RN Comprehensive Predictor 2019 Remediation (urinary tract infection, Hyperglycemia) | STUDY GUIDE.

RN Comprehensive Predictor 2019 Remediation Professional Responsibilities: Identifying Client Advocacy • Support of clients’ health, wellness, safety, and personal rights, including privacy • Autonomy: the right to make one’s own personal decisions, even when those decisions might not be in that person’s best interest • Beneficence: action that promotes good for others, without an self interest • Fidelity: fulfillment of promises • Justice: fairness in care delivery and use of resources • Nonmaleficence: a commitment to do no harm • Veracity: a commitment to tell the truth 1) Ensures the client has the information they need to make decisions about healthcare 2) Advocate even when they disagree with the client’s decision 3) Advocate when clients are unable to speak or act for themselves Managing Client Care: Action Requiring Intervention during Tracheostomy Suctioning • Provide tracheostomy care every 8 hours to reduce risk of infection • Use sterile suctioning supplies • Remove soiled dressings and excess secretions • Apply the oxygen source loosely if the client’s SpO2 decreases during procedure • Use cotton tip[ed applicators and gauze pads to clean exposed outer cannula surfaces. Clean in a circular motion from the stoma site outward • Use surgical asepsis to remove and clean the inner canula . Use a new inner cannula if it is disposable. • Clean the stoma site and then the tracheostomy plate • Place a fresh split gauze tracheostomy dressing of nonraveling material under and around the tracheostomy holder and plate 1) An open airway is necessary for breathing so it is the highest priority 2) Breathing is necessary for oxygenation of the blood to occur 3) Circulation is necessary for oxygenated blood to reach the body’s tissues Managing Client Care: Effective Time Management 1) Taking time to plan care and taking priorities into consideration 2) Making repeated trips to the supply room 3) Completing one task before beginning another task for equipment Coordinating Client Care: Planning Care for a Client Following a Stroke • Assess swallow and gag reflex before feeding • Can have thin (water, juice), nectar like (cream soups, nectars), honey like (honey, yogurt), spoon thick ( pudding, cooked cereals) • Pureed, mechanically soft, regular 1) Initiation revision and evaluations of the plan of care 2) Facilitating referrals and the use of community resources 3) Facility to another, such as from an acute care facility to a skilled facility Coordinating Client Care: Information to Report to Occupational Therapist • Assess and plans for clients to regain activities of daily living skills, especially motor skills of the upper extremities • Ex. A client has difficulties with using an eating utensil with her dominant hand following a stoke. 1) Client medical diagnosis and care providers 2) Overview of health status, plan of care, and recent progress 3) Most recent vital signs and medications Multiple Sclerosis: Priority Referral for a Client who has Amyotrophic Lateral Sclerosis • Degenerative neurological disorder of upper and lower motor neurons, resulting in progressive paralysis • Eventually causes respiratory paralysis within 3-5 years. Cognitive function is not impacted. No cure. • Palliative care is top priority 1) Plan for disease progression 2) Consider referral to occupational and physical therapy for home environment assessment to determine safety and ease of mobility. 3) Refer to speech language therapist for dysarthria and dysphagia. Information Technology: Using Correct Documentation 1) Begin each entry with the date and time 2) Record entries legibly, in nonerasable black ink, and do not leave blank spaces in the nurses’ notes 3) Sign all documentation as the facility requires, generally with name and title Professional Responsibilities: Priority Action When Obtaining a Signature on an Informed Consent Form • The reason the client needs the treatment or procedure • How the treatment or procedure will benefit the client • The risks involved • Other options to treat the problem • The nurse’s role is to witness the client’s signature on the informed consent form to ensure that the provider has obtained the informed consent responsibly 1) For an invasive procedure or surgery, the client is required to provide written consent 2) State laws regulate who is able to give informed consent 3) The nurse must verify that consent is informed and witness the client sign the consent form Communicable Diseases, Disasters, and Bioterrorism: Reportable Infectious Diseases • TB, Hep A/B/C, anthrax, diptheria, gonorrhea, HIV, influenza- associated pediatric mortality, pertussis, mumps, lyme disease, rubella, smallpox, syphilis, toxic shock syndrome Cultural and Spiritual Nursing Care: Communicating with a client who speaks a language different from the nurse • Always have a professional interpreter when translating 1) Nurses should accommodate each client’s cultural beliefs and values whenever possible, unless they are in direct conflict with essential health practices 2) Study the client and their environment for examples of cultural relevance 3) Use only a facility-approved medical interpreter Professional Responsibilities: Understanding Regulations for Nursing Scope of Practice 1) Nurses should refuse to practice beyond the legal scope of practice and/or outside of their areas of competence regardless of reason 2) Nurses should use the formal chain of command to verbalize concerns related to assignment in light of current legal scope of practice, job description, and area of competence 3) Standards of care guide, define, and direct the level of care that should be given by practicing nurses Medications Affecting Urinary Output: Teaching About Furosemide • Indications: pulmonary edema, edema, hypertension • Mode of action: blocks reabsorption of Na, Cl, and water in the ascending loop of Henle, causing rapid diuresis • Side effects: dehydration, electrolyte imbalances (hyponatremia, hypokalemia), hypotension, ototoxicity, hyperglycemia • Key points: administer during the day vs. night, infuse IV at 20 mg/min, weigh patients daily, monitor I/Os, monitor electrolytes, encourage foods high in potassium 1) Monitor blood pressure 2) Monitor electrolytes and weight 3) Report urine output less than 30 Ml/hr Musculoskeletal Trauma: Discharge Teaching Following Surgery for Carpal Tunnel Syndrome • Hand movements and heavy lifting might be restricted 4 to 6 weeks • The client can expect weakness and discomfort for weeks or months • Remind the client to report any changes in neurovascular status including increase in pain to surgeon immediately 1) Ensure the client is aware of application protocol regarding full-time or part-time use 2) Instruct the client to observe for skin breakdown at pressure points 3) Do not remove unless instructed to do so Cancer Treatment Options: Caring for a Client Who Has a Radiation implant • Wear a dosimeter film badge that records personal amount of radiation exposure • Limit visitors to 30 minute visits, and have visitors maintain a distance of 6 feet from the source • Visitors or healthcare professionals who are pregnant or under the age of 18 should not come into contact with the client or radiation source • Wear a lead apron while providing care keeping the front of the apron facing the source of radiation • Keep a lead container in the client’s room if the delivery method could allow spontaneous loss of radioactive material. Tongs are available for placing radioactive material into the container. 1) Place the client in a private room away from other clients when possible 2) Keep the door closed as much as possible 3) Place a sign on the door warning of the radiation source Medical and Surgical Asepsis: Maintaining Aseptic Technique • The outer wrappings and 1 inch edges of packaging that contains sterile items are not sterile. The inner surface of the sterile drape or kit, except for that 1 inch border around the edges, is the sterile field to which other sterile items may be added. • To position the field on the table surface, grasp the one inch border before donning sterile gloves; discard any object that comes into contact with the 1 inch border • Consider any object held below the waist or above the chest contaminated • Do not reach across or above the sterile field • Do not turn your back on a sterile field • Hold items to add to a sterile field at a minimum of 6 inches above the field • Open the top flap away from the body 1) Perform hand hygiene before and after every client contact, and after removing gloves 2) Use protective clothing such as masks, gloves, gowns, and protective eyewear 3) Avoid coughing, sneezing, and talking directly over a sterile field Newborn Assessment: Expected Findings • Temp: 36.5-37.5 • Skin: pink or acrocyanotic with no jaundice present on the first day, jaundice can appear on the third day 1) Blood pressure should be 60 to 80 mm Hg systolic and 40 to 50 mm Hg diastolic 2) Normal heart rate ranges from 110 to 160/min with brief fluctuations above and below this range depending on activity level 3) Respiratory rate varies from 30 to 60 breaths/min with short periods of apnea occurring most frequently during the rapid eye movement sleep cycle Client Education: Creating Written Teaching Materials 1) Assess/monitor learning needs 2) Evaluate the learning environment 3) Identify learning style Health Promotion and Disease Prevention: Evaluating Understanding of Genetic Risks 1) Use stress management strategies 2) Get adequate sleep and rest 3) Avoid saturated fats Sources of Nutrition: Teaching About Food Sources of Calcium • Dairy, broccoli, kale, grains 1) Dairy 2) Kale 3) Egg Yolks Care of Specific Populations: Evaluating Health Risks of Migrant Farm workers • Key health risks: tuberculosis, dental disease, skin cancer, diabetes, obesity, high risk of suicide, increased work related injuries (exposure to pesticides, injuries to machinery) • Primary prevention: education on reducing exposure to pesticides, accident prevention, (immunizations, dental care) • Secondary prevention: screen for skin cancer, pesticide exposure, communicable diseases • Tertiary prevention: provide ER or primary care services, including treatment of symptoms of pesticide exposure 1) Climate caused illnesses 2) Communicable diseases 3) Bladder and kidney disorders Medications for Substance Use Disorders: Evaluating Teaching about Disulfram • If patient ingests alcohol, they will get unpleasant side effects, including: nausea, vomiting, sweating, palpitations, and hypotension 1) Daily oral medication that is a type of aversion (behavioral therapy) 2) Wear medical adult bracelet 3) Used concurrently with alcohol will cause acetaldehyde syndrome Anxiety Disorders: Action for a client who is Experiencing a Panic Level of Anxiety 1) Structured environment for physical safety 2) Monitor for, and protection from, self-harm 3) Open-ended questions, to help the client express feelings of anxiety Anxiety Disorders: Planning Care for a client Who Has Obsessive-Compulsive Disorder • Patient has persistent thoughts or urges that cause anxiety. The patient engages in compulsive/ obsessive behaviors to alleviate anxiety. • Help patient set limits for compulsive behavior and lengthen the time between rituals • Cognitive therapy to help the patient identify source of anxiety that leads to compulsive behavior • Thought stopping to interrupt obsessive behavior 1) SSRI antidepressant, such as sertraline or paroxetine 2) Assess client risk for self-harm 3) Ensure client is provided with a safe environment Cultural, Ethnic, and Religious Influence: Food Selections for a Client Who Follows a Kosher Diet 1) Tuna 2) Herring 3) Salmon Effective Communication: Responding to a Client Who is Obese and Crying 1) Interactive, purposeful communication skills 2) Express empathy and genuine concern 3) Elicit and attend to a client’s thoughts, feelings, concerns, and need Psychotic Disorders: Caring for a Client who has Auditory Hallucinations • Patient hears voices or sounds • Command hallucinations: voice instructs patient to perform action (at risk to hurt self or others) • Priority: ask patient directly about hallucinations, including command. • Do not argue or agree with hallucination or delusions • “ I don’t hear anything, but it must be scary to hear voices.” 1) Ask directly about hallucinations 2) Should not argue or agree with the client’s view of the situation 3) Provide for safety, due to the increased risk for harm to self or others Sedative-Hypnotics: Identifying Antidote to Diazepam • Antidote is flumazenil 1) Administer by oral route 2) Instruct clients to take medication 30 min prior to bedtime 3) Instruct clients to take medication on an empty stomach and to avoid high-fat foods before taking Substance Use and Addictive Disorders: Identifying Manifestations of Opiod Withdrawal • Sweating, rhinorrhea, pupil dilation, tremors, irritability, insomnia, GI upset, muscle spasms 1) Diarhea 2) Insomnia 3) Pupil Dilation Effective Communication: Responding to a Client Who Has Major Depressive Disorder • Acute phase: severe clinical signs of depression, 6-12 weeks in duration, possible need for hospitalization, greatest risk for suicide during this phase (1:1 observation needed) Goal: treat and reduce depressive manifestations • Continuation phase: increased ability to function, 4-9 months in duration. Goal: relapse prevention through education, medication therapy, psychotherapy • Maintenance phase: remission, can last for 1 or more years. Goal: prevention of future depressive episodes • Priority: assess patient’s suicide risk and implement 1:1 observation • No private room • Communicate with simple sentences. Allow extra time for responses 1) Caring Attitude 2) Active listening 3) Eye contact Bowel Elimination: Assessing a Client Who Has an Ileostomy • Inspect the stoma- should be pink and moist. Pale pink or blue/purple indicates ischemia • Empty ostomy bag when its ¼-1/2 full • Patient can use breath mint in pouch to decrease odor • Teach patient to avoid foods that cause gas and odor • Cut opening in skin barrier 1/8 inch larger than stoma 1) Closely monitor fluid status and elimination pattern 2) Record food and fluid intake and output 3) Observe and document the character of bowel movements Postpartum Physiological Adaptations: Interventions to Promote Voiding • assess the client’s ability to void ever 2 to 3 hours • assess bladder elimination pattern (more than 3,000 mL/day is normal within first 2 to 3 days after delivery) • frequent voiding of less than 150 mL of urine is indicative of urinary retention with overflow • encourage client to increase her fluids 1) Encourage the client to empty her bladder frequently to prevent possible displacement of the uterus atony 2) Measure the client’s first few voiding after delivery to assess for bladder emptying 3) Encourage the client to increase her oral fluid intake to replace fluids lost at delivery and to prevent or correct dehydration Spinal Cord Injury: Planning Care to prevent skin breakdown • change the client’s position every 2 hour or every 1 hour if in a wheelchair • clients with SCI cant move or feel pain • pressure relief devices in both the bed and the wheelchair must be consistently used 1) Maintain body alignment and ensure cervical tong weights hang freely 2) Monitor skin integrity by providing pin care and assessing the skin under the halo fixation vest as appropriate 3) Do not use halo device to turn or move client Benign Prostatic Hyperplasia: Identifying Medication Interactions with Saw Palmetto • increased affect with anticoagulants: heparin, rivaroxaban, warfarin, aspirin, alteplase 1) Reinforce that it can take 6 months to 1 year before effects of the medication are evident 2) Inform the client that impotence and a decrease in libido are possible adverse effects 3) Advise the client to report breast enlargement to the provider Overview of Community Health Nursing: Identifying a Tertiary Prevention Strategy for Parkinson’s Disease 1) Referral to support groups that allow members to share strategies for living well 2) Have client to create a space they are familiar with 3) Have client to avoid multi-tasking while walking Pain Management: Promoting Comfort During a Heel Stick 1) Lidocaine and prilocaine is available in cream or gel for puncture 2) Place an occlusive dressing over the cream after application 3) Instruct parents to apply medication at home as well Burns: Supporting Nutritional Requirements • no fresh fruit/ veggies • increase calorie and protein intake 1) Increase caloric intake to meet increased metabolic demands and prevent hypoglycemia 2) Increase protein intake to prevent tissue breakdown and promote healing 3) Caloric needs double or triple 4 to 12 days after the burn Medications for Depressive Disorders: Food and Medication Interactions • phenelzine: MAOIs: do not eat foods rich in tyramine ( aged cheese, avocados, bananas, red wine, salami/ pepperoni, chocolate) • paroxetine (SSRIs): do not take with St. John’s wort 1) Discontinue MAOI’s 14 days prior to starting an SSRI 2) Fluoxetine should be discontinued 5 weeks before starting an MAOI 3) Advise against concurrent use of TCA’s and St. John’s wort along with SSRI’s Nasogastric intubation and enteral feedings: Nursing actions for continuous enteral feeding • change tube and bag every 24 hours • if TPN is unavailable administer 10% dextrose in water 1) Prepare the formula, tubing, and infusion device 2) Assist the client to Fowler’s position, or elevate the head of the bed to a minimum of 30 degrees 3) Auscultate for bowel sounds Renal disorders: Teaching a client who has chronic kidney disease • Diet: high carbs, moderate fats. Restrict sodium, potassium, phosphorus, magnesium 1) Explain why dietary changes are necessary 2 )Provide support for the client and family 3) Caution clients to use vitamin and mineral supplements only when recommended by the provider Stroke: Assisting a client who has dysphagia 1) Assess gag reflex 2) Keep the client completely NPO until evaluated by SLP 3) If the client exhibits difficulty managing food or fluids, a swallowing evaluation should be done by SLP Home Safety: Home recommendations for a client who is postoperative 1) Remove items that could cause the client to trip, such as throw rugs and loose carpets 2) Place electrical cords and extension cords against a wall behind furniture 3) Use a nonskid mat in the tub or shower Rest and Sleep: Priority findings to report to the provider 1) Sleep patterns 2) Sudden attacks of sleep 3) Excessive sleepiness during waking hours Medications affecting coagulation: Medications contraindicated for use with warfarin 1) Aspirin 2) Acetaminophen 3) Sulfonamides Medications affecting urinary output: Identifying an adverse affect of furosemide • Dehydration, electrolyte imbalance, (hyponatremia, hypokalemia) hypotension, ototoxicity, hyperglycemia 1) Monitor potassium levels regularly 2) Avoid salt substitutes that contain potassium 3) Self-monitor blood pressure Postpartum Disorders: Anticipating a provider prescription for postpartum hemorrhage 1) If client loses more than 500 mL blood after a vaginal birth 2) If client loses more than 1,000 mL blood after cesarean birth 3) Complications that can occur include hypovolemic and anemia Dosage Calculation: Calculating Rantidine IV dosage 1) Determine which method one would use ( ratio and proportion, formula, and dimensional analysis) 2) Determine the unit of measurement one should calculate such as capsules 3) Determine what dosage is available Dosage calculation: Liquid medication by weight 30 mL = 1 oz 1 mL= 1cc 1 tsp= 5 mL 3 tsp= 1 tbsp 1 tbsp= 15 mL 2 tbsp=1 oz 1) Determine the of unit measurement such as mL 2) Determine whether the units of measurement need converting 3) Reasses to determine whether the amount one is going to administer makes sense Adjuvant medications for pain: Client teaching about glucocorticoid therapy • Inhaled glucocorticoid: beclomethasone: used for asthma; decreases inflammation o Side effects: hoarseness, candidiasis o Key points: rinse mouth with water after administration o Use bronchodilator first, wait 5 minutes, then use glucocorticoid • Oral glucocorticoid: prednisone: decreases inflammation and suppresses immune response o Side effects: bone loss, weight gain/fluid retention, hyperglycemia, hypokalemia, infection, muscle weakness, peptic ulcer disease, o Do not stop suddenly, taper. Monitor for signs of infection, avoid NSAIDs 1) Monitor potassium and cardiac rhythm 2) Encourage clients to eat potassium-rich foods 3) Administer potassium supplements Medications affecting blood pressure: Preparing to administer nitroprusside • For hypertensive crisis • Side effects: hypotension, cyanide poisoning, thiocyanate toxicity 1) Monitor blood pressure 2) Advise clients to rise slowly from sitting 3) Advise clients to avoid activities that require alertness until effects are known Safe medication Administration and Error reduction: Completing medication reconciliation during admission • Nurse compiles a list of each client’s current medications, including all medication with their dosages and frequency • They compare new medication prescriptions and reconcile it with the Dr to resolve any discrepancies • Should take place at admission, when transferring clients between units or facilities and at discharge 1) Read medication labels and compare them with the MAR three times 2) Leave unit-dose medication in its package until administration 3) When using automated medication dispensing systems, perform the same checks and adapt them as necessary Acute infectious gastrointestinal disorders: Teaching about intermittent parenteral therapy 1) Obtain daily weights at the same time each day 2) Avoid taking a rectal temperature 3) Avoid antibiotics Fluid imbalances: Reportable findings 1) Hyponatremia 2) Hypokalemia 3) Hypocalcemia A1 Kidney transplant: Laboratory values to report to the provider • Monitor urine output; report less than 30 mL/hr • Monitor for excessive diuresis, which can result in hypovolemia and hypotension 1) Report hourly output volumes less than 30 mL/hr 2) Assist in monitoring urine output 3) Assist in blood loss Medications for bipolar disorders: Monitoring lithium levels • Monitor plasma levels: toxicity over 1.5 mEq/L • Closely monitor sodium intake, need fluid and sodium (2-3 liters) • Symptoms of toxicity: coarse tremors, confusion, hypotension, seizures, tinnitus 1) Administer new dosage based on serum lithium levels 2) Monitor for mental confusion, notify provider 3) Ongoing GI distress, notify provider Chest tube insertion and monitoring: Finding to report to the provider • Report drainage over 70 mL/hr to provider or drainage that is cloudy/red • Tidaling expected • Continuous bubbling indicates air leak (water seal chamber) • Continuous bubbling expected (suction control chamber) 1) Notify the provider if an air leak is noted 2) Report if tubing has kinks 3) Report if tubing has occlusions or loose connections Urinary elimination: Preventing urinary tract infection • Risks: menopause, sexual intercourse, pregnancy, synthetic underwear, wet bathing suit, frequent bathing, urinary catheters, stool incontinence, diabetes, incomplete bladder emptying • Prevention: o Drink at least 3L fluid daily o Empty bladder every 3-4 hours o Urinate before and after intercourse o Drink cranberry juice 1) Clean from front to back (Females) 2) Clean beneath the foreskin (Males) 3) Provide catheter care regularly Complications Of infants: Manifestations of dehydration • Poor skin turgor, dry mucous membranes, decreased urinary output 1) Give extra fluids in frequent, small sips, 2) Continue a regular diet 3) Provide parents with education and support Stroke: Manifestations of left hemisphere stroke • Expressive aphasia (inability to speak and understand language), reading and writing difficulty, right sided hemiparesis (weakness), or hemiplegia (paralysis) 1) Monitor vital signs every 1 to 2 hrs 2) Monitor the client’s temperature 3) Institute seizure precautions Cancer disorders: Preoperative teaching for a client who is scheduled for a modified radical mastectomy • Modified radical mastectomy = lymph nodes removed • Teach the client how to care for her incision and drainage tubes ( drains are usually kept in for 1 to 3 weeks) • Advise the client to avoid placing her arm in the dependent position • Encourage early arm and hand exercises • Teach the client not to wear constrictive clothing and to avoid cuts and injuries to the affected arm • Instruct the client to report numbness, pain, heaviness, or impaired motor function 1) Teach the client how to care for her incision and drainage tubes 2) Advise client to avoid placing her arm in a dependent position 3) Teach the client not to wear constrictive clothing Acute and infectious respiratory illnesses: Caring for an infant who has respiratory syncytial virus 1) Closely monitor progression of illness and ensuing respiratory distress 2) Make emergency equipment for intubation readily accessible 3) Implement isolation precautions as indicated Assessment and management of newborn complications: Interventions for phototherapy • Primary treatment for hyperbilirubinemia • Maintain an eye mask over the newborn’s eyes for protection of corneas and retinas • Keep the newborn undresses with exception of a diaper • Avoid applying lotions or ointments • Remove the newborn from phototherapy every 4 hrs • Reposition newborn every 2 hours • Feed newborn early and frequently every 3 to 4 hours 1) Perform ongoing assessment of the newborn using the neonatal abstinence scoring system assessment, as prescribed 2) Elicit and assess the newborn’s reflexes 3) Swaddle the newborn with legs flexed Cancer treatment options: Adverse effects of radiation therapy • Skin changes, hair loss, debilitating fatigue 1) Adverse effects on tissues within the radiation path include skin changes, hair loss, and debilitating fatigue 2) Internal radiation causes body fluids to contaminated with radiation 3) Body waste should be disposed of appropriately Cancer treatment options: Teaching a client about skin care during radiation treatment • Do not remove or wash off radiation tattoos • Do not apply powders, ointments, options, deodorants, or perfumes to the irradiated skin • Wear soft clothing 1) Cytoprotectants, such as amifostine, are sometimes used to protect against harmful effects of radiation 2) Gently wash the skin over the irradiated area with mild soap and water 3) Do not expose the irradiated skin to sun or a heat source Head Injury: Caring for a client who has increased intracranial pressure • Administer oxygen to maintain PaO2 greater than 60 1) Maintain the head of the bed at an angle of less than 30 degrees 2) Elevate head at least 30 degrees to reduce ICP and to promote venous drainage 3) Avoid extreme flexion, extension, or rotation of the head, and maintain the body in a midline neutral position Hemodialysis and peritoneal dialysis: Indications of Peritonitis 1) Maintain surgical asepsis during the procedure 2) Monitor for infection 3) Educate the client to use strict sterile technique during exchanges Medical conditions: Hyperemesis gravidarum • Excessive nausea and vomiting that is prolonged past 12 weeks of gestation and results in a 5% weight loss from prepregnancy weight, electrolyte imbalance, acetonuria, and ketosis • Labs: urinalysis for ketones and acetones: elevated urine specific gravity 1.025 • Education: small, frequent meals; dry toast, crackers, cereal, then move to soft diet 1) Monitor vital signs 2) Monitor weight 3) Assess skin turgor and mucous membranes Heart failure and pulmonary edema: Evaluating teaching about an exercise program • Consult with Dr before starting an exercise regimen • Consume a diet low in sodium along with fluid restrictions 1) Maintain an exercise routine to remain physically active 2) Consume a diet low in sodium along with fluid restrictions 3) Refrain from smoking Postpartum disorders: Evaluating understanding of postpartum hemorrhage • Occurs if the client looses more than 500 mL blood after a vaginal birth or more than 1000 mL blood after caesarean birth • Two complications: hypovolemic shock and anemia • uterine atony (hypotonic or boggy) • blood clots larger than a quarter • perineal pad saturated in 15 minutes or less 1) Monitor vital signs 2) Assess for source of bleeding 3) Assess bladder for distention Enuresis and urinary tract infections: expected findings for a child who has a urinary tract infection • abdominal or back pain • pain with urination • poor appetite, vomiting, slowed growth, increase in thirst, enuresis, swelling of the face, seizures, pallor, fatigue, blood in urine, edema, hypertension, tetany 1) Increase in irritability 2) Abdominal or back pain 3) Pain with urination Pressure ulcers, wounds, and wound management: staging a pressure ulcer • Stage 1 nonblanchable erythema: intact skin with area persistent, nonblanchable redness, typically over bony prominence, tissue swollen with possible discomfort at the site, ulcer can appear blue or purple • Stage 2 partial thickness: epidermis and dermis, the ulcer is visible with reddish-pink bed without slough or bruising , can appear as an abrasion, blister, or shallow crater. Edema persists. Possible pain and scant drainage. • Stage 3 full thickness skin loss: Damage to or necrosis of subcutaneous tissue. The ulcer can extend down to, but not through, underlying fascia. Ulcer appears as a crater but without bone. Drainage and infection are common. • Stage 4 full thickness tissue loss: destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. Can be black, tan, yellow, green • Unstageable: no determination of stage because eschar or slough obscures the wound. The actual depth of injury is unknown 1) Relieve pressure 2) Encourage frequent turning and repositioning 3) Keep the client dry, clean, well-nourished, and hydrated Infections of the renal and urinary system: Client teaching about preventing urinary tract infections 1) Avoid wet bathing suits 2) Poorly fitted diaphragm 3) Frequent submersion into baths or hot tubs Leadership styles • Authoritative: leader dictates decisions for the team, uses penalties or coercion to promote behavior change • Democratic: leader involves team members in decision making process • Laissez faire: leader provides little direction, planning. Emphasis on group decision making RN should not delegate: • Patient education • Any task that requires nursing judgement • Nursing assessment • Blood transfusion OK to delegate to PN: • Medication administration • Enteral feedings • Urinary catheter insertion • Suctioning • Tracheostomy care • Wound care • Reinforcement of patient teaching OK to delegate to CNA: • Bathing, dressing, ambulating, toileting, feeding patients without swallowing precautions, positioning, vitals, bed making, specimen collection, I/Os, basic CPR