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Management of Care (3 items) Case Management (1 item) Develop and manage the overall long-term health care plan for patients with chronic or serious conditions such as Alzheimer’s disease, diabetes, and heart disease. Book their patients’ doctor appointments and follow up to make sure they keep them. Serve as a resource for their patients, offering education and guidance to patients and their families as they navigate complex medical decisions. Act as a liaison between patients and their insurance providers to make sure they receive excellent health care at a fair price. Establishing Priorities (1 item) Dietary assessment should include number of meals per day, fluid intake, food preference, history of indigestion. Allergies, taste, chewing, appetite, medication use, activity levels, and intake and output. Risk factors that can lead to infection include inadequate hand hygiene, immunocompromised individuals, surgery, indwelling devices, skin break, poor oxygen, and chronic illnesses. A potential complication of ECT is memory loss and confusion. They can occur immediately following the procedure and can persist for several hours. Clients have retrograde amnesia which is the loss of memory of events leading up to the procedure and have no memory of the procedure. As a nurse we should provide frequent orientation, a safe environment, and assist with personal hygiene. Referrals (1 item) When clients have assessed needs that cannot be fulfilled and met by the registered nurse in collaboration with other members of the nursing care team, the registered nurse should then seek out resources, as well as utilize and employ different internal or external
resources such as a physical therapist, a clergy member or a home health care agency in the community and external to the nurse's healthcare agency. Medical data and information including referral forms and the client's medical record are shared with the person, department or community resource that is accepting the client according to their legal need to know this information in order to provide the client with their necessary care and treatments. Nurses and the entire healthcare team assess clients and determine their need for referrals relating to actual and potential problems. Safety and Infection Control (1 item) Handling Hazardous and Infectious Materials (1 item) Hepatotoxicity means damage to the liver. It can happen with many different medications. Damage to liver cells can impair metabolism of many medications, causing medication accumulation in the body producing adverse effects. Nephrotoxicity can occur with a number of medications, but it is primarily the result of certain antimicrobial agents and NSAIDs. Damage to the kidneys can interfere with medication excretion, leading to medication accumulation and adverse effects. Angioedema is a severe allergic reaction that affects deep tissues. Generally, seeing in the face. As nurses, we need to obtain complete medical history, and some interventions we may need to do improve oxygen administration, alleviating anxiety, and maintain open airway. Health Promotion and Maintenance (1 item) Health Promotion/Disease Prevention (1 item) Expected findings when going into shock include chest pain, lethargy, somnolence restlessness, anxiousness, dyspnea, diaphoresis, thirst, muscle weakness, nausea, and constipation.
May be necessary to make arrangements for the patient to attend individual, group, and family therapy. Pharmacological and Parenteral Therapies (3 items) Adverse Effects/Contraindications/Side Effects/Interactions (1 item) Native immunity also known as natural or innate immunity is defined as provides the early line of defense against microbes. It consists of cellular and biochemical defense mechanisms that are in place even before infection and are poised to respond rapidly to infections. One of the most important healthy habits to prevent the spread of germs is to clean your hands. Our hands can carry germs, so it is important to wash them often, even if they don’t look dirty. Use hand sanitizer if soap and water are not available and if your hands do not look dirty. To be effective, hand sanitizer must have at least 60% alcohol content. Blood and Blood Products (1 item) Maternal phenylketonuria is a maternal genetic disease where there are high levels of phenylalanine that poses a big danger to the fetus. In the case of PKU, the modified diet should be started 3 months before pregnancy. Some of the foods to avoid are fish, poultry, eggs, meat, and dairy products. For newborns, solid food should not be introduced until after 6 months of age. When they are introduced, they need to start with one food every week to see if there are any sensitives. Pharmacological Pain Management (1 item)
Some orders for pain medications are PRN which means that the client will only receive the pain medication when there is pain or discomfort that can be assessed and documented by the nurse. PRN pain medications can be given using a number of routes including the intramuscular, intravenous, oral, subcutaneous, and topical route as is used for skin irritation and itchiness, for example. Neonates and infants are given dosages of medications based on their weight in terms of kilograms or based on their body surface area. Oral pain medications are given as a liquid using a dropper or a nipple. The elderly population and the normal changes of the aging process also have implications in terms of pharmacological pain management medications. The normal changes of the aging process such as decreased renal, hepatic and gastrointestinal functioning place the client at risk for side effects, adverse drug reactions, toxicity and over dosages. Nurses must, therefore, begin a new medication with the lowest possible dosage and then increase the dosage slowly over time until the therapeutic effect is achieved. Reduction of Risk Potential (4 items) Potential for Complications of Diagnostic Tests/Treatments/Procedures (1 item) The nurse must readily identify and respond to all medical emergencies when they occur and they must also be able to rapidly and knowledgably apply priority setting and critical thinking skills during a time when needs, priorities and the client condition are rapidly changing. This is the time for short term minute to minute simultaneous client care planning and interventions. Airway obstructions can be partial or complete. A complete airway obstruction is signaled with the lack of any cough or other noises from the patient. The airway must be
new home in birthing centers and hospital obstetric departments across the country. The ball easily withstands the pressure applied by the weight of the laboring woman. Comfort measures that provide natural pain relief can be very effective during labor and childbirth. Birthing techniques such as hydrotherapy, hypnobirthing, patterned breathing, relaxation, and visualization can increase the production of endogenous endorphins that bind to receptors in the brain for pain relief. Physiological Adaptation (8 items) Alterations in Body Systems (3 items) All drainage including wound drainage, respiratory secretion drainage, chest tube drainage are assessed and documented in an ongoing manner in terms of the quantity, color, consistency and other characteristics of the drainage. The nurse will intervene in the appropriate manner when the drainage is not considered normal in any of its aspects. Often, the first intervention is notifying the client's doctor of any abnormality in terms of this drainage. Some pathogens are associated with brief periods of communicability, others are characterized with longer periods of communicability; and some pathogens are associated with short periods of incubation and others are associated with longer periods of incubation. Fluid and Electrolyte Imbalances (2 items) Older adults require special considerations when doing assessments because as we age, our body changes. Some things to consider are decreased skin turgor, loss of subcutaneous fat, thinning hair, increased blood pressure and thickening of nails.
Older adults may also have cognitive impairments such as delirium or dementia. Delirium is an acute and temporary state of confusion that can manifest from other illnesses. Dementia is a progressive loss of memory and its cause is unknown. Injury prevention involves installing bath rails, grab bars, handrails, walkers, removing extension cords Illness Management (1 item) Expected findings when going into shock include chest pain, lethargy, somnolence restlessness, anxiousness, dyspnea, diaphoresis, thirst, muscle weakness, nausea, and constipation. Pulmonary artery catheter insertion is catheter that is inserted to measure central venous pressure, pulmonary artery pressures, and cardiac output. Continuous hemodynamic monitoring is important t manage fluids and dosage of inotropic medications. In intubation/mechanical ventilation an artificial airway is inserted and the patients’ respirations are controlled by mechanical ventilation. It is important for nurses to monitored ECG, SaO2, breath sounds, and color. Medical Emergencies (2 items) One of the most challenging things that nurses do is applying a knowledge of client pathophysiology when a medical emergency occurs. Life threatening emergencies focus on the here and now as the client's condition often changes in a rapid and sometimes unpredictable manner. Of the many ways that nurses can somewhat predict the possibility of a medical emergency is knowing all they can know about the client, their medical history and their current physical status, understanding the pathophysiology of their current condition or situation and applying this knowledge to the possible complications and adverse responses to not only their
