edema, throbbing, burning, increased skin temperature, red line up arm. Discontinue and remove catheter, apply warm compress, culture site.
3. Fluid overload - JVD, increased BP, tachycardia, SOB, crackles, edema. Stop infusion and raise head of bed.
4. Cellulitis - pain, warmth, edema, induration, red streaking, fever, malaise, chills. Discontinue and remove, elevate and apply warm compress, obtain specimen.
5. Embolus - missing catheter tip, severe pain at side with migration. Place tourniquet high on extremity to limit venous flow, save the catheter, prepare for removal.

Fluid and Electrolyte Imbalances: Findings to Report

Chapter 57

Fluid and Electrolyte Imbalances

1. Hyponatremia - coma, seizures, respiratory arrest. Hypernatremia - serious neuro, endocrine, and cardiac disturbances.
2. Hypokalemia - PVCs, hyperthermia, hypotension, muscle weakness and cramping, parasthesias. Hyperkalemia - Cardiac arrhythmias and cardiac arrest.
3. Hypocalcemia - painful muscle spasms, parasthesias, Chvosteks sign (facial twitching) and Trousseaus sign (blood pressure cuff). Hypercalcemia - decreased reflexes, bone pain, flank pain (renal calculi).
4. Hypomagnesemia - hyperactive DTR, C and T signs, increased cardiovascular symptoms. Hypermagnesemia - diminished DTR, muscle paralysis, decreased cardiovascular signs.
5. Dehydration indicates increased protein, BUN, electrolytes, and glucose.