pct idks

The Joint Commission

patient safety & quality of care. (pt. identification, test results, training, etc)

Clinical and Laboratory Standards Institute (CLSI)

operational standards for lab testing

CDC and OSHA

infection control, PPE, exposure protocols, exposure protocols, medical examinations

HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)

patient's perspectives of hospital care

National Institute for Occupational Safety & Health (NIOSH)

agency that develops new knowledge in occupational safety, annually updates workplace regulations

facility policy & procedure manuals

protocols & standards required in a healthcare facility

water temperature

37°- 46°C (98.6°-115°)

non-weight bearing

affected leg cannot touch floor

touch down weight bearing

affected leg can only touch floor for balance

partial weight bearing

affected leg can only bear portion of weight

as tolerated weight bearing

stand/walk on affected leg only as tolerated

full weight bearing

affected leg can bear full weight

stage 1 pressure ulcer

redness that does not blanch when pressure is applied

stage 2 pressure ulcer

blister-like, surface is cracked/peeling

stage 3 pressure ulcer

no skin layers, underlying tissue/fat is visible

stage 4 pressure ulcer

crater-like, damage extends to/through muscle/bone

unstageable pressure ulcer

full of dead tissue

fowler’s position

semi-sitting w/ head of bed elevated 45°-60°

resting, eating, receiving care

low-fowler’s position

semi-sitting w/ head of bed elevated 15°-30°

semi-fowler’s position

semi-sitting w/ head of bed elevated 30°-45°

high-fowler’s position

semi-sitting w/ head elevated 60°-90°

sims’ position

semi-prone lying on left side, right knee flexed, left knee extended

relieve pressure, enema care,

remove sequential compression devices every

8 hours

use spirometer every

1-2 hours

check on pts with restraints every

15 min

remove restraints & perform ROM every

2 hrs

requires activation of emergency response team

• no pulse

• no breathing

requires immediate notification of nurse

• cyanosis

• shortness of breath

• difficulty breathing

• changes in/loss of consciousness

• falls

• uncontrollable bleeding

• choking

• sudden intolerable pain

• thoughts of self-harm/suicide

requires reporting but not immediately

• change in urinary/bowel output

• refusal to ambulate

• slight increase in bp

• non-life threatening

• psychological/emotional changes

edema- depth=severity

• 2mm=1+

• 4mm=2+

• 6mm=3+

• 8mm=4+

non-verbal signs of pain

• moaning

• rocking

• pacing

• crying

• grimacing

• clenching

• biting

• restlessness

• insomnia

• rigid/flaccid posture

• holding/rubbing/guarding of part

wound infection

• redness

• swelling

• fever

• increasing pain/discomfort

• foul odor

• warmth around wound

• looseness

• nonadherence of adhesives

blood glucose- fasting: 2-17yrs

70-110 mg/dL

blood glucose- fasting: 18-59yrs

74-106 mg/dL

blood glucose- fasting: 60-90yrs

82-115 mg/dL

blood glucose- fasting: 90+

75-121 mg/dL

blood glucose- random: all

<200 mg/dL

blood glucose- postprandial: 0-50yrs

<140 mg/dL

blood glucose- postprandial: 50-60yrs

<150 mg/dL

blood glucose- postprandial: 60+yrs

<160 mg/dL

blood glucose critical values- female

<40 mg/dL or >450 mg/dL

blood glucose critical values- male

<50 mg/dL or >450 mg/dL

normal temperature- oral

36.5°-37.5°C (97.6°-99.6°F)

normal temperature- tympanic

37°C (98.6°F)

normal temperature- axillary

36°-37°C (96.6°-98.6°F)

normal temperature- temporal

36.5°-37.5°C (97.6°-99.6°F)

normal temperature- rectal

37.5°C (99.6°F)

normal heart rate: newborn (birth-1mon)

120-160 bpm

normal heart rate: infant (1mon-12mon)

80-140 bpm

normal heart rate: toddler (1-3yrs)

80-130 bpm

normal heart rate: preschool (3-5yrs)

80-120 bpm

normal heart rate: school age (6-15yrs)

70-100 bpm

normal heart rate: adults (16+yrs)

60-100 bpm

normal respiratory rate: newborn (birth-1mon)

30-50 bpm

normal respiratory rate: adult (16+)

12-20 bpm

bradypnea

<10 bpm

tachypnea

>20 bpm

normal blood pressure

<120/<80

elevated blood pressure

120-129/<80

hypertension stage 1

130-139 or 80-89

hypertension stage 2

140+ or 90+

hypertension crisis

180+ &/or 120+

pulse oximetry

95%

right task

scope of practice, ability, legality

right circumstance

safety, equiptment, pt condition/stability

right person

confidence, training, experience, concerns, hesitations

right direction

enough information from nurse, understand expectations

right supervision

ability to receive info/help from nurse if needed

tasks outside of scope of practice

• administration of meds

• accepting/processing prescriptions

• supervising other pcts

• inserting/removing tubes

• performing sterile procedures

• diagnosing

• triaging

• prescribing treatment

Maslow’s hierarchy of needs: physiologic

• 1

• fluids

• oxygen

• shelter

• food

• exercise

• elimination

• temperature regulation

• sleep

Maslow’s hierarchy of needs: safety/security

• 2

• implement precautions

• monitor vitals/condition

Maslow’s hierarchy of needs: love/belonging

• 3

• take interest in pts

• show respect for preferences/decisions

Maslow’s hierarchy of needs: self-esteem

• 4

• give privacy

• pay attention to appearance

• self-determinism

Maslow’s hierarchy of needs: self-actualization

• 5

• reach fullest potential

• set goals

coping mechanisms: apathy

indifference, lack of interest/concern/emotion

coping mechanisms: compensation

balancing failure/loss with accomplishments

coping mechanisms: conversion

transform anxiety into physical symptom

coping mechanisms: denial

avoidance of unpleasant situations by rejecting/denying existance

coping mechanisms: displacement

redirect emotions from original subject to less threatening subject

coping mechanisms: intellectualization

analysis with facts over emotion

coping mechanisms: physical avoidance

keeping away a person, object, place, that evokes unpleasant thoughts

coping mechanisms: projection

transferring unpleasant ideas/emotions onto someone/thing else

coping mechanisms: rationalization

justifying/explaining something negative/unjustifiable

coping mechanisms: repression

eliminating unpleasant emotions, desires, problems from conscious mind

coping mechanisms: sarcasm

saying the opposite of something to be funny, insulting, or irritating

coping mechanisms: verbal aggression

verbal attack on someone without addressing original intent of conversation

stages of grief: denial

“no, not me”, cannot/will not accept loss

stages of grief: anger

“why me?”, feelings of hostility at others

stages of grief: barganing

“yes me, but”, avoid loss by making a deal

stages of grief: depression

“yes, me”, reality sinks in, regret, self-blame

stages of grief: acceptance

“yes, me. I’m ready”, comes to terms, makes the best of it

cane

trouble walking, able to bear weight in both legs

walker

trouble with balance

5 barriers to managing pain

• lack of knowledge

• lack of communication

• fear of addiction

• institutional restraints

• pain beliefs

rights of medicine administration

• patient/identity

• medication order

• time

• route

• dose

• documentation

1 oz

30 mL

1 in

2.54 cm

pathogen

presence of infectious agent

reservoir

environment conductive for pathogen survival

portal of exit

exit path from reservoir