NCSBN REVIEW:
Management of Care:
o Advance Directive is AKA a living will
- Legal document where one specifies their wishes concerning medical tx./ end of life
care once they are unable to.
- Advance care planning: sharing personal values/wishes with loved ones and
selecting a medical power of attorney or health care proxy who will make medical
decisions on the client’s behalf once they are unable to do so.
- This document does not expire
- Does not include info. Regarding assets or the client’s estate.
- Includes: health care power of attorney, living will, DNR order, &/or POLST (phys.
Order for life-sustaining tx.)
o Code of Ethics
- Nonmaleficence → to “do no harm”. This is directly tied to the nurse’s duty to
protect the client’s safety.
- Beneficence → doing good and the right thing for the patient
- Autonomy → nurses encourage pt. to make their own decision without any
judgment. The pt. has the right to accept or reject tx.
- Justice → fairness.
- Accountability → accepting responsibly for one’s own actions.
- Fidelity → keeping one’s promise.
- Veracity → being completely truthful with patients. Nurses must not withhold the
whole truth from pt. even when it may upset them.
- Negligence → aka malpractice. Failing to act on behalf of the pt. involving an action
or inaction that results in untended harm to the pt.
o DNR – Do Not Resuscitate. A medical order by the physician.
o AND – Allow Natural Death. Limiting or prohibiting the use of life-extending measures.
This order acknowledges that pt. is dying and everything has been withdrawable
including food/water allowing the dying process to occur as comfortably as possible.
Comfort measures applied.
o Informed Consent – grants permission to perform a test or procedure. HCP explains the
procedure/test along with the risk and benefits. The nurse’s job is to cosign the
document, witnessing the signature by the client. If the pt. does not understand the
procedure the nurse must advocate for the client and have the HCP come and explain
the procedure. Test again before the signature is made.
1
,o Common situations that require incident reports:
- Medication errors
- Complications from dx. Or tx. procedures
- Incorrect sponge counts in sx.
- Failure to report pt. change in condition
- Falls
- Burns
- Aseptic technique
- Refusal of tx./patient
- Family dissatisfied with care
o RN
- Assess pt. physical condition
- Analyze/interpret data
- Intervene based on important data and evaluate
- Health promotion and maintenance
- Provide pt. education
- Offer counsel and support
- Help pt. restore optimal function and comfort
- Nursing Process: ADPIE *** (assess, dx., plan, implement, evaluate)
o LPN/LVN
- Assist with implementation
- Provide care for STABLE pt. with PREDICTABLE OUTCOMES
- Collect data for assessment
- Differentiate abnormal – normal to report to the RN
- Maintain knowledge of asepsis and dressing changes
- Admin. Some meds
o UAP
- Provide basic care
- Assist with ADL’s
- Examples: bathing, feeding, toileting, obtaining vitals, I&Os, recording height
and weight.
o 5 Rights of Delegation
- Right Task
- Right Circumstance
- Right Person
- Right Directions & Communication
- Right Supervision & Evaluation
2
, o Establishing Priorities:
- Life – threatening needs or ones that could result in harm to the pt. if left
untreated are high priority
- Actual problems trump potential problems or needs
- ABC&P = airway, breathing, circulation, pain
- Maslow’s = physiological, safety, social, esteem, self-actualization (that
order)
o Communication:
o
o Provides framework to communicate b/w health care team
o
Used to effectively advocate for pt. when there is a concern.
o
If you have a concern, speak up with this approach
o Documentation has 6 key components: CO – ACTS
- Confidential
- Organized chronologically
- Accurate
- Complete
- Timely
- Subjective and objective date
3
Management of Care:
o Advance Directive is AKA a living will
- Legal document where one specifies their wishes concerning medical tx./ end of life
care once they are unable to.
- Advance care planning: sharing personal values/wishes with loved ones and
selecting a medical power of attorney or health care proxy who will make medical
decisions on the client’s behalf once they are unable to do so.
- This document does not expire
- Does not include info. Regarding assets or the client’s estate.
- Includes: health care power of attorney, living will, DNR order, &/or POLST (phys.
Order for life-sustaining tx.)
o Code of Ethics
- Nonmaleficence → to “do no harm”. This is directly tied to the nurse’s duty to
protect the client’s safety.
- Beneficence → doing good and the right thing for the patient
- Autonomy → nurses encourage pt. to make their own decision without any
judgment. The pt. has the right to accept or reject tx.
- Justice → fairness.
- Accountability → accepting responsibly for one’s own actions.
- Fidelity → keeping one’s promise.
- Veracity → being completely truthful with patients. Nurses must not withhold the
whole truth from pt. even when it may upset them.
- Negligence → aka malpractice. Failing to act on behalf of the pt. involving an action
or inaction that results in untended harm to the pt.
o DNR – Do Not Resuscitate. A medical order by the physician.
o AND – Allow Natural Death. Limiting or prohibiting the use of life-extending measures.
This order acknowledges that pt. is dying and everything has been withdrawable
including food/water allowing the dying process to occur as comfortably as possible.
Comfort measures applied.
o Informed Consent – grants permission to perform a test or procedure. HCP explains the
procedure/test along with the risk and benefits. The nurse’s job is to cosign the
document, witnessing the signature by the client. If the pt. does not understand the
procedure the nurse must advocate for the client and have the HCP come and explain
the procedure. Test again before the signature is made.
1
,o Common situations that require incident reports:
- Medication errors
- Complications from dx. Or tx. procedures
- Incorrect sponge counts in sx.
- Failure to report pt. change in condition
- Falls
- Burns
- Aseptic technique
- Refusal of tx./patient
- Family dissatisfied with care
o RN
- Assess pt. physical condition
- Analyze/interpret data
- Intervene based on important data and evaluate
- Health promotion and maintenance
- Provide pt. education
- Offer counsel and support
- Help pt. restore optimal function and comfort
- Nursing Process: ADPIE *** (assess, dx., plan, implement, evaluate)
o LPN/LVN
- Assist with implementation
- Provide care for STABLE pt. with PREDICTABLE OUTCOMES
- Collect data for assessment
- Differentiate abnormal – normal to report to the RN
- Maintain knowledge of asepsis and dressing changes
- Admin. Some meds
o UAP
- Provide basic care
- Assist with ADL’s
- Examples: bathing, feeding, toileting, obtaining vitals, I&Os, recording height
and weight.
o 5 Rights of Delegation
- Right Task
- Right Circumstance
- Right Person
- Right Directions & Communication
- Right Supervision & Evaluation
2
, o Establishing Priorities:
- Life – threatening needs or ones that could result in harm to the pt. if left
untreated are high priority
- Actual problems trump potential problems or needs
- ABC&P = airway, breathing, circulation, pain
- Maslow’s = physiological, safety, social, esteem, self-actualization (that
order)
o Communication:
o
o Provides framework to communicate b/w health care team
o
Used to effectively advocate for pt. when there is a concern.
o
If you have a concern, speak up with this approach
o Documentation has 6 key components: CO – ACTS
- Confidential
- Organized chronologically
- Accurate
- Complete
- Timely
- Subjective and objective date
3
