Management-Kaplan notes – Flashcards
145 test answers
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Assignment
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Determine care required to meet patients needs
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Assignment
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Consider knowledge/abilities of staff *take into account continuity of care
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Assignment
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*Increase efficiency *Be specific about expected results
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Assignment
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*Provide additional help as needed
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Delegation
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Responsibility and authority for task transferred to another
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Delegation
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Responsibility-Obligation to accomplish task
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Delegation
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Accountability-accepts ownership for results or lack of results
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Steps for Delegation
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*What? =Define the task
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Steps for Delegation
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*Who-Determine who should receive task
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Steps for Delegation
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*How? Identify what task involves
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Steps for Delegation
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Match task to delegates skills and abilities
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Steps for Delegation
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Provide clear expectations
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Steps for Delegation
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Answer questions
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To Delegate
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Face to Face/establish eye contact to the Delegatee
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To Delegate
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Describe "I" statements
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To Delegate
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Provide What, When. where and How of the task
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To Delegate
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Identify any potential changes
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To Delegate
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written or verbal report required
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To Delegate
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Describe expected outcome and timeline for completion
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To Delegate
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Give constructive feedback
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6 rights of delegation
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*right task *right person *right time *right information *Right Supervision *Right follow-up
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Delegations-Do Not Delegate
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Total control Discipline issues
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Delegations-Do Not Delegate
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Confidential tasks Technical tasks
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Delegations-Do Not Delegate
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Controversial tasks During a Crisis
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Change-of-Shift Report
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Basics=regularly scheduled, structured exchange of information
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Change-of-Shift Report
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Focuses on client care for next 24 hours
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Change-of-Shift Report
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Assists health care workers
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Change-of-Shift Report
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Report pertinent, current and accurate information
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Change-of-Shift Report
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Describe: actual or potential client needs, lab studies, Dx.tests
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Change-of-Shift Report
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treatments, care during previous shift, care anticipated during next shift
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Change-of-Shift Report
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*Don't include=Opinions, value judgments
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Change-of-Shift Report **Don't include
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*any information that does not relate to health condition, needs or treatments
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Change-of-Shift Report**don't include
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Descriptions of routines
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Deliver
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Gather data Use outline medical plan
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Deliver
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*Nursing plan=special equipment, nursing assessments, IV's, I & O's, any new concerns, any teaching plan or discharge plan
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Receive
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determine number of clients and number of staff
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Receive
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determine anticipated admissions, transfers, discharges
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Receive
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Determine clients in critical condition
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Receive
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complete assignments sheets for other staff
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Receive
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Make a to-do list identifying tasks to be performed
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method of delivery
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types= **face to face **Taped
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Method of service delivery
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Functional Team Nursing Primary Case Management
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Client Education
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Assessment=type of information needed
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Client Education-Assessment
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Type of learning= Cognitive Psychomotor Affective
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Client Education-Assessment
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Specific Knowledge needed
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Client Education
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Clients motivation-May need help to see need for learning
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Client Education
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Clients needs=knowledge level/understanding **Abilities/skill level **Attitudes/beliefs
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Client Education-Diagnosis
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Client education process requires=skilled communication
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Client Education-Diagnosis
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Client education process requires=Factors influencing compliance *duration *Complexity *Side effects
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Implementation-Client education
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setting of priorities
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Implementation-Client education
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family involvement
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Implementation-Client education
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Demonstration
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Implementation-Client education
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Non-judgmental approach
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Implementation-Client education
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Point out successes/benefits
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Client's Bill of Rights
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Informed Consent=It is the healthcare providers responsibility to obtain informed consent
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Client's Bill of Rights-Informed consent
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Nurses Responsibilities=witness the clients signature and ensure that consent is attached to the chart
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Basic rights
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privacy Confidentiality Refusal of treatment Respectful care Current information
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Basic Rights
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Reasonable response to request for services *right to know hospital/clinic regulations
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Basic Rights
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personal choices
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Informed Consent-requirements
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Voluntary Understandable terms Client cannot give consent if client is drinking or is pre-medicated
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Informed Consent-requirements
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Minor-only if married can they give informed consent,,,imancipated minors do not need to be over 18 years
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Informed Consent-requirements
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explanation of treatment and expected results *Anticipated risks and discomforts
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Informed Consent-requirements
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*Potential benefits *possible alternatives *answers to questions
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Informed Consent-requirements
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Can be withdrawn at any time
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Refusal of Treatment
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*Self-Determination Act *Aggressive Treatment
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Refusal of Treatment
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Advanced Directives= *Living Wills *Durable Power of Attorney
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Critical Thinking Basics
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Involves Creativity, problem-solving and decision-making
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Critical Thinking Basics
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Observation Nurse decides what is important
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Critical Thinking Basics
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Nurse validates and organizes data *Nurse looks for patterns and relationships
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Critical Thinking Basics
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State Problem Nurse transfers knowledge from one situation to another
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Critical Thinking Basics
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Decide on Criteria for evaluation Apply Knowledge
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Critical Thinking Basics
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Nurse evaluates according to established criteria
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Cultural Norms
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Group of individuals values and beliefs that strongly influence actions and behaviors
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Cultural Norms
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Values-Personal preferences, motivation that influences behavior
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Cultural Norms
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Beliefs-Basic assumptions and personal convictions, used to determine values
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Discharge Planning
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Assessment=begins with 1st encounter
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Discharge Planning
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Identify=potential effects of health problems, family and social support, clients functional level
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Discharge Planning
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Identify=Environmental factors, Clients preferences, community agencies
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Diagnose
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Goal is as much independence as safe and possible
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Distribution of Resources
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equal distribution of resources that provides equal health care to all based on need
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Distribution of Resources
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allocation of resources rationing Nursing management conflict resolution
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Documentation
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purpose is to promote communication
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Documentation
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it maintains a legal record
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Documentation
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meets requirements of regulatory agencies
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Documentation
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required for third party reimbursement
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Criteria for Documentation
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Legible Accurate ; factual Timely ; chronological order
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Criteria for Documentation
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Thorough well-organized and concise
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Criteria for Documentation
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confidential authorized abbreviations
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Criteria for Documentation
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Changes=documentation of the clients conditions
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Criteria for Documentation-changes
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assess=VS, symptoms, behaviors, responses to treatments
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Criteria for Documentation-changes
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notify healthcare provider **inform family of changes
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Criteria for Documentation
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Document in timely manner
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Ethics
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principles of right and wrong or good and bad
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Ethics
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ANA Code of Ethics
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Ethics
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Ethical reasoning process
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Ethics
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Behaviors for handling complaints
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Ethical principles of Nursing
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Autonomy Beneficence Non-maleficence (do no harm) Justice Veracity Confidentiality Fidelity
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Incident Reports
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agency record of unusual occurrence or accident and physical response
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Incident Reports
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accurate and comprehensive report on nay unexpected or unplanned occurrence that affects or could potentially affect a client, family member, or staff
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Incident Reports
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Basics=purpose (ex: med errors between 2pm and 4pm)
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Incident Reports
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Sequence-must receive report within 24 hours
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Incident Reports
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risk manager-look at issue, anyalize issue, explain and make referrals
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When charting-Don'ts
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do not include references to the incident report **Do not use inflammatory words
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When charting-Don'ts
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**Do not make judgmental statements
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When charting-Do's
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Do chart the facts as they occurred
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When charting-Do's
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Do chart the clients response
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When charting-Do's
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Do continue documenting
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Common situations
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falls burns break in aseptic technique incorrect sponge count change in condition medical-legal incident
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Legal Issues-Negligence
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Unintentional failure to perform an act
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Legal Issues-Negligence
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Can be act of omission or commission
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Legal Issues-Malpractice
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duty breach of duty causation Injury
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Legal Issues-Intentional wrong
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Assault Battery Invasion of privacy false imprisonment
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Legal Issues-other aspects
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accountability Nurse practice act Licensure requirements Good Samaritan Law Tarasoff Act Assess healthcare providers orders **supervisor notification
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Managed Care
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Goals=maintain wellness, reduced health care costs, focus on client outcomes, maintain quality of care, interdisciplinary approach, critical pathways
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Managed Care
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Aspects=Continuous quality improvement, risk management, collaborative practice team , case manager/case management
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Nurse/Client Relationship
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Professionalism=specific knowledge and skills
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Nurse/Client Relationship
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Professionalism=Person/client centered
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Nurse/Client Relationship
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Professionalism=Accountable legally responsible for care given
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Nurse/Client Relationship
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Professionalism=ethical standards=respect for human dignity, confidentiality, competence, advocacy, research, promotion of public health
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Nurse/Client Relationship---Therapeutic Nature
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*professional *Genuineness *Nurse acts as role model *Nurse copes with own feelings *protected relationship
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Nurse/Client Relationship
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offers information
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Problem Solving
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trying to solve an immediate problem
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Problem Solving
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methods=trial and error, experimentation, purposeful inaction
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Problem Solving
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involves decision making
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Restraints
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proper use=Omnibus Budget Reconciliation Act
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Restraints
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proper use=chemical restraint
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Restraints
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proper use=informed consent
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Restraints
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proper use=false imprisonment
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Restraints
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assess need and document the need
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Restraints
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consider alternative measures
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Restraints
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healthcare providers orders requires, including circumstances and duration
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Restraints
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restraints cannot be used PRN
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Restraints
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monitor client closely
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Restraints
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remove restraints as per policy/skin care/ROM
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Restraints
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Toileting as per policy
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Restraints
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vest=posy vest, keeps client in bed, or in chair
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Restraints
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Belt=keeps client in bed, not to tight on chest or abdomen
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Restraints
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Mitten=keeps hands unable to pull on IV's, cords
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Restraints
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Elbow-usually for children to keep from reaching tubes....
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Restraints
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Mummy=babies/infants-for exam or something on head or neck
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Restraints
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4 hours limit=adults ((nurse must check/assess every hour and check for an order every 4 hours)) adults can have a 24 hour order..up to 6 times at 4 hour checks... 2 hour limit=children (-17 years old) 1 hour limit=children under age 9
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