Exam #2 Study Guide

1. Discuss the legal implications of death and dying.

(PowerPoint)

Dying Persons Bill of Rights: (*see box at top of page P&P 468)
DNR (P&P 328): order to withhold treatment instead of deliver treatment; written not verbal.
Advanced Directives (P&P 328): 2 kinds - living wills and durable powers of attorney for health care; both based on values of informed consent, client autonomy over end-of-life decisions, truth telling, and control over the dying process; witnessed by non-involved parties; some states do not recognize witnessing by relatives valid
Organ Donations (P&P 329): "donation of all or part of a human body to take effect upon or after death"; written; 18 years of age or older.
Euthanasia/Assisted Suicide (P&P 330): allowed only in Oregon (Washington?); elsewhere, feeding/hydration withdrawn to hasten death; high pain medication to "prevent pain" that may subsequently cause death.

(End-of-life Lecture 11/6)
- Dying person’s bill of rights
- DNR (do not resucitate)
- Advanded directives (witnessed by non-involved parties; some states do not recognize witnessing by relatives)
- Living will/Durable Power of Attorney
- Organ donations
- Euthanasia/assisted suicide

Pt and their families have the right to decide what outcome they want to have as it pertains to their end of life care. It should be based on the Pt wishes and should include: if they want to donate organs, advanced directives, and resuscitation. All states have natural death acts which tells the physicians exactly what treatment is or isn’t desired. A person may write his or her wishes w/o special forms. Verbal directives may be given to physicians that are specific instructions that pertains to how the pt would like to proceed with their care. This must be witnessed by 2 people

2. Discuss therapeutic communication when caring for the dying patient.

(P&P 473)

Establishing a caring, trusting relationship with the client and family through the use of therapeutic communication forms the basis for palliative care interventions. A grieving client may experience anger, for example, and become hostile with family members or caregivers. Some clients become demanding and accusing. Remain supportive by letting clients and family members know that feelings such as anger are normal by saying, for example, "You are understandably upset right now. I just want you to know I am here to talk with you if you want." Invite clients to reveal the emotions and concerns of greatest importance to them, and acknowledge their feelings and concerns in a non-judgmental manner.
If a client chooses not to share feelings or concerns, express a willingness to be available at any time. Some clients will not discuss emotions for personal or cultural reasons, and other clients hesitate to express their emotions for fear that others will abandon them. If you are reassuring and respectful of the client's privacy, a therapeutic relationship will likely develop. Sometimes clients need to begin resolving their grief privately before they will discuss their loss with others, especially strangers.
Avoid communication barriers such as denying the client's grief, providing false reassurance, or avoiding discussion of sensitive issues. When you sense that a client wants to talk about something, make time right then, if at all possible. Above all, remember that a client's emotions are not something you can "fix." Instead, view emotional expression as a necessary part of the client's adjustment to significant life changes and development of effective coping skills. help family members access other professional resources. Spiritual care providers, for example, help clients and family members discuss difficult issues related to personal meanings and values, death, and loss.

Face client when speaking to them
Eye-to-eye contact

Holding hands, use of therapeutic touch is acceptable if the pt is comfortable with that, doesn’t have to be verbal, can be nonverbal communication, could be as simple as companionship and just listening to the dying pt. Empathy and active listening are important. Silence is also therapeutic, allowing the pt time to gather thoughts, and listening to silence sends a message of acceptance and comfort.

3. Discuss the types of grief and grief responses.

(P&P 463)

Normal (uncomplicated) grief: feelings of acceptance, disbelief, yearning, anger, and depression.
Complicated grief: the grieving person has a prolonged or difficult time moving forward after a loss; may experience a chronic and disruptive yearning for the deceased and are likely to have trouble accepting the death and trusting others, feel excessively bitter, or are uneasy about the future; may feel emotionally numb; usually associated with conflicted relationships with the deceased, prior or multiple losses or stressors, mental health issues, or lack of social support; loss associated with homicide, suicide, sudden accidents, or the loss of a child usually fall into this category; symptoms and disturbances last at least 6 months after loss and they interrupt every dimension of the person's life.
Anticipatory grief: the unconscious process of disengaging or "letting go" before the actual loss or death occurs, especially in situations of prolonged or predicted loss - usually a benefit; sometimes the stress and strain of a terminal illness, including ruptures in spousal intimacy, separation anxiety, security threats, and the traumatic helplessness of watching a loved one die, outweigh the supposed benefits of anticipatory grieving; forewarning may be a buffer for some, it may increase stress for others, posing a sort of emotional roller coaster of highs and lows.
Disenfranchised grief: known as marginal or unsupported grief because their relationship to the deceased person is not socially sanctioned, cannot be openly acknowledged or publicly shared, or seems of lesser significance; examples include the death of a very old person, an ex-spouse, a gay partner, or even a loved pet.

(End-of-life Lecture 11/6)
**Unresolved Dysfunctional Grief**
absent: taotally absent as if dath never occurred
inhibited: lasting inhibitions of many manifestations of normal grief
delayed: postpones
conflicted: frequently exaggerated or distorted
anger and extreme guilt
can be prolonged; assoc w/previously dependent or ambivalent relationship w/the deceased
chronic: cont. exhibits intense grief
fails to draw natural conclusion
often assoc. w/intense yearning and dependence fastered by mourner’s insecurities
also evident after the loss of an irreplaceable relationship
unanticipated: occusrs affter a sudden unanticipated loss
so disruptive that recovery is usually complicated
adaptive capabilities seriously assaulted
suffer extreme feelings of bewilderment, anxiety, self-reproach, depression which renders them unable to function
difficulty in accepting loss
abbreviated: often mistaken for unresolved grief
short lived byt normal form
may occur because of immediate replacement or insufficient attachement of the lost person
sometimes can occur after a gnificant amount of anticipatory grief was completed before death.

Pathologic grief- which is an intense grief that lasts more than a year the grieved person becomes bogged down in the grieving process.

Conflicted grief- when the bereaved person has not resolved abivalent feelings towards the deceased.

Absent grief when the bereaved person appears to be coping and carrying on as if nothing ever happened.

Dysfunctional/Complicated grief- is grief that is delayed or exaggerated may be identified as dysfunctional. Dysfunctional grieving may relate to a real loss or a perceived loss, it may occur when grief is not resolved from a prior experience. Has a difficult time moving forward after a loss. Can feel bitter or numb, more commonly associated with sudden loss.

Anticapatory grief- is the unconscious feeling of letting go before the actual loss or death occurs, especially in situations where the loss was expected.

Adaptive grief- it is helpful or assists the person in accepting the reality of death. THIS IS A HEALTHY RESPONSE.

Normal uncomplicated grief- when people are in the process of grieving a loss this is a normal and healthy response to grief it’s the most common reaction to death

4. Discuss the concerns of the dying patient.

(PowerPoint)

-Must arrange a variety of affairs
-Cope with loss of loved ones and self
-See to future medical needs
-Plan for the future
-Anticipate future pain and discomfort and face possible loss of various forms of sensory, motor, or cognitive abilities
-Cope effectively with loss of self and identity and deal with the death encounter
-Decide whether to attempt to slow down or speed up the dying process
-Must deal with numerous psychosocial problems:
loss of control
suffering
types of death
living-dying interval
acute/chronic crisis phase
dying as a gradual process

(End-of-life Lecture 11/6)
♣ must arrange a variety of affairs
♣ coping w/loss of loved ones and self
♣ see to furute medical needs
♣ plan for the future
♣ anticipate future pain and discomfort and face possible loss of various forms of sensory, motor, or cognitive abilites
♣ cope effectively w/loss of self and identity and deal w/the death encounter
♣ decide whether to attempt to slow down or speed up the dying process
♣ must deal w/numerous psychosocial problems:
• loss of control
• suffering
• types of death
• living-dying interval
• acute/chronice crisis phase
• dying as a gradual process

Fearing the unknown, what is going to happen to their loved ones once they have died. Making sure that all the loose ends are tied before they die, and having their final affairs in order. Spiritual concerns, where am I going after I die. Fear of pain is it going to hurt, fear of loneliness and abandonment they don’t want to be alone. Fear of meaninglessness what accomplishments have they made, and what have they done with their lives, the fear that all of that will be forgotten

5. Discuss the interventions needed to assist the patients to die with dignity.

(P&P 475)

-Includes a person's positive self-regard, an ability to invest in and gain strength from one's own meaning in life, feeling valued by others, and how one is treated by caregivers; nurses promote this by respecting him or her as a whole person with feelings, accomplishments, and passions independent of the illness experience.
-Giving importance to the things that a client cares about validates the person, at the same time strengthening communication among the client, family members, and the nurse.
-Spending time with clients as they share their life experiences, particularly what has been meaningful, helps you know the client better and facilitates the development of individualized interventions.
-Show respect for older clients by calling them by surnames and titles and by obtaining their permission to include others in private conversations.
-Attend to the client's physical appearance - cleanliness, absence of body odors, attractive clothing. When caring for a client's bodily functions, show patience and respect, especially after the client becomes dependent.
-Allow clients to make decisions, such as how and when to administer personal hygiene, tests, or therapies, their purpose, and anticipated effects. Provide privacy during nursing care procedures, and be sensitive to when the client and family need time alone together.

(End-of-life Lecture 11/6)
Keep pt comfortable

If possible meaning if the Pt is AoX3 let the Pt make their own decisions about their health care, talking to them about their treatments asking for permission before initiating care. Promote the Pt sense of dignity and self-esteem by respecting the person as a whole respecting the person’s feelings, accomplishments, independent from the illness experience. Valuing things that the Pt finds important validates the Pt and helps build better communication.

6. Explain the purpose of Hospice care.

(P&P 478)

Hospice care is a philosophy and a model for the care of terminally ill clients and their families. Hospice is not a place, but rather a client- and family-centered approach to care. It gives priority to manage the client's pain and other symptoms, comfort, quality of life, and attention to physical, psychological, social, and spiritual needs and resources. Hospice services are available in home, hospital, extended care, or nursing home settings.
*see list of "hospice care focuses" at bottom of page 478

(End-of-life Lecture 11/6)
Usually reserved for those living 6 months or less

The purpose of hospice is to provide palliative care to the dying p, compassion, concern and support of the dying pt. Hospice is geared to the trtmnt and management of the persons symptoms rather than trying to cure them. Focuses on caring interventions, such as pain relief or decrease in pain, decrease in symptoms of the disease and psychosocial support, so that they pt is able to live as fully as possible during the EOL transition. This is usually for a pt that has less than 6mo of life left.

7. Discuss the concepts of pain and pain management.

(P&P Ch43)

-McCaffery's definition of pain: "Pain is whatever the experiencing person says it is, existing whenever he says it does."
-pain is categorized by duration (acute or chronic) or by pathologic condition (e.g., cancer or neuropathic).
-factors that influence pain include:
social (attention, previous experience, family & social support) spiritual (punishment, lesson)
psychological (anxiety, coping style)
physiological (age, fatigue, genes, neurological function)
cultural influences (the meaning of pain based on ethnicity)
-Effective pain management improves quality of life, reduces physical discomfort, promotes earlier mobilization and return to work, results in fewer hospital/clinic visits, and shortens hospital stays, thus reducing health care costs.
-Pain management can include:
nonpharmacological:
relaxation & guided imagery
distraction
cutaneous stimulation (TENS), massage
herbals
reducing pain perception
pharmacological:
analgesics (nonopioids, opioids, adjuvants/coanalgesics)
PCA
perineural infusion
topical analgesics
local/regional anesthetics
invasive interventions (injections, spinal cord stimulators, deep brain stimulation)

(Pain management Lecture 11/13)
Affective: emotions, suffering
Behavioral: behavioral responses
Cognitive: beliefs, attitudes, evaluation, goals
Sensory: pain perception
Physiologic: transmission of nociceptive stimuli
**PAIN MANAGEMENT:**
♣ Medications (opioid, non-opioid, co-analgesic or adjuvant)

There are two parts of pain Physical and emotional. The physical part of pain is the sensation which is the unpleasant felling due to stimuli. The other part is the suffering which is the emotional part of the pain. Pain is multidimensional there is the affective, behavioral, cognitive, sensory, physiologic. Pain management refers to helping the pt control their pain not necessarily the absolute reduction of pain. It is unrealistic to expect total pain relief especially if it’s chronic pain, so the reasonable expectation is finding out what is an acceptable pain level for the pt.

8. Discuss ethical considerations for the terminal patient. (from lecture on Ethical and Legal Issues of Dying)

Dying Person’s Bill of Rights
DNR
Advanced Directives
Witnessed by non-involved parties
Some states do not recognize witnessing by relatives valid
Living Will/Durable Power of Attorney
Organ Donations
Euthanasia/Assisted Suicide

You want to make sure that you keep the Pt comfortable, you want to improve the quality of the pt remaining life, you need to know in advance what the pt wishes are about being resuscitated and conversations regarding EOL care needs to include the pt not just the pt family. Early communication about EOL care should be initiated early when the client is still able to make decisions regarding their care and treatment what their wishes are and how to carry them out. Who they want present, what they want to be kept private who they want to administer their last rites, assessing the pt spiritual needs. You want to educate the Pt about

9. Discuss the nursing interventions for the patient receiving chemotherapy or radiation treatment. (from cancer lecture)

Remember speedy nursing encounters and visitor restriction!

INFORM CLIENT BEFORE:
The need to visit the place where they will receive therapy in advance
They need to lie very still on the table while irradiation occurs
They will have a tattoo applied to mark the place – DO NOT REMOVE
They will be alone in the room during therapy, but a technologist will be available via intercom

FOR IMPLANTABLE OR OTHER RADIATION:
Need to avoid contact with others—children should not sit on their laps.
Flush toilet 2-3 times after voiding so all radiation passes
All linens need to be handled according to facility policies for the specific treatment
Drainage from site of radioactive colloid injection – considered radioactive, MUST be reported to MD immediately
Dressings with radioactive seepage, MUST be removed with long handled forceps
MUST NEVER BE TOUCHED WITH UNPROTECTED HANDS
Shielding is REQUIRED

FOR BONE MARROW:
Nursing implications will be needed to deal with nausea, vomiting, GI tract inflammation, taste changes, anorexia, mucositis, stomatitis, esophagitis, intestinal damage, and diarrhea. Pt is also at a risk for infection so all interventions related to that risk diagnosis need to be followed.

(Cancer Lecture 11/6)
Moisturizing lotion
Turning if bedridden
Encourage ambulation
Fluids
Cough and deep breathe
I.S
Rest/activity periods
Food like/disliked
Admin. Antiemetics as ordered
Protective/reverse isolation
Avoid crowded places (no daycare)
No fresh flowers
No animals

Palliative interventions are key such as helping to reduce irritation to skin during radiation. Applying creams and ointments that are nonirritating to the skin in the areas that the pt is receiving radiation treatment, gently cleansing the skin, and making sure that it is dry, dusting with cornstarch may reduce itching, for areas that are oozing, rinse the area with saline solution and expose that area to air to allow it to dry, use no adhesive absorbent dressing to remove drainage, giving pt education about what to avoid while being treated such as wearing loose fitting clothes, taking off bra’s and girdles during treatment, not wearing harsh fabrics like wools and corduroys and avoiding direct sunlight, giving the pt antiemetics prior the procedure, and as a regimen of care to prevent nausea and vomiting helps to counteract the affects of chemotherapy and radiation treatment. Giving the Pt frequent oral care since may pt that receive chemotherapy experience dry mouth due to decreased salivary production. Maintaining a comfortable environment for the pt while they are receiving treatment has a therapeutic affect. Pt should receive small, frequent, soft, nonirritating and high protein and caloric meals to help prevent nausea and vomiting which will help the pt maintain their weight and energy. Encourage ambulation, cough and deep breathing exercises, incentive spirometer use, eat foods they like, resting during periods of activities, and doing things in small increments.

10. Discuss the relevant assessment data needed for the terminal patient on pain medication.

Look for nonverbal signs of pain, ask about possible side effects as they may be worse than pain. Pain medication is often under administered to the terminally ill, so be aware of that.

Pain control is important regardless if the Pt has a terminal illness or an acute illness. Assess what their pain level is, and what is an acceptable pain level to the Pt. Assess their pain level frequently, communicate and collaborate with others regarding the plan of care and how to keep the Pt at their acceptable level of pain. Initiate adequate pain relief measures. Assess the Pt response to analgesics and other no pharmacologic interventions at least 30-60 min after administering. Assessment must include level of sedation.

11. Differentiate between the assessment needed for the patient in acute and chronic pain.
(from pain lecture)

Acute Pain Assessment:
Direct interview (OPQRST)
Observation
Diagnostic studies
Physical examination

Chronic Pain Assessment:
How has the pain affected his/her ADL’s
Ensure informed consent for pain management.
Assess pain and evaluate response to pain management interventions using a standard pain management scale based on patient self-report

Acute: (multidimensional)
♣ Direct interview
♣ Observation
♣ Diagnostic studies
♣ Physical examination
Chronic: How has the pain affected his/her ADL’s

You want to know if the person is having acute pain vs. chronic pain, so that you will know how to treat the pain. Acute pain should be aggressively treated. The goal is pain reduction and pain free if possible. You want to find out where the pain is coming from. Acute pain is usually brief with rapid onset and duration, high intensity and frequency. Chronic pain is gradual or can be sudden the duration lasts longer than 6mo, you want to know how this pain affects the person in their day to day life, what aggravates the pain and what makes it better. How is the person’s social life affected and does the pain make them withdraw from others, does it make them feel depressed, cause fatigue and activity intolerance. Assess pain according to daily activities, direct interview, observation of the Pt, diagnostic studies, and physical examination.

12. Describe the different types of pain.
(from wikipedia)

Acute Pain- pain that comes on quickly, can be severe, but lasts a relatively short period of time
Chronic Pain- pain that persists longer than the temporal course of natural healing, associated with a particular type of injury or disease process
Referred Pain- pain perceived at a site adjacent to or at a distance from the site of an injury's origin
Breakthrough Pain- pain that comes on suddenly for short periods of time and is not alleviated by the patients' normal pain suppression management.
Phantom Pain- perceptions that an individual experiences relating to a limb or an organ that is not physically part of the body.

Acute and chronic, cancer pain which is pain at he tumor site or distant to the site. Nociceptive pain is the stimulation of the afferent nerves which transmitts pain signals, it is caused by damage to the somatic or musculoskeletal tissues, visceral pain which is internal organ pain. Neuropathic pain is pain that is caused by damaged nerves which causes pain. Idiopathic pain which is pain that has an absence of an identifiable cause. Pain can be affective-emotions and suffering. Physiologic-transmission of nociceptive stimuli. Sensory-pain perception. Cognitive-pain beliefs and attitudes. Behavioral-behavioral responses.

14. Discuss the education needed for the patient on opioid medication.
(from pain lecture)

Explain that risk for addiction is low, tell the patient what the side effects to look out for are, other than that educate them on general things relating to pain meds, like how to operate a PCA, dose, interval, and route, and the pain management plan.

Opiod analgesics should be used to treat moderate to severe pain. Pt should be advised that opiods cause sedation, respiratory depression, constipation, nausea, vomiting, itching, urinary retention, cyclones and altered mental processes. Educate the Pt that the appropriate use of opiods for pain rarely leads to addiction.

15. Discuss the nursing diagnoses relevant to grief.

( Ch. 30 Potter)
* Compromised family coping
* Ineffective denial
* Fear
* Grieving
* Complicated grieving
* Risk for complicated grieving
* Spiritual distress
* Anxiety

Potter#470

Death anxiety, caregiver role strain, compromised family coping, readiness for enhanced comfort, disturbed personal identity, ineffective denial, fear, grieving, complicated grieving, risk for complicated grieving, hopelessness, risk for loneliness, spiritual distress, readiness for enhanced spiritual well being


16. Discuss goals/outcomes for patients in chronic pain.

Describe experience in order to treat, identify goal for therapy and
resources for self management, prevent pain whenever possible, will
require only oral analgesics for pain, reports pain is less then 3 on
a 1-10 scale after the use of PCA. Decrease pain to tolerable level
according to patient’s tolerance. NEVER USE: PAIN WILL BE GONE BY…!
(Pain management study guide)
When managing clients’ pain, your goals of care should promote the
client’s optimal function. Determine, along with the client, what the
pain has prevented the client from doing. Then decide on a mutually
acceptable level of pain that allows return of function. An indication
of a plan’s success is dertermined through attainment of goals and
outcomes. For example, in the case of the goal of “ the client will
achieve a satisfactory level of pain relief within 24 hours. The
following are possible outcomes: reports that pain is a 3 or less on a
scale of 0-10. Identifies factors that intensify pain, uses pain
relief measures safely, level of discomfort will not interfere with
ADL activities.(CH. 43 Potter pg.1067)
Goals: Patient will obtain tolerable level of pain before discharge.
Client will actively participate in ADLs. Outcomes: pain control;
client willl report pain at stated goal or below, client uses PCA
device properly. Pain disruptive effects; sleep 5-6 hours without
interruption form pain, will complete own hygiene with minimal
assistance, will walk the hallway with husband every 4 hours for 15
minutes. Medication response; will report having a normal bowel
movement every other day. Will not experience unmanageable opioid side
effects. (CH. 43 potter pg. 1069)

- control pain to possible extent

-focus on enhancing function and quality of life

Decrease pain, ability to administer self-care, ability to do ADL’s, return to doing day to day activities. Pt will achieve satisfactory level of pain relief within 24 hours. Use pain relief interventions safely. To prevent pain as much as possible.

17. Discuss the safety precaution education needed for patients receiving chemotherapy.

Chemotherapy induced side effects are the result of the destruction
of normal cells. Chemotheraupeutic agents cannot distinguish between
normal cells and cnacer cells. (CH. 16 Lewis pg. 291)
Integumentary effects of chemo/radiation: skin changes, alopecia(hair
loss)
Respriratory: pneumonytis
Cardiac: carditis, myocarditis
GI: anorexia, nausea, vomiting (most important) diarrhea,
constipation, indigestion, stomatitis, mucositis, esophagitis
GU: hemmorhagic cystitis (from meds), sterility, nephrotoxicity
Hematologic: pandolopenia (anemia, leudemia, thrombocytopenia)
Phsycosocial: anxiety, depression. (Lecture11/12/2008)

Lewis pp#294-296

- Treatment regime

-supportive care options ( eg. Antiemetic, antidiarrahea)

-what to expect during the course of treatment is important to help decrease fear and anxiety, encourage adherence, and guide at home self-management.

- Common side effects and symptoms ( see table 16-15 Lewis pp295-296)

18. Discuss the use of the pain diary in pain management.

GOOD FOR CHRONIC PAIN!! Help the nurse and patient identify pain
patterns and causative factors. Frequency and total dosages of
medication, including breakthrough pain. ( Pain lecture)

- help the nurse and patient identify pain patterns and causative factors

-it is good for chronic pain

- it includes frequency and total dosages of medication, including breakthrough pain

Pain diary’s are good for people who have chronic pain. Helps the nurse and the Pt identify pain patterns and causative factors. Should include the frequency and total dosages of medication, including break-through pain.

19. Discuss titration in pain management.

Analgesic titration is dose adjustment based on assessment of the
adequacy of analgesic effect versus the side effects produced. There
is wide variability in the amount of analgesic needed to manage pain,
and titration is an important strategy in addressing this variability.
An analgesic can be tritrated upward or downward, depending on the
situatin. For example, in a post op patient the dose of analgesic
generally decreases over time as the acute pain resolves,. On the
other hand, opioids for chronic, severe cancer pain may be titrated
upward many times over the course of therapy to maintain adequate pain
contro. The goal of titrationis to use th smallest dose of analgesic
that provides effective pain control with the fewest side effects.
(Ch. 10 Lewis Pg. 140)
Dose adjustment based on assessment of analgesic effect versus side
effects. Use the smallest dose to provide effective pain control with
fewest side effects. Working with patient to decide the optimal
analgesic dosae required but minimizing side effects. (pain lecture)

- dose adjustment based on assessment of analgesic effect versus side effect

-use the smallest dose to provide effective pain control with fewest side effects

-working with patient to decide the optimal analgesic dosage required but minimizing side effects

Titrated doses should be based on assessment of analgesic effects that are desired versus side effects produced. Use the smallest dose possible to provide effective pain control. When titrating the Pt has to decide the optimal analgesic dosage required while minimizing side effects. There is a wide variability in the amount of analgesic needed to manage pain, and titration is good for addressing this variability. Analgesics can be titrated upward or downward depending on the type of pain and the cause of the pain.

20. Discuss the nursing care for the patient using PCA or continuous opioid analgesia.

Clients need to understand the PCA and be able to locate and press
the button to deliver the dose. Check IV line and PCA device regularly
to ensure proper functioning. Assess to determine if your client is
opiod naïve and if so do not increase dose or shorten time interval
this may cause oversedation and respiratory depressin. Document drug
dosages, and track any waste of medications according to agency
policy. Teach patient how to use PCA before procedure so when they
awaken they know how to use it. Instruct client on lhow to use PCA and
assure they know that they control their medication. Explain how the
pump prevents overdose. No family members may operate pump. Have
client demonstrate PCA pump use. Evaluate clients pain 15-20 minutes
after use. (CH.43 Potter pg. 1076)

Potter pp#1076 & lecture note

Risk factor- Diet- acrylamide, artificial sweeteners, heterocyclic amines, contaminants; obesity, sedentary life style, genetics, fertilized drugs, diethylstilbestrol, contraceptive, HRT, environment, smoking, 2nd hand exposure to smoke, smokeless tobacco , micro-organisms.

Education

- Teach client the use of PCA before any procedure so that clients understand how to use it after awaking from sedation or anesthesia.

-instruct client the purpose of PCA, emphasizing that pt controls the medication delivery.

-explain the pump prevents the risk of overdose.

- tell family member or friends to not operate the PCA device for the pt.

-have client demonstrate use of the PCA delivery button.

-check IV line and PCA device for proper functioning

-In opioid-naïve client do not increase demand or basal dose and shorten the interval time simultaneously because this will increase the risk for over sedation and respiratory depression.

-assess pt for sign of SE such as respiratory depression, sedation, nausea, vomiting , constipation, itching, urinary retention, myoclonus, and altered mental status. Page#1074

- tell pt that if the dosage are inadequate to relieve pain, the pump can be reprogrammed and also bolus dosage can be given by the nurse if it is included in physician order.

-when making transition from PCA to oral drugs , pt should receive increasing doses of oral drug as the PCA analgesic is tapered . Lewis pp#142

-encourage dietary roughage, fluids, and exercise to prevent constipation

PCA is used to administer opiod analgesics when the Pt decides its needed. It’s used to manage acute pain, post op pain and cancer pain. The Pt needs to understand how to use the PCA device, and how to titrate the drug to achieve good pain relief. Encourage the Pt to administer the dose before the pain reaches a level greater than Pt desired intensity level and educate the Pt that they cannot OD from using a PCA.

21. Discuss nursing diagnoses relevant for patients with terminal disease.

* Anxiety
*chronic sorrow
* complicated grieving
* compromised family coping
* disturbed thought process
* fear
* grieving
* hoplessness
* impaired religiosity
* impaired social interaction
* impaired verbal communication
* ineffective coping
* ineffective dnial
* insmnia
* interrupted family processes
* readiness for enhanced spiritual well being
* risk for complicated grieving
* RF lonliness, spiritual distress, prone health behavior
* social isolation
* spiritual distress ( ch11 Lewis pg. 158)

Lewis page#158 table 11.5 and 11.6

22. Discuss risk factors for cancer and the education needed.

DIET: acrylamide source= overcooked vegetables. artificial sweeteners
cyclamates, saccharine, stevia no link with aspartame at this time.
Heterocyclic amines form in meat cooked at high temps, BBQ.
Contaminants :pesticides, and herbicides. WEIGHT AND PHYSICAL
ACTIVITY: energy balance obesity, sedentary lifestyle, diet. GENETICS:
BRCA1 and 2 breast cancer genes help identify those at risk, 30-40% of
women with the gene develop breast cancer, 8-30% of women with the
gene develop ovarian cancer, 16-25% of men with the gene develop
prostate cancer. PSA: measure in levels, should be less than 4,
prostate specific antigen, higher levels=higher level of active
disease. DRUGS-HORMONAL: Diethylstilbestrol (DES) increased risk of
cervical dysplasia, incompetent cervix. Fertility drugs varies with
combinations used. Contraceptives earler intercourse, later firest
births. Hrt (hormone replacement therapy)may encourage breast cancer
growth. ENVIRONMENT: sun, randon exposure, x-rays, cell phones,
electromagnetic field exposure: powerlines, microwaves, TV and
computers. Agricultural exposure, round up. Asbestos, benzene, cancer
clusters, formaldehyde. IRRITANTS: smoking, 2nd hand smoke, smokeless
tobacco, oral pharyngeal concers, gastric cancers. MICROORGANISMS:
Epstein barr virus. HPV, simian virus 40.
Change in bowel or bladder, lesion that does not heal, unusual
bleeding or discharge, thickening or lump in breast or elsewhere,
indigestion or difficulty swallowing, obious changes in wart or mole,
nagging cough or persistent hoarseness. CAUTION! Reducing cancer risk
encourage patient to consume these foods: fruits and vegetables,
especially those rich in vit C or carotene, cruciferous veggies
(cabbage, broccoli, Brussels sprout), whole grains. Encourage patient
to limit these foods: excessive meat, especially when smoked, salted,
charbroiled,or cooked at high temp. Excessive fat, excessive calories,
alcohol. ( Cancer lecture)

- to reduce or avoid cigarette smoking and sun exposure

-To eat a balanced diet that includes vegetables and fresh fruits, whole grains, adequate amount of fiber, and reduced amount of fat and preservatives, including smoked and salt-cured meats containing high nitrite concentration.

-participate in a regular exercise regime

-obtain adequate, consistent period of rest.

-have a health examination on a regular base

- eliminate , reduce or change the perceptions of stressors and enhance the ability to effectively cope wutg stressor.

-Know seven warning signs of cancer, see lecture note (CAUTION)

- learn and practice recommended cancer screening test on a timely basis

-learn and practice self- examination

-seek immediate medical care if you notice a change in what is normal for you and if cancer is suspected.


Dosage and Calculations

23. Can you calculate:
a) Infusion time
b) Flow rate
1) gtt/min
2) mL/hr

Study Guide
Nursing 02 - Exam #1

1. Explain the components of a teaching plan: Cognitive domain, psychomotor domain, and Affective domain. Include in your explanation how the presenter would evaluate each.

Cognitive :( Includes all intellectual behaviors and requires thinking. In the hierarchy of cognitive behavior the simplest behavior is acquiring knowledge whereas the most complex is evaluation cognitive learning includes the following: knowledge, comprehension, application, analysis, synthesis, evaluation) DISCUSSION: 1. involves nurse and one client or nurse with several clients. 2. Promotes active participation and focuses on topics of interest of client. 3. Allows peer support. 4. Enhances application and analysis of new information. LECTURE: 1. is more format method of instruction because it is teacher controlled. 2. Helps learner acquire new knowledge and gain comprehension. QUESTION AND ANSWER SESSION: 1. addresses client’s specific concerns. 2. Assists client in applying knowledge. ROLE PLAY, DISCOVERY: 1. allows client to actively apply knowledge in controlled situation. 2. Promotes synthesis of information and problem solving. INDEPENDENT PROFECT (COMPUTER ASSISTED INSTRUCTION), FIELD EXPERIENCE: 1. allows client to assume responsibility for completing learning activities at own pace. 2. Promotes analysis, synthesis, and evaluation of new information and skills. Affective :( deals with expression of feelings and acceptance of attitudes, opinions, or values. Values clarification is an example of affective learning. The simplest behavior in the hierarchy is receiving, and the most compels is characterizing. Affective learning includes the following receiving, responding, valuing, organizing, characterizing) ROLE PLAY: 1. allows expression of values, feelings, and attitudes. DISCUSSION: 1. allows client to receive support from others in group. 2. helps client learn from others experiences. 3. Promotes responding, valuing, and organization. DISCUSSION (ONE ON ONE): 1. allows discussion of personal, sensitive topics of interest or concern. Psychomotor: (involves acquiring skills that require the integration of mental and muscular activity, such as the ability to walk or to use an eating utensil. The simplest behavior in the hierarchy is perception whereas the most complex is organization. Psychomotor learning includes the following: perception, set, guided response, mechanism complex overt response, adaptation, organization. ) DEMONSTRATION: 1. provides presentation of procedures or skills by nurse. 2. Permits client to incorporate modeling of nurse’s behavior. 3. Allows nurse to control questioning during demonstration. PRACTICE: 1. gives client opputunity to perform skills using equipment in a controlled setting. 2. Provides repetition. RETURN DEMONSTRATION: 1. permits client to perform skill as nurse observes. 2. provides excellent source of feedback and reinforcement. INDEPENDENT PROFECTS, GAMES: 1. requires teaching method that promotes adaptation and origination of psychomotor learning. 2. Permits learner to use new skills.

Cognitive is learning that involves only data and facts. It involves things like problem solving and decision making. One example would be educating the client on the side effects and actions of the medications they’re taking. Psychomotor involves using motor skills. An example of this would be teaching a patient how to give themselves an injection. Lastly is the affective domain. This involves changing the patient’s attitudes or judgment about something. An example of affective teaching would be getting a patient to accept their chronic illness. The three main components of a teaching plan are learning outcomes, content, and strategies. These would all change depending on the domain of teaching. If you were teaching in the cognitive domain, you would probably want to provide charts or visuals to help them learn the information. If you were teaching in the psychomotor domain you would want to demonstrate and have them demonstrate that they can perform the action. If you were teaching in the affective domain, you would want to listen to them a lot more and find out their feelings on the issue before educating them.

2. Describe the elements of a community assessment.

The community has 3 components: structure or locale, the people, and the social systems. To develop=op a complete community assessment you need to take a careful look at each of the 3 components to begin to identify needs for health policy, health programs, and needed healthy services. When assessing the structure or locale, travels around the neighborhood or community and observe its design. The location of services and the locations where residents meet. Obtain the demographics of the population by accessing statistics on the community form a local public health department or public library. Acquire information about existing social systems. Such as schools or health care facilities, by visiting various sites and learning about there services. Once you have a good understanding of the community, perform all individual client assessments against that background. For example, when assessing a clients home for safety consider the following, does the client have secure locks on doors? Are window secure and intact? Is lighting along walkways and entryways operation? As you conduct the client assessment know the level of community violence and the available resources when help is necessary. Always assess an individual in the context of the community. The assessment of health care needs of individuals, families, and communities, development and implementation of public health policies and improved access to care. Assessment includes systematic data collection on the population monitoring of the population health status and accessing available information about the health of the community.

Assess medical needs of community, economic needs, social needs. Look at building and location, social structure, and personal factors. For buildings you want to check the level of repair needed, what types of buildings if the community is residential or mostly apartments or single family homes. For social you want to investigate the social structure of the community. Look for schools, churches, other areas where people congregate. Look for groups of homeless. See what kind of options they have in the community. Is there a hospital close by, are there medical offices or a clinic, are there pharmacies or stores that sell medications? For personal factors you want to see what kinds of factors affect people in the community. It could be something environmental like a high level of pollution.

3. Discuss the factors to consider when providing health education.

Educational efforts need to take into consideration client’s psychosocial, spiritual, and cultural values, as well as the desire to actively participate in the educational process.

The first thing you want to consider are things that would impair their education. First would be if someone has an altered level of consciousness. They could have a mental illness or alzheimers or some other form of dementia. Then you want to assess if they speak the same language as you. You may have to get an interpreter to help you as you don’t want to rely on the family to translate. The family might not tell the patient things they think would hurt them. Then you want to assess their eyesight. They may have poor eyesight, or need glasses and might not be able to read something. Then you want to assess their hearing. If you’re explaining something to them and they can’t hear you, it won’t work. If they can’t hear you very well, then you want to turn facing them so they can see your mouth movements when you talk. Otherwise, you may want to provide written materials or find a sign language interpreter. Lastly you would want to assess their developmental age. If someone has heart problems, you wouldn’t explain it the same way to a 4 year old and a 40 year old.

Then you would want to consider things outside of the other person that could affect the education. You would want to make sure you educate them in a place that has no distractions, like the patient’s room. You would probably want to close the door, turn off the tv, and make sure the lighting is at a good level. You may or may not want other people in there when you provide the education. It could be about a subject they don’t want the visitor to know about so you may want to ask the visitor to step out. On the other hand if the person has a hard time following the education you may want to have someone else in there. If the person is confused or can’t learn a skill, then you would want to teach a significant other or family member the skill instead.


4. Describe the physiological, cognitive and psychosocial changes of the aged. Include pharmacological aspects and multiple health problems.

See concept map pg 198 nursing

5. Discuss the assessment needed for the elderly patient.

It is important to remember that the elderly may face a health problem with fear and anxiety. Health care workers may be perceived as helpful but institutions are viewed negatively. The nurse must communicate a sense of concern and care use simple statements, appropriate eye contact and direct touch and gentle humor. These will help relax the elder patient. Before beginning the assessment attend to primary needs. Ensure that the patient is in no pain and does not have to urinate. Make sure all assistive devices are in place. I.e. hearing aids glasses…etc. Take time and interview the patient alone unless they request their caregiver in the room. Go over all previous med history in there record.
The focus of the assessment is to determine appropriate interventions to maintain and enhance the functional abilities of the older adult. The assessment is interdisciplinary and at a minimum includes the med history, physical exam, functional abilities, and social resources. It often includes an entire team but primarily a nurse, physician and social worker.
Elements include assessment of mood, ADLs, IADLs, mental status, and a social environmental assessment. Focus on the older adult remaining as functionally independent as possible.

6. Discuss the nursing diagnoses appropriate for the elderly patient.

CV SYSTEM: activity intolerance decreased CO, fatigue. RESPIRATORY SYSTEM: impaired gas exchange, ineffective airway clearance, ineffective breathing pattern, risk for aspiration, and risk for infection. INTEGUMENTARY SYSTEM: impaired skin integrity. URINARY SYSTEM: deficient fluid volume, impaired urinary elimination. MUSCULOSKELETAL SYSTEM: impaired physical mobility, chronic pain, and risk for injury, self care deficit, and sedentary lifestyle. REPRODUCTIVE SYSTEM: disturbed body image, ineffective sexuality patterns, sexual dysfunction. GI SYSTEM: constipation, imbalanced nutrition, impaired oral mucosa membrane. NERVOUS SYSTEM: disturbed thought process, disturbed sensory perception, hyperthermia, hypothermia, insomnia. SENSES: disturbed body image, impaired verbal communication, social isolation. IMMUNE SYSTEM: risk for infection.

7. Discuss the roles of the community health nurse. Potter page 38-41

CAREGIVER: focus on individualized care and maintain a healthy community. CASEMANAGER: the ability to establish an appropriate plan of care based on assessment of clients and families ant to coordinate needed resources and services for the client’s well being across a continuum of care. Assume the case management of multiple clients and families. COLLABORATOR: Being able to work with a team to better the heath of a client. EDUCATOR: Determine the needs of the community and then host educational meetings. COUNSELOR: help clients identify health problems and work to fix these problems. CLIENT ADVOCATE: advocate for client provide health care choices that best suit there need. CHANGE AGENT: identifying and implementing new and more effective approaches to problems. Act as a mediator for community or client problems. EPIDEMIOLOGIST: responsible for community surveillance for risk factors.

Care giver-apply nursing process in a critical approach to ensure appropriate, individualized nursing care for specific client and their families. Individualized care within the context of client’s community.

Case manager- establishes appropriate plan of care based on assessment of clients and families and coordinated needed resources and services for the client’s well-being across a continuum of care.

Change agent-empowers individuals and their families to creatively solve problems or become instrumental in creating change within a health care agency.

Client Advocate- provides the information necessary for client to make informed decisions in choosing and using services appropriately. Defend and support client’s decision.

Collaborator- work with other health care disciplines

Counselor- helps clients identify and clarify health problems and choose appropriate courses of action to solve those problems.

Educator-

Epidemiologist- protects the community’s level of health, develop sensitivity to changes in the health status of the community, and help identify the cause of these changes

8. Discuss the principles of appropriate delegation. Potter, pg309-310

* Assess the knowledge and skills of the delegate: determine what the person knows and what he or she is able to do by asking open ended questions.
* Match tasks to delegate’s skills: Know what skills the delegates are able to perform or have performed before. Be there to assist if delegate is uncomfortable with task or needs assistance.
* communicate clearly: never give instructions through another staff member. Be clear on exactly what you want.
*listen attentively: Find out if after you have delegated a responsibility if the AP understands or has any questions. Or If the AP has prior obligations for another nurse.
*provide feedback: give feedback regarding performance.

Right task-one that is delegable for a specific client, such as tasks that are repetitive, require little supervision, have predictable results, and minimal potential risks.

Right circumstances- appropriate client setting, available resources, and other relevant factor considered. If the circumstances have not been assessed or are deemed too complicated, the nurse takes the responsibility and doesn’t delegate.

Right person- the right person is delegating the right task to the right person to be performed on the right person.

Right direction and communication- a clear, concise description of the task is conveyed, including its objectives, limits, expectations, and when to report concerns or assessment findings. Very specific, clear directions are essential for delegation to work well.

Right Supervision- appropriate monitoring, evaluation, intervention, as needed, and feedback. The nurse remains accountable for the tasks that were delegated and for making clinical judgment.

9. Discuss the attributes of a nurse manager.

* assist staff in establishing annual goals for the unit and systems needed to accomplish goals
* monitor professional nursing standards of practice on the unit
* develop an ongoing staff envelopment plan, including one for new employees.
*recruit new employees (interview and hire)
*conduct routine staff evaluations
* establish self as a role model for positive customer service.
* submit staffing schedules for the unit
* Conduct regular client rounds and problem solve client or family complaints.
* establish and implement a unit quality improvement plan.
* review and recommend new equipment for the unit
* conduct regular staff meetings
* make rounds with physicians.
* establish and support staff and interdisciplinary committees.

Effective communicator, assertiveness, honesty, and accuracy

Skill and competency- Critical thinking, communication, managing resources, enhancing employee performance, building and managing teams, managing conflicts, and managing time

In addition, see Box 21-3 Potter, page 304

10. Discuss the interventions for the elderly patient with visual impairment; hearing impairment.

For hearing problems talk facing the patient, Speak loudly and clearly, lower tones are more commonly easier to hear, Use visual cues or write things down. Provide hearing aids when needed. For vision problems: Speak when you enter the room to let them know you are there as to not startle them, Move into their best space of vision. Some elderly patients have central vision and some have better peripheral vision. Keep room well lit it is easier to see in a brightly lit room. Provide glasses when needed.

11. Discuss the home safety strategies for the aged.

Constant evaluations to determine if the patient is properly caring for self or that all of their needs are being satisfied by their home health care provider. The older adult needs an environment safe from crime and needs to feel safe and have a sense of belonging in their community. If needed homes can be made wheelchair accessible, lighting can be increased and adjusted, safety devices can be installed in bathrooms and kitchens. Alarms and assistive listening devices can be used.

12. Discuss the strategies to enhance and maintain long term memory.

Use of memory helps to maintain it “use it or lose it” crossword puzzles, sudoku, or any other memory jogging game or puzzle. Any type of mental stimuli such as conversation or social interaction help to keep the mind young and working.

Nursing Student Convention

http://www.nsna.org/meetings/midyear.asp

Hey everyone. I got an e-mail from the National Student Nurse's Association about their Midyear Conference in Reno. The convention is from November 13 to the 16th at the Nugget. They will have panels on nursing specialties, workshops on topics like pharmacology and nursing exams, and an exhibit hall with employers schools and other groups of interest to nursing students. The above link will take you to the National Student Nurses' Association web site for the conference which has a lot more information about specific presentations and activities.

For students from California, they are offering registration for the conference at $30 per day as long as we get 15 people interested in going. I've already got some people, but we are looking for more. This will be a good chance to talk to hospitals about what they look for when hiring new graduates as well as learning what you can do to score better in class. This is a national convention and I think we really need to take advantage of the fact that its so close. If you're interested in going, please e-mail me with your name, and which day(s) you would like to go. I've already got people who are interested in car pooling and going for Saturday only, but if you would like to stay up there for longer you're more than welcome. The following is the text of the e-mail I received about the event:

Attention Nursing Students and Pre-Nursing Students in California

Registration Special Sale!!

Share this e-mail with Classmates and Faculty

Attend NSNA’s 26th Annual MidYear Career Planning Conference —November 13-16, 2008, in Reno, Nevada

We don’t want you to miss the upcoming Career Planning Conference sponsored by the National Student Nurses’ Association. We know that students are impacted by the current economic crisis so we have created a sale just for you!

Groups of 15 or more nursing students and/or pre-nursing students from the same school may register to attend the MidYear Conference for just $30 per day for Friday and Saturday. This special daily registration fee includes the Keynote Speaker on Thursday, 5:00 – 6:30 pm. See the complete program description and schedule to see which day works best for you. The Career Fair with 100 exhibitors takes place on Friday and Saturday. Nursing Career Specialty Panels take place on Saturday.

Here’s what you need to do to take advantage of this offer—use the attached form to:

• Collect the names of at least 15 nursing students and/or pre-nursing students who will attend the Conference;
• Indicate the name of the school of nursing and contact information;
• Include the day(s) that the students will be attending.
• Have a faculty member at your school sign and date the form;
• Submit the form by Wednesday, November 5.

This offer is for both NSNA members and non-members. Our hope is that non-members will join when they learn about NSNA and experience what the organization offers to members.

Once we receive the list, we will prepare badges which can be picked up at the Pre-Registered conference desk. You may pay by cash, credit card, or check. You will need to show your student ID when you register. Note that walk-in daily registration is also available so that those who do not make it onto the list can also attend at the special rate.

If you have any questions, please call (718) 210-0705 or e-mail nsna@nsna.org

We look forward to seeing you!

Sincerely, Jenna Sanders, NSNA President

PS See more information about the conference below.

Career Fair –Friday and Saturday. Find your first RN position, summer internships, and residencies. There are over 100 exhibits—bring plenty of business cards and your resume!

Nursing Specialty Showcase—Saturday November 15

Hear from 12 nursing leaders in a variety of nursing specialty careers—ask questions and get the answers you need to help guide your career decisions

"Conquering Your Own Everest: Do You Have What It Takes?"

Patrick Hickey, DrPH, MSN, RN, CNOR, is the Keynote Speaker at the National Student Nurses’ Association (NSNA) MidYear Conference in Reno, NV, November 13-16-2008. Dr. Hickey became the first registered nurse to have climbed all Seven Summits when he reached the top of Mt. Everest on May 24, 2007. Known as a humorous and engaging speaker, Dr. Hickey’s keynote speech, promises to deliver a rousing kick-off to NSNA’s MidYear Conference. And be the first to view NSNA’s new Career Advancement Video!

Major General Patricia Horoho presents the Midyear Leadership Address You will not want to miss this important event and an opportunity to meet the Chief Nurse of the US Army Nurse Corps, Major General Patricia D. Horoho. The Leadership Address takes place on Saturday, November 15, immediately following the Leadership Breakfast sponsored by the US Army Nurse Corps Recruiting Command.

Nursing’s Future: Opportunities and Challenges—Friday, November 14

Hear from five top nursing leaders—ask the panel participants questions and discuss the issues that concern your future as a Registered Nurse.

Faculty Program—Earn Contact Hours.

Click here to see what we have in store for faculty.

Special workshops for faculty advisors and state consultants are also offered.

“Tube In To NSNA” & Wall of Fame Challenge

Special event with karaoke, networking, dancing, pizza, cup-cake decorating contest, raffles, and prizes. Event takes place on Friday at 7:00 pm. Admission: $5.00. Join us and help raise funds for the Foundation of the NSNA Disaster Fund.

Please car pool whenever possible! Click here to calculate driving distance to Reno.

MRSA on Youtube

I found this video on youtube about MRSA. It's from UC Davis Health, so it should be fairly reputable. It's pretty long, so you may not want to watch it before the exam, but I'm sure if you have any questions about MRSA it would be good to watch after.

N1 Final Study Guide

Here's the study guide for Nursing 1 with answers we've all provided, put together by Cheryl. Good luck everyone!

1. Discuss the risk factors for complications of the patient undergoing surgery.
Age: immature and declining physical status. Mortality rate hit her in very young and very old. Infants at risk to maintain body temperature.
Nutrition: tissue repair and resistance to infection
Obesity: increases the risk of reducing ventilation and cardiac function

Obstructive Sleep apnea: associated w/oxygen desaturation.
Immunocompromise: increased risk for infection
F & E imbalance: decreased tissue healing and increased risk for infection.
Pregnancy: risk for operative complications are increased

2. Discuss the signs and symptoms of the patient experiencing dyspnea.
SOB (exercise/excitement)
Used of accessory muscles
Increased rate and depth of respirations
Nasal flaring

3. Discuss the nurse’s responsibility to safe medication administration.
Critical thinking skills
Take time to read MAR
Review client hx
Review physical exam
Look up meds if not known
Why client taking meds?
Responsibility/accountability
Do not assume =0 A
Familiarize w/therapeutic effect
Usual dosage
Anticipated changes in lab data, side effects
SIX RIGHTS: med, dose, client, route, time, documentation

4. Discuss the responsibility of the nurse when a medication error has occurred.
Prepare occurrence or incident report w/in 24 hrs (location, time factual description, signature)
Notify physician
Notify patient
Notify person in charge

5. Discuss the nursing actions that will maintain dignity and respect to the patients.
Always provide for privacy when talking with a client. Whether that means closing a door, curtain, or asking if the client wants to have family members present when discussing healthcare matters, it is important to provide the person with privacy and to respect the need for privacy.
Respect, it is always very important to maintain respect for a person’s culture, customs and beliefs, don’t cast judgment regardless of if the nurse believes that they are important or not.
When you are talking with a client it is important to talk with them and not at them keeping the lines of communication open, use of medical jargon should be avoided because most people won’t be able to understand it. You should never talk down to the client or seem condescending. Ask the client if they understand and if they have any questions or concerns and never rush the client. Active listening means being attentive to what the client is saying both verbally and nonverbally. The appropriate use of nonverbal communication, if the client is crying, venting, or not talking, it is ok to just be there for the client without having verbal communication.

6. Discuss the nursing interventions to promote communication with a patient with aphasia.
It is very important for the nurse to first establish a way that the aphasic person can communicate through nonverbal communication. First the nurse needs to establish that the aphasic person is cognitively present. If the person is AOX himself and possible place, or understands why they are in the hospital, the nurse should look for a way to communicate. The nurse should establish if the person can move their head and if the person can, ask yes or no questions and ask the client to nod his head for yes and shake for no. The nurse has to communicate this to the client or the client won’t know how to respond when the nurse asks a question. If possible find out if the client is able to write. If the client is able to write, the nurse can ask the client to write the responses to the questions that the nurse is asking. The nurse could use pictures when trying to communicate with the aphasic person, asking them to point if possible to the picture that describes how the person feels, or conveys the message that the client is trying to make.

7. Discuss the purpose of the implementation phase of the nursing process.
When the nurse establishes an intervention or decides on the plan of care that is based upon the nursing diagnosis of the client. The interventions have to be implemented in order to achieve the goal or outcome that the nurse has decided on for the client. During implementation the nurse must reassess the client to make sure that the interventions that have been implemented are achieving the desired outcomes, or if the implementation of the intervention is having a negative impact on the client. After reassessing the care plan, the nurse needs to review the care plan, comparing the assessment data to validate the nursing diagnoses, and to determine if the interventions are still necessary for that client. Organizing the resources that the client needs to have for care to be delivered is another important step in the implementation process. Anticipating and preventing complications from the interventions is something else that the nurse needs to be alert for while implementing the interventions.

8. Discuss the purpose of open-ended questions when obtaining subjective data.
We all know that Mrs. Semillo loves to say it depends, but she also likes to say KEEP IT SIMPLE. I think that one of the most important things to remember when being in the clinical environment is to keep the questions simple. Of course, IT DEPENDS on the situation. Some questions have to be more detailed than others. The point is, when asking clients questions we don’t want to receive yes or no answers. Ex. You have a client that tells you that she is allergic to peanuts. Your response wouldn’t be: What makes you think you’re allergic to peanuts. To me that has a negative undertone and if someone asked me that I may get an attitude. Because I don’t THINK that I am allergic to peanuts, I KNOW that I am allergic to peanuts, I understand why that wouldn’t be the BEST response when asking a client an open-ended question. A better question that would elicit more information would be Tell me what happens when you eat peanuts. For one the client is going to tell you exactly what happens when they eat peanuts like, Well my tongue swells, my eyes bulge out of my head and I throw up like the little girl from Poltergeist. ON THURSDAY DURING THE LAST LECTURE MRS. SEMILLO SAID SOMETHING VERY PROFOUND “Use your common sense when going through the test, the scenario’s and looking for answers.” I think if we do this along with the other things that we have learned during this course you will know an open-ended question from a closed question.

9. Discuss the nursing interventions to prevent vascular complications for an immobile patient.
Interventions include education, prevention, and early detection. Apply Ted stockings and SCD’s which need to be removed every 8 hours to access for redness, warmth and tenderness. Exercise (ankle pumps, foot circles and knee flexion), Range of motion (ROM). Mobilize the patient as soon as physical condition allows, even if this only involves dangling at the bedside or moving to a chair. Regularly providing fluids, and position changes. Other interventions such as medications (heparin), intermittent pneumatic compression (IPC) and SCDs require a health care providers order.

10. Differentiate between evaluation and assessment.
EVALUATION: Evaluation is an ongoing process whenever you have contact with a client. Once you deliver an intervention, gather subjective and objective data from the client family and health care team members. You also review knowledge regarding the client’s current condition treatment resources available for recovery and the expected outcomes.
ASSESSMENT: Assessment is the deliberate and systematic collection of data to determine a client’s current and past health status and functional starts and to determine the client’s present and past coping patterns. 2 steps. 1. Collection and verification of data from a primary (client) and secondary (family past records) source. 2. The analysis of all data as a basis for developing nursing diagnoses, identifying collaborative problems and developing a plan of individualized care.

11. Explain autonomy. Provide examples.
Autonomy is the ability to be self directed and independent in accomplishing goals and advocating for others. There are independent nursing interventions you will initiate without medical orders. Autonomy is also the commitment to include clients in decisions about all aspects of care.
Examples:
1. The consent that clients read and sign before surgery illustrates this respect for autonomy. The signed consent ensures that the health care team obtained permission from the client before proceeding with the surgery.
2. A nurse has the autonomy to develop and implement a discharge teaching plan based on specific client needs for any client who has been hospitalized. The nurse provides nursing care that complements the prescribed medical therapy.
3. Implementing coughing and deep breathing exercises for a new postoperative client.

Consult with other health professionals to pursue the best treatment plan for your patient.

12. Discuss the nursing responsibilities for the patient while in the PACU.
Nursing care in the PACU focuses on monitoring and maintaining airway, respiratory, circulatory and neurological status and on managing pain. On immediate admission “handoff” the nurse takes vital signs and completes a full physical assessment. Patients often receive some form of oxygen in the immediate recovery period.

13. Discuss strategies to ensure safe administration of medication.
*Follow the 10 rights of medication administration. 1. Right client (2 forms of identification) 2. Right medication (3 checks) 3. Right dose 4. Right route
5. Right time 6. Right client education (information about the medication)
7. Right documentation 8. Right to refuse 9. Right assessment
10. Right evaluation.
*Be sure to read labels at least three times (comparing medication administration record (MAR) with label) before administering the medication.
*Use at least two client identifiers whenever administering a medication.
*Do not allow any other activity to interrupt administration of medication to a client.
*Double-check all calculations, and verify with another nurse.
*Do not interpret illegible handwriting; clarify with prescriber.
*Question unusually large or small doses.
*Document all medications as soon as they are given.
*When you have made an error, reflect on what went wrong and ask how you could have prevented the error.
*Evaluate the context or situation in which a medication error occurred. This helps to determine if nurses have the necessary resources for safe medication administration.
*When repeated medication errors occur within a work area, identify and analyze the factors that may have caused the errors and take corrective actions.
*Attend in-service programs that focus on the medications commonly administered.

14. Discuss the assessment needed for the patient with fluid imbalance.
*Age (very young & very old are more vulnerable)
*Past Medical History: Acute recent illness, surgery extensiveness, burn severity, respiratory disorders (pneumonia), head injury, chronic illness (cancer, cardiovascular disease, renal disorders, GI disturbances), environmental factors (extreme temperatures), diet (acidosis), lifestyle (smoking, ETOH), medication (OTC drugs that cause electrolyte & acid-base disturbances)
*Physical assessment: I&O, daily weight, lab studies (BUN, ABG, Hct, serum electrolyte level), edema
*Assessment questions: Nature of problem, signs & symptoms, severity, predisposing factors, effect on client)

15. List the criteria for writing a correct outcome or goal.
Criteria’s are: Client-Centered- outcomes and goals reflect the client behavior and responsesexpected as a result of nursing intervention. Singular- be precise in evaluating a client responseto a nursing action. Each goal and outcome addresses only one behavior or response. Observable- You need to be able to observe if change takes place in a client’s status.
Observable changes occur in physiological findings and the client’s knowledge, perceptions,and behavior. Measurable- You will learn to write goals and expected outcomes that set standards against which to measure the client’s response to nursing care. Terms describing quality, quantity, frequency, length, or weight allow you to evaluate outcomes precisely.
Time-Limited- The time frame for each goal and expected outcome indicates when you expectthe response to occur. Time frames assist you and the client in determining if the client is making progress at a reasonable rate. Manual Factors- Mutually set goals and expected outcomes ensure that the client and nurse agree on the direction and time limits of care. Mutual goal setting increases the client’s motivation and cooperation. Realistic- Set goals and expected outcomes that a client is able to reach. Realistic goals provide clients a sense of hopethat increases motivation and cooperation.

16. Discuss the criteria needed for writing an accurate nursing diagnosis.
The North American Nursing Diagnosis Association (NANDA) defined nursing diagnosis as "a clinical judgement about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable." The purpose of the NANDA diagnosis it provides nurses with a common frame of reference and standardizes language that improves communication among nurses, helps organize research, and is useful in educating new practitioners. Nursing diagnoses provide a classification system to describe the scientific foundation of nursing practices—a major criterion necessary for nursing to be recognized as a separate profession, differentiated from medicine and other health care professions. It is important to distinguish nursing diagnoses from medical diagnoses. The two are similar because they are both designed to plan care for a patient. However, nursing diagnoses focus on human response to stimuli, while medical diagnoses focus on the disease process. The term "nursing diagnosis" refers to items on the NANDA list of approved diagnoses. The term "nursing diagnostic statement" refers to the approved or accepted way in which a nursing diagnosis is written in practice. Three structural components of a nursing diagnostic statement: the problem, the etiology (cause), and the signs and symptoms. In order to make an appropriate nursing diagnosis, the practitioner must conduct an in-depth interview, physical assessment, and critical observation of the individual, family, or community for which the diagnosis is being made. A complete nursing assessment includes: the patient's current health status, signs and symptoms, strengths, and problem areas. The patient (who can be an individual, a family, or a group) should be the primary source of assessment data. After compiling data through assessment, the data are grouped or organized into categories that will assist the nurse in identifying appropriate diagnoses. A variety of organizing frameworks exist to assist the nurse in organizing the data, including NANDA's human response patterns.

17. Discuss strategies that promote effective communication.
Follow legal, ethical, and clinical standard, Understanding the communication process, reflection about one's communication experience, and the following Critical thinking attitudes promotes effective communication
Curiosity- motivates the nurse to communicate and to know more about the pt. It increases client's willingness to communicate.
Perseverance and creativity- motivates the nurse to communicate and identify effective innovative solutions.
Self confidence- helps to establish interpersonal helping- trust relationships.
Independent attitude- encourages the nurse to communicate with colleagues and share ideas about nursing intervention.
Fairness- ability to listen to both sides in any discussion.
Integrity- allows the nurse to recognize when their opinion conflicts with those of the clients and to decide how to communicate to reach mutual decision,
Humility- helps to recognize and communicate the need for more information before decision making.
Therapeutic communication like active listening, empathy, sharing hope, humor, feeling, using silence, providing information, clarifying, focusing, paraphrasing, asking relevant questions, summarizing, self disclosure, and confrontation encourages the expression of feelings, ideas, and convey acceptance and respect.

18. Discuss the role of the health care team when developing an initial plan of care.
- making admission assessment
-initial selection of nursing diagnosis and collaborative problems
-prioritize the problem
-identify desired out come
-identify intervention
-prioritize intervention

19. Compare and contrast legal decision making and ethical and moral principles.
Understanding the law protects health care professional from liability and the clients' right.
Legal responsibility
Informed consent- disclose the material of facts in terms the client understand to make an informed choice
Delegation- knowing what to delegate or not to delegate
Advance directive- living will and durable power of attorney
Report abuses, sexual harassment, and respect privacy (HIPAA).
Follow the proper policy in applying restraints, avoid false imprisonment.
Respect the client right, avoid assault and battery
Be competent, avoid negligence
Ethical and moral principles
It determines what is good or valuable for individuals, for groups, and for society. It promotes caring and compassionate behavior.
Autonomy- respects clients? ideas in health care decision making.
Beneficence- taking positive action to help others, doing to the best interest of the client.
Nonmalefiecence- avoid harm, evaluate the pro and cons before providing care
Justice- treats everybody equally and fairly.
Fidelity- keeps your promise.
-Be advocate to a client, be responsible and accountable for your action as a health care professional and protects clients privacy.

20. Discuss the nursing care of the patient with a urinary catheter.
- use strict aseptic techniques in inserting catheter.
- After inserting an indwelling catheter, maintain a closed urinary drainage system to minimize the risk of infection.
-keep the catheter tubing free of sediments.
-place the drainage bag below the Pt's bladder.
-provide perineal care at least three times a day
-encourage fluid intake of 2000 to 2500 mL if permitted to keep the catheter tubing free of sediments.
-use sterile aseptic technique and maintain closed system when performing irrigation.
-use sterile technique in collecting specimen from a closed drainage system
-prevent pooling of urine in the tubing
-before exercise or ambulation drain all urine from the tubing to the bag
-avoid prolonged clamping or kinking of tubing
- Empty drainage bag at least every 8 hours.
- ensure every client has a separate receptacle for measuring urine to avoid cross contamination
- if the drainage tube becomes disconnected , do not touch the end of the catheter or tubing. Wipe the tip of the catheter or tubing with anti microbial agent before reconnecting.
-use clean technique when removing indwelling catheter.

21. Patient education needed for patient scheduled for surgery (p. 1379)
-provide the pt with complete understanding of the surgery
-client should understand need for the procedure, steps involved, risks, expected results, alternative treatments
-prepare the client physically and psychologically for surgical intervention
-good pre-operative teaching has positive influence on pt recovery
-how implemented? Through telephone calls, mailings, preoperative teaching guidelines and checklists, use of videotapes or websites
-include family members in perioperative teaching: family member is usual coach for postoperative exercises after surgery. Also, anxious relatives heighten clients fear and anxiety
-provide clients with info on sensations usually felt after surgery: expected pain at surgical site, tightness of dressings, dryness of mouth, sensation of sore throat after endotracheal tube
-provide info to help client anticipate steps of a procedure
-explain and demonstrate postoperative exercises: diaphragmatic breathing, incentive spirometry, coughing, turning, leg exercises. These help prevent postoperative complications. Allow client time for independent practice and return to evaluate effectiveness before surgery.
-tell client and family approximate time of surgery and when they should arrive at the hospital. Surgeon informs client/family of anticipated length of surgery. Make client aware that delays do not necessarily indicate a problem
-orient client/family to location of postoperative unit. Orient family to where they can wait and where the surgeon will attempt to find them after surgery
-explain postoperative monitoring and therapies such as frequent vital signs monitoring, IV lines, monitoring lines, dressings, drainage tubes, ventilator support
-answer clients questions to clarify information about basic purpose of surgery. Augment Dr’s explanations. Inform Dr if client has little or no understanding about the surgery
-explain to client that it is normal to progress gradually in activity and eating after surgery. Some surgeries may let clients quickly resume normal physical activity and eating habits
-pain after surgery is expected. Inform client and family of available interventions for pain relief (analgesics, positioning, splinting, relaxation exercises). Client needs to know schedule for analgesic drugs, route, effects. Encourage use of analgesics at regular intervals to control pain so that client can participate in postoperative therapy. Explain length of time it takes for drug to start working.
-teach the client how to use PCA
-client and family needs time to express feelings about surgery. The more the anxiety, the more frequent the discussions need to be.

22. Nursing care of the patient who is confused (p. 1281; ND book p. 183)
-pts who are confused or disoriented or who have changing levels of consciousness are unable to protect themselves from pressure ulcer development
-able to feel pressure but unable to understand how to relieve it or communicate their discomfort
-prevent overstimulation: maintain calm environment and lessen noise and distractions
-give simple directions and allow time for client to respond, communicate, and make decisions
-safety: call bell, needed items within reach
-provide for undisturbed rest periods

23. Complications of general anesthesia (p. 1392)
- usual side effects of anesthetic agents, cardiovascular depression or irritability, respiratory depression, liver and kidney damage
-burns and other trauma can occur without the client being aware of the injury
-amnesia
-sudden fall in blood pressure

24. Nursing interventions to prevent thrombophlebitis in post-operative pt (p. 1247)
-assess to identify risk factors for deep vein thrombosis (DVT)
-leg, foot, ankle exercises
-regularly providing fluids
-position changes
-give preoperative clients this info before surgery and get them out of bed as soon as possible
-medications, intermittent pneumatic compression (IPC) and sequential compression device (SCD)
-drugs: heparin and LMWH (low molecular weight heparin)
-assess for signs of bleeding when heparin or LMWH is given
-thromboembolic device (TED) hose: do not apply if pt has a local condition affecting the leg (such as skin lesions, gangrenous conditions, vein ligation) because this will compromise circulation
-teach clients to avoid the following: crossing the legs, sitting for prolonged periods of time, wearing clothing that constricts the legs or waist, putting pillows under the knees, massaging the legs
-ROM exercises to reduce the risk of contractures and aid in preventing thrombi
-specific exercises: ankle pumps, foot circles, knee flexion; these are called antiembolic exercises and are to be done hourly while awake
-when DVT is suspected, elevate the leg and report to physician. Instruct client, family, health care team not to massage the area to prevent dislodging the thrombus

29. Discuss the assessment needed for the patient with the diagnosis of Activity Intolerance.
Remember: Know the rationales for each of the below. Rationales are too lengthy to type here, but we can discuss if we have group study at all.
Assess for:
Dyspnea or exertional discomfort, wheezing
Patient’s perception of causes of fatigue or activity intolerance
Patient’s level of mobility
Nutritional status
Potential for physical injury with activity
Ambulation aids: bracing, cane, walker, equipment modification for ADLs
BP changes
Need for oxygen with increased activity
Sleep pattern and amount of sleep
Rapid pulse (>100)
Palpitations in heart rhythm
Weakness, fatigue
Light headedness, dizziness, pallor, diaphoresis
Chest discomfort
Emotional status

30. Discuss the signs and symptoms of severe hypoxia/hypoxemia.
Remember: Severe hypoxia is Late hypoxia - RAT (early) BED (late)
(see lecture notes)
Remember: Hypoxia is the lack of oxygen in the blood, affecting all tissues in the body
Bradycardia
Extreme Restlessness
Dyspnea (severe)
Anemia (insufficient number of RBC in tissues)
Decreased tissue perfusion (decreased SPO2 – normal is 80% - 100%)
Cyanosis

31. Discuss the nursing interventions needed to promote oxygenation of the post-operative patient.
Remember: Oxygenation includes Respiratory (ventilation) and Circulatory (perfusion and circulation)
Remember: Oxygenation interventions prevent possible respiratory complications (on the respiration side), and decrease the risk of deep vein thrombosis (on the circulatory side).
Respiratory interventions Circulatory interventions
Deep breathing and coughing Leg exercises
Turning and positioning Turning and positioning
Early and aggressive ambulation Early ambulation
Use of incentive spirometry Use of antiembolic stockings
Use of compression devices
Adequate hydration
Anticoagulant propholaxis

32. Discuss the preparation needed to safely transfer the patient to the operating room.
Remember: if patient ambulates, always check for lighting, clear walkway, and ortho hypotension.
Identify the right patient by reading the identification name band and by verifying the operative procedure.
Because some client receives preoperative drugs, the transporter and the nurse assist patient when transferring from bed to stretcher to prevent falls.
Have signed surgical consent form.
Attention to left and right operative sites for accuracy
Antiseptic on operative site (s).
Check vital signs (BP. Temp. pulse, and respiration rate). Notify physician of marked changes.
Asked patient if patient is allergic to iodine and latex, glasses, contact lenses.
Allergies to food, medications, chemicals.
Assist with putting on a hospital gown, hair cap, and if ordered, antiembolic hose.
Remove all jewelry.
Verify the NPO status to prevent aspiration.
Empty bladder.
Remove dentures, bridge work to prevent dislodge and airway obstruction during surgery.
Patient transferred feet first on the stretchers


33. Discuss the nursing interventions needed to promote ambulation.
Remember: the main goal is to achieve early ambulation while safely maintaining the functions of the heart, fluid & electrolytes, nutrition & elimination, and patient’s comfort.
Establish guidelines and goals of activity with the patient and caregiver.
Encourage adequate rest periods, especially before meals, other ADLs, exercise sessions, and ambulation.
Refrain from performing nonessential procedures.
Anticipate the patient’s needs (e.g. keep telephone and tissues within reach).
Assist with ADLs as indicated; however, avoid doing for patients what they can do for themselves.
Provide bedside commode as indicated.
Encourage physical activity consistent with the patient’s energy resources.
Assist patients to plan activities for times when they have the most energy.
Encourage verbalization of feelings regarding limitations.
Progress activity gradually.

34. Discuss the assessment needed for the patient who has been on bed rest and has an order to begin ambulation. (1238-1239, 1275)
Monitor all vitals, assess orthostatic blood pressures, check for edema, peripheral pulses, assess for deep vein thrombosis by examining lower legs. Assess range of motion and muscle strength.

While ambulating, constantly assess patient vitals including respiration rate and pulse. When walking, assess environment, assess for assistance needed, and establish potential rest points.

35. Discuss the purpose of bed rest. (1225)
Many different interpretations, and used for clients with a wide variety of conditions, but four main objectives of bed rest: Reducing physical activity and the oxygen needs of the body, reducing pain including postoperative pain or after acute injury to the lower back, allowing ill or debilitated clients to rest, allowing exhausted clients the opportunity for uninterrupted rest.

36. Discuss the correct procedure for administering a subcutaneous medication.
See skill 33-5 and Nursing Skills Online. Basically: Assess, prepare medication, have client relax, cleanse site, hold syringe as dart, spread skin with non-dominant hand, inject quickly at 45-90 degree angle, release skin, inject slowly, pull out, apply pressure but don't massage, discard needle and gloves.

37. Discuss the nursing care for the post-operative patient who had a nasogastric tube. (1398-1399)
Specificallu for NG tube, assess for patency, and color and amount of gastric drainage. In general for post op gastrointestinal, inspect abdomen for distention, monitor for aspiration during oral intake, auscultate for bowel sounds, and ask about flatus.

38. Discuss the purpose of using an assistive device when moving patients. (1261)
Reduce work related injuries for health care providers, some like the trapeze bar allow the client to help more. Some allow the nurse to move uncooperative patients as well as patients too large to move without an assistive device.

39. Discuss the correct procedure for suctioning a patient. (PP 934-940)
There is just way too much stuff to type for these procedures. Please review Skill 40-1 on pages 934 through 940 of Potter and Perry for detailed directions.
* Also see ATI Fundamentals of Nursing book pages 639-642

40. Discuss the physiological effects of prolonged bed rest. (PP 1225-1228)
* Also see ATI table on pages 481-483
* the individual of average weight and height and without a chronic illness on bed rest loses muscle strength from baseline levels at a rate of 3% a day.
* associated with cardiovascular, skeletal, and other organ changes
* tendency of cells and tissue to reduce in size and function
Systemic effects:
* disrupts normal metabolic functioning; decreases metabolic rate; alters metabolism of carbs, fats, and proteins; causes fluid, electrolyte, and calcium imbalances; decreased appetite and slowing of peristalsis.
* weight loss, decreased muscle mass, and weakness result from tissue catabolism
* calcium resorption from bones
* intestinal function may become depressed, dehydration may occur, absorption may cease, and F&E may be disturbed.
Respiratory changes:
* risk for developing pulmonary complications (atelectasis - collapse of alveoli, and hypostatic pneumonia.
Cardiovascular changes:
* orthostatic hypotension
* increased cardiac workload
* thrombus formation
Musculoskeletal changes:
* permanent or temporary impairment or permanent disability
* loss of endurance, strength, muscle mass and decreased stability and balance
* impaired calcium metabolism and impaired joint mobility
Muscle effects:
* loss of muscle mass, muscle weakness, disuse atrophy, loss of endurance
Skeletal effects:
* impaired calcium metabolism
* joint abnormalities & contractures/foot drop
Urinary elimination changes:
* urinary stasis
* renal calculi
Integumentary changes:
* pressure ulcers

41. Discuss dependent nursing interventions for the patient experiencing nausea. (All-in-One Care Planning Resource page 573)
* give antiemetic as prescribed or OTC meds
* administer meds on empty stomach only when indicated
* offer food in small portions, 6 times per day
* give chewing gum or hard candies prn, if permitted
* suggest patient brush teeth and tongue q8hr and prn
* if odor of food induces nausea, remove food immediately
* reduce rate/min of enteral formula infusion
* if Pt. is receiving bolus infusion, change to intermittent or continuous
* inspect abdomen for distention and auscultate bowel sounds
* monitor for and record flatus and bowel movements
* if medically indicated, consider bowel suppository
* monitor electrolytes, especially potassium
* try dry foods (toast, crackers, etc) in morning and throughout day
* encourage ice chips
* encourage slow deep breathing
* wear loose-fitting clothes

42 Dosage and Calculations
Can you calculate pills/tablets/injections?
Can you calculate safe dosage ranges?
Can you safely administer medication (using the correct equipment)?

* You are on you own here!! Review your Dimensional Diagnosis book

43. Can you utilize the nursing process given a specific case scenario?

* Same here! Just think the case scenario through and apply all we have learned from our clinical experience and we will do great! Good luck to everyone.