Kaplan NCLEX-RN Reviewer

Safe and Effective Care Environment  Management of Care (7 13%) Focuses on 3 AREAS: * Health promotion * Consecutive Wellness * Illness Prevention - Primary (delay occurrence of illness) - Secondary (early detection of illness condition) e.g. yearly Pap smear & mammogram, BP screening - Tertiary (permanent dse.; minimize; help the pt to have optional functioning) e.g. rehabilitation * Goal of Nurses. To predict, to prevent and to manage. * Professional Nurse has specific knowledge and skills. * Accountability responsible for the care given. * Nurse Patient Relationship work together as a team. - Acts as clients advocate * Communication 1. Verbal to say 2. Non- verbal culturally driven, w/o using words; body language; facial expressions; eye contact; gestures. 3. Professional communication use names when talking with clients. - should be assertive (work with the clients and inform) * Rights of the Clients - Right for privacy and confidentiality - Right for respectful care - Right to know medication - Right to know the potential benefits - Right to know the alternative way - Right to be informed - Right to refuse treatment y Advanced directive o Living will particular things the pt. want to be done. o Designate other to do it for you o Durable power of attorney - Right to reasonable request for services - Right to know hospital/clinic regulations * Informed consent Must understand by the pt. Explain by not using medical terminologies. - Can be withdrawn anytime by the pt. - Physician will talk to the pt. The nurse will be the witness for signing the form. - The pt must be competent

* Aggressive treatment

COMPLICATIONS OF IMMOBILITY y Decubitus ulcers turn the patient frequently - Good skin care (apply lotion) - Enough protein, vits & minerals Sensory input changes frequently updating the client; time w/ clock & calendar Osteoporosis develop renal calculi - To have wt bearing on a long bones - Good balanced diet - ERT (estrogen replacement therapy) Negative nitrogen balanced (anorexia & wt loss) - High protein diet Hyper Ca - Reduce Ca diet - Increase fluid Increase cardiac work load - Trapeze over the pt. (to prevent doing valsalva maneuver) - Dont hold your breath Contractures (deformities) - Use pillows; trochanter rolls - Use foot board; 90 degrees angle - Change the client position; left, right, front, back Thrombus formation - Use elastic hose; promote venous return - Leg exercise 5 mins every hours - Change formation - Pain in the calf (thrombus) Ortostatic HPN - Change position slowly; raise HOB slowly; increase activity Stasis of resp. secretion - TCDB (turn, coughing, deep, breathing) - Postural drainage Constipation - Let the Pt. out of bed - Increase fluids & fibers (3000cc/day); whole grain (fiber) - Provide privacy during defecation - Stool softeners (colace) Urinary stasis (Urinary infections) - Elevate HOB - Use bedside commode - Increase fluid intake (>3000cc) y

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- Low Ca diet - Acidify urine (Cranberry juice) Boredom (restless) - Equipment: radio, books, TV - Have a visitors Depression (may develop insomnia) - Encourage to do self-care - Start w/ simple activity (assess the pt.; dizzy, weak, breathing)

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