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Last minute Memorizations FUNDAMENTALS 1. Hospital policy and the Nurses Practice Act of each state determine the conditions of

Licensed Nursing Practice Nurses are legally mandated to report suspected child abuse to the proper authorities Incident reports are not placed in a patients chart Do not chart that an incident report has been filed. It is the responsibility of the health care provider to advise a client of any risks involved in their decision to refuse care. This statement is relevant in clients’ situations when they decide to leave the facility against medical advice (AMA) 6. Advanced directives are intended to allow patients to have more control over health care decisions at the end of life. 7. The two main types of advanced directives are Living will and Durable Power of Attorney. 8. Lawsuits involving civil wrongs are called torts. 9. Examples of intentional torts are assaults, battery, defamation, false imprisonment, and outrage, invasion of privacy and wrongful disclosure of confidential information. 10. An unintentional tort is called negligence. Negligence is an unintentional failure of a nurse to perform an act that a reasonable person would or would not perform in similar circumstances; can be an act of omission or commission. 11. Negligence occurs when injury results from the failure of the wrongdoer to exercise care. 12. Intentional torts are lawsuits wherein the defendant is accused of intentionally causing injury to the plaintiff. Malpractice is any professional misconduct that is an unreasonable lack of skill or fidelity in professional duties. Actions such as not inserting a Foley catheter correctly, not taking appropriate steps to decrease client’s temperature, not reporting unusual or worsening condition of the client to his or her physician, not preventing falls can all lead to malpractice suits. Libel is a written communication that injures a person’s reputation Slander is an oral communication that injures a person’s reputation Assault is an unjustifiable attempt to injure or touch another person. It can be physical or verbal Battery refers to touching another person unlawfully or carrying out threatened physical harm A durable power of attorney transfers all rights that the individual normally has regarding health care decisions to the designated agent Confidentiality rules indicate that only those who are directly associated in caring for a patient can have access to a patient’s information Faxing or e-mailing of patient information can be done if a written consent is obtained from patient. Informed consent is not required in emergency situations. • Doctor orders to question are: (1) Ambiguous orders (2) Orders the client question (3) Orders when the client condition has changed (4) Orders which does not match with your experience or licensure requirement. (5) Doctors must cosign verbal orders. When you observe a client’s behavior as culturally based, the nurse should assess the client’s interaction with others (family and friends) to help understand the meaning of behavior. 2. 3. 4. 5.

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Legal Aspect of Nursing: • Regulation of nursing practice • Establishment and authorization of regulatory agency How to protect your licensure: •Do not let any one else borrow it. •Do not copy it unless you write “COPY” across it. In some states, it is illegal to copy your license •If you lose your license report immediately, take appropriate step to obtain a duplicate •Be sure that the board of nursing is notified if you change your address •Practice nursing according to the scope and standards of practice in your state •Know your state law so you will not do anything which could cause you to be disciplined by removal or revoking your license Reporting act: These are conditions which when they occur must be reported to the appropriate authorities. These vary from state to state. They are •Child and elderly abuse •Gun shot wounds •Communicable diseases •Ophthalmic neonatorium •Phenoketouria •Criminal acts Informed Consent Requirements: • Capacity- age (adult), competence (can make choices and understand consequences) • Voluntary- freedom of choice without force, fraud, deceit, duress and coercion. • Cannot sign informed consent if client has been under the influence of a drug, for example alcohol or has been pre-medicated. • The nurse’s signature as a witness on a consent form indicates that the nurse observed the informed client or client’s authorized representative voluntarily sign the consent form. It does not mean that the nurse informed the client about the surgical procedure, because that is the responsibility of the physician. Good Samaritan Laws: This is enacted by individual states to encourage health care providers (professional) to assist at the scene of accidents and emergencies. The Good Samaritan Laws contain the following elements: •Care must be provided in good faith •Care given must be gratuitous- no compensation is made for care rendered •Higher standard of care may be required of health care worker due to higher level of expertise •Nurse will be expected to provide care at the level of ordinary nurses in similar circumstances •Do not cover a person who is soliciting for business or representing an agency •Do not cover the care rendered in an emergency room situation •Care provided should not be willfully or wantonly negligent Liability: •There are two types of liability; individual and vicarious liability Individual liability: •Every body is liable to his or her action or conduct •Liability may be shared by another person or group, for example Doctors and fellow nurses or a facility such as a hospital.

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Vicarious liability: •Liability under the Nurse Practice act, which defines the standard of care a nurse, is expected to perform. For example, wrongfully administering a medication which would result in physical harm to a client. Criminal law: these are wrongdoings against society as a whole •Its punishment is usually prison term or fine. Examples of Criminal Law: •Violation of the nursing practice act •Murder •Manslaughter •False imprisonment •Narcotic’s violations •Assault and battery Civil laws: these are wrong doing against private individual or a group; compensation is usually for the victim(s) Examples of Civil Law: Torts- These are intentional or unintentional civil wrongs. Examples of torts are: Negligence: unintentional harm to another that occurs through failure to act in a reasonable and prudent manner Malpractice: This is a professional practice that injures somebody through failure to meet the proper standard of care; malpractice is the offense of the professional. Elements of malpractice suit: •Professional must owe a duty of an established nurse-client relationship. •A professional must breach the duty by doing something wrong •Harm must occur to client •Direct cause and effect relationship between the breaches of duties •Formability- a professional could reasonably expect injury to occur as a result of the breach of duty •Invasion of privacy is a violation of one’s constitutional right to non- publicity and exposure to public view. Nursing implication: •Intervene when patient or client’s dignity or privacy is affected or violated. Proper ways covering of physical body during procedures is necessary. M •Medical records must be released only with written clients consent •Release of medical records should only be limited to care givers “need to know” •Client’s belongings must be protected and may not be searched without specific authorization. Have a client’s inventory sheets where all clients’ belongings are recorded and signed by the clients. Defamation: •These could be written or oral communication to a third person concerning matters that may injure an individual’s reputation Assault: •It’s a threat or an attempt to make bodily contact with another person without the person’s consent. For example: Threatening to give an injection to a psychotic patient if they do not behave appropriately. Nursing actions: •Try to call your client’s attention before you initiate procedure Battery:

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•This is actually carrying out an assault. These include anger, violence, neglect, touching

person’s body or clothing or anything attached to or held by that person. For example: forcible removal of client’s clothing to give an injection after the patient refused it. •In nursing no threat should be waved off. All threats must be reported to the appropriate authority. Admission: •There are two types of admission: voluntary and involuntary admission Voluntary admission •Is when a pt is willingly taken to the hospital to be admitted. For example: A pregnant woman knowing signs and symptoms of labor takes self to the hospital for delivery. Involuntary admission • When one is unwilling to go to the hospital, someone else makes the decision for the person. In involuntary admission, the person loses the right to make decision for self. • Instances requiring involuntary admissions are: when the client is a pediatric (parent therefore decides for his/her), when a client has mental or cognitive impairment especially when the client’s behavior may be harmful to self or others. •Voluntary admissions could also turn involuntary e.g. communicable diseases Discharges: This could be final or absolute or conditional or incomplete: It is final or absolute, e.g. when you give birth it is absolute. An example of a conditional discharge is one to a halfway house, to nursing home, group home, or OT, PT for rehabilitation. •The patient has a contract with the hospital until final discharge. E.g. follow appointment with patient’s primary physician False imprisonment: •Means unlawful restraining of personal liberty or unlawful detention Types of restraints: Physical restraints: • Omnibus Budget Reconciliation Act provides patients/clients with the right to be free from physical and chemical restraints imposed for the purpose of discipline or convenience and not required to treat medical condition • Inform consent is needed to use restraints • If client is unable to consent to use of restraints, then consent of proxy must be obtained after full disclosure of risks and benefits • Restraining a patient without informed consent or sufficient justification is false imprisonment. • Do not restrain pt except ordered. Should be adequate and appropriate for the purpose • Requires physician’s order to utilize a restraint on client • In emergency situation, restraint may be applied without doctor’s order for a very limited time. But still call the doctor for an order after application. • Restrain is only needed when pt is harmful to self or others. In a very emergent condition, restrain pt before obtaining an order from the MD. • Check restrained client every 10-15 min • Documentation time of each check and the neuromuscular status of the client’s extremities • The duration of a restraint order depends on agency policy. It is now common to have restrain order for psychiatric patients lasting only one hour. Chemical Restraints: • Psychotropic drugs cannot be used to control behavior • Can be used only for diagnoses-related conditions

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Inappropriate use causes deep sedation, agitation, combativeness and possible injury to the patient.

NURSING PROCESS NCLEX note: Most test questions focus on nursing process The nursing process provides the following: •Systematically collection of data (assessing) •Clearly identify the pt’s strength and problems The Nursing process offers: • Improved quality of nursing care • Encourage client participation in care and decision-making • Nursing process is individualized care. Five Phases of the Nursing process: A.D.P.I.E. • A = Assessment • D = Nursing diagnosis/Analysis • P = Planning • I = Implementation • E = Evaluation • NCLEX NOTE: Remember to use the five steps of nursing process in chronological order when answering your test questions • Remember assessment option comes first before planning or implementation Assessment: • This starts as soon as the patient walks into your clinic. This involves establishing the database of patient; collection and organization of physical and psychosocial assessment data. • Collection of physical assessment data e.g. RN does assessment and discharge teaching for they know the principles and responsibility for their actions. For example, during suctioning, an RN/LPN knows the principles of hypoxia that occurs during suctioning, i.e. the stimulation of vagus nerves. If the vagus nerve is stimulated during suctioning this will lead to hypoxia and cardiac arrest. Hence before you suction, pre-oxygenate. Also do not suction adult patients more than 15 seconds and children more than 10 seconds Verification of your data • Verifies your data, clear wherever you have doubts. For example, if patient wants to urinate, assess the symphysis pubis for distension or swelling. If distension, this confirms your doubt. • As a nurse, question doctor’s orders and other health workers or personnel orders e.g. prescribing Demerol for head injury patient because Demerol depresses the respiratory center. Check the patient’s conditions before implementing orders. Also check lab results before administration of some prescribed drugs. For example check potassium levels before administering it. • Before you administer any pain medication, ask the patient to rate the pain. If patient’s rates 0-4 do not give medication, use divers ional therapy. For example, story telling, reading of magazine, but any rates above 5 or 10 give medication. Types of data: Subjective Data: • These are information perceived only by affected person/patient. This is what the patient feels. Any other person cannot verify data. • This is sometimes called symptoms. For example, the patient may be feeling nauseated, with chills and pain. Objective data:

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These are data observed by the clinician. For example, body temperature, blood pressure, and cyanosis.

Diagnosis: Formulate nursing diagnosis by using NANDA approved nursing diagnosis. Analysis: • This is to identify the actual potential problems, the cause or etiological factors • This includes laboratory result of diagnostic test run on the client • Identify the immediate needs • Determine cause of client symptoms • Determine client’s strength and weaknesses • Use your laboratory values to analyze your data (know your lab values and be able to interpret result). Know these lab values before you call in the results to the Physician. (Please pay attention to the highlighted ones). • R.B.C.= 4.5-6.1 million • W.B.C= 4,500-11,000 • Hb. = 12-18 g/dl • Hct. = 38%-54% • Platelets = 150,000-450,000 • PTT. = 35-45 secs. • PT. = 10-15 secs. • APTT. = 25-35 secs • INR = 2-3 • Bleeding time = 1-10 mins • Na. = 135-145 mEq/L • K. = 3.5-5.1 mEq/L • MG. = 1.3-2.1 MEQ/L • • • • • •

Ca. = 8.5-10.5 mg/dl BUN = 10-20 mg/dl Creatinine = .5-1.5 mg/dl Lithium = 0 .5-1.5 mg/dl Digoxin =0 .5-1.5 mg/dl Cholesterol = 160-190 mg/dl

Enzymes: • CKP = 25-175 U/L • AST = 8-20 U/L • Prostate specific antigen (PSA) = .18-.89ng/ml male >15yrs. • Glucose = 70-110 mg/dl • HbA1c = 4-6% ABG’S •pH= 7.35-7.45 •CO2 = 35-45 •O2 = 80-100 •HCO3 = 22-26 •PaO2= 95%-100% •pH 7.45 = alkaline •HCO3 26 = alkaline •CO2 >45 = acid

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•CO2 15-20 mm/h indicate the presence of inflammation • Cultures of suspected infection site must obtained before onset of antibiotic therapy Standard Precaution: • Used with all clients/patients as a primary strategy for nosocomial infection control • Most important way to reduce transmission of pathogens • Apply to blood, all body fluids, secretions, and excretions, except sweat and non-intact skin and mucous membranes Patient room placement: • Immunocompromised, then airborne, droplet and finally contact • Place patient in a private room if patient has poor hygiene habits, contaminates the environment, or can’t assist in maintaining infection control precautions (e.g., infants, children, altered mental status patient) • When sharing room consider the epidemiology and mode of transmission of the infecting organism Transmission Based Precautions: Airborne precautions

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Used with pathogens that are transmitted by airborne route Private room with monitored negative air pressure with 6-12 air exchanges per hour Keep door closed and patient in room Can share room with another patient with the same organism, but no other organism Place mask on patient if being transported Example of disease in category: measles (rubeola), M. tuberculosis, varicella (chicken pox) disseminated zoster (shingles) Droplet Precautions • Used with pathogens transmitted by infectious droplets • Involve contact of conjunctiva or mucous membranes of nose or mouth; happens during coughing, sneezing, talking or during procedures such as suctioning or bronchoscopy • Maintain spatial distance of three feet between infected patient and visitors or other patients. • Place mask on patient when transported • Examples of disease in category: streptococcus pharyngitis, pneumonia, meningitis caused by H. influenza TUBERCULOSIS • Tuberculosis bacteria is transmitted by aerolization; bacillus multiplies in bronchi and alveoli resulting in pneumonitis, may lie dormant for many years and be reactivated in periods of stress Signs and symptoms include: • Progressive fatigue, anorexia, nausea, weight loss • Irregular menses • Low grade afternoon fevers over a period of time • Night sweats • Cough with mucopurulent sputum, occasionally streaked with blood Diagnostic procedures: • Skin test – Mantoux Test (PPD), Tine Test • Sputum smear for acid-fast bacilli ( the most reliable) • Chest x-ray- routinely performed on all persons with positive PPD to detect old and new lesions TB Skin testing: • Given intradermally in the forearm • 10-mm induration (hard area under the skin) indicates significant positive reaction. An induration of 5-mm is positive for clients with AIDS • Does not mean that active disease is present but indicates exposure to TB or presence of inactive dormant disease. • Read in 48-72 hours HEPATITIS • Acute inflammatory disease of the liver resulting in cell damage from liver cell degeneration and necrosis Sign and symptoms: • Jaundice (icterus), yellow sclera • Clay colored stools, tea colored urine • Anorexia, RUQ pain Patient teaching: • Bed rest for severe symptoms • Avoid alcohol and potential hepatotoxic prescription/OTC medications ( particularly aspirin, Tylenol and sedatives) • Do not donate blood NCLEX Note: You must learn the means of transmission of different types of hepatitis; (Hepatitis A, B, C, D, E) Study Tip: Hepatitis A and E are by enteric transmission; the rest are blood borne transmission.

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LYME DISEASE A multi-system infection transmitted to humans by tick bite; most common in summer months. Signs and symptoms (stage 1): • Rash (erythematous papule that develops into lesions with a cleared center) develops at site of tick bite within 2 to 30 days; concentric rings develop, suggesting a bulls-eye; lesion enlarges quickly • Development of flu like symptoms (malaise, fever, headache, myalagia, arthragia, conjunctivitis) within one to several months, last 7-10 days and may reoccur Signs and symptoms (stage 2): • Cardiac conduction defects • Neurological disorders: Bell’s palsy: paralysis that is not permanent Signs and symptoms (stage 3): • Arthalgias, enlarged and inflamed joints occur within one to several months after the initial infection • May persist for several years Patient Teaching: • Cover exposed areas when in wooded areas • Check exposed areas for presence of ticks AIDS • AIDS (acquired immunodeficiency syndrome) – a syndrome distinguished by serious deficits in cellular immune function associated with positive human immunodeficiency virus (HIV): evide...