Capstone B
Management of Care (15 items)
1. Home safety: Planning care for a client who has vision loss (Fundies Chp 13)
a.Remove throw rugs, loose carpets.
b. Electrical cord/ extension against the wall behind the
...
Capstone B
Management of Care (15 items)
1. Home safety: Planning care for a client who has vision loss (Fundies Chp 13)
a.Remove throw rugs, loose carpets.
b. Electrical cord/ extension against the wall behind the furniture
c. Monitor gait
d.Steps/ sidewalks are in good repair
e. Grab bar near toilet/tub, stool riser
f. Non skid mat in tub.shower
g. Shower chair and Bedside commode
h. Proper lightning
2. Cystic Fibrosis: Priority Assessment for a Group of Children (Nursing Care of Children
Chp. 19)
a. Assess lung sounds and respiratory status.
12 yr old child has difficulty swallowing secretion
3. Infection Control: Infectious Diseases to Report (Fundies Chp 11)
a. Report any communicable diseases (TB, STI, communicable disease)
4. Legal Responsibilities: Documenting Admission Data (Fundies Chp. 4)
a. Fall risk data, advance directives (living will, POA)
5. Disorders of the Eye: Evaluating a Client's Understanding of Cataract Removal (Med Surg
Chp 12)
a. Provider will remove lens and use replacement lense, sand grains in the eye is
normal, wear sunglasses, increase light in room, prevent IOP, prevent infection,
provide pain relief, fall prevention
6. Crisis Management: Crisis Intervention for Intimate Partner Abuse (Mental Health Chp.
29)
a. Safety first. Precautions of safeguard on the client
7. Delegation and Supervision: Scope of Practice of Registered Nurses (Fundies Chp 6)
a. Provide supervision, either directly or indirectly (assigning supervision to
another licensed nurse)
b. Monitor performance. Intervene if necessary (for unsafe clinical practice).
c. Provide feedback
d. Evaluate the client and determine the client’s outcome status.
e. Evaluate task performance and identify needs for performance-improvement
activities and additional resources.
8. Facility Protocols: Discovering a Medication Errors (Leadership Chp.5)
a. 1st assess client
b. then call hcp
c. Then do an incident report within 24 hrs (AVOID telling client or place in client’s
chart)
d. Submit to risk manager
9. Managing Client Care: Evaluating an Assistive Personnel Performance (Leadership Chp.1)
a. Assist with breakfast with client who has vision loss
i. AP can do ADL, feeding without swallow precaution, positioning, routine
task, i/o, specimen collection, vitals (if client is stable)
10. Continuity of Care: Interventions Promoting Independence (Community Health Chp. 7)
● home health nurse: nursing home, traditional home, assisted living
● -work as part of team, holistic care. nurses, pt, OT, home health aids, social
workers and dieticians part of the care
● -provide skilled assessment, wound care, lab draws, med education, parenteral
nutrition, IV fluids & meds, central line care, urinary catheter insertion and
maintenance, coordination of other participants in health
● -evaluate living environment for safety - older adults= increase fall risk
● -ask about food in home, help with household activities, living alone, support
system, set up and dispense of medications, access to health care
● -encourage clients to be independent and involved
11. Legal and Ethical Issues: Respecting Clients Rights (Mental Health Chp. 2)
a. Veracity- honest, justice- being fair, fidelity- loyal/ faithful, beneficence- doing
good, nonmaleficence- no harm
b. A voluntarily admitted client has the right to apply for release at any time. This
client is considered competent, and so has the right to refuse medication and
treatment.
12. Managing Client Care: Planning an Audit of Quality Control (Leadership Chp.1)
a. Structure audits evaluate the influence of elements that exist separate from or
outside of the client-staff interaction.
b. Process audits review how care was provided and assume a relationship exists
between nurses and the quality of care provided.
c. Outcome audits determine what results, if any, occurred as a result of the
nursing care provided.
d. Retrospective audits occur after the client receives care.
e. Concurrent audits occur while the client is receiving care.
f. Prospective audits predict how future client care will be affected by current level
of services.
NI: nurses use reliable resources, understand facility policies, provide and document
client care, participate in the collection of information/data related to staff’s adherence
to selected policy or procedure, Assist with analysis of the information/data, Compare
results with the established benchmark, Make a judgment about performance in regard
to the finding, Assist with provision of education or training necessary to improve the
performance of staff, Act as a role model by practicing in accordance with the
established standard, Assist with re-evaluation of staff performance by collection of
information/data at a specified time.
13. Cancers Disorders: Planning discharge Teaching for a client who is postoperative
following a modified radical mastectomy (Med Surg Chp. 92)
a. Discharge teaching includes incision care and drainage tubes. (Drains are usually
left in for 1 to 3 weeks.)
b. AVOID placing her arm in a dependent position.
c. Encourage early arm and hand exercises (squeezing a rubber ball, elbow flexion
and extension, and hand-wall climbing) to prevent lymphedema and to regain full
range of motion.
d. AVOID tight clothing.
e. Teach BSE.
f. Report numbness, pain, heaviness, or impaired motor function of the affected
arm to the surgeon.
g. Encourage discuss breast reconstruction alternatives with the surgeon
(Reconstruction can begin during the original breast removal procedure or after
some healing has occurred, Nipple reconstruction from labia, abdomen, or inner
thigh)
h. Genetic counseling for BRCA 1 and 2
i. Recommendation of bilateral mastectomy, oophorectomy to prevent cancer
occurrence. Clients who do not choose this option should have early, frequent,
thorough screening for breast and ovarian cancer.
14. Acute and Infectious Respiratory Illness: Prioritizing Care for a Group of Children
(Nursing Care Children Chp.17)
a. PRIORITY s a child that’s drooling, sitting upright with tongue out, stridor
(croup can be fatal)
15. Legal and Ethical Issues: Identifying an Ethical Principle(Mental Health Chp.2)
a. Veracity- honest, justice- being fair, fidelity- loyal/ faithful, beneficence- doing
good, nonmaleficence- no harm
16. Care of Special Populations: Recommending Appropriate Referrals (Community Health
Chp.5)
a. social services to eliminate financial difficulties (Know what each role does)
Safety and Infection Control (9 items= missing 2)
1. Nursing Care and Discharge Teaching: Vehicle Safety (Maternity Chp.26)
● approved rear-facing in back preferably
● in the middle, until age 2 or reaches maximum height and weight for the seat,
● do not use hand me downs
2. Medical Conditions: Planning Care For a Client Who Has Severe Preeclampsia (Maternity
Chp 9)
Seizure precaution (side rails/padding…)
● BP 160/110 or higher
● proteinuria greater than 3+
● oligo urea
● elevated serum creatinine greater than 1.1 mg/dL
● headache blurred vision
● hyperreflexia with possible ankle clonus
● peripheral edema
● hepatic dysfunction
● epigastric pain
● right upper quadrant pain
● thrombocytopenia
3. Medical Conditions: Planning Care for a client who has severe Preeclampsia (Maternal
Newborn Nursing Chp.9)
a. Assess level of consciousness.
b. Obtain pulse oximetry.
c. Monitor urine output, and obtain a clean-catch urine sample to assess for
proteinuria.
d. Obtain daily weights.
e. Monitor vital signs with careful attention to blood pressure measurement (e.g.,
using proper size cuff and avoiding talking to client during measurement).
f. Encourage lateral positioning.
g. Perform NST and daily kick counts.
h. Instruct the client to monitor I&O.
i. Side effect: Blurred vision, edema, proteinuria
4. Safe Medication Administration and Error Reduction: Use of Acceptable Identifiers
(Fundies Chp.47)
a. Acceptable identifiers include the client’s name, an assigned identification
number, telephone number, birth date, or other person-specific identifier, such
as a photo identification card. Nurses also use bar-code scanners to identify
clients
5. Immunizations: Contraindications for Influenza Vaccine (Pharm Chap. 41)
a. Live influenza contraindication: < 2yrs old, 50 yrs and older, pregnant, precaution
with guillain barre's, precaution with antiviral meds, live-attenuated influenza
vaccine to clients regardless of the severity of egg allergy. Clients who have a
history of an egg allergy, other than a hive-only reaction, should receive the
immunization where a provider is present and emergency equipment is available.
6. Acute Neurological Disorders: Transmissions Precautions (Nursing Care Children Chp. 12)
a. Meningitisi. Isolate the client as soon as meningitis is suspected, and maintain
droplet precautions per facility protocol.
ii. Droplet precautions require a private room or a room with clients who
have the same infectious disease, ensuring that each client has his or
her own designated equipment.
iii. Provi
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