Management Exam 2
What type of law is responsible for the nursing agency (BON)? A. Constitutional B. Statutory C. Standard D. Common
B Statutory law is created at the Federal, State, and Local levels by elected officials. Examples include BON
The State Board of Nursing (Licensing)
Oversees many aspects of nursing practice Approves the NCLEX RN exam and licensure Each state has their own BON —know your state guidelines —defines scope of practice License renewal Approves nursing schools and education related programs —defines the education requirements for entry into practice Provide disciplinary action for infractions of the nurse practice act Investigates and disciplines impaired nurses —have authority to revoke, make stipulations or terminations for license
What is the governing body for NCLEX?
National Council of State Boards of Nursing
What Governs your nursing license
National Council of the State Board of Nursing
Role Transition (Novice to Expert)
Novice - nursing student Expert - advanced practice nurse or faculty *it will take 2-3 years to build competency and confidence in your new role*
Common Causes of Negligence
--Failure to Document --Medication Errors --Failure to Provide a Safe Environment --Patient Falls --Equipment Failure (BP machine not working, did not tell supervisors, failed to get a manual reading) --Failure to Adequately Assess, Monitor, & obtain assistance --Failure to Communicate Adequately (30% of all cases in negligence) --Failure to Report (changes in lab results, changes in patient)
what is the responsibility of the nurse if a patient is refusing cares?
1. autonomy of the patient 2. provide them education, document their decisions and the education you provided
Scope of Practice FYI
*cannot go ABOVE scope of practice, but can go BELOW*
What are the four elements of nursing negligence?
1. standards of care (was minimum care met?) 2. duty owed (was it owed for hte situation, if owed, was it breached?) 3. ability to cause harm (did the nurse's action of lack of action play a role in the outcome?) 4. did injury or harm occur? (did the breach of duty cause the injury? is there a cause and effect relationship?)
How many MDs for a POA to be activated?
2
Person accepting delegating task
-*Their own actions (if accept, are liable) -*Accepting the delegation with regards to training and education (if not = speak up!) -Communicating with the RN -*Completing the task (responsible)
What is nursing informatics?
"The specialty that integrates nursing science with multiple information management and analytical sciences to identify, define, manage, and communicate data, information, knowledge, and wisdom in nursing practice." -ANA, pg. 531
Respondeat Superior
"let the master answer" --holds the employer liable for any negligence by their employees if acting within the realm of employment
Respondent Superior
"let the master respond", legal doctrine that holds employer responsible for torts/acts committed by its employees ----Must have an employee/employer relationship ----Must be acting in your scope of practice *wisconsin has the least amount of malpractice cases in the US, ranked 50/50
What is reality shock?
'reaction' when moving from nursing student to registered nurse
Legal Considerations when Delegating (I)
(I) --Supervisory duties which are part of the usual functions of a nurse; therefore, the Board of Nursing can discipline a RN who is incompetent or negligent in this area --Supervisory RN is not directly responsible for negligent acts, but is responsible for knowing competence level of subordinates and what is delegated --Responsibility to delegate appropriately and to supervise appropriately --Failure to do so constitutes a breach of duty and is therefore ground for negligence --"but for" cause of injury: if person performing injurious act had not been assigned the task or had been supervised properly, the injury could have been avoided
Legal Considerations with Delegating (II)
(II) --RN's are not employers and therefore are not held liable under respondeat superior (refers to "let the master answer" and holds the employer liable for any negligence by their employees if acting within the realm of employment) --Assignments to other RN's require a lower level of supervision unless the RN is a new graduate or is floating to an unfamiliar unit --"but for" cause of injury: if person performing injurious act had not been assigned the task or had been supervised properly, the injury could have been avoided --Off site supervision: requires RNs to assess the knowledge, skills, and judgment of the UAP before assignments are made; must make regular supervisory visits and a need for impeccable documentation --RNs are responsible for supplementing the training given UAP's
The Nursing Process
***NOT TO BE DELEGATED*** -Assessment (RN ONLY) -Diagnosis -Outcome identification and planning -Implementation -Evaluation *ALSO - DO NOT delegate interpretation of data for LPN/CNA/etc
Should you get Malpractice Insurance?
**PERSONAL PREFERENCE** 2 types of insurance ---Coverage for injury report during policy period ---Coverage for injury that occurred during the policy period, but was reported outside the policy period Limits of Policy/Acts not Covered Personal Cost Peace of Mind
Protecting Ourselves as Nurses
--Always follow standards of care (look @ NPA) --Review policies and procedures --Follow evidence-based practices (changes in profession) --Utilize resources --Delegate appropriately --Document! (Cant document for others) --Communicate effectively with team (clear language, urgency) Understand "High Risk areas" -Consent -Use of Restraints -HIPAA & Confidentiality (no pictures/talk about pt) -Patient's Right to Refuse
Reducing Risk when Delegating
--Keep yourself informed regarding Scope of Practice, facility policies, etc --Only delegating to the 'person' who can do the task under the circumstance --Don't delegate a task if it could involve substantial risk of harm to the patient --Don't delegate a task to a 'person' who is not qualified, trained, and/or competent in that task -Adequately supervise the delegated task ---Direct Supervision ---General Supervision ---On-site or off-site supervision --Evaluate the delegated action by reassessing the patient after the task is completed *When in doubt about the outcome, DO NOT delegate*
HIPAA
--Law was signed in 1996 to help protect the privacy and security of patient data (cannot tell who we saw at the hospital) --Privacy Laws --Data Security Standards --Electronic Transaction Standards
Informed Consent Document Includes
--Name of the procedure, treatment, or intervention --Risks and benefits, side effects --Likelihood of achieving care, treatment, goals --Alternatives --Provider is responsible for explaining and obtaining an informed consent
Things to consider in regards to informatics
--Privacy Laws with cell phone and smartphone in patient care areas --Internet Access (work vs personal use) --User passwords (documentation is very important) --Protecting the medical record (lock computer when walking away) --Firewalls (damage EMR) --Security Software (damage EMR)
Documentation in the EMR (Cardinal Rules of Documenting)
--Readability, Chronological order (good timestamp) --Content, Abbreviations --Compliance with Plan of Care (document correctly) --Correction of Mistakes (within documentation) --Negative or biased entries (encourage direct quotations, unbiased) --Avoid labeling or using judgmental terms (clear, concise)
Incident or Variance Reports
--Record of unusual or unexpected events (ex: unplanned C section, communication issue, equipment failure) --NOT part of the medical record for FACILITY USE ONLY --IF you include it, it can be subpoenaed in court (especially if the patient experienced a poor outcome)
Why is Delegation important?
--Staffing Patterns --Ratio of licensed to unlicensed staff (UAP=unlicensed assistive personnel and in our case unlicensed healthcare professional) -> mix of staff and patient acuity --Political Influences (funding, medicare/caid) --Federal and State Mandates --Availability of trained workforce (work at scope of practice) --Accountability of the RN
Intentional Tort Examples
-Assault (threat of harm) -Battery (Bodily harm)-Unauthorized touching, suturing a wound, injection admin, performing an exam/assessment -False imprisonment-Restraints or confinement -Invasion of privacy
Malpractice Insurance (institutional)
-Covers acts or omission of nurses employed by an organization -Respondent Superior- "let the master respond", legal doctrine that holds employer responsible for torts/acts committed by its employees ----Must have an employee/employer relationship ----Must be acting in your scope of practice -Typically organization does not 'reverse sue' RN unless very gross negligence on RN part
Informatics Examples
-Health Tracking (fitbit, apple watch) -EMR systems- with capability to input data such as BP, HR, O2 -Robotics in surgery -Patient devices-pacemakers -Scheduling, symptom checkers, communicate with providers (patient portal) -Prescription transfer -Telehealth visits with provider
what can we do to prevent burnout?
-Maintain self-care activities (SLEEP) -Recognize warning signs and need to "take care of the caretaker" first -Take your breaks! -It is OK to say NO! -Find and maintain work relationships
RN Delegating
-Making the decision to delegate -**Assessing patient needs and competency of delegatee (are they competent?) -Planning the outcome -Clear direction and communication -Follow-up and feedback *what are they responsible for? *if they dont delegate = will burn out and suffer
Right supervision
-Monitor the outcomes of care that has been delegated -Direct supervision is the immediate availability to continually coordinate, direct, and inspect firsthand the practice of another -General supervision is to regularly coordinate, direct, and inspect the practice of others
Unstable Patient Areas (high risk of legal issues)
-OB -CCU/ICU -Surgery
Recovery phase of reality shock
-beginning to show a sense of humor (nurse humor) -decrease in tension -increase in ability to be objective and see the 'broader' picture of the unit (no longer task oriented)
Maslow's Heirarchy of Needs Theory
-can help us prioritize which patients we see first 1. airway 2. breathing 3. circulation 4. safety 5. pain (unless accompanying other symptom) 6. education (once stable) 7. Feelings (good about education)
What are the four C's of Direction?
-clear -concise -correct -complete
private law examples
-contract law *tort law - nursing -family law -employment law -land law -wills and succession
Before taking the NCLEX the following must happen
-degree audit by CVTC - must "apply for graduation" -approval from registrar to program director -paperwork needs to be submitted to the state by student and program director -money paid to the state board of nursing to take the exam -watch for email: authorization to test (2-4 weeks post graduation date) -testing blocks to take the exam
what is a preceptor
-has set time limit -termination date -assigned role -formalized orientation (get up and running) -assists in fine tuning skills -offers suggestions -work-related focus
public law examples
-international law -administrative law -constitutional law -criminal law -tax law
rejection (shock) of reality shock phase
-may mistrust others -increased concern over minor problems -feeling like a failure and not up to par with other new nurses -blame others for mistakes -may be 'hard' on yourself
What is a mentor?
-occurs over time -no termination date -sought out by mentee -teaches networking -shares personal experiences -experiences are personal -mentoring relationship may be personal, academic, or work-related
Honeymoon phase of reality shock
-real world of nursing, fascination with "arriving" in the nursing profession -"I am the RN now"
Tips to avoid legal trouble
-stay informed with new research and EBP -known policies and procedures for units and facilities -utilitize resources -follow STANDARDS OF CARE -delegate appropriately -ID patients at risk -avoid med errors -maintain a safe environment -document precisely and accurately -provide good communication (SBAR) -recognize behaviors or patients that indicated the possibility for a lawsuit
Transition to RN practice Long Term
-take and pass NCLEX -map out career goals - professional development plan
Dangers of burnout
-turnover -lower quality of care -mortality (patient)
When does reality shock occur?
-unexpected or unrealistic expectations that are not clearly defined -things placed upon you after school
In order to prove negligence/malpractice, the following 4 criteria MUST be PROVEN
1. Duty 2. Breach of Duty 3. Causation 4. Injury
Two primary purposes of licensure
1. Ensure enforcement of the act 2. Protect the public (patient) *license is a privilege, not a right*
The 5 Rights of Delegation
1. Right task 2. Right circumstance 3. Right person 4. Right direction/communication 5. Right supervision/evaluation
Legislative Law
2 houses of congress - senate and house -write the laws
Maximum # of NCLEX questions
265
Minimum # of NCLEX questions
75
Scope of Practice (CNA)
>Feeding (not at risk) >Physical care - ADL's >Ambulating >Positioning >Specimen collection >I/O totals >Vital Signs *can ONLY do CNA tasks*
Why does burnout occur?
>High acuity/complex patients, ie. our patients are getting sicker >Caring for a higher number of patients=> feeling like we aren't doing all we can >Work environment-Long shifts,rotating shifts, working on days off ----Burnout is 2.5x more likely in amongst nurses working more than 10 hour shifts >Unrealistic expectations of the job/nurse >Not taking care of self- Lack of sleep, hydration, nutrition (prioritize self) >High stress environment >Lack of support-both at home and work
Signs and symptoms (WARNINGS) of burnout
>Irritability >Weight Changes >Frequent headache, GI problems, Insomnia >Depression or feelings of hopelessness >Negativity >Cynicism >Angry Outbursts >Self-Criticism
Scope of Practice (RN)
>Patient assessment, evaluation >Admission, Discharge Plans >Nursing Diagnosis >Teaching Plans >IV lines, IV push medications >Blood administration >Planning nursing care >Signing off provider's orders >Directing care for unstable patients *Can do RN/LPN/CNA tasks*
Scope of Practice (LPN)
>Vital signs >Physical cares >Report observations to RN >Generally no IV push meds, IV fluids ok >Reinforcing teaching plan RN has developed the plan >Care for stable patients *can do LPN and CNA tasks*
What should the nurse consider when obtaining an informed consent from a 17-year-old adolescent? A. Whether the client is allowed to give consent B. That the client cannot make informed decisions about healthcare C. Whether the client is permitted to give voluntary consent when parents are not available D. That the client probably will be unable to choose between alternatives when asked to consent
A A person is legally able to sign a consent until the age of 18 or 19 years (depending upon individual state or provincial laws) unless the client is an emancipated minor or married. The nurse must determine the legal status of the adolescent. Parents or guardians are legally responsible under all circumstances unless the adolescent is an emancipated minor or married. Adolescents have the capacity to choose, but not the legal right in this situation unless they are legally emancipated or married.
You are going to visit your 93 year-old grandfather and upon arrival at his home, you find your mother arrived 5 minutes earlier to find your grandfather unresponsive and she has called 911. After Christmas last year, your grandfather told you about his recent doctor's visit and that he wished to be DNR. What events are likely to occur when the EMS crew arrives? A. They will start CPR and transport your grandfather to the hospital B. They will arrive, but not perform CPR as your grandfather is DNR C. They will start CPR and stop when you tell them that you know that your grandfather is DNR D. The will not respond to the call as your grandfather is DNR
A Calling 911 is asking for help and for care to be given. Despite you knowing that your grandfather is DNR, the EMS team does not and responds to every 911 call in the same manner-arrive, treat/perform life-saving measures, and transport to the nearest hospital. Hopefully you know where your grandfather keeps his important documents and can bring them with you to the hospital. There, you may discuss his wishes with the physician and cease CPR. It is much easier to start CPR and then end it at the hospital then to not start CPR and realize after the fact that the patient wished for life-saving measures! Patients need to know that when you call 911, you will get treated. The best thing to do is to not call 911 in the event that your family member has DNR wishes.
Laura, a LPN on the unit, has just received her patient care assignment and will be responsible for the following four patients. Patient J: a one-day post-op knee surgery patient who will need a dressing change. Patient K: a patient with pneumonia receiving IV antibiotics who needs reinforcement of teaching on their incentive spirometer. Patient L: a chronic CHF patient receiving oral Lasix. Patient M: an incoming observation admission from the ER for an acute asthma exacerbation who is now stable. Which of the patients above would require Laura to "reverse back" the assignment as the patient required RN care? A. Patient M B. Patient K C. Patient L D. Patient J
A Patient M requires an admission assessment and ongoing assessment for their acute asthma attack and would be best to "reverse back" to the RN. All of the other patients would fall within the LPN Scope of Practice including: wound dressing changes, IV antibiotics, reinforcing teaching, and administering oral medications.
As a RN, we are required to renew our nursing licenses every two years in the State of Wisconsin. Which agency is responsible for Nursing licensure? A. The State Board of Nursing (BON) B. The National League for Nursing (NLN) C. The American Nurses Association (ANA) D. The U.S. Department of Justice on Nursing Licensure (DOJNL)
A State board of nursing
You have just received report for your upcoming shift and are looking to prioritize your first hours of the day. Which of the following patients would be your first priority? A. 2-hour post-op with saturated abdominal dressing B. COPD patient whose O2 sat is 94% and due for their morning inhalers C. Confused, dementia patient whose family is at the desk with questions re: LTC placement D. Appendectomy patient with a pain of 6/10 and due for pain medication
A The 2-hour post-op patient with a saturated dressing is the priority here due to the potential of a surgery complication and unexpected additional bleeding that would not be considered "normal" following surgery. THINK: Circulation issue here. Other patients fall into the: "feelings" for the family needing teaching re: LTC, "Pain" for the patient needing pain medication, and while the COPD patient could be viewed as "breathing" putting this patient as the priority, the patient's condition is chronic and stable with no signs of SOB or dyspnea which rules out this patient as the priority here.
Unintentional Tort (negligence)
A person is considered to have acted negligently when: one performed or failed to perform an act that a reasonable person would or would not have done in a similar circumstances --"Should have known better" or "didn't intent to do it" --Professional negligence=malpractice
Certain questions are applicable in determining nursing negligence. Select all that apply. A. "Was reasonable care provided?" B. "Was there a breach of nursing duty?" C. "Was there an act of omission that resulted in harm?" D. "Except for the nurse's action, would the injury have occurred?" E. "Did the nurse fully understand the actions would result in harm?"
A,B,C,D Nursing negligence is described as the failure to do or not do what a reasonably careful nurse would do under the circumstances. The elements that must be present to determine negligence include whether the nurse fulfilled the legal duties to provide reasonable care and foresee a risk of injury under certain circumstances and whether there was a breach of duty and whether any injury resulted if there was a breach of duty. The intentional or unintentional nature of a behavior is determined by an understanding of the actions and their consequences
Match the following with their type of law. A. Right to Bear Arms B. R vs. R-ruling that marriage is a partnership of equals, thereby revoking a previous 1736 ruling that a man could not be guilty of raping his wife C. Car accident where you caused injury to someone else D. Medicare/Social Security
A. constitutional B. Common C. Civil D. administrative
Some more law practice, match the following with their applicable type of law. A. Nurse Practice Act Statutory B. Murder Criminal C. Right to Protest Constitutional D.False Imprisonment
A. statutory B. criminal C. constitutional D. civil
Nurses are held responsible for the commission of a tort. What is the definition of a tort? A. The application of force to the body of another by a reasonable individual B. An illegality committed by one person against the property or person of another C. Doing something that a reasonable person under ordinary circumstances would not do D. An illegality committed against the public and punishable by the law through the courts
B An individual is held legally responsible for actions committed against another individual or an individual's property. The application of force to the body of another is battery, which involves physical harm. Doing something that a reasonable person under ordinary circumstances would not do is the definition of negligence. An illegality committed against the public and punishable by the law through the courts is the definition of a crime.
A patient with migraine headaches has a seizure. After the seizure, which task can the RN delegate to the certified nursing assistant to do first? A. Placing restrains on the patient, for protection, from additional seizures B. Taking the patient's vital signs per policy post-seizure C. Documenting the characteristics of the seizure on the neuro flow sheet D. Performing neuro checks q 4 hours and PRN based on the patient's condition
B Delegate to the CNA to take the patient's vital signs as this is within their scope of practice. It is the responsibility of the RN to perform neurological checks to document the type of seizure, patient's condition and response as this is an assessment. Keep in mind that a patient having seizures should never be restrained; however, the RN may guide the patient's movements as necessary to avoid injury.
The RN is preparing to admit a patient with a seizure disorder. Which of the following actions should the RN delegate to the LPN so they can focus on RN responsibilities? A. Completing the initial seizure risk assessment tool until the RN has time to finish it B. Setting up oxygen and suction equipment per protocol C. Completing the admission assessment D. Placing a padded tongue blade at the bedside
B Delegate to the LPN to set up oxygen and suction equipment and then other tasks as indicated (what is the most important of the tasks that can be delegated to another member of the team who can do it?). The RN is responsible for the admission intake and assessment. Tongue blades should not be at the bedside and should never be inserted into the patient's mouth after a seizure begins. Any assessments that need to be done (admission, focused, diagnostic tools such as 'seizure risk assessment, etc) are the responsibility of the RN as this is not in the scope of practice for a LPN as it requires 'assessment' (use the nursing process as your guide). FOCUS: delegation and supervision
A nursing student is listing the different aspects of obtaining informed consent from clients. Which point mentioned by the nursing student needs correction? A. "Informed consent should be obtained in all situations except during extraordinary circumstances." B. "Informed consent is an important part of the nurse-client relationship; it is a vital part of the nursing duty." C. "Informed consent is provided by clients based on the full disclosure of risks, benefits, alternatives, and consequences of refusal." D. "The primary healthcare provider legally has to disclose facts in terms that the client is able to understand to make an informed choice."
B Informed consent is a vital part of the relationship between the healthcare provider and the client. Nurses are responsible for making sure the healthcare provider explains any surgical procedure to the client including risks. Informed consent from clients should be obtained in all situations except emergencies, because failure to do so may lead to battery. Clients provide informed consent after they are made completely aware of the risks, benefits, alternatives, and consequences of refusing treatment. The person responsible for performing the procedure has the legal duty to disclose facts regarding the treatment in terms that the client is able to understand.
You are working on the Med-Tele unit at your local hospital. Which of the following patients would you prioritize after receiving report for your upcoming shift? A. A 3-day post-op CABG patient with 94% O2 sats and rating their pain a 4/10 B. A patient who was admitted overnight to observation to r/o MI who the UAP notes to be sweaty and anxious C. A patient with CHF with +4 edema and lung crackles who is due for their 0800 Lasix D. A 1-day post-op stent placement patient with scant amount of bright-red draining on their dressing, which is due to be changed
B Observation patient who is now experiencing anxiety and sweating. Anxiety and sweating may be early signs of MI for this patient. Further assessment along with potentially an EKG, lab work, etc, may be needed for this patient. Time is critical here in order to minimize damage to cardiac tissue. In the case of the CABG patient, pain is expected for this surgery and their O2 sats are within normal limits at this time and therefore not the priority patient here. Scant amount of drainage is also an expected finding post-stent placement as well. Finally, while the CHF patient is taking on fluid, as evidenced by lung crackles and increased edema, medication administration does not take priority over a potential MI patient. Should this patient have O2 sats >92%, this may present a more urgent need for this patient.
The nurse is admitting a patient with a spinal cord injury at the C3-4 level. What is the priority assessment, by the RN, for this patient? Hint: keep in the mind the location of this injury and its effect on the body's functioning. A. monitoring blood pressure and pulse for beginning signs of spinal shock B. monitoring respiratory effort and oxygen saturation levels C. determining the level at which the patient has intact neurological sensation D. assessing the level at which the patient has retained mobility
B Primary interventions is to monitor respiratory effort and oxygen saturation levels. This patient with a cervical level injury is at risk for respiratory compromise so we need to ensure there is an adequate airway. Keep in mind the ABC's when prioritizing patient care. Even if you are not familiar with C3-5 injuries, you do know that cervical injuries, due to the location, can compromise respiratory effort. The patient is at risk because the spinal nerves (C3-5) innervate the phrenic nerve which controls the diaphragm. The other assessments are also important, but not as high of a priority as breathing
A LPN is providing nursing care, under the supervision of the RN, who has completed an initial assessment for a patient with Guillain-Barre syndrome. What data by the LPN should the RN instruct the LPN to report back immediately? A. complaints of numbness and tingling in the lower extremities B. shallow respirations with decreased breath sounds C. rapid heart rate of 105 or > and core temperature of < 37.6 D. facial weakness with difficulty speaking
B The LPN should report shallow respirations and decreased breath sounds as data collected with the RN doing the initial assessment and evaluating the patient based on additional data that is reported and also to determine if further assessment is needed based on what the LPN has observed, collected or reported. The priority interventions for a patient with Guillain-Barre Syndrome are focused on maintaining an adequate respiratory airway and functioning. These patients are at risk for respiratory failure which is urgent and a priority. Yes, the other findings are important and should also be reported to the RN, but they are not life-threatening.
You have just received report and will be caring for the following 4 patients on this day shift. Which patient would be your FIRST priority? A. A patient who needs discharge teaching and will be leaving to go to a rehab unit in 1 hour B. A patient who was admitted last night to r/o Crohn's flare up who is now vomiting and having 9/10 abdominal pain C. A patient who had a cholecystectomy yesterday who needs assistance ordering his first post-op meal D. A patient who is confused and continues to try to get out of bed to use the bathroom without their walker
B While this patient was admitted for a chronic condition and flare up of Crohn's, the patient is now vomiting with severe pain, indicating a change in condition and possible bowel obstruction. This patient needs immediate assessment, which can not be delegated, and potentially pain medication. The patient needing teaching is not priority despite the 1 hour time frame for discharge. Depending on the patient needs, this teaching may be delegated to another nurse or the charge nurse, if needed. The patient ordering their meal, while also time sensitive due to hunger and has needs for education, is not the priority. The confused patient may need a "sitter" or another unlicensed person to sit with them to ensure safety. Again, a need that may need to be delegated.
You are the charge nurse making out patient-nurse assignments for the next shift. Which patient should you assign to a new graduate nurse who is orienting to the neurology unit? A. A new admission with a spinal cord injury B. A patient with Parkinson's disease who needs assistance with bathing C. A patient with dementia who will be transferred to a nursing home today D. A patient with a stroke four days ago with left-sided weakness
B Parkinsons
A registered nurse is educating a nursing student about nursing malpractice. What information should the nurse provide? Select all that apply. A. "Nursing malpractice includes willful acts that violate a client's rights." B. "Nursing malpractice takes place when nursing care falls below the standards of care." C. "Nursing malpractice may be prevented by developing a caring rapport with the client." D. "Nursing malpractice may occur even when the nurses do not intend to harm the clients." E. "Nursing malpractice refers to the publication of false statements to damage a person's reputation."
B,C,D Nursing malpractice is also known as professional negligence. This takes place if the nursing care provided to the client falls below the expected standards of care. A nurse may avoid malpractice by developing a caring rapport with the client and communicating about treatment plans and tests. Nursing malpractice may take place even when nurses do not intend to harm clients, but are unable to maintain proper standards of care. Nursing malpractice is an unintentional tort. Intentional torts are willful acts that violate a person's rights. Publishing false statements to damage a person's reputation is called defamation of character.
Failure to delegate results in...
BREACH OF DUTY, ground for negligence
In caring for patients with pain and discomfort issues, which task is the most appropriate for the nurse to delegate to a certified nursing assistant: A. Coach the patient to deep breathe during painful procedures B. Evaluate relief after applying a cold application such as an ice pack C.Assist the patient with preparation for a sitz bath D. To assess the patient for signs of discomfort while being ambulated
C -cannot coach, evaluate or assess patients
Greta is a 78 year-old patient that you are caring for in the LTC setting. One day, she states to you, "Oh, my daughter Betty takes care of all of my financial stuff. It's so nice to not have to worry about that anymore." Upon hearing this information, you recognize that Betty has what relationship to Greta? A. Betty is Greta's POA for Finances and would make any healthcare decisions that are needed B. Betty is Greta's Durable POA for Healthcare C. Betty is Greta's POA for Finances but you are unsure about being the POA for Healthcare. You write yourself a note to remind Betty and Greta about this at the next care conference meeting. D. Since Betty and Greta live in Wisconsin, Greta does not need a POA for Healthcare because WI is a "Next of Kin State" and Betty will make Greta's healthcare decisions
C Just because Betty is the POA for Finances doesn't assume that she would also make healthcare decisions. Remember, these are 2 different documents with potentially 2 different parties identified here. Wisconsin is NOT a "Next of Kin State" and therefore, Greta would receive all care possible, as determined by the healthcare provider, should she become unconscious and not have Advanced Directives documented and on file at the healthcare facility.
You are the RN working with a UAP and LPN today to care for a team of 6 patients. You are working very hard at delegating and perfecting this skill in order to make the most out of everyone's time and scope of practice. Which of the following tasks would be appropriate for you to delegate to either the UAP or LPN? A. Caring for a diabetic patient with blood sugars ranging from 110-135 B. Reinforce teaching on urinary catheter care C.Repositioning a patient every 2 hours to decrease skin breakdown D. Administering oral pain medications after you have assessed new onset pain
C Remember, EVERYONE can and is expected to perform skills and tasks below their Scope of Practice, but not above. So for example, YES, RNs can and should ambulate and position patients, as time and teamwork allows, but UAPs can not perform assessments. It is important for us to know what skills fall within which Scope of Practice. All of the other options here would be appropriate for the LPN role, but not the UAP role within this team.
A nurse caring for a client post-surgery takes necessary steps to achieve quality client care. Which nursing actions satisfy the Quality and Safety Education for Nurses (QSEN) competency called informatics? Select all that apply. A. Washing the hands before handling the client's incision site B. Implementing a new method of monitoring the client's incision site for infections C. Documenting in the electronic health record (EHR) after performing wound debridement D. Locking the electronic health record (EHR) after every entrance of necessary information E. Using computer-assisted instruction (CAI) program to provide better quality of care to the client
C, D, E A nurse satisfies the informatics competency by using information and technology to communicate, manage knowledge, minimize errors, and support decision-making. Documenting in the client's electronic health record (EHR) after performing wound debridement enables the nurse to track the client's progress and store information for future reference. The nurse maintains confidentiality of the client's medical information by locking the electronic health record (EHR). This enables the nurse to manage knowledge appropriately and minimizing the possibility of legal issues. The nurse also satisfies the informatics competency by using computer-assisted instruction (CAI) programs to provide better quality of care to the client. To satisfy the safety competency, the nurse is required to reduce the risk of causing harm to the client by ensuring appropriate individual performances. In the given situation, the nurse washes his or her hands to minimize the risk of infections. The nurse satisfies the quality improvement competency by implementing a new method of monitoring the client for infections.
Nursing compact
Can practice in any state that is part of the compact (do not need a nursing license for each state) —condition: you must be in 'good standing' in your home state where licensed Must follow the NPA in that state (when practicing with compact license) WI is in the compact, MN is not GOod to have if you want to be a travel nurse
Transitioning to RN PRactice Short Term
Complete Transitions Clinical Establish Rapport with Preceptor Any Leads for RN position on transitions unit? NCLEX review days (TIME FOR NCLEX STUDYING) HESI Exit exams GRADUATION
Malpractice Insurance (individual)
Cost varies with areas of nursing & with each state --High Risk Areas cost MORE [OB, Surgery, Med Units] --25% of all malpractice cases deal with OB
Which patient would be the most appropriate to assign to a new graduate nurse who has just completed their unit orientation? A. An anxious patient with chronic, uncontrolled pain who frequently uses the call light for 'more meds' B. A patient who is being discharged with a newly surgically implanted venous access catheter C. A patient with HIV who reports headaches, abdominal and sharp, pleuritic chest pain that is rated at 7/10 D. A patient who is second day post-op and needs pain medication one hour prior to wound dressing changes
D Easiest patient to allow new RN to feel comfortable when taking care of them
When being interviewed for a position as a registered professional nurse, the applicant is asked to identify an example of an intentional tort. What is the appropriate response? A. Negligence B. Malpractice C. Breach of Duty D. False Imprisonment
D False imprisonment is a wrong committed by one person against another in a willful, intentional way without just cause or excuse. Negligence is an unintentional tort. Malpractice, which is professional negligence, is classified as an unintentional tort. Breach of duty is an unintentional tort.
The nurse has just received SBAR shift report. Which patient should the nurse assess first as being the highest priority? A. Patient diagnosed with gallbladder disease who refuses to eat the food sent on the meal tray B. Patient diagnosed with osteoarthritis who is complaining of extreme pain in both knees C. Patient diagnosed with pancreatitis who wants the naso-gastric (NG) tube removed now and is becoming more irritable D. Patient diagnosed with a deep vein thrombosis who is complaining of dyspnea and coughing
D Highest priority is the patient with a DVT as he/she is exhibiting s/s that potentially could be fatal complication of a pulmonary embolism (ABC's - respiratory compromise). The patient refusing to eat can discuss dietary choices and preferences with the dietitian or have the CNA assist with meal choices as a self-selection. The patient with pancreatitis has an NG tube to 'rest' the bowel. However, tubes are typically uncomfortable and the RN can discuss the importance of maintaining the tube (would see as patient #2). The patient with osteoarthritis has expected symptoms and is not acute (would see as patient #4). Consider what requires RN intervention and what could be delegated.
A motorist receives a ticket for speeding because the State of Wisconsin has determined that the speed limit in an area is 55mph. What type of law is involved in this case? A. Constitutional B. Criminal C. Case/Common D. Statutory
D Statutory law is created at the Federal, State, and Local levels by elected officials. Examples include traffic regulations and tax laws.
What type of law does the State Board of Nursing implement when granting authority for licensing and nursing practice? A. Statutory B. Constitutional C. Criminal D. Administrative
D The State Board of Nursing has been granted the authority to make laws such as the Nursing Practice Act, which is responsible for RN licensing, examination, and the scope of practice.
Which of the following legal defenses are the most important for a nurse to develop? A. Dedication B. Certification C. Assertiveness D. Accountability
D The concept of accountability is of high priority in nursing practice. As a licensed professional, the nurse is always accountable, which means liable and answerable for his or her actions. Dedication means to be committed, and assertiveness means to be confident. These are desired characteristics in a nurse but not legal defenses. Certification relates to achieving a higher level of knowledge or proficiency in one's area of specialization and is also not a legal defense
You are caring for a team of 4 patients with an UAP on your med-surg unit. After receiving report, you start to plan out your day. Which of the following patient needs would you not want to delegate to the CNA? A. Collecting a urine specimen to rule out UTI B. Ambulating a 78 year-old who is 2 days post-op hip replacement C. Calculating I & O for a CHF patient who is on Lasix D. Providing discharge teaching to a 85 year-old with pneumonia
D UAP staff can collect specimens including urine, stool, and blood sugars. The patient in need of ambulation would also be appropriate to delegate because it would be expected that the patient has already been ambulating post-surgery. Calculating I & O is also within the UAP Scope of Practice and the medications that the patient is on does not change this. While the UAP can collect and document the I & O, it is up to the RN to interpret those results and decide what that means in terms of the patient's plan of care and outcome.
Nurse residency programs
Ease transition from school to nursing practice and improve turnover rates Formalized orientation process (6-18 months) Typically integrates class time, unit time, simulation, observation, collaboration with peers
Prioritizing our Time and Patient Care
Expect (BP 120/80) vs. Unexpected (BP 190/110) Chronic (COPD 10-15 yrs) vs. Acute (dyspnea or onset SOB) Stable (O2 95%) vs. Unstable (O2 88%) Potential Problem (stable patient leave AMA) vs. Actual Problem (trouble breathing, hyperventilating) Safe (not combative, use walker correctly) vs. Unsafe (combative, not use walker correctly)
T/F 2 witnesses who are related can activate a POA
FALSE -two witnesses cannot be related
Right communication/direction
Give clear and complete directions including what, how, and when to report back (what need to do/how/report back) Ex. Time constraints, abnormal VS and changes *be the right RN to give communication
Delegating Dont
IF UNSURE ABOUT OUTCOME, DO NOT DELEGATE!
Common causes for nursing license revocation and suspesion
Impaired —alcohol, OTC/prescription meds, illegal drugs Being found guilty of professional negligence Practicing without an RN license —must renew every 2 years Convicted felon Participating in criminal abortions Not reporting substandard medical or nursing care —legal responsibility to report —if you don't and it becomes known that you had knowledge of it, you could be held liable Providing patient care while under the influence of alcohol or drugs Giving narcotics without and order Falsely holding oneself to the public in a role other than RN (I.e NP)
Preparation for this transition
Increase independence Increase your patient load at clinical/transitions clinical (ask lots of questions0 Engage in entire nursing shift (report, charting, patient care, communication with multidisciplinary team) Perform skills vs observing (observe 1, do 1, teach 1) Find a mentor! Find ways to problem solve and critically think during clinical Request feedback from your preceptor Think positively, be flexible, stay HEALTHY! HAVE FUN!
right person
Instruct, assess, verify the competency of an individual and patient specific basis (can be patient specific; tell if you have not done task before especially if you can be taught it) Ex. New grad with limited experience with complex patients, previous experience?, floating RN (do not delegate tasks to RNs who are not comfortable)
Nursing Compact Licensure Definition
Is a mutual recognition with an agreement among the states that belong to the compact for nursing practice
right task
Know your teammates, their scope of practice, and job description within your facility Ex. WI Scope of Practice for RNs and LPNs, organizational policies, skills checklists
Case law
Law set by legal precedent, court make ruling -no law can be applied ---Judges share decisions with each other, and these decisions become law (Aka. Common law) Examples: Roe vs. Wade; Brown vs. Board of Education
right circumstance
Match the complexity of the activity with the competency of the delegatee Ex. First ambulation post-surgery, feeding patients with risk for aspiration, outcomes need to be considered (best fit and best match)
NCLEX Types of Questions
Multiple Choice Fill in the Blank Multiple Response Hot Spot (use a diagram or graphic) Ordered Response Chart or Exhibit Audio
The nurse is assigned four patients with the following complaints. In what order should the nurse see the patients? Patient 1: A heart failure patient diuresing with furosemide and states "I have bad muscle cramps in my lower legs" Patient 2: A patient with newly diagnosed left lower extremity DVT on IV heparin and states "I just can't catch my breath over the past few minutes and I am feeling very anxious." Patient 3: A patient that takes hydrochlorothiazide twice a day and states "I have to use the bedpan at least every 1 to 2 hours." Patient 4: A 1-day post op CABG patient that states "It seems that the pain medication is not working as well today."
Patient 1: 2nd Patient 2: 1st Patient 3: 4th Patient 4: 3rd
The nurse receives labs on the following four patients. In what order should the nurse see the patients? Patient 1: Patient with history of atrial fibrillation and anticoagulant use with INR of 4.8 Patient 2: Patient with no known infection with WBC's of 18,000, after having normal WBC's yesterday. Patient 3: Patient with history of GI bleeds and anemia with Hgb of 10.0 Patient 4: Patient with heart failure on furosemide with potassium of 2.4.
Patient 1: 2nd Patient 2: 3rd Patient 3: 4th Patient 4: 1st
The nurse is assigned the following patients. Which order should the nurse see the patients in? Patient 1: A patient with pneumonia coughing up yellow sputum needing IV Vancomycin hung Patient 2: An elderly patient with right hip fracture complaining of hip pain 10/10 Patient 3: A patient that just returned from surgery with a saturated dressing and blood pressure 90/60 Patient 4: A patient receiving tube feedings who urgently needs to use the bathroom.
Patient 1: 3rd Patient 2: 2nd Patient 3: 1st Patient 4: 4th
The nurse receives report on the following patients. In what order should the nurse see the patients? Patient 1: A patient complaining of knee pain, status post total knee replacement one day ago. Patient 2: A patient with new ischemic stroke with Glascow Coma Score of 9, previously 12. Patient 3: A new admission with serum potassium level of 3.3. Patient 4: A patient with known coronary artery disease complaining of mid-sternal chest pain.
Patient 1: 4th Patient 2: 2nd Patient 3: 3rd Patient 4: 1st
The nurse is assigned the following four patients. In what order should the nurse see the patients? Patient 1: A patient with heart failure with crackles in lungs and 02 saturation of 89%. Patient 2: A patient with moderate persistent asthma needing scheduled Advair. Patient 3: A patient with COPD with 02 saturation of 89% complaining of shortness of breath. Patient 4: A patient with lung cancer who has just undergone left lower lobectomy and is complaining of pain 8/10.
Patient 1; 1st Patient 2: 4th Patient 3: 2nd Patient 4: 3rd
NCLEX test taking strategies
Putting all the pieces together —-think Blooms taxonomy: application, evaluation, creating Physiological > Psychosocial —-stable vs. unstable pt Maslow's Hierarchy of Needs Common lab values (obvious) Common drugs —-action, implication, SE Underlying pathophysiology —what is causing the problem ABCs
Taking Verbal and Phone Orders
Step 1: Order is communicated verbally (either person to person or by phone) Step: 2 Order is written verbatim Step 3: Order is read back directly to the person who gave order for confirmation (make sure it is correct before you hang up or walk away)
Judicial Law
Supreme court, federal and stage judges and courts -interpret the laws
NCLEX
What is it?- National licensing test to ensure an RN can provide competent and safe nursing care >Designed by National Council of State Boards of Nursing (NCSBN) >Used to regulate entry into nursing practice in US >Same test plan for all states >Every state requires same passing level/standard
Expert Witness
a person called into testify in a case that has exemplary knowledge of the field, may attest to the "standard of care", speak to what a "reasonable or prudent" nurse would have done in a similar situation
what is burnout?
a state of mental, physical, and emotional exhaustion caused by sustained work-related stressors
TORT LAW
civil wrong against a person entitling the injured party to file a lawsuit to receive compensation for damages or suffering Intentional-done on purpose to cause harm to another person Examples: Assault (threat of harm) Battery (Bodily harm)-Unauthorized touching, suturing a wound, injection admin, performing an exam/assessment False imprisonment-Restraints or confinement Invasion of privacy Unintentional- called NEGLIGENCE A person is considered to have acted negligently when: one performed or failed to perform an act that a reasonable person would or would not have done in a similar circumstances --"Should have known better" or "didn't intent to do it" --Professional negligence=malpractice
Joint Comission
created information management standards -10 standards -regulatory requirements
Criteria for Negligence (Injury)
damages or injury must have occurred
Durable Power of Attorney
declares who will make financial decisions -None Medical -Pay bills, make deposits, sign checks
Intentional Tort
done on purpose to cause harm to another person Examples: Assault (threat of harm) Battery (Bodily harm)-Unauthorized touching, suturing a wound, injection admin, performing an exam/assessment False imprisonment-Restraints or confinement Invasion of privacy
Criminal law
elated to punishment of those who commit crimes A. Felony-more severe ----Punishment: death (if applicable in the state) or prison > 1yr ----Examples: Abuse, arson, fraud, illegal drugs, rape, manslaughter, practicing without a license, murder B. Misdemeanor-less serious ----Punishment: Fines or prison < 1 yr ----Examples: Low $ amount theft, traffic violations, attempted burglary
"but for" cause of injury
if person performing injurious act had not been assigned the task or had been supervised properly, the injury could have been avoided
Direct Supervision
immediate availability to continually coordinate, direct, and inspect firsthand the practice of another
Good Samaritan Law
law that provides civil immunity to professionals that help in emergency situations Providing care within your scope of practice What does the law protect? --Civil Liability --Care without Gross Negligence --Cannot be reimbursed for services --Cannot be sued if helping and practicing within your scope of practice
private law
laws between individuals or institutions
Public Law
laws that apply to everyone -between people and government
what is a licensed co-worker's responsibility when noting an impaired nurse (under the influence) who is providing patient care?
notify their superior
Constitutional law
originate from federal or state constitutions Examples: Right to bear arms, right to marry, privacy, Bill of Rights, declare war, taxes
Statutory law
passed by U.S. Congress or state legislature (Legislative branch) -Individual laws are called statutes -Procedures, rules, and regulations of governmental agencies -Nurse Practice Act (NPA)- Nursing Rulebook!, varies from state to state, your responsibility to know and live by ----Violation means you have fallen below the standard of care Examples: Nurse Practice Act (see Wisconsin's NPA here), traffic violations, laws against murder, robbery, blackmail
executive law
president or governor -enforce the laws (veto and appoint judges (senate and house))
Informed Consent
process for getting permission before conducting a healthcare intervention on a person Document includes: --Name of the procedure, treatment, or intervention --Risks and benefits, side effects --Likelihood of achieving care, treatment, goals --Alternatives --Provider is responsible for explaining and obtaining an informed consent Nurse's role: Witness the signature of the patient! --We may also advocate and provide f/u education In emergency situations: Implied Consent is obtained Competence-pt has to have the ability to understand consent Sedation- pt CAN NOT be under the influence of sedation or medications (ones that would alter judgement) when signing consent
General supervision
regularly coordinate, direct, and inspect the practice of others
Administrative law
regulatory laws from a government agency a. State Board of Nursing-Scope of practice ----National Council of the State Board of Nursing-governing body that grants licensure after boards ----Ensures RN are qualified and competent-Licencing, NCLEX ----Investigate violations against NPA ----Evaluate, issue, and renew nursing licenses Examples: Internal Revenue Service (IRS), Social Security Administration, Occupational Safety and Health Administration (OSHA)
Civil Law
related to acts against a person; person vs. person, business, or government; originated from case/common law Examples: Contract violations, trespassing, accidents, divorce, custody, child support, TORTS A. TORT LAW-civil wrong against a person entitling the injured party to file a lawsuit to receive compensation for damages or suffering ----Intentional-done on purpose to cause harm to another person Examples: Assault (threat of harm) Battery (Bodily harm)-Unauthorized touching, suturing a wound, injection admin, performing an exam/assessment False imprisonment-Restraints or confinement Invasion of privacy ----Unintentional- called NEGLIGENCE A person is considered to have acted negligently when: one performed or failed to perform an act that a reasonable person would or would not have done in a similar circumstances "Should have known better" or "didn't intent to do it" Professional negligence=malpractice
Off site supervision
requires RNs to assess the knowledge, skills, and judgment of the UAP before assignments are made; must make regular supervisory visits and a need for impeccable documentation
State Board of Nursing
scope of practice
when disciplinary actions have been taken against a nurse, it is public knowledge - where do you find this information?
state board of nursin
Durable Power of Attorney for Healthcare
statement declaring someone who will make healthcare decisions for you if unable to do so Aka. Healthcare Proxy or Medical POA
Living Will
statement detailing a person's wishes regarding medical treatment --Do Not Resuscitate (DNR)- No CPR/chest compressions --Intubation --Medications/vasopressors --Feeding tubes --Want to go into a nursing home
Criteria for Negligence (Causation)
the breach of duty must have been a cause of injury
Standard of Care
the skills, care, and judgments required by a health team member under similar conditions -Each state has a different standard of care and we as nurses need to know it and live by it. -If you violate the nursing standard of care within the Nurse Practice act or Nursing Rulebook we could be taken to court and sued.
Criteria for Negligence (Duty)
there must be a professional nurse-patient relationship
Delegation
to transfer responsibility for the performance of an activity from one individual to another, with the former person retaining accountability for the outcomes Defined by the ANA-American Nurses Association
What happens if you do not have an advanced directive and are unable to give your wishes for your care?
will receive medical care to the fullest extent possible
Advanced Directives
written statement/instructions of a person's wishes, values, and goals regarding what will be done in the case he/she is incapable of making their own decisions --We should be encouraging ALL patients to complete these documents who are over 18 years old --Activated by 2 MDs (for POAs) --No AD=will receive medical care to the fullest extent possible --Temporary or permanent --Can change or revoke at anytime --2 witnesses required who are NOT related
Criteria for Negligence (Breach of Duty)
you must have fallen below the standard of care for a nurse Expert Witness- a person called into testify in a case that has exemplary knowledge of the field, may attest to the "standard of care", speak to what a "reasonable or prudent" nurse would have done in a similar situation
NCLEX : things to know
~No two tests are alike >16-22% of NCLEX covers concepts related to Professional and Management Issues (AKA Management of Care) >Computerized Adaptive Testing ---Goal: Answer questions correctly quickly as this indicates you are able to answer higher level questions If the question is answered correctly, the next question is at a similar or higher level of difficulty If the question is answered incorrectly, the next question will at a similar or lower level of difficulty You must answer each question (cannot skip a question, cannot go back later)
What are the 5 Sources of Law?
● Legislative - Congress and Senate, write the laws ● Executive - President or Governor, enforce laws, appoint judges ● Judicial - Supreme Court, State & Federal judges/courts, interpret law ● Public - laws that apply to everyone, between people and government ● Private - laws between individuals or institutions
