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Assisting with a performance analysis:

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A formal system for conducting performance appraisals should be in place and used consistently. Performance appraisal tools should reflect the staff member's job description and may be based on various types of scales or surveys. Various sources of data should be collected to ensure an unbiased and thorough evaluation of an employee's performance. Data should be collected over time and not just represent isolated incidents. Actual observed behavior should be documented/used as evidence of satisfactory or unsatisfactory performance. These may be called anecdotal notes and are kept in the unit manager or equivalent position's files Peers can be a valuable source of data. Peer review is the evaluation of a colleague's practice by another peer. Peer review should: Begin with an orientation of staff to the peer review process, their professional responsibility in regard to promoting growth of colleagues, and the disposition of data collected. Focus on the peer's performance in relation to the job description or an appraisal tool that is based on institutional standards. Be shared with the peer and usually the manager. Be only part of the data used when completing a staff member's performance appraisal. The employee should be given the opportunity to provide input into the evaluation. The performance appraisal review should be hosted by the unit manager in a private setting and held at a time conducive to the staff member's attendance. The unit manager should review the data with the staff member and provide the opportunity for feedback. Personal goals of the staff member should be discussed and documented, and avenues for attainment discussed. Staff members who do not agree with the unit manager's evaluation of their performance should have the opportunity to make written comments on the evaluation form and appeal the rating

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Time Management Strategies:

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Nurses must continuously set and reset priorities in order to meet the needs of multiple clients and to maintain client safety. Priority setting requires that decisions be made regarding the order in which: Clients are seen. Assessments are completed. Interventions are provided. Steps in a client procedure are completed. Components of client care are completed. Establishing priorities in nursing practice requires that these decisions be made based on evidence obtained: During shift reports and other communications with members of the health care team. Through careful review of documents. By continuously and accurately collecting client data

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Prioritization Principles in Client Care:

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Prioritize systemic before local ("life before limb"): Prioritizing interventions for a client in shock over interventions for a client with a localized limb injury Prioritize acute (less opportunity for physical adaptation) before chronic (greater opportunity for physical adaptation): Prioritizing the care of a client with a new injury/illness (e.g., mental confusion, chest pain) or an acute exacerbation of a previous illness over the care of a client with a long-term chronic illness Prioritize actual problems before potential future problems: Prioritizing administration of medication to a client experiencing acute pain over ambulation of a client at risk for thrombophlebitis Listen carefully to clients and don't assume: Recognizing that a postoperative client's report of pain could be due to pain in another location rather than expected surgical pain Recognize and respond to trends versus transient findings: Recognizing a gradual deterioration in a client's level of consciousness and/or Glasgow Coma Scale score Recognize signs of medical emergencies and complications versus "expected client findings.": Recognizing signs of increasing intracranial pressure in a client newly diagnosed with a stroke versus the clinical findings expected following a stroke Apply clinical knowledge to procedural standards to determine the priority action.: Recognizing that the timing of administration of antidiabetic and antimicrobial medications is more important than administration of some other medication

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Determining Client Inablility to provide informed consent:

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informed Consent guidelines Consent is required for all care given in a health care facility. For most aspects of nursing care, implied consent is adequate. The client provides implied consent when she complies with the instructions provided by the nurse. For example, the nurse is preparing to administer a TB skin test, and the client holds out her arm for the nurse. For an invasive procedure or surgery, the client is required to provide written consent. State laws regulate who is able to give informed consent. Laws vary regarding age limitations and emergencies. Nurses are responsible for knowing the laws in the state of practice. Signing an informed consent form The form for informed consent must be signed by a competent adult. The person who signs the form must be capable of understanding the information provided by the health care professional who will be providing the service, and the person must be able to fully communicate in return with the health care professional. When the person giving the informed consent is unable to communicate due to a language barrier or hearing impairment, a trained medical interpreter must be provided. Many health care agencies contract with professional interpreters who have additional skills in medical terminology to assist with providing information. Individuals authorized to grant consent for another person include: Parent of a minor Legal guardian Court-specified representative Spouse or closest available individual who has durable power of attorney for health care

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Skeletal Traction Care:

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Skeletal Traction: The pulling force is applied directly to the bone by weights attached by rope directly to a rod/screw placed through the bone to promote bone alignment. Examples include skeletal tongs (Gardner-Wells) and femoral or tibial pins (Steinmann pin). Weights 15 to 30 lb can be applied as needed Nursing Actions: Collect data about neurovascular status of the affected body part every hour for 24 hr and every 4 hr after that. Maintain body alignment and realign if the client seems uncomfortable or reports pain. Avoid lifting or removing weights. Ensure that weights hang freely and are not resting on the floor. If the weights are accidentally displaced, replace the weights. If the problem is not corrected, notify the provider. Ensure that pulley ropes are free of knots, fraying, loosening, and improper positioning at least every 8 to 12 hr. Notify the provider if the client experiences severe pain from muscle spasms unrelieved with medications and/or repositioning. Move the client in halo traction as a unit, without applying pressure to the rods. This will prevent loosening of the pins and pain. Routinely monitor skin integrity and document. Use heat/massage, as prescribed, to treat muscle spasms. Use therapeutic touch and relaxation techniques.

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Protocol for RESTRAINTS:

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seclusion and restraints Seclusion and restraints are used to prevent clients from injuring themselves or others. Seclusion is the placement of a client in a room that is private, isolated, and safe. Seclusion is used for clients who are at risk for injuring themselves or others. Physical restraint involves the application of a device that limits the client's movement. A restraint may limit the movement of the entire body or a body part. Chemical restraints are medications used to control the client's disruptive behavior. Risks Associated with Use of Restraints: Deaths by asphyxiation and strangulation have occurred with restraints. The client may also experience complications related to immobility, such as pressure ulcers, urinary and fecal incontinence, and pneumonia. Legal Considerations Nurses should understand agency polices as well as federal and state laws that govern the use of restraints and seclusion. False imprisonment means the confinement of person without his consent. Improper use of restraints may subject the nurse to charges of false imprisonment. Guidelines: In general, seclusion and/or restraints should be ordered for the shortest duration necessary and only if less restrictive measures have proved insufficient. They are for the physical protection of the client, or the protection of other clients or staff. A client may voluntarily request temporary seclusion in cases where the environment is disturbing or seems too stimulating. The use of restraints is a difficult adjustment for both the client and the family. The client loses his freedom and may be embarrassed and experience low self-esteem and depression. The nurse can allay some of the concerns by explaining the purpose of the restraint and that the restraint is only temporary. Seclusion and/or restraints must never be used for: Convenience of the staff Punishment for the client Clients who are extremely physically or mentally unstable Clients who cannot tolerate the decreased stimulation of a seclusion room PRN prescriptions for restraints are not permitted. Restraints should: Never interfere with treatment Restrict movement as little as is necessary to ensure safety Fit properly Be easily changed to decrease the chance of injury and to provide for the greatest level of dignity When all other less restrictive means have been tried to prevent a client from harming self or others, the following must occur for seclusion or restraints to be used: The treatment must be prescribed by the provider based on a face-to-face assessment of the client. In an emergency situation in which there is immediate risk to the client or others, the nurse may place a client in restraints. The nurse must obtain a prescription from the provider as soon as possible in accordance with agency policy (usually within 1 hr). The prescription must specify the reason for the restraint, the type of restraint, the location of the restraint, how long the restraint may be used, and the type of behaviors demonstrated by the client that warrant use of the restraint. The provider must rewrite the prescription, specifying the type of restraint, every 24 hr or the frequency of time specified by facility policy. Nursing Responsibilities: Obtain a prescription from the provider for the restraint. If the client is at risk for harming self or others and a restraint is applied prior to consulting the provider, ensure that notification of the provider occurs in accordance with facility protocol. Conduct neurosensory checks every 2 hours to include: Circulation Sensation Mobility Offer food and fluids. Provide with means for hygiene and elimination. Monitor vital signs. Provide range of motion of extremities. Follow agency polices regarding restraints, including the need for a signed consent from the client or guardian. Review the manufacturer's instructions for correct application. Remove or replace restraints frequently. Pad bony prominences. Use a quick-release knot to tie the restraint to the bed frame. Ensure that the restraint is loose enough for range of motion and has enough room to fit two fingers between the device and the client. Regularly assess the need for continued use of the restraints. Never leave the client unattended without the restraint. Documentation The behavior or precipitating events that make the restraint necessary Attempts to use alternatives to restraints and the client's response The client's level of consciousness Type of restraint used and location Education/explanations to the client and family Exact time of application and removal The client's behavior while restrained Type and frequency of care (range of motion, neurosensory checks, removal, integumentary checks) The client's response when the restraint is removed Medication administration

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Using Triage Tag System:

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Nurses should be aware that all health care facilities have color code designations for emergencies. These may vary between institutions, but some examples are: Code Red (fire) Code Pink (newborn abduction) Code Orange (chemical spill) Code Blue (mass casualty incident) Code Gray (tornado) Categories of triage during mass casualty events: Emergent category (class I) - Highest priority is given to clients who have life-threatening injuries but also have a high possibility of survival once they are stabilized. Urgent category (class II) - Second-highest priority is given to clients who have major injuries that are not yet life-threatening and usually can wait 45 to 60 min for treatment. Nonurgent category (class III) - The next highest priority is given to clients who have minor injuries that are not life-threatening and do not need immediate attention. Expectant category (class IV) - The lowest priority is given to clients who are not expected to live and will be allowed to die naturally. Comfort measures may be provided, but restorative care will not.

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ATI Nursing Leadership and Management Study Guide – Flashcards

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