Nclex- Management of Care PDF

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Management of Care General Information This category of questions falls under the broader umbrella of Safe and Effective Care Environment and asks you to make relevant decisions about nursing care. Your objective should be to determine the most effective way to deliver optimal care that preserves the health and safety of patients and personnel. These are some of the concepts you will need to know in order to make the appropriate decision(s) when questioned by NCLEX.

Advance Directives Advance directives are legal documents that specify the wishes of patients regarding their care if they were to become incapacitated and unable to communicate on their own. Examples of advance directives include: * Living wills—written statements by a person with their desires regarding medical treatment in the event they will no longer be able to express their informed consent 

Health care proxy—document that names a trusted individual as proxy or agent to act on a person’s behalf in the event they are rendered incapable of expressing their wishes

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Power of Attorney for Health Care—legal document that allows a person to designate another person to make medical decisions for them in the event the person cannot make medical decisions for himself or herself

Self-Determination In 1990, Congress passed the Patient Self-Determination Act. This bill requires that upon admission to a hospital, nursing home, home health agency, or other healthcare institution, patients must be advised of the right to accept or refuse care as well as their options for advance directives. If a patient already has an advance directive, the nurse should help document this in the patient’s chart. If not, the nurse may be involved in educating the patient on what advance directives are and discuss the patient’s healthcare goals for the future. This may also include the patient’s wishes for organ donation or making an anatomical gift as specified in the Uniform Anatomical Gift Act.

Life Planning Advance directives help ensure that a patient’s wishes are carried out by the healthcare team. As a nurse, you will need to incorporate advance directives into your patient’s care plan. This may include determining if a patient needs an advance directive, facilitating conversations with family members, and educating staff members who may

not be familiar with the document. You must also ensure that copies of advance directives are placed in the patient’s chart.

Advocacy Advocacy is at the heart of nursing. Advocacy is promoting or acting on behalf of the interests of another. Nurses are advocates for their patients. Their duties can be varied and diverse. These duties include providing patients and their families education and explanation of various diagnoses, tests, and results; making sure the care plan is executed in a timely and safe manner; and serving as a source of information and communication between various members of the healthcare team. At times, you may need to seek the opinion of those involved in patient care, but with expertise outside of medicine, such as a social worker, dietician, or chaplain.

Assignment, Delegation, and Supervision Delegation is an essential nursing skill. No matter how efficient you are as a nurse, you will need help to complete all aspects of patient care. The key to delegating success is finding the appropriate person to help, clearly explaining the assignment, and maintaining responsibility for the outcome while providing proper support and supervision.

Tasks for Professional Staff Only Some tasks should never be delegated to non-professional staff. These include: nursing assessment, examination, diagnosis, care goals or progress plans, and interventions that require advanced knowledge, training, and skills.

Five Rights of Delegation Prior to delegating a task, it is helpful to consider the five “rights” of delegation: 

Right task—Should the task be delegated?

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Right person—Is the person being asked qualified to perform the task?

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Right circumstance—Is the patient stable and the outcome of the task predictable?

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Right communication—Has the task been clearly explained and proper direction been given?

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Right supervision—Will the nurse retain responsibility and ultimately be responsible for the outcome of the task?

Other Things to Consider Tasks that are usually acceptable to delegate are those with unchanging protocols, such as feeding, bathing, transferring, and dressing. Delegation should only be considered in stable patients. Never delegate tasks when the patient is unstable, when the outcome is uncertain or unpredictable, or when the tasks require complex or complicated knowledge or technical skills. As a nurse, you are a leader. Being a good leader means that you have the ability to unite a team of caregivers to complete tasks to reach an overall goal— to provide exceptional care to your patients.

Being a Good Supervisor As a nurse, you may be asked to supervise a variety of nursing staff members. These may include other RNs, licensed practical nurses (LPNs), licensed vocational nurses (LVNs), and nursing assistive personnel (NAPs). You may be responsible for coordinating the tasks of the nursing team. This will require clear communication, adequate follow-up, active listening, technical knowledge of all aspects of the supervised work, problem-solving, and conflict resolution skills when these needs arise. A supervisor can evaluate the skills and abilities of each team member, especially with regard to time management, and use this knowledge to more effectively and appropriately delegate. Likewise, these skills will also be necessary and useful for performance evaluations of those you supervise.

Case Management Nurses are responsible for developing, implementing, and revising care plans that help patients reach and maintain their independence after they are discharged from medical care.

Things to Consider Nursing case management not only involves patient care in your facility but also includes helping patients find and utilize post-care resources. You will help your patient do this by identifying his or her individual needs and discussing his or her goals. Patient needs may include access to medical therapy and/or medical devices following discharge from healthcare facilities. Commonly ordered medical devices include oxygen machines, suction machine, wound care supplies, and ambulatory assistive devices (braces, crutches, wheel chair, etc.). Effective case management ensures the patient’s safety and the ability to care for himself or herself while also considering options that are most cost-effective for the patient.

Additional Resources When possible, incorporate evidence-based findings into your patient’s care plan. Regularly review the research within medical literature to maintain the most current level of knowledge and familiarize yourself with any newly advised standards of care. Also, don’t hesitate to access local professionals who may have the knowledge you need to manage a case.

Evolvement of Plan In addition to initiating the care plan, it will also be your job to revise it at times. Discussing the care plan with your patient will help you identify if changes are necessary and evaluate his or her individual needs. You must also provide information on medications that must be continued, repeat labs or imaging tests that are necessary for care, and any follow-up visits that are needed after discharge.

Patient Rights The nurse is responsible for not only explaining and educating patients on their conditions and treatment options but also informing them of their rights as patients upon admission to the hospital or other healthcare facility. The right to accept or refuse care is specified in the Patient Self-Determination Act. The nurse needs to be familiar with other healthcare laws that govern and protect a patient, as well.

HIPAA HIPAA stands for the Health Insurance Portability and Accountability Act. It was designed to protect a patient’s personal information such as his or her name, social security number, birth date, and sensitive medical information, such as a diagnosis or treatment received. Only those involved in direct patient care, insurance reimbursement, or patient management can access and share this information.

Patients’ Bill of Rights Adopted by the President’s Advisory Commission on Consumer Protection and Quality in the Healthcare Industry, this document specifies what each patient’s rights and responsibilities are as recipients of healthcare. It includes: 

Information disclosure—the right to accurate and easily understood information about healthcare providers, facilities, and health plans

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Choice of providers and plans—the right to choose healthcare providers that give high-quality care when needed

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Access to Emergency Services—the right to have evaluation and stabilization by emergency services when and wherever needed (These services may be given without authorization and must be given without financial penalty.)

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Participation in treatment decisions—the right to be informed of all treatment options and make decisions about one’s care (This right also extends to other healthcare proxies should the patient not be able to make decisions.)

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Confidentiality of health information—the right to speak privately with healthcare providers and have all healthcare-related information kept private (This also includes the right to access, read, and copy one’s own healthcare record.)

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Complaints and appeals—the right to a fast, fair, and objective review of a complaint against a healthcare plan, provider, care personnel, or facility

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Consumer responsibilities—specifies that a patient must disclose relevant information about medications and past illnesses to his or her healthcare provider

Evaluating the Understanding of Rights Your duty as a nurse is to ensure that your patient understands his or her rights and responsibilities under the Patients’ Bill of Rights, including the right to informed consent. You also are responsible for evaluating your patients’ understanding of privileged communication and duty to disclose as it pertains to informed consent. You must also assess other healthcare team members’ knowledge of patients’ rights and provide education to them as needed.

Collaboration Collaboration, in this case, is defined as the interdisciplinary interaction between the various areas of healthcare. Nurses work with physicians, social workers, dieticians, pharmacists, and many other healthcare specialties to achieve proper patient care. Collaboration requires integration, cohesiveness, and teamwork. As a nurse, you will often have the closest contact with the patient, and you must be ready to initiate interdisciplinary discussions based on your observations and patient-given information. In effect, you will serve as the central point of contact for your patient’s collaborative healthcare team.

Management A nurse often functions as the manager of the healthcare team. You must know the roles and responsibilities of each team member, and you will serve as a liaison between the team and the patient. You are a frontline problem-solver: you will need to use conflict resolution skills to settle problems both between team members and between your patient and the team. Developing an overall strategy for handling problems is key to your success in this role. Supervision of properly delegated work is also a key function of a nurse as a manager.

Confidentiality and Information Security A nurse’s role includes both maintaining confidentiality and taking steps to ensure a patient’s privacy is maintained. Understanding HIPAA (the Healthcare Insurance Portability and Accountability Act) is crucial to this end. You should take steps to ensure only authorized personnel have access to the medical record and that sensitive, private patient information is kept out of public view. This also includes conversations that may relay this type of information to unauthorized persons. Intervention may be necessary if you observe these types of breaches from other healthcare team members.

Continuity of Care Continuity of care refers to the proper communication of information between different departments and agencies, from one agency to another, to ensure that all parties (including the patient) agree upon and understand the patient’s healthcare goals. The nurse must understand the proper procedures for admission, transfer, and discharge to and from a facility, as well as the proper forms or referral paperwork that is required in the patient’s medical record. You will also be responsible for following up on any unresolved issues for your patient and forwarding this information to the appropriate agency or department such as lab or imaging results. You may also need to be prepared to give report to the patient’s new nursing staff.

Establishing Priorities Each day in your nursing work, you will utilize your ability to prioritize. You will need to establish care priorities for individual patients as well as prioritize your assigned patients as a group.

Guidelines to Use There are many frameworks that may be used in developing priorities. They may include:     

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ABCs—airway, breathing, and cardiovascular or circulatory system Maslow’s hierarchy—physiological needs, then safety and security, love and belonging, self-esteem and self-actualization Agency policies—protocol dictated by the regulations of your facility Time—being efficient and delegating when appropriate Patient and family—taking the time to understand your patients and their families in order to better assess individual needs and prioritize your care duties for the day Patient activity—report, which can be a valuable tool in planning your priorities for the day (Likewise, adjusting your priorities based on patient’s needs and activities will help you get your work done most efficiently.) Medication priorities—managing care according to any strict schedule of patient medication

Planning Care Your assessment skills and ability to triage patients’ needs based on your findings will help you prioritize appropriate interventions and give care to those who are unstable and need immediate attention. This is especially true if you have multiple patients. Patients demonstrating these conditions will have priority:     

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Post-surgery—These patients require frequent monitoring of vital signs as well as fluid and pain management. Baseline status deterioration—Any change from baseline requires immediate life-sustaining intervention and assessment as to the underlying cause. Shock—Patients in shock require targeted intervention based on the underlying cause and measures to reverse the physiologic changes triggered by shock. Allergic reaction—Immediate pharmacologic intervention is necessary for patients exhibiting signs of allergic reaction. Chest pain—Patients with symptoms of chest pain need immediate cardiac monitoring, pharmacologic intervention, and close monitoring for cardiovascular deterioration. Post-diagnostic procedure—Some diagnostic procedures (i.e., cardiac or vascular imaging) will require temporary but close, frequent monitoring. Unusual symptoms—Patients with unusual symptoms should be assessed more frequently for worsening or change in their symptoms. Equipment malfunction—Patients with malfunctioning IVs, tubing, or other care equipment will require immediate attention and more frequent follow-up.

Ethical Practice Each day you work as a nurse, you will be required to use the basic principles of morals and ethics to judge your actions and behavior as right or wrong. The American Nurses Association (ANA) has developed a Code of Ethics for nurses to abide by. This code provides the ethical guidelines that define the values and standards for the nursing profession. Understanding these principles is essential to providing ethical nursing care:        

Autonomy—a person’s right to make his or her own decisions Beneficence—doing what is in the best interest of another Justice—providing equal, fair, and impartial treatment Nonmaleficence—acting in a manner that avoids harm Fidelity—maintaining faithfulness to ethical principles and to the ANA Code of Ethics for Nurses Virtues—integrity, honesty, trustworthiness, and compassion, which are standards of nursing Confidentiality—maintaining the privacy of another’s personal information Accountability—maintaining responsibility for one’s own actions

Informed Consent

Informed consent means that a patient has been appropriately counseled on all the risks and benefits of a particular test or treatment before being asked to agree to it. There are four main components of informed consent:  

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a detailed explanation of the procedure or treatment a detailed explanation of the known risks and benefits of the procedure or treatment (Specifically, the risk of death or potential serious injury should be included if applicable.) a discussion of all possible alternative procedures or treatments a discussion of what the potential ramifications are if the patient refuses the procedure or treatment being considered

Obstacles As a nurse, you will facilitate the process of informed consent. This may include evaluating whether or not the patient is capable of giving informed consent (mental competency, minor, etc.) and identifying the proper person (parent, legal guardian, etc.) to act on the patient’s behalf. You may also serve as a witness of informed consent, and you must ensure that it occurs prior to the proposed treatment or procedure. You must advocate for your patients by ensuring they have adequate information to give informed consent. This may include providing a translator or written materials in the patient’s native language. Despite all these responsibilities, the nurse is not responsible for providing the information regarding the procedure(s) being performed. The nurse must work with appropriate providers performing the interventions/procedures and coordinate their conversation with the patient. Any refusal of care by the patient must be properly documented in the medical record.

Information Technology Information technology can improve patient care by allowing expedient access of authorized providers to a patient’s entire medical record. It can improve patient safety and health outcomes and may also be used to enhance patient education and care.

EHR Electronic health records (EHRs) are computer-based versions of a patient’s paper chart. They include all the personal information of the patient, demographics, insurance information, medical notes, test results, past medical history, medications, immunizations, and vital signs. EHRs can facilitate care between authorized users involved in patient management because they allow instant access to all necessary medical information. They may also be helpful either directly or indirectly to other care-related activities such as quality management and outcomes reporting.

eMAR Electronic medication administration records are systems that use electronic tracking systems (i.e., barcodes, etc.) to track medications from order to patient administration and integrate this information into the patient’s EHR. eMARs have been shown to improve patient safety and outcomes by greatly reducing medication administration errors.

Guidelines Nurses working with these types of information technology systems will need to have a thorough understanding of how each works in order to use them properly and efficiently. The rules of patient confidentiality also apply to accessing and transmitting electronic hea...