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Class Notes for Clinical Nursing Skills: Basic to Advanced Skills, 9th Edition

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez Chapter 1 Professional Nursing TEACHING/LEARNING STRATEGIES Lecture – Discussion Instructor Planning. Have students access a copy of their state’s Nurse Practice Act. Th is document may be available online or a copy may be obtained for each student. Draw the students’ attention to the text information regarding the Code of Ethics, ANA’s Nursing’s Social Policy Statement , and the National Student Nurses’ Association Code of Academic and Clinical Conduct. . I nterpret and discuss these documents. Also discuss the Standards of Nursing Practice as outlined in the text. Written Assignment Instructor Planning. Obtain a patient chart or computerized record from the hospital where the students will have clinical experience. Suggest they document the skills as they practice them, i.e., chart vital signs, BP, I&O. Resource Suggestions Access the Joint Commission website at www.jointcommission.org . for information on National Patient Safety Goals and Core Measures. CRITICAL THINKING STRATEGIES Exercise 1 Discuss the Nurse Practice Act by asking students to read sections of the act and then describe in their own words the meaning of the statement. Ask the students to identify how the practice act will affect their career. Exercise 2 Ask the students to obtain the Standards of Practice for the nursing unit where they are assigned for clinical practice. Compare the standards against the ANA published Standards of Nursing Practice. Discuss the Standards of Nursing Practice with the students. Break students into small groups and assign each group to one standard. As a group, define how the standard is used in the clinical setting and how evaluation of that standard is accomplished. Exercise 3 Ask the students to think back to when they first decided to become a nurse. Ask, “How does the i m age compare to the actual role you are assuming now? Identify the major differences you are e x periencing that you didn’t think or know about earlier.” Have the students share their thoughts in a small group and identify similarities among the group. The similarities can be shared with the entire class if time allows. Exercise 4

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez Assign each student to research and describe a potential clinical incident that could be defined as gross negligence, criminal negligence, and malpractice. In a small group, ask the students to d e scribe the incident and ask the group to determine which type of negligence has been described. Exercise 5 Provide information about HIPAA (Health Insurance Portability and Accountability Act) and ask the students to discuss the role of the nurse in carrying out the privacy mandate. Scenario 1 As a new student you are going into the hospital to prepare for the clinical experience tomorrow morning. There are two stages of preparation. The first stage is obtaining all the necessary info r mation you will need to provide safe care. The second stage is reviewing your textbooks and le c ture notes to gain an understanding of the client’s diagnosis, medications, lab values, and diagno s tic tests that will be done during his/her hospitalization. 1. If you have only a limited time to review the client’s chart, what sections of the chart will provide you with sufficient information to render you safe to care for the client? 2. In preparing for clinical practice, what information is essential to review in addition to the data you have obtained from the clinical record? Where is the most appropriate place to find this information? 3. List the priority interventions you will carry out within the first hour of the clinical exper i ence. Explain the rationale for your answers. Scenario 2 As a student nurse, you have been assigned to complete an activity where you compare and co n trast legal/ethical issues related to nursing practice. You are assigned to research the ANA sta n dards of clinical nursing practice, the Nurse Practice Act in your state, and the code of academic and clinical conduct from the National Student Nurses’ Association, Inc. 1. Briefly describe the primary purpose/function of each of these nursing regulations or guid e lines. 2. Select one of the above nursing regulations/guidelines and describe how the regul a tion/guideline will impact your role as a professional nurse. 3. The National Student Nurses’ Association developed the code of academic and clinical co n duct. How do you plan to incorporate the code into your practice as a student nurse? How will this practice prepare you for the registered nurse profession? Resolution Possibilities for Scenario 1 1. Client’s medical diagnosis; medications to be given during clinical; essential lab values for medications or tests; and whether client has any allergies. 2. Information on medications from PDR and drug reference texts; information on medical dia g nosis from textbooks; nursing skills protocols and procedures from skills text; lab information from laboratory diagnostic text.

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez 3. Perform hand hygiene. Receive oral report from nurse; check Kardex or computer generated care plan for new client information; introduce yourself to your client; take vital signs; co m plete a focus assessment; and check that all medications are available in cart if not using Pyxis machine. Each of these tasks is designed to provide safe client care. Washing your hands pr e vents the spread of microorganisms to client. Checking medications and new orders are esse n tial to provide accurate care. Focus assessment provides baseline information on client’s co n dition and promotes individualized client care. Resolution Possibilities for Scenario 2 1. The ANA standards of clinical nursing practice describes the competent level of nursing care. The standards apply to all licensed registered nurses working in clinical practice, regardless of clinical specialty, practice setting, or educational preparation. The standards describe a co m petent level of professional performance common to all nurses engaged in clinical practice. The Nurse Practice Act defines professional nursing and recommends those actions that the nurse can practice independently and those actions that require a physician’s order before completion. The act is a series of statutes enacted by a state to regulate the practice of nur s ing in that particular state. Each state has their own individual nursing practice act. A code of academic and clinical conduct outlines the ethical principles that guide the st u dent’s professional development. Included are guides that describe the advocacy role for the rights of clients, providing for client safety, and actively promoting the highest level of moral and ethical behavior. 2. The answer depends on the regulation or guideline selected. For the content that needs to be addressed, refer to the chapter information. 3. Discussion of how ethical practice is critical in developing as a registered nurse is important. These practices include promoting the highest level of moral and ethical conduct, accepting responsibility for one’s actions, using every opportunity to improve faculty and clinical staff, and providing safe, timely, and compassionate care to clients. All of these behaviors are part of assuming the RN role.

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez Chapter 2 Nursing Process and Critical Thinking TEACHING/LEARNING STRATEGIES Lecture – Discussion Use a nursing diagnosis book to explain in detail how to use nursing diagnosis appropriately. Apply categories to clients in the hospital. Obtain a copy of Nursing Diagnosis Handbook 10 th ed. Judith Wilkinson (Prentice Hall 2014 ) , Nursing Diagnosis Handbook: A n Evidence - Based Guide to Planning Care, 10th edition. Ackley and Ladwig, C.V. Mosby 2014, Nursing Diagnoses 2015 - 2017 : Definitions and Clarification (NANDA ), or Nursing Diagnoses: Application to Clinical Practice, 14th ed .Lynda Carpenito (Lippincott Williams and Wilkins 2012 ). After reading their description of how to use critical thinking, determine which definitions best fit your curriculum framework. Based on that decision, you can develop a methodology for inclusion of critical thinking into your cours e work. Oral Assignment Have students identify a client - based problem and then follow the four steps in the problem - solving process related to Evidence Based Practice. Students need to research the problem using appropriate references. You may need to give them a list of appropriate references. Each student, or student group, should then report their findings to the class. Written Assignment Provide each student with a list of current nursing diagnoses. These could be written on index cards to carry to the clinical setting. Resource Suggestions Critical Thinking and Clinical Judgement : A Practical Approach to Outcome - Focused Thinking , 6th ed., by Alfaro - LeFevre, Rosalinda (Saunders), 2017 . CRITICAL THINKING STRATEGIES Exercise 1 One example of how to introduce both critical skills and nursing process into skills and clinical courses is to have a discussion of how critical thinking skills are used throughout the nursing process. Resolution Possibilities for Exercise 1 You can develop your own “thinking system,” incorporating the nursing model you use as your theoretical framework in the program. As an example, if you use the Roy adaptation model, you may have the students state the critical thinking skills according to the specific terminology in the model. The Roy model would list under assessment, first - and second - level assessment beha v iors. The students then use that data and cluster ineffective behaviors and form a nursing diagn o sis. You then expect them to be able to

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez distinguish relevant from irrelevant data, important from unimportant data. They should also be able to provide a rationale for their answers. You may choose to have the students determine what specific information belongs under each step of the nursing process. They can be given characteristics of each phase in a random order. They are to take each characteristic and place it under the correct phase of the nursing process. After they have placed the characteristics in the appropriate phase of the nursing process, it is a good idea to show multiple - choice test questions that test each phase of the nursing process. Ask the students to identify the phase being tested and provide the rationale for their answer. It may be helpful to administer one of the commercial instruments available on critical thinking to the beginning students and then to the graduating students to determine if an increase in ability to use critical thinking skills has occurred throughout the program. It is important that the faculty look at the many tools available and choose the tool that most represents the definition of critical thinking that is used throughout the nursing program. Scenario 1 You have been assigned to care for Mr. Peters, a 76 - year - old widower who was admitted with the diagnosis of congestive heart failure. He has lived alone for the last two years since his wife died. His children live about one hour away and visit him once a month. The children ordered Meals on Wheels for him, but he refused to eat the food that was delivered. “I can do my own cooking. I am not an invalid,” was the answer when the nurse asked why he didn’t like the Meals on Wheels program. He had not seen the physician for at least 2 years. At the last visit, the ph y sician prescribed a moderately low sodium diet, furosemide ( Lasix ) 40 mg. daily, verapamil (Calan) , and multiple vitamins. His admitting vital signs were BP 180/90, P 98, R 22. His weight indicated a gain of 10 pounds since the last visit. His physical assessment indicated rales in the lung bases, 3+ edema of the a n kles, and difficulty breathing in a supine position. 1. How will you use the nursing process to determine an accurate data base? 2. What information is missing that might be important to the nurse to assist in planning care for this client? What is the best approach for obtaining the information? 3. Identify at least four nursing diagnoses that are relevant for this client’s plan of care. Write a two - part and a three - part diagnostic statement for each nursing diagnosis. 4. Using a nursing diagnosis book, identify NIC and NOC statements for the four nursing diagnoses listed in question 3. 5. Identify the priority nursing diagnosis , and provide the rationale for your decision. 6. Develop a very brief nursing care plan using the nursing process format as outlined in the text. Note: Scenario 1 can be used as a critical thinking scenario for a beginning student. This is a good scenario for role play. To encourage nurse – client communication and questioning techniques to obtain data, have the students divide into pairs. Give one student in each group (the client) cards with additional information regarding his

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez symptoms and clues on how to answer questions posed by the “nurse.” Have the “nurse” proceed to gather additional data without the use of cards or prompts. After the role play is completed, ask the students to complete the nursing care plan with the i n formation they gathered. After completing the care plan, have the students determine if they gathered sufficient information for the care plan. If not, ask them what data they needed. Scenario 2 8 A.M. You are assigned to a 22 - year - old male client who was in a motorcycle crash yeste r day. He sustained a compound fracture of the right fibula and tibia. He states his pain is 9/10 and is throbbing. He is nauseated all the time. He is scheduled for surgery later in the day. You assess his wound area and notice there is a large amount of serosanguinous drainage of the dressing. You reinforce the dressing. 1. Based on the information provided in the scenario, identify two nursing interventions. 2. Determine priority nursing diagnoses and provide rationale for your decision. 3. Using a nursing diagnostic textbook, develop a client care plan incorporating NIC and NOC data. Resolution Possibilities for Scenario 1 1. Assessment phase Gathering data Confirming observations Verifying data Nursing Diagnosis Analyze collected data Determine cluster of clues Identify related factors Identify potential nursing diagnosis 2. a. Can he actually cook for himself? b. What are his physical assessment findings related specifically to his heart and lungs? (e.g. heart assessment, particularly the PMI.) c. Who is responsible for his care at home? Can he actually return to his house with/without outside help? d. Is he taking his medications as prescribed? Does he know the action of the drugs and what happens if he doesn’t take them? The best approach is to ask him questions directly and have him state information about his drugs. It may be that the children will also have to answer the questions as well to get a complete picture of Mr. Peters and his ability to care for himself. 3. There are many potential nursing diagnoses. Four common nursing diagnoses for Mr.

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez Peters might include: Excess fluid volume Ineffective role performance Ineffective self - health management Deficient knowledge related to drug therapy Two - part statement (Example) Excess fluid volume related to decreased cardiac output secondary to congestive heart failure Three - part statement (Example) Excess fluid volume related to decreased cardiac output secondary to heart failure as ev i denced by peripheral edema, shortness of breath, and weight gain The two statements will be reflective of your identified nursing diagnosis. 4. Information for this answer is dependent on the chosen nursing diagnosis. Example for the excess fluid volume: Electrolyte and Acid - Base Balance: Balance of electrolytes and nonelectrolytes in the intra - and extracellular compartments of the body. Fluid Balance: Balance of water in the intra - and extracellular compartments of the body. Hydration: Amount of water in the intra - and extracellular compartments of the body. 5. Excess fluid volume, is the priority diagnosis. His symptoms all indicate a fluid overload state. This condition can increase his poor cardiac output and place the client in jeopardy for adequate tissue perfusion to vital organs. 6. The care plan should include the following information: Problem/need (nursing diagnosis) Expected outcome/goals Nursing interventions — at least two for each nursing diagnosis Resolution Possibilities for Scenario 2 1. The appropriate nursing diagnoses would be: a. Acute pain. b. Risk for infection. c. Nausea. d. Deficient fluid volume. e. Ineffective coping.

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez f. Disturbed body image. 2. Determine the two highest priority nursing diagnoses: a and b are probably the highest prio r ity. After you have identified the diagnoses and their interventions, refer to a nursing diagn o sis textbook to check interventions related to the diagnosis and evaluate the rationale for your selection. 3. The nursing diagnoses most likely considered last would be e and f.

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez Chapter 3 Managing Client Care: Documentation and Delegation TEACHING/LEARNING STRATEGIES Lecture – Discussion Instructor Planning: Obtain examples of different standard care plans from the hospital/computer and review the procedure for using the plans. Include how they are initiated, updated, and disco n tinued. Obtain several copies of clinical or critical pathways and describe how they are used in managed care health systems. Demonstrate the hospital documentation format used in the clinical facility. Discuss various charting formats and the rules for documenting client care. Simulated situations can be printed on 5  9 cards. Ask the students to document their findings on a form. Written Assignment Use a nursing care planning book and have students identify a standard care plan for one client they have cared for in a recent clinical experience. Instruct students to state how and why this standard plan fits their client. Demonstrate and then assign students to write a nursing care plan after they are familiar with the care planning and have sufficient knowledge. Suggest they start by writing only the client needs that are actual problems. (When needs are placed in priority order, this action assists students with critical thinking and decision making.) An excellent critical thinking exercise can be included in the written assignment. Have students provide a brief scientific rationale for the priority nursing intervention, which is determined for the priority client problem. Ask them to state the rationale in their own words. Have students identify if the stated goals on their client’s care plan, either short - or long - term, are measurable and appropriate for the client’s situation. If not, have them identify a more appropr i ately stated goal. Laboratory Experience Provide a taped or verbal shift report /handoff and have students practice writing information on a wor k sheet. Have students complete a prep sheet based on a simulated situation. Prepare a work sheet for students or have them bring a work sheet from the clinical area. Ask them to give a verbal shift report to a group of peers. Have students demonstrate electronic charting on a recent client. Clinical Experience

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez Have students attend a care conference on their assigned client and write a summary of how the conference was organized, which health team members participated in the conference, and their role in delivery of health care to clients. Have them identify the leader of the conference. Include a brief summary of the final results from the conference. Students should begin updating, activating, and deactivating care plans or clinical pathways with instructor guidance early in their first clinical experience if this is permitted by the facility. If not, guide students through the process outside of the clinical site. This helps them identify the need for accurate care plans and pathways. Have students critique a shift report /handoff , including pointing out any information that was not rel e vant to the situation and any essential information that was omitted. Resource Suggestions Use standard care plans developed by hospitals. 1. Obtain several critical pathways for clients that students have been assigned to in the clinical setting. 2. Break students into small groups, each with a different pathway. Have the students prioritize the aspect of care for the first day. Have them state the rationale for their decisions. Asking the students to identify the priority nursing diagnosis can be added to the task if time pe r mits. Assign a time frame for this activity that will allow the groups to present their findings at the end of class. 3. You may need to write a clinical client scenario for a particular pathway if the students have not had an assignment supporting the pathway you have chosen for the activity. 4. Select one spokesperson from each group to present the findings from the group. Allow time for group discussion by the entire student group. Encourage all students to participate, cha l lenge the prioritization, nursing diagnosis, or rationale. If they have a different prioritization, they need to provide the rationale for their choice. CRITICAL THINKING STRATEGIES Exercise 1 Have students complete a mock time management sheet based on a simulated clinical assignment. Provide students with a client assignment sheet with personnel assigned to the client. Ask them to identify if the appropriate personnel is assigned to each client. They need to provide rationale for their answers. They need to indicate the most appropriate category of health care worker who should be assigned the client if they think the assignment is not appropriate. A discussion of the Nurse Practice Act for both RN and LVN/LPN must be discussed for this activity to be pert i nent. The role of the CNA and UAP must be discussed according to policy and procedures for the state and health care facilities used for their clinical experience. Exercise 2

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez To increase students’ observation skills, an activity can be used for students to determine their ability to observe and recall details that are a part of data collection. During a discussion of the various types of documentation and the importance of accurate observation skills, ask a faculty member or a student to pass through the front of the room and exit. It would be helpful if the person looked embarrassed, carried something in his or her hands, and had on nondescript clot h ing. The best time would be about five minutes into the class on documentation. After the person has exited, ask the students to describe what they observed. Leave the observation very open to the students’ recall of the person. Do not ask specifically for clothing, appearance, etc. Allow the students five minutes to recall the information. Ask the person to return to the room. Have the students verify their observations. Identify errors in recall and what observations were missing. After this exercise, discuss the importance of accurate and complete observational skills. Exercise 3 Ask several of the students or the faculty to participate in a role - play situation. The intent of the role play is to depict a potential litigation issue. Examples for the role play include: a client falling out of bed and fracturing a hip when the side rails are down; an antibiotic given to the wrong cl i ent who is allergic to the drug; an IV with a toxic drug infiltrated into the subcutaneous tissue, causing a sloughing of the tissue. During the role, the “nurse” should describe what she or he o b served to a “physician” and to the “nurse manager.” Cue cards may need to be given to the pla y ers, describing what they probably observed. It depends on the level of the student or if a faculty member is acting the part of “nurse” or “physician.” The “client” should be given cue cards d i recting him or her on what to communicate, how to react to the incident, such as grimacing with pain, feeling nauseated, etc. Ask the students to chart the incident and fill out an Unusual Occurrence Report. A discussion related to the content of the documentation should follow the charting and completion of the r e port. Ensure that the critical information needed for the Unusual Occurrence Report is included and stated in the correct manner. Information related to how the Unusual Occurrence Report is used within the hospital facility should be included in the discussion. Scenario 1 Determine appropriate delegation of client activities for a staff team on a unit. This scenario does not take into consideration the acuity of the client, only the nursing tasks needed for the day shift. Each facility and state have differing policies regarding personnel; therefore, these policies need to be reviewed before this activity is completed. The team consists of one RN, one LPN / LVN and one UAP. There are 10 clients and 2 unoccupied beds. There is a charge nurse and ward clerk assigned to the nursing unit. There are two other teams and these three teams make up the medical - surgical nursing unit. RM 601A Mr. Rodriguez , 98, admitted 24 hours earlier Diagnosis : congestive heart failure Bed rest, bed bath and assistance with oral hygiene, daily weight, I&O

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez Vital signs every 4 hrs., low sodium diet, restricted fluids to 1500 mL. IV #2 1000 mL D5 /0 .2NS with 20mEq KCL at 50 mL/hr. 800 mL remaining IV medications: furosemide 40 mg BID Oral medications: digoxin 0.25 mg daily, vitamin supplement RM 601B Mr. Jamisen, 69, admitted this A . M . Diagnosis : coronary artery disease Surgery at 10 A . M . : triple bypass -- will go to ICU following surgery Pre - op checklist and client teaching has been completed Pre - op meds on call to OR. IV medications IV #1 1000 mL D5 /0 .2NS at 75 mL/hr. RM 602A Mr s . Jones, 59, admitted 2 days ago Diagnosis : cholelithiasis Surgery 2 days ago: Laparoscopic cholecystectomy Ambulate ad lib., self care Oral medications for pain IV discontinued at 8 A . M . To be discharged today with discharge teaching RM 602B Not occupied RM 603A Mrs. Henderson, 38, admitted yesterday Diagnosis : metastatic cancer to the brain CAT scan scheduled for 12 noon IV #2 1000 mL D5W with 20mEq. potassium chloride at 50 mL/hr. Assist with ADLs V ital signs and neuro checks every 4 hrs., I&O oral medications for pain RM 603B Miss Johnson, 70, admitted 3 days ago Diagnosis : pancreatic cancer with metastasis to the lungs Chair three times a day , and ambulate to bathroom V ital signs every 4 hrs. Spirometry every 4 hrs. with RT D eep breathing and coughing exercises every 4 hrs,

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez Nasotracheal suction PRN. IV #5 1000 mL D5W at 50 mL/hr. PCA pump for pain medication Chemotherapy IV daily RM 604A Mr. Scott, 64, admitted this A . M . Diagnosis : benign prostatic hypertrophy Surgery : TURP scheduled for 1 P . M . to return to the nursing unit N eeds pre - op teaching and a surgical checklist completed RM 604B Mr. Jackson, 37, admitted last night Diagnosis : torn ACL Surgery this A . M . at 7:30 -- w ill return to unit by 10:30 A . M . Continuous passive motion (CPM) ordered postop RM 605A Mrs. Price, 89, admitted 1 week ago Diagnosis : terminal heart failure, semi - comatose Complete ADLs, keep comfortable, turn and position every 2 hrs. Vital signs every 8 hrs., I&O, Indwelling urinary catheter to drainage IV #8 D5 /0 .45 NS with 40mEq potassium chloride at KVO (keep vein open) rate RM 605B Not occupied RM 606A Mrs. Fellipe, 28, admitted last evening Diagnosis : gastroenteritis for last 4 days Ambulate to bathroom, chair as tolerated Independent in ADLs V ital signs every 4 hrs., NPO, I&O IV #3 1000 mL NS with 40mEq potassium chloride at 125 mL/hr. RM 606B Mrs. Blake, 48, admitted yesterday Diagnosis : sickle cell crisis Bedrest until pain subsides V ital signs every 4 hrs., I&O, diet as tolerated Oral medications, folic acid, non - steroidal anti - inflammatory drug Narcotic analgesic medication for pain IV #3 1000 mL D5 /0 .2NS with 40mEq potassium chloride at 125 mL/hr.

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez 1. Determine the appropriate staff assignment for this client roster. What information do you need to complete this assignment? 2. How would you as team leader make client assignments for each individual staff member? 3. How do the theory of delegation and the facility/state policies of delegation impact on your assignment? 4. What additional factors would you need to consider in making these assignments? Scenario 2 You are assigned to provide nursing care for Mr. Fred Smith, 39 years of age. He is admitted to the hospital for severe dehydration due to the effects of chemotherapy. On your initial rounds at 7:30 A.M., you find him sleeping. His respirations are labored and stertorous. His color is ashen, eyes sunken, and skin dry. At 8 A.M. you enter the room and find him awake. He complains of being very thirsty and wants a glass of water. He cannot tolerate oral fluids and is receiving IV fluids with potassium chloride ( KCI ) added because of his nausea and vomiting on admission the day before. After taking his vital signs (T: 100.6; P: 100; R: 32) you give him his bath and make his bed. You notice he has reddened areas over his coccyx and on his elbows and heels, each area about the size of a quarter. His skin is dry and peeling. Drainage from his Foley catheter is a dark amber color with a very strong odor. You measure the urine at 8 A.M. The total is 75 mL. The last output was measured at 6 A.M. 1. How would you chart the information obtained from the simulated situation? What would be appropriate forms to use? 2. What assessment information (that you just charted) would require nursing interventions ? If you were assigning this client to a team member, who would be most appropriate — RN, LPN/LVN, or CNA? Scenario 3 You have just received your client care assignment. There are two stages of preparation. The first is obtaining all the necessary information you will need to provide safe care. The second stage is reviewing your reference materials to gain an understanding of the client’s diagnosis, medications, lab values, and diagnostic tests that will be done during his/her hospitalization . 1. If you have only limited time to review the client’s chart, what section s of the chart will pr o vide you with sufficient information to render you safe to care for the client? 2. In preparing for clinical practice, what information is essential to review in addition to the data you have obtained from the client’s record? Where is the most appropriate place to find this information? 3. List the priority interventions you will carry out within the first hour of the clinical exper i ence. Explain the rationale for your answers. Resolution Possibilities for Scenario 1 1. Review each client and determine the appropriate staff assignment based on the skill

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez level and Nurse Practice Act, and hospital policies and procedures. 2. An LPN/LVN cannot be assigned to do an initial complete physical assessment; it would be a s signed to an RN. Depending upon state practice act regulations an RN may be required to administer intravenous medications. 3. Ensure that the rationale for the assignment follows the principles of delegation. 4. The team approach should be used when assigning clients. Each staff member may be a s signed to a certain skill for a specific client. Examples follow: a. The RN will initiate PCA medications. b. The RN will be the team leader and other staff will report to the RN, who assumes r e sponsibility for client care. c. The LPN/LVN or RN can give oral meds. Depending upon state practice act the LPN/LVN may or may not complete discharge teaching. d. The RN must complete the initial physical assessment. e. The UAP can assist clients with ADLs, ambulation, baths, and beds. f. The UAP may take basic vital signs and accompany clients to surgery or discharge. The Nurse Practice Act provides guidelines for the different tasks each staff member may pe r form. While making assignments, it is important to remember that the more experienced and ed u cated staff (RN or LPN / LVN ) should care for the most critically ill clients. Clients who are not new admissions (who have already been assessed by an RN) and those about to be discharged may be assigned to UAPs. Resolution Possibilities for Scenario 2 1. Appropriate forms should be used, i.e., I & O Record includes IV (intake), indwelling urinary catheter drainage output, vomiting. 2. Fluid intake — can client take fluids PO now? Pressure ulcer — interventions to prevent from developing. 3. RN or LPN/LVN — continued assessment needs to be made and interventions made to prevent complications. Resolution Possibilities for Scenario 3 1. Client’s medical diagnosis, medications to be given during clinical, essential lab values for medication tests, if client has any allergies. 2. Information on medications from PDR and Drug reference texts. Information on medical dia g nosis from textbooks. Nursing skills protocols and procedures from skills text. Lab inform a tion from lab diagnostic text. 3. Complete hand hygiene, receive oral report from nurse, check Kardex or computer generated care plan for new client information, introduce yourself to your client, take vital signs, co m plete a focus assessment, and check that all medications are available in cart if not using Pyxis machine. Each of these tasks is designed to provide safe client care. Hand hygiene prevents the spread of microorganisms to the client. Checking medications and new orders is essential to provide accurate care for the

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez client. The focus assessment provides the baseline inform a tion on the client’s condition and promotes individualized client care.

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez Chapter 4 Communication and Nurse – Client Relationship TEACHING/LEARNING STRATEGIES Lecture – Discussion Write examples of therapeutic communication and blocks to communication on blank transpare n cies , smart board, or on the chalkboard before class begins. Discuss the importance of communication as the primary link between client and nurse and as the foundation for all nurse – client interactions. Review basic guidelines to communications. Laboratory Experience Ask the class to identify and discuss how specific communication techniques facilitate or block communication with their clients. Pair off students and assign them to role play a situation in which the nurse is assisting the client to • Describe an experience • Talk about feelings • Express needs Role play initiating a relationship with a client as a demonstration, then have students practice in pairs. Written Assignment Assign students in pairs to write actual examples of blocks to communication from a nurse – client interaction. Then have another student critique or correct it so that the nursing responses are more therapeutic. Resource Suggestions There are several excellent short video clips available through the internet. Search “Excellence in Nursing Communication” and review video clips prior to showing them in class. Practicingspanish.com provides common medical and anatomic words useful in providing care for those who speak Spanish as their first language. CRITICAL THINKING STRATEGIES Exercise 1 Assign each student to complete a process recording of an interaction or interview between the nurse and client. A process recording of a client and nurse is a working tool used to understand and analyze the interaction that occurred. Analyzing the components

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez of the interchange increases the student’s awareness of the communication process, the level of communication skills, and the student’s sensitivity to the client’s needs. Step 1 Give a brief introductory description of the client, client’s diagnosis, and context in which inte r action took place. Choose the most significant portion of the interaction (if it was long) or the section that results in the most learning as you analyze it. Step 2 (sample) What Client Says and Does* What Nurse Says and Does* Critique and Analysis *Record only what the client says and the client’s behavior, and what you respond (and your behavior). Step 3 After analyzing the interaction, how would you have responded differently to the client? Write your corrections or alternative interventions under the original response and let’s evaluate how much you can correct your own interventions. Exercise 2 A patient who has been admitted to your unit speaks very little English; Spanish is her first language. The admission diagnosis is ulcerative colitis, and she will be completing a work - up for a possible ileostomy. 1. What parameters should you include in the cultural sensitivity assessment? 2. If the client has an ileostomy, how will cultural diversity parameters fit into the discharge plan for this client? Resolution Possibilities for Exercise 2 1. When completing a total assessment on a client, the individual cultural components that would be important to include are: • Cultural background and orientation • Communication patterns • Nutritional practices • Family relationships • Beliefs relating to health, illness, and treatment • Values relating to health practices • Education • Religious practices 2. Cultural diversity implies the range of differences in values, beliefs, foods, customs, folklore, traditions, language and patterns of behavior. Because all of these aspects potentially affect how an individual experiences, copes with, and responds to illness, the nurse must pay atte n tion to them and incorporate these differences into the discharge plan.

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez • For example, the diet the client will be sent home on will be low - residue high - calorie until she becomes accustomed to the new routine for bowel evacuation. The foods on this diet should be part of her normal intake such as tortillas and other Hispanic food. She will need to increase fluids because of excessive fluid loss. • Because the initial care of an ileostomy is important, a Spanish - speaking nurse should be found to complete the discharge teaching. Scenario 1 A male, twenty - five years old, comes to the emergency department. He has a bleeding wound on his arm, and refuses surgical intervention when told he must remove his clothes and jewelry. 1. What effect would this client response have on the initial nursing plan of care? 2. What is your understanding of this client response? What are some questions you might ask the client? 3. Describe the strategies and goals you would devise to solve this problem. 4. Describe the measures you would implement to resolve this situation. Scenario 2 A client has just been admitted with a diagnosis of cancer of the rectum. He is scheduled for su r gery the next day. When you are completing an assessment and you ask about spiritual beliefs, the client says, “I’m a washed - out Catholic and I don’t think I’m going to live, so what’s the sense in talking about it?” 1. What would be the consequence of not responding to the client’s comments about spiritual beliefs? 2. How would the goals of establishing a nurse - client relationship and assessing spiritual beliefs overlap in this situation? 3. Describe the actions you would take to engage this client in a discussion about these issues. Resolution Possibilities for Scenario 1 1. Assuming that the initial plan was to treat the bleeding wound, this plan would have to change based on recent data. A sterile environment could not be maintained if the client r e fuses to take off his clothes and jewelry. 2. The first step in resolving this dilemma is to determine why the client refuses to take off his clothes and jewelry. Is he concerned that his personal items will be stolen? Is there some cu l tural or spiritual reason he does not wish to remove these items? 3. The strategies and goals should include finding out what lies beneath the client’s unwillin g ness to cooperate. The first measure would be to explain why the clothes and jewelry should be removed and what will be done with them. The next step is to determine if a cultural or spiritual issue (such as an amulet that he never removes) is present.

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez 4. Refer to question #1 when you describe measures to resolve this client dilemma. If the client continues to refuse to remove his clothes and jewelry, then you will have to devise a way to work around these restrictions in order to treat the client. Resolution Possibilities for Scenario 2 1. The consequence would be that the nurse is not dealing with the client’s spiritual issues which entail fear of dying and possibly regret that he has no one to turn to for spiritual co m fort. 2. One of the goals of the nurse - client relationship is to create an atmosphere of open commun i cation and trust. By responding to the client’s comment, the nurse would be addressing both issues, spiritual beliefs and open communication. 3. Arrange to spend quality time with the client using therapeutic communication techniques so that he feels comfortable in sharing fears. Bring up his feelings around being a “washed out Catholic,” spiritual topics, and ask if he would like to talk about spiritual or religious issues.

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez Chapter 5 Admission, Transfer, and Discharge TEACHING/LEARNING STRATEGIES Lecture – Discussion Discuss how hospitalization for elective vs. emergency treatment impacts both the client and the nurse. Discuss the important processes of client admission, transfer, and discharge. Discuss cultural differences and the influence belief systems have on illness and hospitalization. Review client’s rights and Patient Care Partnership brochure . (Chapter 1 in Clinical Nursing S kills , 9th ed.) Discuss the purpose for Advanced Directives and DNR instructions. Laboratory Experience Assign students to work in pairs. Have each student practice admitting a client. Use the standard hospital procedure and document according to hospital protocol. Assign students to begin a client care plan based on the findings. Written Assignment Assign students to write a short paper related to cultural values and how they affect the client’s hospitalization. Resource Suggestions Plan for a panel discussion by culturally diverse participants. The discussions should address the effects of hospitalization, dietary alterations, and rituals surrounding health and illness for diverse cultures. CRITICAL THINKING STRATEGIES Exercise 1 The nurse has been assigned to transfer a woman from the cardiac critical care unit to the step - down unit. The client is refusing to be transferred. Develop several questions to help assess the causes of this situation and help to resolve it. Resolution Possibilities for Exercise 1 Several questions that might be asked are: How is the client feeling right now? Can she talk about her fears? What does she imagine happening when she is transferred? What about the transfer is frightening?

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez Scenario 1 Mr. Moore has been told by his cardiologist that his coronary arteriogram indicates he has three - vessel disease and he is a candidate for coronary artery bypass surgery. The surgery is scheduled and Mr. Moore is welcomed at the facility’s preadmission testing unit one week before admi s sion for preliminary blood work and preoperative instructions. At this time he receives information about his expected clinical course, which includes a multidisciplinary plan of care. 1. What is the advantage of providing the client with information this far in advance of surgery? 2. What is included in the plan of care? 3. Who participates in the development of the plan of care? 4. How does the plan of care facilitate the client’s admission, transfer, and discharge pro c esses? Are there drawbacks? Scenario 2 Marilyn James, age 45, has been admitted to the hospital for corrective back surgery for a herniated disc. She was expected to be discharges the next day. During surgery, she experienced a complication (dural tear) and is required to be on bed rest for an extended period of time, delaying her discharge by several days. After hearing the news , she says she’s going to leave the hospital AMA . She “wasn’t prepared for prolonged hospital i zation” and has to go home to care for her 3 - year - old granddaughter and elderly mother who live with her. 1. What right does a client have to leave the agency prematurely, AMA? 2. What should the nurse’s initial response to this client be? 3. How can the nurse advocate for this patient? 4. What are the usual procedures involved in discharging a client AMA? 5. How is this process documented in the client’s record? Resolution Possibilities for Scenario 1 1. Early information provides anticipatory guidance for the client, answers many questions and explains many unforeseen events. A client who knows what to expect is less anxious, and generally has a smoother transition throughout the hospital course. As a result, discharge is earlier and cost outcomes are better for the hospital. 2. The plan of care outlines daily care goals and related expected interventions for the client with a selected health care problem. A target date is set for the client’s discharge (hospital stay of 5 days). Plans of care vary among hospitals. Most are designed for more common and predictable elective procedures, (total joint r e placement, heart surgery, prostatectomy), but they exist for unanticipated hospitalizations as well (brain attack, pneumonia). While the plan of care usually has a coordinator, all relevant disciplines are partners in planning and targeting the client’s progress. The track helps the client to know what will happen, where it will happen, when it will happen, why it will happen, and who

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez will be i n volved . Clients who receive plan of care information before admission have an opportunity to: • Understand the types of care providers they will encounter (RT, PT, OT) and their roles. • Prepare for diagnostic studies, laboratory tests. • Expect special equipment or monitoring and understand the rationale for their use (mon i tors, chest tubes, ventilator, dressings). • Understand that transfer to a “step - down unit” indicates a positive postoperative pr o gress. • Participate in their own care by adhering to certain restrictions (e.g., activity, diet), expe c tations (e.g., deep breathing, wound splinting, early ambulation), and informing the nurse of subjective needs (e.g., pain management). • Know about the availability of special resources (e.g., chaplain). • Anticipate a projected daily improvement in status that encourages the client’s active pa r ticipation in recovery and timely discharge. • Possible drawbacks to having access to the plan of care include : • Staff’s failure to recognize the need to individualize the care plan due to an unyielding f o cus on the written plan. • Cultural orientation that may not emphasize planning for the future or self - care. • Client’s inability to understand the provided information due to literacy or language limit a tions. • Confounding co - morbid medical states (e.g., diabetes mellitus) that may deter the client’s projected clinical progress. • Client’s feeling of “failure” if projected goals are not met. • Understand that transfer to a “step - down unit” indicates a positive postoperative pr o gress. Resolution Possibilities for Scenario 2 1. Competent clients have the legal right to accept or refuse treatment. 2. The nurse should try to determine why the client wants to leave prematurely. Family or e m ployment obligations, commitments, dissatisfaction with care, lack of understanding. Disco v ering contextual influencing factors facilitates adaptive planning so that the client’s needs can be met while completing the prescribed course of treatment. The nurse should also reinforce the physician’s orders (need for bed rest ). Possible consequences of discontinuation of antibiotic therapy should be emphasized (e.g., the condition may worsen, further surgery may be required). Notify the client’s physician about her intent to leave AMA and request that he/she talk with the client.

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez 3. The nurse functions as an advocate for the client by supporting the client’s self - determination while also functioning as an intermediary between the patient and the health care team. Advocacy includes assisting the client to make informed decisions, suggesting possible alte r natives, and soliciting the expertise of a discharge planner, case manager, social worker, or other relevant team member. It is possible that arrangements can be made for family or neighbors to assist her with her commitments. 4. Follow the agency’s protocol for handling an AMA discharge. Provide any prescriptions, special care instructions, follow up information. Witness the client’s signature on the agency’s “Against Medical Advice” form, including the date and time the decision for leaving was made, or note on the form that the client refuses to sign, obtain signature of a witness, notify appropriate hospital personnel, and complete a variance report. 5. Documentation includes reasons given by client for leaving AMA using the client’s own words. Include any options discussed as well as warnings about risks of leaving prematurely, any prescriptions, information, and follow up instructions provided. Included the client’s telephone number, and the name of persons accompanying the client upon discharge.

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez Chapter 6 Client Education and Discharge Planning TEACHING/LEARNING STRATEGIES Lecture – Discussion Discuss the assessment of client readiness and level of understanding necessary for teaching to be effective. Discuss the various health team members’ roles in discharge teaching and planning. Discuss the role of the discharge coordinator in the hospital and community health setting. Laboratory Experience Assign students to review standard discharge plans for a selected number of client conditions. Clinical Experience Assign each student to a discharge coordinator or nurse who is formulating a discharge plan and is completing discharge teaching. Have students review discharge criteria, procedures, and policies in the hospital. Assign students to complete a discharge plan for an assigned client, including client teaching. Resource Suggestions Arrange to have students work with the hospital discharge coordinator for a day. Arrange to have students accompany a discharge coordinator for a home visit to a client they have helped prepare for discharge, including assisting with the discharge teaching plan. The pu r pose of the visit is to evaluate the effectiveness of the plan. CRITICAL THINKING STRATEGIES Exercise 1 Following a myocardial infarction, a client is to be discharged in 3 days. Evaluate the factors the nurse should take into consideration when planning the teaching strategy as part of the discharge plan. Exercise 2 You are responsible for selecting teaching adjuncts for a client with newly diagnosed diabetes who requires hourly insulin injections. What are the options available? Resolution Possibilities for Exercise 1 Evaluate factors that influence appropriate strategy: 1. Input from client about how he or she learns best.

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez 2. Specific task or nature of the content to be transmitted and how it is best learned. 3. Client attention span and retention ability. 4. Teaching materials and resources available. 5. Time, availability, skills, and abilities of staff; appropriate use of paraprofessional and pr o fessional staff. 6. Participation by members of other health care disciplines as part of a team. 7. Determination of most appropriate time for teaching. The different types of teaching strategy. Note which one(s) would be most effective in this situ a tion. 1. One - to - one education: may use demonstration - return demonstration techniques, role playing, games, or teach - back strategies among others. 2. Group teaching using videotapes or similar technology. 3. Computer - aided instruction 4. Internet resources Resolution Possibilities for Exercise 2 Teaching adjunct possibilities. 1. Videotape or videocassette programs. 2. CDs and computer programs. 3. Films. 4. Slide and tape presentations. 5. Programmed instruction materials. 6. Books. 7. Pamphlets and other written handouts. 8. Diagrams, charts, and illustrations. 9. Support group of other diabetics. Scenario 1 Mr. John Johanson, age 58, was admitted to the medical unit with a diagnosis of congestive heart failure. He is African - American, 5'7", and weighs 260 pounds. He is a cross - country truck driver. He lives alone when not working. He usually watches TV and eats fast foods or frozen dinners. This is his second hospital admission in the last month. His vital signs are: BP 230/108, P 108 and irregular, R 36. He has bibasilar rales, and a 3+ pitting edema of the lower extremities. His point of maximal impulse (PMI ) is at the sixth intercostal space (ICS), midaxillary line. He states he is short of breath and has had difficulty ambulating the last few days. He states he has tried to lose weight but even after dieting , he gains more weight back. When asked about his smoking ha b its, he states

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez he knows he is not supposed to smoke and he has tried to stop, but with his work it is too difficult because he is alone so much. He states he is on blood pressure drugs, but unsure of the name. 1. Identify the current nursing diagnoses by priority and provide rationale for answers. 2. From these data, identify the teaching needs by priority and develop a teaching plan for Mr. Johanson. 3. Are there any cultural considerations that need to be taken into account when considering his teaching plan? If so, identify actions you will take relative to the cultural considerations. 4. Briefly outline how you will determine when it is appropriate to initiate the teaching plan. 5. Describe the discharge plan you might develop for Mr. Johanson. Scenario 2 A very young mother brings a 6 - month - old child to the emergency room and tells the triage nurse that she doesn’t know what is wrong with her child, but the child does not seem to be “normal.” The child is assessed by the pediatrician and is admitted for further testing. The pediatr i cian’s admitting diagnosis is failure to thrive . T he child’s weight is only 5 pounds over what it was at birth (7 lb 2 oz), and the child is still not turning over from back to front. As the admitting nurse, you need to begin the discharge plan and the teaching plan. Based on the limited inform a tion from the physician and the admitting diagnosis, complete the following scenario. 1. What information will you need to obtain before you can plan for discharge? 2. What information is necessary to obtain before you can develop a teaching plan? 3. What approach will you take with the mother in order to obtain the necessary information for both the discharge and teaching plan? 4. Describe the nurse’s role in client teaching for this mother. Resolution Possibilities for Scenario 1 1. Nursing diagnoses include by priority: impaired gas exchange; impaired physical mobility; ineffective self - health management ;; imbalanced nutrition; more than body requirements. Rationale should include some pathophysiology related to the nursing diagnosis, severity of symptoms, and potential outcomes as a result of symptoms. For example, Ineffective self - health management should include the fact that he was readmitted to the hospital within one month. He knows he is supposed to stop smoking, but hasn’t; his weight is very high for his height. The pathophysiology should include a statement regarding the effect of smoking on the resp i ratory system, as well as on the cardiovascular system. 2. Teaching needs should include: nutrition, medications, exercises, and positioning for adequate gas exchange while in bed (considering weight and symptoms of fluid volume overload). The teaching plan should include determining readiness to learn,

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez content, teaching strategies, and evaluation plan. 3. Mr. Johanson is African American; therefore, cultural considerations would include dietary issues, determining if he is active in his church (this could provide support for Mr. Joha n son), and discussion on any ideation related to punishment from God for his health - related problems. The nurse should also consider the cultural requirements of Mr. Johanson’s profession. 4. Base your answers on information provided in the skills found in Unit 1 of this chapter. 5. Discharge planning should include the teaching that is needed. It should also include a referral for smoking cessation support and nutrition counseling. The nurse should also help Mr. Johanson access and review on - line health information specifically focused at long - distance truck drivers. Optional Assignment Based on the scenario, ask the students to develop a teaching plan and be prepared to role - play the teaching for one of Mr. Johanson’s learning needs. Select a student to play the client. This student can be given cue cards on what to say, how to behave, and responses to make as the i n formation is presented. The cue cards should indicate that the client is not responsive to the teaching and tells the nurse he knows all about his drugs. Make the client very noncompliant. At the completion of the role play, have a debriefing with the students to elicit their feelings about trying to teach a noncompliant client. What would they do differently? What would their next step be in the teaching process? What lessons have they learned from this experience? Resolution Possibilities for Scenario 2 1. Where will the mother and child be discharged? Will there be any psychological support for the mother? Does the mother have insurance or does she have Medicaid? Depending on the need for additional nutrition, does she have the finances to manage the cost, or is a referral needed to assist with the finances? Is there need for a social service referral? 2. Determine the best method for teaching the mother about infant care and in particular, about failure to thrive. What is her reading level? Can she understand written information? Does she need to have the information translated into another language? What is her knowledge base about infant care? Identify her specific learning style, in order to best prepare the teaching plan that will meet her needs. 3. Ask her about the child’s normal day. How and what does the child eat? How long does the child sleep during the day? What type of stimulus and encouragement is provided to assist the child to turn over? 4. Identify the client’s reading level, and the appropriate teaching strategy based on learning style. Ensure that both written and verbal information is presented multiple times during the child’s hospitalization. Demonstrate necessary skills the mother will need to care for the child after discharge. Then, have the mother return the demonstration in order to determine her understanding and ability to perform the

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez skill. Repeat and enhance teaching points until the mother successfully performs return demonstration and exhibits understanding.

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    Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez Chapter 7 Safe Client Environment and Restraints TEACHING/LEARNING STRATEGIES Lecture – Discussion Discuss the legal, ethical, and accountability issues of using restraints. Identify alternatives to the use of restraints. Demonstrate the safe application of various types of restraints. Demonstrate the use of various types of equipment to ensure safety for clients, staff, and peers. Compare the level of environmental stimuli in various units of the hospital. Plan a post - conference discussion with the agency’s radiation physicist covering the diagnostic and therapeutic use of radiation. Discuss the components of a home environment safety assessment . Discuss sentinel events and “never events.” Laboratory Experience Have students apply restraints on each other. This experience helps them to identify the feelings of a client who is restrained. In the skills laboratory, have students practice “evacuating” each other from a bed, using a variety of techniques, to determine own preference if ever needed. Written Assignment Review and test students on hospital fire procedures. Examine agency’s clinical restraint protocol documentation forms. Clinical Experience Identify the types of fire extinguishers in the clinical facility. Role play a fire drill, using the same procedure used in the hospital. Resource Suggestions Practice using fire extinguishers, enlisting help from an expert. Usually the local fire department will come and demonstrate the fire extinguishers and allow each person to practice. CRITICAL THINKING STRATEGIES Exercise 1 Your client will be discharged immediately after receiving treatment with radioactive iodine. The following exercise relates to his care: 1. What protective measures are indicated for personnel ? ?

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