Remember the acronym RACE (rescue, alarm, confine, extinguish) to set priorities if a fire occurs.
In the case of dislodgement of an internal radiation implant, the radioactive source is never touched with the bare hands. It is retrieved with long-handled forceps and placed in the lead container (pig) kept in the client’s room. In many situations, the client has a Foley catheter inserted and is on bed rest during treatment to prevent dislodgement. A lead apron, although one may be in the room, is not the required item. Nurses wear a dosimeter badge while in the client’s room to measure the exposure to radiation and limit time spent in the room.
Proper documentation of unusual occurrences, incidents, and accidents, and the nursing actions taken as a result of the occurrence are internal to the institution or agency and allow the nurse and administration to review the quality of care and determine any potential risks present. Incident reports are not routinely filled out for interventions, nor are they used to report occurrences to other agencies.
Nurse Practice Acts require reporting the suspicion of impaired nurses. The Board of Nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This suspicion needs to be reported to the nursing supervisor, who will then report to the Board of Nursing. Confronting the colleague may cause conflict. Asking the colleague to go to the nurses’ lounge to sleep for a while does not safeguard clients.
A Good Samaritan Law is passed by a state legislature to encourage nurses and other health care providers to provide care to a person when an accident, emergency, or injury occurs, without fear of being sued for the care provided. Called “immunity from suit,” this protection usually applies only if all of the conditions of the law are met, such as the heath care provider receives no compensation for the care provided and the care given is not willfully and wantonly negligent.
External cardiac massage is a lifesaving treatment that a client can refuse. The most appropriate nursing action is to notify the physician, because a written Do Not Resuscitate (DNR) order from the physician is needed. The DNR order must be reviewed or renewed on a regular basis per agency policy
A PICC is designed to be a long-term indwelling catheter and is usually inserted into the median cubital vein. The tip of the catheter should lie in the superior vena cava. A PICC does not require the affected arm to be immobilized (a major advantage of a PICC) and can be used for intermittent or continuous fluid infusion. Although the risk of infection is less with a PICC than with a subclavian or other central line, it is possible for phlebitis or infection to develop. Clients must be aware of the need for daily inspection and to report any discharge, redness, or pain immediately to the nurse or physician. Although a PICC can be used for obtaining blood specimens, it is not recommended to routinely aspirate blood to determine patency.
Nurses need their own liability insurance for protection against malpractice lawsuits. Nurses erroneously assume that they are protected by an agency’s professional liability policies. Usually when a nurse is sued, the employer is also sued for the nurse’s actions or inaction’s. Even though this is the norm, nurses are encouraged to have their own malpractice insurance.
Variance analysis occurs continually as the case manager and other caregivers monitor client outcomes against critical paths. The goal of critical paths is to anticipate and recognize negative variance early so that appropriate action can be taken. A negative variance occurs when untoward events preclude a timely discharge and the length of stay is longer than planned for a client on a specific critical path.
he autocratic style of leadership is task oriented and directive. The leader uses his or her power and position in an authoritarian manner to set and implement organizational goals. Decisions are made without input from the staff. Democratic styles best empower staff toward excellence because this style of leadership allows nurses to provide input regarding the decision-making process and an opportunity to grow professionally. The situational leadership style utilizes a style depending on the situation and events. The laissez faire style allows staff to work without assistance, direction, or supervision.
The functional model of care involves an assembly-line approach to client care, with major tasks being delegated by the charge nurse to individual staff members. Team nursing is characterized by a high degree of communication and collaboration between members. The team is generally led by a registered nurse, who is responsible for assessing, developing nursing diagnoses, planning, and evaluating each client’s plan of care. In an exemplary model of team nursing, each staff member works fully within the realm of his or her educational and clinical experience in an effort to provide comprehensive individualized client care. Each staff member is accountable for client care and outcomes of care. In primary nursing, concern is with keeping the nurse at the bedside actively involved in care, providing goal-directed and individualized client care.
Edema of the stump is controlled by elevating the foot of the bed for the first 24 hours after surgery. Following the first 24 hours, the stump is usually placed flat on the bed to reduce hip contracture. Edema is also controlled by stump wrapping techniques.
The pregnant client who tests positive for hepatitis B virus should be reassured that breastfeeding is not contraindicated if the infant receives prophylaxis at birth and remains on the schedule for immunizations.
Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities, therefore decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position, however, so a wedge placed under the right hip provides displacement of the uterus. Trendelenburg positioning places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler’s or prone position is not practical for this type of abdominal surgery.
Some caregivers experience headaches, burning nasal passages and eyes, and crystallization of soft contact lenses as a result of contact with ribavirin (Virazole). Therefore, goggles and a mask may be worn.
Tonic-clonic seizures cause tightening of all body muscles followed by tremors. Obstructed airway and increased oral secretions are the major complications during and following a seizure. Suction is helpful to prevent choking and cyanosis.
Copies of a living will should be kept with the medical record, at the physician’s office, and in the client’s home. A copy should also be maintained in the lawyer’s office. The emergency room does not maintain these documents in its files. A copy of a client’s living will is not sent to the social security office
The nurse turns the water on first and then allows the warm water to wet the hands, applies soap to the hands, keeps the hands pointed downward, and rubs them vigorously. Warm water is used for hand washing because it increases the sudsing action of the soap. Hands should be kept downward to enable the unsanitary material to fall off the skin. The nurse then rinses the hands, dries the hands using a paper towel, and turns the water faucet off with the paper towel. The faucet is turned off by using a paper towel to prevent the hands from getting recontaminated.
At the door of the room and next to an appropriate receptacle, the nurse unties the gown at the waist but does not remove it yet. The nurse then removes the gloves. The gown is then untied at the neck, allowed to fall forward from the shoulders, and removed. The gown is then discarded in the appropriate receptacle. The nurse then removes the mask and goggles and discards them. The hands are then washed.
The defense mechanism of regression is characterized by returning to an earlier form of expressing an impulse.
During the adolescent period, there is a heightened awareness of body image and peer pressure to go on excessively restrictive diets. The extreme limitation of omitting all fat in the diet and weight loss during a time of growth suggests inadequate nutrition and a possible eating disorder.
Play therapy is a nonthreatening avenue through which the child can use artwork, dolls, or puppets to act out frightening life experiences.
Victimization in a family can take many forms. When analyzing a specific client situation, it is important to understand which form of abuse is being considered. Physical abuse can take the form of battering (hitting, slapping, striking) or can be more subtle, such as neglect (failure to meet basic needs). Emotional and psychological abuse can involve inflicting verbal statements that cause mental anguish or alienation of the victim. Sexual abuse can involve unwanted sexual remarks, sexual advances, and physical sexual acts.
Because the client with bipolar disorder is easily stimulated by the environment, sedentary activities are the best outlets for energy release. Most bipolar clients enjoy writing, so the writing task is appropriate. An activity such as planning a dance or supper might be appropriate at some point, but not for the newly admitted client who is likely to have impaired judgment and a short attention span.
The compulsive act provides immediate relief from anxiety and is used to cope with stress, conflict, or pain. Although the client may feel the need to increase self-esteem, that is not the primary goal of this behavior.
The school-aged child understands best with visual aids and concrete language.
An important consideration in alleviating the anxiety is to assist the client to recognize their behavior.
Psychodrama involves enactment of emotionally charged situations. Reality therapy is used for individuals with cognitive impairment.
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