Identify yourself, client, location, diagnosis, and specific current situation
Explain significant medical history and overview of current treatment
Provide current vital signs and critical current assessment data, your clinical impression, and any concerns
Make suggestions; clarify expectations; make recommendations as appropriate to ensure client safety and satisfaction, care continuity, and best outcomes
Process for Medication Reconciliation
- Obtain a list of current medications from the client.
- Develop an accurate list of newly prescribed medications.
- Compare new medications to the list of current medications.
- Identify and investigate any discrepancies and collaborate with the PHCP as necessary.
- Communicate the finalized list with the client, caregiver(s), PHCP, and other team members.
5 Rights of Delegation
Right Task Right Circumstances Right Person Right Direction/Communication Right Supervision/Evaluation
Nurse Practice Act
Defines which aspects of care can be delegated.
UAP Assigned Tasks (Generally)
Noninvasive Interventions: Skin Care ROM Exercises Ambulation Grooming Hygiene Measures
LPN Tasks (Generally)
Medication Admin (PO, Sub Q, IM, ID, PR, Selected Piggyback Meds)
Plus UAP-assigned tasks and review of teaching plans initiated by RN
- The accumulation or sequestration of trapped extracellular fluid in an actual or potential body space as a result of disease or injury.
- Trapped fluid represents a volume loss and is unavailable for normal physiological processes.
- Potential spaces: Pericardial, Pleural, Peritoneal, or Joint Cavities; the bowel; the abdomen; or within soft tissues after trauma or burns
- Gathering data may be difficult; intravascular fluid loss may not be reflected in I/O or wt changes. May not become apparent until after organ malfunction occurs.
Localized- traumatic injury (accidents or surgery), local inflammatory processes, or burns
Generalized (aka Anasarca)- cardiac, renal, or liver failure
Infants and Older Adults are at higher risk for fluid-related problems.
Insensible Fluid Loss
Water loss through Persperation or Respiration.
Unnoticeable and unmeasurable.
Fluid Volume Deficit
Causes: Vomiting/Diarrhea; Cont GI Irrigation; GI Suctioning; Ileostomy or Colostomy Drainage; Draining Wounds/Burns/Fistulas; Inc Urine Output from the use of diuretics
Data Collection: Thirst; Poor skin turgor; Dry mucus membranes; Inc HR, thready pulse, dyspnea, postural hypotension; Wt loss; Flat neck or hand veins; Dizziness or weakness; DEC IN URINE VOL AND DARK/CONCENTRATED URINE; Inc specific grav of urine; confusion; Inc hematocrit level
Tx: Treat the cause; Monitor VS/Resp/Neuro Status closely; Admin prescribed O2; Check mucus mem/Skin turgor; daily wt; I/O; Urine Spec Grav; Hem/electrolyte level monitoring and correction if needed.
Hyponatremia precipitates lithium toxicity. (Hyponatremia can cause diminished lithium excretion.)
Labeling IV Bag
Do not write directly on the bag: use ballpoint pen on a label
IV Extension Tubing
- Restless Patients
- Patients with Special Mobility Needs
Phlebitis and Thrombophlebitis
Phlebitis: inflammation of the vein from mechanical or chemical trauma or local infection. Vein not hard, swelling proximal to site.
Thrombophlebitis: development of a clot as a result of phlebitis. Vein is hard/cord-like
Both: Heat; redness; site tenderness; IV infusion sluggish
Disseminated Intravascular Coagulation (DIC)
- The rapid and extensive formation of clots that occurs in DIC causes the platelets and clotting factors to be depleted.
- Results in bleeding and potential vascular occlusion of organs from thromboemoblus formation