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NUR 280-The Ultimate GuideNUR 280 Essential Concepts (Historical)
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, Maslow
1. Basic Needs- Airway, Resp. Effort, HR, Rhythm, Strength of Contraction, Nutrition, and Elimination
2. Safety/Security- Protect from injury, trust in nurse-client relationship
3. Love/Belonging- Support Systems protect from isolation
4. Self-esteem- control, competence, positive regard, acceptance/worthiness
5. Self-Actualization- Hope, spiritual well-being enhanced growth
(AAPIE) Assess (gather data), Analyze (ID problem and formulate diagnosis), Plan (Write care plan to meet goals),
Implement (Carry out plan), Evaluate (Collect data to determine if goals are met)
Avoid ONLY and ALL, EVERY, MUST, NONE, ALWAYS and NEVER in answers
Usually correct if they have : MAY, USUALLY, NORMALLY, COMMONLY, GENERALLY
5 rights: right pt, med, dose, route, time
PPE: gown, mask, goggles, gloves
Professional Issues / Leadership & Management of Care / Teaching / Cultural
Primary prevention – education, vaccination, reduce risk factors. Immunizations, counseling about safety,
injury, and disease prevention.
Secondary prevention – procedures to detect and treat disease thereby controlling disease progression.
Screening tests, anything diagnostic.
Tertiary prevention – after disease has developed and been treated, tertiary seeks to soften the impact
caused by the disease.
Palliative care – AKA end of life care. Supportive interventions that focus on control of symptoms. Pain
is priority. Symptom management rather than cure of disease.
Disaster preparedness –START Simple Triage and Rapid Treatment. Assess RPM: RESPIRATIONS,
PERFUSION and MENTAL STATUS. No RR= BLACK TAG. RR present move down. RR above 30=
RED TAG. RR less than 30, move to perfusion. Absent radial pulse & Cap Refill < 2= RED TAG. Present
pulse and cap refill >3, move onto mental. Altered LOC= RED TAG. Follows commands=YELLOW TAG.
Walking wounded = GREEN TAG.
Reverse Triage- works on the principle that the greatest good is done for the greatest number of people.
Person who is ambulatory would be triaged first and moved to an area away from the event. Then would be
minor injuries such as a broken leg. Last is the unconscious person with the least chance of surviving.
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Disaster intervention plan – primary prevention. Formal plan of action for coordinating the response of
the health care agency staff in the event of a disaster. Assessment, planning of therapeutic intervention,
, implementation of therapeutic intervention and resolution of the crisis. Determine the crisis severity, assess
the clients perception, formulate nursing diagnosis. Level 1 disaster = massive with significant damage and
a presidential disaster declaration. Level 2 disaster = moderate with possible presidential declaration. Level
3 disaster = minor with minimal damage, president declares emergency.
Health promotion program (planning) – immunization and prevention of disease….? Considering
cultural issues, assessing pt’s ability to perform self-care, identifying high risk behaviors, providing health
screening and prevention programs, identifying high-risk behaviors.
Delegation (LPN;UAP; Float RN) – Cannot delegate what you EAT. LPN cannot do IV med, blood,
admission assessment, nursing diagnosis, teaching, complex skills, unstable/acute patients. UAP lowest
level of skill required. Can do feeding, hygiene, basic skills, chronic diseases, ambulation, ROM. Float
RN gets most stable patient. Possibly familiar area of care. RN- Independent pt. assignment. Initial
physical assessment on admission to hospital, unit, or area. Focused assessment with change in patient
condition. Determine patient problems (nursing diagnosis). Document plan for unresolved problems at
discharge. Insert a midline/PICC catheter to withdraw blood or initiate IV fluids. Flush a PICC line, access
ports, push meds, add meds to IVs, remove a midline or central line, give blood products and manage PCA
pumps. Trach change, dialysis, verbal orders, hourly chart checks. Don’t delegate what you can EAT.
LPN- The experienced LPN is capable of gathering data and making observations, including noting breath
sounds and performing pulse oximetry. May give meds, do dressing changes, suctioning, catheterization
and may review teaching plans the RN has set. Can’t IV push, handle blood or EAT. Delegate stable,
chronic pts to them. UAP- Noninvasive skin care, ADLs, ambulation, grooming, ROM, hygiene, administer
enemas, gather vitals.
Client teaching (strategies) – Know level of education, cultural beliefs. Return demonstration….? Verbal
and written. Tell them to “show you back.”
Preventing medication errors – 5 rights. Right patient, med, dose, route, time. Consider allergies,
documentation, and expiration date.
DNR (family) -- Verbal verification from family does not constitute as a valid DNR. Healthcare
professional must issue and sign the order. A DNR order does not suspend all medical care, but only
instructs that CPR not be performed in the event of cardiac or respiratory arrest. Form must be present
during code in order to honor.
Cultural diversity (communication) – Language spoken, voice quality, pronunciation, use of silence, use
of nonverbal. African American- Head nodding doesn’t always mean agreement, nonverbal communication
is important, prolonged eye contact may be perceived as rude. Asian- Silence is valued. Eye contact may be
considered rude. Don’t express criticism or disagreement verbally. Hispanic- Verbally expressive.
Avoiding eye contact with authority is s sign of respect. Use dramatic gestures and facial expressions to
express emotions. Native Americans- Silence indicates respect. Eye contact may be disrespectful. Body
language is important. White- Silence can either be for respectful or disrespectful. Eye contact indicates
trust.
Client privacy – HIPAA Pt has the right to withhold information from family.
Documentation – Objective not subjective. No opinions. If you don’t document, it didn’t happen.
Document frequently. State facts only. Place pt’s statements in quotation marks. DON’T DOCUMENT
THAT YOU DID AN INCIDENT REPORT.
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, Conflict Resolution (staff) – Avoidance – postpone issues. Accommodation – Serve others, feel
resentment. Competition – pursue own needs at expense of others. Stand up for rights and principles.
Compromise – work openly and creatively to find a solution.
End-of-life care – Shifts care from invasive interventions aimed at prolonging life to supportive
interventions that focus on control of symptoms. 6 months before death. Consider organ and tissue
donations, advance directives, legal documents, withholding or withdrawing treatment, and CPR.
Advocate for patient. Encourage to express feelings. Consider cultural rituals, state laws, etc. Jews usually
oppose prolonging life after brain damage. Amish allow organ donation of everything but the heart. Hindus
prefer cremation and no one other than the family can touch the body after death. Asians view dying at
home to be bad luck and generally the family doesn’t tell the pt the diagnosis or prognosis.
Rapid Response team – Provide nursing staff with internal consultative services provided by expert
clinicians. Early detection and resolution of client problems. Used to assist nurses in the rapid detection
and resolution of pt problems. Made up of ICU nurses, respiratory, lab and EKG.
Impaired professional – If RN suspects that co-worker is abusing chemicals and potentially jeopardizing
patient safety, the nurse must report to the nursing administration in a confidential manner. It’s the
responsibility to report to your nurse manager anyone who seems impaired.
Establishing rapport aka trust.
Informed consent – Legal document. Written. Obtained voluntarily. Explained to client. RN may
witness, but not get consent. Can be waived for urgent intervention. Client has right to refuse or withdraw
consent at any time. Pt’s approval to have their body touched by a specific individual. Pt must fully
understand what they are signing and all questions about a procedure must be answered before signing.
Must be over 18 and competent to sign. Pt must sign before any sedatives/anesthesia are given. A pt may
withdrawal consent at any time. If a pt can’t sign the next of kin, appointed guardian or durable power of
attorney may give consent. A consent may be waved for urgent medical/surgical procedures as long as
policy so indicates.
Poorly written prescription – Inform HCP. Document that HCP was informed and their response.
Inform nursing supervisor. Refuse to carry out prescription.
Sexual harassment – Unwelcome conduct of a sexual nature. Follow agency policies to handle reporting.
Organ donation -- The heart, lungs and liver can only be obtained from someone who has been
mechanically ventilated that suffered brain death. Donor must be free of cancer and infection. Family may
revoke organ donation wishes, even though the pts advanced directives state they want to donate
Transfers; Give ISBAR, POC and interventions that still need to be carried out.
Home care; Consists of nursing, PT, OT, ST and CNAs. Used when pts are considered homebound but
need care like dressing changes or physical therapy.
Restraints; Four side-rails up can be considered a form of restraint. Even in LTC facility when a client is a
fall risk, keep lower rails down, and one side of bed against the wall, lowest position, wheels locked. Geri
chairs (chairs with a lap tray) are also considered a restraint if not ordered by dr. Can be chemical or
physical. HCP’s prescription must indicate use, specific time frame for use and behaviors indicating use.
Not to be prescribed PRN. Secure to bedframe with safety knot. Assess skin and circulation q 30 minutes
and remove at least q 2 hrs to allow movement. Continually document the need for restraints.
Litigation prevention; Recognize suit-prone pts and cater to their needs in a more “sucking up” kind of
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way. Don’t become a suit-prone nurse; establish relationships with your pts, delegate correctly and take
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complaints seriously.
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