(1) LABORATORY TEST.
Take abnormal Lactic acid serious.
( Normal is 0.5to less than 2.0) Report abnormal Lactic acid to the doctor and ask for his/her orders or recommendations.
All abnormal levels should be reported for example low potassium, low sodium, low hemoglobin, abnormal blood sugar, blood pressure. Follow doctor orders. Be proactive. “Report immediately all critical DIAGNOSTIC procedures and LABORATORY TESTS on time. It should be reported within 60MINUTES that you got the critical value results to the DOCTOR”
(2)MEDICATIONS: In giving narcotics for example dilaudid the difference between the amount dispensed and amount wasted should be documented and witnessed the waste by another RN.
(3) NARCOTIC:Assessment of patient before giving the medication and reassessment after giving the medications. 30minutes reassessment for intravenous medications,and 45minutes to one hour for tablets. (po)Common side effects of dilaudid are dizziness, nausea/Vomiting, sedation, constipation. Educate patient and families about the side effects to look for.
(4)COAGULATION:In giving coagulation medication such as heparin, you need to be witnessed by another RN because the medication falls into the High Alert medications. Insulin also needs a withness.
(5)Targeted Range for INR Value.
Treatment of venous thrombosis, pulmonary embolism.Prevention of systemic embolism such as tissue heart values, atrial fibrillation and valvular heart disease.
Mechanical prothosthetic valve high risk .So prevent MI targeted range should be 2.5 to 3.5.
(6) MRSA SWAB:Swab all patients for MRSA upon admission if it is not done in Emergency room. Notify the doctor for abnormal levels. Request for the doctor recommendations. If your patient is in hospital for a long time upto 14days.Swab for MRSA upon discharge. If patient is positive for MRSA ,place patient in isolation precautions.( contact Isolation)Antibiotics such as Vancomycin or Zyvox is often ordered by the doctor. Follow the doctor orders.
(7)LOC: Assessment of Level of Consciousness. Assess for Alertness. Is your patient alert and oriented x4?.
Respond to stimili,
Respond to painful stimuli or
Low blood sugar can lead to unresponsiveness,very low Hemoglobin of 4.5 to 5 can lead to unresponsiveness,narcotic can lead to unresponsiveness.
(8) Pain Assessment.
What is the onset of the pain?.That is what triggers the pain to start?.
What symptoms are you having?.
What is the quality of the pain?.Sharp,dull,stabbing, pulling, aching etc.
Does the pain radiate to other parts of the body. What helps the pain to go away?.
What is the severity of the pain?.
On a scale of 0 to 10 ,ten being the highest level of pain.What is your level of pain?.
How often do you have pain,time intervals.
(10)Muscle Strength Assessment.
5+ is full movements against gravity and able to Apply resistance. Able to push back and push forward.
0 means that there is no movement. (Zero movement)
1+ Means that there is a slight contraction of muscle.
2+ Muscle cannot move against gravity but can move with support.
3+ Muscle is weak against gravity but will move actively.
4+ Muscles move actively against gravity with slight weakness. You assess one leg against the other to see if they are both strong or slight resistance.