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Kaplan Management of Care

Therapeutic nature of the nurse/ client relationship
Nurse/Client Relationship : Professionalism
“1. Specific knowledge and skills”— foundation of nursing science
“2. Person-centered”
“3. Autonomy and accountability”— adheres to standards of practice and is responsible for care given
“4. Nurse practice act”
“5. Ethical standards”
“a. Respect for human dignity”— give respectful service regardless of client’s personal characteristics “b. Confidentiality”— does not discuss condition with anyone not involved with care “c. Competence”— has knowledge and skills to provide care “d. Advocacy”— protects client from incompetent or unethical practice “e. Research”— participates in process of scientific inquiry “f. Promotion of public health”— committed to local and global goals for health of community
Nurse/Client Relationship : Therapeutic
“1. Professional”
a. Client-centered
b. Responsible
c. Goal-oriented
d. Ethical
“2. Characterized by genuineness”
“3. Nurse acts as a role model”
” 4. Nurse copes with own feelings”
“5. Protected relationship”— nurse or client (client) cannot be forced to reveal communication between them unless person who would benefit from relationship agrees to reveal it
“A. Privacy”
“B. Respectful care”
“C. Current information”
“D. Informed consent”
“E. Confidentiality”
“F. Refusal of treatment”
“G. Reasonable response to a request for services”
“H. Right to know hospital/ clinic regulations”
Client Bill of Rights: Privacy
“1 Right to be left alone without unwarranted or uninvited publicity”
“2. Right to make personal choices without interference”
“3. Right to have personal information kept confidential and distributed only to authorized personnel”

a. Violated when confidential information revealed to unauthorized person( s), or unauthorized personnel directly or indirectly observes client without permission

b. Authorized personnel— people involved in diagnosis and treatment (related to care of client)

c. Health care team can’t use data, photographs, videotapes, research data “without explicit permission of client”

d. Be cautious about release of information on the phone (difficult to identify caller accurately)

e. Necessary to obtain client’s permission to release information to family members or close friends

f. For employees, can only verify employment and comply with a legal investigation

Client Bill Of Rights: Informed consent
1. Requirements
a. Capacity— age (adult), competence (can make choices and understand consequences)
b. Voluntary— freedom of choice without force, fraud, deceit, duress, coercion
c. Information must be given in understandable form (lay terminology)
d. Cannot sign informed consent if client has been drinking alcohol or has been premedicated e. Informed consent may not be required in emergency situations

2. Minors who can provide own consent for treatment
a. Married minors
b. Over a specific age (e.g., 12) for STDs, HIV testing, AIDS treatment, drug and alcohol treatment
c. Emancipated and mature minors
d. Minors seeking birth control services
e. Minors seeking outpatient psychiatric services or inpatient voluntary admissions to a psychiatric facility
f. Pregnant minor 1) Can sign consent for themselves and the fetus 2) After delivery a) The mother retains right to provide consent for infant b) Mother cannot give own consent unless she fits into one of other exemptions

Bill of Rights Informed Consent “Includes”
a. Explanation of treatment and expected results
b. Anticipated risks and discomforts
c. Potential benefits
d. Possible alternatives
e. Answers to questions
f. Statements that consent can be withdrawn at any time
Bill of Rights Informed Consent “Legal responsibility”
a. Rests with individual who will perform treatment
b. When nurse witnesses a signature, it means that there is reason to believe that the client is informed about upcoming treatment
Bill of Rights Confidentiality
1. Right to privacy of records
2. Information used only for purpose of diagnosis and treatment
3. Not released to others without permission; verify identity of persons asking for information
Bill of Rights Refusal of Tx
1. Self-determination act— federal law requiring health care facilities to provide written information to adult clients about their rights to make health care decisions

2. Aggressive treatment a. Extraordinary support measures used to maintain individual’s physiologic processes b. May be withheld to avoid prolonging life without dignity c. Supportive care is provided to promote comfort and reduce suffering

“3. Advanced directives”
“a. Living wills” 1) Legal document signed by competent individual indicates treatment or life-saving measures (e.g., surgery, CPR, antibiotics, dialysis, respirator, tube feedings) to be used if individual’s ability to make decisions is lost due to terminal illness or a permanently unconscious state 2) Indicates who is authorized to make health care decisions if individual becomes incapacitated 3) Legally binding in most states

“b. Durable power of attorney for health care” 1) Permits a competent adult to appoint surrogate or proxy in the event that the adult becomes incompetent 2) Health care provider must follow decisions stated in documents 3) In most states proxy can perform all legal actions needed to fulfill adult’s wishes

A. Restraints

1. Omnibus Budget Reconciliation Act (OBRA) provides clients with the right to be free from physical and chemical restraints imposed for the purpose of discipline or convenience and not required to treat medical symptoms

2. Chemical restraint
a. Psychotropic drugs cannot be used to control behavior
b. Can be used only for diagnoses-related conditions
c. Inappropriate use causes deep sedation, agitation, combativeness

RESTRAINTS: Informed Consent
Informed consent is needed to use restraints

If client is unable to consent to use of restraints, then consent of proxy must be obtained after full disclosure of risks and benefits

Restraint of client without informed consent or sufficient justification is “false imprisonment”

1. Assess and document need for restraints (risk for falls, risk of injury to others, potential for removal of IV lines or other equipment)

2. Consider and document use of alternative measures

3. Health care provider’s order is required specifying duration and circumstances under which restraints should be used

4. Cannot order restraints to be used PRN

5. Monitor client closely, periodically reassess for continued need for restraints, document

6. Remove for skin care and range of motion exercises

7. Use alternative measures prior to use of restraints (reorientation, family involvement, frequent assistance with toileting)

“A. Negligence”— unintentional failure of individual to perform an act that a reasonable person would or would not perform in similar circumstances; can be act of omission or commission
“B. Malpractice”— professional negligence involving misconduct or lack of skill in carrying out professional responsibilities 1. Required elements a. Duty – legal relationship between nurse and client b. Breach of duty c. Causation – nurse conduct causes injury d. Injury
“C. Invasion of privacy”— release of information to an unauthorized person without the client’s consent
“D. Assault”— intentional threat to cause harm or offensive unwanted contact; battery— intentional touching without consent
“E. Laws” 1. Rules of conduct established and enforced by authority 2. Reflect public policy 3. Indicates what society views as good and bad, right and wrong behavior
“F. Accountability” 1. Nurse is responsible for using reasonable care in practicing nursing 2. To remain competent, nurse needs to participate in lifelong learning programs
“G. State laws” 1. Nurse practice acts— define “reasonable care” in each state; scope of nursing practice, roles, rules, educational requirements 2. Licensure requirements— differ slightly in RN requirements among states 3. Good Samaritan laws— limit the liability of professionals in emergency situations 4. Tarasoff Act- duty to warn of threatened suicide or harm to others
“H. Need to assess health care provider’s orders”— must be safe and correct
“I. Notify supervisor if more nurses are needed for safe client care”
A. Health care focuses on individual client needs along the health continuum (wellness to illness)

“B. Managed care”

“C. Continuous quality improvement (CQI; previously called quality assurance)”

“D. Risk management”

“E. Collaborative practice team”

“F. For managed care to be successful, need”

“G. Critical pathways”

“H. Variance”

“I. Case Manager”

J. Case management

1. Goal is reduced health care costs
2. Focuses on client outcomes and maintenance of quality
3. Uses an interdisciplinary approach
4. Emphasizes costs; approval needed for diagnostic tests
5. Critical pathways (care maps) used as foundations for activities and guide services that clients receive for specific health conditions
MANAGED CARE: Continuous Quality Imporvement
1. Prevention-focused approach provides basis for managing risk
2. Involves organized incident reporting
3. Managed by team of 5- 10 people
4. Process a. Senior management establishes policy b. Coordinator provides for process and management health care team training c. Team, headed by a team leader, evaluates and improves the process
MANAGED CARE: Risk Management
1. Planned program of loss prevention and liability control
2. Problem-focused
3. Identifies, evaluates, develops plan, and takes corrective action against potential risks that would injure clients, staff, visitors
4. Focuses on noncompliance, informed consent, right to refuse treatment
MANAGED CARE: Collaborative Practice Team
1. Consists of clinical experts: nursing, medicine, physical therapy, social work 2. Determines expected outcomes 3. Determines appropriate interventions with a specified time frame 4. Involves specific client diagnoses that are high-volume (frequently seen), high-cost, high-risk (frequently develop complications)
1. Support from health care providers, nurses, administrators
2. Qualified nurse managers
3. Collaborative practice teams
4. Quality management system
5. All professionals are equal members of the team (one discipline doesn’t determine interventions for another discipline)
6. Members agree on final draft of critical pathways, take ownership of client outcomes, accept responsibility and accountability for interventions and client outcomes
MANAGED CARE: Critical Pathways
1. Reduce complications
2. Reduce cost
3. Increase collaboration
4. Improve quality of care
5. Provide direction for care
6. Orient staff to expected outcomes for each day 7. If outcomes not achieved, case manager is notified and situation is analyzed to determine how to modify critical path
8. Alteration in time frame or interventions is a “variance”
9. All variances are tracked to note trends
10. Variance— change in established plan that includes more, different, or fewer services to client to achieve desired outcome
11. Interventions presented in modality groups (medications, nursing activities)
12. Include a. Specific medical diagnoses b. Expected length of stay c. Client identification data d. Appropriate time frames (days, hours, minutes, visits) for interventions e. Clinical outcomes f. Client outcomes
1. Deviations from specific plans (individual receives more, less, or different services)
2. Information is included in a database and is used to evaluate services provided
3. Continuous quality improvement (CQI) strategies are used to monitor variances
MANAGED CARE: Case Manager
usually has advanced degree and considerable experience
1. Doesn’t provide direct client care
2. Supervises care provided by licensed and unlicensed personnel
3. Coordinates, communicates, collaborates, solves problems
4. Facilitates client care for a group of clients (10- 15)
5. Follows client through the system from admission to discharge
6. Notes “variances” from expected progress
MANAGED CARE: Case Management
1. Identifies, coordinates, monitors implementation of services needed to achieve desired outcomes within specified period of time 2. Involves principles of CQI
3. Promotes professional practice
“Assignment” vs Delegation
“A. Assignment”— allocating to health care team members work required to care for groups of individuals
1. Process a. Determine nursing care required to meet clients’ needs (take into account time required, complexity of activities, acuity of clients, and infection control) b. Consider knowledge and abilities of staff members c. Decide which staff person is best able to provide care d. Take into account continuity of care e. Determine assignments to increase efficiency f. Describe assignments in measurable terms g. Be specific about expected results h. Give assignments to staff members (assign total responsibility for total client care, avoid assigning only procedures) i. Provide additional help as needed
Assignment vs “Delegation”
1. Responsibility and authority for performing a task (function, activity, decision) is transferred to another individual who accepts that responsibility and authority
2. Delegator remains accountable for task
3. Delegatee is accountable to delegator for responsibilities assumed
4. Can only delegate tasks for which the nurse is responsible
5. Definitions a. Responsibility— obligation to accomplish a task b. Accountability— accept ownership for results or lack of results
6. In delegation, responsibility is transferred; in accountability, it is shared
7. Guidelines a. Can delegate only those tasks for which you are responsible b. Responsibility is determined by 1) Nurse practice acts (defines scope of nursing practice) 2) Standards of care (established by organization) 3) Job description (defined by organization) 4) Policy statement (from organization) c. Must transfer authority (the right to act) along with the responsibility to act d. Empowers delegatee to accomplish task
Assignment vs “Delegation”: Steps
a. Define task to be delegated 1) Can delegate only work for which you have responsibility and authority 2) Delegate what you know best so you can provide guidance and feedback a) Routine tasks b) Tasks you don’t have time to accomplish c) Tasks with lower priority

b. Determine who should receive delegated task

c. Identify what the task involves, determine its complexity

d. Match task to individual by assessing individual skills and abilities 1) Evaluate capacity of individual to perform task 2) Consider availability, willingness to assume responsibility

e. Provide clear communication about your expectations regarding the task, answer questions

Assignment vs “Delegation”: To delegate:
a. Assume face-to-face position
b. Establish eye contact
c. Describe task using “I” statements
d. Provide what, when, where, how of the task to be delegated
e. State if delegatee needs to provide written or verbal report after the task is completed
f. If written report is needed, inform delegatee where to put the report (e.g., table, chart, form) g. Identify what changes or incidents need to be brought to delegator’s attention (e.g., “If client’s BP is greater than 140/ 90, let me know immediately.”)
h. Provide reason for task, give incentive for accepting responsibility and authority
i. Tell delegatee how and how often task will be evaluated
j. Describe expected outcome and timeline for completion of task
Assignment vs “Delegation”: Continues
10. Identify constraints for completing task and risks
11. Identify variables that would change authority and responsibility (e.g., “Feed client if coherent and awake; if client is confused, do not feed and notify me immediately.”)
12. Obtain feedback from delegatee to make sure he/ she understands task to be performed and your expectations; ask for questions, give additional information
13. Reach mutual agreement on task
14. Monitor performance and results according to established goals
15. Give constructive feedback to delegatee
16. Confirm that delegated tasks are performed as agreed
17. Delegator must remain accessible during performance of task
18. Don’t delegate
a. Total control
b. Discipline issues
c. Confidential tasks
d. Technical tasks
e. Controversial tasks
f. During a crisis
19. Levels of delegation (in ascending order)

20. Rule for determining delegatee—
21. Obstacles to delegation
22. Ineffective delegation
23. Rights of delegation
24. Delegation empowers others, builds trust, enhances communication and leadership skills, develops teamwork, increases productivity
25. Failure to delegate and supervise properly can result in liability; need to consider delegatee’s competence and qualifications
26. Nurses have a legal responsibility to make sure persons under their supervision perform consistently with established standards of nursing practice

Assignment vs “Delegation” Levels of Delegation
a. Gather information for delegatee so you can decide what needs to be done
b. List alternate courses of action and allow delegatee to choose course of action
c. Have delegatee perform part of task and obtain approval before proceeding with the rest of the task
d. Have delegatee outline entire course of action for the task and approve it before proceeding
e. Allow delegatee to perform entire task using any preferred method, and report only results
Assignment vs “Delegation” : Rules of Determining a Delegatee
delegate to lowest person on hierarchy who has the required skills and abilities and who is allowed to do the task legally and according to the organization
Assignment vs “Delegation” : Obstacles of Delegation
a. Nonsupportive environment— rigid organizational culture, lack of resources (limited personnel)
b. Insecure delegator
c. Fear of competition
d. Fear of liability
e. Fear of loss of control
f. Fear of overburdening others
g. Fear of decreased personal job satisfaction
h. Unwilling delegatee
i. Fear of failure
j. Inexperience or incompetence
Assignment vs “Delegation” Ineffective Delegation
a. Underdelegation
1) Doesn’t transfer full authority
2) Takes back responsibility
3) Fails to equip or direct delegatee
4) Questions competence of delegatee
b. Reverse delegation— lower person on hierarchy delegates to person higher on hierarchy
c. Overdelegation— delegator loses control of the situation by delegating too much authority and responsibility to delegatee
Assignment vs “Delegation” Rights of Delegation
a. Right task
b. Right person (knowledge, skills, abilities)
c Right time (not in a crisis)
d. Right information
e. Right supervision (is task being performed correctly?)
f. Right follow-up
Assignment vs Delegation “C. Staff mixes”
Staff mixes— combination of registered nurses (RNs), licensed practical or vocational nurses (LPN/ LVNs), nursing assistive personnel (NAP), and support staff combined to complement, not substitute for, professional staff
“1. LPN/ LVN” a. Assist with implementation of defined plan of care b. Perform procedures according to protocol c. Differentiate normal from abnormal; report data to RN d. Care for physiologically stable clients with predictable conditions e. Has knowledge of asepsis and dressing changes f. Ability to administer medications varies with educational background and state nurse practice act

“2. Nursing assistive personnel (NAPs)” a. Assist with direct client care activities (bathing, transferring, ambulating, feeding, toileting, obtaining vital signs, height, weight, intake and output, housekeeping, transporting, stocking supplies) b. Includes nurses aides, assistants, technicians, orderlies, nurse extenders c. Scope of nursing practice is limited

Assignment vs Delegation “Hierarchy of Chain of Command”
Hierarchy or chain of command
“1. Organizational hierarchy”- designed to promote smooth functioning within a large and complex organization
“2. Hierarchy”- employees are ranked according to their degrees of authority within an organization
“3. Chain of command”- emphasis on vertical relationships (e.g., nurse reports to nurse manager who reports to nursing supervisor, etc.)
“4. Nurse reports variances”, problems, and concerns to next person with authority in direct line in their area
Nurses Responsibility in Critical Thinking
Nursing responsibilities
1. Observe
“2. Decide what data are important”
“3. Validate and organize data”
“4. Look for patterns and relationships”
5. State problem
“6. Transfer knowledge from one situation to another”
7. Decide on criteria for evaluation
8. Apply knowledge
9. Evaluate according to criteria established
Decision Making
A. Purposeful and goal-directed; nurse identifies and selects options and alternatives
Types of Decision Making
B. Types of decision making
1. Prescriptive a. Involves routine decisions with objective information b. Options are known and predictable c. Decisions made according to standard procedures or analytical tools

2. Behavioral a. Involves the nonroutine and unstructured information b. Options are unknown or unpredictable c. Decisions made by obtaining more data, using past experiences, using creative approach

3. Satisficing a. Solution minimally meets objectives b. Expedient; use when time is an issue

4. Optimizing a. Goal is to select ideal solution b. Best decision comes from this process but is the most time consuming

Phases of Decision Making
1. Define objectives
2. Generate options
3. Analyze options a. Identify advantages and disadvantages b. Rank options
4. Select option that will successfully meet the defined objective
5. Implement the selected option
6. Evaluate the outcome
Distribution of Resources
E. Nursing management
1. Judiciously use resources to achieve identified client goals
2. Coordinate the services received by a group of clients over a specific time period
3. Identify client needs
4. Identify resources available to meet needs
5. Organize and direct use of available resources 6. Evaluate the extent to which desired client outcomes are met controlling the process of client care
A. Purpose
1. Promotes communication
2. Maintains a legal record
3. Meets requirements of regulatory agencies
4. Required for third-party reimbursement
Charcteristics of Documentation
1. Legible
2. Accurate, factual, no summarizing data
3. Timely
4. Thorough
5. Well organized and concise
6. Confidential
7. Proper grammar and spelling
8. Authorized abbreviations
1. Assess a. Client’s vital signs, symptoms, behaviors, complaints, responses to treatments (PRN meds, dietary changes, I and O) b. Interdisciplinary team information c. Information from family members or significant other
“2. Notify health care provider” if client’s physiological status and functional abilities change significantly
3. Notify interdisciplinary team of changes in medical plan (nurse is responsible for coordinating interdisciplinary team for client)
4. Notify family or significant other about changes in client’s condition and plan of care a. Nature of change b. Why changes were made c. Actions undertaken to provide needed care for client d. List of revisions on medical plan of care e. Help family to take active part in client’s care and management f. Follow policy for privacy and confidentiality
“5. Document in timely manner a. Date and time b. Nursing assessment c. Name of health care provider informed d. Date, time, method (e.g., telephone) e. Information provided about client f. Actions taken (revisions in plan of care) g. Information given and to whom (client, name of family, significant other) h. Responses by client and family members or significant other”
Incident Report
A. Definition
1. Agency record of unusual occurrance or accident and physical response
2. Accurate and comprehensive report on any unexpected or unplanned occurrence that affects or could potentially affect a client, family member, or staff person
Incident Report: Purpose
1. Documentation and follow-up of all incidents 2. Used to analyze the severity, frequency, and cause of occurrences
3. Analysis is the basis for intervention
Incident Report: Charting
1. Don’t include a reference to the incident report
2. Don’t use words such as “error” or “inappropriate”
3. Don’t include inflammatory words or judgmental statements
4. If there are adverse reactions to incident, chart follow-up note updating client’s status
5. Documentation of client’s reactions should be included as status changes and should be continued until client returns to original status
Incident Report: Common situations that require an incident report
1. Medication errors— omitted medication, wrong medication, wrong dosage, wrong route
2. Complications from diagnostic or treatment procedures (e.g., blood sample stick, biopsy, x-ray, LP, invasive procedure, bronchoscopy, thoracentesis)
3. Incorrect sponge count in surgery
4. Failure to report change in client’s condition
5. Falls
6. Client is burned
7. Break in aseptic technique
8. Medical— legal incident a. Client or family refuses treatment as ordered and refuses to sign consent b. Client or family voices dissatisfaction with care and situation cannot be or has not been resolved
Change of Shift Report
1. Client’s status
2. Current care plan
3. Responses to current care
4. Things needing further attention
“Change-of-shift reports should not contain”
1. Information already known by the oncoming shift
2. Descriptions of routines (AM or PM care)
3. Rumors or gossip
4. Opinions or value judgements (about client’s lifestyle)
5. Client information that does not relate to health condition, needs, or treatments (e.g., idiosyncrasies)
Change of Shift: E. Reporting nurse describes
1. Actual or potential client needs
2. How these needs were addressed during previous shift by nursing and interdisciplinary team
3. Information about laboratory studies, diagnostic tests, treatments, and nursing activities anticipated during next shift
4. Reporting nurse must legally communicate all facts relevant to continuity of care of assigned clients
5. Information must be pertinent, current, and accurate

Nurse receiving report should learn
1. Individual client’s symptoms
2. Discomforts
3. What has been done
4. What remains to be done
5. How client has responded to treatments and activities so changes can be made to meet client needs

Change of Shift Report: Methods
“1. Functional method”
a. RN of previous shift reports to RN of oncoming shift
b. Other staff may attend report or be given report according to assignments from RN
“2. Team nursing method”
a. All members of oncoming shift attend report
b. Reduces amount of time and communication needed to make changes in nursing care for client
“3. Primary nursing method”
a. RN assigned to direct care of individual clients reports to RN assigned to direct care of same individual clients
“4. Case management method”
a. Scheduled structured discussions with nursing team and interdisciplinary team in addition to change-of-shift reports
A. Cultural norms— group of individuals’ values and beliefs that strongly influence individual’s actions and behaviors

B. Values— personal preferences, commitments, motivations, patterns of using resources, objects, people, or events that have special meaning and influence individual’s choices, behaviors, actions

C. Beliefs 1. Basic assumptions or personal convictions that the individual thinks are factual or takes for granted 2. Used to determine values 3. Handed down from generation to generation 4. Include cultural traditions

ETHICS: Definition
1. Principles of right and wrong, good and bad
2. Governs our relationship with others
3. Used to identify solutions to problems arising from conflicts
4. Based on personal beliefs and cultural values that guide decision- making and determine conduct
5. As cultural diversity increases, need to understand ethical principles increases
Ethical principles of nursing
1. Autonomy— support of client’s independence to make decisions and take action for themselves

2. Beneficence— duty to help others by doing what is best for them; client advocacy for refusal of care, autonomy overrides beneficence

3. Nonmaleficence—” do no harm”; act with empathy toward client and staff without resentment or malice; violated by acts performed in bad faith or with ill will, or when making false accusations about client or employee

4. Justice— use available resources fairly and reasonably

5. Veracity— communicate truthfully and accurately

6. Confidentiality— safeguard the client’s privacy

7. Fidelity— following through on what the nurse says will be done; carefully attending to the details of the client’s care

Client’s motivation a. Client may need help to see need for learning b. Important to remove barriers to learning readiness, if possible

Client’s needs a. Health behavior desired b. Current level of knowledge/ understanding c. Skill level d. Client’s attitudes and beliefs e. Social, cultural, and environmental factors influence health behavior

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