Safe and Effective Care- Kaplan NCLEX
Client's Bill of Rights- Privacy
Right to be left alone
Right to make personal choices
For employees, can only
... [Show More] verify employment and comply with legal investigation
Client's Bill of Rights- Informed consent
Age (adult) and competent (can make choices and understand consequences)
Voluntary
Cannot sign informed consent if drinking alcohol or pre-medicated
May not be required in emergencies
Client's Bill of Rights- Minors who can provide consent for treatment
Married
Over a specific age for STD, HIV, AIDS, drug and alcohol treatment
Emancipated and mature minors
Minors seeking birth control
Minors seeking psych services
Pregnant
Clients must be informed of this before signing for a procedure:
Explanation of treatment
Expected results
Potential benefits
Possible alternatives
Answers to questions
Statements that consent can be withdrawn at any time
Legal Responsibility of informed consent
Rests with the individual who will perform treatment
Nurse can witness if client is informed about upcoming treatment
Self-determination Act
federal law requiring health care facilities to provide written info to adult clients about their rights to make healthcare decisions
Aggressive Treatment
Extraordinary support measures used to maintain individuals physiologic processes
May be withheld to avoid prolonging life without dignity
Supportive care is provided to promote comfort
Living Will
legal document that indicates
1) treatment or life-saving measures to be used if individual's ability to make decisions is lost due to terminal illness or permanent unconscious state
2) who is authorized to make health care decisions
Durable Power of Attorney for Healthcare
Competent adult appoints surrogate or proxy in the event that the adult becomes incompetent
Omnibus Budget Reconciliation Act
provides clients with right to be free from physical or chemical restraints imposed for purpose of discipline or convenience
Informed consent- restraints
If unable to consent, consent of proxy must be obtained after full disclosure of risks and benefits
False Imprisonment
restraint of client without informed consent or sufficient justification
Nursing considerations for restraints
Assess and document need for restraints (risk for falls, risk of injury to others, potential to remove IV lines)
Consider and document use of alternative measures
HCP order is required specifying duration and circumstances
Cannot order PRN restraints
Remove for skin care and ROM
Evaluate need every 4 hours
Alternative measures to restraints
Reorientation
Family Involvement
Frequent assistance with toileting
Negligence
unintentional failure of individual to perform an act that a reasonable person would or would not perform in similar circumstances; can be act of omission or commission
Malpractice
professional negligence involving misconduct or lack of skill in carrying out professional responsibilities
Required elements of Malpractice (4)
1) Duty- legal relationship bet. client and nurse
2) Breach of Duty
3) Causation
4) Injury
Invasion of privacy
release of info to an unauthorized person without the client's consent
Assault
intentional threat to cause harm or offensive unwanted contact
Battery
intentional touching without consent
Nurse Practice Acts
define "reasonable care" in each state, scope of practice, roles, rules, educational requirements
Tarasoff Act
duty to warn of threatened suicide or harm to others
Good Samaritan Laws
limit the liability of professionals in emergency situations
Who do you notify if more nurses are needed for safe client care?
Supervisor
Quality Improvement
involves organized incident reporting
Focused team- 5-10 people
What does risk management focus on?
Non-compliance, informed consent, right to refuse treatment
Case Manager
Doesn't provide direct patient care
Supervises care provided
Coordinates, communicates, collaborates, solves problems
Facilitates client care for a group of clients
Assignment
allocating to healthcare team members work required to care for group of individuals
Delegation
responsibility and authority for performing a task is transferred to another individual who accepts that responsibility and authority
Steps of Delegation
Define task to be delegated
Determine who should receive delegated task
Identify what task involves, determine complexity
Match task to individual
Provide clear communication
How to properly delegate
Establish eye contact
Describe task using "I" statements
Provide what, when, where, how
Identify what changes or incidents need to be brought to the delegator's attention
Which tasks should you NOT delegate?
Total control
Discipline issues
Confidential tasks
Technical tasks
Controversial tasks
During a crisis
Rights of Delegation
Task
Person
Time
Information
Supervision
Followup
Tasks to delegate to LPN
Perform procedures according to protocol
Differentiate normal from abnormal
Care for stable clients with predictable outcomes
Has knowledge of asepsis and dressing changes
Tasks to delegate to CNA
Assist with direct client care activities (bathing, transferring, ambulating, feeding, toileting, vitals, height, weight, I/O, transporting, stocking supplies)
Incident Reports
Accurate and comprehensive report on any unexpected or unplanned occurrence that affects or could potentially affect a client, family member, or staff member
Charting Considerations for Incident Reports
Don't include a reference
Don't use words such as "error" or "inappropriate" or inflammatory words
If adverse reaction, chart followup note updating client's status
Document status changes until returned to original status
Sequence of Incident Reports
Person discovers and reports actual or potential risk
Risk Manager receives report within 24 hours
Investigation of incident is conducted
Referring HCP and risk management committee consult together
Common situations that require an incident report
Medication errors, complications from diagnostic or treatment procedures, incorrect sponge count, Falls, burns, break in aseptic technique, failure to report change in client's condition
ANA code of ethics
Respect for human dignity
Right to privacy
Nurse safeguards client
Nurse assumes responsibility
Maintains competence in nursing
Autonomy
support of client's independence to make decisions and take action for themselves
Beneficence
Duty to help others by doing what is best for them; client advocacy for refusal of care, autonomy overrides beneficence
Non maleficence
"do no harm" act with empathy toward client and staff without resentment or malice
Justice
use available resources fairly and reasonably
Veracity
communicate truthfully and accurately
Fidelity
following through on what the nurse says will be done; carefully attending to the details of the client's care
Types of Learning (3)
Cognitive
Psychomotor
Affective
When does discharge planning begin?
Begins with first encounter
Local Assessment of Infection
heat, redness, pain/tenderness, swelling, possible drainage, abscess, cellulitis
Systemic Assessment of Infection
Fever, malaise, weakness, WBC > 10,000, increased neutrophils, elevated ESR, highly sensitive C-reactive protein
Erythrocyte sedimentation rate (ESR) normal
15-20 mm/h
When should cultures be done?
obtain BEFORE onset of antibiotic therapy
What causes most hospital-acquired infections?
Staphylococcus aureus
When are standard precautions used?
with ALL clients
Chickenpox (Varicella) Incubation
13-17 days
Varicella S/S
slight fever, malaise, anorexia, rash begins as macule then papule then vesicle with all 3 stages resent at any one time
Varicella Transmission
Direct contact, airborne, contaminated object
Can spread 2 days before rash
Varicella Nursing Considerations
Isolate until all vesicles are crusted
DO NOT USE aspirin
Use Tylenol and calamine lotion
Diphtheria Incubation
2-5 days
Diphtheria S/S
resembles common cold, low grade fever, hoarseness, malaise, pharyngeal, characteristic white/gray pharyngeal membrane
Diphtheria Transmission
Contact and droplet
Diphtheria Nursing Considerations
Precautions until 2 successful negative nose and throat cultures are obtained
Complete bed rest, WATCH AIRWAY, provide humidification, suctioning
Diphtheria medication given
Antitoxin therapy
Pertussis (Whooping cough) Incubation
5-21 days, usually 10
Pertussis S/S
severe cough with high-pitched "whooping" sound, especially at night, lasts 4-6 weeks, vomiting
Pertussis Transmission
Contact and droplet
Pertussis Nursing Considerations
Hospitalize infants, bed rest and hydration
Maintain high humidity, restful environment, suction, oxygen
Pertussis Complications
Pneumonia, weight loss, dehydration, hemorrhage, hernia, airway obstruction
Pertussis medications given (2)
Erthromycin and pertussis immune globulin
Rubella (german measles) Incubation
14-21 days
Rubella S/S
Maculopapular rash appears first on face and then on rest of body, S/S subside 1st day after rash
Is there a prodromal phase in kids with Rubella?
No
Is there a prodromal phase in adolescents with Rubella?
Low fever and sore throat
Rubella Transmission
Droplet and contact
Rubella Nursing Considerations
Isolate child from pregnant women, comfort measures like antipyretics and analgesics
Rubella Complications
Rare: arthritis and encephalitis
Rubeola Incubation
10-20 days
Rubeola Prodromal S/S
Fever and malaise followed by cough and Koplik's spots on buccal mucosa
Rubeola S/S
Erthyematous maculopapular rash with face first affected; turns brown after 3 days when S/S subside
Rubeola Transmission
Airborne and seizure precautions
Rubeola Nursing Considerations
Isolate until 5th day, bed rest 3-4 days
dim lights, humidifier for room, keep skin clean, maintain hydration
Rubeola medication given
Antipyretics
Scarlet fever Incubation
2-4 days
Scarlet fever Prodromal Phase S/S
High fever with vomiting, chills, malaise, enlarged tonsils with strawberry tongue
Scarlet fever S/S
Tiny red lesions that become generalized and then desquamate; rash appears within 24 hours
Scarlet fever Transmission
Droplet and contaminated articles
What causes Scarlet fever?
Group A beta-hemolytic streptococci
Scarlet fever Nursing Considerations
Soft diet, Analgesics for sore throat, oral antibiotic therapy
Scarlet fever medication given
Penicillin or erythromycin
Mononucleosis Incubation
4-6 weeks
Mono S/S
malaise, low grade fever, enlarged lymph nodes, sore throat, flu-lie aches
Mono Transmission
Contact with oral secretions
Mono Nursing Considerations
Tell family to avoid contact with saliva for 3 months
Avoid strenuous exercise
Mono Complications
Encephalitis and spleen rupture
Tonsillitis (strep) S/S
Fever, white exudate on tonsils, positive culture GpA strep
Strep Complications
Rheumatic fever, glomerulonephritis
Strep med given
antibiotics
Mumps Incubation
14-21 days
Mumps S/S
Malaise, H/A, fever, parotid gland swelling
Mumps transmission
Contact with saliva, droplet
Mumps Nursing Considerations
soft, bland diet, isolate before and after appearance of swelling
Mumps complications
Deafness, meningitis, encephalitis, sterility
When to use clean, non-sterile gloves?
Blood, bodily fluids, secretions, contaminated items or if gloves are torn or heavily soiled
Who gets a private room?
Poor hygiene habits, contaminates the environment, can't assist in maintaining infection control (infants, children, altered mental status)
What to consider when cohorting (shared room)
consider epidemiology and mode of transmission of the infected organism
Airborne Precautions
private room with negative air pressure, door closed, wear N-95 HEPA filter
can cohort with same organism
Airborne Examples
Measles (rubeola), TB, varicella, shingles (disseminated zoster)
Droplet Precautions
Private room or with client with same infection
Maintain 3 feet between infected client and visitors or wear mask if less than 3 feet
Door can be open
Place mask if transported
Droplet Examples
Diphtheria, Strep pneumonia, pneumonia, meningitis, Flu Type B, Rubella, mumps, pertussis, influenza
Contact Precautions
Clean, nonsterile gloves, Private room or with same infection, use gown if clothing will have contact
Contact Examples
MRSA, Vancomycin resistant, herpes simplex, herpes zoster, C-diff, RSV, pediculosis, scabies, excessive wound drainage, fecal incontinence, rotavirus, hepatitis A, H influenza pneumonia
Tuberculosis S/S
fatigue, nausea, night sweats, irritability, cough with sputum (may be streaked with blood), chest tightness, dull aching chest, dyspnea
TB diagnostic test
Chest X-ray
Quantiferon TB Gold test (takes 24 hr)
Skin testing
What causes TB?
Mycobacterium TB
TB Risk Factors
Immunocompromised
IV drug abuser
Persons in institutions
Lower socioeconomic groups
Immigrants (Latin Amer, Asia, Africa)
Close contact with active TB
Mantoux Test
Intradermal
Read in 48-72 hours
15 mm or greater= positive
Greater than 5 mm for AIDS= positive
Greater or equal to 10 mm for elderly or immunocomp= may be positive
look for induration
TB therapy under 35 y.o. (inactive, susceptible, newly infected)
6-9 months therapy with isonazid
Not recommended over 35 y.o.
TB therapy for chemotherapy pts.
isoniazid, rifampin, ethambutol and streptomycin
TB nutrition
increased iron, protein, vitamins B and C
Hepatitis S/S
Jaundice, RUQ pain, tenderness, clay colored stool, pruritus (bile salts under skin), fatigue, perc. liver biopsy done
Hep A transmission
fecal-oral route, shellfish from contaminated water, poor sanitation, oral-anal sex activity
Hep A treatment
Gamma globulin
Hep B transmission
blood and body fluids, maternal-fetal, sex
Hep B complications
cirrhosis and liver cancer
Hep C transmission
Blood and body fluids, IV drug users
Hep C S/S
may be asymptomatic
Hepatitis nutrition
low in fat, high in calories, carbs and protein; no alcohol
Hepatitis meds
Vitamin K, antiviral drugs interferon and Iamivudine
Lyme Disease Stage 1
concentric rings develop, flu-like S/S
Order to take off equipment:
Untie gown, remove gloves, remove mask, take gown off from inside
Risk Factors for Nosocomial Infections
Burns, NG tubes, foley, abdominal surgery, diabetes, alcoholism
Common sign of Hep A in kids?
Anorexia
Lyme Disease medications given
Doxycycline, ceftriaxone, azithromycin
Opportunistic infections
P. jiroveci pneumonia
C. albicans stomatitis
Cytomegalovirus
Kaposi's Sarcoma * common
Genital Herpes Nsg. Considerations
sitz baths, monitor pap smears, virus can survive up to 3-14 days on objects
HIV/AIDS nutrition
high protein and calories
HIV/AIDS transmission
Contact
Who should you treat first with poison control?
Client first, then poison
What are contraindications for inducing vomit in poison control?
Lighter fluid, kerosene, paint remover, acid/alkali drain cleaner
What will delay vomiting? (poison control)
Milk
Who should receive cardiac monitoring (poison control)?
Tricyclic antidepressant or phenothiazine ingestion
What will help mercury, lead and arsenic be eliminated from the body?
chelating agent that is eliminated by kidneys
Aspirin (salicylate) poisoning S/S
tinnitis, nausea,sweating, dizziness, H/A, temp, hyperventilation
Aspirin toxicity level
150-200 mg/kg
4 grams may be fatal to child
How to eliminate aspirin from the body?
Induce vomiting with activated charcoal
IV sodium bicarbonate
Acetaminophen poisoning levels
begins at 150 mg/kg
Acetaminophen antidote
N-acetylcysteine - most effective in 8-10 hrs.
give within 24 hours, PO
Lead toxicity S/S
irritability
sleepiness
N/V
constipation
decreased activity
increased ICP
Who absorbs more lead: children or adults?
Children
What do you treat first for hazardous materials causing immediate threat to life?
Client, then decontaminate
** healthcare workers put on protective garments
Hazardous materials that are immediate threats to life
Chlorine, cyanide, ammonia, hydrogen sulfide, nitrogen dioxide, phosgene, organopphosphate insecticides
What do you treat first for hazardous materials with cancer causing potential?
Decontaminate, then treat client
Hazardous material with cancer-causing potential
Poly-chlorinated biphenyls
How long is a rear-facing car seat used?
until child is 2 years old or child reaches height and weight allowed
Triaging- Red
unstable (occluded airway, active hemorrhaging)
Triaging- Yellow
stable who can wait 30-60 min for treatment (moderate burn, eye injury)
Triaging- Green
stable (walking wounded)
Triaging- Black
unstable with massive injuries that will probably prove fatal (massive body trauma)
support and comfort measures
Smallpox transmission
Airborne, contact, and standard precautions [Show Less]