Professonal Responsibilities: Evaluating Understanding of Advance Directives

L and M Chp 3

Advance Directives

1. Purpose is to communicate a client's wishes regarding end of life care should the client be unable to do so.

2. PSDA requires that all clients admitted to a health care facility be asked if they have an advance directive.

3. Living will is a legal document that expresses the client;s wishes regarding medical treatment in the event the client cannot do so.

4. Durable power of attorney for health care is a legal document that designates a health care proxy, who is an individual authorized to make health care decisions for a client who is unable to do so.

5. Unless a DNA or AND order is written, the nurse should inituate CPR when a client has no pulse/respirations.

Managing Client Care: Appropriate Client Assignment to a Float Nurse

L and M Chp 1

Assignment, Delegation, and Supervision

1. Assigning is performed in a downward or lateral manner with regard to members of the health care team.

2. Client factors include condition of client, level of care needed, specific care needs, need for special precautions, and procedures requiring a significant time committment.

3. Health care team factors include knowledge and skill level of team members, amount of supervision necessary, staffing mix, nurse-to-client ratio, experience with similar clients, and familiarity of staff members.

4. If an assignment is inappropriate, the nurse should bring the assignment to the attention of the scheduling/charge nurse and negotiate a new assignment.

5. Failure to accept the assignment without following the proper channels may be considered abandonment.

Managing Client Care: Delegating Tasks to Assistive Personnel

L and M Chp 1

Assignment, Delegation, and Supervision

1. AP's can perform ADL's, specimen collection, intake and output, and vital signs.

2. LPN's can monitor client findings, reinforce client education, trach care, suctioning, checking nasogastric tube patency, administer enteral feedings, insert urinary catheters, and administer meds (except IV meds).

3. Use the 5 rights of delegation (right task, right circumstance, right person, right direction/communication, and right supervision/evaluation).

4. RN's cannot delegate the nursing process, client education or tasks that require clinical judgement to LPN's or AP's.

5. Task factors include predictability of outcome, potential for harm, complexity of care, need for problem solving and innovation, and level of interaction with the client.

Managing Client Care: Evaluating Effective Time Management

L and M Chp 1

Assignment, Delegation, and Supervision

1. Good time management facilitates productivity, descreases stress, helps ensure provision of quality and appropriate care, and enhances satisfaction with care provided.

2. Poor time management impairs productivity, leads to feeling overwhelmed/stresses, increases omission of important tasks, and creates disatisfaction with care.

3. Consider what must be done immediately, what must be done by a specific time, and what must be done by the end of the shift.

4. Consider what can be delegated.

5. Time management is a cyclic process - spend time initially developing a plan, and reprioritize based on continual reassessment.

Coordinating Client Care: Advantages of Using a Critical Pathway

L and M Chp 2

Case Management

1. A critical/clinical pathway or care map may be used to support the implementation of clinical guidelines and protocols.

2. These tools are based on cost and length of stay parameters mandated by prospective payment systems such as Medicare and insurance companies.

3. Case manager nurses do not usually provide direct patient care.

4. Case managers usually oversee a caseload of clients with similar disorders or treatment regimens.

5. Case managers in the community coordinate resources and services for clients who care is based in a residential settings.

Coordinating Client Care: Components of a Critical Pathway

L and M Chp 2

Case Management

1. Case management is the coordination of care provided by an interprofessional team from the time a client starts receiving care until he or she is no longer receiving services.

2. Critical pathways are care plans that detail the essential steps in patient care with a view to describing the expected progress of the patient.

3. Critical pathways are one of the main tools used to manage the quality in healthcare concerning the standardization of care processes.

4. It has been shown that their implementation reduces the variability in clinical practice and improves outcomes

5. Clinical pathways promote organized and efficient patient care based on evidence based practice.

Coordinating Client Care: Implementing Change

L and M Chp 2

Concepts of Management

Decision making styles include:

1. Decisive- The team uses a minimum amount of data and generates on option.

2. Flexible- The team uses a limited amount of data and generates one options.

3. Hierarchical- The team uses a large amount of data and generates one options.

4. Integrative- The team uses a large amount of data and generates several options.

Managing Client Care: Guidelines and Principles

L and M Chp 1

Concepts of Management

1. Characteristics of managers include holding formal position of authority and power, possessing clinical expertise, networking with members of the team, coaching subordinates, and making decisions about organization function, including resources, budget, hiring, and firing.

2. The 5 major management functions are planning, organizing, staffing, directing, and controlling.

3. Planning- the decisions regarding what needs to be done, how it will be done, and who is going to do it.

4. Organizing- the organization structure that determines the lines of authority, channels of communication, and where decisions are made.

5. Staffing- the acquisition and management of adequate staff and staffing mix.

6. Directing- the leadership role assumed by a manage that influences and motivates staff to perform assigned roles.

7. Controlling- the evaluation of staff performance and evaluation of unit goals to ensure identified outcomes are being met.

Managing Client Care: Identifying Leadership Styles

L and M Chp 1

Concepts of Management

1. Authoritative- makes decisions for the group, motivated by coercion, communication occurs down the chain of command, work output by staff is usually high, and effective for employees with little or no formal education.

2. Democratic- includes the group when decisions are made, motivates by supporting staff achievements, communication occurs up and down the chain of command, and work output by staff is usually good quality.

3. Laissez-faire- makes very few decisions and does little planning, motivation is largely the responsibility of individual staff members, communication occurs up and down the chain of command and between group members, work output is low unless and informal leader evolves from the group, and it is effective with professional employees.

4. Leaders are initiative, inspirational, energetic, have a positive attitude, have good communication skills, respectful, and have problem solving and critical thinking skills.

5. Contemporary leadership theory supports the belief that leaders can develop the necessary skills.

Managing Client Care: Ordering the Steps of the Conflict Process

L and M Chp 1

Concepts of Management

1. Identify the problem- state it in objective terms, minimizing emotional overlay.

2. Discuss possible solutions- brainstorming solutions as a group may stimulate new solutions to old problems.

3. Analyze identified solutions- the potential pros and cons of each possible solution should be discussed in an attempt to narrow down the number of viable solutions.

4. Select a solution- based on this analysis, select a solution for implementation.

5. Implement the selected solution- a procedure and time line for implementation should accompany the implementation of the selected solution.

6. Evaluate the solution's ability to resolve the original problem.

Professional Responsibilities: Maintaining Confidentiality

L and M Chp 3

Confidentiality/Information Security

1. HIPAA rights include the right of the client to obtain a copy of their medical record and submit requests to amend erroneous information.

2. Further rights include a requirement for health care providers and insurance providers to provide written information about how medical information is used and how it is share with other entities.

3. A last right includes the right of clients to privacy and confidentiality.

4. Only health care team mebers directly responsible for the client;s care should be allowed access to the clients records. Nurses may not share information with other clients or staff not involved in the care of the client.

5. No part of the client record can be copied except for authorized exchange of documents between health care institutions- for example, transfer from a hospital to an extended care facility or exchange of documents between a general practitioner and a specialist during a consult.

Managing Client Care: Priority Assessment Following Report

L and M Chp 1

Establishing Priorities

1. Prioritize systemic before local ("life before limb").

2. Prioritize acute before chronic.

3. Prioritize actual problems before potential future problems (ie give meds for acute pain before a client at risk for something).

4. Listen carefully to clients and don't assume.

5. Recognize and respond to trends versus transient findings.

6. Recognize signs of medical emergencies and complications versus "expected client findings".

7. Apply clinical knowledge to procedural standards to determine the priority action.

Professional Responsibilities: Assessing Client Understanding

L and M Chp 3

Informed Consent

1. Nurses must ensure that clients understand their rights, and nurses must also protect client's rights during nursing care.

Each client has the right to...

2. Be informed about all aspects of care and take an active role in the decision-making process.

3. Accept, refuse, or request modification to the plan of care.

4. Receive care that is delivered by competent individuals who treat the client with respect.

5. When the client decides to refuse a treatment, the client is asked to sign a document indicating he understands the risk involved with refusing and that he has chosen to refuse it.

Coordinating Client Care: Discharge Against Medical Advice

L and M Chp 2

Legal Rights and Responsibilities

1. When a client decides to leave the facility without a discharge order, the nurse notifies the provider and discusses with the client the potential risks associated with leaving the facility prior to discharge.

The client should be informed of the following...

2. Possible complications that could occur without treatment.

3. Possibility of permanent physical or mental impairment or disability.

4. Possibility of other complications that could lead to death.

5. The client is asked to sign an AMA form, and if the client refuses to sign, this is also documented by the nurse.

Managing Client Care: Priority Steps in the Performance Improvement Process

L and M Chp 1

Performance Improvement

1. A formal system for conducting performance appraisals should be in place and used consistently.

2. Various sources of data should be collected to ensure an unbiased and thorough evaluation of an employee's performance.

3. Data should be collected over time and not just represent isolated incidents.

4. Actual observed behaviour should be documented and used as evidence of satisfactory or unsatisfactory performance.

5. Peers can be a valuable source of data.

6. The employee should be given the opportunity to provide input into the evaluation.

Facility Protocols: Fire Safety Protocol

L and M Chp 5

Emergency Response Plan

1. Rescue- rescue the client and other individuals from the area.

2. Alarm- pull the fire alarm

3. Contain- Shut the doors to keep the flames enclosed in one area

4. Extinguish- make an attempt to extinguish small fires

5. If the nurse is unable to extinguish the fire, complete evacuation of the area should take place.

Facility Protocols: Using Triage to Determine Order of Client Care

L and M Chp 5

Security Plan

1. Emergent category class 1- highest priority is given to clients who have life threatening injuries but also have a high possibility of survival.

2. Urgent category class 2- second highest priority is given to clients who have major injuries that are not yet life-threateing and usually can wait 45-60 minutes.

3. Nonurgent category class 3- next is given to clients who have minor injuries that are not life threatening and do not need immediate attention.

4. Expectant category class 4- lowest priority is given to clients who are not expected to live.

5. Type of triage is baed on doing the greatest good for the greatest number of people

Maintaining a Safe Environment: Appropriate Infection Control Precautions

L and M Chp 4

Standard Precautions/Transmission-Based Precautions/Surgical Asepsis

1. Staff education on infection prevention and control is a responsibility of the nurse.

2. Clients suspected of or diagnosed with a communicable disease should be placed in the appropriate form of isolation.

3. Hand hygiene facilities, as well as hand sanitizer, must be readily accessible to employees in client care areas.

4. Retractable needles or needles with capping mechanisms, needleless syringes, and IV tubing with needless connections should be available for use to prevent accidental needlesticks.

5. Study, moisture-resistant bags should be used for soiled items, and the bags should be tied securely with a not at the top. Double bagging is unnecessary.

Maintaining a Safe Environment: Appropriate Use of Restraints

L and M Chp 4

Use of Restraints/Safety Devices

1. Deaths by asphyxiation and strangulation have occured with restraints.

2. False imprisonment means the confinement of person without his consent. Improper use of restraints may subject the nurse to charge of false imprisonment.

3. Restraints should never interfere with treatment, they should restrict movement as little as is necessary to ensure safety, should fit properly, and should be easily changed to decreased the change of injury.

4. Conduct neurosensory checks every 2 hours to include circulation, sensation, and mobility.

5. Pad bony prominences, use quick release knots, offer food and fluids, provide ROM, and provide means for hygiene and elimination.

Reporting Incidents

Chapter 5 - Review

Incident reports are records made of unexpected or unusual incidents that affected a client, employee, volunteer or visitor.

Examples of circumstances include:

Medication errors, procedure/treatment errors, needlestick injuries, client falls/injuries, visitor/volunteer injuries, threats made, and loss of property.