Professional behaviors, Ethics, Delegation (wks 1,2)

When an analgesic is titrated to manage pain, what is the priority goal? 1. Titrate to the smallest dose that provides relief with the fewest side effects. 2. Titrate upward until the client is pain free or acceptable level is reached. 3. Titrate downward to prevent adverse effects. 4. Titrate to a dosage that is adequate to meet the client's subjective needs.

1. Titrate to the smallest dose that provides relief with the fewest side effects.

Which of these must be assigned to an experienced RN? Select all that apply 1. Client who was in an automobile crash and sustained multiple injuries. 2. Client with chronic back pain related to a workplace injury. 3. Client who has returned from surgery and has a chest tube in place. 4. Client with abdominal cramps related to food poisoning. 5. Client with a severe headache of unknown origin. 6. Client with chest pain who has a history of arteriosclerosis.

1: Client who was in an automobile crash and sustained multiple injuries. 3: Client who has returned from surgery and has a chest tube in place. 5: Client with a severe headache of unknown origin. 6: Client with chest pain who has a history of arteriosclerosis.

A client with a VRE infection is admitted to the medical unit. Which action can be delegated to the UAP who is assisting with the client's care? 1. Teaching the client and family members about ways to prevent transmission of VRE. 2. Communicating with other departments when the client is transported for ordered tests. 3. Implementing contact precautions when providing care for the patient. 4. Monitoring the results of ordered laboratory cultures.

3. Implementing contact precautions when providing care for the patient. Implementing contact precautions involves ensuring proper infection control measures, including wearing appropriate personal protective equipment (PPE) when providing care. This task can be performed by UAP under the guidance and supervision of the healthcare team.

The RN is caring for a client who has been admitted to the hospital with a leg ulcer that is infected with VRE and MRSA. Which nursing action can be assigned to an LPN? 1. Planning ways to improve the client's oral protein intake. 2. Teaching the client about home care of the leg ulcer. 3. Obtaining wound cultures during dressing changes. 4. Assessing the risk for further skin breakdown.

3. Obtaining wound cultures during dressing changes.

The healthcare team is providing emergency care to a client who received an excessive dose of opioid pain medication. Which task is best to assign to the LPN? 1. Calling the HCP to report SBAR of situation. 2. Administering naloxone and evaluating response to therapy. 3. Monitoring the respiratory rate for the first 30 minutes. 4. Applying oxygen per nasal cannula as ordered.

4. Applying oxygen per nasal cannula as ordered.

Which is not an intentional tort? A. False imprisonment B. Defamation of character C. Invasion of privacy D. Negligence

D. Negligence Rationale: An intentional tort requires that the act be committed with the awareness of the perpetrator.

Tort Law

Law that deals with harm to a person or a person's property.

Legal Doctrines Guiding Courts in Decision Making......They are known as.... Stare decisis Res judicata Respondeat superior ^^^Define these three doctrines!!!

Stare decisis:(let the decision stand): uses precedents as a decision-making guide Res judicata: (a thing or matter settled by judgment): applies only when a competent court has decided a legal dispute and when no further appeals are possible Respondeat superior: (the master is responsible for the acts of his servants): an employer should be held legally liable for the conduct of employees whose actions he or she has a right to direct or control

The CNA and UAP scope of practice is defined as VAPER. What this?

V-vitals, get them signs for us! A-Ambulation P-Position changes/bathing E-Eating R-Recording I and O

expert testimony

testimony from people who are recognized experts in their fields

Burden of proof

the obligation to present evidence to support one's claim

drug diversion

the transfer of a drug from the person for whom it was prescribed to another individual (usually to the administrator themselves)

the chemically impaired nurse

when nurses are unable to provide safe and competent care because of the use of substances. These nurses cannot perform their professional responsibilities and duties consistent with nursing standards.

Unprofessional Behaviors

•Abuses of Power •Sexual Harassment •Improper Use of Authority •Chronic Overtime -Inappropriate use of Sick Time •Chronic Tardiness

•A nurse is teaching a newly licensed nurse about reporting suspected child abuse. Which of the following statements indicates an understanding by the newly licensed nurse? •A. "Evidence must exist prior to reporting." •B. "If the potential abuser commits to stopping the abuse, health care workers are not required to report it." •C. "I don't want to defame someone if the report is false." •D. "If suspicion of abuse exists then reporting is mandatory."

•D. "If suspicion of abuse exists then reporting is mandatory." Rationale: Healthcare workers are legally required to report any suspicions of child abuse even if evidence does not exist. (CORRECT)

Delegation vs Dumping

•Delegation needs to provide greatest benefit to client & to time management needs of staff, as well as allowing opportunities for delegate to grow. •"Never ask a nursing assistant to do something you wouldn't do!"

Reducing Risk of Malpractice Claims

•Practice within scope of nurse practice act. •Observe agency policies & procedures. •Model practice after established standards by using evidence-based practice. •Always put patient's rights & welfare first. •Be aware of relevant law & legal doctrines. •Practice within area of individual competence & upgrade technical skills consistently.

Chemicals Most Commonly Abused by Nurses

-Alcohol (most frequently used) -Demerol (2nd most frequent) -Oxycontin -Klonopin -Valium -Morphine Basically: opiates, stimulants, and Benzos Usually happens on floors with a lot of IVs

In MN, kids under 18 have the right to privacy for...

-STI/std testing -abortion -birth control -exception to the rule: a 14 year old being coerced into sx with an adult. -Don't let the 18 year old take sexual relations with a 14 year old. Think of Statutory Rape.

Late-Stage Chemical Dependency

-Tolerance is developed to the chemical and the individual needs the chemical in greater amounts and more often to achieve the same effect.

"breach of Duty" in a sentence examples......

1 There has been a breach of duty by an engine driver in failing to sound his whistle. 2 The plaintiff had to prove that the breach of duty was at least a material contributory cause of the harm. 3 The punishable causations were corruption and breach of duty.

There's Criminal Court, Civil Court, and Administrative Court. Put them in order of severity (1 being the most severe) and includes consequences for a guilty verdict.

1-Criminal;Guilty Verdict=Incarceration, probation, or fines 2-Civil;Guilty verdict=Monetary compensation 3-Administrative;Guilty verdict=Suspension or loss of liscense

In the care of clients with pain and discomfort, which task is most appropriate to delegate to unlicensed assistive personnel (UAP)? 1. Assisting the client with taking a shower. 2. Monitoring the client for signs of discomfort while ambulating. 3. Teaching the client to deep breathe during painful procedures. 4. Evaluating relief after applying a cold compress.

1. Assisting the client with taking a shower.

Guidelines for Informed Consent Person(s) giving consent must fully comprehend....

1. Procedure to be performed 2. Risks involved 3. Expected or desired outcomes 4. Expected complications or side effects that may occur as result of treatment 5. Alternative treatments that are available

A client received as needed (PRN) morphine, lorazepam, and cyclobenzaprine. The unlicensed assistive personnel [UAP] reports that the client has a respiratory rate of 10 breaths/min. What is a priority action? 1. Call the health care provider to obtain an order for naloxone. 2. Assess the client's responsiveness and respiratory status. 3. Obtain a bag-valve mask and delivery breaths at 20 breaths/minute. 4. Double-check the prescription to see which drugs were ordered.

2. Assess the client's responsiveness and respiratory status.

Which clients can be appropriately assigned to an LPN who will function under the supervision of an RN or team leader? Select all that apply. 1. Client who needs preoperative teaching about the patient-controlled analgesia pump. 2. Client with a leg cast that needs neuro-circ checks and as needed (PRN) hydrocodone. 3. Client underwent a toe amputation and has diabetic neuropathic pain. 4. Client with terminal cancer and severe pain who is refusing medication. 5. Client who reports abdominal pain after being, kicked, punched, and beaten. 6. Client with arthritis who needs scheduled oral pain medications and heat application.

2. Client with a leg cast that needs neuro-circ checks and as needed (PRN) hydrocodone. 3. Client underwent a toe amputation and has diabetic neuropathic pain. 6. Client with arthritis who needs scheduled oral pain medications and heat application.

For a postoperative client the HCP prescribed multimodal therapy, which includes acetaminophen, NSAIDs, opioids PRN, and nonpharmaceutical interventions. The client continually asks for the PRN opioid, and the nurse suspects that the client may have a drug abuse problem. Which action by the nurse is best? 1. Administer acetaminophen and spend extra time with the client. 2. Explain that opioid medication is reserved for moderate to severe pain. 3. Give the opioid because client deserves relief and drug abuse is unconfirmed. 4. Ask the HCP to validate suspicions of drug abuse and alter the opioid prescription.

4. Ask the HCP to validate suspicions of drug abuse and alter the opioid prescription.

A client has severe pain and bladder distention related to urinary retention and possible obstruction. An experienced UAP states that she received training in indwelling catheter insertion at a previous job. What task can be delegated this UAP? 1. Assessing the bladder distention and the pain associated with urinary retention. 2. Inserting the indwelling catheter after verifying her knowledge of sterile technique. 3. Evaluating the relief of pain and bladder distention after the catheter is removed. 4. Measuring the urinary output after the catheter is inserted and obtaining a specimen.

4. Measuring the urinary output after the catheter is inserted and obtaining a specimen.

Question 5: A nursing student is preparing to provide care to a group of patients under the supervision of a registered nurse (RN). Which action by the nursing student requires correction by the RN? A) Administering medications to a patient according to the medication administration record B) Collecting vital signs and reporting abnormal values to the RN C) Assisting a patient with a feeding tube in setting up and starting a continuous feeding D) Educating a patient about dietary restrictions based on their medical condition

A) Administering medications to a patient according to the medication administration record

•Which are changes that can be indicative of substance abuse? • Irritability • Forgetfulness • Social isolation • Change in physical appearance • All of the above

All the above

LPN's and LVN's when it comes to Meds, Assessing, and Teaching....

Assess -No Primary, Initial, First (remember UEAT) Teaching -Reinforce/remind what RN or Doc Teaches Meds: No to...... IV Push, IV Primary bag, Blood Transfusion setup (but can monitor), and administering Central Line meds

Question 3: The charge nurse is supervising a group of nursing staff members. Which action by a nursing staff member requires intervention by the charge nurse? A) An LPN administering medications via a nasogastric tube B) An RN teaching a patient about post-discharge wound care C) A nursing assistant assisting a patient with range-of-motion exercises D) An RN assessing a patient's response to pain medication

B) An RN teaching a patient about post-discharge wound care

A nurse is charged with administering a fatal dose of morphine to a patient on hospice. In which type of court would this nurse be charged? A.Civil B.Criminal C.Administrative D.None of the above

B. Criminal Rationale: Nurses found guilty of intentionally administering fatal doses of drugs to patients would be charged in a criminal court. In civil cases, one individual sues another for money to compensate for a perceived loss. In administrative cases, an individual is sued by a state or federal governmental agency assigned the responsibility of implementing governmental programs.

Question 4: An RN is delegating tasks to the nursing team for a group of patients. Which patient assignment should the RN reconsider due to the complexity of care required? A) A patient with diabetes requiring insulin administration and glucose monitoring B) A patient recovering from a routine appendectomy with stable vital signs C) A patient on a ventilator needing frequent respiratory treatments and suctioning D) A patient with a history of hypertension due for a routine blood pressure check

C) A patient on a ventilator needing frequent respiratory treatments and suctioning

Question 2: A registered nurse (RN) is caring for a group of patients and needs to delegate tasks to the nursing assistive personnel (NAP). Which of the following tasks would be most appropriate to delegate to the NAP? A) Administering oral medications to a postoperative patient B) Assessing a patient's wound for signs of infection C) Assisting a patient with ambulation after surgery D) Developing a plan of care for a newly admitted patient

C) Assisting a patient with ambulation after surgery

Which of the following accurately describes why nurses are at increased liability for malpractice suits? A.Their realm of responsibility has decreased. B.Fewer nurses have liability insurance. C.Nurses are making more money. D.Nurses currently have less independence in decision making.

C. Nurses are making more money. Rationale: Higher salaries have corresponded to increased liability in the nursing profession.

omission vs comission

Commission means doing something, omission means not doing something.

Question 1: A charge nurse is responsible for assigning tasks to the nursing staff on the floor. Which of the following tasks is appropriate for the charge nurse to delegate to a licensed practical nurse (LPN)? A) Administering intravenous (IV) push medications B) Developing the patient's care plan C) Performing a head-to-toe assessment on a new admission D) Teaching a patient about their newly prescribed medications E) None of the Above

E) None of the above

expressed vs implied vs informed consent

Expressed: happens either verbally or in writing. Implied: indicated by the patient's actions. For example, if you walk into the emergency room before passing out, you are giving implied consent to be treated. Informed: the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention

Malpractice

Failure by a health professional to meet accepted standards

How about IV push meds, blood transfusion, or central line meds. Can RNs delegate that?

Never LPNs can hang piggy back IV bags CNAs can't do any meds

Reentry Guidelines for the Recovering Nurse

No psychoactive drug use is tolerated The employee should be *assigned to day shift for the first year* The *employee should be paired with a successfully recovering nurse whenever possible* The employee should be *willing to consent to random urine screening with toxicology or alcohol screens* The employee must give *evidence of continuing involvement with support groups such as Alcoholics Anonymous or Narcotics Anonymous* Employees should be *encouraged to attend meetings several times each week* The employee should be encouraged to participate in a structured aftercare program The employee should be encouraged to seek individual counseling or therapy as needed

You have a patient returning to the floor after surgery. Obviously they need an assessment. Do you delegate that assessment?

No!

What does "Right Supervision" entail?

That the RN follows up and reassesses tasks that they've delegated. If you delegate and forget, then there's potential trouble.

substance misuse

The use of a substance for unintended purposes or for intended purposes but in improper amounts or doses. -Nurse using the substance on themselves -Nurse giving patient too much/not enough

Delegation in nursing

Transferring the authority to perform a selected nursing task in a selected situation to a competent individual

As an RN, you must NOT delegate what UEAT. What that mean ?

U=unstable patients E=Evaluations A=Assessments (First initial, or primary assessments) T=Teaching (UAPs can give reminders though)

Liability

a person or thing whose presence or behavior is likely to cause embarrassment or put one at a disadvantage.

Breach of Duty [on the test]

a person's conduct fails to meet an applicable standard of care.

Each state's NPA is enforced & administered by.....

a state board of nursing [BON].

Controlled Substance Act

law that established penalties for possession, use, or distribution of illegal drugs and established five schedules for classifying drugs. AKA: how marijuana became "schedule 1 drug"

Statutory law

legislative acts declaring, commanding, or prohibiting something

Minnesota Whistle-blower Act

prohibits retaliation against an employee who makes a good-faith report of a violation or suspected violation of law.

Nurse Practice Act [NPA] =

series of state statutes that define scope of practice, standards for education programs, licensure requirements, & grounds for disciplinary actions.

•A nurse is planning to assign care activities to nursing assistive personnel (NAP) on her team. Which of the following activities can the nurse assign to the NAP? [SELECT ALL THAT APPLY] •A. Accompany a client who has depression to occupational therapy. •B. Assess a client who has hypomania for exhaustion. •C. Initiate soft wrist restraints on a client who is at risk for self-harm. •D. Set limits with a client who has mania. •E. Sit with a client who has alcohol use disorder and whose last drink was five days ago. •F. Work a jigsaw puzzle with a client who has dementia.

•A,E,F --- TELL ME WHY?

•A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances? •A. A dependent adult admitted for the treatment of a spiral fracture. •B. A young adult client admitted for asthma and has track marks that may indicate IV drug abuse. •C. A young adult client admitted for acute glomerulonephritis following a viral infection. •D. An emancipated minor who has acute appendicitis and wants to leave the facility without treatment.

•A. A dependent adult admitted for the treatment of a spiral fracture Rationale: Physical signs of dependent adult abuse include skeletal fractures, as well as burns, bruises, welts, and lacerations. Nurses are responsible for reporting suspicion of dependent adult abuse to the proper legal authorities within the state. It is important for the nurse to note that a competent older adult has the right to make his or her own decisions about pursuing legal action. Unless a client has been found to be legally incompetent, he or she is not classified as a dependent adult. (CORRECT)

•A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take? •A. Call the emergency response team. •B. Seek immediate help from the risk manager. •C. Call the provider for a stat DNR order. •D. Respect the family's wishes and do nothing.

•A. Call the emergency response team. Rationale: Unless the provider writes a DNR order, the nurse should make every effort to revive the client. The nurse should follow the facility's protocol for enacting the emergency response procedure. (CORRECT)

•A client who fell and broke his hip while being assisted to the bathroom by a nurse states he plans to sue the nurse. The nurse should know that, in a legal proceeding, the standard that will be used to determine if the nursewas negligent is which of the following? •A. An expert nurse provides testimony that the nurse should have handled the situation differently. •B. Another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation. •C. The client's attorney states that injury to the client could have been prevented. •D. The client's provider testifies the nurse was at fault for the injury.

•B. Another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation. Rationale: The definition of negligence is practice that is below the standard of care. The benchmark for standard of care is what a reasonable, prudent person who has similar background and experience would do. Another staff nurse who has similar background is the correct person to provide testimony. (CORRECT)

•A nurse is caring for a client who is scheduled to have surgery. In preparing the client for surgery, which of the following actions is considered outside the nurse's responsibilities? •A. Assessing the current health status of the client •B. Explaining the operative procedure, risks, and benefits •C. Reviewing preoperative laboratory test results •D. Ensuring that a signed surgical consent form was completed

•B. Explaining the operative procedure, risks, and benefits Rationale: Explaining the procedure and any risks that may be associated with it is the responsibility of the person performing the procedure. This is not a nursing responsibility. (CORRECT)

•When a substance-abuse problem is suspected, what is the cause for immediate confrontation? •If the employee is defensive •If the employee may pose a risk to clients •If it is not possible to gather sufficient evidence

•B. If the employee may pose a risk to clients •Rationale: Although other instances may warrant an intervention, immediate action is most important if the employee's behavior threatens clients' well-being or safety

Benefits of APROPRIATE delegation

•Benefits to the nurse •Benefits to the delegate •Benefits to the manager •Benefits to the organization

•A nurse accidentally administers the wrong medication to a client, which results in a severe allergic reaction and prolongs the client's hospitalization. The client could rightfully sue the nurse for which of the following? •A. Battery •B. Assault •C. Malpractice •D. Abuse

•C. Malpractice Rationale: The client could sue the nurse for malpractice, which is the failure to meet the standard of conduct another professional would exercise in similar circumstances and that failure causes harm. This nurse has made an error that harmed the client. (CORRECT)

•A home health care nurse is visiting an older adult client who tells the nurse that she is feeling tired, is unable to shop for groceries, and would like the nurse to shop for her. Shopping and performing personal errands for the client is prohibited in the nurse's job description. Which of the following is an appropriate nursing response? •A. "I won't be able to shop for you today because I have to get home to my family." •B. "I would be happy to do whatever I can to help you." •C. "What I think you should do is wait for the days when you feel better and do your grocery shopping then." •D. "Let's look at some other resources to solve this problem."

•D. "Let's look at some other resources to solve this problem." Rationale: Acknowledging that the client needs assistance on certain days and encouraging the formulation of an action plan regarding community resources for that problem is an appropriate nursing response. The nurse should work within her job description and collaborate with others, making appropriate referrals within the community. (CORRECT)

•A registered nurse has been leading teams of nursing assistive personnel (NAP) for several years and will soon be leading licensed practical nurses (LPNs) for the first time. In preparation for delegating to these nurses, the RN should: •A. delegate the same tasks to the LPNs that the RN normally delegated to NAPs. •B. consult a decision tree for delegation to unlicensed assistive personnel. •C. ask each LPN what tasks he or she is comfortable performing. •D. review the practical nurse scope of practice in the jurisdiction where they are working.

•D. review the practical nurse scope of practice in the jurisdiction where they are working. Rationale: Delegation to an LPN is different from delegation to an NAP. The parameters vary from state to state, and the RN should review the scope of practice. The LPN's comfort level is secondary to his or her knowledge, skills, and scope practice. A decision tree for delegation to unlicensed assistive personnel would guide delegation to NAPs, not LPNs. (CORRECT)

Most actions taken ag nurses by their BON included probation, revoked licenses, or suspended licenses r/t............

•Drug-related events [drug abuse, drug diversion] •Alcohol abuse •Drug related convictions •Writing illegal prescriptions •Presenting illegal prescriptions •Wasting errors •Drug Diversion Criminal actions related to medication adm

Categories of Negligence that Result in Malpractice

•Failure to follow standards of care (ignore/fail to complete MD orders, incomplete admission assessment) •Failure to use equipment in a responsible manner (ceiling lifts/bed alarms) •Failure to communicate (changes in pt cond) •Failure to document (client injuries) (timeline of client status changes) •Failure to assess/monitor (O2 sat, pt shift assessment, pain reassessement) •Failure to act as patient advocate (must question incomplete medical order)

Six Attributes of Professional Behaviors

•Knowledge •Competence •Teamwork •Integrity •Positive attitude •Compassion

Areas of Risk Management

•Medication Errors-Use Barcoding! & 6 R's •Falls- Use bed/chair alarms & gait belts •Allergies- Double check every time! •Orders-Avoid verbal orders/VORB/ Question any order a patient questions! •Narcotics [CSA] •Confidentiality •Code Status/EOL care/ADs •Other high risk activities/Maintain competence

How to Avoid Negligence

•Meet standard of care •Document accurately & completely •Know your limits •Protect your patient •Know that people have cell phones •Expert testimony •Assessment •Ongoing monitoring •Interventions •Planning •Equipment •Documentation •Communication •Advocacy

Professional Nurses Are at Increased Legal Liability.......

•More authority & independence in decision making. •Increased legal accountability for decision making. •Performing more actions that used to be in realm of medical practice. •Making more money. •More nurses are carrying malpractice insurance.

Five Elements of Professional Negligence or Malpractice to Establish Liability

•Patient must be owed a duty •Breach of duty must occur by either commission/omission •Element of foreseeability must be present •The injury must have resulted as a direct result of nurse's breach of duty = causation •The plaintiff must demonstrate that some type of physical, financial, or emotional injury/harm resulted from breach of owed duty.

Signs of Substance Use Disorder/ impaired Nurse

•Personality/behavior changes [Subtle changes in appearance. Less focus on personal hygiene] •Job performance changes [Frequent trips to bathroom. Excessive # of mistakes in practice] •Time & attendance changes [Unexplained absences. Arriving late & leaving early]

Common Causes of Professional Nursing License Suspension or Revocation....

•Professional negligence •Practicing medicine or nursing without a license •Obtaining a nursing license by fraud or allowing others to use your license •Felony conviction for any offense substantially related to the function or duties of an RN •Participating professionally in criminal abortions •Not reporting substandard medical or nursing care •Providing patient care while under the influence of drugs or alcohol •Giving narcotic drugs without an order •Falsely holding oneself out to the public or to any health-care practitioner as a "nurse practitioner"

•Five Rights of Delegation

•Right task •Right circumstances •Right person •Right direction •Right supervision Task, Situation,Person, Direction, Supervision Task, Sit, PD, Supervision For situation: don't delegate an unstable client to a uap

•Ineffective delegation

•Under-delegation /fails to equip & direct delegate •Reverse delegation / lower rank delegates to one with > authority •Over-delegation / delegator loses control by giving delegate too much authority