San so and I only and they're supposed to leave tomorrow so I had to take care of that I got I got all this working for the class and so of course all these things you know teacher mom multitasker insane you got your moms and dads now right um things happen but I'm on let me see if I could I'm hoping I could do this know right I just need a second so there okay I just have way to okay I just have way too many FS I already have the other one it's not so bad today um and there's three PowerPoints but they're very um chapter one two and five and chapter five is the one I posted on the announcements okay see if I blend thing clean or dirty I just rinsed it but it's pretty clean what you think yeah just rinse it with hot water and that's it that's what I'm going to do I didn't put milk or anything say thank you to your dad oh you just burped in my face you jackass go away go Harley okay I know to okay I'm gonna um I just get second I'm gonna open up my P let's going can you see the full screen we see something but not a full screen yeah overlap kind of yeah I don't like yeah okay let me see if I could highlight I'm going to um and I'm going to make it a full part I could going to connect my monitor maybe the next break I'm going to move you guys up to the top I might not be able to see you guys I think this is what I'll do it I'll see the screen okay and I'm gonna put this can you see the whole screen did I do that yes yes okay okay this is the way it's going to be just um when we have another break I'm going to see if I can connect this monitor this HDMI I I can't get it going so let me go ahead and I'm gonna put it on um show right from the start okay can you see that guys yes thank thank you guys I know it's kind of weird and I don't want to look at myself St I'm try to look at okay you guys are the top of my screen oh goodness it's it's a great thing okay so yeah so I got to go through some of the general um some of you are lbn and CNAs and some of you are students which is great um you're not missing too much but I kind of want to talk about some of the basic concept for Med search nursing some of it will go pretty quick some of it I'll I'll elaborate more but the first two PowerPoints are very dry and this is the on from the book okay so I will try to emphasize the most important one um concept that we need to know for these Powerpoints and again for the quizzes and for the test I will go ahead and give you some guidance on that okay and I just saw an email from oh I'm sorry that's not your class the other class never mind scratch that okay so um you know Med search it's basically from 18 to 100 and a lot of you already working in in the setting um it's not includes the hospitals the um skilled nursing facilities Ambulatory Care and the community um under 18 is going to be Pediatrics and that's going to be in the upcoming terms and this is the book that we're going to use and you know for Med search nursing um you know you have to have knowledge on and this is where I can't decide oop sorry can you see all that okay um care coordinators caregivers patient Educators and leaders and advocates for the um patient and family all of those um cons constitute the medical surgical um team as part of Med search nursing um they call ksa's Knowledge skills and and attitudes and this is a important concept cusin houon means um quality and safety education for nurses and you're going to see couston thrown a lot um not only in nursing school but in the hospital and they do set some guidelines and regards to patient safety how we as nurses provide patient Center Care and it's not just the nurses and the doctors and the therapists we all work together as a this interdisciplinary health Team and everything that we do nursing is Evan spased and so it constitutes evidence-based practices and also quality improvement in patient care and we are going to be using a lot of informatics such as the um the computers and I can see I'm just trying to see I this is too okay I'm sorry that part of my slide is cut off but it's okay you're not missing much I'll let you know um if whatever it's not shown on the screen that you're missing okay so you know Med search nursing I talk you know we talk about patient centered care that's the theme and the interprofessional team and some of you have um seen in clinicals maybe you did your first clinical in fundamentals in a SK Nursing Facility um you do have some experiences working with the inter you know the other healthc care um professionals so this basically what we s the other slide regarding evence based practice and quality improvement but we are going to like these question on the exam there we are going to try to get you um geared and prepared to make judgments independently and think systems wise and we are going to look at the ethics of why um certain decisions are done the way they are sometimes there is going to be some conflict their ethics and what is done the hospital and what it said in the book that's going to happen all the time it happens today I see it and also the last B points says Healthcare disparities and that is a big Hot Topic right now um especially um in the recent years for example um African-Americans blacks um there's been discussion regarding their lack of access to labor and delivery um care maternity care and it um blacks especially and I just went to a conference and one of the guest speakers she was black from Mrs um African-American from um Louisiana and she spoke about how um the struggles of women trying to access um care and you know what I'm sorry it's going to get worse especially know and I know I hate I don't want talking about politics it's just crazy as it is right now but one of the topics out there for healthcare professionals is um the right to choose and pro life and no matter where you are on you know whatever your beliefs are um it's going to be a challenge for women to seek care and so especially there's disparities now trying to get maternity care you are you do see a movement of women going um like Texas I believe has trying to really push the pro life so people who um not necessarily want to have an abortion and that's their right too but they are advised through their doctors okay if you don't get this termination um your Life's a Jeopardy so those situations they're still even holding the women accountable so um and do you see doctors um their practices are in Jeopardy because um they're providing this um services to the women so you see a lot of turmoil right now and other states like Alabama and Tennessee they're trying to follow suit of that and so that's for the healthcare disparity so that's an example um African black women um accessing maternity care you see with um and people of color um Hispanics um in Hawaii um in in our where I live I think it's just um we just don't have enough hospitals there's only one main hospital where I live um in the island and so um you see that I think you see it everywhere but um just keep your eyes open to that I just see some people no I didn't call you go away you're putting drool everywhere people having technical issues okay so patient care center um patient Center Care again we are gonna try to focus even though you know no matter how many patients we are on patient center care and things that to consider is that each patients have their own um they have autonomy as far as um making their own decisions whether they make the decisions or they assign someone through an advanced directive or a a legal other legal documents of who's going to um make their um their choices and so you have to consider their cultural um you want to make sure um and that's most hospitals are very good at that right now before you start U orientation even the clinicals you have to um be aware be culturally sensitive and also look at people's values and also um Family C care that's like the key thing for joint commission um during Co it was a little um challenging because people were separated you see those sad stories that people were not being able to be with their ones when they pass just because they're trying to prevent this um the spread of Co and we'll talk more about that emiology but we do try um to get family centered care um involved families involved as much as possible especially when we're in the maternity setting as well you'll see that so you know we mentioned about the values and um some of the attributes you know we want to make sure they stay in form and we give them communication and if English is not their second language then we make sure that we have the proper things in place such as a translator line and we make sure that they get enough blankets um pillows emotional support because they maybe uh even though we're we get so caught up in being in the hospital sometimes we forget that there's a patient in that bed and we have to make oursel you know nursing is caring too you can have all the technical stuff in the world like learning IV giving the medication process um giving meds um doing a a procedure but we need to be show caring and show that we listen we communicate and we really pay attention to the person's needs and even if you're in the middle of a midp pass and um your patient has an acent they have to have they have a um they have a bow movement you stop everything you help the patient that nurses aid can't be every single patient you guys all work together as a team and hopefully in your clinical you guys could partner up in the clinical and work together as a team when you do these tasks so some I think one of you mentioned that you want to work with geriatrics it's great um then there's right now you know especially today's times we have gender Health considerations um you know with the lgtbq look at this one I know lbq but now they have I a2s plus it's a lot okay there lesbian gay B so all of those components you know make sure you really be more sensitive to the gender um you have the veterans especially now a lot of wars and conflict in the world you know just need um so you're going to have veterans that go out there and fight you know for United States freedoms LGB i2s they're going to a lot of them are G to have PTSD so they need some special consideration and then you live in Los Angeles we work in Los Angeles so you have people from different cultures you have Korean you have hispanic Mexican El Salvador um just to name a few um even the Nigerian um and then you have the um the island blocks like the Jamaicans and then they have different types of um religious preferences Islam um Hindu um Jewish you know the big Jewish thing right now because we're talking B strip this is a lot so again just I think everyone should just be patient each other and kind with each other and um yeah go from there and it's also genetic considerations as well and they do have um some integrated therapies and I am I am big on um on Chinese medicine my husband and I we do fast four times a year and I do I can't afford it right now but I love acupuncture and um we do um pong where we do a lot of meditation and there's also like in the hospitals they have pet therapy very therapeutic for patients if they're don't have allergies to the um to the pets and there's some other ones to like massage therapy and exercise some of you just have stated you like what gym and there's aroma therapy to all kinds of therapies music therapy for example so care coordination and you know we don't work we we have our own patient assignments as nurses we we but we truly do work together as a team and so communication we try to organize the patient activities they try to give the senior nurses the more complicated patients they try if you're a new nurse they try to have you usually have a mentor even if you're out of orientation to help you so once you become a nurse you should try to find a training program it's kind of you're kind of entering nursing in a good time because uh I do help our students find um placements um after they become RNs and at least here in the islands in the Big Island we do have a hospital that provides a year-long training program and some hospitals in the in California Los Angeles that have yearlong training programs and then even if you don't get a whole year to get at least six months so and after you finish that you you do meet people you could consider as a mentor and hopefully they will even if you get these patient assignments they could help you along the way and do things there are you won't feel comfortable for at least a year or two being alone and even if you're LVN going into the RN being an ran is a completely different go as you as you know you might be able to have experience with assessments and doing tasks but just the coordination ourn are the managers so just coordinating between the providers and other nurses and Admissions and discharge I still get it's still lot that's why I prefer night sh I he admissions that s get some emergency rooms and also facilities and um it's a lot of coordination not just straight up um provision care and so like even Francisco being administrator you you appreciate that because there's a lot of little moving Parts when you're caring for patients from the bedside to the facilitation the P you know the other things outside of just the the nursing beds I care um mentioned case management I think I forgot there was one of you that said that you don't want to do bide care which is okay you could do the case management of them want you to have some bed experience first because once you get that Foundation then you can look at the charts and figure out and do the case managements and then there's care transition um especially patients going from um just being discharged from their place going to um another facility or another hospital maybe they they happen to get to a non- Kaiser hospital but they're Kaiser patients so they have to be transferred to a Kaiser placement just because their insurances so when they're stable now and so you're going to see a lot of those things happening and transition management um you you you as a nurse are going to help the the RN and you're going to be exposed to giving uh discharge instructions and what to do that's that's key because I can't even if me being in health care my mom was recently in the hospital not too long ago and I you know I'm a nurse and nurse season nurse and there's a lot of instruction so and some patients don't have that strong support system as others and so you really have to take your time and make sure that the patient understands how to take the medications how to access their um Healthcare Providers and like what some um activities they need to do to be successful um do they need other sources um like Community referrals um make sure that the information that they receive is their language and their culture and um medication again that is a joint um aici safety goal medication which conciliation um and then you know this just this really comp you know it just shows you from you know your home you go to Mission to go to facility and all the different types of steps you know of how to um reconcile as far as medications um because sometimes when you enter the the hospital setting you may not be able to stay in all the medications just because depending on what the medical issue is but you have to reconcile um if you're going to continue with this medications when you leave the hospital so it has all of these um things and as far as best care um transition processes we want to not just educate the patients but also the people they're going to be with the patients and um again followup is the key and communication is the key as well and yeah um so you going have your high-risk patients too especially like the the older patients above 80 um are patients that have many corn abilities like especially diabetes and hypertension and it's not going to when you do med path um one of my very first Med PS with one of my students she had 21 meds I don't think anyone has beat me with 21 meds and like my goodness but she did it gracefully and and she's not a season um she's a brand new student with no experience and she had to get 21 meds I remember that she had like um 15 G2 meds she had three IV meds she had um some ey drop n 21 um it's and then she did it gracefully and she was able to do it in it was 40 minutes so um it was towards the end that I was able to pass meds with um half my patients I could half my actually of all my students I only had five or six but I was busy that day especially with the 21 meds so that that was crazy I don't know who yeah anyway so we have this after you nurs nursing schools B is full of acronyms I'm not how you memorize this but this is just one called phase it talks about um kind of um in correlation with the houon and with the Joint Commission these are some of the things that we do to try to keep the patient safe um you know we identify the patient with two forms of identification we report and communicate any critical Labs or any um incidents We Men Med cautiously Med errors is what is the number one cause of deaths in um don't have to write that as a not I'm not to ask that question but it's a top up there the number one cause of deaths in the hospitals met errors we give we over give we don't give enough we don't give in time can't stress enough um medicate giving medication accurately and promptly um and hand washing too like you see patients they come in they get the surgery we take care of them but somewhere along the line you break the chain of infection and so really important to do handwashing um and also detecting suicide risk detection people who are not safe within themselves or even domestic violence and eliminate surgery errors so when they undergo surgery you are ad accurately calling out okay um you know you you hear about these crazy cases in the news like okay this one man he was supposed to get his um right testicle removed and he got the left testicle removed he goes you're moving the right testicle right yeah but he's supposed to left you know like it was he got the wrong testical Mo so guess what he has no he doesn't have any good testicles this happened like many many years ago but those are again it's can't stress the importance of calling out the right part and make in marking the area you're going to have the surgery that is part of ccon and Joint Commission that those are the safety guidelines that we try to aim for um to give the best quality care for our patients talking about the U medication right I mean it grows longer as the years go by but the first one two 3 four five six you know right drug right patient right dose right right right root right time in right documentation also that all these are like new the recent history history assessment drug approach R fuse drug interaction education but the first three four five six is the most the ones that the foundation and after that these came after that okay we want to work in an area that's a blamef free approach we are to work together um when I do teach clinicals at the bedside I try to I don't I remembered when my teachers were teaching me I actually cried almost every day no hiding cry do it I cried often it was very stressful my teachers was scary I went to Pacific and then years after I graduated nursing school I went to a an alni event and I saw her and she said oh yeah please call me sh my big first name and I said and I couldn't and after I said oh thank you Professor wee but she was nice and then then after that she passed away but um but she scared me but when I your teacher professor mavic and the other teachers very kind people but very fair so they try to work with you and make sure you get the best learning experiences possible and also to you know you always again you are working with other members if you have question about anything ask for Teacher ask the nurses and um if you do see something that's not right such as a um an adverse event um something that happened that there was puts the patient safety at Jeopardy you need to record it um you might not be comfortable talking to the nurse talk to your teacher at least and then then then your teacher could talk to the nurse and and let them know what you served um again teamwork um the team members you have the patient the family um the healthcare providers the nurses the nurses aid and the other team like um I I'm sorry this like um case managers social workers occupation therapy phys therapy so go all here start by cutting the slide and then there are some interprofessional education collabor um collaborative there's some competencies um talks about you know interprofessional practice and about responsibilities and teamwork and all that that's obiously best and then there's some here I that communication this is important so whether you know if sometimes if you're seeing like there's a language barrier like Spanish and and you just need to see something like I need to go to the B I need to go the bathroom then that's fine but when you're trying to give a consent to to do surgery or something legal you need to use the translation services so the patient and or the person that's assigned to the patient's care that they are fully um informed of all the risk to that procedure so but something technical where signatures are involved you need to use a translative line you can't just ask the janitor or another nurse i l the nurse you know could very um you know they T they they understand how to to um to convey and communicate these instructions you need to find someone that could help you and work with you okay and we do use esar Loot and you'll be practicing this in clinical if you haven't already as a CNA or LVN um it's a formal hand off between two more um Health Care team members and hopefully you guys will see the shift report between the night shift and the day shift and they do esart type of method what's the situation their background and how many days they've been there um what is their Cur assessment at time are their blood pressures running low um is it the first day um post um postoperatively after KNE surgery and so forth communication okay the SAR I might ask this on the quiz um this is always a question um SAR means the situation um what is the situation happening to that patient the background um what is the background um how long have they had the disease or what is how did they come into the hospital did they come in by ambulance or um mother um the daughter finder um down you know what's the background kind of goes with the situation but the background is like do they have um diabetes or they've had that history that part in the past um assessment um you know if um what kind of assessment what's the current Finance at the time and the recommendations that they could um you would give them okay um so then they have a there's a isar is like identify who you to to the person you're giving the report to and this is is actually pretty good you know this gives a detail of which part part of the situation for example I'm calling because I any changes so that's situation the background like um sub admiss diagnosis previous illnesses uh a lot of it too when you get report you get there early enough you could go into the computer and look at the um the doctor's the provider dictation and in their dictation their history physical you can see some of the background like oh yeah they came in with this they've had years of they have diabetes they have hypertension they have kidne disease and it goes on and on so that's the background assessment is what the finding is and what the problem is at that moment and the recommendation you know what um doctor or you what nurse I think this patient might benefit from um the blood pressures are running low so maybe if you I can consult with the on call provider maybe possibly giving um IV fluids to increase the blood pressure for example those are examples of recommendations and then also really important to do a readback after you get a doctor's order and you read it back to make sure for accuracy that it's correct always do read back after you get an order no um another method of it's like a um safety um guideline um is team steps and they use these strategies tools enhance performance of patient safety um it's very systemic um for interprofessional teams U so they use this um communication method process um to communicate with other and the goal of this is to improve safety and volume how the car is um delivered so these are some of the common communication tools um you know we do bedside report you see the Whiteboard like okay what Pain Scale is tolerable for them can um before medication can they are they okay with the two or they to be like absolutely no pain or see us is again unconcerned I'm uncomfortable I don't like it's safe um call out shout out important information such as the vital signs especially if you have a Cod going on a rapid response a two chall Ro rule is you say concern T ignore then you go up the chain of command as well and then also delegation and supervision and also um you want to make sure that as new nurses you hopefully they don't give you the hardest patient um you delegate what's appropriate to the particular um Health Prof um the nurse like um I forgot which one of you is a traveler but there a CNA and you want to make sure that you get patients that you feel comfortable with because it is a safety issue even though that you're should have um experiences and knowledge to take care of any patient but you want to be also comfortable in that setting so you don't commit any errors so um there's this whole delegation supervision thing that's enough that's what I can say for that so the nurse can delegate things and this is important these are always questions on the enlex the nurse can delegate to the Personnel the CNAs the patient care technicians or nursing assistants that even though like for example that the nurses say okay so and so go take the blood pressure ultimately the nurse is responsible for that task even though you ask them to to take the blood pressure um hopefully the nurses aid um will tell you with the blood pressure is slow they tell you the blood pressure they don't just write it down not say anything the nurs is are ultimately responsible for that and then just like medication there are some Rights of Delegation the right task the right circumstances the right person um the right communication and the right supervision and then um so you could assign by RN to another RN or to LPN every state differs regarding um what the RN can do the LPN LVN can do for example here in California um the lvans could start IVs but they in um for the most part they cannot give IV medication like IV piggy boxs but they could start IVs and so um and also I think some of them could like the blood um to do a blood transfusion it differs um you have to see what the hospital policy of that is for example so you know yeah so again you want to be able to communicate what um the nurses could do and delegate tasks mentioned before about evidence-based practice when we do practice nursing um we do research based on experiences and and that's where we do our um you know we do the best based on the current research and also um patients preferences and values and then considers um also clinical expertise for delivery Optimal Care as well and then there's different levels of research and I'm not going to go too deep into this I talk a little bit about this in epidemiology but this is like a different different types of um research level one and level goes all the way um to like single experiments and all the way to level five um and then all the Improvement that kind of goes along with the cin um where um you do have some every hospital every unit have some type of quality improvement tools or program where um they use um they have guidance on how they do things like for example um they do have standing nursing orders where you could give um how to give medications for example and then they do have those um manuals in the nurses stations to guide you and how we um do things okay they call Quality prence and then the continuous quality improvement or evidence-based practice as well and then um I'm just I'm not going to go into this detail this just different types you have plan you study act you focus pdca you could just read that okay and if I do as test I'll let you know which one but I don't remember asking this on the test but these are the different ones okay and yeah just I'm G to skip all that um yeah this is just different examples of how um they analyze data and what they do okay but our role in cute quality improvements um you know like if you do the peacock question like what is like the the problem like Falls the intervention putting bed alarms comparison the outcomes to reduce fall reduction and time frame and some of the indicators and evaluate the data that's just and that we do that continuously in all hospitals informatics know we you know we have the computer to help US charting computer charting um informatics are great it helps us communicate um manage knowledge prevent errors and support decision making and also we are very aware of the um health records um we have the computers at the bedside and the handheld mobile devices and using devices as Sy such as um the smart infusion pumps um we scan all the medications before given safely um hopefully you get to do that at um your clinicals okay and also some hospitals are fancy and have as special phones some are not fancy it just depends how they use informatics in their workplace clal judgment this is the okay so this is an important slide so I would start this slide this slide talks about the nursing process here go yeah and um guys and also the six okay so there's two the see these two little these multicolored boxes the nursing process is what it's been bring for many years you know you have the assessment you analyze um make an analysis which is a nursing diagnosis you make your goals which is planning you do your interventions and you evaluate if your interventions work so that is like the old end clux and that's what they do but now you guys are in the new end clux the New Gen and flex so they have this you um you need to have this me memorized or ingrain imprinted in you before you graduate we don't do even though nursing process is the foundation this the six functions of clinical judgment is the key here we recognize the cues um so we we recognize them and then you know you kind of cluster them and analyze them then once you have all the cues and you said okay what's prioritize what is the priority here and then you can generate Solutions of how how do we um address this possible solutions we take action and evalue the outcome so this is the new way of um how we practice nursing okay so you know clinical judgment is um and this is important so you again know the slide so clinical judgment is to observe outcome of critical thinking and decision- making so you go through the process critical thinking and go through the process of decision making and then you that observe outcome after you've done all that thinking decision making that's that observed outcome is the clinical judgment and you know you hope that the clinical judgment that's made and formulated it leads to positive outcomes and and unfortunately and and it happens it's not the end of the world but sometimes it happens um poor clinical judgments leads to risk and safety issues okay but um again you're going to have lots of help doing that we're not going to be alone and um um Tanner um he did this um this little concept map of how clinical judgment um noticing interpreting responding um you know we have to take actions to outcomes and then again reflecting and this is what we do in simulation so when you do simulation we kind of go through this process we know we interpret respond so his things like assessment noticing making an analysis interpreting it and making plans for it responding to um whatever the actions are and evaluation and reflection um so the ncsbn those the ones who decide when we need to um make adjustments for the nursing boards again this is that slide with the six clue recognized Clues and analyzed Clues so again you're going to memorize that and um also you have the rapid response team and know this slide also this will be on your quiz uh and so you need to know um if you have changes like as far as greeing um they can't um or they have obstructed Airway also sorry or they their pulse is less than 40 beats per minute or greater than 120 or they suddenly Chang their Consciousness they're not alert and oriented times four they're alert and oriented times two you need to call the rapid response team and something needs to be done and so um there is guidelines for that and they do have this paperwork called a ear early warning system where they do this they score like okay where they are they at this process and they come up with the score um you know you know regarding like the vital signs and other things yeah this is an example of that um I'm G move you guys again like you know your temperature and then you know three two one Z you know they have these various scores and then there the algorithm score 0 to one and Vital Signs and score two three and then score greater than six and out of then go ahead and activate the gra response team that kind of gives you guideline is it emergency or can I manage it I GRE around um the term systems thinking and systems thinking is just the ability to recognize and understand and synthesize interactions and interdependencies in a set of component I know such a fancy definition components designed for a specific purpose so you know Healthcare is not just simple if there's many systems you have the pharmacy system nursing system health care provider and we all interact with each other and we try to do systems so it's you want to the purpose of system thinking is being methodical you want to be methodical and do things the right way consistently every time because if you're not methodical in your nursing practice and if you're not methodical in communicating with other people that's where errors are made and so they propose systems thinking so we don't deviate of how we do things I mean there's of course if there's something that comes up you are going to um treat the acute problem but you have to have some methodology in order um to address and approach the problem or the the concern so you're not just going to like kind of suddenly think oh yeah I'm going to treat like this you have these um set orders these set guidelines and this meth methodology of how to do things okay and you know it's a dynamic system systems is Dynamics continuously changing um we we want to um be holistic not just think about the patient but the other aspects you know related to the patient's care um identify patterns with complex situation transform transformative is just a fancy way being Dynamic um trying to create change and that's more like towards the nurses and the leaders and of course um there is some ethics involved and ethical principles I mentioned autonomy that's the most important one that's like patient needs autonomy to to do these um actions if they don't have autonomy some of these others will fly um will will go by the wayside they have to have autonomy um the you have to be beneficent the quality of being good you want to be loyal that's Fidelity Justice like I mentioned like we have Healthcare disparities we're trying to prevent that from trying to reduce that from happening non Mal malic is never doing harm to any individ idual it's a little different than beneficence benefic is probably doing good where non umic is never doing harm and veraity being honest little different than Fidel Fidel you're always loyal promising individual but ver you're as honest as possible mentioned about the health disparities in the beginning of class okay ass care insurances this happens because of poor communication um also lack the health care um access um inadequate health literacy um P Primary Healthcare provided by assist that's called implicit bias okay um where um healthc care providers um have their own provid it's becoming so um it's there that they practice the way practice just because it's always been done or their experiences or Expos to certain things so um I think we all have biases but the more important thing the biases is to not is to recognize them if um sometimes it's hard because we don't know to bias tell something happens and we try to change the way to make it not a bias it's easier said to be done but if every person makes an attempt to try to change the bias and I think the bo could be a better place that um unfortunately everyone has their biases um I mentioned publish to special needs like the older adults and those who are racial and ethnic minorities and then lgbtq and then the safe the safe zone is like you know where you see these signs where all lgbtq and patients are welcome okay let me um I I'm G to ask a couple questions for you guys and you answer the best you can and there not too many just to kind of um and I'm gonna call you guys as whoever is first on my um my zoom thing okay okay um and I'm gonna have to look back at the names again there's 25 of you um okay Su young um tell me the answer the first question to your best ability okay so do I have to read the question or just um you can just answer that's fine um I think it's a b and know that's tricky huh or C I know yeah you know what Ed guess is great okay B or C we're all going to see and then the answer is it's C okay so it's c um page for consultation from the surgical team so which document reflects cin competency of teamwork collaboration because it's c um you know because you're paging for consultation and evaluating painting reflects patient Center Care you did good good job Su young and um I'm going to ask the next one up is um okay so so I think I meant to call you by call young but Sun Yun you answer this question what do you think Sun Yun what happen is still there all the above how's that whiskey good it smooth so you could you could choose more than one so it's not just one answer what do you think a uh reference templon for the present good basil oh the basil [ __ ] delicious that's I think all of them all of them they sound good okay price a b c d y you're right all of them okay yep all of them good job and this one all of them good job and know so tricky right yeah all of them buy another one okay and Valerie you take the next one but for the price can't go wrong with that big ass bottle what I got for that um I think it's b d evaluate Trends and develop a plan of improvement okay and yep you are right good job okay so I gotta stop there okay everyone's like bathroom bathroom okay so let's come back at um let's come back at 8:45 guys okay come back at 8:45 and then I'll see you then okay thanks okay guys uh let's take a 5 minute break for Harley bear Harley bear for it's good not bad huh that's with two and a half shots not bad my bad we don't have H this is not for youing I do for right right back for for 3 a good morning s my you for sure all right you right those so ch is that's got l you know guys bring out your thing your cops for thank you cck of e okay I'm back um I actually figure out the whole cable thing but it's still not working I think it's just um that's okay I give up but I I actually figure out um my husband gave me this extra Gizmo like I didn't even need this but I just connected it and connected to hdmis but I actually think it's C anyway I have to get the monitor okay okay that's fine so I just have to I'm not sure if if I could finish the pain lecture but I have next week as well but chapter two I might be able to get through actually chapter two has not it's not that much and the pain is not that much though I might be able to do it you guys so this will be good no more breaks and I will I'll do my very best here so let me see if I I I'm so I wanted to use the second screens but it is what it is so let's see here I'm going to um yeah that share and I'm G to move you guys up and I'm gon I'm gonna make this kind of yeah I'll make this as a slideshow yeah it's it is it is it's okay okay so okay I got missed a bit okay so we go um I'm g go it's this is just a little bit more about clinical judgment and systems thinking and hopefully I'll get to the pain lecture to on today okay so just trying this that's okay so when we talk about health care Concepts um these are some of the um things to consider you know we talk about the complexity of care and what are some of the behavioral and social determinants of health and there are different I'm not I'm going to talk about population management and epidemiology um so I don't want to go into that and a little bit about policy and Healthcare reform and there's also change advancing Technologies uh we talked about interprofessional practice and also we talked about system um systems thinking so um I'll let you read this on your own I'm not going to ask any questions I don't think so but I'll let you know if I do and we are going to talk about population Health on Frid Friday and Saturday and you know we are constantly going through Healthcare reform and all know it depends on you know it's so important to to be informed even if you don't have time to be involved um you know Health Care is a right it's not a privilege and so we should be active participants in healthcare choices and actions that's why it's so important to vote you guys um depending what your beliefs are so we could have some reform anyway those are some explanations of what we saw and we are I me this this will be on your quiz I remember this question um the differences between critical thinking critical reasoning and cral critical clinical judgment critical thinking is informed by information that is directed by nursing standards and practice as well as National competencies um critical clinical reasoning is the process by which n um nurses collect cues process information come to an understanding of a patient problem or situation um clinical judgment um is the observe outcome of critical thinking decision making that's the clinical judgment clinical reasoning is like that whole nursing process with the six steps you know you analyzing the cues and processing information um and C think is just the information and then critical thinking critical reasoning is a little similar but you could see there's slight difference there okay and you know it's a whole system this is the iceberg okay you have the care you have the proactive patient Cent care the healthcare Value polation Health it's it's a lot of systems this is when I talked about systems thinking this is one way to look at systems here question um and this is a repe of that um the the clinical judgment measure model this is your how your ngn this is how you guys are it's a little different than the the traditional nursing process here and this is a good slide too it talks about spe specifically about the six steps for clinical judgment as far like for example for um analyzing cues consider the cues in the context of the patient history and presentation how do the cues connect to the patient's condition um prioritizing hypothesis consider all possibilities generating possible solutions and then taking action and then the first one recognizing cues um what data is relevant because you're going to have all this data is this important or is just extra or does not even matter um you're going to get and they try to throw that in the ngn questions and so um they use this is what is called the clal judgment model that's used in the new Inox and this is actually a good slide you guys this slide here so just compare the nursing process the our current ncsbn an T model okay where you see that the AR what you're you learning is recognizing cues the old way is assessments so the first two is like the main ones the third one is the model that arose from um the the ncsbn and nursing process came from the Tanner model but you could looking at Side by SL side is really good you can see how like the analysis you know and the planning so just take a look at that okay good slide so we talk about the Health Care system and environmental care so we do we're so used to the traditional impatient care St and then you have the Community Health Care um and the Managed Care is care provides for members with needed Health Services for cost so they U Managed Care is like the cost already set and so it's just one way to manage cost and and unfortunately sometimes there might be like if you have a complicated case manag care might not be the best way to to navigate that but sometimes most of the time people don't have um the opportunity to um to use um to seek Specialties because they're tied in their network is manage care and um the medical home which is the home for the americ you know and then you have the long-term care here so that's our health care System there could be improvements in many areas especially long-term care and manag care and again it's a contined um challenge for us as far as the healthare system um goes so we have you know we have the physician and the physician assistant the advanced practice nurse which is a nurse practitioner they call um that's the preferred name that's the political correct name advanced practice registered nurse um also knows nurse practitioners and then you have the registered nurse and the syic personnel with just the CNAs other teams like you have the occupation therapy the speech therap pathologist um they're important because like they do the swallowing EVS the speech pathologist and um speech therapist and then the the LSW you have the pharmacist the respiratory therapist and the radi radiologic technologists and you you could just read all that on your own don't have to talk about that you guys know what the register nous is but this is helpful because it talks about the role um you know like occupational therapy they help patients develop recover improve and maintain ADLs because maybe they had a stroke and they may not be able to to do their a um activities of daily living um prior to the stroke so they need to learn new ways on how they could um get around to doing their daily um daily activities and you know Farm dispense prescription medic ations and then you know and then M nurse Works along with the MD with their scope of practice and then includes the Midwife too and the nurse because some of you want to midwives nurse they all here so again we are trying to move towards a systems thinking system thinking you know it's methodical reinforces safety and quality improvement this is why we have systems think and you should know the slides might be a p question it it it's important because it uses the um nurses individual actions and awareness to shape the gr of conscious of care expands critical judgment and it just reinforces safety and quality improvement and there are some influencers that guide care um you know depends on the complexity the interprofessional practices we have evidence-based practice um determinance of health and Health um emerging technology and health policy and it has explanations of all that okay and so yeah we are kind of moving towards a system thinking just talking about the inter relationships between all the systems okay question let okay and I'm look at um okay Ena um go ahead take the first question me H did you call me yes you can diamond in the room okay nursing statement youx awareness of the system thinking a my client values spiritually when receiving care awareness B I looked out I looked at our un policy to be sure it was evidence based see the care we provide prevent pressure injury should work on other unit appropriate documentation in Contin of see see okay that's a good guess yeah you are right good job okay he for you okay Regina you take the next one oops are you looking Regina I'm looking it's just a lot up it's a lot yeah okay just making sure okay okay no worries it's take good time I think it's um everything that's a good gu a yep it's everything okay good job okay um okay that's it just a pain lecture and then we're done close this off let me stop sharing here for us one more to go I way too many window this open I know I couldn't get this I think it's the cable I I don't know this is the one my my I didn't develop this PowerPoint from my school my friend one of my friends did but it's pretty good it's better than the book and that's why I I like this one does the school provide you with one first and then you get to choose yeah and then I tried to adjust but like the this one I I like this one because it has pictures and stuff and it gets down to the points so um I'm going to do it for some of them not all of them like the first two is like the really generic and dry you know but this one it you know it's it's it's pretty B online and I could get you more details and then I go back to the school one and see if I if I miss anything and I'll mention it but um yeah it's pretty good this one and pain um it's a good place to start so we're now really getting into the nursing part now so I can't get this um I'm trying to um I know I get this I'm GNA get a new cable scen okay I got it okay let's see and it's in the book and I think it just align to chapter 5 igy if not um just look for the chapter in the Iggy book um and also the ATI book that talks about K Comfort okay I'm G talk about the highlights of and then I have welcome to the audio almost okay I might be able to finish most of it and this is important regarding pain is it a pain we have to treat pain whatever the patient says um we treat it and again everybody has different experiences everybody has a sense of neurons and neur neurotransmitters in regards to pain and so therefore everyone's experiences to pain is different so this definition is it is what it is to the patient and that is what you will want to treat and pain is always what the patient says it is and then also um the primary role of a nurse is to advocate for the patient by believing reports of and acting promptly to relieve it while respecting the patient's preferences and values okay that's just a um definition and then so you have the acute pain and chronic pain so um the cute pain is sudden onset and short duration less than three months and usually has a warning sign and this is someone that that happens you know at trauma or tissue trauma and that may be caused by fractures by Burns lacerations and so when this pain is not relieved it could prolong um Hospital stay and it it could it could just make things complicated basically if you don't address aute pain so well The Chronic and persistent pain is that Pain's longer than three months and it's usually gradual also persist there's no purpose and sometimes it's vague or involving deep body structures like the back for example that could be a chronic you hear about people with chronic back pain and when this is not addressed or not adequately you know can't treat it it could impair personal relationships and daily um daily activity and it can result in emotional and financial burden and then you have cancer pain and then you have the non-cancer pain too as well um yeah those are some examples so then you have diabetic neuropathy and very cause a persistent pain no it's usually the pain in the legs and the arms sensation of numbness of the limbs and cause less um heat are the palms and the feet um rapid fatigue and muscle weakness that's the diabetic neuropathy then um you have the differences between no acceptive and neuropathic pain this is pretty good so the notive pain is the tissues that Send The Pain signal to the CNS system where the neuropathic pain you know you have damage to the nerve itself causing the typical pain symptoms so it's like it's very un localized the neuropathic pain for neur receptive it's like this like I I get a signal I feel it and um yes I feel it want to Cent the central nervous system it's like the major um like telephone major Network where neuropathic is more localized the damage to the nerve itself causes typical pain symptoms so there's some damage where it's um the pain is and notive pain uh we you know we have SIM um nerve pain receptors and the substance p and I'm sorry this is review from pathophysiology or Anatomy um they um so you have the suance p and the serotonin the pandin when you do have when you have pain these neurotransmitters of sustance p and serotonin PL glands they're released they're in released in in response to the pain so you have these various medications such as enets for example they block the production of the prandin so enets would include like aspirin and ibuprofen so you can see this little map here I'm not going to ask Anatomy question but basically when you have an um these substances are made are increased when no susceptive pain is curring okay just all you need to know for that where neurop neuropathic neuropathic pain is the it's the nerve destruction um at the side you have sharp neck like pain um it could be prickly pins need needle numbness and and we don't really quite understand it and you know some even after you know diabetics they complicate the worst case scenario is that um their Di I abetes gets um more advanced and they end up having an amputated leg or um arm usually leg and so they have that Phantom limb pain and even though that that limb is not there anymore they feel that pain okay so and then you have um the physiological response to pain um the changes in um Vital Signs um increase cerebral blood flow and then the tunnel vision and Vital Signs being change and so the sympathetic system um that's the one that um you know they have this is the the sympathetic response whereas your people dilate when you have pain and it can inhibit flow saliva it does speed up the heart rate um your bronchite can dilate um inhibits peristalsis when you have pain conversion of gly glycogen to glucose for example so increase blood glucose and secretion of adrenaline neur um neur adrenaline and inhibit BL constraction okay so that's a response to pain based on sympathetic nervous system responses where the um and then you this is where us this is important so when we see these patients especially you you first see the patient in the morning when you do your clinical you going to um maybe they're not they may not be verbal they will um have um facial grimacing um M or crying um restlessness um rigid body posture holding or guarding of the affected area so if you see the you could do um um mark that I did a pain assessment even though they can't say what is your pain level zero no pain in 10 is a lot of pain you can look at their face or their behaviors based on these things okay so that's a different type of chart to to assess their pain okay so psychologically pain affects us because if the pain is not addressed you will have your attention um span will be unpaired um you could only focus on the pain um there's anger um your fear anxiety um you're irritable and low self-esteem and depression and fatigue and then so when we um are emotional um ways to in to get some relief from the pain we release endorphins you know to try to combat some of that um pain and unpleasant emotions can lead to decreased pain tolerance and increased perception of the pain I know you hear about people who run um I know one of you um like running or exercising they said I like to run because I like I do enjoy that releas of endorphins it's very true these Natural Body chemicals because you're happy you're running so these endorphins are coming out you want and people continue to run people like I don't understand the whole running thing and I used to run I ran marathons like 10 or 12 marathons I used to run a lot and it's just that endorphin release that endorphin high and that's why I enjoy um running so um pain assessment um you do have the self-reporting um you do look at the physic changes behavioral changes and psychological signs there's that um that that face scale you see that illustration this is like the fifth Vital sign pain assessment so every patient needs to be assessed you take the vital signs we do our um initial assessment and we ask we rate their pain no matter it's like from surgery or it's um whatever the pain is or it's just pain in general you always have sess their pain that's the fifth Vital sign you want to tell you what the level pain there's there's different ways there's that pqrst t and then there's the other one um oh gosh the old fashioned I can't even think of the name that it's not p t but I want to say I think it's old chart Old Chart is another way that's like really old but this old chart in pqs where it's like what is the level of pain what is the sight of the pain um what is the quality of pain is it burning is it intermittent is the pain acute or chronic um what UMES pain movement or activities um and the patient's Desires in relation to the pain as well and then this is this talks about yet the oh the um the p as I mentioned the onset what provokes the pain or the pting factors what is the quality um what is the feel like um where's the region does a stay in that area there's a radi to other areas is a severe um scale of 1 to 10 um time in treatment and then the understanding impact of pain as well and an assessment here you could you know there's that um 0 to five it goes up to 10 you can do the faces as well and then for ADL especially um the functional status are they able to do the ADLs so you again we have to treat the pain what the patient says and you do search for potential causes of pain You observe their behaviors and you recognize the value of the surg reporting and you anesis and I want to say that especially for the acute pain like post surgical pain like for knee surgeries or some you know whatever the surgical um whatever the the acute pain is surgeons are going to want you to get the Nar I'll talk about more narcotics later and they want to you have to get a good control Baseline and once you get a good handle on the pain then you could tight tra um you know reduce the number of En and I'll talk about some multimodal um approaches to pain as well because there's a concern about becoming um dependent and addiction you know that that is very concerning to a lot of people which is very very much so you know so so here's just some sample scale for cognitively impaired for pain here so um it should not inter interpret CL um question judgment whether the pain is in the um patients in the pain um after listening to the pain description quick to respond inform the patient about pain relief measures and other these um ways to relieve pain and then pain management um you have the non-pharmacological that's why even though um they had surgery they they try to do physical therapy as they can that um baby steps of course you have to take into consideration this is where you come in hand um especially if it's like fresh posttop surgery or physical therapy and occupational therapy you are going to watch out for orthostatic hypotension so when they first get up um you know the pulling the blood um they get dizzy because um they're just not used to getting up from the bed so you got to man monitor the changes in blood pressure they become lower so you have to be aware of that that's that's why when they first get up initially they should be um two people to make sure in case they fall down and you know consider their safety and then they also have um hot cold treatment like ice and heat um I mean again the endorphins for exercising and braces and devices and also there's different types of um integrative strategies there's U Mind Body you know relaxation meditation guided imagery um body work like massage and acupuncture and consuling here or distraction as well and then I here's the multimodal anesia because we do um not just um inset but there's other medications that are not traditionally considered for pain that are used such as like antic compuls and anti-depressants and local anesthetics such as liin and you know we prefer to give it or but sometimes you might have to um give it IV or you could give it um rarely do we give it I that's usually um IV or oring with the multim modals two or more classes so you should know this for your quiz there's two or more classes of anales to Target different pain mechanisms in the powerful nervous system and Cal nervous system two more combination analytics to manif maximize the belief and to prevent the analgesic Gap EP uncontrol pain and you try L does first of each drug in the treatment of pain it may result in comparable greater relief than a single anesis that's why they use different um multi you know depending on the situation they do multiv and especially surgeons and fresh post up they do it around the claw so you could find a stable um so they could get them um you get that P under control you want to get that under control in the first 24 hours there are PCA pumps the main thing about the PC pump is the patient has to press it and they have to be cognitively and physically um able to use the equipments and they do have different types of PCA pump where they could do the continuous rid um usually for those patients that don't have a an ADD ition and and also um then they have the like the the bullus rate where you just you push the button and you get the medication but it's locked up for a certain time period so you don't get an overdose of the medication so the danger of the contus rate is that the patient could go into deep sedation I've seen that happen and patient has no control and you get respiratory depression and it could lead to excessive s that can lead to respiratory depression and sedation scale here where um one is awaken alert and four is Su you should never have suent they may be sleepy like two or three but they should never be suent that's like commos you guys you don't want that for your patient and again safety um it's you know given by The Sur um basil continuous rate basil um or the Bolis do that's that's very safe the safest is both do where you have to press yourself and there's there is a lockout interval and they analyze and like okay they're pressing a lot they need modification or they need to change or they're getting to PCA we need to change through our um or narcotics so education you want to teach them how to use a PCA pump um to report any side effects or dizziness na vomiting um inability to void and then correct order amount ofuse amount remaining and IL legal responsibilities um patient only to to push button um to prevent other people or staff from ministering medication so patient only the patient could push the button unless they designates unless otherwise designated that their special um designated people to press the button but typically it's only the patient and then there is a flow sheet that um this is like a paper one but there's one in the computer as well of how much they receive and the attempts and the demands they look at that to see if the medication is adequate or they're not using enough so let's just go ahead and discontinue so the happens very times and the side effects like are they over sleepy or is the resp rations less because you're getting too much medication for example and you know again um sometimes we bring our implicit biases of what we think the patient um needs and needs to receive for pain we may not know the um scope of painful conditions associate with the disease um everybody's different regarding reaction to acute and chronic pain and sometimes patients are scared to report to pain maybe because they don't want to be considered to be an addict or just that fear of being addicted to to narcotics and again a to take any P medications especially the opioids but as nurses we need to be as objective as possible and be um you know treat patient with empathetic empathy and be respectful to our patients when caring for these patients with um you know receive these um pain control meds and so this is like the um one supposed way um you know you have the nonopioid and then you have the pain persisting and then you have the opioid what climbing and they're eventually going to need opioids they have the nonopioids you have the opioids and the jum um juvant g6s the non that includes the um you know the C medicin and there is you need to to know how much they could get in 24 hours the mass is 4,000 mgram so if they're getting around the clock um after 4,000 milk because of sorry it's not within like the calendar day it's a 24 hours like so I always go if I'm giving town no I'm going to check how many times before they give the town no so it does not exceed 400 4,000 milligrams because it is harmful to the kidneys for example um and they say for the longterm use no more than 3600 per day some s to say 3,000 but if I ask a question like that um I don't think I will but I will tell you what number is the maximum I 4,000 seems excessive to me honestly I like um the 3600 and 2400 for the geriatrics that's the ones that I'm used to and then so the Nets the purpose of inets is to reduce inflammation and then so you have the non- selective ones such as the ibuprofen and the aspirin again um GI irritation um it could cause failure because you don't want to give it for longterm these um but some some of them are on it unfortunately and then you have with food you could get um nap napasin um ibuprofen and aspirin and then you could also give the um the Fletcher patch and the koric toll and the Cox to selective an to CRA and I heard that that's a really great one for pain control the opioids are like we have the first line um opioids such as the morphine and fenol and the Hydromorphone some other opioid anesis includes oxycoin which is short sh acting you have the hydrocodone and then we have the Dual mechanism you can get um trod Ultram it does um bind to the m up re allows neur transmiss seron neurop more available to fight pain so you need the um the neurotransmitter to fight the pain so it kind of opens those synapses up and we try these days not to give the Codine and um demal too many side effects in those medications so some of the principles like you want to start with the low effects and you know small those providing satisfactory pain relief it should be tried first um we going to do eal anesia from um s when switching from one drug or root or Administration to another and it not the common side effects which includes nausea and constipation sedation um itching respiratory depression and also this's addiction Miss as well and reversal is Nar um naram and then um for opioids morphine is the Prototype um proy is commonly given again Morphin usually the ones that using the PC pums long as well as fenel and they usually don't keep them longer than two or 3 days um but and you are going to have patients with constipation and usually they're constipated because they're on these um incets and respiratory depression is possible again you g to have Noone or Naran as a reversal agent that you should know that for your test and OPI are often compounded with tanel such as perin vadin so the um you know allergies mod to strong oate agents here here are some of the examples such as per oxy did you want those my needful children are derivatives of me and so good for controlling mod severe pain why don't you eat that I put strawberries Fen I'm a Fen man I'm strong medication and U strong pain control strong steps to use watch for respiratory depression and in morphine the Opium poppy is one of that nature find controlling pain side effects includes rash and respiratory depression and um Nar caner reversal agent fit um sometimes you have to watch for in um increased blood pressure and hyperventilation Tremors the cake okay and then um anales and anesthesia um analgesia it monitors sites for leakage and there some key points where for the anesthesia is a monit um monitor site for leakage as well this is the differences between anesthesia and analgesia um let me see where I am think I finish it okay I'm almost done you guys I'm good I'm getting um I'll finish why so late because it's a late class so you want to again um you're going to do a pre um assessment and then give the medication and do assessment at least an hour after but just know um pharmacologically 12 to 18 hours to reach its full effect usually for the continuous um oh no if you do the that's for the patch okay um chronic pains would use SP on catch four you change it every day or every two days and you rotate the site you docum make the location they'll try not to touch the medication touch of the edges or gloves old patches disposed of out of the rib and designated spot and then the aduen analgesics very a little different than the traditional ones it does when given together potentiate the effects of opioids and opioids um for example like the Gabapentin which is anti convulsant and antidepressent ametrine and you can take it two to three weeks to be effective and you can take a patch along with it and local anesthetics and adant analgesics um two Inhibitors selectively block the Co to inhibitor that cause arthritis um the aduen drugs not not for pain but work well for some kinds of pain belief intractable pain the non pharmacological management of pain um you have High full cacks and massage such as that's the electrical one sometimes especially if you guys have um injuries it's like it stimulates the electrical nerve you have ACU pressure and acupuncture you have relaxation and distraction humor music and imagery that's nonic ones that's the T you can see that there heat and cold um for the heat you try the um 20 to 30 bit um minutes maximum um with the heat um it dilates the blood vessels it increases capillary permeability um reduce muscle tension and speeds healing and release pain where the cold it can restricts the blood vessels reduce muscle spasm you try not to leave it more than 30 minutes u i Tred 20 but some people could tolerate 30 um it does decrease the local release of histamine um it controls bleeding reduces edema numb sensation and reduces fever so both are um appropriate you could um um it has this different ways of working for the pain relief so you know that the heat um increase the blood flow and tissue metabolism it works good on sore muscles with lactic acid built up like few marathons it relaxes the muscles and eases Joint stiffness and pain where the cold decreases inflammation especially if you you like you spray your ankle from basketball or running someone mentioned um I I don't think you do po but if it happens you know you use coal and then for cold those ice packs and cold packs they have those pry made ones now yeah so with the heat the main thing is you um you want to be careful the boning promises you don't want to heat up a heating p in the microwave because it um there's going to be some hot spots especially if they're pregnant don't get put in the abdomen the cold um you don't want to if they have a cold intolerance don't use it for those clients don't um give it to those patients who have vascular insufficiency and don't use for people who are aggravated by cold for example um rol syndrome and then there's the acupuncture acup pesture that works really well as well um they you know the sticking of the needles it does stimulat the Endorphin um production um jar j this is this is an important slide to to know when giving to older people the pain is under reported usually from this population less pain tolerance they may fear addiction to the medication pain is part of aging um do not want others to know they have pain punishment nothing can be done about it and then adverse effects okay you want to start low and go slow no more than half of the recommended dose and that is it okay wow I I I got St sh it is 2135 I could do um I'm just going to see if there's any questions um from that PowerPoint that they give the modules and then um then we'll call it night you guys it's been long and um oh the people have clal tomorrow did did they get back to you did you hear anything guys are checking out let's see I was looking at my emails but I have clinicals on Thursday any word yet anybody I don't have anything okay but I would imagine if they didn't send meem a clinical um I my class is uh my clinical is on Wednesday which is tomorrow but I haven't I mean I sent it um through the canvas yeah but I haven't received anything yet okay um but uh I think we going to the clinical site I think you if I remember from the last class they went to clide the first didn't pass M it's do like a scavenger hunt they do all this skills stuff and that's what I'm guessing you guys so yeah be careful though they've said they sent us an email so um I think at like 2 in the morning when we had clinical the yeah so just before you leave the house check yeah I would do that that's a good idea yeah yeah um but just when we asked um Dr Thompson he said clinical so yeah oh like you know if of course like if we received then a message during 2: am or 3:00 A.M I know you answer but what the time you wake up before you leave just be the first thing yeah that's honestly I they shouldn't do that because that kind of message you don't know you have to prepare you know I oh what can we do it's okay I know it is what it is during nursing school it's gonna happen yeah and I have canceled Pentacles because of well like there's a hurricane thread or something like that you know like turn me yeah tsunami that's different yeah U I'm just checking the PowerPoint for um to see there's anything I didn't cover and I think I covered everything and you know what I might just course yeah this the one that's prevented um in the modules is very generic yeah I cover all that this there's cancer pain procedural pain I didn't cover that but that's okay it's no receptive and neuropathic I I cover that um and you know what I'll do yeah all cover um let's see there's three there there's three questions I'll ask the three questions and then we'll call night that's what I'll do okay three questions let me see let's just end end with that but um that PowerPoint um I think okay and I'm just gonna yeah I didn't covered the I'm not going to ask for but I thought about no susceptive in Nur your so know those I think it's at the end of my day okay that's fine think I me I yeah the the main thing too is you don't want to give too many insects because they could get liver failure and kidney failure and he toxicity so that's the main thing you you want to monitor for okay also cardiovascular those are it hits those systems pretty hard yeah P Leos is very controversial only if the patient can sense to it and they um yeah that not too often ethical issues implications let's Nikki why don't you take this first question it's going to eat of food that our high okay yes you're right good job okay okay for you okay Carlo you go take the next one the nurse on the post shop unit is caring for four clients which client does a nurse discuss with the surgeon that may benefit from PCA a 37y old who broke both bone or both arms and skiing accident B 47-year-old who underwent bariatric surgery for weight loss C a 59-year-old with temperature of 103 following surgery for bow obstruction or D 66y old with cognitive deficient who had hip replacement B would it be B that's a good guess it's actually yeah it's B mentally alert the best canid get good um and then the last one is um Vivian he take the last one maybe b b okay that's a quick s oh it's a it's okay he must administ okay so what is the appropriate okay so the hos Place PL on the men plan who ask for the nurse to administer cannabis what is the appropriate nursing action um you must administer okay so you know you must okay so it's a only the the patient or destinate caregiver identified through the MMP can administer cannabis so that's actually yeah that's all right I'm not going to ask a Canabis question it's a big gu so that's okay no worries okay that is I think that's y that is it I think I think we're done I'm done I can't do this anym so I'm gonna I know it's a little sad but I'm going to call it a night but I'll stay on if you guys have questions I did see that some of you sent emails with in the case the care um the groups and stuff I I'll work on that um I will be if you want office I don't have office hours but I'm around if you need me for anything yes Heather um what days are our discussions and ATI assignments due um today's Tuesday like the end of the week like probably I'll give like a like Monday but yeah so we just let do Monday before butay yeah 10: a.m. yeah midnight yeah don't say about night for it but let me go and I'm gonna go ahead and while we're here let me go ahead and open up discussion real I I see yeah just see a second let me just go ahead and and open that up for you so I won't forget what we're here get okay I'm I'm going to go to um one and I am going to open up oh I see the problem I know why my monitor is not working I don't think this extension code is working that's it okay okay when class ended huh rightwing class ended yeah and my dad is going to die soon so this actually works up I understand now I was looking at my batteries like okay it's not connected it's okay okay and then um who who else had a question I'm so sorry someone else okay I'm gonna call it a night is that okay and I'll stay on if anybody has a question for me what are we it was nice to meet all of you before my battery dies and I will see you guys on Friday and Saturday this week and I'm still working on the asynchronous next week because um I have that big convention um but I I'll do something um asynchronously and then um I have a med search too fast tomorrow morning at 8 but I have to take my home to the airport so it's a long night but it's fine um but anyway by I hope you guys have a great day night there like Pi tomorrow I have a feeling you're going to meet I'm like 95% sure but there's I don't know but anyway good luck um let me know if you have questions you heard from the teacher you can't find the teacher you know I can see but Professor mck's pretty good about these things she's she's been around for a while so I'm just surprised you haven't heard about that okay I'll let you guys go um Aloha have a great night thank you thank you you're welcome aloha