Delegation - ✔✔ Right Person, Right Task, Right Circumstance, Right Communication, Right Supervision
AP's: vitals and ALDs
PN: stable clients
... [Show More] and the expected outcome
Bleeding - ✔✔ Stabilize object
Colorectal Screening - ✔✔ Sigmoid: 5 yrs Colon: 10 years ages 50-75
Manual BP - ✔✔ 1 Inch above antecubital space
Manual Systolic Measurement - ✔✔ Palpate radial pulse, inflate until pulse disappears, inflate another 30 mmHg, release and note when pulse is palpable again
Clear Diet - ✔✔ Fruit juices, gelatin, broth
Cane Use - ✔✔ On Stronger side. Move can, move weak leg, move stronger leg past cane
Move 6-10 inches forward
Infiltration - ✔✔ pallor, swelling, decrease skin temp
stop, remove, elevate, ROM, cold compress, restart
hypoxemia - ✔✔ early: Tachypnea, increased BP
Late: Bradypnea, decrease BP
Hypernatermia Risk Factors - ✔✔ older age, decrease total body water content, inadequate fluid intake, altered thirst
Seizure precautions - ✔✔ Rescue equipment at bedside
Fire Safety - ✔✔ R: Rescue A: Alarm C: contain E: extinguish
P: Pull A: Aim S: Squeeze S: Sweep
Radiation Precautions - ✔✔ wear monitoring badge for exposure
Client Transfer - ✔✔ Fold arms of patient across chest while lifting head
Positioning - ✔✔ Prone: on stomach, post lumbar puncture, tonsillectomy
Supine: On back, spinal cord injury
Crutches - ✔✔ 3 inch widths between axilla and top of crutch, hand grips with elbows at 30 degree
Walker - ✔✔ Wrist even with hand grips
Standard Precautions - ✔✔ Teir One
protective equipment when in contact with blood and bodily fluids, dispose PPE in clients room, clean spills with bleach water
Transmission Precautions - ✔✔ Airborne: N95 mask
Droplet: Mask within 3 feet of patient
Contact: gloves and gown
Order of PPE - ✔✔ On: gown, mask, goggles, gloves
OFF: gloves, goggles, gown, mask
Precautions for Diseases - ✔✔ AIDS/HIV: standard
Varicella: airborne
C-diff: contact
Hep A: standard
Hep B: standard
Hep C: standard
Herpes simplex: standard
shingles: airborne
Measles: airborne
Meningococcal: droplet
MRSA: contact
Pneumonia: droplet
Respiratory syncytial virus: droplet
Rotovirus: contact
Rubella: droplet
Salmonellosis: contact
Shigellosis: contact
TB: airborne
Vancomycin resistant enterococci: contact
Screening Guidelines - ✔✔ Physical: annually
Dental: 6 months
BP: 2 years
BMI: every visit
Cholesterol: 5 years
glucose: 3 yrs
colorectal: 10 yrs
pap: 3 yrs
breast exam: 3 yrs
mammogram: yearly
testicular examination: monthly
prostate and rectal: yearly
Morse Fall Scale - ✔✔ Secondary Diagnosis, mental status, IV locks, ambulatory aid, history of falls, gait
Sodium - ✔✔ 135-145
sezuire precautions
Potassium - ✔✔ 3.5-5
weakness, restlessness, irritability
Magnesium - ✔✔ 1.3-2.1
facial flushing, calcification
Calcium - ✔✔ 9.0-10.5
bone pain, constipation
Pressure Ulcers - ✔✔ inspect every 2 hrs, barrier cream, turn every 2 hrs, 2,000-3,000 L/day, Vitamins A, C, zinc, shift weight every 15 mins
Six Rights of Medication Administration - ✔✔ Right Med, Right Dose, Right Route, Right Documentation, Right Patient, Right Time
Guidelines for IV - ✔✔ never administer meds through tubing being used for blood products
Complications with IV's - ✔✔ Infiltration, extravasation, phlebitis, thrombophlebitis, hematoma, catheter embolism
Infiltration Prevention - ✔✔ use smallest catheter for prescribed therapy, stabilize port-access, assess blood return
Extravasation Prevention - ✔✔ know vesicant potential before giving medication
Phlebitis Prevention - ✔✔ Rotate, secure, aseptic
Hematoma Prevention - ✔✔ avoid veins not seen
Catheter embolism Prevention - ✔✔ do not reinsert
Complications of central venous catheter - ✔✔ Pneumothorax (ultrasound), air embolism (lie flat, valsalva maneuver) lumen occlusion (flush properly), bloodstream infection (sterile technique)
Complications of PICC - ✔✔ Occlusion, dislodges, phlebitis, embolism, infection
Care for TPN - ✔✔ serum glucose levels every 4-6 hrs, change dressing every 48-72 hrs, change IV tubing every 24 hrs
Drug Classes - ✔✔ PRIL (ACE inhibitors)
LAM (Benzos)
ASONE (Corticosteroid)
IDE (Oral hypoglycemic)
PRAZOLE (PPI)
ASE (Thrombolytics)
PHYLLINE (bronchodilators)
ARIN (anticoagulants)
DINE (antiulcer)
ZINE (antihistamine)
TYLINE (trylic antidepressant)
PRAM (SSRIs)
Side Effects - ✔✔ ACE Inhibitors: Angioedema
Benzos: Anterograde amnesia
Beta Blockers: bronchospasm
Ciprofloxacin: tendon rupture
Digoxin: Yellow rings
Doxycyline: tooth discoloration
Furosemide: hypokalemia
Lithium: tremors
Tobramycin: ototoxicity
Valacyclovir: thrombotic thrombocytopenia purpura [Show Less]