Unit I Wrap-Up

Define nursing independent action & 3 examples

Define nursing independent action & 3 examples

Things we can do on our own such as

• Turning & positioning

• Vital signs

• Assessment

Define dependent nursing action & 2 examples

Things we need an order to do such as

• Treatments

• Medical administration

What is the nursing process & what acronym do you use

Guides how we care for patients

A: Assessment

D: Diagnosis

P: Planning

I: Implementation

E: Evaluation

Define “PES”

Problem
Etiology
Symptoms

If your patient has an actual problem, you use PES.

Define “PE”

Problem

Etiology

If your patient has risk for a problem, you use PE

ex - Risk for diabetes, risk for fall

How do you handle fire safety?

You use “RACE”

R: Rescue

A: Alarm

C: Contain

E: Extinguish

What is subjective data?

Things that the patient has to tell us, we cannot measure or see.

ex - nausea, tingling, pain, numbness

What is considered objective data?

Things we can see or measure

ex - vital signs, vomiting, rashes, wounds

What are four things that LPNs are not able to do?

LPNs cannot:

Assess a patient
Cannot do an INITIAL TEACHING to the patient (but are allowed to reinforce)

Cannot write care plans.

Cannot administer IV push, but can administer other medications

Name four vulnerable populations and why.

Very young / very old: Young people haven’t developed a strong immune system yet, old people have a weakened immune system

LGBTQ: discrimination, mental health concerns, stigmas against

Disabled: physical and cognitive impairments, dependency on caregiver

Socially Isolated: Mental health concerns, reduced support system

What does NCSBN stand for, and what do they do?

The National Council of State Boards of Nursing (NCSBN) is an organization that helps set up and administer the NCLEX.

What does NLN stand for, and what do they do?

The National League of Nursing (NLN) helps shape the future of nursing education and development

What does ANA stand for, and what do they do?

American Nurse Association (ANA) helps advocate for nurses. Focuses on the health and wellness of nurses, (position papers, policy updates ?)

What are the body mechanics you need to know?

• Bend at the knees; not the waist

• Keep feet in a wide stance

• Point feet in the direction that you are moving the patient

• Keep patient close to you as you move

• Use devices if available

  • ex - Hoyer, friction reducing devices.

What is “HIPAA” and what do they do?

Health Insurance Portability & Accountability Act, helps protect patients health information.

Some possible violations could be:

• posting your patient on social media

• talking to your coworkers in a public area about your patient

• looking at a patient’s chart that you are not caring for

What is Evidence-Based Practice?

Using evidence such as studies, journals to guide practice

Name some professionals that you can collaborate with

• Physical therapist: gross motor skills, walking, stairclimbing

• Occupational therapist: fine motor skills, ADLs

• Speech therapist: speaking & swallowing

• Dietician: diet therapy, calorie intake

What’s the difference between Medicaid & Medicare?

Medicaid: health insurance for people under the poverty level

Medicare: health insurance for the elderly

What are the five types of restraints?

Physical: The manual holding or immobilizing the client using physical strength

Mechanical: A physical device that is applied to a person to restrict their movement (ex: straps, fabric)

Chemical: The administration of medications to reduce the client’s movement or behavior (ex: antipsychotics, benzodiazepines)

Barrier: Restrain a patient’s movement with the use of physical things that cannot be moved (ex: concave mattresses and lapboards that are attached to chairs, all four bed rails)

Seclusion: Placing the client alone in a securely locked room

What are the categories of the Hendrich II fall risk assessment?

• Confusion/disorientation

• Symptomatic depression

• Altered elimination

• Dizziness/vertigo

• Male gender ☹

• Antiepileptics

• Benzodiazepines

• Get up & go test

Score of 5 or higher = high risk

What are the four types of nursing education?

• Diploma programs (very few left)

• Master’s degree

• Associate nurses (2 yr programs)

• Baccalaureate (BSN) 4 year programs

What tests do LPNs & RNs take?

LPNs will take the NCLEX-PN

RNs will take the NCLEX-RN

What is a compact license?

A license that covers multiple states

What is SBAR?

Situation: Describe what is CURRENTLY happening & what needs to be accessed

Background: Provide context, background information related to the situation (ex: relevant medical diagnosis, recent changes to the patient's condition)

Assessment: give a brief evaluation of the situation

Recommendation: Give suggestions for care

Repeat/Repack: Repeat information back

use SBAR for handoffs when needing to give clear & concise communication

What are some techniques to physically assess a patient?

• Inspection: looking

• Palpation: feeling,

• Percussion: tapping on the body

• Auscultation: listening

PERFORM IN THIS ORDER!! (EXCEPT FOR ABDOMINAL ASSESSMENT, WHERE IT WILL BE AUSCULATE THEN PALPATE)

What are the standard precautions? Name some standard precautions

Standard precautions are the minimum infection prevention practices that apply to all patient care.

• Hand hygiene

• Use of PPE

• Respiratory hygiene / cough etiquette

• Sharps safety

• Safe injection practices

• Sterile instruments & devices

• Clean and disinfected environmental services

What is "delegation,” and who do we delegate to?

Delegation is when you entrust a task to a colleague. You can only delegate DOWN the chain of command.

you CANNOT delegate with other RNs (you collaborate with people equal to you)

The delegator retains accountability for the task

What are some learning domains?

• Cognitive: learning, memorization, and analyzing information

• Affective: learning that changes values and attitudes

• Psychomotor: learning hands-on skills

we use learning domains to provide a framework for organizing and categorize different types of learning experiences & outcomes

Name the three abnormal spinal curves

Scoliosis: lateral curve

Lordosis: lumbar curve (inward curve)

Kyphosis: curvature of the thoracic spine, caused by osteoporosis (outward curve, hunchback, gamerneck)

Name some positioning & tips for positioning

Supine - flat

Lateral - side lying, supporting arms & legs on pillows

use trochanter rolls to prevent external rotation of hip

foot boards / boots to prevent plantarflexion and foot drop

“float” heels to prevent pressure injury of the heel

hand rolls prevent contractures

using positioning devices is an independent nursing intervention

what is the "braden” scale?

It assess the risk of skin breakdown

categories:

nutrition

shearing/friction

sensory perception

moisture

activity

mobility

lower the score, HIGHER the risk

• severe risk: total score 9

• high risk: total score 10–12

• moderate risk: total score 13–14

• mild risk: total score 15–18

Things you can do for restraint safety

• Tie to a non-movable part of the bed

• Allow the patient as much movement as possible

• ONLY USE AS LAST RESORT

• tie with an east release knot (slipknot)

• release & assess under the restraint as per policy

What is a “occurrence report”

Occurrence reports are used when there was patient harm, the potential for patient harm, or anything unusual that happened on your unit (a visitor fall)

they are done to prevent future incidents, include only facts no speculation or blaming