Professional Documents
Culture Documents
prescribed treatments
Client Rights Collaboration with Interdisciplinary Team Concepts of Management Confidentiality/Information Security Health Insurance Portability and Accountability Act (HIPAA) Consultation Continuity of Care
medical record
referral/transfer form
Delegation
five rights of delegation (right task, right circumstances, right person, right direction or communication, right supervision or feedback)
Establishing Priorities
pathophysiology
risks of procedure
in-service Supervision
job description
Safety & Infection Control Accident Prevention Disaster Planning Emergency Response Plan
emergency plan
assistive devices proper lifting frequent changing of position routine stretching of the shoulders neck, arms, hands, fingers Handling Hazardous and Infectious Materials Home Safety
lighting handrails Injury Prevention Medical and Surgical Asepsis Reporting of Incident/Event/Irregular
client fall
hospital bomb threats communicable diseases and the modes of organism transmission airborne transmission droplet transmission contact transmission
hand hygiene room assignment isolation aseptic/sterile technique universal/standard precautions Use of Restraints/Safety Devices Health Promotion & Maintenance Aging Process Ante/Intra/Postpartum and Newborn Care
support systems perception of pregnancy coping mechanisms desire for female caregiver Developmental Stages and Transitions
toilet training methods peri-natal education performing/learning newborn care providing post-partum care providing newborn care puberty retirement limiting risk taking behaviors
contraceptive methods Family Systems Growth and Development Health and Wellness
excessive sun exposure lack of regular exercise fatigue calcium deficiency Human Sexuality
sexual orientation family planning safe sexual practices Immunizations Lifestyle Choices
homeopathic health care practices massage therapy Principles of Teaching/Learning Self-Care Techniques of Physical Assessment
age of client
defense mechanisms symptoms of relapse signs & sx of impaired cognition acute & chronic mental illness
spiritual distress conflict between recommended treatment and beliefs Sensory/Perceptual Alterations
hallucinations delirium
promote adaptation
therapeutic milieu
family dynamics
amputation alopecia
prosthetic limbs hearing aid compensatory techniques Complementary and Alternative Therapies
relaxation therapy
skin breakdown contractures external fixation device halo traction anti-embolic stockings sequential Non-Pharmacological Comfort Interventions
compression devices skin care turn client alternating pressure mattress skeletal traction impaired skin integrity pain rating scale verbal reports
body mass index (BMI) intake and output edema signs & sx of dehydration Palliative/Comfort Care
post-mortem care Rest and Sleep Pharmacological & Parenteral Therapies Adverse Effects/Contraindications and Side
adverse effects of medications and parenteral therapy allergic reactions to medications Blood and Blood Products
prescription for administration correct type correct client cross matching complete
Expected Effects/Outcomes
Medication Administration
six rights (right drug, right dose, right client, right time, right route, right documentation) vital signs lab results allergies
Parenteral/Intravenous Therapies
Pharmacological Agents/Actions
pathophysiology
Pharmacological Interactions
oral IV
subcutaneous IM
topical prescriptions
PRN pain medication Total Parenteral Nutrition Reduction of Risk Potential Diagnostic Tests
oxygen saturation glucose monitoring testing for occult blood gastric pH urine specific gravity electrocardiogram test Laboratory Values for
feeding tube immobilized limb sedation post surgery, diabetes swallowing difficulties nasogastric (NG) tube immobility emesis nutritional status contractures incontinence foot care for client w/ diabetes mellitus Potential for Complications of Diagnostic Tests/Treatments/Procedures
psychomotor skills fluid restriction dysrhythmia following cardiac cath sodium restriction oral/NG tube raise side rails decompression suicide precautions chest tubes monitor airway hemorrhage foot drop embolus numbness shock tingling Potential for Complications from Surgical Procedures and Health Alterations
preventing aspiration promoting venous return promoting mobility sensory impairment potential for falls level of mobility skin integrity
level of consciousness muscle strength mobility peripheral edema hypoglycemia or hyperglycemia Therapeutic Procedures
log-rolling abduction pillow chest tube drainage tubes wound drainage devices Vital Signs
continuous bladder irrigation preoperative care intraoperative care,positioning maintain sterile field operative assessment
hypertension bradycardia
tachypnea fever
phototherapy central line dressing client wound healing surgical wound drains chest tube suction central line placement biopsy, debridement peritoneal dialysis Fluid and Electrolyte Imbalances
chest physiotherapy spirometry nasopharyngeal suctioning endotracheal tracheostomy tube complications of pregnancy/labor eclampsia, precipitous labor increased icp client electrolyte imbalance
decreased cardiac output diminished peripheral pulses hypotension,cardiac rhythm strip abnormalities sinus bradycardia PVCs V. tach fibrillation pacemaker Illness Management
biventricular pacemaker implantable cardioverter defibrillator arterial lines telemetry monitoring cardiac arrhythmias hemodialysis (AV) shunt fistula graft cast placement tuberculosis treatment evisceration dehiscence restoration of breathing restoration of pulse
cardiopulmonary resuscitation Heimlich maneuver respiratory support automated external defibrillator wound disruption Pathophysiology Radiation Therapy