ATI Fundamentals for Nursing ATI

Types of unintentional torts

-Negligence -Malpractice (professional negligence)

Types of intentional torts

-Assault -Battery -False imprisonment

Types of quasi-intentional torts

-Breach of confidentiality -Defamation of character

Documentation must be: F___, A___ & C___, C___ & C___, and O___.

-Factual -Accurate & Concise -Complete & Current -Organized

Registered Nurse (RN)

-Functions under state nurse practice laws -Perform assessments; establish nursing diagnoses, goals, and interventions; conducts ongoing client evaluations -Participate in developing interdisciplinary plans for client care -Share best practices; continuing education

Federal laws impacting nursing practice include:

-HIPAA -ADA -the Mental Health Parity Act (MHPA) -the Patient Self-Determination Act (PSDA)

Unlicensed Assistive Personnel (UAP)

-Includes CNAs, CMAs, and non-nursing personnel -Work under direct supervision of an RN or LPN -Specific tasks usually outlined in position description -Tasks may including feeding clients, preparing meals, lifting, basic care, measuring & recording vital signs, and ambulating clients

Provider's orders

"do not resuscitate" (DNR) or "allow natural death" (AND) are orders written by a provider and must be placed in the client's medical record; the provider consults the client and family prior to administering a DNR or AND

Refusal of treatment

-PSDA stipulates all clients have the right to accept and refuse care and must be advised of this right upon admission -if client refuses treatment, will be asked to sign an "Against Medical Advice" form and nurse must document information was provided and provider notified -if client refuses to sign form, nurse must document -if a client decided to leave the facility w/o discharge order, nurse must notify provider and discuss risks of leaving prior to discharge

Health care regulatory agencies include:

-US Dept of Health and Human Srvcs -US FDA -State and local public health agencies -State licensing boards (to ensure providers & agencies comply with state regulations) -the Joint Commission/JCAHO (set quality standards for accreditation of health care facilities) -Professional Standards Review Organizations (PSROs) -Utilization review committees (monitor for appropriate diagnosis and treatment of hospitalized clients)

Licensed Practical Nurse (LPN)

-Works under supervision of the RN -Collaborate with other team members -Possess technical knowledge and skills -Participate in the delivery of nursing care, using the nursing process as a framework

Mandatory reporting

-abuse: child or elder abuse, domestic violence -communicable diseases (according to CDC) such as hepatitis and TB

Nurse's roles in ethical decision making include:

-agent for client facing an ethical decision: adolescent child debating on abortion; parent contemplating blood transfusion even when against religious beliefs -decision maker in regard to nursing practice: increasing staff load due to shift cuts; witnessing a surgeon discussion only surgical options without informing client of more conservative options

According to the UDDA, death is determined by one of two criteria:

-an irreversible cessation of circulatory and respiratory functions -irreversible cessation of all functions of the entire brain, including the brain stem

The client has the right to:

-be informed about the aspects of care in order to be active in the decision making process -accept, refuse, or request modification to the plan of care -receive care that is delivered by competent individuals who treat the client with respect

Legal guidelines of documentation

-begin each entry with date & time -legible and in black, non-erasable ink -no white out or blackened out errors -info inadvertently omitted may be added as a "late entry" -signed with signature of person making entry and dated -should reflect assessments, interventions, and evaluations

Nurse's role in client rights includes:

-client understands their rights -protecting rights of clients under their care

Advanced directives

-communicate client's end-of-life care wishes for them if they become unable to -PSDA requires all clients be asked if they have advanced directives upon admission -clients with out advanced directives must be provided with written information about their health care rights and how to formulate advanced directives -a health care rep should be available to help with the process

Objective data should be documented:

-descriptive and should include what the nurse sees, hears, feels, and smells -w/o derogatory words, judgments, or opinions -accurately

Professional negligence

-failure of person with professional training to act in a reasonable and prudent manner -issues that prompt malpractice suits include failure to: follow standards of care, use of equipment in responsible & knowledgeable manner, effectively & thoroughly communicate with the client, document care was provided

Nurses can avoid being liable for negligence by:

-following standards of care -giving competent care -communicating with other health team members -developing a caring rapport with clients -fully documenting assessments, interventions, and evaluations

The client's responsibility for informed consent:

-giving informed consent -must give consent voluntarily (no coercion), be competent and of legal age (or authorized individual), and receive enough information to make a decision

Board of nursing

-has authority to adopt rules and regs for nursing practice in that state -has authority to both issue and revoke a nursing license -set standards for nursing programs -delineate scope of practice among RNs, LPNs, and APNs

Steps in ethical decision making

-identify whether or not the issue is indeed an ethical dilemma -state the ethical dilemma including all surrounding issues and individuals involved -list and analyze all possible options for resolving the dilemma and review implications of each option -select option that is in concert with the ethical principle applicable to this situation, the decision maker's values and beliefs, and the profession's values set forth for client care; justify why chosen over other options -apply this decision to the dilemma and evaluate the outcomes

Criminal law:

-is a subsection of public law -relates to the relationship of an individual with the government -ex: a nurse falsifies a record to cover up a serious mistake may be found guilty of breaking a criminal law

A problem is an ethical dilemma if:

-it cannot be solved solely by a review of scientific data -it involves a conflict between two moral imperatives -the answer will have a profound effect on the situation/client

Client's rights

-legal guarantees that clients have with regard to their health care -situations where nurses have opportunity to protect client's rights include: informed consent, refusal of treatment, advanced directives, confidentiality, and information security

The provider's responsibility for informed consent:

-obtain informed consent -must give complete description of treatment/procedure, description of who will be involved in treatment, description of risks, options for other treatments, and the right to refuse -provide clarification if requested

Individuals who are authorized to grant consent for another person include:

-parent of a minor -legal guardian -court-specified representative -individual who has durable power of attorney for health care -emancipated minors (for themselves)

Civil law:

-protect the individual rights of people -one type that relates to the provision of nursing care is tort law

Nursing role in advanced directives

-provide written information regarding advanced directives -document the client's advanced directives status -ensure that the advanced directives reflect the client's current decisions -inform all members of the health care team of the client's advance directives

State laws

-regulate the core of nursing practice -each state has enacted statutes defining parameters of practice and gives authority to regulate to the state board of nursing

By practicing nursing within the confines of the law, nurses are able to:

-shield oneself from liability -advocate for client's rights -provide care that is within the nurse's scope of practice -discern the responsibilities of nursing in relationship to the responsibilities of other members of the health care team -provide safe, competent care that is consistent with standards of care

Entities with codes of ethics that may be used to guide nursing practice include:

-the American Nurses Association (ANA) -the International Council of Nurses (ICN) -the National Association for Practical Nurse Education and Services, Inc.

Consent considered informed when the client has been provided and understands:

-the reason the treatment or procedure is needed -how the treatment or procedure will benefit the client -risk involved if treatment or procedure is chosen -other options to treat the problem (including no action)

The nurse's responsibility for informed consent:

-witness informed consent -must ensure provider provided necessary information, ensure the client understood and is competent to give consent, have the client sign informed consent document, notify provider if more information or clarification needed/requested by client, and document client questions and that the provider was notified (also if interpreter was used)

5 elements necessary to prove negligence

1) duty to provide care as defined by a standard 2) breach of duty by failure to meet standard 3) foreseeability of harm 4) breach of duty has potential to cause harm (combines 2&3) 5) harm occurs

Pharmacist

Job: provide & monitor meds for the client as prescribed by the provider; supervises pharm techs in states in which the practice is allowed Refer to when: client concerns over meds; dosage concerns; etc

Clergy

Job: provide spiritual care to client (pastors, rabbis, priests) Refer to when: the client requests communication or the family asks for prayer prior to client undergoing a procedure

DAR (focus charting)

D-ata A-ction R-esponse

Social Worker

Job: work with client and client's family by coordinating inpatient and community resources to meet psychosocial and environmental needs that are necessary for recovery and/or discharge Refer to when: ex- client dying of cancer wishes to go home but is unable to perform ADLs; the spouse needs med equipment in the home to care for client

Physical Therapist

Job: assess and plan for client to increase musculoskeletal functions, esp of lower extremities, to maintain mobility; direct care of physical therapy assistants Refer to when: ex- following a hip replacement, a client requires assistance learning to ambulate and regain strength

Occupational therapist

Job: assess and plan for the client to regain ADLs, esp motor skills of the upper extremities; direct care of occupational therapy assistants Refer to when: ex- client has difficulties using an eating utensil with dominate hand following a stroke

Provider

Job: assess, diagnose, and treat cllient for disease and/or injury; includes MDs, DOs, APNs, and PAs Refer to when: ex- client experiences change in vital signs

Registered dietitian

Job: assess, plan for, and educate the client reg. nutritional needs; direct care of nutritional aids Refer to when: ex- the client has low nutrient levels and/or experienced a recent unexplained weight loss

Speech therapist

Job: evaluate and make recommendations regarding the functions of speech, language, and swallowing impacted by various client disorders or injuries; teach client techniques and exercises to improve function when possible Refer to when: ex- a client is having difficulty swallowing a regular diet after trauma to the head and neck

Respiratory therapist

Job: evaluate resp status and provide prescribed resp treatments including O2 therapy, chest physiotherapy, inhalation therapy, and artificial mechanical ventilation Refer to when: ex- client with resp disease experiences SOB and requests nebulizer treatment that is ordered PRN

Lab tech

Job: obtain specimens of the client's body fluids and perform the necessary diagnostic tests Refer to when: ex- the provider orders a CBC to be performed immediately

Rad Tech

Job: position client and perform x-rays and other imaging procedures for providers to review for diagnosis of disorders of various body parts Refer to when: ex- provider orders x-ray of client's hip after a fall

PIE

P-roblem I-ntervention E-valuation

SOAPIE

S-ubjective O-bjective A-ssessment (inc nursing diagnosis) P-lan I-ntervention E-valuation

Problem-orientated medical records consist of:

a database, problem list, care plan, and progress notes; examples include SOAPIE, PIE, and DAR

Nonmaleficence

avoidance of harm or pain as much as possible when giving treatments

Narrative documentation records information as

a sequence of events

Autonomy

ability of client to make personal decisions, even when those decisions may not be in the client's best interest

Accountability

ability to answer for one's own actions

Beneficence

agreement that the care given is in the best interest of the client; taking positive actions to help others

Fidelity

agreement to keep one's promise to the client about care that was offered

Nurse licensure compact

allows licensed nurses who reside in a compact state to practice in other compact states under a multi-state license; must provide care in accordance to statutes and rules in state care is being provided

The foundation of ethics is based on:

an expected behavior of a certain group in relation to what is considered right and wrong; it is the study of conduct and character

Implied consent

client adheres to instructions provided by the nurse; ex: the nurse is preparing to administer a TB test and the client holds out his arm for the nurse

Preferred Provider Organizations (PPOs)

client chooses from a list of contracted providers. using non-contracted providers increases the client's out of pocket costs

Managed Care Organizations (MCOs)

comprehensive care is overseen by a primary care provider & focuses on prevention and health promotion

Continuing health care

designed to address long-term or chronic health care needs. examples include hospice, adult day care, and in-home respite care

Subjective data can be documented as:

direct quote, within quotation marks, or summarized and identified as the client's statement

Durable power of attorney for health care

document that designates a health care proxy, who is authorized make health care decisions for a client who is unable

Primary health care

emphasizes health promotion, and includes prenatal and well-baby care, nutrition counseling, and disease control. is based on a sustained partnership between client and provider. examples include office or clinic visits and scheduled school/work centered screenings (vision, hearing, obesity)

Malpractice (professional negligence)

example: a nurse administers a large dose of medication due to a calculation error; the client has a cardiac arrest and dies

Breach of confidentiality

example: a nurse releases the medical diagnosis of a client to a member of the press

Defamation of character

example: a nurse tells a coworker that she believes the client has been unfaithful to her spouse

Negligence

example: a nurse who fails to implement safety measures for a client who has been identified as at risk for falls

False imprisonment

example: a person is confined or restrained against his will (using restraints on a competent client to prevent his leaving the health care facility)

Battery

example: intentional and wrongful physical contact with a person that involves and injury or offensive contact (restraining a client and administering an injection against her wishes)

Assault

example: the conduct of one person makes another person fearful and apprehensive (threatening to place a nasogastric tube in a client who is refusing to eat).

Justice

fair treatment in matters related to physical and psychosocial care and use of resources

Preventive health care

focuses on educating and equipping clients to reduce and control risk factors of disease. Examples include immunizations, stress management programs, and seat belt use

Medicare

for clients over age 65 and/or with permanent disabilities. premiums applied as insurance program reimburses providers based on DRGs. Premiums applied as Managed Care Organizations (MCOs) provide enrolled clients with comprehensive care overseen by a primary care provider. Is federally funded.

Medicaid

for clients with low income. is federally funded and individual states determine eligibility requirements.

Resident rights

further protection of rights for residents in nursing facilities that participate in Medicare programs; govern the operation of such facilities

A determination of death must be made:

in accordance with accordance with accepted medical standards

Secondary health care

includes the diagnosis and treatment of emergency, acute illness, or injury. examples include care given in hospital settings (inpatient and EDs), diagnostic centers, or emergent care centers

Restorative health care

involves intermediate follow-up care for restoring health. examples include home health care, rehab centers, and skilled nursing facilities

Tertiary health care

involves the provision of specialized highly technical care. examples include oncology centers and burn centers

The client's chart or medical record is the ____ record of care

legal

Living will

legal document that expresses client's wishes regarding medical treatment in the event the client becomes incapacitated and is facing end-of-life issues

Informed consent

legal process by which the client has given written permission for a procedure or treatment to be performed

Hospital's ethics committee

may meet to discuss/resolve unusual or complex ethical issues; not a legal entity

Ethical dilemmas are:

problems about which more than one choice can be made and the choice made is influenced by the values and beliefs of the decision makers

Confidentiality

protection of privacy without diminishing access to quality care

Long-Term Care Insurance

provides for long-term care expenses not covered by Medicare

Traditional Insurance

reimburses for services on fee-for-service basis.

Ethical principles

standards of what is right/wrong with regard to important social values and norms

Advocacy

support of the cause of the client regarding health, safety, and personal rights

Exclusive Provider Organizations (EPOs)

the client chooses from a list of providers within a contracted organization

Ethical theory examines:

the different principles, ideas, systems, and philosophies used to make judgments about what is right/wrong and good/bad

Morals are:

the values and beliefs held by people that guide their behaviors and decision making

Nurse's role in the informed consent process is:

to witness the client's signature on the informed consent form and to ensure the informed consent has been appropriately obtained

Flow charts are used to record and show trends in:

vital signs, blood glucose levels, pain level, and other frequently performed assessments

Responsibility

willingness to respect obligations and follow through on promises

For an invasive procedure or surgery, the client is required to provide ____ consent.

written