A clinic nurse is preparing to teach student nurses about care of clients with viral pharyngitis. Which information should the nurse include in the teaching plan? Select all that apply.

A. Evaluate outcomes at the end of the shift: This is an important recommendation as it allows nurses to assess the effectiveness of interventions and the overall condition of patients. Evaluating outcomes helps in identifying areas for improvement, ensuring that patient care meets safety and quality standards. This practice fosters accountability and continuous improvement in patient-centered care.
B. Evaluate outcomes at the start of the shift: While evaluating outcomes at the beginning of the shift can provide valuable information, it is more effective to evaluate outcomes after care has been provided. Starting the shift with a review of previous outcomes can guide care planning, but the actual evaluation of interventions should occur after implementation to assess their effectiveness.
C. Plan and report outcomes: Planning and reporting outcomes are essential components of providing safe, quality, patient-centered care. This involves setting clear goals for patient care and documenting the expected results, which allows for effective communication among the healthcare team and ensures that everyone is aligned in their approach to patient care.
D. Communicate the plan: Effective communication of the care plan is critical to patient safety and quality care. Sharing the plan with all team members ensures that everyone is aware of the goals and interventions, facilitating collaboration and reducing the risk of errors. Clear communication enhances the patient's understanding of their care and promotes involvement in the decision-making process.
E. Think critically: Critical thinking is fundamental to nursing practice and promotes safe, quality, patient-centered care. It involves analyzing information, evaluating evidence, and making informed decisions based on patient needs and circumstances. Encouraging critical thinking enables nurses to assess situations thoroughly, anticipate potential problems, and implement appropriate interventions.

A. Client develops ecchymosis at the venipuncture site. Minor bruising at venipuncture sites is a common and expected side effect of heparin therapy due to its anticoagulant effect. While the nurse should monitor for increased bruising, isolated ecchymosis at an IV site does not necessarily indicate excessive anticoagulation or require immediate provider notification.
B. PTT 70 seconds (control 25-40). Heparin therapy is adjusted based on the activated partial thromboplastin time (aPTT). The therapeutic range is typically 1.5 to 2.5 times the control value, which in this case would be approximately 60-100 seconds. A PTT of 70 seconds is within the therapeutic range, so it does not require urgent intervention.
C. Client develops hematuria. Hematuria is a sign of potential excessive anticoagulation or internal bleeding, which can be a serious complication of heparin therapy. This finding suggests that the client's coagulation status may need immediate reassessment, and the heparin infusion may require adjustment or reversal with protamine sulfate if necessary. The healthcare provider should be notified promptly.
D. Order for Coumadin 2.5 mg to begin today. It is common practice to start warfarin (Coumadin) while a client is on heparin therapy because warfarin takes several days to reach therapeutic levels. Heparin is typically continued until the INR reaches a therapeutic range. Therefore, this order does not require provider notification.