Comprehensive Predictor Retake Review
Delegation to Assistive Personnel
- ADLs
- Bathing
- Grooming
- Dressing
- Toileting
- Ambulating
- Feeding (without swallowing precautions)
- Positioning
- Rountine Tasks
- Bed making
- Specimen collection
- I&O
- Vital Signs ( for stable clients )
Planning Care for a Client Who Has Hypothyroidism
- Monitor for low Bp & bradycardia
- Monitor for chest pain & peripheral edema
- Monitor clients weight
- reorient the client if confusion occurs
- provide frequent rest periods to avoid fatigue & decrease myocardial oxygen demands
- Monitor respiratory status
- encourage client to cough and breathe deeply to prevent pulmonary complications
- low calorie, high fiber diet , & encourage fluids to prevent constipation and promote
weight loss
- Administer cathartics and stool softeners as needed. (Avoid fiber laxatives, interfere
with absorption of levothyroxine)
- Provide extra clothing and blankets for clients who have decreased cold intolerance
- caution use of electric blankets
- Encourage verbalization of feelings and fears about body changes
- Reassure client that most physical manifestations are reversible
- use caution with CNS depressants (barbiturates or sedatives)
Signs of hypothyroidism
- Fatigue/ lethargy
- irritability
- intolerance to cold
- constipation
- weight gain
,- pallor
- think brittle fingernails
- depression & apathy
- joint or muscle pain
- bradycardia, hypotension, dysrhythmias
- slow thought process & speech
- hypoventilation & pleural effusion
- thickening of the skin
- hair loss
- thickening of hair on eyebrows
- dry flaky skin
- decreased acuity of taste
- impotence
- abnormal menstrual periods (menorrhagia/ amenorrhea)
- delayed physical and mental growth in children
Medication for hypothyroidism
levothyroxin (synthetic thyroid hormone replacement)
Risk factors for hypothyroidism
- females 30 to 60 years of age
- use of lithium & amiodarone medications
- Inadequate intake of iodine
- Radiation Therapy the head and neck
What is hypothyroidism
underactive thyroid
Hyperthyroidism risk factors
- Graves' disease
- Thyroiditis
- Toxic adenoma
- Toxic nodular goiter
- Exogenous hyperthyroidism
What is hyperthyroidism?
overactive thyroid
Signs of hyperthyroidism
- nervousness/ irritability
- muscle weakness
- heat intolerance
- weight loss
- insomnia
- irregular menstrual flow
- frequent stools and diarrhea
,- decreased libido
- Tremor, hyperkinesia, hyperreflexia
- Exophthalmos
- blurry vision or changes
- bloodshot appearance of eyes
- Goiter
- Tachycardia, palpitations, dysthymia
- Elevated blood pressure
- dyspnea
Nursing care for hyperthyroidism
- minimize clients energy
- promote calm environment
- monitor mental status
- monitor nutritional status
- monitor I&O / weight
- provide eye protection (patches, eye lubricant, tape to close eyelids)
- monitor vital signs and hemodynamic parameters
- reduce room temp
- provide cool shower/ sponge bath
- Report a increased temp of 1*F immediately
- Avoid excessive palpation of the thyroid
Medication for hyperthyroidism
- Methimazole
Reinforcing Teaching About Ostomy Care
stoma should be moist , shinny, and pink. The peristomal area should be intact
- use mild soap and water to cleanse the skin, then dry it gently and completely (
moisturizing soaps interfere with adherence of the pouch)
- Apply paste if necessary
- measure and mark the desired size for the skin barrier
- cut the opening 0.15 cm to 0.3 cm ( 1/18 to 1/8) in larger, allowing the stoma to appear
through the opening
- apply barrier paste to creases
Developing a Improvement Plan for Assistive Personnel
- performance should reflect the staff member's job and description
- various sources of data should be collected
- data should be collected over time and not just represent isolated incidents
- actual observed behavior should be documented
- peers can be a valuable source of data
- the employee should be given the opportunity to provide input
- the unit manager to host a private meeting with the staff member
, Monitoring the Performance of Assistive Personnel
- have ap demonstrate the tasks before doing it
Reinforcing Teaching About Client Privacy
- only health care team members directly responsible for a clients care can access that
client record. Nurses cannot share info with other clients or staff not caring for the client
- Client have the right to read and obtain a copy of their medical record
- Nurses cannot photocopy any part of a medical record
- staff must keep medical records in a secure area.
- staff cannot use public display boards toots clients names and diagnostics
- Electronic records are at password protected
- Nurses must not disclose clients info to unauthorized individuals or family members
who request it by telephone or email unless person is able to give the code
- communication regarding clients status should take place in private areas
Obtaining Telephone Prescriptions
- have a second nurse listen
- repeat it back, making sure to include the medication's name ( spell it out) , dosage,
time, and route
- Question any prescription that seems inappropriate for the client
- Make sure the provider signs the prescription in person within a 24hr time frame
Evaluating Client Understanding of Nitroglycerin Storage
- store tablets in original bottles
- store in a cool dark place
- store at room temperature
- store away from light & moisture
Prioritizing patient care
- client with an acute problem takes priority over a client who has chronic problem
- A client who has an urgent need takes priority over a client who has non urgent need
- client who has unstable findings takes priority over a client who has stable findings
Evaluating Understanding of Informed Consent
- Consent is informed when a provider explains and the client understands:
* the reason for the treatment or procedure
* how the treatment or procedure will benefit the client
* the risk involved with the procedure or treatment
* other options to treat the problem, including not treating the problem
Nurse role in Verifying informed consent
- Witness clients signature on informed consent
- ensure the provider gave the client the necessary info
- notifying the provider if client has more questions
Nurse Documentation for informed consent:
- reinforcement of info originally given by the provider
Delegation to Assistive Personnel
- ADLs
- Bathing
- Grooming
- Dressing
- Toileting
- Ambulating
- Feeding (without swallowing precautions)
- Positioning
- Rountine Tasks
- Bed making
- Specimen collection
- I&O
- Vital Signs ( for stable clients )
Planning Care for a Client Who Has Hypothyroidism
- Monitor for low Bp & bradycardia
- Monitor for chest pain & peripheral edema
- Monitor clients weight
- reorient the client if confusion occurs
- provide frequent rest periods to avoid fatigue & decrease myocardial oxygen demands
- Monitor respiratory status
- encourage client to cough and breathe deeply to prevent pulmonary complications
- low calorie, high fiber diet , & encourage fluids to prevent constipation and promote
weight loss
- Administer cathartics and stool softeners as needed. (Avoid fiber laxatives, interfere
with absorption of levothyroxine)
- Provide extra clothing and blankets for clients who have decreased cold intolerance
- caution use of electric blankets
- Encourage verbalization of feelings and fears about body changes
- Reassure client that most physical manifestations are reversible
- use caution with CNS depressants (barbiturates or sedatives)
Signs of hypothyroidism
- Fatigue/ lethargy
- irritability
- intolerance to cold
- constipation
- weight gain
,- pallor
- think brittle fingernails
- depression & apathy
- joint or muscle pain
- bradycardia, hypotension, dysrhythmias
- slow thought process & speech
- hypoventilation & pleural effusion
- thickening of the skin
- hair loss
- thickening of hair on eyebrows
- dry flaky skin
- decreased acuity of taste
- impotence
- abnormal menstrual periods (menorrhagia/ amenorrhea)
- delayed physical and mental growth in children
Medication for hypothyroidism
levothyroxin (synthetic thyroid hormone replacement)
Risk factors for hypothyroidism
- females 30 to 60 years of age
- use of lithium & amiodarone medications
- Inadequate intake of iodine
- Radiation Therapy the head and neck
What is hypothyroidism
underactive thyroid
Hyperthyroidism risk factors
- Graves' disease
- Thyroiditis
- Toxic adenoma
- Toxic nodular goiter
- Exogenous hyperthyroidism
What is hyperthyroidism?
overactive thyroid
Signs of hyperthyroidism
- nervousness/ irritability
- muscle weakness
- heat intolerance
- weight loss
- insomnia
- irregular menstrual flow
- frequent stools and diarrhea
,- decreased libido
- Tremor, hyperkinesia, hyperreflexia
- Exophthalmos
- blurry vision or changes
- bloodshot appearance of eyes
- Goiter
- Tachycardia, palpitations, dysthymia
- Elevated blood pressure
- dyspnea
Nursing care for hyperthyroidism
- minimize clients energy
- promote calm environment
- monitor mental status
- monitor nutritional status
- monitor I&O / weight
- provide eye protection (patches, eye lubricant, tape to close eyelids)
- monitor vital signs and hemodynamic parameters
- reduce room temp
- provide cool shower/ sponge bath
- Report a increased temp of 1*F immediately
- Avoid excessive palpation of the thyroid
Medication for hyperthyroidism
- Methimazole
Reinforcing Teaching About Ostomy Care
stoma should be moist , shinny, and pink. The peristomal area should be intact
- use mild soap and water to cleanse the skin, then dry it gently and completely (
moisturizing soaps interfere with adherence of the pouch)
- Apply paste if necessary
- measure and mark the desired size for the skin barrier
- cut the opening 0.15 cm to 0.3 cm ( 1/18 to 1/8) in larger, allowing the stoma to appear
through the opening
- apply barrier paste to creases
Developing a Improvement Plan for Assistive Personnel
- performance should reflect the staff member's job and description
- various sources of data should be collected
- data should be collected over time and not just represent isolated incidents
- actual observed behavior should be documented
- peers can be a valuable source of data
- the employee should be given the opportunity to provide input
- the unit manager to host a private meeting with the staff member
, Monitoring the Performance of Assistive Personnel
- have ap demonstrate the tasks before doing it
Reinforcing Teaching About Client Privacy
- only health care team members directly responsible for a clients care can access that
client record. Nurses cannot share info with other clients or staff not caring for the client
- Client have the right to read and obtain a copy of their medical record
- Nurses cannot photocopy any part of a medical record
- staff must keep medical records in a secure area.
- staff cannot use public display boards toots clients names and diagnostics
- Electronic records are at password protected
- Nurses must not disclose clients info to unauthorized individuals or family members
who request it by telephone or email unless person is able to give the code
- communication regarding clients status should take place in private areas
Obtaining Telephone Prescriptions
- have a second nurse listen
- repeat it back, making sure to include the medication's name ( spell it out) , dosage,
time, and route
- Question any prescription that seems inappropriate for the client
- Make sure the provider signs the prescription in person within a 24hr time frame
Evaluating Client Understanding of Nitroglycerin Storage
- store tablets in original bottles
- store in a cool dark place
- store at room temperature
- store away from light & moisture
Prioritizing patient care
- client with an acute problem takes priority over a client who has chronic problem
- A client who has an urgent need takes priority over a client who has non urgent need
- client who has unstable findings takes priority over a client who has stable findings
Evaluating Understanding of Informed Consent
- Consent is informed when a provider explains and the client understands:
* the reason for the treatment or procedure
* how the treatment or procedure will benefit the client
* the risk involved with the procedure or treatment
* other options to treat the problem, including not treating the problem
Nurse role in Verifying informed consent
- Witness clients signature on informed consent
- ensure the provider gave the client the necessary info
- notifying the provider if client has more questions
Nurse Documentation for informed consent:
- reinforcement of info originally given by the provider
