Module 2 Flashcards
Documentation, PCT Data Collection & Nurse Assessment, Fluid Management, Vascular Access, Laboratory, Hemodialysis Treatment
What are the key concepts related to “Reasonable & Prudent” Care?
The Standard of Care is care which a reasonable and prudent nephrology nurse would give under the same or similar circumstances
Actions a reasonable and prudent nephrology nurse would do, as well as actions the nurse would avoid doing
The skills and knowledge expected of a nephrology nurse is key to the specialty of nephrology nursing
Who established the Standards of Care for Nephrology Nursing and for what purpose?
American Nephrology Nurses Association (ANNA) establish the standards of care and scope of practice for Nephrology nursing
Standards of Care can serve as a basis for many areas including policy and procedures, protocols, educational offerings, regulatory systems, and more
What are three considerations when delegating nursing care activities?
Must be within the nurse’s scope of practice
Must be delegable by State Board of Nursing
Personnel must be adequately trained to perform activity
What role does DaVita’s P&P play?
Provides evidenced-based guidance
Meets CMS’ Conditions for Coverage (CfC)
Complies with state & federal law
What are the risks of performing activities your way?
Not providing safe and evidence-based care can lead to Civil Liability
What are the four reasons that we document in the medical record?
Proof that care was rendered
Provides data continuity
Communication Tool
Permanent Legal Record
List 6 occurrences when to document
Change from baseline assessment
Change in patient’s condition
Procedure performed or treatment provided
Medication given and patient response
Patient teaching
Care plan review and interventions
What does SMART communication stand for?
S: Simple: Keep message clear and simple
M: Meaningful: Think about what and why you are sending the message
A: Actual: just report the facts
R: Read: Make sure you are sending the message you intend
T: Teach: Others about SMART communication
What are the possible consequences of not using SMART communication?
Exposes you and DaVita to liability
Reputational Injury
Jeopardizes the recipient
Potentially career threatening
How do you document late entries?
From Policy 3-02-02: Medical Record Preparation and Charting Guidance
Late Entries: If unable to chart immediately after rendering a service or at the time of an observation, the teammate is to make the appropriate entry as soon as possible
Electronic: If documenting within the electronic medical record, the notation will automatically contain your electronic signature, date and time
Paper Chart: The late entry must be signed by the person making the late entry, and timed and dated at the time it is entered
How do you document charting errors?
When documenting on paper, draw a single line through the entry, date/signature/teammate credentials, chart the correct information
If documenting in an electronic health record system, follow facility procedure for that system
What is the difference between data collection and assessment and who is responsible for which?
Assessment- Nurse
- Determining Depth of edema
- Heart rate, rhythm, quality of heart sounds
- Respiration rate, rhythm, effort being put into breathing, identifying unusual lung sounds
Data Collection- PCT
- Noting presence of edema
- Counting the patient’s heart rate
- Respiration rate, recognizing unusual breath sounds
- Machine parameters, safety checks
What is the role of the licensed nurse prior to treatment initiation?
Assess abnormal findings from data collection, determine appropriate interventions (based on physician orders) and contact physician if needed.
When is a pre-treatment assessment by the RN required
For CKD hemodialysis patient: Based on State Law (may be before treatment initiation or within an hour of treatment initiation) or if data collection has abnormal findings
For patients with AKI: a pre-treatment is always required.
What is the role of the PCT prior to treatment initiation?
Complete data collection and PCT must notify the RN if there are any abnormal findings prior to initiation and treatment
What are the appropriate times for documentation?
Pre-treatment safety checks: Prior to treatment initiation
Pre-treatment Patient data collection: Completed pre-treatment/assessment: prior to treatment initiation if required by state law or within the 1st hour of dialysis treatment
Observations during treatment: Document Assessment pre-treatment, continuous monitoring during treatment, as they occur
Post Treatment Data Collection/Assessment: Must be done after treatment is complete - some of the things need post treatment:
- Documentation of clearance of dialyzer after rinse back
- Blood Pressure
- Heart Rate
- Temperature
- Respiratory Rate
- Weight
What is the preferred location for taking a blood pressure?
Upper, non-vascular access arm
What BP reading error can be caused by an incorrect cuff size?
Cuff too small: reading may be higher than actual BP
Cuff too large: reading may be lower than actual BP
What is a normal pre-treatment blood pressure?
Systolic: =/< 180mm/Hg or =/> 90mm/Hg
Diastolic: <100mg/Hg or >50mm/Hg
What is the normal heart rate range?
60-100 BPM
What is the normal respiratory range?
12-20 breaths
What is a normal temperature?
<100F or 37.8C
or
<2F(1C) change of Baseline (pre-treatment temperature reading)
The 3 words DaVita uses in order to easily recall the pre-treatment AVF/AVG access evaluation are:
Look
Listen
Feel
When is post-treatment assessment by the licensed nurse required?
If required by state law
If there were abnormal findings
What are the 6 “W”s to be used when completing a REM?
What
When
Where
Why
Witness
Who
