Management of Care – (9)
Advance Directives/Self-Determination/Life Planning – (1)
Professional Responsibilities: Client Teaching About Do-Not-Resuscitate Orders
(Active Learning Template – Basic Concept, RM Lea
...
Management of Care – (9)
Advance Directives/Self-Determination/Life Planning – (1)
Professional Responsibilities: Client Teaching About Do-Not-Resuscitate Orders
(Active Learning Template – Basic Concept, RM Leadership 7.0 Chp. 3)
Unless a do not resuscitate (DNR) or allow natural death (AND) prescription is
written, the nurse should initiate CPR when a client has no pulse or respirations.
The written prescription for a DNR or AND must be placed in the client’s medical
record. The provider consults the client and the family prior to administering a
DNR or AND.
Client Rights – (1)
Coordinating Client Care: Appropriate Action When a Client Leaves Against Medical
Advice (Active Learning Template – Basic Concept, RM Leadership 7.0 Chp. 2)
A client who leaves a facility without a prescription for discharge from the
provider is considered leaving against medical advice (AMA). A client who is
legally competent has the legal right to leave the facility at any time. The nurse
should immediately notify the provider. If the client is at risk for harm, it is
imperative that the nurse explain the risk involved in leaving the facility. The
individual should sign a form relinquishing responsibility for any complications
that arise from discontinuing prescribed care. The nurse should document all
communication, as well as the specific advice that was provided for the client. A
nurse who tries to prevent the client from leaving the facility can face legal
charges of assault, battery, and false imprisonment.
Collaboration with Interdisciplinary Team – (1)
Coordinating Client Care: Information to Report to Occupational Therapist (Active
Learning Template – Basic Concept, RM Leadership 7.0 Chp. 2)
Patient’s condition and current status; any medications the patient is on; patient’s
tolerance level for pain; any assistive devices the patient uses
Confidentiality/Information Security – (1)
Professional Responsibilities: Protecting Confidential Client Information (Active
Learning Template – Basic Concept, RM Leadership 7.0 Chp. 3)
It is essential for nurses to be aware of the rights of clients in regard to privacy
and confidentiality. Facility policies and procedures are established in order to
ensure compliance with HIPAA regulations. It is essential that nurses know and
adhere to the policies and procedures. HIPAA regulations also provide for
penalties in the event of noncompliance with the regulations.
Continuity of Care – (1)
Information Technology: Preparing a Change-of-Shift Report (Active Learning
Template – Basic Concept, RM FUND 9.0 Ch 5)
Nurses give this report at the conclusion of each shift to the nurse assuming
responsibility for the clients. Formats include face to face, audiotaping, or
presentation during walking rounds in each client’s room (unless the client has a
roommate or visitors are present). An effective report should: include significant
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objective information about the client’s health problems; proceed in a logical
sequence; include no gossip or personal opinion; relate recent changes in
medications, treatments, procedures, and the discharge plan
Legal Rights and Responsibilities – (1)
Professional Responsibilities: Understanding Regulations for Nursing Scope of
Practice (Active Learning Template – Basic Concept, RM Leadership 7.0 Chp. 3)
Standards of care guide, define, and direct the level of care that should be given
by practicing nurses. They also are used in malpractice lawsuits to determine if
that level was maintained. Nurses should refuse to practice beyond the legal scope
of practice and/or outside of their areas of competence regardless of reason
(staffing shortage, lack of appropriate personnel). Nurses should use the formal
chain of command to verbalize concerns related to assignment in light of current
legal scope of practice, job description, and area of competence.
Performance Improvement (Quality Improvement) – (1)
Maintaining a Safe Environment: Demonstrating Quality and Safety Education for
Nurses Competencies (Active Learning Template – Basic Concept, RM Leadership
7.0 Chp. 4)
Safe use of equipment refers to appropriate operation of health care-related
equipment by trained staff. Equipment-related injuries can occur as a result of
malfunction, disrepair, or mishandling of mechanical equipment. Nurses must
ensure that they have the competence necessary to use equipment for tasks that
fall within their scope of practice. Nurses should use equipment only after
receiving sufficient instruction. Equipment should be regularly inspected by the
engineering or maintenance department and by the user prior to use. Faulty
equipment (frayed cords, disrepair) can start a fire or cause an electrical shock and
should be removed from use and reported immediately per agency policy.
Referrals – (2)
Alzheimer’s Disease: Resources for Home Care (Active Learning Template – System
Disorder, RM AMS RN 10.0 Chp 8)
Refer to social services and case managers for long-term/home management,
Alzheimer’s Association, community outreach programs, and support groups
Nutrition and Oral Hydration: Priority Finding Following an Ischemic Stroke (Active
Learning Template – System Disorder, RM FUND 9.0 Ch 39)
Identify if someone has dysphagia, this patient will need pureed foods; clear and
full liquids plus pureed meats, fruits and scrambled eggs, low residue: low in fiber
Safety and Infection Control – (6)
Accident/Error/Injury Prevention – (2)
Adverse Effects, Interactions, and Contraindications: Priority Action to an Allergic
Response (Active Learning Template – Medication, RM Pharm RN 7.0 Chp 5)
Treat with epinephrine, bronchodilators, and antihistamines. Provide respiratory
support and inform the provider.
Health Promotion of Infants (2 Days to 1 Year): Car Seat Safety (Active Learning
Template – Basic Concept, RM NCC RN 10.0 Chp 3)
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Infants and toddlers remain in a rear-facing car seat until the age of 2 years or the
height recommended by the manufacturer. The safest area for infants and children
is the backseat of the car. Do not place rear-facing car seats in the front seat of
vehicles with passenger airbags. Infants should not be left in parked cars.
Emergency Response Plan – (1)
Facility Protocols: Nursing Role During Mass Casualty Incident (Active Learning
Template – Basic Concept, RM Leadership 7.0 Chp. 5)
Principles of mass casualty triage should be followed in health care institutions
involved in a mass casualty event. These differ from the principles of triage
typically following during provision of day-to-day services in an emergency or
urgent care setting. During mass casualty events, casualties are separated related
to their potential for survival, and treatment is allocated accordingly. This type of
triage is based on doing the greatest good for the greatest number of people.
Nurses can find this situation very stressful because clients who are not expected
to survive are cared for last.
Home Safety – (1)
Nursing Care and Discharge Teaching: Teaching About Newborn Safety (Active
Learning Template – Basic Concept, RM MN RN 10.0 Chp 26)
Never leave the newborn unattended with pets or other small children. Keep small
objects (coins) out of the reach of newborns due to choking hazard. Never leave
the newborn alone on a bed, couch, or table. Newborns move enough to reach the
edge and fall off. Never place the newborn on his stomach to sleep during the first
few months of life. The back-lying position is the position of choice. The newborn
can be placed on his abdomen when awake and being supervised.
Standard Precautions/Transmission-Based Precautions/Surgical Asepsis – (1)
Medical and Surgical Asepsis: Setting Up a Sterile Field (Active Learning Template –
Nursing Skill, RM FUND 9.0 Ch 10)
Open the covering of the package per the manufacturer’s directions, slipping the
package onto the center of the workspace with the top flap of the wrapper opening
away from the body.
Grasp the tip of the top flap of the package, and with arm positioned away from
the sterile field, unfold the top flap away from the body.
Next, open the side flaps, using the right hand for the right flap and the left hand
for the left flap
Grasp the last flap and turn it down toward the body.
Use of Restraints/Safety Devices – (1)
Complications of Infants: Treatment of Positional Plagiocephaly (Active Learning
Template – Therapeutic Procedure, RM NCC RN 10.0 Chp 42)
Educate parents about the importance of daily “tummy time” when infant is
awake. Educate parents of the importance of alternating the infant’s head position
during sleep. Refer parents to physical therapy for neck exercises. Assist parents
in the proper use of the skull-molding helmet. Educate parents that the helmet
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needs to be worn 23 hr/day, usually for 3 months. Educate parents to continue to
place infant in the supine position for sleep.
Health Promotion and Maintenance – (8)
Aging Process – (1)
Chronic Neurologic Disorders: Teaching About Phenytoin (Active Learning Template
– Medication, RM Pharm RN 7.0 Chp 13)
Monitor for manifestations of CNS effects, and notify the provider if they occur
Advise clients to maintain good oral hygiene (dental flossing, massaging gums).
Folic acid supplements can decrease the occurrence.
Stop medication if rash develops.
Administer at slow IV rate (no faster than 50 mg/min) and in dilute solution to
prevent adverse cardiovascular effects. Avoid administering to a client who has
sinus bradycardia, sinoatrial block, or Stokes-Adams syndrome
Instruct client to report changes. Encourage the client to consume adequate
amounts of calcium and vitamin D.
Administer prophylactic vitamin K to the mother for 1 month before the infant is
delivered.
Ante/Intra/Postpartum and Newborn Care – (2)
Complications Related to the Labor Process: Findings to Report to the Provider
(Active Learning Template – Basic Concept, RM MN RN 10.0 Chp 16)
Prolapsed umbilical cord and Meconium-stained amniotic fluid
Nursing Care and Discharge Teaching: Circumcision (Active Learning Template –
Therapeutic Procedure, RM MN RN 10.0 Chp 26)
Circumcision is the surgical removal of the foreskin of the penis. It is a personal
choice made by the newborn’s family for reasons of health and hygiene, religious
conviction (Jewish male on eighth day after birth), tradition, culture, or social
norms. Parents should make a well-informed decision in consultation with the
provider. Circumcision should not be done immediately following birth because
the newborn’s level of vitamin K is at a low point, and the newborn would be at
risk for hemorrhage.
Health Promotion/Disease Prevention – (2)
Pediatric Emergencies: Planning Education About Sudden Infant Death Syndrome
(Active Learning Template – Basic Concept, RM NCC RN 10.0 Chp 43)
Teach the family how to reduce the risk of SIDS: place the infant on the back for
sleep; avoid exposure to tobacco smoke; prevent overheating; use a firm, tightfitting mattress in the infant’s crib; remove pillows, quilts, and stuffed animals
from the crib during sleep; ensure that the infant’s head is kept uncovered during
sleep; offer pacifier at naps and night; encourage breastfeeding; avoid cosleeping; maintain immunizations up to date.
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