Review Session

Here's what I took away from the review with Julie Kay.

The intervention should match the goal. If it doesn't, you need to reevaluate.

Nursing diagnoses should be CLIENT CENTERED

Nursing diagnoses should be written legally. Example of an ND that is NOT legally advisable is..."Impaired skin integrity related to improper positioning (implies legal liability)". A correctly written ND would be "Impaired skin integrity related to immobility."

Meds: If there is no order, DO NOT pick medication as your answer.
When giving meds: 1. Know what it will do and know what the adverse effects are.
If pt states the med is different than it normally looks or that they do not normally take an antihypertensive, then RECHECK.

SubQ injection: Taut or pinch (depending on the thickness of the subq tissue).
45 o angle with 5/8 " needle
Slow administration
IM injection: Z track method (keeps medication from coming out
90o angle with 1-1 1/2" needle
Aspirate (if you see blood, start over with new needle)

Preoperative prep: VS
Consent - explained by Dr., witnessed by nurse
Chart should be up-to-date
Preop meds given (prophylactic antibiotic, antianxiety)
Explain process through postop/postanesthesia
urinary cath
Medication hung
Four bedrails up

Postoperative: VS compare to baseline
Keep them Oxygenated
Suction
IV pole
Check incision/IV site/Dressing
Basin for nausea
Be aware of flatus

Check surgical site for redness, swelling, heat, odor (normal is red and beefy, her words, not mine!)

ND's dealing with Oxygenation, Circulation, Pain, Anxiety....with 3 interventions

If pt is ambulating, you need to address their pain level
If pt is agitated (test question!), safety first (Secure lines!).

Euthanasia is LEGALLY wrong.
Who has rights to pt's care....the patient.

Pt c impaired mobility: Turn, ROM.....make sure foot drop, contractures, DVT does not occur.

Legal documentation is using medical terminology.

Know your own biases when it comes to spirituality

For meds, units never convert, if a questions talks about insulin the answer should be written in units, not mL's.

**Do not add anything to the questions**

Good luck Everyone!! :o)