What is the main measure of quality practice? And who is the guardian of the nursing profession?
Client care outcomes. CNL
What system level is the locus of most "motivators" and "demotivators," & controls variables of pt satisfaction the most?
Microsystem
What is the system unit of clinical policy being in-use: Meso or microsystem?
Microsystem
Microsystem vs Mesosystem?
Micro: face-face pt care - home, day center, inpt. Meso: Nurse division. 2 or more settings that affect pt care (not direct pt contact). Communication (mng to mng and mng to staff/staff to mnge), collaboration
5 P's of Clinical Microsystem Assessment?
Purpose, Pts background, Professionals (all pple on team), Processes, Patterns
Clinical Micro Assess: Purpose, all professionals, patterns, pts (means what?)impt w/process to do what?
Pt: Who are they? Make sure all staff know population knowledge/facts. Process: gives insight to all micro members. Impt to view through eyes of pt.
Define process. Impt to view this through?
flow of tech, supplies, or info leading to output/results. View through eyes of pt and let all profs know.
What are the 5 Why's?
Ask 5 why sequential qstns to get at root cause. Why did he come in with broken leg? He jumped from the high slide. Why did he jump? ...etc.
Parts A, B, C, D of Medicare: Which have premiums? Which are optional with premiums?
A (hospital care, some nursing, home health). B (
Premium -Med: Md visit, equip, rehab, labs, x-rays, mental health, ambulance, prevention). C. (
prem: Private replacement to A & B-Med Advantage). D. (drugs through medicare approved private Ins (*premium)
What medicare options are not optional? Which are public insurers?
Part A (hospital), unless - you choose C which replaces A & B. Otherwise have A & can choose D (meds) and B (Dr/primary). Public = A&B
Need an xray and atenolol rx - what medicare parts used?
B, D
What part of medicare is private option to replace public A&B?
C
Leadership theories: Traits (great man), Style (Shartle & Stogdill are employee centered). + Situational-Contingency vs Transformational?
S-C: task, interpersonal skills/trust, work environment (adapt to issue at hand). Trans: role-model, inspires through optimism, intellectual stim & encourages creativity.
Who are transformational theorists?
Bennis & Nanus, Bass, Ticky & Devanna. (inspire others through modeling optimism, intellect, creativity)
Luthans OB theory?
organizational behavior - positive/negative reinforcement
who/what is leadership theory when person perceives positive rltnshp b/w effort and performance?
Vroom Expectancy (expect satisfaction w/good work)
What is the 2 Factor theory by Herzberg?
Need hygiene (salary, work cndts) and Motivators (achievement, recognition) to avoid disatisfaction and give satis
Learning Organizations - living/thinking open systems learn from experience expand capacity to create future: Features = adaptive/generative. 2 cndtns for learning organization:
1) design of org action matches intended outcome 2) initial mismatch b/w intentions & outcomes is corrected - match
Adaptive vs Generative features of Learning org?
Adaptive: coping w/situation (limited by current org structure/assumptions). Generative: from coping to creating improved org reality (necessary for survival)
What type of org are living/thinking open systems that learn from experience in either adaptive or generative way to move into future?
Learning Orgs
Chaos theory? Every complex system has a life of its own. (weather, neurons). fractals?
change is normal, chaos = part of change, look for patterns that emerge from chaos. Fractals = complex systems/shapes that can be broken into mini complex copies of whole (snowflake)
What change theory involves idea of complex fractals and that change is normal, need to look for patterns from continuous change?
chaos theory
Who has written on complexity science theory?
Wheatley
Complexity science theory main pts?
(think of wheat) Orgs are adaptive, but not predictable, living w/own life, rltns all there is, normal to grow, die & reinvent, small changes - big effects. Static = dead. Leaders not about control but engaging in interation w/event and pple in it!
What change theory says it's all about relationships (horizontal leadership engages not controls pple), normal to continuosly grow, die & reinvent?
Complexity science theory (wheatley)
Where in a system are "good value" and "safe" care made? Also where most health professional "formation" occurs?
Microsystem
What are the force field analysis and chnge model of Lewin theory?
Begin change by ID driving and restraining forces to current state. Remove restrainers/add drivers in chnge of unfreezing, change, refreezing.
What change theory believes in ID of restraining/driving forces and then doing unfreezing, change, refreezing?
Lewin theory
5 stages of adoption of rogers' diffusion of innovation? (bell curve - innovators (2.5), early adopters (13.5%), early maj, late, laggards (16%)
1) awareness 2) interest 3) evaluation 4) trial 5) adoption
In the bell curve of roger's diffusion of innovation model who adopts change first (3) and last (2)?
1) innovators (2.5%) (2) early adopters 13.5% (3) early maj 34%( 4) late maj 34% (5) laggards 16%
how is Positive deviance change proces diff from traditional? (4 parts)
IDs solution first, then designs change around success (define, determine, discover, design)
What change process looks @ solution first , then designs change? 4 parts?
Positive deviance: define, determine, discover, design
Disting chars of org: complexity, formalization, centralization:
comp: division of labor, specialization, hierarchy, geographic dispersion. Formal: degree org has rules/policies. Central: where dscns made
If an org goes across whole country in thoursands of specialities with multiple divisions of labor, would say it's highly...
complex (high degree of complexity)
If an org has few rules stated in terms of policies it has low...If decisions made all by one guru = highly ...
low formalization, high centralization
Disting b/w multi, cross, and transculturalism:
multi = mtng several diff cultures simultaneously, cross-cult: mediating b/w 2 cultures, trans: bridging diff in cult practices
IOM quality improvement report of 1999 rec 6 themes for QI:
Patient centeredness, effectiveness, efficiency, equity, timeliness, safety
Flow charts, cause/effect, mapping, Pareto analysis, good problem-solving tools - so is PDSA - stands for?
Plan (the implementation), Do a trial, Study data/what's learned, Act (decide to adjust & try again, standardize, or dump)
What is Pareto Analysis as problem solving tool?
ID top 20% of causes that can resolve 80% of probs. Just work on top 20%.
Nurse Practice Acts guided at what level? Define what?
States. Define categs of nurses (what then would be negligence or malpractice for each role)
informatics defined
transformation of data into knowledge
Traditional vs non-linear change
Traditional (lewin) change can be sequential and directional. Non-linear: chaos, complexity, learning orgs adapt, rltnshps, anticipate
While early and late majority response to change are: prefer what's been done, but will accept or openly negative but agree after most. What are innovators, early adopters, laggards, and rejectors?
Innovators: thrive on change, early: respected by peers/sought for advice; laggards: prefer keeping traditions, express resistance, reject: may use sabotage
who thrives on change and who's respected by peers and sought for advice - innovator or early adopter?
Innovator thrives on change, early respected by peers
To get pple to do stuff can communicate, educate, empower, facilitate, neogiate and coopt? Manipulate? Coercion?
Coopt: manipulate by apptns to assigned role. Manipulate - use stick/carrots. Coercion - use of power
manipulating someone's involvement in change by assigning them to specific role = ? What about using stick/carrots?
cooptation, manipulate
Giving advice, defensive, patronizing, false reassurance okay?
no (not are blaming, Why qstns, judging)
Why qstns okay for team bldg/communication?
no
Can avoid, compete (use power to win), compromise, collaborate to resolve. What do accomodating pple do?
self-sacrifice
Hospital Priorities: Pressure Ulcers, Falls, Hospital Acq'd infctns, _+ 3 others
Reduce costs, reduce errors, improve pt & staff satisfaction
Hospital Priorities: Reduce costs, reduce errors, improve pt & staff satisfaction + 3 others
Pressure Ulcers, Falls, Hospital Acq'd infctns
When do you call Rapid Response (RRT?) - multiple reasons - (6) - plus chest pain unrelieved w/Nitro, threatened airway, seizure, uncontrolled pain
Acute changes in pt HR, Sys BP (>180,<90) O2 Sat <90 w/O2, RR, UO, Conscious
RRT vs Code Blue
RRT needs to come during crucial period of warning signs (VS changes). Code blue after cardiopulm arrest occurred
call Rapid Response (RRT?) if Acute changes in pt HR, Sys BP (>180,<90) O2 Sat <90 w/O2, RR, UO, Conscious or what (4)
chest pain unrelieved w/Nitro, threatened airway, seizure, uncontrolled pain
Did the TJC mandate RRTs?
not by name, but do need help from specially trained individual(s) when the pt's condition appears to be worsening
Hypoglycemic critical values - s/s?
<40/50. H/ache, nausea, tremors/seizure, hunger, confused, slurred speech, mouth tingling, sweat, anxiety
You see tremors, hunger, and sweat in DM pt, what do you suspect? Could also see? (6)
hypoglycemia - check BS (if low (40-50) give OJ then prtn. Also: h/ache, NV, confused, slurred, tingle mouth, seizure
Hyperglycemia critical values and s/s? Do?
>250/450. Polydipsia, polyuria, polyphagia. Weak/syncope/wgt loss, blurred vision. Falls risk!! Give Insulin, NS, Foley, find out why lack in proper self-monitoring
Who's more of falls risk - hypo or hyperglycemic ?
both! Hyper - weak w/low BP dt polyuria & blurr vision, hypo - confused w/trmors & anxiety
Low K value - worry?
<3.0 DT vomit/sweat, diarrhea/diuretics. Worry: Dig toxicity (CHF), Vent arrythmias
High K value - worry?
>5 dt K supplements, renal/endocrine probs. Worry Vent arrythmia/asystole
Low Na values? - worry?
<125 dt vomit/diarrhea, diuretics, sweat. Worry: FALLS (low BP), weak, cognitive/h/ache, ab cramps
High Na values? - worry?
>150. dt dehydration, high salt, renal probs. Worry: edema, tachycardia
Low Ca value - worry?
<8.2 Low Ca/Vit D, diuresis/vomit, renal probs, Inc Mg. Worry: arrythmia/asystole, muscle spasms, osteoporosis
High Ca value - worry?
>10.2. dt Immobilization (!), bone cancer, Antacids. Worry: arrythmia/asystole, polyuria, low muscle tone/DTR, stones
Vulnerable populations ( a lot - select all!) 14
Kids, Old, Disabled, homeless/transients, illiterate/non ES, Uninsured, mentally ill, minorities, low SES, prisoners, rural, terminally ill, women, urban
CDIFF vs MRSA more impt?
CDIFF higher rates. Contact precautions plus (gown, gloves) and soap after (not just purell)
IOM 9 Priority Preventative & early tx care areas
HTN, Asthma (varies w/SES), Cancer screen (EBP, colorectal, Pap, PSA), Immunizations, Ischemic Hrt Dse, Maj Depression, Prenatal/intrapartum, tobacco, obesity, DM
Kid immunizations in order (0, 2 mos, 12 mos, 4-6 yrs)
Vit K, Hep B. 2 mos: DTaP, Hib, PCV (Pneumo), IPV (polieo), RV. 12 mos: MMR, HepA, Varicella. 4-6 yrs: DTaP, IPV, MMR, Varicella, HepA
What vaccines kid needs again at 4-6 yrs?
DTaP, IPV, MMR, Varicella, HepA (MVA, DI)
When kid get 1st MMR and DTaP?
MMR: 12 mos, DTaP: 2 mos
What vaccines given at 12 mos?
MMR, HepA, Varicella
IOM top 12 chronic area tertiary focuses?
Frail elderly, DM, asthma, HTN, Kids w/special health needs, End of life (CHF/COPD), CAD, Maj Depression/mental illness, Med mngmt (overuse antbcs or errors), pain control (CA), CVA or Brain Attack, Tobacco, Obesity
w/CHF, how prevent initial cardiac injury (6)? & things to ask to see if couldn't do at home..
MONA, limit Act, Monitor Hrt (EG, Tele), Diet low Na/Caffeine (educate), Check wgt, exercise
Non-aggressive CHF post-MI tx? Risk? What if long HS of same lifestyle?
Meds: ACE/BB, Diuretics, digoxin (inatropics). Risk: Falls dt HOTN. In HS: Get Hrt Rehab team involved
A life threatening compl of CHF = ? How know? Prevent?
Pulm edema w/Pink Frothy sputum. Head up & fluid/Na restrictions
See pink frothy sputum in pt, what you suspect?
Pulm edema often assoc w/CHF!
COPD exacerbation - pt looks like (5) & O2 sats?
Barrel chest, O2 88-92%, thin cuz use energy to breathe, pink puffer, purse-lipped, low immunity
Pt come in for flu, carrying O2 tank & stays 88-92%. What type of pt? why in w/flu? What hrt prob you watch for?
COPD. Low immunity gives them flu/pneumonia easiliy. Can get Cor pulmonale (RF) dt Pulm HTN
What critical value will show you Respiratory failure?
Abnormal ABGs even if on O2
Why COPD get Cor pulmonale?
RHF dt pulm HTN
COPD - what's issue w/ short term & long-term bronchodilators?
Short (albuterol) & _phylline long: Inc HR. Long: Inc BS (steroids), arrythmias, and risk for infctn. Predni_sone: thrush.
Why is dextrose hypertonic >20% a high-alert med? Action? Electrolytes? Severe rxns? Where injected?
Hyperglycemia, if stopped rebound hypo. Pulls water from cells into vascular space - diuresis and K Loss. Need to go in lrge vein like sup VenaCava to prvt thrombosis in peripheral. Rapid inj = hypergly & hyperosmolar (to coma/death)
High-alert meds: Insulin, anti-coags, thrombolytics, chemo (suppress bone marrow, vesicant), epi/norepi (adrenergic agonists), BB (Hrt block/asthma), antiarrythmics (lidocaine) + 6
anesthetics, dextrose (hypertonic >20%), epidural, sedatives, opiates, TPN (aspirate, BS high & rebound)
High-alert meds: anesthetics, dextrose (hypertonic >20%), epidural, sedatives, opiates, TPN (aspirate, BS high & rebound) + 7
Insulin, anti-coags, thrombolytics, chemo (suppress bone marrow, vesicant), epi/norepi (adrenergic agonists), BB, antiarrythmics (lidocaine)
What is Human B-type natriuretic peptide (nesiritide)? used for?
Normal Cardiac Hormone. Stops Renin-Angio tensin, does vasodilation/diuresis. Lows BP
What is methyldopa? Used for?
Antiadrenergic. Relaxes bld vessels so bld can flow more easily through body. HTN
What are clopidogrel & ticlopidine used for? Watch for?
(Plavix & Ticlid). Inh platelet aggregation. Reduces CVA/MI risk. Worry: bldg (stool, hemoptysis, bruises, toothbrus)
What is hemoptysis? What type of meds watch out for it?
Cough up blood. Anticoags (antithrombin, platelet inh - clopidogrel, heparin, coumadin)
What is isosorbide?
vasodilator for HTN
What are tamsulosin, doxazosin used for?
Relax peripheral bld vessels for HTN & BPH (benign prostatic hyperplasia) (alpha blockers - antiadrenergic)
Diff b/w Flomax and Fosamax?
Flomax (tamsulosin) relaxes periph bld vssls for HTN/BPH. Fosamax: Osteoporosis by inh bone resorption
what anti-HTN drugs used during preg terms 2-3? (4)
CCB: nifedipine, amlodipine, dilitiazam, verapamil
Common ending of Angiotensin II Rec Blockers? (for HTN)
_sartan (losartan/valsartan)
what is losartan or any _sartan for?
HTN. Blocks Angiotensin II (vasoconstrictive and aldosterone release)
Sympathetic Nervous system stimulates Renin-angiotensin-aldosterone system (RAAS). What stimulates? Where aldosterone come from?
HOTN & Dec Na stimulate renin release from kidney. After AI (ACE) to AII, Adrenal Cortex releases aldosterone
How are prolonged elev of Norepi, renin, Angio I & II, aldosterone, endothelin (also vasocontrictor) toxic to hrt - what they cause (3)?
apoptosis, myocyte hypertrophy, interstitial fibrosis
How do glipizide (sulfonylureas) & metformin (biguanide) act?
Glip: stim Pancreas inc Insulin & inc Ins Rs. Met: inc glucose up in cells & dec hepatic glucose output.
How soon should pt w/throat tightness be seen?
w/in 30 mins!
Pt w/asthma exacerbated speaks in complete sentence w/O2 sat vs pt w/spurting laceration - who first?
Spurting laceration
If elderly pt in for fall, why put on cardiology floor?
could have had dysrhythmia or hematoma w/CVA like cogn effects
Strong radial pulse tells you what about BP? What min needed for brain?
Syst BP > 80 mm Hg. Brain >40 mm Hg
How many days does Medicare pay in hospital expenses? in SNF?
60 days for flat ~$1100. then per day premium up to 150 days. SNF: $141 days 20 - 100. (medicaid covers more)
Do you have to work min amt of years to get medicare?
no, but less than 40 or 30 years you pay premiums.