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Chapter 19 Evaluation – Apply to all chapters – Once you implement a intervention -you need to assess whether it worked or not---- equals = EVALUATE whether it worked, --- Do I need to change the intervention, do I need to modify the intervention or do I say it worked = met the evaluation -- I achieved the outcome I was looking for. Chapter 20- Read over the terminology at the beginning. Very important terms. What does it mean to document and why is it so important? What does the patient record contain? What are the characteristics of effective documentation? What is the purpose of privacy and confidentiality? What happens if you do not follow those rules? READ over Box-20-1, what does HIPAA stand for? Glance at the abbreviations but we will go over !! Delegation is important when it comes to documentation - working with Nursing assistants - must follow all policies of what NA can chart/ LVN's and what the RN will chart . Need to know job description and duties!! For quality performance improvement how important is documentation? Types /Methods of documentation - Electronic EHR records, source oriented records, problem- oriented medical records = SOAP charting , PIE, focus charting, charting by exception, . Models of charting = CASE Management, collaborative, unusually occurrence, … Nursing documentation - Assessments, care plan, patient care summary - area charting- critical care, progress notes, flow sheet=graphic record. MAR, acquity, discharge/transfer, Home health documentation AMA, Nurses reporting to each other at the change of shift = change of shift report=Handoff reports , calling doctors, transferring patients < Incident reports. Chapter 30 -Medication Chapter: Administering medications is very important- understanding terminology is first- what do all the terminology mean and why? Pharmacology, pharmokinetics, pharmacist( knowing their responsibility - Prinicipals of pharmacology what/why do we need to understand nomenclature of drugs? Generic vs. trade, What are the different types of drugs ? why is that important? What is the importance of drug classification? Again what is Drug indications mean? Versus action of drug? How do the mechanics of drugs interfer with drug action? Pharmokinetics! What does the word Bioavailability mean? What are the different types of Drug reactions and how do they differ?( adverse, allergic, toxic, idiosyncratic). What type of factors can affect Drug action: ( developmental, weight, cultural/genetic, psychological, environmental, timing)- More terminology – half life, why do we need to know that? Can you give an example of that? Peak and trough -again what is the importance of collecting a peak and trough and demonstrate or explain how to do both? Principles of medication- medications prescriptions and orders. You need to know what an order is , what is included on an order what are the details of importance about the order ( what are the components on the order). What are different types of orders and can you describe the difference of how they work? Who can write orders? Are there rules to for checking orders and questioning orders? Know your math for medication . what are the rights to medication( there are a lot but ) which are the most important up front. Now, apply the Nursing Process to this chapter- what type of problems can the patient demonstrate while starting med, taking meds or . Here is a question-"Pharmacokinetics question type" – medication administered that are renal toxic should have what frequent assessment of which blood values: WBC, Ptt, BUN , creatinine, glucose. chapter 33 Skin/wounds- What is the function of the skin, layers of the skin- after that understand why I am asking you to know those functions and sites. Because you need to think how deep and where the wound is and what it looks like. Assess the wound : type clean/dirty, acute/chronic, intentional/unintentiona. How does a wound heal: phases of healing,- look at each phase- and recognize a specific details to know about that phase. What are complications of wounds? What do they mean? And if they happen what will the nurse do to assist the patient to over come their complication. What are factors to develop wounds? What different factors that can actually create or assist in the development of a wound? What do you look for when you are ASSESSING-(patient responses)- color, size, smell, location, drainage =color-what are colors and names of drainage? , amount, smell, - terminology-maceration, evisceration, fistula, tunneling, - . Pressure wounds- what are they? how do they develop? How do you know it is a pressure wound? Are there stages of a pressure wound? How do you tell the difference- again, look at specific detail!! ( earlier I asked you about the layers of the skin)!!!! How do we take care to of pressure ulces (wounds)???? What are some Nursing Interventions that can be done by nurse to prevent pressure wounds and how do care for them once they have developed and how do we slow them down to not progress to the next stage.?? Critical think -- what is important to take care of a wound. How do help people heal a wound. Can you create a pressure wound in 1-day??What are some colors of a pressure wound? What do the colors mean? If we need to debride a wound-- what does debridement mean? What types of debridement are there? ( autolytic, mechanical, enzymatic, sharp) --How do you know a wound is infected? What does a nurse need to do to check for an infection? How do they collect a specimen. lastly , Utilizing the Nursing process in this chapter-- and referring to Chapter 15 also -- when you have skin broken--- what type of Nursing diagnosis would you use to label the patients wound response???? Look over the different type of Nursing diagnosis. How does Heat and Cold help a patient and what problems could develop from either heat or cold. Chapter-text-37 Nutrition Chapter- what is the purpose of reading the labels on store items, what is the GI tract function? What is the function of the esophagus , stomach, small intestine, large colon, rectum and anus? What does a nutrient mean? How much of fat, Carbs , protein, ? Food label look it over. Look over the PLATE Food!! Why is nutrition so important? How does it help the patient? Why is this an important intervention to assess. How do you assess a patients nutritional status? What does Positive or Negative Nitrogen Balance mean? Anorexia Nervosus means what ? Anorexia means what ? Bulemia? What is malnutrition? How much weight can you lose that is steady and good to lose? Look at some labs: Albumin, Prealbumin, Cholesterol, triglycerides, CBC, SMA7=Na+, K+, cl, co2, gluc BUN, CREAT, Mg, CA. : Types of Diet- NPO, Ice chips, clear liquid, full liquid, puree diet, mechanical diet, - renal diet, liver diet, cardiac diet- what is included in the diet ( each of these diets) ie- what can you eat to get your potassium? To give you eyes nutrition? Pharmacology Book: (enteral/Parenteral chapter)-first what is the difference between enteral and parenteral nutrition? Under Enteral Nutrition- what is a the purpose of a salem sump tube versus a soft silastic tube with a wire in it? What is the primary purpose for each tube. What is the direction of how to place an nasogastric tube in position? How do we verifiy it is in the correct position. What are some management of care towards the nasogastric tube. What are some problems/complications having a nasogastic tube. Ok , we started tube feeding, what are some complications with starting tube feeding to someone who hasn’t had any food in awhile . If there is any complications from tube feeding how do you handle them? What is Parenteral Nutrition ? What is PPN vs. TPN. What is the primary ingredient in the PPN or the TPN? What are complications with TPN nutrition? How does Enteral Nutrition compare to Parenteral (TPN) Nutrition? What are some complications from TPN nutrition? Pharmacology Book : Vitamins/minerals vitamins and minerals - fat soluble and water soluble how do they differ? What is important about each vitamin? What should you teach your patient about these meds. Which meds can be toxic? What is important about IRON, what is important about Ferrous . How did the two differ? ( read very carefully for the difference)