283 COMP REVIEW
PRIORITY PATIENTS REQUIRING FOLLOW-UP - - - - - -
New, developed, becomes
BP change of 20mmHg
Glucose < 70
Post-procedures
o ***VERIFY PATIENT ID WHEN COMING BACK FROM PACU!!!***
Patient who
...
283 COMP REVIEW
PRIORITY PATIENTS REQUIRING FOLLOW-UP - - - - - -
New, developed, becomes
BP change of 20mmHg
Glucose < 70
Post-procedures
o ***VERIFY PATIENT ID WHEN COMING BACK FROM PACU!!!***
Patient who hasn’t been to doctor in years
***BURN PATIENT WITH LOW O2!!!***
SCOPE OF PRACTICE - UAP:
o Transport
o I+O collection & documentation
o Feedings
o Ambulation
o Positioning
o Vitals AFTER the RN does first set
o Remind but not reteach or demonstrate - LPN:
o Reinforce teaching
o Reassessments
o ***OBTAIN PAST MEDICAL HX!!!***
o Accuchecks
o Wound vacs
o Dressing changes
o Trach care - RN:
o Initial assessments (admission, post-op)
o Initial teaching
o Planning of care
o Discharges
o Anything IV
o Blood Products
o ***RN MUST BE THE FIRST PERSON TO GET THE PATIENT UP
AFTER ANY SEDATION TO ENSURE THEY CAN BEAR WEIGHT!!!***
PALLIATIVE CARE - -
Symptom management
Improving quality of care
HOSPICE CARE -
***NO ANTIBIOTICS!!!***
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***GRIEF STAGES!!!*** - -
Bargaining: “I just want to see my son graduate.”
Acceptance: “I’ve lived a good life.”
LEGAL/ETHICS - Battery: physical harm -
Defamation: damaging someone’s reputation
o Slander: spoken defamation
o Libel: written defamation
INCIDENT REPORTS
***DO NOT GO IN PATIENT CHARTS!!!*** -
Complete for:
o ***MEDICATION ERRORS!!!***
o Adverse reactions
o Falls/injuries
o Lost/stolen items
INFORMED CONSENT
***MUST BE SIGNED BEFORE GIVING ANY MIND-ALTERING MEDICATIONS!!!*** -
Before signing, patient ***MUST BE INFORMED OF:
o Risks vs benefits
o Alternative treatments
o Procedures
o Plan of care in layman’s terms - -
***PATIENT CAN CHANGE MIND AT ANY TIME!!!***
***DOES NOT MEAN THE PATIENT UNDERSTANDS THE PROCEDURE!!!***
o Gives approval to have body touched by specific individual and to have a
specific procedure performed
ADVANCED DIRECTIVES - -
***ON ADMISSION, THE NURSE MUST ASK ABOUT THE STATUS AND
PLACE A COPY IN THE MEDICAL RECORD!!!***
Provides guidance on healthcare-related decisions if the patient is unable to do
so for themselves
LIVE VACCINES - - - -
MMR
Varicella
Flumist
Rotavirus
***CONTRAINDICATION: LOW WBCs!!!***
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INTERDISCIPLINARY TEAMS - - - - - -
***FOR CHRONIC CONDITIONS!!!***:
o Cystic fibrosis
o Parkinson’s
o Hip dysplasia at 6mths
Respiratory
o Inhaler
o Breathing treatments/nebulizer
o Incentive spirometer
Physical Therapy
o Improving mobility
o Canes, crutches, walkers
Occupational Therapy
o Improving ADLs (bathing, dressing, feeding)
Speech Therapy
o Helps with language, communication, and swallowing disorders
***DYSPHAGIA PATIENTS!!!***
Chaplin
o Spiritual needs
o Advanced directives
ISOLATION PRECAUTIONS -
Airborne: Private room w/ negative pressure; N95; ***KEEP DOOR CLOSED!!!***
o Measles
o ***TUBERCULOSIS!!!***
o Varicella - Droplet: Private room OR shared room w/ same organism
o Sepsis/Scarlet Fever/Strep
o Pneumonia/***PERTUSSIS!!!***
o ***INFLUENZA!!!***
o Diphtheria
o Epiglottitis
o Rubella
o Mumps/Meningitis
o AN: Adenovirus
***SURGICAL MASK ON PATIENT DURING TRANSPORT!!!*** -
Contact: Private room; Don gown and gloves before entering room
o C. diff
o RSV
o Eye infections
o Wound infections
o Skin infections ***SCABIES/LINEAR RASH NEEDS ISOLATION!!!***
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RESTRAINTS - - - - -
Least restrictive measure first
o Distraction: Music NOT television
Tied to immobile part of the bed
2 fingers between restraints & skin
Q30min neuro/skin assessment
Q2hr document & release one restraint at a time for toileting, food/water, ROM
ER TRIAGE -
Emergent:
o ***HIGHEST PRIORITY!!!*** - Urgent:
o Serious but not life threatening -
Non-urgent:
o Episodic illnesses
***MASS CASUALITY TRIAGE!!!*** - Black = Injured beyond repair, move on
o Fixed/dilated pupils
o Burns 60%
o Exposed grey matter - Red = Life-threatening requiring immediate assistance
o Airway obstruction
o Cardiac arrest
o Shock
o Pulseless fractures - Yellow = Will require treatment but can be delayed 30min-2hrs
o Hypoglycemia
o Deep lacerations
o Open fractures with distal pulses - Green = Walking wounded, can wait to be seen 2-4hrs
o Ambulatory and alert w/ non-life-threatening injuries
Contusions
Rash
Closed fracture with distal pulses
CHOKING - S/S:
o Coughing, wheezing, gagging, cannot speak, gesturing hands -
Intervention:
o ***ABDOMINAL THRUSTS!!!***
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STERILE TECHNIQUE - - -
Clean gloves to open outer packaging
Sterile gloves to open inner packaging
Maintain 1in border
***OPEN FIRST FLAP AWAY FROM BODY!!!***
***MAINTAIN AT WAIST LEVEL & NEVER TURN BACK TO FIELD!!!***
***NO HANDS BELOW WAIST OR ABOVE CHEST!!!***
INJECTIONS - - -
Subcutaneous: into fat tissue in abdomen, upper outer arms/thighs, buttocks
o 45 angle for normal weight
o 90 angle for obese
o Usually for insulin and heparin
Intradermal: into dermis, just below epidermis
o 15 angle
o ***0.1ml MAX!!!***
o Mantoux/TB skin test: 25G
***FOLLOW-UP IF USING 22G!!!***
Intramuscular: into muscles like deltoid, vastus lateralis, gluteus maximus
o 90 angle
o ***Z-TRACK METHOD!!!***
o ***1ml MAX IN DELTOID!!!***
LIQUID FERROUS SULFATE ADMINISTRATION - -
NO milk/dairy, take with Vitamin C
***ENCOURAGE DARK LEAFY VEGGIES/BEANS/LEGUMES!!!**
AUSCULTATING LUNG SOUNDS - - -
Bronchial:
o ***OVER TRACHEA, 2-3 INTERCOSTAL SPACES!!!***
Bronchovesicular:
o Over major bronchi, between scapulae
Vesicular:
o Over lung bases
o ***VESICULAR BREATH SOUNDS ARE NORMAL!!!***
TRACH CARE - - -
1 finger between skin and ties; 2 extra ties at bedside
PRN suctioning, NEVER scheduled!
o Semi-Fowler’s or High-Fowler’s
o Hyperoxygenate
o 10-15 seconds; 2-3 times
***FOLLOW UP IF CANNULA MOVES IN AND OUT WHILE COUGHING!!!***
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VENT ALARMS - Low:
o Air leak, cuff leak, disconnection, dislodgment - High:
o Increase in pressure, kink in tubing, biting on tube
***IF UNABLE TO FIND SOURCE OF ALARM, MANUALLY BAG & VENTILATE!!!***
AUSCULTATING HEART SOUNDS - - -
AFIB - - -
PVCs - - - -
Aortic Valve:
o 2nd intercostal space, right sternal border
Tricuspid Valve:
o 4th intercostal space, left sternal border
Bicuspid/Mitral Valve:
o 5th intercostal space, left midclavicular line
Irregularly irregular
O2, anticoags, diltiazem, amiodarone, synchronized cardioversion
***START HEPARIN DRIP IMMEDIATELY!!!***
Check peripheral pulses
***MONITOR POTASSIUM!!!***
Identify and treat underlying cause, admin O2
Amiodarone can be used for treatment
PACEMAKERS - -
Can shower with back turned to water
***DON’T RAISE ARM FOR 2 WEEKS POST-OP!!!***
 By Jerry Weygandt, Donald Kieso, Paul Kimmel, Trenholm, Warren, Novak.png)
