Legal
Pt rights/responsibilities: right to ask questions, right to refuse
o Pt can revoke a consent even after they signed.
Assault: makes a person fear they will be harmed
Battery: physical contact w/o a person’s consent. RN grabbing pts arm when trying to leave.
o Dr doing more than what was consented.
Libel: writing false statements to
Defamation: intent to injure an individual’s reputation. damage reputation.
Slander: RN talking about MD doing
False imprisonment: lap tray on chair/over bed. 4 side rails up. something bad that is false.
Negligence: RN notices change in AM & doesn’t report it until PM.
o RN tells BPD pt its ok to refuse their meds.
o RN failing to admin a prescribed med that causes har
Informed consent: RN signs as witness. NOT THAT patient understands.
Wasting meds: waste w/ 2nd nurse before administrating meds.
Abuse/Report:
o Child w/ bruises = get hx of each bruise = report to outside agency
o Elderly pt living w/ dtr & stage 3 pressure injury = report to outside agency
o STI/STD = report to public health
Incident reports: what they’re used for & why we would use it
Phlebitis/infiltration from the IV require the nurse to document it in the medical record as well as complete and
incident report.
Do not state in the medical record that you completed an incident report.
Correct documentation: pt ambulating in the hallway.
o Visitor falls in café.
o Missing pt belongings.
o Phlebitis
o Med error
Can patients view their medical records? Yes.
View own medical records while working? No. fire able offense.
*triple lumen cath: flush w/ 10 mL NS before & after use.
Contact
Standard: all pts.
Airborne: Disseminated/herpes zoster (shingles), varicella (chicken pox), TB, SARS/COVID,
measles (rubeola)
o “Which pt should be put in treatment room first?” Patient with linear rash
(disseminated/herpes zoster)
o Unsecular rash/rash on side near rib cage/linear rash
Neutropenic: no litter box, no gardens, check temp. daily. Wash cups between use.
, Delegation:
Tasks to assign to LPN: reinforce teaching, collect PMH. obtaining a wound culture during
dressing changes.
UAP:
RN: new admission v/s, first time walking, teaching, assess, planning
Prep an IV site for insertion: up & down.
Skin integrity:
protect the fragile skin of older adults w/ IV insertion by using a soft cloth between the
tourniquet & skin.
Intervene:
New RN cleans IV hub back & fourth. Should be in circle, inner to outer.
New RN opens sterile flap towards self first.
Gave warfarin 1 hr before d/c. *DVT/VTE: hydration,
Health screenings:
Scoliosis: 10-14 yo annually
SCD/Teds/compressions, ROM, exercise, OOB
Colonoscopy: 50 yo then Q10yrs
q2rs, no pillows under knees
o Colon/colorectal cancer:
*Primary: diet, exercise,
Crohns disease risk
Father w/ polyposis risk
o stress management class
risk w/ previous stomach cancer &
smoker
*Secondary: scoliosis screenings
TSE: monthly after hot shower; same time; same day
10-14 yo,
BSE: 7 days post period, same time
o No period? Pick same day monthly. o BSE (7 days after period),
o Smoking risk for breast cancer
o TSE
Spinal bifida + multi. Surgeries = r/f latex
allergy. o colonoscopy @ 50 yo. Q 10
Cervical cancer = HPV vax yrs.
Meds/Vax: Teaching pt taking nitro: let it dissolve!
o HPV ages 9-26 (53 yo) Good for 5-6 months
Mg Sulfate:o s/eNo HPV Vax = risk o TSA – men q5yrs.
Anticonvulsant – pre-eclampsia & eclampsia Pt @ home w/ angina. Takes 1 nitro. Waits 5 mins.
Restrict fluids to < 125 mL/hr Still have CP. Do what next? Call 911 & then
aTertiary:
take teach
second Nitro. DM5daily
Wait minsfoot care.
& take a 3rd if
UOP 25-30 mL/hr
needed.
*pt taking Dig. Store in a light-resistant container.
Mg toxicity: N/V, vision Further teaching – “I will call my PCP to
RR, DTR changes, Dig request a new rx 3 months after opening
BB 160/110 + level >2. new bottle.”
Absences of DTR Next action?
RR <12
Assess v/s Prednisone/hydrocortisone: *priority to f/u if BGL
LOC, h/a, visual disturbance
Cardiac dysrhythmias
2
Antidote: Calcium Gluconate is 19, or 135
*No ACE inhibitors with K-sparing diuretics
Fluphenazine: antipsychotic – schizo. No pt w/
glaucoma. *No grapefruit w/ statins
MAOIs = avoid tyramine (dried fruit, organ meats,
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