VATI IRN ICOMPREHENSIVE IPREDICTOR IFOCUSED IREVIEW ISTUDY IGUIDE
❖ Management Iof ICare I– I(9)
➢ Advance IDirectives I– I(1)
▪ Legal IResponsibilities: IPurpose Iof Ia ILiving IWill I(RM IFUND I9.0 IChp I4)
• A Iliving Iwill Iis Ia Ilegal Idocument Ithat Iexpresses Ithe Iclient’s Iwishes Iregarding
Imedical Itreatment Iin Ithe Ievent Ithe Iclient Ibecomes Iincapacitated Iand Iis Ifacing Iend-
Iof-life Iissues. IMost Istate Ilaws Iinclude Iprovisions Ithat Iprotect Ihealth Iattention
IprovidersIwho Ifollow Ia Iliving Iwill Ifrom Iliability.
➢ Assignment, IDelegation Iand ISupervision I– I(2)
▪ Delegation Iand ISupervision: IDelegating ITasks Ito Ian IAssistive IPersonnel I(RM IFUND
9.0 IChp I6)
• Examples Iof Itasks Inurses Imay Idelegate Ito IAps I(provided Ithe Ifacility’s Ipolicy Iand
Istate’s Ipractice Iguidelines Ipermit)
◆ Activities Iof Idaily Iliving I(ADLs) I– Ibathing, Igrooming, Idressing, Itoileting,
Iambulating, Ifeeding I(without Iswallowing Iprecautions), Ipositioning
◆ Routine Itasks I– Ibed Imaking, Ispecimen Icollection, Iintake Iand Ioutput, Ivital
Isigns I(for Istable Iclients)
▪ Managing IClient ICare: IDelegation IStrategy Ifor IEffective ITask IManagement I(RM
ILeadership I7.0 IChp I1)
• Consideration Ifor Iselection Iof Ian Iappropriate Idelegate Iinclude Ithe Ifollowing:
Ieducation, Itraining, Iand Iexperience; Iknowledge Iand Iskill Ito Iperform Ithe Itask; Ilevel
Iof Icritical Ithinking Irequired Ito Icomplete Ithe Itask; Iability Ito Icommunicate Iwith
Iothers Ias Iit Ipertains Ito Ithe Itask; Idemonstrated Icompetence; Ithe Idelegatee’s
Iculture;Iagency Ipolicies Iand Iprocedures Iand Ilicensing Ilegislation I(state Inurse
Ipractice Iacts)
➢ Case IManagement I– I(1)
▪ Cardiovascular IDisorders: ITetralogy Iof IFallot I(RM INCC IRN I10.0 IChp I20)
• Tetralogy Iof IFallot I– Ifour Idefects Ithat Iresult Iin Imixed Iblood Iflow: IPulmonary
Istenosis, Iventricular Iseptal Idefect, Ioverriding Iaorta, Iright Iventricular Ihypertrophy
◆ Cyanosis Iat Ibirth: Iprogressive Icyanosis Iover Ithe Ifirst Iyear Iof Ilife. ISystolic
Imurmur. IEpisodes Iof Iacute Icyanosis Iand Ihypoxia I(blue Ior I“Tet” Ispells)
• Surgical Iprocedures I– Ishunt Iplacement Iuntil Iable Ito Iundergo Imajor Irepair;
Icomplete Irepair Iwithin Ithe Ifirst Iyear Iof Ilife
➢ Collaboration Iwith IInterdisciplinary ITeam I– I(1)
▪ Communicable IDiseases, IDisasters, Iand IBioterrorism: ICDC IReportable IDiagnoses
I(RM ICH IRN I7.0 IChp I6)
• Anthrax. IBotulism. ICholera. ICongenital Irubella Isyndrome I(CRS). IDiphtheria.
IGiardiasis. IGonorrhea. IHepatitis IA, IB, IC. IHIV Iinfection. IInfluenza-associated
Ipediatric Imortality. ILegionellosis/Legionnaires’ Idisease. ILyme Idisease. IMalaria.
IMeningococcal Idisease. IMumps. IPertussis I(whooping Icough). IPoliomyelitis,
Iparalytic. IPoliovirus Iinfection, Inonparalytic. IRabies I(human Ior Ianimal). IRubella
I(German Imeasles). ISalmonellosis. ISevere Iacute Irespiratory Isyndrome-associated
Icoronavirus Idisease I(SARS-CoV). IShigellosis. ISmallpox. ISyphilis. ITetanus/C.
Itetani. IToxic Ishock Isyndrome I(TSS) I(other Ithan IStreptococcal). ITuberculosis
, (TB). ITyphoid Ifever. IVancomycin-intermediate Iand Ivancomycin-resistant.
IStaphylococcus Iaureus I(VISA/VRSA)
➢ Continuity Iof ICare I– I(1)
▪ Information ITechnology: IChange-of-Shift IReport I(RM IFUND I9.0 IChp I5)
• Nurses Igive Ithis Ireport Iat Ithe Iconclusion Iof Ieach Ishift Ito Ithe Inurse Iassuming
Iresponsibility Ifor Ithe Iclients.
◆ Formats Iinclude Iface Ito Iface, Iaudiotaping, Ior Ipresentation Iduring Iwalking
Irounds Iin Ieach Iclient’s Iroom I(unless Ithe Iclient Ihas Ia Iroommate Ior Ivisitors Iare
Ipresent)
◆ An Ieffective Ireport Ishould: Iinclude Isignificant Iobjective Iinformation Iabout Ithe
Iclient’s Ihealth Iproblems; Iproceed Iin Ia Ilogical Isequence; Iinclude Ino Igossip Ior
Ipersonal Iopinion; Irelate Irecent Ichanges Iin Imedications, Itreatments,
Iprocedures, Iand Ithe Idischarge Iplan
➢ Establishing IPriorities I– I(1)
▪ Managing IClient ICare: IDetermining IPriority ICare Ifor Ia IGroup Iof IClients I(RM
ILeadership I7.0 IChp I1)
• Prioritize Isystemic Ibefore Ilocal I(“life Ibefore Ilimb”)
◆ Prioritizing Iinterventions Ifor Ia Iclient Iin Ishock Iover Iinterventions Ifor Ia Iclient
Iwho Ihas Ia Ilocalized Ilimb Iinjury
• Prioritize Iacute I(less Iopportunity Ifor Iphysical Iadaptation) Ibefore Ichronic I(greater
Iopportunity Ifor Iphysical Iadaptation)
◆ Prioritizing Ithe Icare Iof Ia Iclient Iwho Ihas Ia Inew Iinjury/illness I(e.g. Imental
Iconfusion, Ichest Ipain) Ior Ian Iacute Iexacerbation Iof Ia Iprevious Iillness Iover Ithe
Icare Iof Ia Iclient Iwho Ihas Ia Ilong-term Ichronic Iillness
• Prioritize Iactual Iproblems Ibefore Ipotential Ifuture Iproblems
◆ Prioritizing Iadministration Iof Imedication Ito Ia Iclient Iexperiencing Iof
Imedication Ito Ia Iclient Iexperiencing Iacute Ipain Iover Iambulation Iof Ia Iclient
IatIrisk Ifor Ithrombophlebitis
• Listen Icarefully Ito Iclients Iand Idon’t Iassume
◆ Asking Ia Iclient Iwho Ihas Ia Inew Idiagnosis Iof Idiabetes Imellitus Iwhat Ihe Ifeels Iis
Imost Iimportant Ito Ilearn Iabout Idisease Imanagement
• Recognize Iand Irespond Ito Itrends Ivs. Itransient Ifindings
◆ Recognizing Ia Igradual Ideterioration Iin Ia Iclient’s Ilevel Iof Iconsciousness Iand/or
IGlasgow IComa IScale Iscore
• Recognize Iindications Iof Imedical Iemergencies Iand Icomplications Ivs. Iexpected
Ifindings
◆ Recognizing Iindications Iof Iincreasing Iintracranial Ipressure Iin Ia Iclient Iwho Ihas
Ia Inew Idiagnosis Iof Ia Istroke Ivs. Ithe Ifindings Iexpected Ifollowing Ia Istroke
• Apply Iclinical Iknowledge Ito Iprocedural Istandards Ito Idetermine Ithe Ipriority Iaction
◆ Recognizing Ithat Ithe Itiming Iof Iadministration Iof Iantidiabetic Iand
Iantimicrobial Imedications Iis Imore Iimportant Ithan Iadministration Iof Isome
Iother Imedications
➢ Ethical IPractice I– I(1)
, ▪Professional IResponsibilities: IDemonstration Iof IVeracity I(RM ILeadership I7.0 IChp I3)
• Veracity: Ithe Inurse’s Iduty Ito Itell Ithe Itruth
➢ Legal IRights Iand IResponsibilities I– I(1)
▪ Professional IResponsibilities: IRights Iof IClients I(RM ILeadership I7.0 IChp I3)
• Client Irights Iare Ithe Ilegal Iguarantees Ithat Iclients Ihave Iwith Iregard Ito Itheir Ihealth
Icare
◆ Clients Iusing Ithe Iservices Iof Ia Ihealth Icare Iinstitution Iretain Itheir Irights Ias
Iindividuals Iand Icitizens Iof Ithe IUnited IStates. IThe IAmerica IHospital
IAssociation I(AHA) Iidentifies Iclient Irights Iin Ihealth Icare Isettings Iin Ithe IPatient
ICare IPartnership I(www.aha.org)
◆ Residents Iin Inursing Ifacilities Ithat Iparticipate Iin IMedicare Iprograms Isimilarly
retain Iresident Irights Iunder Istatutes Ithat Igovern Ithe Ioperation Iof Ithese Ifacilities
• Nurse Iare Iaccountable Ifor Iprotecting Ithe Irights Iof Iclients. ISituations Ithat Irequire
Iparticular Iattention Iinclude Iinformed Iconsent, Irefusal Iof Itreatment, Iadvance
Idirectives, Iconfidentiality, Iand Iinformation Isecurity.
❖ Safety Iand IInfection IControl I– I(5)
➢ Accident/Error/Injury IPrevention I– I(2)
▪ Medications IAffecting IUrinary IOutput: IIndications Ifor Ithe IUse Iof Ia IDiuretic I(RM
IPharm IRN I7.0 IChp I19)
• High-ceiling Iloop Idiuretics Iwork Iin Ithe Iascending Ilimb Iof Iloop Iof IHenle I– Iblock
Ireabsorption Iof Isodium Iand Ichloride Iand Iprevent Ireabsorption Iof Iwater. ICauses
Iextensive Idiuresis Ieven Iwith Isevere Irenal Iimpairment
• They Iare Iused Iwhen Ithere Iis Ian Iemergent Ineed Ifor Irapid Imobilization Iof Ifluid I–
Ipulmonary Iedema Icaused Iby Iheart Ifailure; Iconditions Inot Iresponsive Ito Iother
Idiuretics, Isuch Ias Iedema Icaused Iby Iliver, Icardiac, Ior Ikidney Idisease; Ior
Ihypertension
◆ Unlabeled Iuse I– Ihypercalcemia
▪ Seizures: IMaintaining ISeizure IPrecautions I(RM INCC IRN I10.0 IChp I13)
• Seizure Iprecautions Ifor Iany Ichild Iat Irisk I– Ipad Iside Irails Iof Ibed, Icrib, Iand
Iwheelchair; Ikeep Ibed Ifree Iof Iobjects Ithat Icould Icause Iinjury; Ihave Isuction
IandIoxygen Iequipment Iavailable
➢ Handling IHazardous Iand IInfectious IMaterials I– I(1)
▪ Cancer ITreatment IOptions: IImplanted IInternal IRadiation IDevice I(RM IAMS IRN I10.0
IChp I91)
• Brachytherapy Idescribes Iinternal Iradiation Ithat Iis Iplaced Iclose Ito Ithe Itarget Itissue.
IThis Iis Idone Ivia Iplacement Iin Ia Ibody Iorifice I(vagina) Ior Ibody Icavity I(abdomen) Ior
Idelivered Ivia IIV Isuch Ias Iwith Iradionuclide Iiodine, Iwhich Iis Iabsorbed Iby Ithe
Ithyroid
◆ Brachytherapy Iprovides Iradiation Ito Ithe Itumor Iand Ia Ilimited Iamount Ito
Isurrounding Inormal Itissues. IWaste Iproducts Iare Iradioactive Iuntil Ithe IIsotope
Ihas Ibeen Icompletely Ieliminated Ifrom Ithe Ibody. IWaste Iproducts Ishould Inot Ibe
Itouched Iby Ianyone.
• Nursing IConsiderations
❖ Management Iof ICare I– I(9)
➢ Advance IDirectives I– I(1)
▪ Legal IResponsibilities: IPurpose Iof Ia ILiving IWill I(RM IFUND I9.0 IChp I4)
• A Iliving Iwill Iis Ia Ilegal Idocument Ithat Iexpresses Ithe Iclient’s Iwishes Iregarding
Imedical Itreatment Iin Ithe Ievent Ithe Iclient Ibecomes Iincapacitated Iand Iis Ifacing Iend-
Iof-life Iissues. IMost Istate Ilaws Iinclude Iprovisions Ithat Iprotect Ihealth Iattention
IprovidersIwho Ifollow Ia Iliving Iwill Ifrom Iliability.
➢ Assignment, IDelegation Iand ISupervision I– I(2)
▪ Delegation Iand ISupervision: IDelegating ITasks Ito Ian IAssistive IPersonnel I(RM IFUND
9.0 IChp I6)
• Examples Iof Itasks Inurses Imay Idelegate Ito IAps I(provided Ithe Ifacility’s Ipolicy Iand
Istate’s Ipractice Iguidelines Ipermit)
◆ Activities Iof Idaily Iliving I(ADLs) I– Ibathing, Igrooming, Idressing, Itoileting,
Iambulating, Ifeeding I(without Iswallowing Iprecautions), Ipositioning
◆ Routine Itasks I– Ibed Imaking, Ispecimen Icollection, Iintake Iand Ioutput, Ivital
Isigns I(for Istable Iclients)
▪ Managing IClient ICare: IDelegation IStrategy Ifor IEffective ITask IManagement I(RM
ILeadership I7.0 IChp I1)
• Consideration Ifor Iselection Iof Ian Iappropriate Idelegate Iinclude Ithe Ifollowing:
Ieducation, Itraining, Iand Iexperience; Iknowledge Iand Iskill Ito Iperform Ithe Itask; Ilevel
Iof Icritical Ithinking Irequired Ito Icomplete Ithe Itask; Iability Ito Icommunicate Iwith
Iothers Ias Iit Ipertains Ito Ithe Itask; Idemonstrated Icompetence; Ithe Idelegatee’s
Iculture;Iagency Ipolicies Iand Iprocedures Iand Ilicensing Ilegislation I(state Inurse
Ipractice Iacts)
➢ Case IManagement I– I(1)
▪ Cardiovascular IDisorders: ITetralogy Iof IFallot I(RM INCC IRN I10.0 IChp I20)
• Tetralogy Iof IFallot I– Ifour Idefects Ithat Iresult Iin Imixed Iblood Iflow: IPulmonary
Istenosis, Iventricular Iseptal Idefect, Ioverriding Iaorta, Iright Iventricular Ihypertrophy
◆ Cyanosis Iat Ibirth: Iprogressive Icyanosis Iover Ithe Ifirst Iyear Iof Ilife. ISystolic
Imurmur. IEpisodes Iof Iacute Icyanosis Iand Ihypoxia I(blue Ior I“Tet” Ispells)
• Surgical Iprocedures I– Ishunt Iplacement Iuntil Iable Ito Iundergo Imajor Irepair;
Icomplete Irepair Iwithin Ithe Ifirst Iyear Iof Ilife
➢ Collaboration Iwith IInterdisciplinary ITeam I– I(1)
▪ Communicable IDiseases, IDisasters, Iand IBioterrorism: ICDC IReportable IDiagnoses
I(RM ICH IRN I7.0 IChp I6)
• Anthrax. IBotulism. ICholera. ICongenital Irubella Isyndrome I(CRS). IDiphtheria.
IGiardiasis. IGonorrhea. IHepatitis IA, IB, IC. IHIV Iinfection. IInfluenza-associated
Ipediatric Imortality. ILegionellosis/Legionnaires’ Idisease. ILyme Idisease. IMalaria.
IMeningococcal Idisease. IMumps. IPertussis I(whooping Icough). IPoliomyelitis,
Iparalytic. IPoliovirus Iinfection, Inonparalytic. IRabies I(human Ior Ianimal). IRubella
I(German Imeasles). ISalmonellosis. ISevere Iacute Irespiratory Isyndrome-associated
Icoronavirus Idisease I(SARS-CoV). IShigellosis. ISmallpox. ISyphilis. ITetanus/C.
Itetani. IToxic Ishock Isyndrome I(TSS) I(other Ithan IStreptococcal). ITuberculosis
, (TB). ITyphoid Ifever. IVancomycin-intermediate Iand Ivancomycin-resistant.
IStaphylococcus Iaureus I(VISA/VRSA)
➢ Continuity Iof ICare I– I(1)
▪ Information ITechnology: IChange-of-Shift IReport I(RM IFUND I9.0 IChp I5)
• Nurses Igive Ithis Ireport Iat Ithe Iconclusion Iof Ieach Ishift Ito Ithe Inurse Iassuming
Iresponsibility Ifor Ithe Iclients.
◆ Formats Iinclude Iface Ito Iface, Iaudiotaping, Ior Ipresentation Iduring Iwalking
Irounds Iin Ieach Iclient’s Iroom I(unless Ithe Iclient Ihas Ia Iroommate Ior Ivisitors Iare
Ipresent)
◆ An Ieffective Ireport Ishould: Iinclude Isignificant Iobjective Iinformation Iabout Ithe
Iclient’s Ihealth Iproblems; Iproceed Iin Ia Ilogical Isequence; Iinclude Ino Igossip Ior
Ipersonal Iopinion; Irelate Irecent Ichanges Iin Imedications, Itreatments,
Iprocedures, Iand Ithe Idischarge Iplan
➢ Establishing IPriorities I– I(1)
▪ Managing IClient ICare: IDetermining IPriority ICare Ifor Ia IGroup Iof IClients I(RM
ILeadership I7.0 IChp I1)
• Prioritize Isystemic Ibefore Ilocal I(“life Ibefore Ilimb”)
◆ Prioritizing Iinterventions Ifor Ia Iclient Iin Ishock Iover Iinterventions Ifor Ia Iclient
Iwho Ihas Ia Ilocalized Ilimb Iinjury
• Prioritize Iacute I(less Iopportunity Ifor Iphysical Iadaptation) Ibefore Ichronic I(greater
Iopportunity Ifor Iphysical Iadaptation)
◆ Prioritizing Ithe Icare Iof Ia Iclient Iwho Ihas Ia Inew Iinjury/illness I(e.g. Imental
Iconfusion, Ichest Ipain) Ior Ian Iacute Iexacerbation Iof Ia Iprevious Iillness Iover Ithe
Icare Iof Ia Iclient Iwho Ihas Ia Ilong-term Ichronic Iillness
• Prioritize Iactual Iproblems Ibefore Ipotential Ifuture Iproblems
◆ Prioritizing Iadministration Iof Imedication Ito Ia Iclient Iexperiencing Iof
Imedication Ito Ia Iclient Iexperiencing Iacute Ipain Iover Iambulation Iof Ia Iclient
IatIrisk Ifor Ithrombophlebitis
• Listen Icarefully Ito Iclients Iand Idon’t Iassume
◆ Asking Ia Iclient Iwho Ihas Ia Inew Idiagnosis Iof Idiabetes Imellitus Iwhat Ihe Ifeels Iis
Imost Iimportant Ito Ilearn Iabout Idisease Imanagement
• Recognize Iand Irespond Ito Itrends Ivs. Itransient Ifindings
◆ Recognizing Ia Igradual Ideterioration Iin Ia Iclient’s Ilevel Iof Iconsciousness Iand/or
IGlasgow IComa IScale Iscore
• Recognize Iindications Iof Imedical Iemergencies Iand Icomplications Ivs. Iexpected
Ifindings
◆ Recognizing Iindications Iof Iincreasing Iintracranial Ipressure Iin Ia Iclient Iwho Ihas
Ia Inew Idiagnosis Iof Ia Istroke Ivs. Ithe Ifindings Iexpected Ifollowing Ia Istroke
• Apply Iclinical Iknowledge Ito Iprocedural Istandards Ito Idetermine Ithe Ipriority Iaction
◆ Recognizing Ithat Ithe Itiming Iof Iadministration Iof Iantidiabetic Iand
Iantimicrobial Imedications Iis Imore Iimportant Ithan Iadministration Iof Isome
Iother Imedications
➢ Ethical IPractice I– I(1)
, ▪Professional IResponsibilities: IDemonstration Iof IVeracity I(RM ILeadership I7.0 IChp I3)
• Veracity: Ithe Inurse’s Iduty Ito Itell Ithe Itruth
➢ Legal IRights Iand IResponsibilities I– I(1)
▪ Professional IResponsibilities: IRights Iof IClients I(RM ILeadership I7.0 IChp I3)
• Client Irights Iare Ithe Ilegal Iguarantees Ithat Iclients Ihave Iwith Iregard Ito Itheir Ihealth
Icare
◆ Clients Iusing Ithe Iservices Iof Ia Ihealth Icare Iinstitution Iretain Itheir Irights Ias
Iindividuals Iand Icitizens Iof Ithe IUnited IStates. IThe IAmerica IHospital
IAssociation I(AHA) Iidentifies Iclient Irights Iin Ihealth Icare Isettings Iin Ithe IPatient
ICare IPartnership I(www.aha.org)
◆ Residents Iin Inursing Ifacilities Ithat Iparticipate Iin IMedicare Iprograms Isimilarly
retain Iresident Irights Iunder Istatutes Ithat Igovern Ithe Ioperation Iof Ithese Ifacilities
• Nurse Iare Iaccountable Ifor Iprotecting Ithe Irights Iof Iclients. ISituations Ithat Irequire
Iparticular Iattention Iinclude Iinformed Iconsent, Irefusal Iof Itreatment, Iadvance
Idirectives, Iconfidentiality, Iand Iinformation Isecurity.
❖ Safety Iand IInfection IControl I– I(5)
➢ Accident/Error/Injury IPrevention I– I(2)
▪ Medications IAffecting IUrinary IOutput: IIndications Ifor Ithe IUse Iof Ia IDiuretic I(RM
IPharm IRN I7.0 IChp I19)
• High-ceiling Iloop Idiuretics Iwork Iin Ithe Iascending Ilimb Iof Iloop Iof IHenle I– Iblock
Ireabsorption Iof Isodium Iand Ichloride Iand Iprevent Ireabsorption Iof Iwater. ICauses
Iextensive Idiuresis Ieven Iwith Isevere Irenal Iimpairment
• They Iare Iused Iwhen Ithere Iis Ian Iemergent Ineed Ifor Irapid Imobilization Iof Ifluid I–
Ipulmonary Iedema Icaused Iby Iheart Ifailure; Iconditions Inot Iresponsive Ito Iother
Idiuretics, Isuch Ias Iedema Icaused Iby Iliver, Icardiac, Ior Ikidney Idisease; Ior
Ihypertension
◆ Unlabeled Iuse I– Ihypercalcemia
▪ Seizures: IMaintaining ISeizure IPrecautions I(RM INCC IRN I10.0 IChp I13)
• Seizure Iprecautions Ifor Iany Ichild Iat Irisk I– Ipad Iside Irails Iof Ibed, Icrib, Iand
Iwheelchair; Ikeep Ibed Ifree Iof Iobjects Ithat Icould Icause Iinjury; Ihave Isuction
IandIoxygen Iequipment Iavailable
➢ Handling IHazardous Iand IInfectious IMaterials I– I(1)
▪ Cancer ITreatment IOptions: IImplanted IInternal IRadiation IDevice I(RM IAMS IRN I10.0
IChp I91)
• Brachytherapy Idescribes Iinternal Iradiation Ithat Iis Iplaced Iclose Ito Ithe Itarget Itissue.
IThis Iis Idone Ivia Iplacement Iin Ia Ibody Iorifice I(vagina) Ior Ibody Icavity I(abdomen) Ior
Idelivered Ivia IIV Isuch Ias Iwith Iradionuclide Iiodine, Iwhich Iis Iabsorbed Iby Ithe
Ithyroid
◆ Brachytherapy Iprovides Iradiation Ito Ithe Itumor Iand Ia Ilimited Iamount Ito
Isurrounding Inormal Itissues. IWaste Iproducts Iare Iradioactive Iuntil Ithe IIsotope
Ihas Ibeen Icompletely Ieliminated Ifrom Ithe Ibody. IWaste Iproducts Ishould Inot Ibe
Itouched Iby Ianyone.
• Nursing IConsiderations
