Exit Exam Review
Coordinated Care
Advanced Directives
Legal Responsibilities: Reinforcing Teaching about Advance Directives
• Purpose is to communicate client’s wishes regarding end -of-life care
• Life saving measures
o resuscitation, intubation, artificial hydration, and nutrition
• There are two components of an advanced directive: Living Will and Durable Power of Attorney
• Living Will clients wish regarding medical treatment
• Durable Power of Attorney clients health care surrogate who can make their decisions when the client is
unable to.
• Nurse must provide written information and document the client’s decision
Advocacy
Legal Responsibilities: Client Advocacy
• Process where nurse assists clients to grow and develop toward self-actualization
• Supports clients by ensuring they are informed, have their rights respected, and ensure they are receiving
the proper level of care
• Caring, autonomy, respect, and empowerment
• Discuss identified treatment options with client and respect their decisions
• Ensure the client has the information needed to make decisions in HC
• Situations where nursing might need to advocate for clients or assist:
o end of life decisions
o Access to healthcare
o Informed consent
o Substandard practice
• Nurses are accountable for actions even if they are carrying out a providers Rx
Assignments/Delegation
Managing Client Care: Assigning Care of a Client Who Has restraints
• Obtain a Rx for the restraints
• Conduct Neurosensory checks every 2 hours (circulation, sensation, and mobility)
• Offer foods and fluids
• Provides with means for hygiene and elimination
• Monitor vital signs
• Provide ranger of motion of extremities
• Follow facility policies
• Remove or replace restraints frequently
• Pad bony prominences
• Use a quick release
• Must be able to fit two fingers in between the device and the client
• Regularly assess the need for restraints
• Never leave client unattended without the restraint
• Rx: 4 hours at a time but can be prescribed for 24 consecutive hours
Client Rights
,Cancer Treatment Options: Therapeutic
• Chemotherapy
• Surgical interventions
• Hormone therapy
• Radiation therapy
• Immunotherapy
Collaborations with Interdisciplinary Team
Basic Mental Health Nursing Concepts: Making Referrals Using the Interdisciplinary Team
• Make appropriate referrals
• Make referrals based on the clients need that can involve social worker, speech therapist, occupational
therapist
• Referrals can also be based on the needs a client may have such as a cane walker
Coordinating Client Care: Information to Include in an Inter-professional Meeting
• Setting priorities • Documentation
• Delegation • Consultations
• Conflict resolution • Transfers
• Problem solving • Discharge
Concepts of Management and Supervision
Managing Client Care: Intervention When Supervising an Assistive Personnel
• A licensed nurse is responsible for providing clear directions when a task is initially delegated
• Must provide supervision either directly or indirectly
• Monitor performance
• Intervene if unsafe
• Provide feed back
Bowel Elimination: Reinforcing Teaching about Ostomy Care
• Monitor for leakage
• Monitor skin integrity and appearance (should be pink and moist)
• Apply skin barrier and cream prior to attaching bag
• Observe stoma output (should be liquidly)
• Empty when its 1/3 to ½ full
• Monitor for fluid and electrolyte imbalances
• Determine if client can care for Ostomy
• Mint can be placed to keep odor under control
• Foods that cause odor & gas cruciferous vegetables, asparagus, fish, eggs, garlic, beans
Managing Client Care: Supervising an Assistive Personnel
• Direct, monitor, and evaluate the performance of tasks
• Delegation is based on individual client needs, facility policies, and job descriptions, state acts, and
professional standards
• Nurse is responsible for providing clear directions when a task is initially delegated and for periodic
reassessment and evaluation of the outcome of the tasks.
• Give AP a time frame to complete task
Confidentiality/Information Security
, Professional Responsibilities: Protecting Client Confidentiality
• Nurses must follow facility policies and procedures that are established to follow HIPAA regulations
• Only health care team members directly responsible for the client’s care are allowed to access to the clients’
records.
• Nurses cannot share the information with other clients or staff that are not involved in the care of the client
• Clients have the right to read or obtain a copy of their medical record
• No part of the client record can be copied except for the authorized exchange of the documents (transfer
from a hospital to an extended care facility, exchange of documents between general practitioner and
specialist)
• Client records must be kept in a secure area and password protected
• Cannot share information to the family
Continuity of Care
Arthroplasty: Reinforcing Discharge Teaching Following a Total Hip Arthroplasty
• Keep abductor pillow in place while in bed or while turning
• Do not flex hip more than 90 degrees
• Do not position the client on the operative site
• Use elevated seating and a raised toilet seat
• Use straight chairs with arms
• Externally rotate the toes
• Use extended handles on shoehorn and dressing sticks
• Avoid low chairs
• Do not cross legs for at least 3 months
• Do not internally rotate toes
• Follow exercise program at home
Information Technology: Change-of-Shift Report
• Describe current health status of the client
• Performed with nurse assuming responsibility for the client’s care
• Informs pertinent client care information (new medications, procedures, dressing changes)
• Should be given in private area
Medications Affecting Blood Pressure: Addressing Effects of an ACE inhibitor
• Ending in -pril
• Ace inhibitors reduce production of angiotensin II and increasing levels of bradykinin
• Can lead to vasodilation, excretion of sodium and water, and reduction in pathological changes in blood
vessels
• Complications:
• Orthostatic hypotension
• Cough
• Hyperkalemia
• Rash and Dysgeusia (altered taste)
• Angioedema
• Neutropenia
• Nonproductive cough
• Electrolyte imbalance
Establishing Priorities
Managing Client Care: Prioritizing Care for a Group of Clients
• Prioritize by:
o Systemic before local
Coordinated Care
Advanced Directives
Legal Responsibilities: Reinforcing Teaching about Advance Directives
• Purpose is to communicate client’s wishes regarding end -of-life care
• Life saving measures
o resuscitation, intubation, artificial hydration, and nutrition
• There are two components of an advanced directive: Living Will and Durable Power of Attorney
• Living Will clients wish regarding medical treatment
• Durable Power of Attorney clients health care surrogate who can make their decisions when the client is
unable to.
• Nurse must provide written information and document the client’s decision
Advocacy
Legal Responsibilities: Client Advocacy
• Process where nurse assists clients to grow and develop toward self-actualization
• Supports clients by ensuring they are informed, have their rights respected, and ensure they are receiving
the proper level of care
• Caring, autonomy, respect, and empowerment
• Discuss identified treatment options with client and respect their decisions
• Ensure the client has the information needed to make decisions in HC
• Situations where nursing might need to advocate for clients or assist:
o end of life decisions
o Access to healthcare
o Informed consent
o Substandard practice
• Nurses are accountable for actions even if they are carrying out a providers Rx
Assignments/Delegation
Managing Client Care: Assigning Care of a Client Who Has restraints
• Obtain a Rx for the restraints
• Conduct Neurosensory checks every 2 hours (circulation, sensation, and mobility)
• Offer foods and fluids
• Provides with means for hygiene and elimination
• Monitor vital signs
• Provide ranger of motion of extremities
• Follow facility policies
• Remove or replace restraints frequently
• Pad bony prominences
• Use a quick release
• Must be able to fit two fingers in between the device and the client
• Regularly assess the need for restraints
• Never leave client unattended without the restraint
• Rx: 4 hours at a time but can be prescribed for 24 consecutive hours
Client Rights
,Cancer Treatment Options: Therapeutic
• Chemotherapy
• Surgical interventions
• Hormone therapy
• Radiation therapy
• Immunotherapy
Collaborations with Interdisciplinary Team
Basic Mental Health Nursing Concepts: Making Referrals Using the Interdisciplinary Team
• Make appropriate referrals
• Make referrals based on the clients need that can involve social worker, speech therapist, occupational
therapist
• Referrals can also be based on the needs a client may have such as a cane walker
Coordinating Client Care: Information to Include in an Inter-professional Meeting
• Setting priorities • Documentation
• Delegation • Consultations
• Conflict resolution • Transfers
• Problem solving • Discharge
Concepts of Management and Supervision
Managing Client Care: Intervention When Supervising an Assistive Personnel
• A licensed nurse is responsible for providing clear directions when a task is initially delegated
• Must provide supervision either directly or indirectly
• Monitor performance
• Intervene if unsafe
• Provide feed back
Bowel Elimination: Reinforcing Teaching about Ostomy Care
• Monitor for leakage
• Monitor skin integrity and appearance (should be pink and moist)
• Apply skin barrier and cream prior to attaching bag
• Observe stoma output (should be liquidly)
• Empty when its 1/3 to ½ full
• Monitor for fluid and electrolyte imbalances
• Determine if client can care for Ostomy
• Mint can be placed to keep odor under control
• Foods that cause odor & gas cruciferous vegetables, asparagus, fish, eggs, garlic, beans
Managing Client Care: Supervising an Assistive Personnel
• Direct, monitor, and evaluate the performance of tasks
• Delegation is based on individual client needs, facility policies, and job descriptions, state acts, and
professional standards
• Nurse is responsible for providing clear directions when a task is initially delegated and for periodic
reassessment and evaluation of the outcome of the tasks.
• Give AP a time frame to complete task
Confidentiality/Information Security
, Professional Responsibilities: Protecting Client Confidentiality
• Nurses must follow facility policies and procedures that are established to follow HIPAA regulations
• Only health care team members directly responsible for the client’s care are allowed to access to the clients’
records.
• Nurses cannot share the information with other clients or staff that are not involved in the care of the client
• Clients have the right to read or obtain a copy of their medical record
• No part of the client record can be copied except for the authorized exchange of the documents (transfer
from a hospital to an extended care facility, exchange of documents between general practitioner and
specialist)
• Client records must be kept in a secure area and password protected
• Cannot share information to the family
Continuity of Care
Arthroplasty: Reinforcing Discharge Teaching Following a Total Hip Arthroplasty
• Keep abductor pillow in place while in bed or while turning
• Do not flex hip more than 90 degrees
• Do not position the client on the operative site
• Use elevated seating and a raised toilet seat
• Use straight chairs with arms
• Externally rotate the toes
• Use extended handles on shoehorn and dressing sticks
• Avoid low chairs
• Do not cross legs for at least 3 months
• Do not internally rotate toes
• Follow exercise program at home
Information Technology: Change-of-Shift Report
• Describe current health status of the client
• Performed with nurse assuming responsibility for the client’s care
• Informs pertinent client care information (new medications, procedures, dressing changes)
• Should be given in private area
Medications Affecting Blood Pressure: Addressing Effects of an ACE inhibitor
• Ending in -pril
• Ace inhibitors reduce production of angiotensin II and increasing levels of bradykinin
• Can lead to vasodilation, excretion of sodium and water, and reduction in pathological changes in blood
vessels
• Complications:
• Orthostatic hypotension
• Cough
• Hyperkalemia
• Rash and Dysgeusia (altered taste)
• Angioedema
• Neutropenia
• Nonproductive cough
• Electrolyte imbalance
Establishing Priorities
Managing Client Care: Prioritizing Care for a Group of Clients
• Prioritize by:
o Systemic before local
