CNL Certification CNL Certification Exam ReviewExam Review

SystemsSystems

Macro vs. Micro systemsMacro vs. Micro systems

MicrosystemsMicrosystems Assess, Diagnose, Treat, EvaluateAssess, Diagnose, Treat, Evaluate All players including patientAll players including patient

Health Care ImprovementHealth Care Improvement

Quality Improvement( CQI, QA)Quality Improvement( CQI, QA)

Risk ManagementRisk Management Sentinel eventsSentinel events Patient injuryPatient injury

Outcomes ManagementOutcomes Management

Advanced Med SurgAdvanced Med Surg

Key populationsKey populations

Safety Safety

MedsMeds

Emergency/critical thinkingEmergency/critical thinking

VaccinesVaccines

Chronic illnessChronic illness

GerontologyGerontology

Care Issues- Vulnerable Care Issues- Vulnerable PopulationsPopulations

Groups of persons who may be compromised in their ability to giveGroups of persons who may be compromised in their ability to giveinformed consent, who are frequently subjected to coercion in theirinformed consent, who are frequently subjected to coercion in theirdecision making, or whose range of options is severely limited, decision making, or whose range of options is severely limited,

makingmakingthem vulnerable to health care quality problems.them vulnerable to health care quality problems.

ChildrenChildren All infants, children, and adolescents, i.e., all individuals who have All infants, children, and adolescents, i.e., all individuals who have

not reached the legal age for consent.not reached the legal age for consent.DisabledDisabled

Persons with physical or mental disabilities that affect or limit their Persons with physical or mental disabilities that affect or limit their activities of daily living and that may require special activities of daily living and that may require special accommodations. These include cognitively disabled, accommodations. These include cognitively disabled, communicatively disabled, mentally disabled, and physically communicatively disabled, mentally disabled, and physically disableddisabled

Frail ElderlyFrail Elderly Older adults or aged individuals who are lacking in general strength Older adults or aged individuals who are lacking in general strength

and are unusually susceptible to disease or to other infirmityand are unusually susceptible to disease or to other infirmity

HomelessHomeless Persons who have no permanent residence, Persons who have no permanent residence,

including children and adolescents with no fixed including children and adolescents with no fixed place of residence.place of residence.

Illiterate/Low-literate PopulationsIlliterate/Low-literate Populations Persons with low levels of education.Persons with low levels of education.

ImmigrantsImmigrants Persons coming into a country of which he or she Persons coming into a country of which he or she

is not a native for the purpose of setting up is not a native for the purpose of setting up residence. This category is also defined to include residence. This category is also defined to include refugees, asylees, and undocumented aliens or refugees, asylees, and undocumented aliens or immigrants.immigrants.

Medically UninsuredMedically Uninsured Mentally IllMentally Ill Minority GroupsMinority Groups

Non-English Speaking PopulationsNon-English Speaking Populations

Poverty PopulationsPoverty Populations PrisonersPrisoners

Rural PopulationsRural Populations Terminally IllTerminally Ill

Transient/MigrantsTransient/Migrants Urban PopulationsUrban Populations

WomenWomen

IOMIOM

Care IssuesCare Issues Frailty associated with old age - preventing falls and Frailty associated with old age - preventing falls and

pressure ulcers, maximizing function, and developing pressure ulcers, maximizing function, and developing advanced care plansadvanced care plans

Hypertension - focus on appropriate management of Hypertension - focus on appropriate management of early diseaseearly disease

Asthma - appropriate treatment for persons with Asthma - appropriate treatment for persons with mild/moderate persistent asthmamild/moderate persistent asthma

Cancer screening that is evidence-based - focus on Cancer screening that is evidence-based - focus on colorectal and cervical cancercolorectal and cervical cancer

Care Coordination (cross cutting)Care Coordination (cross cutting)

Immunization - children and adultsImmunization - children and adults

Ischemic heart disease - prevention, reduction of Ischemic heart disease - prevention, reduction of recurring events, and optimization of functional recurring events, and optimization of functional capacitycapacity

Major depression - screening and treatmentMajor depression - screening and treatment

Medication management - preventing medication Medication management - preventing medication errors and overuse of antibioticserrors and overuse of antibiotics

Nosocomial infections - prevention and surveillanceNosocomial infections - prevention and surveillance

Obesity (emerging area)Obesity (emerging area)

Pain control in advanced cancerPain control in advanced cancer

Pregnancy and childbirth - appropriate prenatal and Pregnancy and childbirth - appropriate prenatal and intrapartum careintrapartum care

Self-management/health literacy (cross-cutting)Self-management/health literacy (cross-cutting) Severe and persistent mental illness - focus on treatment Severe and persistent mental illness - focus on treatment

in the public sectorin the public sector

Stroke - early intervention and rehabilitationStroke - early intervention and rehabilitation

Tobacco dependence treatment in adultsTobacco dependence treatment in adults

Children with special health care needsChildren with special health care needs

Diabetes - focus on appropriate management of early Diabetes - focus on appropriate management of early diseasedisease

End of life with advanced organ system failure - focus on End of life with advanced organ system failure - focus on congestive heart failure and chronic obstructive pulmonary congestive heart failure and chronic obstructive pulmonary diseasedisease

Exam ContentExam Content

Illness/Disease Management Illness/Disease Management

Knowledge Management Knowledge Management

Health Promotion and Disease Prevention & Health Promotion and Disease Prevention & Injury Reduction/Prevention Management Injury Reduction/Prevention Management

Evidence-Based Practice Evidence-Based Practice

Uses clinical judgment and decision-Uses clinical judgment and decision-making skills to make clinical decisions making skills to make clinical decisions regarding patient care decisions, regarding patient care decisions, delegation of patient care activities, and delegation of patient care activities, and nursing care outcomes nursing care outcomes Uses care management skills and Uses care management skills and principles to provide and supervise client principles to provide and supervise client care within specific episodes and across care within specific episodes and across episodes of illness and disease episodes of illness and disease

Exam ContentExam Content

Illness/Disease ManagementIllness/Disease Management

1. 1. Assumes responsibility for the provision and management of care at the point of care in and across all environments

2. Provides care at the point of service to individuals across the lifespan with particular emphasis on health promotion and risk reduction services

3. Performs a comprehensive health assessment, including a comprehensive history and physical assessment

4. Identifies patient problems that require intervention, with special focus on those problems amenable to nursing intervention

16. Uses advanced knowledge of pathophysiology and pharmacology to anticipate illness progression, response to therapy and to guide/teach patients and families regarding care

CHFCHF

Treatment goals:Treatment goals: Prevent initial cardiac injuryPrevent initial cardiac injury Prevent further injury; aggressive tx post MIPrevent further injury; aggressive tx post MI Prevent post injury deterioration( ACE)Prevent post injury deterioration( ACE) General txGeneral tx Prevent life threatening complications: PEPrevent life threatening complications: PE

COPDCOPD

Stop smokingStop smokingBronchodilators; short term, long termBronchodilators; short term, long termSteroidsSteroidsAntimicrobialsAntimicrobialsOxygen- acute and chronicOxygen- acute and chronicVaccinesVaccinesPulm rehabPulm rehabSurgerySurgery

High Alert MedicationsHigh Alert Medications

Insulin, Oral hypoglycemicsInsulin, Oral hypoglycemicsAnticoagulants-Heparin...Anticoagulants-Heparin...ThrombolyticsThrombolyticsChemo agentsChemo agentsAdrenergic agonists- epinephrine, norepinephrineAdrenergic agonists- epinephrine, norepinephrineAdrenergic antagonists- Beta blockersAdrenergic antagonists- Beta blockersAntiarrythmics- LidocaineAntiarrythmics- LidocaineAnesthetic agentsAnesthetic agentsDextrose, hypertonic- Dextrose, hypertonic- >>20%20%Epidural agentsEpidural agentsSedativesSedativesOpiatesOpiatesTPNTPN

Source: www.ismp.org

MedicationsMedications

AntihypertensivesAntihypertensives (il) ACE inhibitors (il) ACE inhibitors LisinoprilLisinopril Ol) Beta blockers Ol) Beta blockers MetaprololMetaprolol (tan) Aldosterone II receptor blockers(tan) Aldosterone II receptor blockers (ine) Ca Channel Blockers (ine) Ca Channel Blockers NifedipineNifedipine Antiadernergics ( dilationAntiadernergics ( dilation) Aldomet/Methyldopa) Aldomet/Methyldopa VasoldilatorsVasoldilators Human B-type natriuretic peptides Human B-type natriuretic peptides DiureticsDiuretics K, K K!!!!K, K K!!!! Fluid balanceFluid balance

AnticoagulantsAnticoagulants Antithrombin ( newer drugs)Antithrombin ( newer drugs) Platelet inhibitors : Platelet inhibitors : clopidogrelclopidogrel, , ticlopidineticlopidine HeparinHeparin Coumarins( Warfarin)Coumarins( Warfarin)

Insulin controlInsulin control

Hypoglycemic agentsHypoglycemic agents

EmergencyEmergency

Prevent sentinel eventsPrevent sentinel events RRTRRT

Principles of TriagePrinciples of Triage

Critical lab valuesCritical lab values

Pain managementPain management

When and how much???When and how much???

Case 1: Mrs. S was diagnosed with Type II Diabetes 6 months ago. She has been admitted twice with HHNKC. This admission she came in with a BG of 650, and was barely conscious. Her English is limited and she has few financial resources.

Case 2

Mr. J is receiving palliative care for terminal cancer of the stomach. His pain meds do not seem to be effective. He is somewhat confused but moans constantly. The nurses on the unit seem reluctant to give him the prescribed medication. You have noticed that the nurses do not medicate unless the patient asks for the pain meds

Case 3The patient, Mrs. B, in room 12 is complaining of tightness in her chest; she is pale and diaphoretic. Her VS are as follows: (98/54, 103, 24, SaO2 89%.She has an IV at kvo rate. You have left another RN in the room with her and you now have to reach the MD..

What do you suggest be done to solve this What do you suggest be done to solve this problem?problem?

Who should be involved in the problem Who should be involved in the problem solving? solving?

What are the important considerations What are the important considerations during the problem solving process?during the problem solving process?

What CNL roles and competencies apply What CNL roles and competencies apply to this scenarioto this scenario

Case 4 A nurse working on a medical nursing unit during an external disaster

is called to assist with care for clients coming into the emergency room. Using principles of triage, the nurse initiates immediate care for a client with which of the following injuries?

a. bright red bleeding from a neck woundb. b. penetrating abdominal injuryc. fractured tibiad. open massive head injury in deep coma

Case 5Furosemide( Lasix) 40 mg po has been prescribed

for a client. The nurse administers 80mg at 10:00 am. Following discovery of the error, the nurse completes an incident report. Which of the following would be documented on the report?

a. Lasix 80mg was given instead of 40mgb. The wrong dose of medication was given to the

client at 10 amc. Lasix 80 mg administered at 10amd. I meant to give 40mg but I was rushed to help

another patient and I gave the wrong doseThis has been the 4th Lasix error on the unit this

month

Case 6Case 6 The physician’s order reads heparin sodium 25,000 The physician’s order reads heparin sodium 25,000 units in 250ml, 5% Dextrose in water to run units in 250ml, 5% Dextrose in water to run continuously at a rate of 800 units per hour by IV, continuously at a rate of 800 units per hour by IV, The nurse sets the pump to how many ml per hour? The nurse sets the pump to how many ml per hour? a. 8a. 8b. 32b. 32c. 40c. 40d. 80d. 80

What is the significant problem with Heparin that led to What is the significant problem with Heparin that led to use of Lovenox?use of Lovenox?

What are the nursing issues if the patient is going to What are the nursing issues if the patient is going to take Lovenox at home?take Lovenox at home?

Case 7Case 7 The mouth care measure that should be used The mouth care measure that should be used

with caution by the nurse when the client has with caution by the nurse when the client has a nasogastric tube is:a nasogastric tube is:a. regularly brushing teeth and tongue with a soft a. regularly brushing teeth and tongue with a soft

brushbrushb. sucking on ice chips to relieve drynessb. sucking on ice chips to relieve drynessc. occasionally rinsing mouth with a nonastringent c. occasionally rinsing mouth with a nonastringent

solution and massaging gumssolution and massaging gums

d. application of lemon swabs and glycerin to the d. application of lemon swabs and glycerin to the lipslips..

What other complications may occur when a What other complications may occur when a patient has a NG tube ?patient has a NG tube ?

How do you prevent these?How do you prevent these?

Case 8Case 8Forty-eight hours after a nephrectomy, a client complains of Forty-eight hours after a nephrectomy, a client complains of increasing nausea and abdominal pressure. The nurse’s first increasing nausea and abdominal pressure. The nurse’s first nursing action is: nursing action is: a. change the client’s position to relieve pressurea. change the client’s position to relieve pressureb. ausculatate bowel soundsb. ausculatate bowel soundsc. administer a rectal tube to relieve flatusc. administer a rectal tube to relieve flatusd. administer 6mg Morphine SO4 as ordered for the relief of discomfortd. administer 6mg Morphine SO4 as ordered for the relief of discomfort

You also find that he has a rigid abdomen and is diaphoretic. What will You also find that he has a rigid abdomen and is diaphoretic. What will you do now?you do now?

You have patient who is being treated for You have patient who is being treated for clinical depression while he is on the clinical depression while he is on the Med-Surg unit for exacerbation of his Med-Surg unit for exacerbation of his liver disease and GI bleedingliver disease and GI bleeding

What are the issues? What are the issues?