"DELEGATION"

RN ONLY: P- Plan

A- Assessment

C- Collaborate E- Evaluate

T- Teaching

.Choosing appropriate clothing

.Assisting 1st TIME MOM w/BreastFeed
.SET-up BLD.TRANS. Equi.
.Dealing w/ emotional state
.Checking AMT. of LOCHIA
.Establish IVlines
.Orientation
.ESCORT family to place of PRivacy
.Encouraging INDEPENDENCE
.RANGE OF MOTION
.REMOVING OF TUBE
.PLACE NG tube
.DEFIBRILLATOR PADS's Placement
.INITIATE SALINE LAVAGE
==>LVN CAN report, can take note of v/s etc. but CANNOT evaluate.
NSG.ASSISTANT:

LVN/LPN:

.Obtain stool specimen

.Observe & Document onset&duration of any seizure

.Routine Nsg.skills (V/S,etc.)

supervision

.If given (ACP/Acute Care Pt. Assignment) MUST work under RN

.Skin Care

.SET-UP O2 and Suctioning equipment

.Morning Care

.CHECKING for S/sx of pressure&Infection

.Ambulation

.Cleaning the HALO insertion site w/HydrogenPeroxide

.Reminding the Pt.

.CHECKING for therapeutic and adverse effect of med.

.Encouraging the pt. to eat

.Review handwashing &hygiene practices

.Turning & Repositioning

.Show pt. how to gently cleanse eyelid margin

.Reapply Compression boots

.Routine check of pt's visual acuity via snellenchart

.Personal Care&hygiene
(UNCOMPLICATED)

.STANDARDIZED ASSESSMENT W/ PREDICTABLE OUTCOME

.Obtaining supplies

.DEMONSTRATING STANDARD PROCEDURE

.Reinforce dietary &fluid restriction .IRRIGATION

.Disconnecting the suction

.FLUID MONITORING

.Collect urine samples

.Assist in planning of interventions

.CPR

.Check DRESSING for bleeding

.Assisting POST-mortem care

.Can PROVIDE EMOTIONALsupport & supportive comm.

.Bag & label pt's belonging

.ATTACHING CardiacMonitor LEADS

.REMOVE FOLEY CATHETER(EXPERIENCED)

.OBTAINING ECG

.PULSE OXIMETRY (EXPERIENCED)

.INCREASING O2 flow

.CHECKING BLD.GLUCOSE (EXPERIENCED)

UROMETER

.INSERTION Of UrinaryCATH., FoleyCATH. attached to a

.Observe & Doc. onset&duration of any seizure .COLLECTION of urine specimen

000----000-----00---000000----0000> .MEDICATION ADMIN. (OG, NGtube, INSULINadmin. etc. except IV)

HOME H-AID:

NEW RN grad/ "TRAVELER"

EXPERIENCED AMBULATORY RN:

.Assisting w/ CATH.care

.Pt. w/stable, NON-COMPLEX condition .PRE-OP & POST-OP Instructions

.Ambulation

.Perform TRIAGE

.Making HOME HEALTH REFERRALS

.Hygiene

.Assessing for med. R/t loss of vision

.V/s & daily wt.

UNIT CLERK:

MED.ASSISTANT:

CLERGY: (RN assume Resp. if UNAVAILABLE)

.Calling & Paging the doc. .Sched. Appointment for the Pt. .Liaison w/ Family members in the waiting
.Can Sched. the Pul.Fn.Test & X-ray

SOCIAL WORKER:
.ENSURE Area STOCKED & ORGANIZED
.

room.

APN:

RESP. THERAPIST:

.PERFORM well-being PHYSICAL EXAM .ADMIN. via HAND-Held

nebulizer

PT:

MD:

.EVALUATE Movement

.Obtain Informed Consent

.REVIEW the need for adaptive aids (walker,etc.)

.Determining med. Diagnosis

.Teaches AMBULATION techniques

.Explaining OUTCOMES & RISKS for Sx.PROCEDURE

.SETTING-up specialized equipment (trapeze bar,etc.)

.Range of MOtion
.INSTRUCT & SUPERVISE use of TENS

*Pt. with advanced AIDS and activeTB would recv:

Isoniazid
Rifampin
Ethambutol (Ethambutol and streptomycin aren't given 2gether with this Pt.)
Pyrazinamide

*Tamoxifen - used in breast cancer

- MUST report VISION CHANGES (may be irreversible)
-may cause anorexia, headache, hotflashes

*A Td vaccine given 10 years after the most recent childhood DTaP vaccination,a second MMR
vaccine, and a hepatitis B vaccine, if not given earlier, are all recommended immunizations for
adolescents.

* ARF, characterized by abrupt loss of kidney function, commonly causes oliguria, which is
demonstrated by a urine output of 250 ml/24 hours.

*During the client's first postpartum rest or sleep, which usually occurs 2 to 4 hours after delivery,
the heart rate typically decreases, possibly slowing to 50 beats/minute (bradycardia).
This probably results from supine positioning and such normal physiologic phenomena as the
postpartum rise in stroke volume and a reduction in vascular bed size
* Decerebrate posturing indicates damage of the upper brain stem.
Decorticate posturing indicates cerebral dysfunction.

*Like other viral and bacterial venereal infections, human papillomavirus is a risk factor for cervical
cancer. Other risk factors for this disease include frequent sexual intercourse before age 16, multiple
sex partners, and multiple pregnancies

*otosclerosis,a correctable mid. ear d/o ,chronic, progressive hearing loss results from excess bone
formation around the oval window, which impedes normal stapes movement and prevents sound
transmission

-Mnire's disease, an inner ear disease that results from a labyrinth dysfunction, causes severe
vertigo, sensorineural hearing loss, and tinnitus.

-Presbycusis is progressive hearing loss associated with aging.

-Otitis media refers to a group of inflammatory middle ear conditions that may lead to
life-threatening mastoiditis or a brain abscess if not treated properly.

*The client is instructed to hold the CANE on the UNAFFECTED side, 24" to 26" from the base of the
little toe.
This is done to promote a reciprocal gait pattern. The nurse should instruct the client to hold the cane
close to his body to prevent leaning. The stride length and timing of each step should be equal.
To prevent falls, the nurse stands behind the client as he is learning to use the cane.
*The vastus lateralis, ventrogluteal, and deltoid muscles are considered safe sites for infants and small
children.
*In early pregnancy, amniocentesis can identify chromosomal defects and neural tube defects.
It can also be used to determine the sex of the fetus.
Amniocentesis can be used to evaluate fetal lung maturity only during the last trimester of
pregnancy.
A blood test performed between 24 and 28 weeks' gestation is used to screen for gestational
diabetes.
Ultrasound is used to identify polyhydramnios (excessive amount of amniotic fluid);
amniocentesis can be used to treat polyhydramnios by removing excess fluid.
*HERPES SIMPLEX 2: Burning and tingling genital discomfort is the most common initial finding.
This symptom will advance to vesicular lesions rupturing into ulcerations, which then dry into a crusty
erosion.
The client may also experience fever, headache, malaise, myalgia, regional lymphadenopathy, and
dysuria

*(mild air leak in the tracheostomy tube cuff)

check for insufficient air in the cuff the most common cause of a cuff air leak.
To do this, the nurse should suction the client, withdraw all residual air in the cuff,

and then reinflate the cuff to prevent overinflation and possible cuff rupture.

*CD4+ levels in the blood of an individual with HIV infection determine the extent of damage to the
individual's immune system.
*Until the 7th month of pregnancy, both estrogen and progesterone are secreted in progressively
greater amounts.
Between the 7th and 9th months, estrogen secretion continues to increase while progesterone
secretion drops slightly. This increasing estrogen-progesterone ratio promotes the onset of uterine
contractions.
*Nihilistic delusions are false ideas about the self, others, or the world.
Somatic delusions involve a false belief about the functioning of the body.
Body dysmorphic disorder is characterized by a belief that the body is deformed or defective in a
specific way.
Apraxia is the inability to carry out motor activities.
*Finger foods and sandwiches help maintain adequate nutrition and provide calories for this client's
high energy level.
* When cleaning the area around the drain, the nurse should wipe in a circle around the drain,
working from the center outward. The nurse wipes laterally, from the center to the opposite side,
when cleaning a large horizontal wound and wipes from top to bottom when cleaning a vertical
incision.
*A dusky appearance of the stoma indicates decreased blood supply; A healthy stoma should appear
beefy-red.
Protrusion indicates prolapse of the stoma and sharp abdominal pain with rigidity suggests
peritonitis.
A urinary output greater than 30 ml/hr is a sign of adequate renal perfusion and is a normal finding.
Because mucous membranes are used to create the conduit, mucus in the urine is expected.
Stomal edema is a normal finding during the first 24 hours after surgery.
*Vision changes, such as halos around objects, are signs of digitalis toxicity.

*Nitrates must be stored in a dark place in a closed container.

Sunlight causes the medication to lose its effectiveness.
HEMODYNAMIC
-vascular capacity -how much bld/pressure is pulling back 2 d heart
-BV - how much bld. vol. on heart having 2 push

-Pump effectiveness (cardiac output, stroke vol., preload, afterload) is what swans cath. trying to
measure
-Tissue perfusion -oxygen
SWANs Catheter (Pulmonary Artery Catheter)
*measure..PRESSURE
-Cath. is inserted 2 d right atrium (Right side of d heart pumps bld. directly nto d heart)
measure how much pressure is coming from the body & being pushed into d lungs
1.Right Atrial pressure (Central Venous Pressure) = 1-8mmhg
2.Pulponary Artery Pressure (PAP) - balloon ALWAYS deflated
systolic =15-26mmHg Diastolic= 5-15mmHg
3.Pulmonary Artery Wedge Pressure (PAWP) - Inflate for 3 sec. then have direct measurement of d
pressure
being backflow from the lungs 2 d balloon = 4-12mmHg
Decrease=Hypovolemia
Increase=Hypervolemia =Left Vent. Failure
Left Ventricular End-Diastolic Pressure (LVEDP)

*CARDIAC OUTPUT (N=4-8L/min) -Thermo DIlution Method (Pumps about 5-10ml of Cold normal
sailing (goes thru d heart)
(measures how fast thru d heart) how long does it takes?

*Oxygen
using SVO2 little caliber in the SWANs cath. N=60-80% on hemoglobin back 2 d lungs

SWANS/PAC summary
is inserted with pt. with cardiac surgery, CABG, Bad2 Heart Failure,
to insert: pt. is in SUPINE/TRENDELENBURG via Jugular/subclavian vein inserted thru Right Atrium.

EKG
Pwave =squeezes the atrium

QRS=squeezes the ventricles

Twave=relaxes the ventricles
MI= ST elevation
Hypokalemia= ST depression

Signs of extravasation, such as redness or swelling at the insertion site and a decreased infusion rate.
If extravasation occurs, the registered nurse needs to be notified; he or she will then contact the
health care provider.

Isotretinoin is a metabolite of vitamin A and can produce generalized intensification of isotretinoin

toxicity.
Because of the potential for increased toxicity, vitamin A supplements should be discontinued before
isotretinoin therapy.
Isotretinoin can elevate triglyceride levels. Blood triglyceride levels should be measured before
treatment and periodically thereafter until the effect on the triglycerides has been evaluated.

Mafenide acetate (sulfamylon) is bacteriostatic for gram-negative and gram-positive organisms and is
used to treat burns to reduce bacteria present in avascular tissues. The client should be informed that
the medication will cause local discomfort and burning and that this is a normal reaction; and it is a
carbonic anhydrase inhibitor and can suppress renal excretion of acid thereby causing acidosis. Clients
receiving this treatment should be monitored for signs of an acid-base imbalance (hyperventilation). If
this occurs, the medication should be discontinued for 1 to 2 days.
Salicylic acid is absorbed readily through the skin, and systemic toxicity (salicylism) can result.
Symptoms include tinnitus, dizziness, hyperpnea, and psychological disturbances.

Calcitonin, a thyroid hormone, decreases the plasma calcium level by inhibiting bone resorption and
lowering the serum calcium concentration.
Bleomycin is an antineoplastic medication (Chemotherapeutic Agents) that can cause interstitial
pneumonitis, which can progress to pulmonary fibrosis. Pulmonary function studies along with
hematological, hepatic, and renal function tests need to be monitored. The nurse needs to monitor lung
sounds for dyspnea and crackles, which indicate pulmonary toxicity.
The medication needs to be discontinued immediately if pulmonary toxicity occurs.
Busulfan (Myleran) can cause an increase in the uric acid level. Hyperuricemia can produce uric acid
nephropathy, renal stones, and acute renal failure.

A side effect specific to etoposide (Vepesid) is orthostatic hypotension. The client's blood pressure is
monitored during the infusion. Hair loss occurs with nearly all the antineoplastic medications.

Antineoplastic medications lower the resistance of the body; clients must be informed not to receive
immunizations without a HCP's approval. Clients also need to avoid contact with individuals who have
recently received a live virus vaccine.

A side effect specific to vincristine (Oncovin) is peripheral neuropathy, which occurs in almost every
client. Peripheral neuropathy can be manifested as numbness and tingling in the fingers and toes.
Depression of the Achilles tendon reflex may be the first clinical sign indicating peripheral neuropathy.
Constipation rather than diarrhea is most likely to occur with this medication, although diarrhea may
occur occasionally.

Asparaginase (Elspar) is contraindicated if hypersensitivity exists, in pancreatitis, or if the client has a

history of pancreatitis. The medication impairs pancreatic function and pancreatic function tests should
be performed before therapy begins and when a week or more has elapsed between administration of
the doses. The client needs to be monitored for signs of pancreatitis, which include nausea, vomiting,
and abdominal pain.

Tamoxifen is an antineoplastic medication that competes with estradiol for binding to estrogen in
tissues containing high concentrations of receptors. Tamoxifen is used to treat metastatic breast
carcinoma in women and men. Tamoxifen is also effective in delaying the recurrence of cancer following
mastectomy. Tamoxifen reduces DNA synthesis and estrogen response. It may increase calcium,
cholesterol, and triglyceride levels. Before the initiation of therapy, a complete blood count, platelet
count, and serum calcium levels should be assessed. These blood levels, along with cholesterol and
triglyceride levels, should be monitored periodically during therapy. The nurse should assess for
hypercalcemia while the client is taking this medication. Signs of hypercalcemia include increased urine
volume, excessive thirst, nausea, vomiting, constipation, hypotonicity of muscles, and deep bone and
flank pain.

Cisplatin is an alkylating medication. Alkylating medications are cell cycle phase-nonspecific medications
that affect the synthesis of DNA by causing the cross-linking of DNA to inhibit cell reproduction. Cisplatin
may cause ototoxicity, tinnitus, hypokalemia, hypocalcemia, hypomagnesemia, and nephrotoxicity.
Amifostine (Ethyol) may be administered before cisplatin to reduce the potential for renal toxicity.

When alcohol is combined with glimepiride (Amaryl), a disulfiram-like reaction may occur. This
syndrome includes flushing, palpitations, and nausea. Alcohol can also potentiate the hypoglycemic
effects of the medication. Clients need to be instructed to avoid alcohol consumption while taking this
medication.

Sildenafil (Viagra) enhances the vasodilating effect of nitric oxide in the corpus cavernosum of the penis,
thus sustaining an erection. Because of the effect of the medication, it is contraindicated with
concurrent use of organic nitrates and nitroglycerin. Neuralgia and insomnia are side effects of the
medication.

Exenatide (Byetta) is an incretin mimetic used for type 2 diabetes mellitus only. It is not recommended
for clients taking insulin. It is administered within 60 minutes before the morning and evening meal. The
client is monitored for gastrointestinal side effects after administration of the medication.

Humulin NPH is an intermediate-acting insulin. The onset of action is 1.5 hours, it peaks in 4 to 12
hours, and its duration of action is 24 hours. Hypoglycemic reactions most likely occur during peak time.

Prednisone may decrease the effect of oral hypoglycemics, insulin, diuretics, and potassium
supplements.

Ondansetron is an antiemetic used to treat postoperative nausea and vomiting, as well as nausea and
vomiting associated with chemotherapy.

Pancrelipase (Pancrease MT) is a pancreatic enzyme used in clients with pancreatitis as a digestive aid.
The medication should reduce the amount of fatty stools (steatorrhea). Another intended effect could
be improved nutritional status. Its use could result in weight gain.

Cimetidine (tagamet) is a histamine 2 (H2)-receptor antagonist. Older clients are especially susceptible
to CNS side effects of cimetidine. The most frequent of these is confusion.

Cycloserine (Seromycin) is an antitubercular medication that requires weekly serum drug level
determinations to monitor for the potential of neurotoxicity. Serum drug levels lower than 30 mcg/mL
reduce the incidence of neurotoxicity. The medication must be taken after meals to prevent
gastrointestinal irritation. The client must be instructed to notify the HCP if a skin rash or signs of central
nervous system toxicity are noted.

Rifabutin (Mycobutin) may be prescribed for a client with active MAC disease and tuberculosis. It
inhibits mycobacterial DNA-dependent RNA polymerase and suppresses protein synthesis. Side effects
include rash, gastrointestinal disturbances, neutropenia (low neutrophil count), red-orange body
secretions, uveitis (blurred vision and eye pain), myositis, arthralgia, hepatitis, chest pain with
dyspnea, and flu-like syndrome.

Isosorbide mononitrate is an antianginal medication. Headache is a frequent side effect of isosorbide

mononitrate and usually disappears during continued therapy. If a headache occurs during therapy, the
client should be instructed to take the medication with food or meals.

Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications, and a client with a sulfa
allergy is at risk for an allergic reaction. Also, clients are at risk for hypokalemia, hyperglycemia,
hypercalcemia, hyperlipidemia, and hyperuricemia.

Nicotinic acid, even an over-the-counter form, should be avoided because it may lead to liver
abnormalities. All lipid-lowering medications also can cause liver abnormalities, so a combination of
nicotinic acid and cholestyramine resin (Questran)is to be avoided. Constipation and bloating are the
two most common side effects.

Flushing is a side effect of Nicotinic acid (Niacin). Aspirin or a nonsteroidal anti-inflammatory drug can
be taken 30 mins before taking the medication to decrease flushing. and should be taken with meals.

Nalidixic acid can intensify the effects of oral anticoagulants by displacing these agents from binding
sites on plasma protein. When an oral anticoagulant is combined with nalidixic acid, a decrease in the
anticoagulant dosage may be needed.

Clients taking trimethoprim-sulfamethoxazole (TMP-SMZ) should be informed about early signs of

blood disorders that can occur from this medication. These include sore throat, fever, and pallor, and
the client should be instructed to notify the health care provider if these symptoms occur.

The nurse should instruct the client that a reddish-orange discoloration of urine may occur in taking
(Pyridium). The nurse also should instruct the client that this discoloration can stain fabric. The
medication should be taken after meals to reduce the possibility of gastrointestinal upset. A headache is
an occasional side effect of the medication.

Bethanechol chloride (Urecholine) can be harmful to clients with urinary tract obstruction or
weakness of the bladder wall. The medication has the ability to contract the bladder and thereby
increase pressure within the urinary tract. Elevation of pressure within the urinary tract could rupture
the bladder in clients with these conditions.
Toxicity (overdose) produces manifestations of excessive muscarinic stimulation such as salivation,
sweating, involuntary urination and defecation, bradycardia, and severe hypotension. Treatment
includes supportive measures and the administration of atropine sulfate subcutaneously or
intravenously.

Toxicity (overdosage) of Oxybutynin chloride (Ditropan XL) produces central nervous system
excitation, such as nervousness, restlessness, hallucinations, and irritability. Other signs of toxicity
include hypotension or hypertension, confusion, tachycardia, flushed or red face, and signs of
respiratory depression.

Nephrotoxicity can occur from the use of cyclosporine (Sandimmune). Nephrotoxicity is evaluated by
monitoring for elevated blood urea nitrogen (BUN) and serum creatinine levels. Cyclosporine is an
immunosuppressant but does not depress the bone marrow.

Folic acid (vitamin B6) may be prescribed for a client with renal insufficiency to prevent anemia.

Cholinergic crisis occurs as a result of an overdose of medication. Indications of cholinergic crisis

include gastrointestinal disturbances, nausea, vomiting, diarrhea, abdominal cramps, increased
salivation and tearing, miosis, hypertension, sweating, and increased bronchial secretions.

An edrophonium (Enlon) injection, a cholinergic drug, makes the client in cholinergic crisis temporarily
worse. This is known as a negative test. An improvement of weakness would occur if the client were
experiencing myasthenia gravis.

Dyskinesia and impaired voluntary movement may occur with high levodopa dosages. Nausea,
anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia (the temporary muscle
weakness that lasts 1 minute to 1 hour, also known as the "on-off phenomenon") are frequent side
effects of the medication.
The potential for decreased effectiveness of the birth control pills exists while taking phenytoin
(Dilantin). Phenytoin (Dilantin) enhances the rate of estrogen metabolism, which can decrease the
effectiveness of some birth control pills.