Transcript Delayed – yellow tag

NCLEX Review
Class 2: Safe, Effective Care
Environment
Client Needs
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Safe Effective Care Environment
Health Promotion and Maintenance
Psychosocial Integrity
Physiological Integrity
Safe Effective Care Environment
• Management of Care
13-19%
• Safety and Infection Control 8-14%
Health Promotion and Maintenance 612%
Psychosocial Integrity
6-12%
Physiological Integrity
• Basic Care and Comfort
6-12%
• Pharmacological and Parenteral Therapies
13-19%
• Reduction of Risk Potential
13-19%
• Physiological Adaptation
11-17%
Integrated Processes
• Nursing Process
• Caring – nurse provides hope, support and
compassion to help achieve desired
outcomes
• Communication and Documentation
• Teaching and Learning
Safe Effective Care Environment
• Management of Care
Scope of Practice of Nursing
Personnel
• Baccalaureate prepared nurses equipped
to care for individuals, families, groups &
communities in both structured &
unstructured health settings
• Associate degree prepared nurses
equipped to care for individuals in a
structured health care environment
RN’s cannot delegate
• Initial assessment of patients
• Evaluation of patient data
• Nursing judgment
• Patient/family education/evaluation
• Nursing diagnosis/nursing care planning
• Licensed practical/vocational nurses
equipped to assist in implementing a
defined plan of care & to perform
procedures according to protocol.
Assessment skills are directed at
differentiating normal from abnormal.
Competence is in caring for physiologically
stable patients with predictable conditions.
• Unlicensed assistive personnel have
most limited scope of practice. They can
assists in a variety of direct patient care
activities such as bathing, transferring,
ambulating, feeding, toileting, obtaining
measurements such as vital signs, height,
weight & I & O. Can also perform indirect
activities such as housekeeping,
transporting & stocking supplies
The RN is very short staffed because two people did
not show up for work. Of the following four clients,
which one would the RN care for first?
1. A client just admitted with acute abdominal pain &
possible cholecystitis.
2. A client with nephrotic syndrome with increasing
edema; hourly urine checks & vital signs.
3. A confused client yelling because he is in soft
restraints & cannot get out of bed.
4. A head-injury client (with an IV) who was just
admitted to the unit.
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The RN tells the LPN she is very busy & needs
assistance. Which one of the following tasks
cannot be delegated to an LPN?
Checking the blood glucose level of a client &
giving the appropriate insulin dose.
Completing a peripheral vascular assessment that
a nursing assistant identified as being different
from the earlier assessment.
Completing an initial health assessment on a newly
admitted client.
Completing client teaching for a client scheduled
for discharge.
Safety and Infection Control 8-14%
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Accident Prevention
Disaster Planning
Emergency Response Plan
Ergonomic Principles
Error Prevention
Handling Hazardous & Infectious Materials
Home Safety
Injury Prevention
Medical and Surgical Asepsis
• Reporting of Incident Event/Irregular
Occurrence/Variance
• Safe Use of Equipment
• Security Plan
• Standard/Transmission-Based/Other
Precautions
• Use of Restraints/Safety Devices
Accident Prevention
• Accident prevention interventions (Chapter
37 Potter & Perry)
• Visual/Hearing deficits, other
sensory/perceptual alterations.
• Infant/child car seats
• Factors that influence accident prevention
(developmental stage, lifestyle)
Disaster Planning
• Disaster planning actions
• Nursing role in disaster planning
• Determine which client(s) to recommend
for discharge in a disaster situation
Emergency Response Plan
• Prepare for and implement emergency
response plans (internal/external disaster)
Security Plan
• Apply principles of triage and evacuation
procedures/protocols
• Participate in security plan activities
• Review security plan with staff
DISASTERS
(Brunner Ch. )
• Know the agency’s disaster plan
• Internal disasters are those in which the
agency is in danger
• External disasters occur in the community,
and victims will be brought to the health care
facility for care
• When the health care facility is notified of a
disaster, specific plans as specified in the
agency policy must be carried out
TRIAGE
EMERGENCY DEPT. TRIAGE
• Making tentative diagnosis and prioritizing each
patient’s care
• Brief eval. of pt’s airway, breathing, circulation –
document chief complaint in pt’s own words
• Determine is pt. needs immediate intervention,
then transport for care. If they don’t, continue
with more detailed assessment
Emergency Dept. Triage
Categories
• Emergent
• Urgent
• Nonurgent
• Delayed
Emergent – need immediate
attention
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Chest pain – cardiac complaints
Cardiac arrest
Trauma codes – MVA, penetrating injuries
Airway compromise: foreign bodies,
allergic reactions (respiratory distress)
• Eye injuries
• Falls/jumps more than 20 ft
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Hemodynamic instability
Hypo- or hyperglycemia
Inhalation injuries
Limb amputations
Seizures/post-seizure states
Stroke
Head injuries
URGENT – Problems that should be
treated as soon as possible (1-2 hours)
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Acute abdominal pain
Acute headache
Cellulitis
Major laceration
Obvious fracture
Sexual assault
Nonurgent complaint in pt with diabetes, cancer,
hypertention, AIDS
NONURGENT – Problems that need
to be treated sometime today (not always in
ER)
• Common cold
• Minor injury
• Simple laceration
• Sore throat
• Sprains/strains
• Toothache
DELAYED – Conditions that don’t
require ER care & can be seen at any time
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Exams
Prescription refill
Rash
Request for work slip
Suture removal
Wound check
DISASTER TRIAGE
• Provides for rapid life saving stabilization
(airway & breathing control) but no CPR
• 4 Categories:
Red – Immediate –highest priority
Yellow – Delayed – serious, not life-threating
Green – Minimal – lowest priority
Black – Expectant – dead or unsalvageable
• First, separate walking wounded from
other victims to be tagged later (green)
• Next, triage remaining victims using:
R=respirations
P=perfusion
M=mentation
• R – no respiratory effort – reposition &
reassess – still no response – black tag. If
breathing, check rate – if > 30/min – red
tag. If needs airway maintenance, assign,
may need to be done without cervical
spine precautions. If < 30/min, move on to
next part of assessment
• P – check for presence of radial pulses.
No pulse – red tag. Control bleeding if
possible. If there is a pulse → next step
• M – mental status. Pt. unconscious or
conscious but unable to follow directions –
red tag. If normal LOC & can follow
directions – yellow tag
Immediate – Red tag
Injuries are life-threatening but survivable
with minimal intervention
Examples: sucking chest wounds, airway
obstruction RT mech. cause, shock,
hemothorax, tension pneumothorax,
unstable chest abd wounds, incomplete
amp. Open fx of long bones, 2/3 burns of
15-40% BSA
Delayed – yellow tag
Injuries significant & require medical care,
but can wait hrs without threat to life/limb
Examples: stable abd wounds without
evidence of sign. Hemorrhage, soft tissue
inj. Face wounds without airway
problems, vascular inj. With ade. Circ.,
most fx. Most eye and CNS injuries
Minimal – Green tag
Injuries are minor and treatment can be
delayed hours to days.
Examples: upper extremity fx, minor burns,
sprains, small lac. Behavioral disorders or
psych. disturbances
Expectant – Black tag
Injuries are extensive & chances of survival are
unlikely even with definitive care. Separate
from others but not abandoned. Provide comfort
measures.
Examples: unresp pt. with penetrating head
wounds, high SC injury, multiple wounds to
many organs, sites, burns>60% BSA seizures
or vomiting w/I 24hrs radiation exposure,
profound shock with multiple wounds
Prioritize in this order:
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Breathing
Bleeding
Broken bones
Burns
Hospital Evacuation in Disaster
• A Ambulatory - Remove walking first
(may help with others)
• B Bed ridden • C Critically ill last
• Objective in disaster plan – evacuate
volumes of clients.
Ergonomic Principles
Prevention of injury to health care workers.
Back injury common
Principles of body mechanics – Ch. 36
Potter & Perry
Chart page 934
Chart page 946
Error Prevention
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Check for client allergies
Check for accuracy of client prescriptions
Prevent errors by following agency policies
Utilize client identification policies (Name
and allergy bands)
• Verify client identity prior to procedures
Handling Hazardous/Infectious
Materials
• Control spread of infectious agents
• Safe handling techniques
• Identify biohazardous, flammable &
infectious materials
Infection notes
• A pathogen cannot infect if you break even one
of the six links in the chain of transmission
• Clients at high risk for infection get prophylactic
antibiotics before surgical procedures
• The major sites for nosocomial infections are
urinary & respiratory tracts, blood & wounds
• All nosocomial infections that occur in hospitals
must be tracked & recorded
Home Safety
• Home safety interventions
• Evaluate client care environment for fire or
environmental safety hazards
• Involve client/family when recommending
modifications (lighting, handrails, kitchen
safety) (p. 1021 Potter & Perry)
Injury Prevention
• Injury Prevention interventions
• Factors related to mental status may contribute
to client’s potential for accident or injury (
confusion, altered thought processes, diagnosis)
• Factors R/T allergy may contribute to client’s
potential for injury (food, meds, vaccines,
environmental factors.
• Use protective equipment when using devices
that can cause injury (Home disposal of
syringes)
• Protect individual from injury (from another
ind., falls, environmental hazards, burns)
• Remove fire hazards
• Meds and treatments that contribute to
accident or injury
• Client allergies
Safety notes
• Know institution’s plan for fire drills &
evacuation
• Know emergency phone number for
reporting fire
• Know locations of all fire alarms, exits &
extinguishers
• PRC: first protect people, then report fire,
then try to contain it
• In a fire, never use an elevator
• Turn off all oxygen supplies in the area of
fire
• In a fire, close all doors & windows
• In a power failure, only certain electrical
outlets access the emergency generators,
know which ones they are
Poison notes
• Never induce vomiting for these poisons:
lye, household cleaners, petroleum
products, furniture polish
• If it is suspected someone has taken
poison, save any vomitus & take it with the
victim to ER
Medical & Surgical Asepsis
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Nursing procedures & psychomotor skills
Assess client area for sources of infection
Correct aseptic technique
Employ methods to control/eliminate infectious
agents (handwashing most effective preventer of
infection)
• Set up sterile field and use appropriate supplies
• Correct techniques to apply & remove mask,
gloves, gown, protective eyewear
Reporting of Incident/Event/Irregular
Occurrence/Variance
• Complete report according to policy
• Identify situations requiring completion of
report (med error, fall)
Safe Use of Equipment
• Check equipment for safe functioning
• Ensure safe equipment use (CPM device,
oxygen, mobility aids, restraints)
• Inspect equipment for safety hazards
(frayed electrical cords, loose/missing
parts)
• Remove malfunctioning equipment from
client area to appropriate personnel
Standard/Transmission-Based
Other Precautions
• Apply infection control principles
(handwashing, isolation, aseptic tech,)
• Review with client and staff
• Universal/standard precautions
• Identify communicable diseases & modes
of transmission (airborne, droplet, contact)
• Protect spread through use of equipment
• Protect immunocompromised clients
• Report client with communicable disease
• Correct handwashing technique
Use of Restraints/Safety Devices
• Apply knowledge of science in use of restraints (
maintain function)
• Apply knowledge from social sciences when
using restraints (respect dignity of older clients,
older adult risk for hip fx)
• Apply & maintain prescribed restraints, bed
alarms, safety devices according to policy
• Evaluate appropriateness of type of restraint
used
• Identify & use least restrictive safety
device/restraint
• Monitor client’s response to restraints
• Use appropriate device procedure for
client
RESTRAINTS
• Protective device used to limit the physical
activity of a client or to immobilize a client or
an extremity
• Physical restraints
– Restricts client movement through the
application of a device
• Chemical restraints
– Medications given to inhibit a specific
behavior or movement
RESTRAINTS
• IMPLEMENTATION
– When restraints are necessary, the
physician’s orders should state the type of
restraint, specific client behaviors for which
restraints are to be used, and identify a
limited time frame for use
– Physicians’ orders for restraints should be
renewed within a specific time frame
according to the agency’s policy
RESTRAINTS
• IMPLEMENTATION
– Restraints are not to be ordered PRN
– The reason for the restraints should be given to
the client and the family, and their permission
should be sought
– Restraints should not interfere with any treatments
or affect the client’s health problem
– Use a half bow or clove hitch knot so that the
restraint can be changed and released easily
– Ensure that there is enough slack on the straps to
assure some movement of the body part
RESTRAINTS
• IMPLEMENTATION
– Secure restraint to the bed frame, not to
the side rails
– Assess skin integrity, neurovascular, and
circulatory status every 30 minutes and
release the restraint to permit muscle
exercise and promote circulation
– Continually assess the need for restraints
RESTRAINTS
• DOCUMENTATION
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Reason for restraint
Method of restraint
Date and time of application of restraint
Duration of use of the restraint and client’s
response
– Release from restraint with periodic exercise and
circulatory, neurovascular, and skin assessment
– Assessment of continued need for restraint
– Evaluation of the client’s response
ALTERNATIVES TO
RESTRAINTS
• Orient client and family to surroundings
• Explain all procedures and treatments to the
client and family
• Encourage family and friends to stay with
client and utilize sitters for clients who need
supervision
• Assign confused and disoriented clients to
rooms near the nurses’ station
• Provide appropriate visual and auditory
stimuli to client, such as clocks, calendars,
television, and a radio
ALTERNATIVES TO RESTRAINTS
• Place familiar items near the client’s bedside,
such as family pictures
• Maintain toileting routines
• Eliminate bothersome treatments, such as
tube feedings, as soon as possible
• Evaluate all medications that the client is
receiving
• Use relaxation techniques with the client
• Institute exercise and ambulation schedules
as the client’s condition allows