Nursing E2 Review

• Delegation responsibilities

       Right task: can this be delegated?

  -        Right circumstance: is this appropriate at this time?

  -        Right person: can this person do this task?

  -        Right communication and direction: does this person have all the proper information to perform this task?

  -        Right supervision/evaluation: has the nurse who delegated the task followed up to ensure it was done correctly?

  **Cannot delegate critical thinking or decision making
• RN is responsible for the nursing process and does not delegate evaluation, assessment, or teaching
• The RN remains responsible for any delegated task
• RN works under the APN, physician, or dentist
• LPN can collect data, determine normal from abnormal, and provide care for patients with a stable, predictable outcome
• LPN cannot delegate care
• LPN works under the RN, physician, or dentist
• Assistive personnel (AP) can gather data and perform routine tasks
• AP cannot trade or delegate tasks
• AP works under the RN or LPN
• Collaboration is the development of partnerships to achieve the best possible outcomes that reflect the needs of the patient, family, or community [WORKING TOGETHER]
• It requires an understanding of what others have to offer
• Scope of collaboration includes values and ethics, roles and responsibilities, communication, and teamwork
• Benefits of collaboration:

  • Increased job retention
  • Decreased resignation rates
  • Increased perception of RN-physician communication
  • Increased communication skills
• Collaboration can occur at all areas of the nursing process: assessment, diagnosis, planning, implementation, evaluation
• 4 categories of collaboration:

  • RN-Pt
  • RN-RN (Intraprofessional, 'within profession')
  • Interprofessional (between professions)
  • Interorganizational
• Nurse to Patient collaboration definition and examples

  ○       Nurse to Patient Collaboration: patient and nursing working together to support patient well-being and best outcomes

  ○       Used in every step of ADPIE

  ○       Example: End of life decisions - hospice vs. palliative care.

  ○       Lifestyle changes - smoking cessation
• Nurse to Nurse Collaboration definition and examples  

  ○       Collaboration WITHIN the nursing profession

  ○       A joint responsibility for patient outcomes, ensures the most effective and efficient care.

  ○       Example: SBAR hand off report

  ○       Example: Nurse mentoring less experienced nurse

  ○       Example: Bedside shift report
• Health Insurance Portability and Accountability Act (HIPAA) requires protection of patient medical records: only share with those who have a NEED and RIGHT to know
• Patients have a right to privacy, which includes the right to be free from intrusion into their private life
• HIPAA DO'S:

  • Only share patient information with those who have a need and right to know
  • Respect patient privacy
  • Report any identified breach of privacy
• HIPAA DON'TS:

  • Don't share passwords
  • Don't share patient information with individuals who do not need to know
  • Don't share patient information without consent
  • Protect medical records from unauthorized users
• Electronic Medical Records (EMR):

  • Only use accepted abbreviations when documenting
  • Notes should never be altered or obliterated; use the correction process
  • Chart as soon as possible after care is given
  • Nursing notes are considered legal documents
• Verbal Orders-definition, rules, do’s and don’ts

  A nurse who takes a verbal order must:

  ○       Always read the order back.

  ○       Enter order into electronic system

  ○       Document if it was in person or by phone

  ○       Include date, time, physicians name, and RN signature

  ○       This removes the nurse or unit secretary from the ordering process and decreases the possibility of error.

  Often limited to emergency situations
• Sentinel event definition, examples

  ○       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.

  ○       Example: Wrong site surgery, medication error, wrong treatment.
• Incident reports-purpose, how documented

  ○       Don't put it in the health record but it does need to be very detailed.

  The purpose is so that the hospital can prevent it from happening again (quality improvement).

  ○       In detail something that occurred in error.

  ○       Report is objective, non judgemental, and factual.

  ○       Incident report does not go into the medical record but the event does.
• 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
  • Example: "I'm Mia, giving you shift report on 4C for TM in room 333. Newly developed stage I dermal ulcer on left buttock over L ischial tuberosity"
• Background:

  • Pertinent Data: admitting Dx and date; current assessment findings (VS trend, allergies, medications, lab trends)
  • Example: 76-year-old female admitted to medical respiratory unit with pneumonia after 4 days of increasing SOB, fever, and a productive cough. She reported sleeping difficulties and not being able to breathe when lying down. Physical assessment revealed Stage I ulcer
• Assessment/ Analysis:

  • Analysis of findings - what do you think is the problem?
  • Example: Newly developed stage I ulcer which will now require frequent turning, repositioning, adequate nutrition, hygiene, and vigilant toileting to prevent moisture and further breakdown
• Recommendations:

  • What do you want to do to improve the patient's situation?
  • What should be monitored?
  • What interventions do you recommend?
  • Example: turn q2 hours when in bed; up in chair for no more than 2 hours at a time; use pillows to take pressure off of L ischial tuberosity; apply barrier cream with toileting episode
• Purpose: to standardize communication and allows parties to have common expectations in how communication is structured. Ensure continuity of care and patient safety. "provides information that increases patient safety, improved quality of care, increases accountability, and strengthens teamwork"
• Nursing documentation is part of the permanent medical record and is a 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 entry should include the date, time, and signature with credentials of the person documenting
• Nursing documentation is guided by the five steps: assessment, diagnosis, plan, implement, evaluate
• Expected nursing documentation includes:

  • Nursing assessment
  • Care plan
  • Interventions
  • Patient’s outcomes or response to care
  • Assessment of the patient’s ability to manage after discharge
• Use standardized nursing language and avoid using abbreviations, except for accepted abbreviations and acronyms (e.g., U, u for unit)
• Only document what was DONE, including only interventions that were performed
• Medical entries should NOT be altered or obliterated