RN 1137 Study Guide Final exam summer 2016

Advance Directives

"are instructions that indicate health care interventions to initiate or withhold, or designate someone who will act as a surrogate in making decisions in the event we lose decision-making capacity" (Burkhardt & Nathaniel, 2002, p. 213). Examples: Informed Consents, and DNR's

Prioritization of Care

2

Professionalism/Commitment to Profession

2

Teamwork & Collaboration/Case Management

2

Urgent/Emergent situations (hemorrhagic)

2

Patient Advocacy

2 Nurses Physicians Social Workers Dieticians Family Members Healthcare Personnel Clergy

Advanced Directives

2 Communicates a client's wishes regarding and end-of-life care should the client become unable to do so. PSDA requires that all health care facilities ask if a patient has advanced directives upon admission. A legal document that delineates a patient's wishes for future medical care or no medical care, Implemented if patient is cognitively impaired, Can include living wills and durable Power of Attorney

Ethical Dilemmas

3

Ethical Principles

3

Patient's Rights

3

Alarm (Alert) Fatigue

4

Computer Based Reminder Systems

4

DRG (Diagnostic Related Grouping)

4

Legal Aspects

4

Nursing Care Delivery Systems

4

Point of Care

4

Resource Utilization

4

Tele-Health

4

Tertiary Care

4 Diagnostic or therapeutic procedures

Emergency Preparedness

4 Identify various public health threats to which the medical community is susceptible Identify regulatory initiatives undertaken to prevent and respond to future emergencies Discuss the variety of diseases and agents likely to be involved in a biological, chemical, or radiological terrorism attack and the clinical and community health consequences of each Discuss the importance of personal protective devices and when to implement their use Identify approaches to enhance personal and family preparedness for emergencies

Secondary Care

4 Most cost-effective, efficient place of service

Primary Care

4 Point of entry Location of gatekeeping

The Script: Begin by enter rooming and announcing your name and you are there for hourly rounding. Exiting a Room

4 P's Potty Positioning Pain Possessions Any questions that need to be addressed? Anything else I can do for you? I will return in an hour to check on you. Ensure all safety precautions are in place: Is bed in lowest position Are 2 side rails up as needed Is call bell in reach? Did you perform hand hygiene as leaving?

Access to Healthcare

5

Regulatory Agencies

5

QI (Quality Improvement)

5 Standards of quality health care management Standards of nursing care (ANA) Accrediting group standards (TJC) The Joint Commission (TJC) Publishes Sentinel Event Alert monthly Sentinel event—an unexpected occurrence involving death or loss of limb or function Sounds a warning of the need for immediate investigation and response Clinical practice treatment guidelines (AHRQ) Standards of practice (each health care agency)

Safety/Hand off communication Fatigue (Compassion and Physical) (Safety- Nurse fatigue)

6 5 Inadequate sleep Extended work hours Risk for error increases with each consecutive shift worked Can have deleterious effects on nurses' health

What opportunities are available to nurses for emergency preparedness education and training?

A. Becoming certified in Basic and Advanced Disaster Life Support B. Getting hands-on training for first responders C. Completing additional courses on public health emergency planning D. Joining the Emergency Nurses Association

What have you observed or been involved with in your clinical experience regarding QI?

A. Observed nurse collecting data B. Staff nursing meeting regarding findings of last evaluation C. Changes on nursing unit after an evaluation D. Worked with the nurse involved in the QI process E. Did not have any experience or aware of any activity with quality improvement

Are there persons other than health care professionals who could assist with disaster mental health counseling for a large event? A. Yes B. No C. Not sure

A. Yes

Duty to the safety of patient

Ana code of ethics Texas bon standards of practice Duty to patient includes physical and emotional fitness

Key components

Autonomy in Decision Making Informed Consent Justice Advance Directives Ethical Issues Patient Bill of Rights Patient Self Determination Act (1991) Code of Ethics for Registered Nurses Confidentiality Care and Compassion

What do you foresee as being the most important item to have in an emergency preparedness kit? A. Food B. Water C. Matches D. Personal hygiene items E. Battery-powered radio

B. Water

Clinical Preparedness

Biological agents Anthrax, botulism, plague, and smallpox Chemical agents Nerve agents are the most severe and incapacitating. Sarin, soman, tabun, and VX gas Choking or pulmonary agents Chlorine gas and phosgene gas notes from lecture: Anthrax Botulism The Plague- no vaccine, airborne precautions Smallpox- have a vaccine, but there have been no cases in the US and has been eradicated Sarin Soman Tabun VX gas- bradycardia- atropine is the antidote Chlorine gas Phosgene gas- smells like freshly cut grass

Do you think the mental health response to a disaster is more likely to be acute, prolonged, or both? A. Acute B. Prolonged C. Both

C. Both

Which of these scenarios would be an epidemiological clue of a bioterrorism event? A. Increased flu cases in January B. Norovirus outbreak on a cruise ship C. Smallpox in an ED client D. Malaria in an African traveler E. H1N1 flu outbreak in large populated city

C. Smallpox in an ED client

Health Care Provider Credentialing for QI

Certified professional in healthcare quality (CPHQ) Must pass a certification test 2 years of experience in quality management required

Factors in fatigue

Circadian rhythm- 24 hour clock- can be shifted 1- 2 hours in either direction Sleep-wake homeostasis - duration and intensity of sleep Sleep deprivation - lack of a block of quality sleep (7-8 hours/day) Time on task - fatigue during work period when prolonged concentration may result in fatigue

Quality Improvement Methods

Commitment to CQI Empowerment of nurses Collecting data systematically Anticipating risks to prevent them Working groups with sense of collaboration Everyone wins when nurses become involved and invested in being a part of a group willing to make things work well; thus, it is critical to be knowledgeable about current CQI methods

Hand-off Communication

Communication and collaboration is essential in providing quality care health to patients. Ineffective/poor communication has been linked to: Medical error Poor patient outcomes Misunderstandings between healthcare providers 98,000 people die each year due to medical error 70% of sentinel events across the United States was the result of communication failures

What are the barriers to quality improvement?

Cost Tradition Institutional values

START System and Color Replacement Paired Together

Deceased (black)—injured persons who are beyond the scope of medical assistance Immediate (red) —injured persons who must be assisted by advanced medical care immediately or within the next hour Delayed (yellow) —injured persons who are medically stable but require medical assistance Minor (green) —injured persons who do not need medical care for at least several hours; can usually walk with assistance, mainly consisting of bandages and acute first aid Red- priority 1 Yellow- priority 2 Minor- priority 3 Black- priority 4

Compassion fatigue

Defined as a combination of physical, emotional, and spiritual depletion associated with caring for patients in significant emotional pain and physical distress https://www.youtu.be/kse7UE82UFU

Nursing Responsibilities: Caring and Safety

Demonstrate care and concern for welfare of patients and their families Provide for safe environment Organized workflow

What are Core Measures?

Developed by the Joint Commission to improve quality of health care by implementing a national standardized performance measurement system Measures are focused on patients with the following medical diagnoses: Acute myocardial infarction Congestive heart failure Community-acquired pneumonia Surgical infection prophylaxis Pregnancy-related conditions Deep vein thrombosis

Clinical preparedness cont'd 4

Disaster nursing Primary public health prevention- education and drills Nurse emphasizes principles of preparedness Interventions that occur before the event or disease Secondary public health prevention- actual event occurs Nurse emphasizes principles of response Interventions that occur during the event or disease Tertiary public health prevention- hurricane recovery Recovery stage Nurse deals with sudden loss of individuals and manages the mental health issues of those affected by the disaster Interventions that occur after the event or disease

Get a good night's sleep- sleep hygiene

Do's Regular schedule Relaxing bedtime routine Cool, dark, quiet environment Don'ts Go to bed hungry or if not sleepy Exercise vigorously before bed Read, eat, watch tv in bed Consume alcohol, caffeine, heavy/spicy/sugary food 4-6 hours before bed

Given the worldwide increase in terrorism in the past decade, what do you see as the biggest threat to the health of society? A. Nuclear bomb B. Anthrax or other biological attack C. Chemical weapons D. Petroleum factory explosion E. Water and/or food source contamination

E. Water and/or food source contamination

Community Health Nurse Issues and Public Health Preparedness

Epidemiological aspects Surveillance and monitoring of patients Critical component Acute identification and recognition of epidemiological clues that could signal a biological event Early intervention methods What seems out of place or not common to the nurse could be an epidemiological indicator of a potential bioterrorism attack Syndromic surveillance Strategic National Stockpile (SNS) Operated under Centers for Disease Control and prevention(CDC) Federal program stores large quantities of medicine and medical supplies to protect U.S. citizens during public health emergency, including but not limited to a terrorist attack, pandemic outbreak, or natural disaster SNS "push-pack"—includes antibiotics, chemical antidotes, antitoxins, airway maintenance supplies, and other medical equipment that can be delivered within 12 hours of request CHEMPACK Federal program under the SNS Provides a supplement to the medical response in case of a chemical nerve agent release Containers distributed to all 50 states; stored at strategic geographic locations Contain atropine injectors, sterile water, PAM kits, and diazepam Nurse must be current on the proper administration and dosage guidelines for these medications Emergency System for Advanced Registration of Volunteer Health Professionals (ESAR-VHP) Federally funded program through ASPR Uses volunteer health personnel in an emergency Medical Reserve Corps (MRC) Initiated by U.S. Office of the Surgeon General Created for volunteers in the community who want to donate their time and expertise to prepare for and respond to emergencies on a local scale Includes medical and health care professionals Physicians, nurses, dentists, veterinarians, pharmacists, and epidemiologists Disaster Medical Assistance Team (DMAT) Team of those in various clinical health specialties, including but not limited to communications, logistics, maintenance, and security Responsibilities include triage of victims at a disaster site, medical care at the site, and staging locations outside the disaster site for transportation of patients to alternative health care facilities.

Patient Coping Methods

Explore various relaxation methodologies Discuss the event in a calming yet compassionate approach Rely on sources of support (including but not limited to family and friends) Return to normal routine when ready Avoid day to day potential conflicts that might cause stress

2010 Institute of Medicine Report

IOM report Emergency Nurses Association Recommendations based on IOM Report Enhance education and training on emergency preparedness Partner with physicians and other health care providers Aim at improving workforce planning

What are some patient safety goals?

Improve accuracy of patient identification Improve communication among caregivers Improve the safety of medication administration Improve the safety of using infusion pumps Eliminate wrong-site, wrong-patient, and wrong-procedure errors Improve effectiveness of clinical alarm systems www.jointcommmission.org/standards_information/npsgs.aspx Reduce the risk of health careassociated infections Accurately and completely reconcile medications across the continuum of care Reduce the risk of patient harm resulting from falls Reduce the risk of influenza and pneumococcal disease in institutionalized older adults Implement applicable NPSQ and associated requirements at practitioner sites Reduce risk of surgical fires Encourage the active involvement of patients and families in the patient's care Prevent health careassociated pressure ulcers Identify safety risks in the patient population Improve recognition and response to changes in patient's condition

Individual and Family Preparedness Issues

Initiated at home, work, and school Preparation of a disaster preparedness kit Should include enough supplies for each family member for a minimum of 3 consecutive days Formation of family emergency communication and evacuation plans Awareness of potential disasters in the family's community

I-SBAR-R

Introduction Introduce yourself and your role in the patient's care State the unit you are calling from when speaking with a physician over the phone Situation Specify the patient's name and current condition or situation Explain what has happened to trigger this conversation Background State the admission date of the patient, his or her diagnosis, and pertinent medical history Give a brief synopsis of what's been done so far (e.g., lab test) Assessment Give a summary of the patient's condition or situation Explain what you think the problem is or say, "I'm not sure what the problem is, but the patient is deteriorating" Expand upon your statement with specific signs and symptoms Recommendation Explain what you would like to see done (e.g., lab tests, treatments, or "I need you to see the patient now") State any new treatments or changes ordered (e.g., monitoring and frequency or when to renotify the physician if there is no improvement in the patient) Repeat-- of any orders obtained from the physician.

Informed Consent

Involves disclosure and understanding of essential information. Patient must be given a description of the health concern, treatment options and risk of benefits of intervention versus no intervention. The patient advocate ensures that proper protocol is followed and that the patient has been given adequate explanation.

Disaster Mental Health

Long-term psychological manifestations depend on several factors: Proximity to the event Previous psychological stability and history of past traumatic events Importance and depth of the event to the person Posttraumatic stress disorder (PTSD) Re-experiencing of the trauma Avoidance of stimuli associated with trauma Persistent symptoms of increased arousal or exaggerated response Alterations in mood

What Do I Need to Know About Community Preparedness?

Mental health preparedness Individual preparedness Family preparedness Disaster mental health issues Affect those who witness the event, including survivors, rescue workers, and friends and relatives of victims directly related to the event Focus and be aware of the development of psychological reactions that persist from days to years after the public health event (CDC, 2007) Cognitive, emotional, physical, and behavioral abilities may be affected

Other Agencies Influencing Patient Safety

National Patient Safety Foundation (NPSF) Institute for Healthcare Improvement (IHI) Quality and Safety Education for Nurses (QSEN): Comprehensive, competency based resources to empower nurses with knowledge, skills, & attitudes to improve quality & safety across the healthcare system Overall goal is to address the challenge of preparing nurses with the knowledge, skills and attitudes (ksas) necessary to continuously improve the quality and safety of the healthcare systems in which they work Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems Institute of Medicine (IOM): Independent, nonprofit that works outside of government to provide authoritative advice The health arm of the national academy of sciences Provides evidence to make informed health decisions

Confidentiality

Non-disclosure of private or secret information. HIPPA-ensures confidentiality of all patients. Everyone is responsible. Patient Advocates ensure that patient confidentiality is respected.

Emerging Trends and Issues

Nurse must be cognizant of how a disaster affects the environment and anticipate potential adverse events on the environment to ensure the safety of the community. Natural disasters Excess standing water- mosquitos ect. Accumulation of trash, rubbish from tornado, hurricane, earthquake Increased wildlife interaction Food safety Foodborne illnesses Foodborne outbreaks Proper storage and disposal of food following a disaster Pollution control Hazardous materials Air and water pollution Building infrastructure

Patient Advocates

Nurses are primary patient advocates because they spend a significant amount of time caring for their patients and families while developing holistic and therapeutic relationships

Public Health Preparedness and Administrative Efforts

Office of the Assistant Secretary for Preparedness and Response (ASPR) ASPR Federal program that provides funding to hospitals, outpatient care facilities, critical access hospitals, private and public health care providers National Incident Management System (NIMS) NIMS Developed by Federal Emergency Management Agency (FEMA) Facilities receiving preparedness funding must be in compliance with NIMS, Requirement under TJC for all hospitals and health care facilities Hospital Emergency Incident Command System (HEICS) HEICS Comprehensive incident management system intended for use in emergent and non-emergent situations Component under NIMS Designed to be implemented for all routine or planned hospital events Standardized response process

Patient Advocate Challenges

Patient Advocates may face work-related repercussions for going against administration/and physicians. • Risk termination or isolation of peers. • Conflicts may arise among family members with patient advocate being in the middle

Patient Bill of Rights

Patient Advocates strive to help patients understand their rights and ensure these rights are respected.

Disaster Mental Health Recommendations

Pay attention to the patient's experience and show compassion for his or her emotions Empathize with the patient and his or her emotions and experiences Encourage patients to discuss the experience, in both positive and negative aspects Speak to the patient in nonmedical terms—be a friend, a confidant Reinforce patient's emotions and reactions; these are natural and tacit

Clinical preparedness cont'd 3

Personal protective equipment (PPE) Protect layer that provides barrier against agents Consists of four levels for protection against different agents Level D—work uniform Level C—requires respirator; airborne substance known Level B—requires highest level of respiratory protection; initiated until causative agent identified Level A—same as level B but skin, eye, and mucous membrane protection also required

The Joint Commission (TJC) (formerly called JCAHO)

Primary agency for hospital accreditation Must meet certain quality standards to pass inspection Mandates continuous quality improvement Endorses plan-do-study-act (PDSA) cycle for process improvement Major accrediting body for health care institutions that are Medicare- and Medicaid-funded Addresses patient safety issues Requires error reduction and design of safe patient care processes

What Is Triage? (Cont.)

Primary contributing factor to triage in emergency department is hospital bed availability Overall goal of triage Determine appropriate level of care for patient Ensure hospital resources are used effectively

What is root cause analysis (RCA)?

Process designed for use in investigating and categorizing the root causes of events (errors) Identifies all factors leading up to the event Conducted by agency's risk management department Results given to quality improvement department Emphasized meaning of Pareto principle 80% of problems caused by 20% of sources, people, or things Led to idea of total quality management (TQM) Father of "Zero Defects" Proposed simplification of everything so all could understand Communicate quality efforts to whole organization

What is quality improvement (QI)? How do we monitor quality?

Process or activities used to monitor, evaluate, and control services, providing some measure of quality to consumers Includes incident and/or variance reports that track progress and serve as a guide for risk management and QI departments to make system improvements QI department receives data, analyzes trends, and recommends actions for improvement Should also be a continuous quality improvement (CQI) council, quality circles, and service lines that collaborate to improve patient care What is an indicator and a metric? Quality indicator: Item of concern Metric: Indicator measurements being monitored

Autonomy

Promoting and protecting patient autonomy is one of the most important roles of a patient advocate. Patients have the right and freedom to self-determination.

Nurses Code of Ethics

Provides guidance for nurses in making ethical decisions in the care of their patients. 1. The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems. 2. The nurse's primary commitment is to the patient, whether an individual, family, group, or community. 3. The nurse promotes, advocates for and strives to protect the health, safety and rights of the patient. 4. The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse's obligation to provide optimum patient care. 5. The nurse owes the same duties to self as others, including the responsibility to preserve integrity and safety, to maintain competence and to continue personal and professional growth. 6. The nurse participates in establishing, maintaining and improving healthcare environments and conditions of employment conducive to the provision of quality healthcare and consistent with the values of the profession through individual and collective action. 7. The nurse participates in the advancement of the profession through contributions to practice, education, administration and knowledge development. 8. The nurse collaborates with other health professionals and the public In promoting community, national, and international efforts to meet health needs. 9. The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice and for shaping social policy.

What is hourly rounding? Hourly rounding enhances patient satisfaction and safety

Purposefully and intentionally checking on your patients at regular intervals Patients are less anxious and have less adverse events, like falls, pressure ulcers, or unrelieved pain; and contribute to patients' satisfaction with nursing care. Rounding addresses immediate and anticipated needs. Saves frustration of call lights Saves nurse's and tech's time by completing tasks while already there with patient Conveys caring and concern for physical and psychosocial needs.

Clinical preparedness cont'd 2

Radiological-radioactive agents "Dirty bombs"- have radioactive material and other metal such as nails or schrapnel Acute radiation syndrome (ARS) Acute illness; irradiation of entire body by high dose of penetrating radiation in very short period of time Natural disasters Two categories Public health prevention (primary, secondary, and tertiary) Emergency triage and response Pandemic Rapid and expansive surge of H1N1 influenza worldwide in 2009 Pandemic- not enough vaccines, rationed Healthcare workers receive vaccines first, then children, and elderly and others as vaccine becomes available Guillian-barre cannot take vaccine, allergy to eggs can't take

What is HCAHPS?

Refers to Hospital Consumer Assessment of Health Plans Survey National program for collecting and providing health care information from consumer perspective

Centers for Medicare & Medicaid (CMS)

Regulates organizations, not nurses Oversees medicare/Medicaid reimbursement Measures nursing quality through hospital quality data for annual for payment Must be a participate in a systematic clinical database registry for nurse sensitive care 14 preventable hospital-acquired conditions

What Is Public Health Preparedness?

Response measures for licensed nurses to provide efficient and expedient care Two major categories Clinical preparedness Community-based preparedness Preparing for chemical, biological, radiological, nuclear and enhanced conventional weapons (CBRNE) events Chemical Biological Radiological Explosive Nuclear

Where does hand off occur?

Shift to shift Unit to unit Unit to diagnostic area OR to recovery Physician to physician ER to unit Facility to Facility

Why use "the script"?

Standardization of language helps the patients know what to expect from the practice Customize "the script" to fit the essential needs of patients

The Joint Commission Acronym: SHARE

Standardize critical content Hardwire within your system Allow opportunities to ask questions Reinforce quality and measurement Educate and coach

What Is Triage?

System of sorting patients according to medical need when resources are unavailable for all persons to be treated START system (Simple Triage and Rapid Treatment) Most common type of triage used by emergency and field (EMS) personnel NATO system Another concept of triage replaces colors with the common terminology (see next slide)

What are core measures? What is performance improvement?

The Joint Commission mandates certain key indicators to monitor and track: Advance directives Autopsy rates, mortality rates AMAs and elopement rates Blood product utilization rates, blood transfusion reaction rates Code Blue rates, conscious sedation complication rates Fall rates, medication error rates Pain management effectiveness Restraint use Surgical site infection rates Synonymous with quality improvement (QI) Newer term being used; referred to as "improvement science" Data-driven focus Plan and documentation method that demonstrates what standard procedures will be for nurses and others in the hospital Similar to the nursing process (assess, diagnose, plan, implement, evaluate)

IOM- Institute of Medicine

There are 6 dimensions of patient-centered care: 1. Respect for patients' values, preferences, and expressed needs 2. Coordination and integration of care through collaboration and teamwork 3. Accessibility and free flow of information, communication, and education 4. Physical comfort 5. Sensitivity to non-medical and the spiritual dimension of care: Emotional support 6. Involvement of family and friends

Disaster Kit Essentials

Water Food Flashlight Battery-powered radio Prescription medications First aid kit Whistle (to signal for help) Local maps Can opener Cash, traveler's checks ID cards, documents Dust mask Moist towelettes Infant food or formula Pet food and water Fire extinguisher Matches (in waterproof container) Personal hygiene items Paper and pencil Eating utensils (paper cups, plates)

What is Hospital Compare?

Website designed for consumers to compare hospitals and their services in terms of how well the selected hospitals provide recommended care to patients Information provided through Medicare and Hospital Quality Alliance

Patient Advocacy is

comprehensive support to help clients: clarify their diagnosis and treatment options assess their own values, strengths and priorities gain access to quality healthcare connect with personal and community resources communicate constructively with employers make evidence- and value-based medical decisions identify necessary financing options partner with healthcare and other service providers

SBAR

is the same as I-SBAP-R with I for introduction at the beginning and R for repeat at the end

Reinforce quality and measurement, including:

• demonstrating leadership commitment to successful hand-offs • holding staff accountable for managing a patient's care • monitoring compliance with use of standardized forms, tools and methods for hand-offs • using data to determine a systematic approach for improvement

Hardwire within your system, including:

• developing standardized forms, tools and methods, such as checklists • using a quiet workspace or setting that is conducive to sharing information about a patient • stating expectations about how to conduct a successful hand-off • identifying new and existing technologies to assist in making the hand-off successful

Standardize critical content, including:

• providing details of the patient's history to the receiver • emphasizing key information about the patient when speaking with the receiver • synthesizing patient information from separate sources before passing it on to the receiver

Educate and coach, including:

• teaching staff what constitutes a successful hand-off • standardizing training on how to conduct a hand-off • providing real-time performance feedback to staff • making successful hand-offs an organization priority

Allow opportunities to ask questions, including:

• using critical thinking skills when discussing a patient's case • sharing and receiving information as an interdisciplinary team (e.g., a pit crew) • expecting to receive all key information about the patient from the sender • exchanging contact information in the event there are any additional questions • scrutinizing and questioning the data