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Ep066: Safety and Infection Control  Reporting Incident  Identify Where Reporting of Incident is Appropriate

Ep066: Safety and Infection Control Reporting Incident Identify Where Reporting of Incident is Appropriate

  • Acknowledge and document practice error per policy
    • For example, medication error, accidental needlestick, incorrect order entry, patient transferred to incorrect unit
  • Evaluate response to error/event/occurrence
    • Evaluate patient
    • Does a process need to change to prevent this from occurring in the future or was it human error?
Ep065: Safety and Infection Control  Home Safety  Assess Need for Patient Home Modifications

Ep065: Safety and Infection Control Home Safety Assess Need for Patient Home Modifications

  • Examples include lighting, handrails, kitchen safety
  • Apply knowledge of patient pathophysiology to home safety interventions
    • Are they hard of hearing, have visual deficits?
    • Do they have the dexterity to use handrails or a LifeAlert?
    • Can they use their home oxygen/respiratory equipment?
    • Can they call someone if there’s an issue?  
  • Educate patient on home safety issues
    • Hot water heater setting
    • Appropriate lighting on the interior and exterior of the home
    • Rugs
    • Cleanliness
    • Stairs
    • Pets
    • Medication labeling
    • Ability to lift things (pot full of hot water)
  • Encourage the patient to use protective equipment when using devices that can cause injury
    • When disposing of used needle/syringes/medical equipment
    • Oven mitts for kitchen safety
    • Respiratory equipment
  • Evaluate patient care environment for fire/environmental hazard
    • Complete a walk through
    • Note concerns like rugs, things that are difficult to see, space heaters, electric blankets, smoking, steps, electrical cords, compromised electrical equipment
    • Keep exits clear and clearly marked
    • Assess if patient has fire extinguisher
    • Assess if patient knows who to call if fire/emergency occurs
    • If patient has oxygen at home, make sure they understand the fire hazard concern
    • RACE / PASS
Ep064: Safety and Infection Control  Handling Hazardous and Infectious Materials  Safe Internal Radiation

Ep064: Safety and Infection Control Handling Hazardous and Infectious Materials Safe Internal Radiation

  • Never touch the device/implant
  • Label things appropriately
  • Follow protocol/policy/procedure specifically
  • Ensure patient is in private room to prevent exposure to other patients and their loved ones
  • Maintain distance between yourself and device consistently
    • If necessary use shield (like lead apron)
  • Handle linen and all patient care items per policy
    • Typically linen and trash disposed of in specific manner with appropriate labeling and only removed at specific intervals
Ep063: Identify Bio-hazardous, Flammable and Infectious Materials

Ep063: Identify Bio-hazardous, Flammable and Infectious Materials

  • Follow procedures for handling biohazardous materials
  • Ensure proper labeling is in place
    • For example, linen used with a patient with chemotherapy
  • Demonstrate safe handling techniques to staff and patient
  • Never recap needles, can result in a needlestick
  • Utilize proper storage devices for used needles
    • Color-specific (typically red or orange), leak-proof, puncture resistant
Ep062: Use Ergonomic Principles When Providing Care

Ep062: Use Ergonomic Principles When Providing Care

  • Assistive devices: use lifts as often as possible with appropriate staff and supplies, prepare client for use of lift, try to allow time to use lift
  • Optimize bed height every single time
    • Raise bed so you are not bending for an extended period while providing care, this will make a difference
  • Proper lifting technique: utilize this when a lift is not possible or necessary.  Have enough people to help, adjust height of bed, lift with legs and bend at knees (not back), tighten abs/tuck pelvis, instruct client to assist as much as possible (tuck chin, bend knees and push up)
  • Utilize gait belts appropriately during patient ambulation
    • Put it on before getting them up
    • Used at the patient’s center of gravity/midline (not always at their hips)
  • Utilize physical therapy and reference their notes when unsure how to transfer/move a patient
  • Sit straight up with proper posture while charting; large amounts of time are spent on a computer and this can add up
Ep061: Provide Instruction and Information to Patient About Body Positions that Eliminate Potential for Repetitive Stress Injuries

Ep061: Provide Instruction and Information to Patient About Body Positions that Eliminate Potential for Repetitive Stress Injuries

  • Carpal tunnel, back injuries are common examples
  • Encourage appropriate body mechanics and not merely treating pain when it occurs
  • Proper posture is essential
  • Encourage working with physician and deciding appropriate supportive devices
Ep060: Assess Patient’s Ability to Balance, Transfer and Use Assistive Devices Prior to Planning Care

Ep060: Assess Patient’s Ability to Balance, Transfer and Use Assistive Devices Prior to Planning Care

  • Examples of assistive devices: crutches, walker, cane
  • Important to assess their abilities first before coming up with a care plan
    • Don’t assume they can use crutches, plan care, and then find out they have a sprained wrist
  • Not all assistive devices are appropriate for all patients
  • Work with both physical and occupational therapy to maximize using assistive devices
Ep059: Participate in Disaster Planning Activities/Drills

Ep059: Participate in Disaster Planning Activities/Drills

  • Nurses must participate so their role is known and appropriate
  • Help to identify must-have equipment, potential issues or obstacles to providing care
  • Have an emergency contact tree to contact all staff when/if disaster occurs
Ep058: Implement Emergency Response Plans

Ep058: Implement Emergency Response Plans

  • Nurses frequently use a color-coding system to triage patients, as identified by the facility
    • Example:
      • Red: highest priority, life-threatening yet survivable injuries
      • Yellow: medium priority, injuries but not life-threatening
      • Green: low priority, can wait an extended time, non life threatening
      • Black: deceased on arrival, or actively dying
    • Have both an internal and external plan
      • This is what you do when you’re already at work
      • This is what you do when you’re at home, but a disaster has occurred and aid is needed at the facility
Ep057: Use Clinical Decision-making/Critical Thinking for Emergency Response Plan

Ep057: Use Clinical Decision-making/Critical Thinking for Emergency Response Plan

  • Complete primary and secondary assessments
    • Primary: identify immediate high-priority needs (think ABC’s)
    • Secondary: identify next priority needs (think getting vitals, neuro, cardiac, pain, history, or focused assessments)
  • When in doubt, think back to your ABC’s and Maslow’s hierarchy of needs at this time
  • Consider the resources you’d need to provide care as well as time constraints
    • “They need an MRI but it would take hours to get that and the machine is down”
Ep056: Determine Which Patients(s) to Recommend for Discharge in a Disaster Situation

Ep056: Determine Which Patients(s) to Recommend for Discharge in a Disaster Situation

  • Important that only the sickest ones are in the facility
    • Think patients on ventilators or respiratory support, on vasoactive medications, patients that would likely die or have profound, life-altering effects  if not receiving care they can only receive in the hospital
Ep055: Identify Nursing Roles in Disaster Planning

Ep055: Identify Nursing Roles in Disaster Planning

  • If a disaster occurs, immediately activate the emergency response plan
  • Make sure that you are prepared both at home, at work, and in the community
    • Have an emergency plan and supplies at home and communicate this with those that live with you
    • Know the plan at work
    • Have supplies with you when you travel, if possible
  • What will you do, on this unit, when certain events occur?  What will nursing’s responsibility be?
    • Participate in drills, if applicable
Ep054: Verify Appropriateness and/or Accuracy of a Treatment Order

Ep054: Verify Appropriateness and/or Accuracy of a Treatment Order

  • Do not blindly follow orders; practice with a questioning attitude
  • Quote from Scrubs, the TV show
    • Nurse (to doctor): “Doug wanted me to give him 500,000 mg of morphine… I thought I’d check with you first before I killed a man.”
  • Doctors and ordering providers may order or write for the incorrect thing when they meant something different, they may have put an order in on the wrong chart, or wrote an incorrect dosage.  
  • This is why there are many checks and balances… the ordering provider, the pharmacist, the nurse and so forth
  • Report errors and incidents appropriately
Ep053: Ensure Proper Identification of Patient When Providing Care

Ep053: Ensure Proper Identification of Patient When Providing Care

  • You must check their appropriate ID before doing anything
  • Medications: check name, birthday, and so forth
  • Check patient’s armband (or other identifying device) if patient is unable to speak
  • Many facilities require scanning the armband before giving any medications
  • Always communicate important patient identifiers when delegating care as well
    • Make sure you provide name, room number, birthdate, and verify order before providing care for another staff member; also make sure to communicate aforementioned pieces of information to others when delegating
Ep052: Make Appropriate Room Assignments for Cognitively Impaired Patients

Ep052: Make Appropriate Room Assignments for Cognitively Impaired Patients

  • If a patient is confused, impulsive, forgetful, or agitated, make sure they have a room close to the nurse’s station
  • Do not put these patients at the end of the hall, where it’s harder to hear them if they call out (maybe they can’t figure out how to use the call bell, forget about how to use it, refuse to use it… and so forth)
  • Place them in a room near the nurse’s station, in which staff are frequently walking by or are in earshot of the patient
Ep051: Implement Seizure Precautions for At-risk Patients

Ep051: Implement Seizure Precautions for At-risk Patients

  • Many disease processes can put patients at an increased risk for seizures
    • Brain injury or trauma
    • Drugs, medication
    • Withdrawing from alcohol or other drugs
    • Fevers
    • History seizure activity
    • See this list from John Hopkins about various causes of seizures
  • Patients can experience a seizure with little to no warning
  • Must provide a safe environment should this event occur, therefore all patients at risk for seizures should have precautions in place
  • Hospitals will have policies that outline specifics.  These most likely will include, but are not limited to:
    • Padded side rails
    • All 4 side rails up
    • Suction MUST be set up and ensure that it works appropriately
    • Ambu bag must be nearby
Ep050: Review Necessary Modifications with Patient to Reduce Stress on Specific Muscle or Skeletal Groups

Ep050: Review Necessary Modifications with Patient to Reduce Stress on Specific Muscle or Skeletal Groups

  • Change positions
  • Pillow support
  • Active and passive range of motion
  • Routine stretching of the shoulders, neck, arms, hands, fingers
Ep049: Protect Patient from Injury

Ep049: Protect Patient from Injury

  • Falls: initiate fall risk care plan if appropriate, make sure patient is safe to ambulate, initiate all fall precautions
  • Electrical hazards
  • Unsafe behavior from other patients or visitors
Ep048: Provide Patient with Appropriate Method to Signal Staff Members

Ep048: Provide Patient with Appropriate Method to Signal Staff Members

  • Call lights
    •  Adaptive call lights can be used for patients with poor dexterity
  • Phones, or other technology
Ep 047: Safety and Infection Control: Accident Prevention: Idenitfy and Faciliate Correct use of Infant and Child Car Seats

Ep 047: Safety and Infection Control: Accident Prevention: Idenitfy and Faciliate Correct use of Infant and Child Car Seats

  • Really important, especially with first time parents
  • Can be easily done incorrectly, not as straightforward as some anticipate
  • Some facilities may have it as part of policy to make sure family knows how to properly use before leaving
Ep 046: Safety and Infection Control: Accident Prevention: Verify Prescriptions that may Contribute to an Accident or Injury

Ep 046: Safety and Infection Control: Accident Prevention: Verify Prescriptions that may Contribute to an Accident or Injury

  • (This does not include medications)
  • At home oxygen and supplies, CPAP’s, assistive devices, drains, tubes, and so forth.
  • Make sure assistive devices are sized appropriately
    • Crutches not too tall, walker not to short, and so forth
  • Make sure they know how to use assistive devices
  • Make sure they know who to call if they have an issue or if it malfunctions (and after-hours numbers)
Ep 045: Safety and Infection Control: Accident Prevention: Identify deficits that may impede patient safety

Ep 045: Safety and Infection Control: Accident Prevention: Identify deficits that may impede patient safety

  • Visual: can they see what’s in front of them while walking? Can they see that they are taking the appropriate medication?
  • Hearing: can they hear someone speaking to them or yelling at them? Can they hear if they are in danger?
  • Sensory/perceptual: can they feel if they are too hot or cold?
Ep 044: Safety and Infection Control: Accident Prevention: Identify factors that inlfuence accidents

Ep 044: Safety and Infection Control: Accident Prevention: Identify factors that inlfuence accidents

  • Various factors can influence the likelihood that a  patient will get injured
  • Age and developmental stage: elderly as well patients that may physically be older, but mentally younger
  • Lifestyle: do they use seat belts? Do they drive impaired (alcohol, texting/using their smartphone?) Do they use drugs recreationally? Do they own guns?
  • Mental status:  confusion, meds or recreational drugs that influence level of alertness and decision-making capabilities
  • Environmental factors:  rugs at home, tripping hazards (for example, oxygen tubing), unsafe living environments, sanitation issues
Ep043: Safety and Infection Control: Accident Prevention: Determine Patient/staff Member Knowledge of Safety Procedures

Ep043: Safety and Infection Control: Accident Prevention: Determine Patient/staff Member Knowledge of Safety Procedures

  • Many facilities have various protocols on how to deal with various safety issues
    • Falls
    • Armed intruder
    • Large patient influx/at capacity
    • Infant abduction
    • Weather issues
    • Acts of terrorism
    • Unsafe/violent patients or visitors
  • Know what you need to do as a nurse for your personal safety and the safety of your patients
  • Participate in drills
  • Know how to safely exit building and expectations of how to get patients out
EP042: Safety and Infection Control: Accident Prevention: Assess for allergies and intervene as needed

EP042: Safety and Infection Control: Accident Prevention: Assess for allergies and intervene as needed

  • Important to ask about all allergies, not just medication allergies
  • Some medications may have ingredients from different foods in their coating or capsules
  • Must ask about allergies to IV dyes or contrast
  • Ask about all food, environmental, and medication allergies
  • Ensure this is charted appropriately
  • Make sure to chart what happens when the patient has a medication
    • Is it a true allergy, or is it an adverse reaction?
      • Example: “I’m allergic to morphine because it makes me tired,” or “I’m allergic to aspirin because it upsets my stomach”… those are adverse reactions, not allergies.  This is especially important with antibiotics.  Patients may say they’re allergic to something, but when you ask further about specifics it’s really an intolerance.
  • Know what to do if there’s an allergic reaction
    • Follow hospital’s policies/procedure
    • Most likely notify MD and give meds, depending on severity of reaction
    • Make sure the allergy is added to the chart, after patient is addressed and clinically stable

 

Ep041: Management of Care: Referrals: Assess the Need to Refer Patients

Ep041: Management of Care: Referrals: Assess the Need to Refer Patients

        • Examples of necessary referrals include therapy services (physical, occupational, speech), wound care, nutritional services, and so forth
        • Recognize the need for referrals and obtain necessary orders
        • Identify community resources for the client with health care team (Meals on Wheels, respite services, public transportation, various programs and shelters)
        • Identify which documents to include for referrals (actual referral form, H&P’s, various signatures, insurance information)
        • Work with members of the healthcare team to facilitate process if necessary (case management, social work, referral coordinators)
Ep040: Management of Care: Performance Improvement: Define performance improvement and quality assurance

Ep040: Management of Care: Performance Improvement: Define performance improvement and quality assurance

 

  • Performance Improvement (Quality Improvement)

 

      • Define performance improvement/quality assurance activities
        • Participate in performance improvement/quality improvement process*
        • Report identified client care issues/problems to appropriate personnel (e.g., nurse manager, risk manager)
        • Utilize research and other references for performance improvement actions
        • Evaluate the impact of performance improvement measures on client care and resource utilization
Ep039: Providing Care Within the Legal Scope of Practice

Ep039: Providing Care Within the Legal Scope of Practice

Ep037 Report Patient Condition as Required by Law

Ep037 Report Patient Condition as Required by Law

  • Abuse and neglect
    • Child, elderly, domestic
    • Know your local reporting agencies (Child Protective Services)
  • Communicable diseases
  • Vaccine Adverse Event Reaction System (VAERS, vaers.hhs.gov)
  • Report to Center for Disease Control (CDC)
  • 2016 list of reportable conditions: https://wwwn.cdc.gov/nndss/conditions/notifiable/2016/
  • Adverse reactions to vaccinations
  • Local organ procurement organizations with patients with a GCS less than 5 (may depend on state)
  • Gunshot wounds
Ep036 Review facility policy and state mandates prior to agreeing to serve as an interpreter for staff or primary health care providers

Ep036 Review facility policy and state mandates prior to agreeing to serve as an interpreter for staff or primary health care providers

  • To be clinically appropriate medical interpreter, you must have appropriate credentials
  • This is important because medical jargon is very different from fluency in a language, therefore competency and knowledge of specific medical jargon in various languages must be verified prior to the facility being able to say one is an official medical interpreter
Ep035 Recognize Limitations of Self and Others and Seek Assistance

Ep035 Recognize Limitations of Self and Others and Seek Assistance

  • Be able to know when something is outside of your comfort zone
    • High risk, low frequency procedures
  • Know your chain of command for both clinical “how-to” situations and also administration issues
  • Document appropriately
Ep034 Identify and Manage the Patients Valuables According to Facility Policy

Ep034 Identify and Manage the Patients Valuables According to Facility Policy

  • Most facilities have policies and procedures to properly secure valuables
  • Ideally, valuables are given to family/friends to be taken home and secured
  • If this is not possible, there should be a secured and locked location within the facility to keep valuables
  • Paperwork must be completed, appropriate documentation maintained
  • Patients may experience a sudden trauma (MVA) and not have family or friends at the bedside to take valuables home
  • Know who you should contact if you identify any items that compromise safety (for example, weapons)
Ep033 Identify and Educate About Legal Issues Affecting the Patient

Ep033 Identify and Educate About Legal Issues Affecting the Patient

  • Refusing treatment
  • HCPOA disputes/living wills
  • Mental illness and inability to sign own consents
Ep032: Utilize Information Resources to Enhance the Care Provided to a Patient

Ep032: Utilize Information Resources to Enhance the Care Provided to a Patient

  • This includes evidenced-based research, information technology, policies and procedures)
  • Access data for client through online databases and journals
    • Most hospitals have subscriptions to journals
  • Professional organization journals have a plethora of information available, directly related to nursing
  • Consistent review of these ensures staff if exposed to and using latest EBP to support their practice
Ep031 Enter Computer Documentation Accurately, Completely and in a Timely Manner

Ep031 Enter Computer Documentation Accurately, Completely and in a Timely Manner

  • Apply knowledge of facility regulations when accessing patient charts
  • Ideal to do chart and enter orders in real time, however this is not always possible
  • Important to document in real time or as close to real time as possible because the longer the time in between the action (an assessment, for example) and charting the findings, the higher the likelihood that you will not remember it accurately.
  • Paint a clinical picture with your documentation
  • Document as if it will be read in a deposition in 5 years and by reading it, you and others reading it knew exactly what was going on at that time
Ep030 Receive and or Transcribe Health Care Provider Orders

Ep030 Receive and or Transcribe Health Care Provider Orders

  • Each facility may have a different process
  • Identify inappropriate and/or unclear treatments or medications
    • A nurse must administer treatments unless they believe they are inappropriate or unclear
    • If this occurs, you must contact the prescriber and discuss further, document appropriately, and follow hospital policies and procedures
  • Ideal if ordering provider enters own order
  • Know downtime procedures
Ep029: Obtaining Informed Consent

Ep029: Obtaining Informed Consent

        • What is informed consent?  Basically the patient is giving permission for treatment and acknowledging that they understand the risks and benefits of the procedure as well as the consequences for not receiving the treatment.
        • Wikipedia
        • The patient must be an adult that is mentally and emotionally competent to sign their own consent
          • Those that may not be able to consent for themselves:  unconscious, declared incompetent, under the influence of medications/alcohol/illegal drugs, or mentally impaired (for example, advanced dementia)
        • Questions must be answered
        • It is also signed by the health care provider performing the procedure and an adult witness (many times the nurse is the witness)
        • It is a LEGAL document
        • Identify appropriate person to provide informed consent for patient
          • The patient should always consent if it is medically appropriate
          • parent, legal guardian, health care power of attorney, next of kin
          • If patient is unable to consent themselves, you may need to reference advanced directives or work with case management to determine the appropriate person to get consent from
        • Make sure to use an appropriate interpreter if English is not the patient’s primary language
          • Interpreter must be from the facility, not the patient’s loved ones
        • There are different kinds of consent
          • Admission / consent to treat
          • Immunization
          • Blood transfusion
          • Surgical
          • Research
          • Special consents: organ donation, autopsy, restraints, photographs, food from home, and many others
        • It is really important to make sure the patient understands the procedure both at the consent is obtained and continually after
        • Consent should be placed in the chart – they are extremely important
        • Patient example:
          • A patient is admitted to the ICU for an obstructed bowel
            • An admission / consent to treat is obtained
          • The patient needs 2 units PRBC’s
            • The nurse obtains a consent to transfuse blood products
          • The patient needs to go to surgery for a bowel resection
            • The surgeon and nurse obtain consent for surgery
          • The patient has complications and qualifies for a research study
            • The patient signs consent for the study
          • The patient codes after surgery and has an anoxic brain injury; declared brain dead and is now an organ donor
            • The HCPOA signs consent for donation
Ep028: Practice in a Manner Consistent with a Code of Ethics for Registered Nurses

Ep028: Practice in a Manner Consistent with a Code of Ethics for Registered Nurses

Ep027: Recognize Ethical Dilemmas and Take Appropriate Action

Ep027: Recognize Ethical Dilemmas and Take Appropriate Action

        • Basic definition of ethics: attempt to distinguish between right and wrong as it relates to knowledge as opposed to opinion
        • This can get very challenging in medical situations, especially related to death, suffering, rights, and religion
        • Examples of various kinds of medical ethical dilemmas and scenarios
        • Ethical dilemmas can be related to the patient, their support system, and staff members
        • Inform patients and staff members of ethical issues affecting client care
          • Work with the multidisciplinary team to approach ethical dilemmas together to address and resolve ethical issues
            • May need to consult ethics committees
        • The nurse should function as the patient’s advocate and ensure the patient’s rights are being upheld
Ep026: Evaluate Plan of Care for Multiple Patients and Revise As Needed

Ep026: Evaluate Plan of Care for Multiple Patients and Revise As Needed

          • While getting report, make sure to understand the overall goal(s) for each patient for that shift
            • Examples
              • Getting discharged today
              • Remove feeding tube and start oral diet
              • Get dialysis completed today
              • Better pain control and adequate oral intake to discontinue fluids and IV pain meds
              • Transfer out of ICU

 

  • After report it is important to look at all of the tasks that need to be completed for your patient load and address them appropriately
  • Come up with a plan of attack and change it as needed
  • Get report on 5 patients, decide who you will see first and who you will see after that
  • Address anyone who is unstable or has immediate needs
  • If everyone is stable and has no immediate needs, look at timing of medications that are due and any other time-sensitive tasks

 

                • For example, insulin due and patient’s breakfast tray has arrived

 

  • Consolidate tasks and trips as often as possible to save time

 

        • Delegate tasks to support staff as appropriate
        • Collaborate with the rest of the healthcare team
          • If you know one patient needs a walk and physical therapy is going to round on them today, see if you can coordinate with them
Ep025: Apply Knowledge of Pathophysiology When Establishing Priorities for Interventions with Multiple Patients

Ep025: Apply Knowledge of Pathophysiology When Establishing Priorities for Interventions with Multiple Patients

        • Prioritize the delivery of care
        • ANA: Helping new nurses set priorities
        • Nurse Eye Roll: For the Overwhelmed New Grad Nurse
        • How to figure out prioritization
          • ABC’s – if something is compromising their airway, breathing, or circulation then it is a priority
            • Breathing / airway issues are always a top priority and deserve immediate attention
          • Maslow’s Hierarchy of Needs may also help you determine what to do first
          • High, intermediate, and low priorities
            • High priorities are life threatening, affecting ABC’s
            • Intermediate priorities are not life threatening, but are related to their diagnosis / clinical problems
            • Low priorities are issues that don’t have to with their diagnosis / clinical problems
        • Ask yourself:
          • Is this patient stable?
          • Is this patient experiencing difficulty or is this an expected finding?
          • Do I have PRN medications, treatments, or orders to address this issue?
        • It will take time and development of critical thinking to perfect this, it does not come overnight
        • You will have test questions about this, but when you are in clinical setting it will occur much faster and situations change frequently
Ep024: Follow Up on Unresolved Patient Issues

Ep024: Follow Up on Unresolved Patient Issues

        • Issues arise frequently that require the nurse to address them and ensure the problem has been resolved
        • Examples
          • Lab problems: unable to get serum sample, sample obtained hemolyzed, came to draw lab and patient at another test
          • Nutrition issues: patient received wrong food, need appropriate enteral feeding formula, food not received, diet order not in place
        • Various patient requests: medication changes/concerns, internet connections, missing items, communicating to loved ones
        • Prioritize by level of urgency
        • Let patients know about progress in resolution if not yet complete
          • Example
            • Patient’s husband upset that his wife has not had food in 2 days.  Speech therapy saw patient 2 days ago and said she was not safe for oral intake.  MD wanted to give her a few days before inserting a feeding tube.  At the beginning of the shift, he is very angry that staff has not fed her yet.  
            • Immediately let him know you will address this issue and touch base with speech therapy because they arrive at 0830 and then begin rounding.  Re-educate him that it is not safe to give her food until they clear her.  (Many times it is helpful to bring things back to the bottom line: safety.)
            • Let him know when you called them and what they said
            • Let him know roughly when to expect speech therapy to round
            • After they have evaluated patient and addressed need, touch base with him again to make sure he understood what they said and expectations going forward
        • Always follow up, close loops and make sure all concerns and needs have been addressed
Ep023: Know the Processes for Admission, Discharge and Transfer

Ep023: Know the Processes for Admission, Discharge and Transfer

  • Procedures and policies for this will look different at each facility
  • Paperwork and processes will different but it is essential to know what to do to ensure a smooth transition
  • Correct orders must be in place from physician to facilitate admission, transfer and discharge
  • Always review orders and clarify any concerns with the MD before moving a patient
  • Patient must be stable before going between units
    • Some patients may require a nurse to transport them (for example, if transferring to a higher level of care)
Ep022: Use Approved Abbreviations and Standard Terminology

Ep022: Use Approved Abbreviations and Standard Terminology

        • Abbreviations are incredibly helpful and significantly reduce time to document and communicate
        • Abbreviations are standardized because they can be easily confused and result in miscommunications and poor outcomes
          • Example:
            • QD = daily
            • QID = 4 times a day
        • Because of this, facilities typically have an “approved abbreviation list”
        • Example of abbreviations:
          • 93M DNR NKDA with Hx of PVD, AVR, DM, HTN, CVA is admitted today with an MI
            • Translation: a 93 year old male patient who has a do not resuscitate order and no known drug allergies has a history of peripheral vascular disease, aortic valve replacement, diabetes mellitus, hypertension, cerebrovascular accident was admitted today with a myocardial infarction
Ep021: Nursing Documentation

Ep021: Nursing Documentation

 

  • If it wasn’t documented, it wasn’t done!

 

        • Nurses are responsible for documenting many things. Some of which include:
          • Care plans
          • Medications (many facilities use barcode scanning)
          • Nursing notes
          • Assessments (focused, head to toe, vascular access devices, lines, tubes, airways, pain, sedation, restraints)
          • Patient education
        • Pay close attention to documentation training courses; the faster and more efficient you are at charting, the less time you spend in front of the computer
        • Have the mentality when you’re charting that you want whomever reads it in the future to have a clear picture of what was happening with the patient at any point in their stay while you’re caring for them.
        • Write like it’s going to be read in a deposition in the future
        • Always document the facts and things that you’ve seen or done, never assume anything
          • For example, if you walk into your patient’s room and they are on the floor and the patient says they fell..
            • Do not chart: “Patient fell.”
            • Chart: “Walked into patient’s room, noted patient lying on ground at the foot of the bed.”
Ep020: Provide and Recieve Report

Ep020: Provide and Recieve Report

  • Report will look different in various areas of the hospital
    • ED report is very short and concise
    • Critical care report is very detailed
    • Floor report is more detailed than the ED, but less detailed than critical care
    • Some facilities use standardized report forms (for example, SBAR)
    • Basically communicating info from one shift to the next:
      • What the nurse needs to know to safely care for the patient for the next 12 hours and coordinate care within the healthcare team
    • When receiving report, wait until reporting nurse is done to ask questions
Ep019: Intervene Appropriately When Confidentiality Has Been Breached By Staff

Ep019: Intervene Appropriately When Confidentiality Has Been Breached By Staff

  • This can happen via technological devices (phones, social media, EHR breaches) or in person (discussing sensitive information in a public area or in the presence of others)
  • This can be intentional or unintentional
  • Facilities will have differing policies and procedures
    • Utilize chain of command and document appropriately
    • Follow procedure precisely
    • Ensure education occurs so that breech does not occur again
Ep018: Maintain Patient Confidentiality and Privacy

Ep018: Maintain Patient Confidentiality and Privacy

  • Keep your password of EHR’s protected and confidential
  • Don’t talk about sensitive information in public areas
  • Speak with patient about which members of their support system they want involved in their care and identify anyone they may not want visiting
  • Ask visitors to leave the room before discussing private health information with the patient
Ep017: Assess Understanding of Confidentiality

Ep017: Assess Understanding of Confidentiality

  • Make sure the patient knows that their privacy is a priority to us
  • It is one of their rights, it is not optional
  • Intervene if necessary (episode 018)
Ep016: Manage Conflict Among Patients and Staff

Ep016: Manage Conflict Among Patients and Staff

        • The nurse is at the bedside with the patient 24 hours/day and they typically feel most comfortable with their nursing staff.  Therefore, if a problem or personality conflict arises, the patient will most likely verbalize this to the nurse and look for guidance
        • Find the balance of supporting the patient, making them feel heard, but not throwing your team members under the bus
          • Listen to concern, take appropriate action if necessary
            • Follow up with team member that is involved in conflict, communicate any concerns
            • Involve administration if necessary (nurse manager, team member’s manager)
          • Don’t cut down others or place blame
          • Handle in a professional manner
          • If any correction or restitution is needed, ensure that it is provided
            • For example, if patient ordered food 3 hours ago and never received it, make sure you follow up and get them something to eat
Ep015: Identify Responsibilities of Each Health Care Team Member

Ep015: Identify Responsibilities of Each Health Care Team Member

        • Nursing staff
          • Continual care provider, advocate, administer medications and orders placed by medical team, evaluate effectiveness, notify medical staff of concerns, facilitate collaboration of entire healthcare team, work with health care team to optimize care
          • Manage additional nursing support staff, delegate
            • Nursing assistants
            • Medical unit receptionists
        • Medical staff
          • Consists of an attending physician and support staff (PA’s, NP’s, colleagues), as well as a consulting physicians and support staff (PA’s, NP’s, colleagues)
          • Diagnose and prescribe treatments, perform procedures
        • Respiratory therapist
          • Provide specialized respiratory support from in-depth respiratory assessments, breathing treatments, to intubations and ventilator management
        • Physical therapist
          • Evaluate and maximize level of function from a mobility standpoint, works closely with OT
        • Occupational therapist
          • Evaluate and maximize ability to care for self; focuses on ADL’s, works closely with PT
        • Speech therapist
          • Evaluate ability to swallow safety, and also language abilities (understanding what’s being spoken, responding appropriately)
        • Dietician
          • Evaluates and recommends various forms of therapeutic nutrition (enteral, parenteral, specialized oral diets and care plans)
          • Works with dietary services
        • Case manager
          • Coordinates resources, facilitates discharges, works closely with social worker
        • Social worker
          • Assess social situation (living concerns, financial issues, support systems) and provides resources and support
        • Pharmacist
          • Review all ordered medications for safety, appropriateness
          • Mixes meds, facilitates preparation of various medications
          • Advises the nursing staff on administration
        • Chaplain
          • Provide spiritual support or facilitate getting a spiritual leader of the patient’s specific faith to the bedside
        • Administrative positions
          • Nurse manager, nursing director, chief nursing officer, medical director
        • Additional roles, not as common
          • Music therapist, child life specialist
Ep014: Identify Responsibilities of Health Care Team

Ep014: Identify Responsibilities of Health Care Team

  • This needs to be done daily to ensure we are facilitating the appropriate plan of care
  • As other members of the health care team assess the patient and develop plans and goals, we need to update our plans and goals, and update one another as things change and progress (or digression) occur
Ep013: Serve as a Resource to Other Staff

Ep013: Serve as a Resource to Other Staff

  • Work with others on the health care team to facilitate the plan of care and various consultations
  • Know and understand your patient, work as their advocate
    • Be aware of their needs, their struggles, and how they work with others
    • You’re their home base
  • Identify the need for interdisciplinary conferences
  • For example, if the patient verbalizes financial concerns, let the social worker know.  If the patient
  • Note discrepancies between disciplines (typically in notes in the chart) and suggest meeting when people are not on the same page to resolve issues
    • Keep what is best for the patient at the center and as the goal
  • Identify significant information to report to other disciplines
Ep012: Advocating for the Patient’s Rights

Ep012: Advocating for the Patient’s Rights

  • Make sure these rights are upheld across the board
  • You may need to advocate for them to their loved ones, the physician, or other members of the health care team during different phases of their stay
Ep011: Patient Rights: Discuss Treatment Options with Patient

Ep011: Patient Rights: Discuss Treatment Options with Patient

  • Discuss treatment options with the health care team and make sure you understand them fully, then the physician (or support staff) will present to the patient
    • The patient and their support system may have few questions when they hear the options initially, and many more later as they have had time to think about things.  Continually answer questions and reinforce.
  • The patient always has the right to refuse treatment/procedures
    • The Patient Bill of Rights must be posted in the building in a visible area or in their admission paperwork; make sure they have a copy and understand their rights
    • There is a Patient Bill of Rights and rights for the mentally ill (the Mental Health Systems Act)
    • Patients have the right to be informed, refuse treatment, privacy, clear communication, respectful care, right to health care, right to know their health care team, autonomy over health care essentially
      • Handful of others: make sure you’re familiar
    • Make sure they fully understand potential outcomes if they want to exercise this right
    • Document appropriately
    • Provide education to patients and staff about client rights and responsibilities
    • Evaluate client/staff understanding of patient’s rights
  • This is not always obvious; some patients may say yes, but not really understand
  • Don’t just hand them written material and assume they know what’s going on
Ep010: Case Management: Initiate, Evaluate, and Update Plan of Care

Ep010: Case Management: Initiate, Evaluate, and Update Plan of Care

Care plans / clinical pathways must be initiated upon admission and are complete at discharge

Complete an initial evaluation to assess their current situation, read the notes from the health care team to understand what potential needs and realistic goals upon discharge will be, introduce self to patient and support system

The clinical pathway evolves as the needs of the patient change

Ep009: Case Management – Ensure an Informed Discharge

Ep009: Case Management – Ensure an Informed Discharge

The patient and their support system must have all information related to the discharge process as early on as possible

  • Location, contact information (and contact info for after-hours situations), financial information, transportation, follow-up appointments, equipment (ensure understanding of proper use and care)

Make sure the  patient has all contact information if they have questions or concerns after discharge

Ep008: Case Management – Plan Care Specific to Patient Needs

Ep008: Case Management – Plan Care Specific to Patient Needs

Consider diagnosis, prescribed treatment recommendations, ability to remain compliant, patient’s understanding of situation, support system available, ability to utilize resources when questions or concerns arise, affordability, level of self care

Patient situations differ widely and it is not a “one size fits all” approach

Ep007: Case Management – Work to Provide Cost Effective Care

Ep007: Case Management – Work to Provide Cost Effective Care

Consider cost when setting up care/resources

  • Is this sustainable?

How does their insurance coverage, Medicare, or Medicaid factor in?

Do so in a non-judgemental way

Speak with the patient and support system about finances, what they can realistically afford and commit to

You may need to discuss different options with the rest of the health care team if the original or ideal plan is not something the patient can afford currently or will be able to afford for the duration of treatment

Ep006: Case Management: Assess the Patient’s  Need for Equipment

Ep006: Case Management: Assess the Patient’s Need for Equipment

What kind of equipment or materials will the patient need?  Oxygen, walker, shower chair, adaptive eating utensils

Collaborate with other members of the health care team (physical therapy, occupational therapy, and so forth) to incorporate their recommendations

  • The physician may consult therapy services like PT, OT, ST and then order whatever they recommend

Make sure the patient knows how to use the equipment, that it’s set up to their specifications, and they know who to contact if they have questions

Address all safety concerns

Ep005: Case Management: Explore Resources to Maintain Independence

Ep005: Case Management: Explore Resources to Maintain Independence

  • Become familiar with your community’s resources that can be helpful to patients attempting to maintain independence
  • Nursing homes, respite care, SNF, home health agencies, Meals on Wheels
  • Consider insurance coverage, Medicare, Medicaid, family support and availability to utilize resources
Ep004: Identify Tasks for Delegation Base on Patient Needs

Ep004: Identify Tasks for Delegation Base on Patient Needs

  • NCSBN Delegation | ANA: Developing Delegation Skills
  • You will be responsible for delegating tasks to others; nursing assistants, other nurses, and so forth
  • Not all tasks are appropriate to delegate
    • You can only delegate tasks for which you are responsible for
    • Even after you have delegated a task, you are still ultimately responsible for it.  The person delegated to also assumes some responsibility, but it ultimately goes back to you.
  • Make sure the person you’re delegating tasks to has had the appropriate training, skills, and experience before having them complete tasks independently and unsupervised
  • Right task (for example, removing a foley)
  • Right circumstances (is the patient stable?  Is it a routine removal?)
  • Right person (is it the correct person to delegate this task to?)
  • Right direction or communication (are you communicating expectations clearly?)
  • Right supervision or feedback (do you need to supervise directly, or someone else? Is this someone else qualified to do so?  Do they know what complications to report to you?)
  • The nurse practice act, your state’s limitations, and your facility’s policies and procedures all can dictate which tasks you can delegate and who you can delegate to
  • Communication is vital: use the 5 rights of delegation
  • Follow up to make sure the task was completed appropriately
  • Evaluate effectiveness of staff members’ time management skills
Ep003: Organizing Your Workload to Manage Time Effectively as a Nurse

Ep003: Organizing Your Workload to Manage Time Effectively as a Nurse

  • There are so many tasks that need to be completed during a shift, the nurse must have a plan and adapt it continually to address the constantly changing needs of the patient(s)
    • Look at all tasks, prioritize, implement, re-prioritize as needed (which will be frequently)
  • Always start by addressing unstable patients first
  • Be ready to change entire plan in an instant
  • Organize tasks by considering:  level of urgency, time to completion, if it is time sensitive, if any other staff members are needed to assist, if resources are readily available (for example, do you need to wait for a med to be sent from pharmacy?), if other tasks can be completed simultaneously
  • Time management looks different on various units (ED vs. ICU vs. floor)
  • 3 Time Management Tools for Nursing Students
Ep002: Advocating for Your Patient – What Does it Mean?

Ep002: Advocating for Your Patient – What Does it Mean?

Advocating – help the patient and their support system understand the clinical picture and identified treatment options, identify their wants/needs, support the patient, speak on their behalf if needed, and uphold and protect their rights

The foundation of being an advocate is checking your personal beliefs at the door to help the patient figure out what is best for them

Use resources to facilitate their decision-making process and decisions. Examples include:

  • Interpreter if not English-speaking
  • Case manager to facilitate identified agreed-upon discharge needs (hospice, SNF, nursing home, and so forth)

Educate staff as appropriate

Ep001: What Do Nurses Need to Know About Advanced Directives

Ep001: What Do Nurses Need to Know About Advanced Directives

It is the nurse’s job and part of the law (Client Self-Determination Act) to assess for existing advanced directives and integrate them into the patient’s care, and inform and educate about them if the patient is unfamiliar with advanced directives

Wikipedia | Mayo Clinic

  • Check the EHR for any advanced directives
  • Ask the patient: “Mr. Smith, do you have any advanced directives already set up? Do you have a living will or healthcare power of attorney?”
  • If the patient says yes, ask for copies so that they can be added to the chart

Educate the patient about them if they don’t have any or know what they are

Definitions:

  • A living will is a document that says what you want to be done, or not done, in the event that you become incapacitated
  • A durable power of attorney is someone who makes medical decisions for you when you are incapacitated
  • Assess for existing advanced directives
  • If the patient becomes incapacitated, integrate them into their care

A health care proxy is the document that outlines who the durable power of attorney is

Ep000: Welcome to the Unofficial NCLEX® Prep Podcast for Nursing Students

Ep000: Welcome to the Unofficial NCLEX® Prep Podcast for Nursing Students

Welcome to our brand new . . . hot off the presses podcast.  This podcast is designed to provide you with a step-by-step outline for the majority of the key points the NCSBN wants nursing students to know before taking the NCLEX®.

Each episode is between 5-15 minutes and covers one bullet point from the NCLEX® Test Plan.

We do have a free download that goes along with this podcast outlining the points discussed. You can download that here at: NRSNG.com/NCLEXprep.

This document is an ever growing study guide that includes well outlined points.  Rather than outlining disease processes, meds, and other medical information, this podcast will focus on the nursing concepts and fundamental nursing information.

This podcast is sure to be a massive resource for you as a nursing student.  New episodes will be added every Monday, Wednesday, and Friday.

To help see this podcast grow the best thing you can do is subscribe, share, and review.