What are some disasters that you would expect to fall into the disaster plan:

1) terrorism
2) emergency response
3) handling hazardous substance
4) security plan

Emergency care situations - involves caring for emergencies that are life threatening or
potentially life threatening and requires immediate treatment. They can occur anywhere in the
hospital and not just the ER.

What are some examples of emergency situations:

1) cardiac arrest
2) choking
3) chest pain
4) acute hemorrhage
5) stroke
6) heat stroke
7) anaphylactic reaction
8) suicide attempt
9) partial amputation
10) snake bite
11) acute injuries s/a falls or crushing injuries
12) shock
13) critical electrolyte levels
14) frostbite
15) poisoning
16) abuse

Responsibilities of the ER nurse:

1) assessment and id of problems in a crisis- must be able to perform a fast, accurate
assessment
2) triage
3) performing tech skills s/a vital signs, iv(16g), o2 sat, blood gases, administer meds, o2, and
IV fluids, draw labs, arrange for x-rays, neuro check, getting consent for treatment and
procedures, get baseline assessment
4) d/c planning
5) documentation of consents, if unconscious and alone on arrival, condition, treatments,
meds administration, condition at dc and dc instructions with follow up appointments
6) psych support to pt and family

What type of info should the ER nurse obtain in a crisis situation:

1) how, when, and where the injury occurred
2) when did s/s appear
3) were they unconscious afterwards
4) what was their health status beforehand
5) medical history or shx and admission history
6) current meds s/a hormones, insulin, dig, and anticoagulants
7) allergies, all of them
8) last meal eaten because of possible need for anesthesia
9) bldg tendencies
10) date of last tetanus shot
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11) patient's doctor
12) how they got to the hospital

True/false: you should obtain both subjective and objective data.

True b/c the subjective data isn't always congruent w/ the objective data

***an ongoing assessment is important because changes can occur very rapidly***

What is the ER nurse's role in d/c planning:

1) provide verbal and written instructions
2) include prescribed meds, treatment, diet, activity, when to contact doctor, and follow up
appointments

What is involved in psych support in a crisis situation:

1) coping w/ loss
2) coping w/ sudden death prepare them
3) allow expression of emotions
4) encourage family to view body if they wish,
5) don't give unnecessary info

How can the nurse help family members to cope w/ sudden death:
1) take to private area
2) assure everything possible was done
3) avoid using phrase s/a "passed on"
4) encourage family to support ea other and express feelings
5) encourage family to view body if they wish (pt should be prepared by removing tubes,
cleaning, and covering)
6) avoid divulging unnecessary info

Systematic approach to assessment and helps the ER nurse to determine which pt needs
immediate attn and which pts can wait. The rank can change if another pt comes to the ER w/
a more emergent prob.

Triage
What are the 3 categories of triage:
1) emergent- life threatening or potentially so or an illness requiring immediate treatment. Ex:
mi, choking, multiple trauma, anaphylaxis, stroke.
2) immediate non acute, non life threatening injury or illness. Ex: GI disturbances s/a vomiting
and diarrhea w/ dehydration
3) urgent- minor illness or injury needing 1st aid level treatment

Field triage - used in disasters such as a tornado, earthquake, large number of injured people
from a bus, plane, or train crash.

Categories patients are divided into in field triage:

1) red tag- emergent
2) yellow- immediate
3) green- urgent
4) blue- fast track or psych support needed
5) black- dead or fastly progressing toward death (put on back burner)
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What types of patients would you expect to be tagged "black":
1) people w/ burns >60% BSA
2) elderly pt w/ broken leg
3) people w/ multiple injuries and bldg badly
4) pregnant pt w/ crushing injuries
5) people w/ crushing injuries

What are some things that can affect care given in field triage:
1) limited resources- ONLY POTENTIAL SURVIVORS ARE RED TAGGED AND GET
RESOURCES
2) availability of surgeons or operating room space

***what is the ruling principle when dealing w/ disaster care?

The greatest good for the greatest number of people

What are some ex of disasters for which emergency care can be done:
Tornados, earthquakes, floods, fires, weapons of mass destruction s/a chemical warfare and
nerve agents

Emergency response plan - every healthcare facility is required by JCAHO to create this for
emergency preparedness and practice twice a year. It's a detailed plan that outlines strategy
used during a disaster for meeting the needs of those injured. It talks about who initiates it and
resources available.

What are some facilities who are available to help in disasters:

1) dhhs
2) cdc
3) Department of justice
4) American red cross
5) health department

Why do nurses need to know response plans?

To know their roles

What occurs when a disaster emergency response plan is initiated:

1) id patients and document
2) tag patients with name, age, address, injury, treatments, triage category
3) triage of disaster victims
4) communicating w/ media by reporting certain info and family to which you don't divulge
unnecessary info to

What are the nurse's roles in disaster emergency response plan:

1) roles may vary from usual area of expertise
2) allocating resources
3) documentation
4) triage
5) communicating w/ family

What are some ethical dilemmas that can arise in emergency situations:
1) confidentiality
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2) rationing of care
3) futile care
4) consent
5) duty
6) resuscitation
7) assisted suicide

What are some general principles of things to be aware of to prepare for possible bioterrorism:
1) unusual number of people seeking treatment for fever, GI, and respiratory complaints
2) unusual illnesses for the particular time of yr
3) rapidly fatal cases occurring
4) increased disease incidence in a normally healthy population

If you came across a substance that was spilled on the floor, what should you do?
Cover it, leave the area, close the door, wash your hands, and report type of spill and exact
location

How can you implement emergency preparedness:

1) know your agency's plan for handling disasters
2) use ppe prn
3) handle materials as directed

***tips for emergency: stay calm, listen, look, pay attn, know what team members are doing,
anticipate needs, know your roles, and keep big picture in mind while focusing on your specific
duties***

What is a factor that create a less stressful environment in a code situation?

Good team leader

What are the roles of the nurse in a code situation:

1) documentation
2) iv
3) administration of meds and iv fluids
4) CPR
5) vital signs

What are the roles of rt in a code situation:

1) inserting and maintaining airway
2) bag the pt

What are the roles of pharmacy:

Calculate drugs

What can make you feel more confident in a code situation?

Know the code cart

What do you do w/ the code cart after a code?

Restock

***NEVER LEAVE THE PT, CALL FOR HELP***

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Who gets highest priority:
a. fell at work yesterday and hurt ankle
b. 16 wks pregnant spotting and abdominal pain
c. 3 y/o fever
d. 70 y/o fractured hip

b. b/c could be losing the baby

Nurse finds pt not breathing and unresponsive, initially:

a. take vital signs
b. CPR
c. call code
d. go get the cart

c. call code then start CPR, d is wrong b/c you never leave the pt

What do you do to control an external hemorrhage:

1) apply pressure
2) immobilize and elevate
3) tourniquet is LAST RESORT

What do you do for an internal bleed:

1) administer packed red blood cells
2) prepare for surgery
3) maintain pt in supine position and monitor till surgery

What do you do for hypovolemic shock:

1) abc's
2) do physical exam to diagnose cause
3) insert 2 IV's and administer iv fluids and blood
4) slightly elevate feet,
5) insert Foley
6) possible sedation

What do you do for wounds:

1) clean w/ ns and betadine then rinse betadine off
2) cover w/ non-adherent dressing

What do you do for intra abdominal injuries:

1) abc's
2) apply pressure to ext bldg
3) administer iv fluids and blood
4) monitor for shock
5) keep on stretcher if blunt injury
6) assess for s/s of intraperitoneal involvement (rebound tenderness, guarding, rigidity,
spasms, increased distension)
7) no opioids
8) NG tube to suction
9) administer tetanus and broad spectrum antibiotics
10) send to diagnostic tests

5
What does pain in the right shoulder in an intra abdominal injury indicate?
Ruptured spleen
What does pain in the l shoulder in an intra abdominal injury indicate?
Liver laceration

What do you do for a crush injury?

1) Abc's
2) assessment for hypovolemic shock, paralysis, erythema and blistering, and damages to
body part
3) administer pain and anxiety meds
4) transport to operating room

What is the main thing to remember when treating a pt w/ multiple injuries?

Determine extent of injuries and prioritize them and give those life threatening injuries top
priority

What do you do for fracture:

1) abc's
2) if pulseless extremity reposition
3) apply splint before moving patient and recheck pulses
4) do head to toe assessment

For a fracture you would do neuro checks and abd assessment before or after an extremity is
treated?
Before unless the extremity is pulseless

True/false: you would check pulses that are proximal to a fractured extremity?
False. Check pulses that are distal

What are some ways to cool a pt down quickly after suffering heat stroke?
1) remove clothing and cool to 102 as fast as poll by cool sheets and towels
2) cont cool h20 sponging
3) ice on skin while spraying w/ tepid h20
4) cooling blankets
5) iced saline lavage
6) electric fan directly on patient

What are some other things you can do for a pt w/ heat stroke besides cooling them down:
1) massage during cooling to promote circulation
2) administer 100% o2
3) draw blood for detecting d/o s/a DIC and for monitoring enzymes
4) monitor uop
5) continue monitoring of vital signs, ECG, and LOC
6) administer iv fluids
7) may have to prepare for dialysis

What do you do for frostbite:

1) remove constrictive apparel
2) no walking if legs or feet involved
3) re-warm w/ 98.6-104 deg whirlpool x30-40 min and repeat until circ restored
4) administer pain meds during re-warming
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5) NO massaging
6) place cotton or gauze b/t fingers or toes
7) correct problems s/a dehydration, hyperkalemia, hypovolemia
8) use strict asepsis
9) do hourly active ROM of digits after re-warming
10) no caffeine or tobacco

What do you do for hypothermia:

1) monitor abc's, vital signs, urine outpup, abg's, labs, chest x-ray, ecg
2) rewarm w/ core rewarming or passive external rewarming
3) supportive care such as external cardiac compression; defib for vfib;, vent; administer warm
iv fluids, na bicarb, antiarrhythmics;, insert Foley,

Core rewarming - type of rewarming method for hypothermia which is for severe form. It
involves putting the pt on cardiopulmonary bypass, administer warm IV fluids, humidified o2
(via vent), and peritoneal lavage. The pt is monitored for v fib as they pass thru 90 degrees.

Passive external rewarming - type of rewarming method for hypothermia in which warming
blankets or over the bed heaters are used. The pt is monitored for arrythmias and elec
disturbances during the rewarming.

What do you do for a patient w/ near drowning:

1) monitor abg's to determine vent support needed
2) ett if not spontaneous breathing or supplemental o2 if spontaneous breathing
3) monitor temp via rectal probe
4) start prescribed rewarming procedures
5) administer iv volume expanders and inotropic agents
6) monitor ecg
7) insert Foley
8) insert NG tube and put to suction

Decompression sickness - results from nitrogen bubbles trapped in body causing pain if in joint
or muscle spaces or stroke, paralysis, or death if becomes embolus. Abc's are maintained,
100% o2 administration, iv lactated ringers or normal saline administration, cardiopulmonary
and neuro sys supported, transport to chest x-ray to id aspiration, wet clothes removed and pt
is rewarmed, and then transported to nearest hyperbaric chamber ASAP.

If a pt gets an air embolus complication from the decompression sickness, what can you do?
Lower HOB

What do you do for anaphylactic reaction:

1) abc's- while 1person establish airway another adminsters epi sq for mild generalized s/s, im
for severe and progressive s/s, iv for complete loss of consciousness
2) additional treatment

What should you have nearby while administering epi iv?

Code cart b/c can cause cardiac dysrrhythmias

What do you do for insect stings:

1) sq epi and massage site
2) assess for s/s and treat
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3) patient and family education

What do you do for snake bites, initially:

1) have patient lie down
2) remove constrictive clothing
3) provide warmth
4) cleanse and cover wound
5) immobilize and lower body part below level of heart
6) NEVER APPLY ICE OR TOURNIQUET

What is done in the ed for snake bites:

1) incident history
2) assess for signs and symptoms
3) monitor vital signs
4) no corticosteroids in 1st 6-8 hrs
5) check circumference of extremity periodically
6) draw blood for labs s/a cbc, ua, pt/ptt
7) iv fluid for hypotension
8) NEVER LEAVE UNATTENDED

When preparing to administer the antivenin to a peds pt, what must 1st be done?
Skin or eye test to check for allergy

Antivenin is most effective if given when?

W/in 12 hrs of the bite

What are some things to do when administering antivenin for snake bite:
1) check circumference proximally before administering and q15 min thereafter, after
decrease s/s check q30-60 min x48hrs
2) premedicate w/ benadryl and tagamet
3) if giving iv, must have code cart there. it must be diluted in 500-1000ml of ns
4) infuse slowly initially then increase after 10 min if no reaction

How much time should the total amt of antivenin be infused in?
In 4-6 hrs after bite

What is the most common cause of an allergic reaction to antivenin?

Infusing too rapidly

What should you do if a pt experiences an allergic reaction to iv antivenin?

Stop the infusion, administer iv benadryl and vasopressors

What do you do for ingested poisoning:

1) abc's
2) monitor ECG, vital signs, and neuro status
3) monitor for shock
4) insert Foley
5) determine what was taken, how much, s/s, age and weight, and pertinent health history
6) draw blood to monitor blood level
7) detox or decrease absorption
8) education and possible psych consult
8
What are some methods of decreased absorption of ingested poisons:
1) milk or h20 for corrosives
2) ipecac if alert but not used if acid/alkaline substance or petroleum distillates
3) gastric lavage if obtunded
4) activated charcoal
5) cathartic
6) multiple doses of charcoal, diuretics, dialysis, or hemoperfusion if above doesn't work

What do you do for inhaled poisoning:

1) carry to fresh air
2) loosen tight clothing
3) CPR if needed
4) prevent chilling
5) 100@o2 until carboxyhgb level is <5%
6) keep quiet and calm
7) no alcohol of any kind
8) carboxyhgb levels monitored on arrival and before o2 started

What do you do for skin poisoning:

1) drench skin w/ h20 and continue while removing clothing, don't use h20 if r/t lye or white
phosphorus
2) determine causant

What do you do for food poisoning:

1) abc's
2) monitor for fluid/electrolyte imbalance
3) monitor for hypovolemic shock which can result from severe vomiting and/or diarrhea
4) antiemetics parenterally
5) diet for mild nausea is sips of weak tea, carbonated drinks, or tap H20 and after nausea
subsides clear liquids x12-24hrs and increase to low residue or bland diet

What do you do for alcohol intoxication:

1) approach nonjudgementally w/ firm, consistent, accepting and reasonable attitude
2) speak in calm and slow manner
3) must r/o hypoxia, hypovolemia, or neuro impairment before can diagnose intoxicated
4) draw blood for blood alcohol level
5) allow to sleep off
6) undress and keep warm (not too sure about this one)
7) if noisy and belligerent, sedate but monitor
8) examine for other injuries

What do you do for alcohol withdrawal delirium:

1) physical exam to id preexisting or contributing illness or injuries
2) obtain drug history
3) obtain baseline blood pressure because treatment depends on that
4) sedation w/ librium, diazepam, a clonidine to decrease agitation, prevent exhaustion, and
promote sleep
5) place in private room w/ lights on, closet doors closed, and have someone stay w/ them
as much as possible
9
6) explain any visual misinterpretation
7) po and IV fluids
8) monitor vital signs q 30 min if in severe delirium
9) dilantin to prevent or control repeated withdrawal seizures
10) monitor for ↓ blood sugar and treat w/ parenteral dextrose, or oj, gatorade, or cho
11) administer supplemental vitamin therapy and high protein diet

How do you go about assessing a patient for possible abuse:

1) obtain history from patient in private
2) assess general appearance
3) exam entire body
4) document description of events and pictures or drawings
5) assess mental status
6) assess how pt interacts w/ significant others

If there is a true suspicion of abuse, what do you do?

If patient is in immediate danger, separate them from the possible perpetrator and according to
law report to appropriate authorities

***you must remember that a competent adult can refuse help***

What is involved in the phsical exam of a rape victim:

1) must have written consent
2) obtain history unless police have already
3) ask patient if bathed, douched, brushed teeth, changed clothes, used the bathroom since
attack
4) help undress and drape appropriately and place each item of clothing in a separate PAPER
bag
5) exam head to toe and exam pelvic and rectum w/ wood lamp or filtered ultraviolet light
6) document time of admission and exam, date and time of event, emotional state, and
general appearance

What are some meds the patient can be offered:

1) prophylaxis against std's
2) anti-pregnancy meds such as ovral which is given w/in 12-24hrs afterwards

What do you do w/ a violent patient:

1) safety 1st priority
2) restraints are last resort
3) Thorazine or Haldol for psychosis

What is involved in the management of ptsd:

1) crisis intervention strategies
2) establish trusting and sharing relationship
3) education regarding stress mgmt and supportive svc

Management - problem oriented process w/ similarities to the nursing process. It's the process
of getting work done thru others. It's needed whenever 2 or more people work together toward
a common goal.

10
Manager - coordinates activities of the group to maintain balance and direction.

What are the 4 functions of the manager:

1) planning what's to be done
2) organizing how it's to be done
3) directing who is to do it
4) controlling when and how it's done (level determines time spent)

What are some specific activities of the manager:

1) hiring
2) firing
3) coordinating
4) budget prep
5) evaluation at least once a year

Nurse manager - occupies a formal position in which the boss expects them to "make the place
run." Each level uses diff methods of mgmt, depending on who their subordinates are.

What are the 3 levels of nurse managers:

1) Director of Nursing
2) Supervisor
3) Head nurse

Who is under the Director of Nursing?

Nursing supervisor who is over several units

Who is under the nursing supervisor?

Head nurse who is over a specific unit

Who is under the head nurse?

Staff s/a LPN, NA, RN working under them who require a lot of direct supervision and gives
very specific directions

Head nurse - caught between administrators and caregivers with which they must balance,
they represent administration to staff nurses and na, but viewed as part of the clinical
workforce by execs. They need to work along side staff to oversee them but often are unable
to do so. They have to please both administration and staff. This position usually has a big
turn over.

What are 3 leadership/management styles:

1) laissez faire
2) autocratic
3) democratic

autocratic - type of leadership style which uses a "my way" of doing things. They use an
authoritarian manner. Decisions are made w/out input from staff. Their emphasis is on tasks
to be done. They make the staff feel frustrated and inferior. They show little concern for the
individual staff members who perform the tasks.

When is the autocratic leadership style useful?

11
When in crises, when structure or control is needed s/a w/ agency nurses or nurse not wanting
to be there, and in family situations

Laissez faire – a type of leadership style which abdicates leadership. They function in a
permissive climate w/ little direction or control. They allow staff to make and implement
decisions independently. They release all power and responsibility. Not good for the
healthcare settings s/a hospitals.

When is the laissez faire leadership style useful?

Works well w/ a highly motivated group

Democratic - type of leadership style which is people oriented, emphasizes effective group
functioning, keeps the group headed in the right direction, and provides an open environment.
It allows for communication both ways and encourages participation in decision making. This
type of leader assumes responsibility for decisions when needed.

Leadership - a way of behaving. It's an interpersonal ability to cause others to respond, not b/c
they have to but b/c they want to. It involves moving into a position b/c of special abilities,
skills, or attributes. They don't have to occupy a formal position in an org. There is one in
every group of people. They must have a variety of skills and the ability to select the most
appropriate style for each situation.

Contingency leadership - the ability of a person in the leadership role to select one of a variety
of skills which is most appropriate for a particular situation.

Leadership abilities can be understood in relation to 2 major components of mgmt:

1) employee centered behavior
2) job centered behavior

Democratic leadership style - leader who is high in both job centered and employee centered
behaviors. They care equally for needs of the employees and effective and efficient
completion of the job. This is which type of leadership style.

Laissez faire - leader who is low in both job centered and employee centered behavior. They
don't care about the employee or the job. This is which type of leadership style.

Autocratic - leader who is high in job centered and low in employee centered behaviors. They
focus on the job to be done w/ little concern for the needs of the employees. This is which
leadership style.

Can a manager be a leader and vice versa?

Some people are good leaders but not good managers, some people are good leaders and
managers, and some are good at managing but poor in leadership

Which is this, a manager or a leader?

Assigned or appointed, relies on the system, control is a big role, and maintains the role
Manager

Leader - selects and assumes the role, relies on the people, he/she leads the people, position
requires trust, and develop things s/a ways to change or do things diff.
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True/false: a nurse must choose to be a manager or leader?
False. They can be both

Decision making - value based. Nurses do this based on their personal values, life
experiences, perceptions of the situation, knowledge of risks ass w/ possible decisions, and
their individual ways of thinking. similar to problem solving. Requires an objective. A problem
may arise but the objective may not be to solve it.

Problem solving - more of a scientific process. Its focus is on solving an immediate problem
s/a understaffing. Before beginning the process, the people involved will gather info in an
effort to define it. It's important for everyone to know the facts.

Before attempting to solve a problem, a manager must ask certain questions:

1) Is it important
2) Do I want to do something about it
3) Am I qualified to handle it
4) Do I have the authority to do anything
5) Do I have the knowledge, interests, time, and resources to deal w/ it

When a manager is asking him/herself the questions for problem solving, what do they do if
they answered no to any?
Ignore the problem, refer it to others, or work w/ others to solve it

What are the steps to problem solving:

1) define the problem - everyone must know problem exist
2) id alternative solutions
3) select and implement solutions
4) evaluate outcomes

What are the steps to decision making:

1) set objective- what you want to accomplish
2) id and evaluate alternative decisions
3) make decision and implement
4) evaluate outcome

Inventory of the unit must be completed by the end of the week, it's Wednesday and it hasn't
been done yet. Determine what should be done about this situation using the problem solving
process:
1) define problem - unit inventory due by Friday and as of Wednesday, it hasn't been done
2) id alternative solutions- stay late after work to do the inventory, delegate to the floor na's
parts of the inventory
3) select and implement solution- select time to meet w/ na's to discuss roles in inventory
4) evaluate outcome- was the inventory completed by Friday

What is the difference b/t problem solving and decision making:

1) both require a decision to be made
2) decision making involves setting an objective while problem solving requires def of the
problem

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3) problem solving is concerned w/ solving the problem while decision making is concerned w/
dealing w/ results of problem

Their philosophy, personality, self concept, and interpersonal skills influence the functioning of
the group?
Leader

What is the role of a group leader prior to a group meeting:

1) plan who is to come, how the meeting is to be run, purpose for ea item on agenda
2) prepare members for the meeting by sending agenda ahead of time indicating any prep or
materials needed
3) secure an appropriate meeting room prepared w/ chairs and av equip
4) appoint a note taker for minutes

What is the role of group leader during a group meeting:

1) guides and directs the group
2) provides a positive milieu
3) use tact and diplomacy
4) keep group on track
5) respect members
6) provide positive feedback
7) maintain open communication
8) encourage participation

What is the role of group leader at the end of a group meeting:

Review and summarize decisions and decide on actions

Power - ability to effect change and influence others to meet identified goals (they get results).
It affects organizations by influencing decisions and behaviors s/a by warnings and by
changing situations for which you need to identify people in power to get involved in deciding
how that change will occur. People have different levels.

Authority - gives one a legitimate right to give commands and act in the interest of an
organization. It is position related and carries responsibility. They may or may not get results.
RN behind your name gives you this.

Authority-power gap - says that just b/c you have right to command doesn't mean employees
will follow that command.

True/false: it's never good to question authority.

False. If nurse manager is not getting job done and pt care suffers

Empowerment - increase one's power by giving more autonomy causing them to grow
professionally. Their power is shared, encouraging employees to take responsibility for job,
the employees become trusted and are given praised and given recognition allowing
communication to flow down the chain of command.

Why is it important for a nurse manager to get employee trust in them?

It strengthens their power and allows them to show that he/she cares about them by granting
rewards if possible.

14
Good leader - communicates their vision, gives employees the opportunity to make the most of
their talents and learning, encourages creativity and exploration which plants seeds of
leadership, colleagueship, self respect, and professionalism.

What are some types of power:

1) legitimate - connects to position of authority, has right to expect you, if under them, to do
your job (position power)
2) reward - must be done equally
3) info - possessed by people w/ knowledge and inside info needed
4) referent - power r/f personal characteristics, they have "charisma", based on connection to
another powerful person
5) expert - based on special skills and knowledge, earns respect by being good at a certain
skill
6) coercive - based on fear of consequences, usually threatens others, you must avoid getting
them angry

What is the source of the types of power:

1) legitimate- organization
2) reward- organization
3) info- organization
4) referent- personal
5) expert- personal
6) coercive- organization

What types of power do the following positions have:

1) faculty- coercive, expert, info, legit, referent on individual basis, reward
2) nurse manager- legit, expert, coercive, info, referent
3) wound care nurse- expert, legit, info

How can a new nurse increase their power:

1) increase competence
2) refine interpersonal skills (best way)
3) communicate clearly
4) delegate appropriately
5) give and receive feedback
6) think positive which develops referent power

What are some things that might detract from your power:
1) poor appearance
2) unorganization
3) inconsistent
4) poor work habits
5) negative attitudes

***if you have power, use it correctly and constructively, used for personal gain or good of the
organization. If you're a nurse manager, treat others w/ respect and treat employees as people
w/ inner worth and not an object to be manipulated***

What are some ways to react to change:

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1) react by changing jobs which prevents growth
2) not act which threatens job
3) act by running w/ change and pace along w/ it

Who initiates change:

1) system by replacing old equip w/ new equipment
2) management such as in management change in a healthcare facility
3) for patient who has multiple complaints, change should be made
4) nurse by planning to decrease medication errors part of their job is to promote successful
change which helps their organization grow by trying to help others to see change as an
exciting opportunity and by communicating effectively throughout the process
5) nurse leader

What are the rules which must be implemented when attempting a change:
1) change should always be implemented for a good reason
2) change should always be gradual
3) all change should be planned, and not be sporadic or sudden
4) all individuals who may be affected should be involved in the planning for the change

What are some requirements for successful change:

1) timing
2) trust
3) have a clear vision of what change will look at and person w/ vision must be able to sell it to
others
4) people at all levels should be involved

What is the change process:

1) recognize change is needed and collect data for it
2) id external and internal forces for change
3) state problem
4) id change strategies and select best one
5) implement that strategy
6) evaluate the effects
7) stabilization of change

What is Lewin's change theory:

Unfreezing - phase of Lewin's change theory in which there is a recognition that a problem
exists and those impacted are sought out & given the option to be involved. Then they
determine if the environment of the institution is receptive to change and motivates participants
to be engaged in the process. There is a thawing out of the old phase.

Moving - phase of Lewin's change theory where a recruited group takes on responsibility of
implementing change by sorting out what must be done and determining which sequence of
actions that would be most effective. They id individuals who have the power to make the
change happen, they id strategies to overcome resistance, and affect a cooperative approach
to implement change. When the plan is in place, the employees move up to a new level of
behaviors.

Refreezing - phase of Lewin's change theory which occurs when the plan is in place and those
involved know what is happening and what to expect. Continuous assessment of pros and
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cons of the plan is an important part of the ultimate success. New behaviors must be
enforced. Someone must be responsible for working on the plan so it doesn't lose momentum
and changes need to become a part of everyday life so it's not perceived as something new.

Why might people be resistant to change:

1) resistance- feel threatened personally that the change will lower their position
2) uncertainty - may have lack of understanding of the change
3) assimilation - unable emotionally to cope w/ change
4) transference - don't agree w/ benefits of change
5) integration - feel insecure b/c it will affect their self confidence

How do you conquer change:

1) resistance- like old way better
2) uncertainty- how is change affecting me, maybe it won't be so bad
3) assimilation- I can do this
4) transference- I like new way better
5) integration- why doesn't everyone do it this way

Who moved my cheese: the handwriting on the wall

change happens- someone keeps moving the cheese anticipate change - ready for the cheese
to be moved monitor change - smell the cheese often so you know when it's getting old adapt
to change quickly- quicker you let go of old cheese, sooner you get new cheese change- move
w/ the cheese enjoy change- savor adventure and enjoy new cheese be ready to change
quickly and enjoy it again and again - someone keeps moving the cheese

JCAHO - they conduct systematic and intensive surveys of hospitals and other health care
institutions to determine whether accepted standards of structure, process, and outcome are
being met. Founded in 1951 and in 1953 their standards were put into a book. Many 3rd party
payers, such as Medicare, will only reimburse hospitals that are accredited by them. The
accreditation is good for 3 yrs. It's not a regulatory agency but regulates standard of care.
They give an overall score or a score w/ comments for which they f/u on.

What is JCAHO’s mission?: Enhance the quality of care provided to the public

Tue/false: when JCAHO comes to a health facility, they go out to the various units to survey
them.
True

What are the focuses of JCAHO as of 2004:

1) improved accuracy of pt id- recommended id of pt in 2 forms other than room number, and
id of pts and are of body for surgery
2) improved effectiveness of taking orders- d/o, lab results
3) improved safety of using high alert meds- proper procedure in administering chemo meds
and meds requiring levels
4) eliminating wrong site procedures- in surgery
5) improved safety of using infusing safety pumps- pain pumps
6) improved effectiveness of clinical alarm sys and implementing reg preventative
maintenance and testing of alarm sys s/a bed alarms, mechanism should be in place and
maintenance periodically checks them
7) decrease r/f healthcare acquired infections s/a handwashing and personal protective
equipment
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Quality assurance - nursing's method of monitoring and improving consumer oriented svc. It's
a process of evaluating outcomes or goals of care and ensuring that each patient receives a
predetermined high standard of care. Those standards of care where written and adopted by
JCAHO in 1980.

What is quality measured against?

Standards of those consuming the care

What must any quality improvement program focus on?

Measuring and improving nursing care to pts

Quality improvement approaches offer 3 perspectives from which to evaluate nursing care
provided:
1) structure- evaluates physical environment, organized structure, and licensure of healthcare
providers
2) process- examines what is being done for the pt and involves the pt's plan of care
3) outcome- highlights changes in the pt's health status

Preventative medicine and preventative care - buzzwords for the future where instead of
waiting until someone is ill and needs hospitalization or emergency treatment, emphasis will be
on preventing disease and keeping people in a state of wellness.

Incident report - an ex of a tracking mechanism put into place which determines if there are
deficiencies which the facility needs to address.

What is the performance improvement and quality assurance process:

1) set standards
2) establish criteria for achieving standards
3) determine if established criteria has been met
4 )implement action plan for improvement
5) re evaluate standards which is an ongoing process

A hospital in Maine underwent the first audit of a healthcare facility when?

1957

Nurses began to play a more active role in quality assurance process when?
1970

Quality improvement - decrease costs and allows for predicted outcomes from such things as
surveys to patients.

In a survey done by the ANA on 7,300 nurses about their facility and staffing, 5,000 stated
what was the major factor that declined quality in their facility?
Inadequate staffing

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Government health programs, healthcare org, and healthcare managers should make what
their strategic priority ?
A reduction in medical errors and improvement in pt safety

Should strive to create a culture facing their institution or organization.

Healthcare managers

Healthcare culture - defined as everyone who has a responsibility for risk reduction and error
prevention. Goes back to making sure the support staff is educated.

True/false: it's a JCAHO requirement that health facilities routinely perform self assessments
for risk reduction and error prevention.
True

What does quality assurance and improvement affect:

1) customer service
2) other things that affect customer svc s/a media, rising cost, diminishing resources,
technological complexity, ethical dilemmas, and previous exposure of self or friends to the
system

Comm based approach - focuses on correcting weaknesses after the deficits have been id. Ex
of this is our health care system. Based on needs.

What is an ex of community programs which are instituted thru public policies and are based
on needs?
Welfare assistance programs

Community development approach - allows individuals or organizations to id their own

strategies and issues by the building of coalitions and the assessment of the competencies
and strengths of communities. The decision makers are the community leaders id by the
community itself. This is an ex of empowerment.

What is the nurse's focus for the community:

To improve health of the community and build healthier lives thru health promotion, disease
prevention, and a healthier environment all done by education, health fairs, and school and
church projects

What role does the nurse play in building a healthier community?

Being knowledgeable of community needs which they learn thru establishing a trusting
presence in the community

Members and leaders of the community - this group of people, besides those providing
healthcare education, will help the community become more aware of healthcare needs and
the importance of meeting them.

Increase availability of medical info, allows for research in nursing, to keep up with and access
data, nursing documentation, accessing doctors and healthcare facilities, schedules

***always redirect the pt back to their doctor***

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What is the cause of the projected growth in home health care service?
Technological changes have made it possible to deliver service at home now

3 ways health care can be financed:

1) self payment
2 3rd party payments thru health insurance
3 )healthcare assistance

3rd party payment - form of financing health care which is for the working individual and is
employer provided. Includes HMO's s/a tricare, ppo's, Medicare.

Medicare - most common ex of 3rd party payment which is a government operated or public
program that is federally funded and financed thru taxes on wages. Its funding status is being
threatened right now.

Who is eligible for Medicare?

Those individuals age 65 and over who are eligible for ssi, disabled individuals, and individuals
w/ end stage renal disease can receive this.

What does Medicare consist of?

Part A which is hospital insurance and part B which is supplementary medical insurance that's
voluntary and limited to those who have the premium deducted from their social security check

Self payment - form of financing health care in which an individual or family pays the bill for
medical service

Health care assistance – is a form of financing health care which is a type of 3rd party payment
but is provided by the federal or state program or a private charity.

Medicaid - an ex of a health care assistance program which is a grant program designed to

provide medical assistance to the poor. It's a state and federal partnership. Families w/
children on welfare and pregnant women are eligible.

Private charity - non profit organizations which target special health needs s/a acquired
immune deficiency syndrome or special risk groups s/a pregnant teens along w/ philanthropic
gifts to hospitals and various agencies, assists individuals w/out insurance to obtain care.

How does the method of payment for healthcare svc affect you as a nurse?
It's where your paycheck comes from and from where raises come

Retrospective - cost based reimbursement based on a svc being provided then being paid for
after the fact. The doctor and pt has almost unlimited autonomy in deciding what svc were
needed.

Prospective - today's health care reimbursement relies on this type of payment system that
compensates the provider on an individual care basis for health care service. It encourages
efficiency and cost containment.

Drg - an ex of prospective payment system where the healthcare agency and providers of care
know in advance exactly how much they will receive for service required to care for a patient

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with a particular disease. They've been criticized for not adequately measuring the severity of
illness or the diff kinds of nursing resources used to care for patients.

HMO - an example of prospective payment system in which the member pays a flat fee.
They're expected to obtain care at the designated facility, except in emergency cases. The
organization provides both input and output care to families and individuals.

PPO - an ex of prospective payment system in which a group of healthcare providers

negotiated a special reduced rate to attract health plan members. If offers individuals more
freedom of choice in providers. Most operate independently and aren't regulated by the
government.

What is the challenge to nurses in regards to their role in health care financing?
Provide high quality care that is cost effective

assets = ? liability and owner's equity

severity of illness? acuity

what's owned? Assets

what's owed? Liability

difference b/t budgeted and actual amts? Variance

Budgeting process - plan which uses numerical data to determine expenses of a fixed income?

What are 3 types of budgets:

1) operating budget- day to day supplies, usually exceeds personnel costs
2) capital- large or fixed assets or types of equip such as iv poles, ass w/ long range planning
of 3-5 yrs
3) personnel- for unit staffing, referred to as full time equivalent budget

What are the steps to budget planning:

1) determine requirements- who develops the budget, unit managers should be included
2) develop a plan- keep in mind if facility is state funded or whether or not operation will
depend on leg decision
3) analyze and control the op- monthly ongoing analysis of computerized statements
describing expenditure
4) review plan- look at seasonal variances

Costing out - takes into account the cost of running a unit and the cost according to the type of
pts.

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