Nursing Delegation notes PDF

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Delegation Delegation

Assignment

Supervision

Judgment

Unlicensed Assistive Personnel

Definition of Terms Nurse practice acts in all states either specifically state or imply Transfer of responsibility for the that delegation is within the scope of practice for the registered performance of an activity from one nurse (RN), the professional nurse. individual to another while retaining accountability for the outcome. Distribution of work that each staff member Staff members can only be “assigned” to do activities that they is to accomplish on a given shift or work already have the scope of practice to do. For example, an RN can be assigned to admit new clients, because this is within the period. RN scope of practice. A licensed practical nurse (LPN) or licensed vocational nurse (LVN) can be assigned to administer medications to a group of clients, because this is within the LPN scope of practice. An LPN cannot be assigned to a client who needs an admission assessment because an RN must do the initial assessment of a client. Active process of providing guidance and direction, oversight, evaluation, and followup by the RN for accomplishment of a nursing task delegated to unlicensed assistive personnel (UAP) and licensed practical nurses/licensed vocational nurses (LPN/LVNs). Intellectual process that a nurse exercises in forming an opinion and reaching a clinical decision based upon analysis of the evidence or data. UAP’s are persons not authorized under respective nurse practice acts to provide direct nursing care

Certified nursing assistant’s (CNA’s), orderlies, clerical workers, and client care technicians PCT’s* These persons work under the auspices and license of the institution, not the professional nurse (Only licensed persons are granted that license and only they can retain or lose it).

* PCT’s (also known as CNA’s): Job description varies from institution to institution with each facility defining the PCT’s scope of practice. Each institution is responsible for its own training.

Q1. Does the Illinois Nurse Practice Act specifically state that delegation is within the scope of practice of the RN? Please find the appropriate section in the Illinois Nurse Practice Act.

Some states allow LPN/LVNs to delegate, some prohibit them from delegating, and others allow them to assign nursing activities. Q2. Does Illinois allow LPNs to delegate? Please find the appropriate section in the Illinois Nurse Practice Act.

The 5 “Rights” of Delegation

1. Right Task

2. Right Circumstance 3. Right Person

The task must be delegable according to the state nurse practice act (see web sites above). If delegated, there should be a low potential for harm to the client and the outcome for the task should be highly predictable. Even if the task is delegable, the RN must consider if it is actually the best course of action to delegate. Decision-making is based on client condition and preferred client results. The nurse must know the licensure, role, and preparation of each member of the team. The RN also needs to consider the amount of supervision required once the task is delegated: If the nurse is unsure if the person to whom the task is to be delegated is able to perform the task adequately, it may be best not to delegate it at all.

4. Right Direction/Communication

Clear and specific directions regarding the task should be given to ensure the plan of care has been individualized to meet the client’s specific needs. Expected outcomes should be clear so it will be clear if the task was performed correctly

5. Right Supervisor/evaluation

The provision of guidance and direction, oversight, evaluation and follow-up by the licensed nurse for accomplishment of a nursing task delegated to nursing assistive personnel

Q3. You are the charge nurse. Which client is most appropriate to assign to the step-down unit nurse pulled to the intensive care unit (ICU) for the day? 1. A 68-year-old client on ventilator with acute respiratory failure and respiratory acidosis 2. A 72-year-old client with COPD and normal ABGs who is ventilator dependent 3. A 56-year-old new admission client with DKA on an insulin drip 4. A 38-year-old client on a ventilator with narcotic overdose and respiratory acidosis Q4. You are the charge nurse in an ER and must assign 2 staff members to cover the triage area. Which team is the most appropriate for this assignment? 1. An APN and an experienced LPN 2. An experienced LPN and an inexperienced RN 3. An experienced RN and an inexperienced RN 4. An experienced RN and a nursing assistant

The Nursing Process Is Related to Delegation Although state nursing practice acts vary, there is consensus that certain aspects of care can be delegated, but the nursing process itself can never be delegated to someone who is not an RN. Assessment, planning, evaluation, and nursing judgment are RN-level skills that require in-depth education and the highest level in nursing scope of practice. Assessment The RN needs to assess not only the client and the client’s individual needs, but also the staff member to whom a task will be delegated. This assessment should include the individual’s strengths, weaknesses, training, and experience. Assessment is the initial phase of the nursing process which involves interpretation of the significance of the available subjective and objective data regarding a specific client situation, performed in order to formulate an individualized plan of care. RNs must complete the initial assessment upon admission, return from OR, or upon a change in condition. LPNs and UAPs may collect some data for the RN to interpret and evaluate. However, the responsibility for the interpretation/evaluation of the collected data (which requires nursing judgment) must be done by the RN. Diagnosis

Only RNs can make a nursing diagnosis. Planning The RN uses critical thinking and makes clinical decisions to determine what client care activities need to be completed during a timeframe and who will accomplish them. Implementation The most common nursing actions that are delegated fall under the implementation phase of the nursing process. For example, the nurse can delegate measuring urine intake and output to UAP, but the decision of how frequently the intake and output need to be measured (which requires nursing judgment) must be made by the RN. The nurse may delegate administration of insulin to a diabetic client to an LPN/LVN and also delegate the monitoring of the blood glucose after insulin administration to an LPN/LVN. The RN retains the accountability for using nursing judgment to hold the regularly scheduled insulin for a client who is at risk for hypoglycemia. The RN must then communicate clearly to the LPN/LVN that the insulin is to be held, including the information, about which type of insulin, which dose of insulin, and how long the insulin is to be held. Included in implementation is client and family education. The RN is responsible for client education. An LPN can only teach from a standardized care plan (? what ever that means), assist in client education, or reinforce teaching that has already been completed. The UAP should not be doing any client education. Evaluation The RN will need to evaluate: (1) whether all the delegated actions have been done and (2) whether the tasks have been done correctly. In addition, critical thinking and nursing judgment are needed to determine whether changes in delegation or assignment need to be made. This may occur throughout a given shift as client care needs and/or resources change, or it may occur at the end of a shift when planning for the next shift.

What Can/Cannot Be Delegated to the LPN? The LPN can delegate and supervise other LPNs in the delivery of care within the LPN’s legal scope of practice and level of competency. 1. The LPN can supervise unlicensed assistive personnel. 2. While LPNs can do data collection, they cannot do client assessments. 3. LPNs cannot independently develop the nursing care plan. 4. LPNs cannot administer IV chemotherapy; however, bladder instillation of chemotherapy is permissible. 5. LPNs cannot administer any direct IV push medications or administering heparin in heparin locks. 6. Starting or adding blood or blood components. 7. LPNs cannot access any form of central line, or venous chest or arm port line device. 8. LPNs cannot do triage or case management. 9. LPNs cannot independently complete client education. LPNs may assist in and reinforce client education, but the RN should not delegate the evaluation of client understanding. Q5. Which intervention for the client with PE could be delegated to the LPN? 1. Evaluate client report of chest pain. 2. Monitor lab values for changes in oxygenation. 3. Assess for symptoms of respiratory failure. 4. Auscultate lung sounds for crackles.

Q6. An elderly client in your LTC facility has candidiasis in the skin folds of the abdomen & groin. Which intervention is best to delegate to the LPN/LVN? 1. Apply nystatin powder TID. 2. Clean skin folds q 8 hrs with soap & dry thoroughly. 3. Evaluate the need for further antifungal tx at least weekly. 4. Assess for ongoing risk factors for skin breakdown & infection. Q7. The nursing care plan for the client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for the LPN being supervised by the nurse? Select all that apply. 1. Remind client to avoid commercial mouthwashes 2. Encourage mouth rinsing with warm saline 3. Assess lips, tongue, and mucous membranes 4. Provide mouth care every 2 hours while client is awake 5. Seek dietary consult to increase fluids on meal trays Q8. A LPN from the pediatric unit is assigned to work in a critical care unit. Which client assignment would be appropriate? 1. A client admitted with multiple trauma with a history of a newly implanted pacemaker 2. A new admission with left-sided weakness from a stroke and mild confusion 3. A 53 year-old client diagnosed with cardiac arrest from a suspected myocardial infarction 4. A 35 year-old client in balanced traction admitted 6 days ago after a motor vehicle accident Q9. As a charge nurse you assign the nursing care of a client who has just returned from open carpal tunnel release to an experienced LPN. Which of the following instructions will you provide? Select all that apply. 1. Check the client’s vital signs every 15 minutes in the first hour 2. Check the dressing for drainage and tightness 3. Elevate the client’s hand above the heart 4. The client will no longer need pain medication 5. Check the neurovascular status of the fingers every hour Q10. Which one of these tasks can be safely delegated to a LPN? 1. Assess the function of a newly created ileostomy 2. Care for a client with a recent complicated double barrel colostomy 3. Provide stoma care for a client with a well-functioning ostomy 4. Teach ostomy care to a client and their family

What Can Be Delegated to the UAP?       

ADLs Bathing Grooming Dressing Toileting Ambulating Feeding

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Positioning Bedmaking Specimen collection Intake and Output Vital Signs

Q11. A client’s nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be delegated to a nursing assistant? 1. Administer IV fluids as prescribed by the physician 2. Provide straws and offer fluids between meals 3. Develop plan for added fluid intake over 24 hours 4. Teach family members to assist client with fluid intake Q12. Which action should you delegate to the nursing assistant for the client with DKA? Select all that apply. 1. Check finger stick glucose every hour 2. Record I & O every hour 3. Check VS every 15 minutes 4. Assess for indicators of fluid imbalance Q13. You are initiating a NCP for a client with osteoporosis. All of these nursing interventions apply to the diagnosis risk for falls. Which intervention should you delegate to the nursing assistant? 1. Identify environmental factors that increase risk for falls 2. Monitor gait, balance, and fatigue level with ambulation 3. Collaborate with PT to provide client with walker 4. Assist the client with ambulation to bathroom and in halls. Q14. You are caring for a client with a NG tube. Which task can be delegated to the experienced nursing assistant? 1. Remove NG tuber per physician order 2. Secure the tape if the client accidentally dislodges the tube 3. Disconnect the suction to allow ambulation to the toilet 4. Reconnect the suction after the client has ambulated

Accepting Delegated Tasks Aside from assignments, other tasks may be delegated by RNs to other RNs. A busy nurse might ask another nurse to perform a task for him/her, or a nurse might be assigned to another unit with a different client mix. While it is easy to assume that the delegator always applies the principles, or the 5 “Rights,” of delegation when delegating, there may be circumstances when some principles may be overlooked. The delegator might assume that a nurse possesses more advanced training than there actually is, for example. When accepting the delegated responsibility, it is prudent to remember the following principles: Am I the Right Person? Remember that when you, as an RN, accept responsibility for a task from another nurse, accountability comes with it. You are using your RN license, and you are not “borrowing” the delegator’s license. So, make sure that the delegated task or assignment you accept is within your scope of practice and within your competence or training level (e.g., patients on ventilators, ACLS certification, CRRT training, titration of vasoactive medications.) This might sound common sensical, but when staffing is low and everybody is asked to “pitch in,” the inclination to relax the rules sometimes comes fore. The same principle applies when asked by doctors to perform tasks/procedures. Safety First Patient safety, that is. Nuff said.

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Summary of Principles for Implementation of Delegation Refer to your state’s nurse practice act as well as your institution’s job descriptions for current information about roles and responsibilities of parties involved (RN, LPN/LVN, and UAP). Student nurses, novices, float nurses and other infrequent workers will require variable levels of supervision, guidance or support. The RN is accountable for nursing judgment decisions and for ongoing supervision of any care that is delegated or assigned. The RN cannot delegate the nursing process or clinical judgment to a non-RN. Some interventions or data-gathering activities may be delegated based on the circumstances. The RN must know as much as practical about the clients and their conditions, as well as the skill and competencies of team members. Decisions must be specifically individualized to the client, delegates and institution. In a clinical situation, everything is fluid and changing. No priority, assignment or delegation is written in stone without ability to alter. The RN in charge of the unit, team or client is accountable to choose the best course to achieve the client/family’s preferred results. When accepting delegation, take into consideration whether you are the right person for the job and whether patient safety might be compromised.

Q15. The client’s K+ is 6.7 mEq/L. Which intervention should you delegate to the student nurse under your supervision? a. Administer Kayexalate 15 g orally b. Administer spironolactone 25 mg orally c. Assess ECG strip for tall t-waves d. Administer potassium 10 mEq orally.

References American Nurses Association & National Council of State Boards of Nursing (2005). Delegation joint statement NCSBN-ANA. Retrieved from https://www.ncsbn.org/1625.htm Gauwitz, D. F. (2007). Leadership and management. In Thompson Delmar Learning’s Nursing Review Series: Legal & Ethical Nursing (p. 32). Clifton Park, NY: Thompson Delmar Learning. Guido, G.W. (2006). Legal & ethical issues in nursing. Upper Saddle River, NJ: Pearson Education, Inc. Illinois General Assembly (2015). Part 1300 nurse practice act. Joint Committee on Administrative Rules. Retrieved from ftp://www.ilga.gov/JCAR/AdminCode/068/06801300sections.html LaCharity, L.A., Kumagai, C.K., and Bartz, B. (2006). Prioritization, delegation & assignment: Practice exercises for medical-surgical nursing. St. Louis: Mosby/Elsevier. Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-surgical nursing: Assessment and management of clinical problems. (10th ed.). St Louis, MO: Elsevier....