Nurs211 Exam 2

• what are the delegation responsibilities?

  right task, right circumstance, right person, right direction, right supervision/evaluation.
• What does "right task" mean?

  can this be delegated.
• What does "right circumstance" mean?

  Is this appropriate at this time?
• What does "right person" mean?

  can this person do a task?
• What does "right direction" mean?

  Does this person have all the proper information to perform this task?
• What does "right supervision/evaluation" mean?

  Has the nurse who delegated the task followed up to ensure it was done correctly?
• Scope of practice for RN = responsible for the nursing process
• Not in the RN scope of practice = do not delegate: evaluations, assessment, or teaching. Works under APN, physician, or dentist.
• Scope of practice for LPN = can collect data, determine normal from abnormal, and provide care for patients with stable, predictable outcomes.
• Not in the LPN scope of practice = Can not delegate care. Woks under RN, physician, or dentist.
• Scope of practice for AP = can gather data and perform routine tasks
• Not in scope of practice for AP = cannot trade or delegate tasks. Works under RN or LPN.
• Collaboration: a development of partnerships to achieve the best possible outcomes that reflect the needs of the patient, family or community, requiring an understanding of what others have to offer.
• Scope of Collaboration: values and ethics, roles and responsibilities, communication, and teamwork.
• Benefits/Impact of Collaboration = no EBP of benefits. Impacts include increased job retention, decreased resignation rates, increased perception of RN- physician communication, and increased communication skills.
• Nurse Patient Collaboration: Used in every step of ADPIE
• Examples of Nurse-Patient collaboration = end of life decisions (hospice or palliative care) and lifestyle changes.
• Nurse-Nurse Collaboration = A joint responsibility for patient outcomes, ensures the most effective and efficient care.
• Examples of nurse-nurse collaboration = SBAR hand-off report, nurse mentoring, and bedside shift report.
• Always read verbal orders back
• Sentinel Event: causing severe harm or death and requires immediate follow-up.
• Breakdown in communication between team members is the primary factor in sentinel events.
• Examples of sentinel events = wrong site surgery, medication error, and wrong treatment.
• Verbal orders are often limited to emergencies, including date and time with RN signature, entering orders into an electronic system, and documenting if it was in person or by phone.
• HIPAA: Health Insurance Portability and Accountability Act of 1996
• SBAR is a situation briefing tool used when handing off a patient from one caregiver to another
• Situation: Purpose of SBAR; Your name, unit, patient name, room #, description of problem. “What is going on right now?”
• Background: Pertinent Data - admitting Dx and date; current assessment findings (VS trend, allergies, medications, lab trends).
• Assessment/ Analysis:  Analysis of findings - what do you think is the problem?
• Recommendations: What do you want to do to improve the patient's situation? What should be monitored? What interventions do you recommend?
• Purpose of SBAR: to standardize communication and allows parties to have common expectations in how communication is structured.
• Incident report's purpose: To record the details of an incident and to provide a basis for investigation and corrective action. Objective info only not judgmental or factual.
• Incident reports do not go into the medical record but the event does.
• Part of the permanent medical record (legal document based on fact)
• Events should be reported in the order they happened, and documentation should occur as soon as possible after assessment, interventions, condition changes, or evaluation. 
• Each nursing documentation entry includes the date, time, and signature with the credentials of the person documenting.
• Expected findings for cardiovascular =

  • Walls of blood vessels thicken; vessels narrow and lose elasticity
  • Peripheral circulation decreases and systolic BP increases
  • Cardiac output decreases
  • Decreased sensitivity of baroreceptors
• Unexpected finding for cardiovascular =

  • New hypertension 
  • Orthostatic hypotension 
  • Abnormal vital signs

  Critical conditions: chest pain, new onset or changes in O2
• Expected findings for respiratory =

  • Decreased cough reflex
  • Increased chest wall rigidity 
  • Decreased lung compliance
  • Fewer alveoli
• Unexpected finding for respiratory =

  • Labored breathing
  • Abnormal vital signs 

  Critical conditions: hemoptysis (cough up blood from lungs, decreased O2 saturation levels