Exhaustive Comprehensive Notes on Nursing Evaluation, Scope of Practice, and Informatics

Institutional Assumptions and Clinical Practice Standards

  • Avoidance of Assumptions in Transfer and Practice:
    • When transferring between facilities within the same organization (e.g., from Orlando Health in Longwood to Orlando Health near Dr. Phillips), healthcare providers must not automatically assume that processes or clinical workflows are identical.
    • Even though the institutions belong to the same entity and organization, the specific ways tasks are performed may differ.
    • Actionable Step: It is the nurse's responsibility to take the time to investigate and confirm the specific protocols and standard operating procedures for the current facility.
    • The emotional impact of assuming knowledge only to be corrected (the "that's not how we do it here" scenario) can be disheartening and counterproductive to clinical excellence.

The Evaluation Process in Nursing

  • Initial Steps in Evaluation:

    • Assessment and Inspection: The first physical and cognitive step is the assessment of the patient or the situation to determine exactly what is being evaluated.
    • Tool Analysis: Nurses must determine whether to use existing evaluation tools already in place within the system or to implement new tools.
    • Literature Review: If an evaluation or procedure is being conducted for the first time in an institution, providers must consult the current scientific and professional literature to ensure evidence-based practice.

  • Policy and Regulatory Frameworks:

    • Every nursing unit utilizes policy and procedure manuals, which may be electronic or paper-based.
    • The hierarchy of regulations includes:
      1. Federal Regulations: Top-level mandates.
      2. State Regulations: State-specific laws.
      3. Hospital Regulations: Built upon the foundation of state and federal laws.
    • Compliance oversight is provided by entities such as JCO (The Joint Commission) and internal/external quality health examiners.

Educational and Financial Regulations: Clinical Hours and SAP

  • Clinical Hour Standards:

    • Clinical hours for nursing programs are not determined by individual schools such as UCF, UF, Kaiser, Valencia, or Rigs (Briggs).
    • These hours are strictly mandated by the State Board of Nursing in Florida.

  • Financial Accountability (SAP):

    • SAP (Satisfactory Academic Progress): Refers to the status required to maintain financial aid (loans or grants). If a student "saps out," they have exhausted their allocated funds and must pay cash to continue their education, or their education will stop.

Case Study: Frequent Flyers and Medicare Constraints

  • Frequent Flyer Identification: This term describes patients (often with chronic conditions like Emphysema or COPD) who require repeat hospitalizations.
  • Medicare Hospitalization Limits:
    • Medicare only covers a fixed number of hospitalization days per year. For example, a patient may be limited to a maximum of 1313 hospitalization visits annually.
    • Clinical Scenario: If a patient is on their 10th10^{\text{th}} hospitalization by June 17th, there are only 33 visits remaining for the rest of the year.
  • The Nursing Role in Case Management:
    • Nurses must identify these limits during admission and discharge planning.
    • While the nurse does not coordinate the funding themselves, they are obligated to alert the Social Service Department to apply for additional funding or alternative resources.
  • Critical Evaluation of the Treatment Plan:
    • If a chronic patient is frequently hospitalized, the team must evaluate if the current plan is working.
    • Education should focus on compliance: checking medication adherence and the correct following of medical recommendations.
    • Nurse Self-Reflection: If a patient has had a condition for years, simply repeating "education" may be insufficient. The nursing staff must reassess their own interventions. If an intervention is not working, it must be DC (discontinued) and replaced with a new strategy.

Eliminating Error and Professional Scope of Practice

  • Eliminating Human and Equipment Error:
    • If a clinical reading—such as blood pressure—is out of the expected parameter, the nurse must not immediately escalate to medication.
    • The protocol is to retake the measurement within 15 minutes15\,\text{minutes} to eliminate human error and equipment error before determining next steps.
  • Scope of Practice: RN vs. LPN:
    • LPN (Licensed Practical Nurse): Trained to focus on immediate signs and symptoms and take action based on what is currently presented.
    • RN (Registered Nurse): Trained to analyze the "bigger picture." This includes:
      • Interpreting blood work and laboratory data.
      • Reviewing patient history and longitudinal data.
      • Performing "comparables" (e.g., comparing the current presentation to a visit from a month ago to identify changes or patterns).

Nursing Informatics and Safety Standards

  • Informatics Concepts:

    • Measurability and Retrievability: Data must be in a standardized electronic format so it can be tracked and used to improve outcomes.
    • SMART Goals: Data and plan components must be Specific, Measurable, Achievable, Relevant, and Timely.
    • Standardized Terminology: Essential for data integrity across sophisticated databases.

  • The Houston Safety Block (Page 561):

    • Nurses are responsible for minimizing patient and provider risk through system effectiveness and individual performance.
    • Individual Performance Assessment: This must occur every time the nurse sees the patient. While the standard is a check every 2 hours2\,\text{hours}, a 12 hour shift12\,\text{hour shift} should result in at least 66 to 77 individual performance assessments.

  • System Security and Passwords:

    • Password management is a critical component of clinical system security (Box 21.3).
    • Colleague Accountability: Nurses must never share login IDs or passwords. Any action taken under a specific login is legally attributed to that person, regardless of who performed the task.

Patient Privacy and Portals

  • Content of Patient Portals: Includes personal info, billing, age, history, medical record numbers, religion, next of kin, power of attorney, and DNR (Do Not Resuscitate) status.
  • Privacy Protocols:
    • Information should never be shared with anyone outside the immediate care team.
    • Sensitive information (like a new diagnosis) should never be discussed in the presence of roommates; private conference rooms should be utilized.
  • The Michael Jackson Sentinel Event Case Study:
    • While on a gurney at Los Angeles Mount Sinai Hospital, staff members from different floors accessed the patient's personal file without clinical necessity.
    • As a result, 5353 people were terminated because they were not part of the emergency team and had no reason to access the records.

Questions & Discussion

  • Question: What does SAP stand for and why is it important in nursing schools?

  • Response: SAP refers to funds (loans or grants) provided for education. Once those funds are exhausted, the student must pay cash or stop their education. It is relevant because nursing clinical hours are mandated by the Board of Nursing, and financial limitations impact a student's ability to complete them.

  • Question: If a patient's blood pressure is out of parameter, what are the first two things to eliminate?

  • Response: Human error and equipment error. The measurement should be retaken in 15 minutes15\,\text{minutes}.

  • Question: How often should individual performance assessments occur?

  • Response: Every time a nurse lays eyes on a patient. Standards suggest every hour or every two hours, but an RN should conduct at least 66 to 77 checks during a typical 12\,\text{hour shift.

  • Closing Logistics: Students are reminded to have their grade books open for screen sharing during individual meetings next week. The next class session is scheduled for 06/24.