BIO 2020 103 NCLEX/MedSurg Master Study Guide/BIO 2020 103 NCLEX/MedSurg Master Study Guide

Nursing Process: A - assessment D - diagnosis O - outcome planning (specific, measurable, timely)  Ex. The patient will walk 300 ft in the hallway by the end of the shift (3pm) P - planning  Planning is done WITH ...

Nursing Process: A - assessment D - diagnosis O - outcome planning (specific, measurable, timely)  Ex. The patient will walk 300 ft in the hallway by the end of the shift (3pm) P - planning  Planning is done WITH patient, not FOR them. Let them assist in making goals that they see as doable I - intervention E - evaluation  Reflecting on whether the goal was met/ what could be changed to help the pt. Reach it  not evaluating **ourselves** we are evaluating whether or not the goal was MET Nursing Virtues: Beneficence - “do good” Non maleficence - “do no harm” Veracity - telling the truth, never lying or trying to deceive a patient  If you make a med error, if a patient asks you about their disease Fidelity - keeping your promises Autonomy - pt. Is allowed (and supported) to make their own decisions  Choosing treatment plans, right to advance directives, DNR orders, etc. Justice - providing fair care to all  Providing equal care to patients no matter what (age, sex, race, LGBT, religion, disease) Confidentiality - keeping things between you and the patient  If a patient tells you something, it should remain between the two of you  The ONLY times you can break confidentiality are when the patient’s safety is involved (ex. Pt. is going to commit suicide, mandatory reporting of elder abuse, etc) Privacy - pt. Is entitled to their own personal privacy  Closing the door /curtain when they are physically exposed/leaving the room if the patient is on the toilet Normal Lab Values: Digoxin 0.5-2, anything above 2 will give nausea, vomiting, diarrhea, and VISUAL disturbances (yellow halo around anything they are looking at)  If the patient is hypokalemic (low potassium), makes it easier for them to go into Dig. toxicity  Hold digoxin if their heart rate is below 60 bpm Lithium - 0.5-1.5, hold for anything higher! Tremors, confusion, seizures etc.  Typically used for bipolar disorder  Never double up 22 on lithium doses if you miss one -- safety!  Lithium messes with their sodium! They need to stay stable with their sodium intake and consult their doctor before vigorous work outs / saunas / etc. because sweat can cause them to lose too much sodium. When they lose sodium, it makes it easier for lithium toxicity to occur Phenytoin/Dilantin 10-20  Used most often for seizure disorders  Blood levels have to monitored over time to adjust dosage -- pt. Gets frequent lab draws  Phenytoin reaction can cause anemia - dyspnea, fatigue, paleness, rashes, swelling and bleeding of the gums. BUN: 10-20, indicative of kidney function, monitor for nephrotoxic drugs Creatinine: 0.6-1.3, indicative of kidney function, monitor for nephrotoxic drugs