PREDICTOR FOCUSED REVIEW
Management of Care – (9) Advance Directives – (1) Legal Responsibilities: Purpose of a Living Will (RM FUND 9.0 Chp 4) A
... [Show More] living will is a legal document that expresses the client’s wishes regarding medical treatment in the event the client becomes incapacitated and is facing endof-life issues. Most state laws include provisions that protect health care providers who follow a living will from liability.
Assignment, Delegation and Supervision – (2) Delegation and Supervision: Delegating Tasks to an Assistive Personnel (RM
FUND 9.0 Chp 6) Examples of tasks nurses may delegate to Aps (provided the facility’s policy and state’s practice guidelines permit) Activities of daily living (ADLs) – bathing, grooming, dressing, toileting, ambulating, feeding (without swallowing precautions), positioning Routine tasks – bed making, specimen collection, intake and output, vital signs (for stable clients)
Managing Client Care: Delegation Strategy for Effective Task Management (RM Leadership 7.0 Chp 1) Consideration for selection of an appropriate delegate include the following: education, training, and experience; knowledge and skill to perform the task; level of critical thinking required to complete the task; ability to communicate with others as it pertains to the task; demonstrated competence; the delegatee’s culture; agency policies and procedures and licensing legislation (state nurse practice acts)
Case Management – (1) Cardiovascular Disorders: Tetralogy of Fallot (RM NCC RN 10.0 Chp 20) Tetralogy of Fallot – four defects that result in mixed blood flow: Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy Cyanosis at birth: progressive cyanosis over the first year of life. Systolic murmur. Episodes of acute cyanosis and hypoxia (blue or “Tet” spells)
Surgical procedures – shunt placement until able to undergo primary repair; complete repair within the first year of life
Collaboration with Interdisciplinary Team – (1) Communicable Diseases, Disasters, and Bioterrorism: CDC Reportable Diagnoses (RM CH RN 7.0 Chp 6)
1 | P a g eAnthrax. Botulism. Cholera. Congenital rubella syndrome (CRS). Diphtheria.
Giardiasis. Gonorrhea. Hepatitis A, B, C. HIV infection. Influenza-associated
pediatric mortality. Legionellosis/Legionnaires’ disease. Lyme disease.
Malaria. Meningococcal disease. Mumps. Pertussis (whooping cough).
Poliomyelitis, paralytic. Poliovirus infection, nonparalytic. Rabies (human or
animal). Rubella (German measles). Salmonellosis. Severe acute respiratory
syndrome-associated coronavirus disease (SARS-CoV). Shigellosis. Smallpox.
Syphilis. Tetanus/C. tetani. Toxic shock syndrome (TSS) (other than
Streptococcal). Tuberculosis
(TB). Typhoid fever. Vancomycin-intermediate and vancomycin-resistant.
Staphylococcus aureus (VISA/VRSA)
Continuity of Care – (1)
Information Technology: Change-of-Shift Report (RM FUND 9.0 Chp 5)
• Nurses give this report at the conclusion of each shift to the nurse assuming
responsibility for the clients.
Formats include face to face, audiotaping, or presentation during
walking rounds in each client’s room (unless the client has a roommate
or visitors are present)
An effective report should: include significant objective information
about the client’s health problems; proceed in a logical sequence;
include no gossip or personal opinion; relate recent changes in
medications, treatments, procedures, and the discharge plan
Establishing Priorities – (1)
Managing Client Care: Determining Priority Care for a Group of Clients (RM
Leadership 7.0 Chp 1)
• Prioritize systemic before local (“life before limb”)
Prioritizing interventions for a client in shock over interventions for a
client who has a localized limb injury
• Prioritize acute (less opportunity for physical adaptation) before chronic
(greater opportunity for physical adaptation)
Prioritizing the care of a client who has a new injury/illness (e.g. mental
confusion, chest pain) or an acute exacerbation of a previous illness
over the care of a client who has a long-term chronic illness
• Prioritize actual problems before potential future problems
Prioritizing administration of medication to a client experiencing of
medication to a client experiencing acute pain over ambulation of a
client at risk for thrombophlebitis
• Listen carefully to clients and don’t assume
Asking a client who has a new diagnosis of diabetes mellitus what he
feels is most important to learn about disease management
• Recognize and respond to trends vs. transient findings
Recognizing a gradual deterioration in a client’s level of consciousness
and/or Glasgow Coma Scale score
2 | P a g e• Recognize indications of medical emergencies and complications vs.
expected findings
Recognizing indications of increasing intracranial pressure in a client
who has a new diagnosis of a stroke vs. the findings expected following
a stroke
• Apply clinical knowledge to procedural standards to determine the priority
action
Recognizing that the timing of administration of antidiabetic and
antimicrobial medications is more important than administration of
some other medications
Ethical Practice – (1)
Professional Responsibilities: Demonstration of Veracity (RM Leadership 7.0 Chp
3) Veracity: the nurse’s duty to tell the truth
Legal Rights and Responsibilities – (1)
Professional Responsibilities: Rights of Clients (RM Leadership 7.0 Chp 3)
Client rights are the legal guarantees that clients have with regard to their
health care
Clients using the services of a health care institution retain their rights
as individuals and citizens of the United States. The America Hospital
Association (AHA) identifies client rights in health care settings in the
Patient Care Partnership (www.aha.org)
Residents in nursing facilities that participate in Medicare programs
similarly retain resident rights under statutes that govern the operation
of these facilities
Nurse are accountable for protecting the rights of clients. Situations that
require particular attention include informed consent, refusal of treatment,
advance directives, confidentiality, and information security.
Safety and Infection Control – (5)
Accident/Error/Injury Prevention – (2)
Medications Affecting Urinary Output: Indications for the Use of a Diuretic (RM
Pharm RN 7.0 Chp 19)
• High-ceiling loop diuretics work in the ascending limb of loop of Henle –
block reabsorption of sodium and chloride and prevent reabsorption of
water. Causes extensive diuresis even with severe renal impairment
• They are used when there is an emergent need for rapid mobilization of
fluid – pulmonary edema caused by heart failure; conditions not responsive
to other diuretics, such as edema caused by liver, cardiac, or kidney disease;
or hypertension
Unlabeled use – hypercalcemia
Seizures: Maintaining Seizure Precautions (RM NCC RN 10.0 Chp 13)
• Seizure precautions for any child at risk – pad side rails of bed, crib, and
wheelchair; keep bed free of objects that could cause injury; have suction
and oxygen equipment available
3 | P a g eHandling Hazardous and Infectious Materials – (1)
Cancer Treatment Options: Implanted Internal Radiation Device (RM AMS RN
10.0 Chp 91)
• Brachytherapy describes internal radiation that is placed close to the target
tissue. This is done via placement in a body orifice (vagina) or body cavity
(abdomen) or delivered via IV such as with radionuclide iodine, which is
absorbed by the thyroid
Brachytherapy provides radiation to the tumor and a limited amount to
surrounding normal tissues. Waste products are radioactive until the
Isotope has been completely eliminated from the body. Waste products
should not be touched by anyone.
• Nursing Considerations
Place the client in a private room away from other clients when possible.
Keep door closed as much as possible. Place a sign on the door warning
of the radiation source. Wear a dosimeter film badge that records
personal amount of radiation exposure. Limit visitors to 30-min visits,
and have visitors maintain a distance of 6 feet from the source. Visitors
and health care personnel who are pregnant or under the age of 18
should not come into contact with the client or radiation source. Weal a
lead apron while providing care keeping the front of the apron facing
the source of radiation. Keep a lead container in the client’s room if the
delivery method could allow spontaneous loss of radioactive material.
Tongs are available for placing radioactive material into this container.
Follow protocol for proper removal of dressings and bed linens from the
room.
Client Education
Inform the client of the need to remain in an indicated position to prevent
dislodgement of the radiation implant. Instruct the client to call the
nurse for assistance with elimination. Instruct the client and family
about radiation precautions needed in health care and home
environments.
Standard Precautions/Transmission-Based Precautions/Surgical Asepsis – (2)
Acute Neurological Disorders: Priority Intervention for Meningitis (RM NCC RN
10.0 Chp 12)
• The presence of petechiae or a purpuric-type rash requires immediate
medical attention
•
Isolate the client as soon as meningitis is suspected, and maintain droplet
precautions per facility protocol – droplet precautions require a private
room or a room with clients who have the same infectious disease, ensuring
that each client has his or her own designated equipment. Providers and
visitors should wear a mask. Maintain respiratory isolation for a minimum
of 24 hr after initiation of antibiotic therapy
4 | P a g e• Monitor vital signs, urine output, fluid status, pain level, and neurologic
status
• For newborns and infants, monitor head circumference and fontanels for
presence of or changes in bulging
• Correct fluid volume deficits and then restrict fluids until no evidence of
increased ICP and serum sodium levels are within the expected range
• Maintain NPO status if the client has a decreased level of consciousness. As
the client’s condition improves, advance to clear liquids and then a diet the
client can tolerate
• Decrease environmental stimuli – provide a quiet environment; minimize
exposure to bright light (natural and electric)
• Provide comfort measures – keep the room cool; position the client without
a pillow, and slightly elevate the head of the bed. The client can also be
positioned side-lying to reduce neck discomfort
• Maintain safety (keep the bed in a low position, implement seizure
precautions)
• Keep the family informed of the client’s condition
Skin Infections and Infestations: Expected Findings of Pediculosis Capitis (RM NCC
RN 10.0 Chp 30)
• Manifestations – intense itching; small, red bumps on the scalp; nits (white
specks) on the hair shaft
• Nursing interventions – 1% permethrin shampoo; Spinosad 0.9% topical
suspension; Remove nits with a nit comb, repeat in 7 days after shampoo
treatment; wash clothing, bedding in hot water with detergent; difficult
cases; use malathion 0.5%
Health Promotion and Maintenance – (2)
Health Promotion/Disease Prevention – (2)
Hepatitis and Cirrhosis: Client Teaching About Viral Hepatitis (RM AMS RN 10.0
Chp 55)
• Viral hepatitis is the most common type of hepatitis. After exposure to a
virus or toxin, the liver becomes enlarged from the inflammatory process.
As the disease progresses, there is an increase in inflammation and
necrosis, interfering with blood flow to the liver. Individuals can be infected
with hepatitis and remain free of manifestations, and therefore are unaware
that they could be contagious.
• Nursing Care – most clients will be cared for in the home unless they are
acutely ill. Enforce contact precautions if indicated. Provide a high-
carbohydrate, highcalorie, low- to moderate-fat, and low- to moderate-
protein diet, and small, frequent meals to promote nutrition and healing.
Promote hepatic rest and the regeneration of tissue (administer only
necessary medications; avoid over-thecounter medications or herbal
supplements; avoid alcohol; limit physical activity). Educate the client and
family regarding measures to prevent the transmission of the disease to
5 | P a g eothers at home (avoid sexual intercourse until hepatitis antibody testing is
negative; use proper hand hygiene). Provide culturally sensitive care.
Immunizations: Recommendation for Older Adults (RM AMS RN 10.0 Chp 85)
Td booster. MMR vaccine. Varicella vaccine. Pneumococcal vaccine. Hepatitis A.
Hepatitis B. Influenza vaccine. Meningococcal polysaccharide vaccine (MPSV4)
and Meningococcal 4-valent conjugate (MenACWY) vaccine. Human Papilloma
virus HPV2, HPV4, or HPV9. Zoster vaccine
Psychosocial Integrity – (5)
Abuse/Neglect – (1)
Family Violence: Evaluating Child Abuse (RM MH RN 10.0 Chp 32)
•
Infants – shaken baby syndrome: shaking can cause intracranial
hemorrhage. Assess for respiratory distress, bulging fontanels, and an
increase in head circumference. Retinal hemorrhage can be present. Any
bruising on an infant before age 6 months is suspicious.
• Preschoolers to Adolescents – assess for unusual bruising, such as on
abdomen, back or buttocks. Bruising is common on arms and legs in these
age groups. Assess the mechanism of injury, which might not be congruent
with the physical appearance of the injury. Numerous bruises at different
stages of healing can indicate ongoing bearings. Be suspicious of bruises or
welts that resemble the
shape of a belt buckle or other object. Assess for burns. Burns covering
“glove” or “stocking” areas of the hands or feet can indicate forced
immersion into boiling water. Small, round burns can be from cigarettes.
Assess for fractures with unusual features, such as forearm spiral fractures,
which could be a result of twisting the extremity forcefully. The presence of
multiple fractures is suspicious. Assess for human bite marks. Assess for
head injuries, level of consciousness, equal and reactive pupils, and nausea
or vomiting.
Mental Health Concepts – (2)
Anxiety Disorders: Expected Findings for a Client who has Social Anxiety
Disorder
(RM MH RN 10.0 Chp 11)
• Social anxiety disorder (social phobia) – the client experiences excessive
fear of social or performance situations
The client reports difficulty performing or speaking in front of others or
participating in social situations due to an excessive fear of
embarrassment or poor performance
The client might report physical manifestations (actual or factitious) in
an attempt to avoid the social situation or need to perform
Personality Disorders: Antisocial Personality Manifestations (RM MH RN 10.0
Chp
16)
6 | P a g e• Antisocial – characterized by disregard for others with exploitation, lack of
empathy, repeated unlawful actions, deceit, and failure to accept personal
responsibility; sense of entitlement, manipulative, impulsive, and seductive,
nonadherence to traditional morals and values; verbally charming and
engaging
Support Systems – (1)
Neurocognitive Disorders: Planning Care for a Stage 2 Alzheimer’s Disease (RM
MH
RN 10.0 Chp 17)
• Stage 2: Moderate
Forgetting events of one’s own history. Difficulty performing tasks that
require planning and organizing (paying bills, managing money).
Difficulty with complex mental arithmetic. Personality and behavioral
changes: appearing withdrawn or subdued, especially in social or
mentally challenging situations; compulsive, repetitive actions. Changes
in sleep patterns. Can wander and get lost. Can be incontinent. Clinical
findings that are noticeable to others.
• Nursing Care
Perform self-assessment regarding possible feelings of frustration, anger,
or fear when performing daily care for clients who have progressive
cognitive decline. Nursing interventions are focused on protecting the
client from injury, as well as promoting client dignity and quality of life.
Provide for a safe and therapeutic environment – assess for potential
injury, such as falls or wandering. Assign the client to a room close to
the nurses’ station for close observation. Provide a room with a low
level of visual and auditory stimuli. Provide for a well-lit environment,
minimizing contrasts and shadows. Have
the client sit in a room with windows to help with time orientation.
Have the client wear an identification bracelet. Use monitors and bed
alarm devices as needed. Use restraints only as an intervention of last
resort. Use caution when administering medications PRN for agitation
or anxiety. Assess the client’s risk for injury and ensure safety in the
physical environment, such as a lowered bed.
Cognitive support – provide compensatory memory aids, such as clocks,
calendars, photographs, memorabilia, seasonal decorations, and familiar
objects. Reorient as necessary. Keep a consistent daily routine. Maintain
consistent caregivers. Cover or remove mirrors to decrease fear and
agitation.
Physical needs – monitor neurological status. Identify disturbances in
physiologic status which can contribute to the cause of delirium. Assess
skin integrity which can be compromised due to poor nutrition, bed rest
or incontinence. Monitor vital signs. Tachycardia, elevated blood
pressure, sweating, dilated pupils can be associated with delirium.
7 | P a g eImplement measures to promote sleep. Monitor the client’s level of
comfort and assess for nonverbal indications of discomfort. Provider
eyeglasses and assistive hearing devices as needed. Ensure adequate
food and fluid intake. Underlying causes of delirium can result in
electrolyte imbalance.
Communication – communicate in a calm, reassuring tone. Speak in
positively worded phrases. Do not argue or question hallucinations or
delusions. Reinforce reality. Reinforce orientation t time, place, and
person. Introduce self to client with each new contact. Establish eye
contact and use short, simple sentences when speaking to the client.
Focus on one item of information at a time. Encourage reminiscence
about happy times. Talk about familiar things. Break instructions and
activities into short timeframes. Limit the number of choices when
dressing or eating. Minimize the need for decision-making and abstract
thinking to avoid frustration. Avoid confrontation. Approach slowly and
from the front. Address the client by name. Encourage family visitation
as appropriate.
Basic Care and Comfort – (3) Assistive Devices – (1)
Sensory Perception: Speaking to a Client Who Has a Hearing Impairment (RM
FUND 9.0 Chp 45)
For clients who have hearing loss – sit and face the clients. Avoid covering
your mouth while speaking. Encourage the use of hearing devised. Speak
slowly and clearly. Do not shout. Try lowering vocal pitch before increasing
volume. Use brief sentences with simple words. Write down what clients do
not understand. Minimize background noise. Ask for a sign-language
interpreter if necessary. Do not shout.
Mobility/Immobility – (1)
Musculoskeletal Trauma: Skeletal Traction (RM AMS RN 10.0 Chp 71)
• Nursing actions – assess neurovascular status of the affected body part
every hour for 24 hr and every 4 hr after that. Maintain body alignment and
realign if the client seems uncomfortable or reports pain. Avoid lifting or
removing weights. Ensure that weights hang freely and are not resting on
the floor. If the weights are accidentally displaced, replace the weights. If
the problem is not corrected, notify the provider. Ensure the pulley ropes
are free of knots, fraying, loosening, and improper positioning at least every
8-12 hr. Notify the provider if the client experiences severe pain from
muscle spasms unrelieved with medications or repositioning. Move the
client in halo traction as a unit, without applying pressure to the rods. This
will prevent loosening of the pins and pain. Routinely monitor skin integrity
and document. Use heat/massage as prescribed to treat muscle spasms. Use
therapeutic touch and relaxation techniques.
• Pin Site Care – pin care is done frequently throughout immobilization
(skeletal traction and external fixation methods) to prevent and to monitor
8 | P a g efor manifestations of infection (drainage and redness [color, amount, odor], loosening of pins, tenting of skin at pin site [skin rising up in]). Pin care protocols (chlorhexidine) are based on provider preference and facility policy. A primary concept of pin care is that one cotton swab is designated for each pin to avoid cross-contamination. Pin care is provided usually once a shift, 1-2 times a day, per facility protocol.
Nutrition and Oral Hydration – (1) Renal Disorders: Dietary Prevention of Nephrolithiasis (RM Nutrition 6.0 Chp 14) • The most common type of kidney stone is made of calcium oxalate. Contributing factors include inadequate fluid intake, elevated urine pH, and excess excretion through the kidneys of oxalate, calcium, and uric acid. Kidney stone formation is more influenced by the amount of oxalate in the client’s system than calcium. A client who has an ileostomy has an increased risk of kidney stones
• Preventative nutrition – excessive intake of protein, sodium, calcium, and oxalates (rhubarb, spinach, beets) can increase the risk of stone formation
• Therapeutic nutrition – increasing fluid consumption is the primary intervention for the treatment and prevention of kidney stones. Daily fluid intake should be at least 1,500 mL to 3,000 mL. At least 8-12 oz (240-360 mL) of fluid, preferably water, should be consumed before bedtime because urine becomes more concentrated at night. Recommendation for calcium oxalate stone formation is to limit animal protein, excess sodium, alcohol, and caffeine use. Low potassium can contribute to calcium stone formation. Foods high in oxalates include spinach, rhubarb, beets, nuts, chocolate, tea, wheat bran, and strawberries, and should be limited in the diet. Avoid megadoses of vitamin C, which increase the amount of oxalate excreted. Recommendation for prevention of uric acid stones is to limit foods high in purines, which include lean meats, organ meats, whole grains, and legumes.
Pharmacological and Parenteral Therapies – (7) Adverse Effects/Contraindications/Side Effects/Interactions – (1) Medications for Psychotic Disorders: Screening for Extrapyramidal Adverse
Effects
(RM MH RN 10.0 Chp 24) • Acute dystonia – severe spasm of the tongue, neck, face, and back. Crisis situation that requires rapid treatment Nursing considerations – begin to monitor for acute dystonia anywhere between 1-5 days after administration of first dose. Treat with an antiparkinsonian agents such as benztropine. IM or IV administration diphenhydramine can also be beneficial. Stay with the client and monitor the airway until spasms subside (usually 5-15 min) [Show Less]