RN Lesson 1 Management of Care

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Course RN: Review for the NCLEX-RN Examination v5.4 Start Date 28 Apr 2012 End Date 19 May 2012 In Progress

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Introduction and Diagnostic Pretest RN Lesson 1 Management of Care RN Lesson 2 Safety and Infection Control RN Lesson 3 Health Promotion and Maintenance RN Lesson 4 Psychosocial Integrity RN Lesson 5 Basic Care and Comfort RN Lesson 6A - Pharmacological and Parenteral Therapies RN Lesson 6B - Classification of Medications by Body System RN Lesson 6C - Classification of Medications by Health Status RN Lesson 6 Posttest (for all Lessons 6A-6C) RN Lesson 7 Reduction of Risk Potential RN Lesson 8A Cardiovascular RN Lesson 8B Respiratory RN Lesson 8C Neurological RN Lesson 8D Gastrointestinal RN Lesson 8E Genitourinary RN Lesson 8F Endocrine RN Lesson 8G Orthopedic RN Lesson 8H Oncology

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RN Lesson 1 Management of Care

Concepts of Management and Supervision

Review standards and/or position statements of the following agencies before delegating any nursing tasks State board of nursing National Council of State Boards of Nursing (NCSBN) Nursing organizations American Nurses Association (ANA) National League for Nursing (NLN) Health care institutions Use critical thinking in management situations

Learn more about the National Council of State Boards of Nursing (NCSBN). Visit the Web site of the National League for Nursing (NLN). Learn more about the American Nurses Association (ANA).

2. Delegation

Definition of delegation: a process by which responsibility and authority for performing tasks are transferred from one individual to another who accepts that authority and responsibility o Delegation involves Responsibility: an obligation to accomplish a task Accountability: accepting ownership for the results or lack of Authority: right to act or empower o Principles of delegation A nurse can only delegate those tasks for which that nurse is responsible, according to the specific state's nurse practice act The delegator remains accountable for the task Along with responsibility for a task, the nurse who delegates must also transfer the authority necessary to complete the task The delegator knows how to perform the task being delegated Delegation is a contractual agreement that is entered into voluntarily Consider the scope of practice of nursing personnel registered nurses (RNs): baccalaureate prepared nurses are equipped to care for individuals, families, groups and communities in both structured and unstructured health settings associate degree prepared nurses are equipped to care for individuals in a structured health care environment RNs cannot delegate the following activities to unlicensed assistive personnel (UAP): assessment of clients evaluation of client data nursing judgment client/family education/evaluation nursing diagnosis/nursing care planning licensed practical or vocational nurses (LPN/VN) assist in implementing a defined plan of care and to perform procedures according to protocol assessment skills are directed at differentiating normal from abnormal competence to care for physiologically stable clients with predictable conditions unlicensed assistive personnel (UAP) because they are unlicensed, they have no scope of practice assist in a variety of direct client care activities or tasks, e.g., bathing, transferring, ambulating, feeding, toileting, and obtaining measurements (vital signs, height, weight, intake and output, blood glucose levels) perform indirect activities such as housekeeping, transporting people and stocking supplies 3. Steps of delegation o Define the task o Match the delegatee to the task determine that the task is within the scope of practice for the delegatee nurse practice acts: each state defines nursing practice for registered nurses (RNs) and licensed practical/vocational nurses (LPN/VNs)

standards of practice: the American Nurses Association (ANA) defines standards of practice for registered nurses some nursing tasks can be delegated to unlicensed assistive personnel (UAP) to assist, but not replace, the nurse only licensed individuals have a legally determined scope of practice know the employer's role expectations organizational charts policies and procedures job descriptions competency requirements o Communicate clearly about expectations regarding the task clearly state who will do what and by when it will be done clearly state expected outcomes o Reach mutual agreement about the task to be completed the delegator validates with the delegatee that an understanding exists regarding what is to be done and the expected outcomes potential problems and solutions are discussed o Supervise the performance of the task provide directions and clear expectations of how the task is to be performed monitor performance of the task to assure compliance with established standards of practice, policies and procedures intervene if necessary ensure appropriate documentation of the task o Evaluate the delegation process assess the degree to which nursing care needs of the client are being met review the performance by the delegatee of the delegated task determine the need for further instruction determine the need to continue or withdraw the delegation o Provide feedback to individual on outcomes performance; review with the delegatee what went right as well as what went wrong with the process o Five rights of delegation Right task Right circumstances Right person Right direction/communication Right supervision 4. Client care assignments o Assign the right task o Assign the task to the right person o The LPN may assign tasks to the unlicensed assistive personnel or nursing assistants o Unlicensed assistive personnel (UAP) or nursing assistants cannot delegate to other UAPs or nursing assistants

NCSBN Learning Extension offers an online continuing education course called Delegating Effectively . For more information go to www.learningext.com. Read NCSBN's Working with Others: A Position Paper (2005). Use the decision tree to help you to understand the concept of delegation and how to better manage and supervise others.

6. Communication skills and conflict resolution o Communication: involves perception to receive a message involves expectation - the unexpected may be ignored makes demands on nurses to think and respond is different than information o Types of communication downward: used to relate organizational policy such as position description and rules and regulations upward: include such things as staff meetings lateral: between staff members, i.e. to coordinate activities diagonal: staff from different levels work together on a project o Causes of conflict inadequate communication incorrect facts unstable leadership or inadequate action plans misunderstood roles or responsibilities receiving directions from two or more delegators lack of or limited staff input into decisions inability to accept change power issues o Prevention of conflict includes allocating resources fairly avoiding unexplained changes clearly stating expectations addressing staff fears o Dealing with conflict take prompt action help parties resolve conflict among themselves (communicate trust that parties can accomplish resolution) maintain an objective approach avoid criticism use problem solving approach provide privacy for sensitive issues negotiate for agreements- not winning or losing focus on patient care interests avoid emotional outbursts include a third party when mediation seems the best choice

7. Performance Improvement & Quality Assurance

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Quality: the degree to which client care services increase the probability of desired outcomes and reduce the probability of undesired outcomes given the current state of knowledge Performance improvement/assurance: the process of attaining a new level of performance or quality that is superior to any previous level of performance or quality Total quality management: a philosophy that emphasizes a commitment to excellence throughout the organization Six characteristics of total quality management Focus on customer, i.e., client Focus on outcomes Total organizational involvement

Multi-professional approach Use of quality tools and statistics for measurement Identification of key areas for improvement with an emphasis on SAFETY Mandated by the Joint Commission (formerly called Joint Commission on Accreditation and Healthcare Organizations)

Learn more about the Joint Commission's accreditation survey process. View the Joint Commission's 2010 National Patient Safety Goals.

QUALITY IMPROVEMENT Quality assurance involves an evaluation of the conditions under which care was provided, including a(n): Identification of a problem Determination of the source and nature of the problem Assessment on how to effect improvement in the situation Designing policies for remedying the problem Implementation of those policies Quality management , on the other hand, involves quality improvement with a change in the focus from Detection to prevention Reactive to proactive Correction of special causes to correction of common causes Problem-solving by authority to involving employees at all levels Almost all regulatory and voluntary accrediting agencies now require some form of quality management Regulatory agency: Centers for Medicare & Medicaid Services (CMS), U.S. Department of Health & Human Services Other agencies committed to quality improvement: The Joint Commission (read the Facts about Hospital Accreditation) National Committee for Quality Assurance (NCQA) Institute for Healthcare Improvement (IHI) Agency for Healthcare Research and Quality (AHRQ) Institute for Safe Medication Practices (ISMP) The focus is on improving quality of care and client safety through taking evidencebased practices (from computer information systems to different pain management protocols) and implementing them in various health care settings Standardized processes are the foundation for improvements Clinical guidelines

Critical pathways Case management Nurses enable an organization to be successful in meeting standards facilitate collaborative practice with other health care professions to identify problems initiate change monitor ongoing effectiveness of care

Nursing Care Delivery Systems

Functional nursing (task nursing) Needs of clients are broken down into tasks Tasks are assigned to various levels of health care workers according to licensure and skill Example: RN gives medications and UAP give bed baths for one group of clients Team nursing Most common nursing care delivery system A team of nursing personnel provides total care to a group of clients Team leaders supervise client care teams, which usually consist of an RN, LPN, and UAP Team leader reviews the client's plan of care and progress with team members during team conference Total client care (case method) An RN is responsible for all aspects of care of one or more clients The LPN may be assigned to assist the RN Currently, this type of care is provided in areas requiring high level of nursing expertise, such as the critical care unit (CCU) or the post-anesthesia recovery unit (PACU) Primary nursing The RN maintains a client load of primary clients The primary nurse designs, implements and is accountable for the nursing care of those clients during their entire stay on the unit has the benefit of continuity of care but may not be feasible with varying schedules has been found to result in greater nurse satisfaction, more personalized care, less turn over, and fewer negative outcomes for patients Practice partnerships An RN and an assistant (UAP, LPN, less-experienced RN, graduate nurse, or nurse intern) agree to be practice partners Partners work together on same schedule with same group of clients Senior partner directs the work of the junior partner within the scope of each partner's practice

Remember the steps in the Nursing Process - A D elicious PIE A =Assessment D =Diagnosis P =Planning I = Implementation

E =Evaluation

6. Case management o Model for identifying, coordinating, and monitoring the implementation of services needed to achieve desired client outcomes within a specified period of time o Organizes client care by major diagnosis or Diagnosis Related Group (DRG) o A collaborative health care team defines the expected outcomes of care and care strategies for a client population by defining critical paths o A registered nurse manager is assigned to coordinate, communicate, collaborate, problem solve, facilitate and evaluate client care for a group of clients o Case manager usually does not provide direct client care but coordinates care provided by licensed and unlicensed nursing personnel according to a critical path o Critical pathways are plans for providing care to the client and family identify desired outcomes state expected amount of time and resources to be used focus on specific diagnoses or procedures that are high volume and or high resource use (and therefore costly) promote collaboration among disciplines (health care professionals) o The essential components of case management include collaboration of all health care team members identification of expected patient outcomes with time frames use of principles of continuous quality improvement (CQI) and variance analysis promotion of professional practice o Client involvement and participation is key to successful case management

The Case Management Resource Guide is a free, searchable database of health care services, facilities, businesses and organizations. Refer to the University of Texas Medical Branch Web site for examples of clinical practice guidelines, critical pathways and primary care guidelines.

7. Differentiated practice o Identifies distinct levels of nursing practice based on defined abilities that are incorporated into job descriptions o Structures nursing roles according to education, experience, and competency 8. Client-centered care o The RN coordinates a team of multi-functional unit-based caregivers o All client care services are unit-based, including admission, discharge, diagnostic testing and support services o Uses UAPs to perform delegated client care tasks

Arrive at the testing center early so you have time to register, become accustomed to your surroundings, and relax. Bring the proper identification and your Authorization To Test (ATT).

5. Documentation
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Types of patient records Problem-oriented medical record (POMR) a decision is made on the nature of the client's problem or problems and these problems are assessed regularly recorded using a standardized format, by narrative notes in the S.O.A.P. format or by flow sheets discharge summary relates the overall assessment of progress during treatment and plans for follow-up care, encouraging continuity of care four parts data base: the client's present health status problem list: numbered list of health problem(s) initial plan: plan to help overcome health problem(s) progress notes: all disciplines chart on the same page Source-oriented most traditional type of charting, with different disciplines charting on separate forms drawback: records become very bulky, very quickly Methods (styles) of charting narrative charting the nurse records observations, data (including reactions from the client) in a sequential and chronological order baseline charted every shift source-oriented S.O.A.P.: problem-oriented charting; comes from a medical model S = subjective; what client tells you O = objective; what you observe, see, etc. A = assessment; what you think is going on based on the data P = plan; what you are going to do Focus charting charting on an acute condition, a potential problem, a treatment or procedure, or a client behavior components of this type of charting include: information about the condition/problem, action, and client's responses P.I.E. charting; uses the nursing process P = problem I = intervention E = evaluation Charting by exception uses flowsheets emphasis on abnormal (or what is abnormal for this particular client); normal routine is presumed as having been done, without any problems

Documentation has six key components - CO-ACTS: C onfidential O rganized (chronologically) A ccurate C omplete T imely S ubjective and objective data

3. Documentation guidelines o General check that you have the correct chart record the facts as accurately as possible chart as you go never chart for another person do not mention incident reports avoid the use of abbreviations - when in doubt, write it out! all health care institutions have a list of accepted abbreviations refer to the Joint Commission's official "Do Not Use" list of abbreviations never alter a client's record (altering a client chart is a criminal offense) six things that nurses must document assessment nursing diagnosis and client needs interventions care provided client response to care client's ability to manage continuing care after discharge o Legal guidelines for charting electronic health record (EHR) charting never share access or password with another person change your password frequently maintain confidentiality of documented information printed from the computer carefully check your information before you press enter access information for clients under your care only log off when you are finished date and time are automatically recorded paper-ink do write in chronological order use permanent black ink chart the time and date for each entry include consent for or refusal of treatment, client responses to interventions, calls made to other health care professionals write legibly

cross through the error once, date and initial the change correct any errors in a timely manner erase, scratch out or use correction fluid (Liquid Paper or Wite Out) document for others or change documentation by others leave blank spaces recopy any charting form make photocopies without permission

do not

NCSBN Learning Extension offers several continuing education courses, including Documentation: A Critical Aspect of Client Care . For more information, go to http://www.learningext.com. The American Recovery and Reinvestment Act (ARRA) will require all health care facilities to use electronic medical records by 2014. Review the Joint Commission's Official "Do Not Use" List of abbreviations (last updated 3/5/2009)

6. Establishing Priorities
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Prioritizing: decisions of which needs or problems require immediate attention or action and which ones can be delayed until a later time if they are not urgent Needs that are life-threatening or could result in harm to the client if left untreated are high priorities Actual problems or needs have higher priority than potential problems or needs Problems or needs identified by client are of a higher priority Consider Maslow's principles (hierarchy of needs) or the ABCs (airway, breathing, circulation) of emergency care to guide decisions Mutual decision-making for priorities may be made with the client based on the client's physiologic needs, desires, and safety

Get a good night's sleep the night before the test.

7. Nurse Practice Acts

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Definition: passed by each state legislature to regulate the practice of nursing in that state Nurse practice acts define Scope of practice Education Licensure

Professional misconduct negligence the impaired nurse the nurse who violates boundaries Administered by the board of nursing in each state The nurses must know how their state defines professional misconduct For professional misconduct, the state board of nursing imposes penalties (in order of severity) on probation censured reprimanded license suspended license revoked

Don't Confuse these! Scope of Practice - determined by a state's Nurse Practice Act Standards of Practice - established by the nursing profession, i.e., the American Nurses Association Standard of Care - institutional policy and procedure documents

8. Standards of Nursing Practice and Standard of Care

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The American Nurses Association (ANA) publishes its Standards of Nursing Practice, which defines the responsibilities of the RN to all clients for quality of care Each institution sets standards of care, both across the institution and for specific clinical populations

Learn more about the Standards of Nursing Practice by visiting the National League for Nursing (NLN) and American Nurses Association (ANA) web sites.

9. Legal Responsibilities
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Negligence: legally, a breach of the duty to provide nursing care to the client Malpractice is professional negligence The unintentional failure of an individual to perform or not perform an act that a reasonable person would or would not perform in a similar set of circumstances Negligence involves four legal concepts: Duty: nurses have a legal obligation to provide nursing care to clients

must meet a reasonable and prudent standard of care under the circumstances must deliver care as any other reasonable and prudent nurse of similar education and experience would, under similar circumstances Breach of duty: failure to provide expected, reasonable standard of care under the circumstances (includes errors of omission or commission) Proximate cause: relationship between the breach of duty and the resulting injury the injured party must prove that the nurse's action or omission led to the injury Damages: the injury and the monetary award to the plaintiff

A former client sues a nurse for negligence. The client must prove that the nurse not only committed a breach of duty but that this breach of duty was the proximate cause of any damages incurred by the client.

NCSBN Learning Extension offers continuing education courses on Professional Accountability and Legal Liability for Nurses and Disciplinary Actions: What Every Nurse Should Know . For more information on this and other available courses, go to www.learningext.com.

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Professional Misconduct
The impaired professional Remember that the impaired nurse is compromising client care Be sure that the problem exists and can be proven Communicate specific concerns to appropriate persons such as a nurse manager or risk manager Document incidents in terms of behaviors, specific times, dates - be objective File a report according to the policies and procedures of the institution Boundary violations Definition: actions that overstep established interpersonal boundaries and meet the needs of the nurse rather than the client. Guiding principles in determining professional boundaries nurse is responsible for setting and keeping boundaries nurse must avoid simultaneous professional and personal relationship with a client nurse must avoid flirtation

Learn more about the American Nurses Association's Code of Ethics for Nurses.

NCSBN Learning Extension offers a continuing education course called Ethics of Nursing Practice . For more information about this course, and the other courses that are available, go to http://www.learningext.com.

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Client Rights
Privacy Confidential information may only be released by signed consent of the client Unauthorized release of client data may be an invasion of privacy Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides individuals with access to their medical records and more control over how their personal health information is used provides privacy protection for consumers of health care Health care workers must release information when a court orders it or when statutes require it (as in child abuse or communicable diseases) Special regulations apply to release of information about psychiatric illness or HIV

Learn more about HIPAA from the US Department of Health & Human Services NCSBN Learning Extension offers a continuing education course called Patient Privacy . For information on this, and all other available courses, please go to www.learningext.com.

2. Advance directives o As part of the Omnibus Budget Reconciliation Act (OBRA) of 1990, Congress established the Patient Self-Determination Act; this requires states to provide written information to clients outlining their rights to make health care decisions o These rights include: the right to refuse or accept treatment the right to formulate advance directives o Nurses and other members of the health care team are required to assess the clients knowledge of advance directives and their status regarding the advance directive process provide information and assistance to the client in developing advance directives plan care that incorporates the clients decisions regarding advance directives Three common advance directives are: living will: identifies what a client wishes for his care should he become unable to communicate these wishes

durable power of attorney for health care decisions: the client has appointed a person to make decisions about their care if they are unable to do so. do not resuscitate (DNR) status: this has been expanded to include identification of medications that may be given without any defibrillation attempts (comfort measures only) follow the facility policy on obtaining and implementing DNR orders generally, the order must be written by a physician; some facilities may have a policy to allow verbal orders under specific conditions the order must be communicated clearly to all personnel caring for the client the client or her or his health care proxy can withdraw the order at any time a nurse who attempts to resuscitate a client with a valid DNR order may be committing battery

ADVANCE DIRECTIVES The Patient Self-Determination Act of 1990 requires hospitals to inform their patients about advance directives. Advance directives are legal documents that allow someone to convey his or her decisions when he or she is unable to make a decision. Anyone age 18 and older may prepare advance directives. Copies of any advance directives should be kept on file in the physician's office and in the hospital. Advanced directives include Living wills Durable power of attorney for health care Living will A living will is a legal written document; it is sometimes called a "health care declaration" or a "health care directive" in some states. Although it is recommended, a person does not need a lawyer to draw up a living will. A living will should be signed, dated, and witnessed by two people who are not related and are not potential heirs or a health care provider. A person indicates what, if any, type of life-prolonging medical care should be provided if he or she becomes terminally ill, permanently unconscious, or in a vegetative state.

A living will goes into effect when the person is no longer able to make his or her own decisions. Durable power of attorney for health care Durable power of attorney for health care is a signed, dated, and witnessed document naming another person to make medical decisions should someone be unable to make a decision at any time, not just at the end of life. Most states do not allow the appointed agent to act as a witness. Although it is recommended, a person does not need a lawyer to draw up a durable power of attorney for health care. The document is also known as a "health care proxy" or "appointment of a health care agent." The named person may be called a "health care agent" or "surrogate." This document includes instructions about treatment one wants or wishes to avoid, e.g., surgery or artificial nutrition and hydration. This document goes into effect when the physician declares that a person is unable to make his or her own medical decisions. All states legally recognize some form of advance medical directive Refusal of treatment - competent clients may refuse treatment, even life-sustaining treatment Freedom from safety devices/restraints Physical restraints/safety devices require a signed, dated physician's order specifying the type of restraint/safety device and a time limit Types of restraints/safety devices chemical - central nervous system depressants, paralytics physical - vest restraints, side rails Use the least restrictive form of restraint/safety device Know agency guidelines for use of restraints The nurse must document three factors why restraints/safety devices were used how the client responded whether the client needs continued restraints/safety devices Restraining clients without consent or sufficient justification may be interpreted as false imprisonment.

Guidelines for Restraints

Laws and accreditation guidelines The Omnibus Budget Reconciliation Act (1997) states that freedom of restraints is a right by all clients across care settings The Social Security Act states: "Free from restraints is the right to be free from physical or mental abuse, corporal punishment, involuntary seclusion, and any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms."

Social Security Act Requirements for Nursing Facilities (Sec. 1919 [42 U.S.C. 1369r]) Social Security Act Requirements For, and Assuring Quality of Care in, Skilled Nursing Facilities (Sec. 1819 [42 U.S.C. 1395i-3]) Social Security Act Medicare and Medicaid Programs; Hospital Conditions of Participation: Patients' Rights; Final Rule (42 CFR Part 482) Review the Joint Commission FAQ sheet about Restraint and Seclusion, which includes time frames for reevaluation and reordering of restraint or seclusion for an adult and a child Policies and procedures The restraint must be necessary to: meet the client's therapeutic needs ensure the safety of the client or others There are two categories of restraints and there are different rules and restrictions for each type behavioral medical Health care providers can legally restrain a client under certain conditions defined by the law and by the health care facility's policies and procedures use of restraints must be accompanied by the health care provider's orders, except in an emergency there can be no "standing orders" or "PRN" orders for restraints physicians or licensed independent practitioners (LIP) are required to see and evaluate the need for a behavioral restraint or seclusion within 1-hour of the initiation of the intervention physicians or licensed independent practitioners (LIP) are required to see and evaluate the need for a medical restraint within 24 hours of the initiation of the intervention restraint orders must be updated according to policy (commonly every 24 to 48 hours) The least restrictive type of restrain must be used first Training about restraints is required for all staff who have direct contact with clients There must be documentation of attempts at restraint alternatives General guidelines when restraints are used The client must be closely monitored when restrained Restraints should be released periodically and the skin integrity of the area checked for breakdown Document all pertinent details, including why the restraint is being used and the client's response Remember that death can result from improper use of restraints Restraints are a LAST RESORT Informed consent Basic requirements capacity voluntariness information The client must understand purpose of the procedure and expected results anticipated risks and discomforts potential benefits any reasonable alternatives

 that consent may be withdrawn at any time The care provider has the legal obligation to obtain informed consent for medical treatment, but the nurse should confirm consent and answer the client's questions Transition planning - recognizes that clients are not discharged from care but moved across the continuum to another level of care

Ethics in Nursing
Ethics A theory or system of moral values, based on the ideas of right and wrong It governs our relationships with others A code of ethics provides standards and values for a profession; individuals must integrate the values of the profession with their own values Ethical principles Respect for others Autonomy Nonmaleficence - "do no harm" Beneficence - do good and avoid evil Justice Veracity - the ethical duty to tell the truth Confidentiality Fidelity - loyalty, faithfulness and honoring commitments

Learn more about the American Nurses Association's Code of Ethics for Nurses. NCSBN Learning Extension offers a continuing education course called Ethics of Nursing Practice . For more information about this course, and the other courses that are available, go to http://www.learningext.com.

Points to Remember
Nursing practice is governed by legal restrictions and professional standards. What a nurse can do depends on the nurse practice act in the state in which the nurse is licensed. Each state defines what constitutes professional misconduct. The state board of nursing has the authority to impose a penalty for professional misconduct. Penalties include probation, censure, reprimand, suspension or revocation of the license. Standards of nursing practice apply to all nurses in all practice settings. Standards of care are based on facility policy and procedure, nursing education, experience, and publications of professional nursing associations and accrediting groups. To avoid negligence: Know the standard of care

Deliver care that meets the standard and follows the facility's policies and procedures Document care accurately and in a timely manner The only employee of a health care organization who may be the legal witness to the signing of an advance directive is a clinical social worker. It is at the discretion of each health care facility as to whether or not this is done. Always check the policy of your facility. A relative or heir to the estate should never be the witness to the signing of an advance directive. Ethics guide the nurse toward client advocacy and the development of a therapeutic relationship. Ethical dilemmas result from conflicts in values. An effective leader modifies his/her style according to the situational requirements. Final responsibility for any delegated task resides with the RN. The RN must monitor delegated tasks and evaluate the outcomes.

Become familiar with the NCLEX Test Plan's distribution of questions and use this to make notes, like I can recall or I need to review. Use the I need to review list to help you to select the questions where you need more practice.

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