L & M Flashcards
Authoritative Leadership
Leader dictates decisions for team, uses penalties and/or coercion to promote behavior change
Democratic Leadership
Leader involves team members in decision-making process. Characterized by team cooperation, resulting in higher quality resutls
Laissez-Faire Leadership
Leader promotes little direction and planning. Emphasis is on group decision making. Team results may be lacking
ABCDE Principle in Nursing
A: Airway (Ensure patency. Stabilize cervical spine if neck/ head trauma is suspected.
B: Breathing (Assess resp depth, rate, etc.)
C: Circulation (Check HR, BP, CRT)
D: Disability (Assess LOC)
E: Exposure (Assess body for trauma, exposure to heat/cold)
Prioritization of Patient Care
A _ _ _ _ before taking A _ _ _ _ _.
Prioritize u _ _ _ _ _ _ _ over s _ _ _ _ _ patients.
- Assess before taking action. (Check O2 before notifying provider, check FSBG before giving insulin).
- Prioritize unstable patients over stable patients. (Patients with expected findings for their medical diagnoses are stable; not the priority; ex: COPD patient with SPO2 of 90%).
Prioritization of Patient Care
Prioritize a _ _ _ _ over c _ _ _ _ _ _ conditions.
Prioritize s _ _ _ _ _ _ _ over l _ _ _ _ issues.
- Acute over chronic condition (Abnormal VS or UOP < 30 mL/hr has priority over a patient with a chronic condition like a pressure ulcer)
- Systemic over local issues (A patient with fever, HTN, tachypnea, tachycardia has priority over a patient with local symptoms like leg pain and erythema)
Prioritization of Patient Care
ABCDE Framework?
Maslow’s?
____ invasive interventions first?
- ABCDE: giving O2 has priority over giving pain meds
- Maslow’s: Physiological > safety > love/belonging > self-esteem > self-actualization
- Least invasive first (i.e. instead of restraints, move patient near nurses’ station)
Efficient Nursing Practice
Prioritizing/planning? Charting? Task completion? Delegation? Assistance?
- Prioritize and plan at the beginning of the shift
- Complete charting ASAP after intervention
- DO NOT WAIT until end of shift to document assessment or interventions
- Group tasks for a single patient (or for multiple patients in the same location) to prevent frequent trips to supply room
- Complete difficult or time-consuming tasks early in the shift (when energy is higher)
- Perform non-essential tasks later in the day
- Know when to delegate and ask for help
- Do not help other team members with low priority tasks when you still have outstanding tasks
Delegation
RN should not delegate…
Ok to delegate to PN…
Ok to delegate to CNA…
- Should not delegate patient education, any task that requires nursing judgment, nursing assessment, or blood transfusions
- PN: medication administration, enteral feedings, urinary catheter placement, suctioning, trach care, wound care, REINFORCEMENT of patient teaching
- CNA: bathing, dressing, ambulating, toileting, feeding patients without swallowing precautions, positioning, VS, bed-making, specimen collection, I&Os, basic CPR
5 Rights of Delegation
Hint: TCP likes to go to DC, but there was an SE
- Right task: repetitive, non-invasive, doesn’t require much supervision
- Right circumstances: do NOT assign a patient who is unstable
- Right person: make sure person is competent and working within their scope of practice. check facility’s job description or the individual’s skill competency checklist
- Right direction and communication: communicate specific details of task, timeline for completion, and expectation for communicating findings back to you
- Right supervision and evaluation: intervene if needed, provide feedback. If delegate reports results outside expected range, assess patient yourself!
Quality Improvement
What is it?
Process used to improve quality of care and/or correct performance deficiencies on a unit or team
Quality Improvement
7 Steps?
1) ESTABLISH best practice guidelines or benchmark goal against which nursing care will be measured.
2) DEVELOP plan for collection of data.
3) COLLECT data.
4) COMPARE data against benchmark. If benchmark isn’t met, perform RCA.
5) ID/ANALYZE potential solutions, select one to implement.
6) IMPLEMENT solution (corrective action plan, education)
7) RE-EVALUATE issue at predetermined time to evaluate effectiveness of solution
Quality Improvement
Whom should unusual trends be reported to?
First step when there is a QI issue on the unit?
What is a good way to obtain quantitative data on factors related to QI issue?
Patient is upset with their care; what do you do first?
- Unusual trends on the unit should be reported to the QI team
- First step is to assess causative factors before taking action
- Audits are helpful to obtain quantitative data
- First assess patient’s feelings and clarify their expectations before taking action
Key Points on Performance Reviews
- Collect data over time (throughout year)
- Allow for self-appraisals before review
- Include peer (other RN) evals
- Go through performance checklist
- Compare RN against standards, not other RNs
- Discuss employee goals
- If employee doesn’t agree with eval, they can make written comments on the evaluation and/or make an appeal, depending on facility policy
Key Points on Disciplinary Action
Serious offense?
Less serious offense?
- Serious offenses (working under influence of ETOH or drugs) would result in immediate dismissal
- For less serious offenses, provide progressive discipline: verbal reprimand»_space; written reprimand»_space; suspension»_space; termination
Conflicts
Intrapersonal?
Interpersonal?
- Intrapersonal: individual’s internal struggle/conflict
- Interpersonal: Cofnlict between 2 or more people
Conflicts
Hint: Lily Pad Flowers (Are) My Choice
- Latent: no conflict yet but high likelihood of one occurring
- Perceived: individual believes a problem exists, but other party is unaware of the problem
- Felt: individual has emotional response to a conflict
- Manifest: both parties are aware of the conflict and action is taken to resolve the conflict
- Conflict aftermath: conflict is resolved, with either positive or negative results
Negotiation Strategies
(1) Avoiding/Withdrawing?
(2) Smoothing?
(3) Competing/coercing?
(4) Cooperating/accommodating?
(5) Compromising?
(6) Collaborating?
1) Both parties refuse to acknowledge or work on resolution to conflict
2) one party attempts to keep peace by complimenting the other party; conflict remains unresolved
3) win-lose; one party gets desired solution at expense of other party
4) lose-win; one party gives up what they want (caves in) and allows other party to get their desired solution
5) both parties give up something and come to compromise
6) win-win; both parties put aside individual desires and work together to define a mutually agreeable solution
Case Manager Responsibilities
Does not provide direct patient care. Acts as care coordinator for healthcare team to safely transition patient from acute care to SNF, home, or LTAC.
Arranges home health, referrals, and equipment needs
Occupational Therapist Responsibilities
helps patients regain abilities to perform ADLs
SLP Responsibilities
assists with patient issues r/t speech, language, and swallowing
Physical Therapist Responsibilities
helps patient improve mobility and strength
Critical Pathways
Used to promote cost-effective are and shortens a patient’s length of stay by standardizing care for patients with a specific, common diagnosis
Developed using EBP and include: time-bound activities, interventions, and outcomes
It is a multidisciplinary tool that guides client care and based outcomes on a externally-imposed timeline
Patient Transfer: Nursing Handoff
What you SHOULD include?
What you SHOULD NOT include?
- Should: immediate needs and priorities, allergies, advanced directives, diet/activity restrictions, recent changes r/t patient condition, time of patient’s last dose of pain meds
- Should not: info about routine care found in medical record, info about patient’s visitors (unless it directly affects client care), subjective comments/negative statements about a patient
Discharge Planning
When does it begin?
Teaching should include…?
- BEGINS AT ADMISSION
- Instructions: diet and activity restrictions, detailed teaching for procedures at home. allow for return demonstration. list of meds, when to take them and precautions. s/s of complications and when to seek medical attention. names, numbers of providers and community resources
Refusal of Treatment
Who can refuse?
Who is incompetent patient?
What to do?
- Competent adults or emancipated minors have the right to refuse treatment. This includes patients who are involuntarily admitted.
- Incompetent patients: adults with dementia, adults under influence of drugs or alcohol (BAC >= 0.08%), schizophrenic patients experiencing command hallucinations
- Ask patient to sign document indicating that they understand the risks of refusing treatment
AMA
1) Notify provider
2) Discuss risks of leaving
3) Have patient sign AMA form (or document their refusal to sign)
DO NOT call security
Informed Consent: Provider Responsibilities
- communicate purpose and complete description of procedure in the patient’s primary language *use medical interpreter if needed
- explain risks vs benefits
- describe other treatment options
Informed Consent: RN Responsibilities
- confirm patient understands information provided by provider
- notify provider if pt has more questions or doesn’t understand the information provided
- verify patient is competent to give informed consent
- ensure patient signs consent document voluntarily
Note: if the patient has already signed the consent form and forgets, you can reinforce the procedure purpose; if they still have questions, call provider
Informed Consent
Who can give consent for another person?
- parent or legal guardian of a minor; if they are not available, another family member or relative can give consent in an emergency
- durable power of attorney
- spouse or closest relative, based on state law
- court specified rep
Living Will
communicates patient wishes regarding medical treatment if the patient becomes incapacitated
- evidence that the client was incompetent at the time of making the living will could result in its revocation
- no need to contact provider unless client has questions regarding treatment options. RN to contact provider and document in medical record once client has completed a living will
DPOA
patient designates a health care proxy to make medical decisions for him/her if they become incapacitated
Providers Orders
prescription for DNR or AND (allow natural death)
Information Security: HIPAA
ensures confidentiality of a patient’s health information
Information Security: Important Key Points
- only those responsible for patient’s care may access their records (need to know basis)
- pt has the right to obtain a copy of their medical record. follow facility protocol
- copies of the record should not be made except for exchange of documents between health care facilities
- do not use patient names on public display boards
- communication about client should happen in private place
- need permission from patient to share test/lab results with others; do not share to unauthorized people
- password protect EHRs; don’t share; log out
- report breaches of client confidentiality to the nurse manager
Torts
Unintentional?
Intentional?
Unintentional: negligence, malpractice
Intentional: assault, battery, false imprisonment
State Board of Nursing
- determines laws & regulations governing nursing in each state (nurse practice acts)
- ensure HCPs comply with state regulations, issues and revokes nursing licenses
Nursing Responsibilities (in terms of legalities)
- need to know laws/regulations that govern nursing in the state that they practice
- MUST have license in every state in which they practice/reside in a state that is part of the nurse licensure compact
- nurses should refuse to practice beyond their legal SOP
Patient Protection and Affordable Care Act
4 main points?
- protects patients from annual and lifetime coverage limits
- allows patients to insure dependents until the age of 26
- states that an insurance provider cannot deny coverage to a patient due to preexisting conditions
- protects the patient from cancellation of his/her insurance due to illness
Impaired Coworkers
RN responsibilities?
Signs of impairment?
Nurse manager responsibilities? What do they NOT do?
- report suspicion to charge nurse immediately; do not confront coworkers or delay reporting to further observe coworker’s behavior
- impaired coordination, difficulty focusing, bloodshot eyes, mood swings, frequent errors and wasting controlled substances, isolating oneself from others
- remove nurse from work environment, arrange for safe transportation back home. meet with impaired nurse within 24 hours to reiterate facility expectations and outline rehab measures. handle incident in confidential manner. do NOT report individuals to risk management
Mandatory Reporting
suspicion of abuse (child, elderly, domestic violence)
Nationally Notifiable Communicable Diseases
mandated by state. report to state health department
anthrax, botulism, chlamydia, cholera, diptheria, gonorrhea, haemophilus influenzae, hantavirus, hep a/b/c, HIV, lyme, malaria, measles, meningococcoal, mumps, pertussus, rubella, salmonella, shigellosis, smallpox, syphilis, tetanus, TB, varicella
Telephone Orders
- have second RN listen on call
- make sure to get all components of prescription dose, frequency, route
- repeat prescription back to provider to confirm information obtained is correct
- make sure provider signs prescription within time frame required by facility (usually 24 H)
- question any inappropriate or contraindicated orders
Nursing Ethical Principles
- autonomy: pt has right to make his/her decision even if not in the patient’s best interest…RN needs to support the choice
- beneficence: do what is best for pt
- fidelity: keep promises
- justice: fairness in care and allocation of resources
- nonmaleficence: do not do harm
- veracity: tell the truth
Ethical Decision-Making
What is an ethical dilemma?
What does the ethics committee do?
- problem cannot be solved by reviewing scientific data; involves conflict between 2 moral imperatives. The decision has major impact on the patient
- interprofessional team: examines facts and supports the patient and caregivers. does NOT offer legal support. does NOT impose a decision or recommend the best course of action…the decision is up to the patient and/or family
Contact Precautions
infections: impetigo, scabies, shigella, herpes, MRSA, VRE, C Diff (& other enteric infections), RSV, wound infections
private room or with another pt with the same infection
gloves and gowns for caregivers and visitors
Droplet Precautions
infections: influenza, PNA, pertussis, mumps, sepsis, rubella, bacterial meningitis, strep pharyngitis
private room or with another patient with same infection
gloves, gowns, masks for caregivers and visitors
Airborne Precautions
infections: measles, varicella, TB
private, negative airflow room
N95 masks, gloves, gown for caregivers and visitors
Radiation Therapy
- limit visitors to 30 min visis. instruct visitors to maintain 6 ft distance
- providers wear lead aprons when caring for patient and always face apron toward the radiation source (do not turn back to patient)
- keep door to patient’s room closed
- providers wear dosimetry badge to monitor exposure
- pt with radioactive implant will usually be on bed rest to prevent dislodgement of the implant
Sterile Field
Set up?
Maintenance?
set up: position package with top flap facing away from you, open top flap away from you, open right side with r hand, left side with l hand, open last flap towards you
maintenance: do not cough, sneeze, or talk over field, 1” is non sterile, any object held below waist or above client is contaminated, add objects to sterile field at least 6 in above field, NEVER turn back on field or reach across it
Equipment Safety Measures
inspected by engineering dept. on regular basis
pull from plug, not cord
tag equipment as broken, take out of use immediately, notify appropriate department
Needlestick injuries
use retractable needles, needles with capping mechanisms, or needleless connections to avoid injuries to begin with
notify supervisor right away. test RN and nurse for bloodborne illnesses (hepatitis, HIV) and file incident report
Fall Prevention
have patients sit at side of bed before standing (esp with orthostatic hypotension)
wear skid proof socks
provide regular toileting to patients needing assistance
place patients at risk near nurse’s station
hourly rounding
put frequently used items within reach
position bed in lowest position, lock breaks, set bed alarm
do not put up all 4 side rails for patients who will try to get out of bed on their own
Restraints Considerations
- in emergency, RN can place client in restraints but provider needs to see patient and write RX within 1 hour
- PRN is NOT allowed
- apply padded portion to client wrists to prevent skin breakdown
- vests are placed OVER patient gown
- perform neurovasc checks Q2H
- assess skin integrity
- provider must rewrite Rx within 24 hours
- provide ROM exercises
- use least restrictive measures to correct issue (mittens are less restrictive than wrist restraints)
- apply restraints tso 2 fingers can fit between restraint and patient
- quick release knot (slipknot)
- place restraints on non-movable part of bed frame (NOT siderails)
- apply belt restraints over the patient’s gown/clothing
Injury Prevention General (Children/Home)
- crib slats < 2 and 3/8 in
- use rear facing car seats until 2 years old; 5 point harness car seat, place in back seat
- use car booster seat while child is under 40 lbs or under 4’9”
- reduce water heating settings to less than 120 F
Oxygen Safety
increased risk of combustion; place system away from walls and in a well-ventilated, clutter free environment
keep in stand/rack, not on floor
no smoking sign posted
make sure equipment is grounded and in good shape,, no extension cords
use COTTON bedding and clothes, no synthetic fabrics or wool
keep flammable items away from equipment, no petroleum jelly; use water-based lubricant instead
monitor oxygen delivery rate daily to make sure it is being administered at the prescribed rate
Carbon Monoxide
- odorless, tasteless gas; binds to Hgb, reducing O2 supplied to the body
- use carbon monoxide detectors
- maintain proper ventilation when using fuel-burning items (wood stoves, gas fireplace)
- know symptoms of poisoning: N.V, headache, loss of consciousness
Injury Prevention: Food poisoning
Best practice? Who's at higher risk? Food storage practice? Avoid consuming...? Food prep...?
perform frequent HH
immunocompromised individuals at higher risk; consume low microbial diet
refrigerate perishable products within 2H, 2H when temp is 90 F or higher
do not consume unpasteruized dairy or untreated water
prevent cross-contamination during food preparation (handle raw and fresh food separately)
cook foods to recommended temps
Ergonomics
spread feet apart to lower center of gravity to increase stability
distribute weight between major muscle groups in arms and legs when lifting
when lifting an object, hold it as close to your body as possible, tightening ab muscles
avoid twisting/bending at waist
get help with repositioning
use smooth movements when moving patients
Incident Reports
What are they?
What to do?
- created when an accident/unexpected event occurs; used for QI at a facility
- provide immediate care to patient to prevent further injury and notify the provider
- RN responsible to complete within 24 hours of the incident
- confidential facility documents; do NOT share with the patient
- information regarding the event must be charted objectively in the patient’s medical record, but do NOT include the report or reference its existence!
Mass Casualty Event
Triage?
Class 1 (Red): immediate threat to life (sucking chest wound, pneumothorax, major burn)
Class 2 (Yellow): major injury requiring prompt tx within 2 hours (bone fracture)
Class 3 (Green): minor injury that does not require treatment within 2 hours (laceration, sprain)
Class 4 (Black): expected and allowed to die (penetrating head wound, chest crush injury)
Mass Casualty Event
Discharge and patient relocation?
ambulatory patients requiring minimal care
transfer stable patients out of the PACU to the surgical unit
Nursing Actions During Disasters
Tornadoes?
close shades, move patients away from windows (ideally in hallway), place blankets over bed-bound patients
Nursing Actions During Disasters
Chemical exposure?
undress patient, irrigate profusely
for dry chemicals, brush chemicals off patient clothing/skin
Nursing Actions During Disasters
Hazardous material incident?
locate safety data sheet (SDS)
water is universal antidote (in most cases)
use bleach to clean blood spills!!
Nursing Actions During Disasters
Radiological Incident?
- RN should…
- Patient care…
- Primary “to do”
- wear dosimetry badge to monitor radiation exposure
- decontaminate patients with soap, water, disposable towels
- contain water runoff! (it is contaminated)
Nursing Actions During Disasters
Bomb threat?
keep caller on the phone as long as possible, listen for background noises and clues
