Scope of practice - determined by the states Nurse Practice Act. Standard of practice – determined by the nursing profession American Nurse’s Association Standard of care – policy and procedure of the institution.
QSEN project – quality and Safety for nurses
1- Patient centered care
2- Teamwork and collaboration
3-Evidence based practice.
SBAR – provides standard framework for communication between members of the health care team. S-Situation – concise statement of problem
B- Background – brief information related to situation.
A- Assessment – analysis, what you see think.
R- Recommendation – action requested or recommended
IPASSBATON – used to improve handoffs and transitions in care. Giving opportunities to ask questions clarify and confirm. I- Introduction – (introduce yourself, explain your role and function) P- Patient- (Name, age, identifiers, location, gender)
A- Assessment – (chief complaint, v/s, systems and dx)
S- Situation- (current status, code status, recent changes responses to tx.) S-Safety - (Critical labs, IR, allergies, isolation)
B-Background- ( comorbilities, current meds, family Hx.)
A- Actions- (which were taken and what is required.)
T- Timing- level of urgency, prioritization of actions
O- Ownership- responsible party - nurse/ MD/team or pt/ family, N- Next – what will happen next, plan, change or contingency plan?
CUS – used to advocate for clients when there is a concern Concern – I am concerned
Uncomfortable – I am Uncomfortable
Safety – This is not safe
Five Rights of delegation:
1- Right person
4- Right Direction
5- Right evaluation
4 C’ of Communication
Clear – Do they understand the instructions?
Concise – Do not give too much unnecessary information.
Correct- direction given according to job description, policy, procedures, and law. Complete- do they have info to complete the task.
Steps of nursing Process
Six Key components of Documentation:
S- subjective and objective data
Fire rescue plan
R-Report the fire
C-contain the fire
A-activate fire alarm
R-rescue and remove clients
C-contain fire by closing doors and windows
E-extinguish flames with fire extinguishers
Assessing Geri patients:
R-relative or caregiver strain
O-otic and ocular impairment (audio and visual problems)
OB interventions 7 “R”
Review and Reinforce
E-Episiotomy / c section incision / Emotions
Tasks of mourning:
R- Real accept the loss is real
E-Experience the emotions associated with the loss.
A-Adjust or readjust to life or activities
L-Let go or move on with one’s own life
C-Chest pain, chills, choking
Four A’s of schizophrenia
A-Affective disturbance – inappropriate blunted effect, flattened effect A-Autism – preoccupation with self, little concern for external reality A-Associate looseness – Stringing together of unrelated topics A-Ambivalence – Simulations opposite feelings
Characteristics of Schizophrenia
S-Self-care often fails
S-Social adjustment impaired
O-Orientation to environment
B-Boundaries between self and others dissolve
E-External / internal stimulus are confused (Delusions/hallucinations) R-Reality testing fails
Nursing care for psych patients
P- Protection – protect client and others from harm, establish trust M-Administer medications, monitor for compliance,...
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