Nursing Care Management Study Guide

Management of Care

Delegating Tasks to Assistive Personnel (AP)

  • Definition: APs include Certified Nursing Assistants (CNAs), Unlicensed Assistive Personnel (UAPs), or other staff who assist with patient care, but they cannot perform assessments or plan care.

  • RN Responsibility: Registered Nurses (RNs) are responsible for assessing, planning, evaluating, and teaching. Delegation is the process of assigning tasks to others, with the RN maintaining ultimate responsibility for patient care.

Tasks You CAN Delegate:
  • Vital signs for stable clients.
  • Bathing and hygiene tasks.
  • Feeding tasks for non-critical patients.
  • Repositioning or ambulating stable clients.
  • Collecting Intake & Output (I&O) data.
Tasks You CANNOT Delegate:

  • Initial assessments of patients.

  • Administration of medications.

  • Teaching patients about their health or conditions.

  • Clinical judgment and evaluation of patient progress.

  • NCLEX Tip: Ask yourself, "Could this task harm the patient if done incorrectly?" If yes, do it yourself as the RN. Remember: RNs EAT - Ensure Assessment Tasks are performed by RNs only!

Initiating Discharge Planning

  • Definition: Discharge planning is the process of ensuring a patient's safe transition from a hospital to home or to another facility.

  • RN Responsibility: RNs assess patient needs, teach the patient, and coordinate follow-up care.

Steps:
  1. Assess home support system (family, caregiver, living environment).
  2. Identify patient needs (medications, mobility aids, oxygen, wound care).
  3. Provide teaching on medication schedules, diet, and activity level.
  4. Arrange follow-up appointments.
  • Mnemonic: ADMIT - Assess, Document, Med teaching, Instructions, Time follow-up.

Use of Correct Terminology in Documentation

  • Definition: Documentation must consist only of objective, factual information pertinent to patient care.
What to Do:
  • Record: Vital signs, lab results, direct quotes from patients.
What NOT to Do:

  • Do NOT Record: Opinions or assumptions about patient conditions.

    • Example: Instead of stating "Patient seems confused," document "Patient oriented x1 to person only" to ensure documentation is objective.

  • NCLEX Tip: Documentation serves as legal evidence; specificity and factual information are crucial.

Legal Responsibilities on Admission (Advance Directives)

  • Definition: This involves ensuring that patients' wishes regarding medical treatment and end-of-life decisions are known and documented.

  • RN Role: Ask patients about advance directives, provide them with information on relevant options, and document their preferences.

Types of Advance Directives:

  • Living wills.

  • Do Not Resuscitate (DNR) orders.

  • Healthcare proxies.

  • Mnemonic: PAD - Patient Autonomy Documentation.

Informed Consent

  • Definition: Informed consent is when a patient voluntarily agrees to a procedure after being informed of the risks, benefits, and alternatives.

  • RN Role: Responsible for witnessing signatures and ensuring the patient comprehends the information provided.

Steps Component:
  • Components include Disclosure, Comprehension, Voluntariness, and Competence.
  1. Ensure the healthcare provider has explained the procedure adequately.
  2. Ensure that the patient understands the risks and benefits.
  3. Witness the patient's signature.
  4. Document the consent in the patient's medical record.
  • Mnemonic: DCVC+ - Doctor explained, Comprehension, Voluntary, Competent.

Priority Action for Client Who Refuses Treatment

Steps:
  1. Assess the reason for the patient's refusal.
  2. Provide information and teaching to clarify any misconceptions.
  3. Notify the healthcare provider of the refusal and patient concerns.
  • Ethical Principle: Autonomy - Respect the patient's right to refuse treatment, as long as they are competent to make decisions.

Initial Assessment of Pain

  • Pain Assessment: Assess and determine the quality, intensity, location, and impact of pain on the patient.
Tools for Pain Assessment:
  • Numeric Rating Scale.
  • Wong-Baker Faces scale (useful for nonverbal patients).
  • FLACC scale (for assessing nonverbal pain in children or patients with cognitive impairments).
Documentation of Pain:

  • Record details such as onset, location, quality, severity, aggravating or relieving factors, and timing of the pain.

  • Mnemonic: OLD CARTS+ - Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing.

Oxygen Therapy

  • Oxygen must be stored safely, in a secured area, and away from any heat sources.
RN Role:
  • Ensure safe administration of oxygen therapy and monitor its effectiveness in patients.
  • Actions include:
    • Checking SpO2 levels, respiratory rate, work of breathing, and skin color.
    • Humidification should be used for flows greater than 4 L/min.
    • Monitoring for signs of hypoxia or carbon dioxide retention, especially in patients with Chronic Obstructive Pulmonary Disease (COPD).
Safety Tips:
  • No smoking or exposure to flammable materials should be allowed near the oxygen source.

Safety & Infection Control

Latex Allergy Precautions
  • Definition: Take measures to avoid latex exposure in patients with a known allergy to latex.
Nursing Actions:
  • Identify risk factors: History of latex allergy, spina bifida, multiple surgeries, allergies to bananas or kiwi.
  • Use latex-free gloves and equipment when caring for these patients.
  • Monitor for signs of an allergic reaction such as rash, wheezing, and anaphylaxis.
Priority Action When Responding to a Fire
  • Mnemonic: RACE
    • R: Rescue clients from danger.
    • A: Activate the fire alarm to alert emergency services.
    • C: Contain the fire by closing doors and windows if safe to do so.
    • E: Extinguish the fire if small and manageable, or evacuate the premises if necessary.

Implementing and Monitoring Wrist Restraints

Indications for Use:
  • Used to prevent harm to the patient or others, or to prevent patients from removing essential medical devices.
Nursing Actions:
  • Use the least restrictive method appropriate for the situation.
  • Assess circulation, skin integrity, and neurological status every 2 hours.
  • Remove restraints every 2 hours to allow for range-of-motion exercises and toileting needs.
Documentation Requirements:
  • Record the reason for restraint use, the type of restraint, ongoing assessments, and monitoring findings.

Standard & Transmission-Based Precautions

Standard Precautions:
  • Apply to all patients, including hand hygiene practices, use of gloves, and masks as needed.
Transmission-Based Precautions:

  • Contact Precautions: For MRSA, C. difficile; require use of gloves and gowns.

  • Droplet Precautions: For flu and pertussis; require masks if within 3 feet of the patient.

  • Airborne Precautions: For tuberculosis (TB) and measles; require N95 masks and placement in a negative pressure room.

  • Mnemonic: "CD Air" for Contact, Droplet, Airborne.

Protective Environment

  • Definition: Specific precautions taken to protect immunocompromised clients (e.g., those undergoing stem cell transplants).
Actions Include:

  • Providing a positive pressure room to reduce pathogen exposure.

  • Utilizing HEPA filtration systems.

  • Requiring masks for visitors.

  • Limiting patient exposure to sick individuals.

  • Mnemonic: "P-P-H-M" - Positive pressure, HEPA, PPE, Mask for visitors.

Mobility & Immobility

Care Plan Highlights for Hemiplegia:
  • Reposition the patient every 2 hours to prevent sores.
  • Perform passive range of motion exercises to maintain joint function.
  • Implement measures to prevent skin breakdown, such as using pressure-relieving mattresses.
  • NCLEX Tip: Early mobility significantly contributes to preventing pneumonia, Deep Vein Thrombosis (DVT), and contractures.

Reporting Incidents/Irregular Occurrences

  • Definition: An unexpected event that may cause harm to a patient or staff member.
Steps to Take:
  1. Ensure the immediate safety of the patient first.
  2. Notify the healthcare provider or supervisor about the incident.
  3. Complete an incident report; do not document the incident within the patient’s medical record.
  • Mnemonic: "S-N-D" - Safety, Notify, Document.

Priority Action After a Client Fall

Steps:
  1. Assess the client for any injuries sustained during the fall.
  2. Provide immediate care if necessary, such as stabilization of injuries.
  3. Notify the healthcare provider regarding the client’s condition.
  4. Complete the incident report.
  • NCLEX Tip: Fall prevention is critical; always evaluate the environment and check mobility aids for safety.

Ergonomic Principles for Bed-to-Chair Transfer

  • Keep the back straight while bending at the knees, rather than at the waist.
  • Use assistive devices to help with lifting.
  • Seek assistance with heavier patients to avoid injury.

Health Promotion & Maintenance

Evaluating Herbal Supplement Use

  • Definition: Assess for potential interactions between herbal supplements and prescribed medications.
Common Interactions:

  • Ginkgo can increase bleeding risk when taken with anticoagulants.

  • St. John's Wort can lead to serotonin syndrome when taken alongside antidepressants.

  • NCLEX Tip: Always ask patients about the supplements they are currently taking.

Home Safety for Oxygen Therapy

Actions Include:
  • Implement strict no smoking policies in the vicinity of the oxygen supply.
  • Maintain a safe distance between oxygen sources and any open flames.
  • Regularly check oxygen tubing for kinks or leaks to ensure proper function.
  • Use fire-retardant materials and equipment in the home where oxygen therapy is administered.

Physical Assessment Techniques

Steps Include:
  1. Inspection.
  2. Palpation.
  3. Percussion.
  4. Auscultation (often abbreviated as IPPA).
  • Mnemonic: "I Play Piano Always" reflects the order of assessment techniques.

Teaching Adolescents About Health

Tips for Effective Communication:
  • Use language that is appropriate for the adolescent's age and comprehension level.
  • Encourage active participation in their own care decisions.
  • Include social or peer considerations in discussions regarding health.

Promoting Self-Care for Caregivers

Actions Include:
  • Encourage caregivers to rest, maintain proper nutrition, and take necessary breaks from caregiving responsibilities.
  • Provide support resources to assist them in managing their roles.
  • Teach safe patient handling techniques to prevent caregiver injuries.

Auscultating Breath Sounds

Normal Breath Sounds:
  • Vesicular Sounds: Soft, low-pitched sounds typically heard over lung fields.
  • Bronchial Sounds: Loud, high-pitched sounds normally heard over the trachea.
Adventitious Sounds:

  • Crackles: Indicative of possible fluid in the airways.

  • Wheezes: Suggestive of narrowed airways.

  • Rhonchi: Low-pitched rattling sounds from blockages or secretions in larger airways.

  • NCLEX Tip: Always compare lung sounds bilaterally and assess during the full respiratory cycle for a thorough evaluation.