Clinical Nursing Skills: Basic to Advanced Skills, 9th Edition

Chapter 3 Managing Client Care: Documentation and Delegation TEACHING/LEARNING STRATEGIES Lecture–Discussion Instructor Planning: Obtain examples of different standard care plans from the hospital/computer and review the procedure for using the plans. Include how they are initiated, updated, and discontinued. Obtain several copies of clinical or critical pathways and describe how they are used in managed care health systems. Demonstrate the hospital documentation format used in the clinical facility. Discuss various charting formats and the rules for documenting client care. Simulated situations can be printed on 5 9 cards. Ask the students to document their findings on a form. Written Assignment Use a nursing care planning book and have students identify a standard care plan for one client they have cared for in a recent clinical experience. Instruct students to state how and why this standard plan fits their client. Demonstrate and then assign students to write a nursing care plan after they are familiar with the care planning and have sufficient knowledge. Suggest they start by writing only the client needs that are actual problems. (When needs are placed in priority order, this action assists students with critical thinking and decision making.) An excellent critical thinking exercise can be included in the written assignment. Have students provide a brief scientific rationale for the priority nursing intervention, which is determined for the priority client problem. Ask them to state the rationale in their own words. Have students identify if the stated goals on their client’s care plan, either short- or long-term, are measurable and appropriate for the client’s situation. If not, have them identify a more appropriately stated goal. Laboratory Experience Provide a taped or verbal shift report/handoff and have students practice writing information on a worksheet. Have students complete a prep sheet based on a simulated situation. Prepare a work sheet for students or have them bring a work sheet from the clinical area. Ask them to give a verbal shift report to a group of peers. Have students demonstrate electronic charting on a recent client. Clinical Experience Have students attend a care conference on their assigned client and write a summary of how the conference was organized, which health team members participated in the conference, and their role in delivery of health care to clients. Have them identify the leader of the conference. Include a brief summary of the final results from the conference. Students should begin updating, activating, and deactivating care plans or clinical pathways with instructor guidance early in their first clinical experience if this is permitted by the facility. If not, guide students through the process outside of the clinical site.This helps them identify the need for accurate care plans and pathways. Have students critique a shift report/handoff, including pointing out any information that was not relevant to the situation and any essential information that was omitted. Resource Suggestions Use standard care plans developed by hospitals. 1. Obtain several critical pathways for clients that students have been assigned to in the clinical setting. 2. Break students into small groups, each with a different pathway. Have the students prioritize the aspect of care for the first day. Have them state the rationale for their decisions. Asking the students to identify the priority nursing diagnosis can be added to the task if time permits. Assign a time frame for this activity that will allow the groups to present their findings at the end of class. 3. You may need to write a clinical client scenario for a particular pathway if the students have not had an assignment supporting the pathway you have chosen for the activity. 4. Select one spokesperson from each group to present the findings from the group. Allow time for group discussion by the entire student group. Encourage all students to participate, challenge the prioritization, nursing diagnosis, or rationale. If they have a different prioritization, they need to provide the rationale for their choice. CRITICAL THINKING strategies Exercise 1 Have students complete a mock time management sheet based on a simulated clinical assignment. Provide students with a client assignment sheet with personnel assigned to the client. Ask them to identify if the appropriate personnel is assigned to each client. They need to provide rationale for their answers. They need to indicate the most appropriate category of health care worker who should be assigned the client if they think the assignment is not appropriate. A discussion of the Nurse Practice Act for both RN and LVN/LPN must be discussed for this activity to be pertinent. The role of the CNA and UAP must be discussed according to policy and procedures for the state and health care facilities used for their clinical experience. Exercise 2 To increase students’ observation skills, an activity can be used for students to determine their ability to observe and recall details that are a part of data collection. During a discussion of the various types of documentation and the importance of accurate observation skills, ask a faculty member or a student to pass through the front of the room and exit. It would be helpful if the person looked embarrassed, carried something in his or her hands, and had on nondescript clothing. The best time would be about five minutes into the class on documentation. After the person has exited, ask the students to describe what they observed. Leave the observation very open to the students’ recall of the person. Do not ask specifically for clothing, appearance, etc. Allow the students five minutes to recall the information. Ask the person to return to the room. Have the students verify their observations. Identify errors in recall and what observations were missing. After this exercise, discuss the importance of accurate and complete observational skills. Exercise 3 Ask several of the students or the faculty to participate in a role-play situation. The intent of the role play is to depict a potential litigation issue. Examples for the role play include: a client falling out of bed and fracturing a hip when the side rails are down; an antibiotic given to the wrong client who is allergic to the drug; an IV with a toxic drug infiltrated into the subcutaneous tissue, causing a sloughing of the tissue. During the role, the “nurse” should describe what she or he observed to a “physician” and to the “nurse manager.” Cue cards may need to be given to the players, describing what they probably observed. It depends on the level of the student or if a faculty member is acting the part of “nurse” or “physician.” The “client” should be given cue cards directing him or her on what to communicate, how to react to the incident, such as grimacing with pain, feeling nauseated, etc. Ask the students to chart the incident and fill out an Unusual Occurrence Report. A discussion related to the content of the documentation should follow the charting and completion of the report. Ensure that the critical information needed for the Unusual Occurrence Report is included and stated in the correct manner. Information related to how the Unusual Occurrence Report is used within the hospital facility should be included in the discussion. Scenario 1 Determine appropriate delegation of client activities for a staff team on a unit. This scenario does not take into consideration the acuity of the client, only the nursing tasks needed for the day shift. Each facility and state have differing policies regarding personnel; therefore, these policies need to be reviewed before this activity is completed. The team consists of one RN, one LPN/LVN and one UAP. There are 10 clients and 2 unoccupied beds. There is a charge nurse and ward clerk assigned to the nursing unit. There are two other teams and these three teams make up the medical-surgical nursing unit. RM 601A Mr. Rodriguez, 98, admitted 24 hours earlier Diagnosis: congestive heart failure Bed rest, bed bath and assistance with oral hygiene, daily weight, I&O Vital signs every 4 hrs., low sodium diet, restricted fluids to 1500 mL. IV #2 1000 mL D5/0.2NS with 20mEq KCL at 50 mL/hr. 800 mL remaining IV medications: furosemide 40 mg BID Oral medications: digoxin 0.25 mg daily, vitamin supplement RM 601B Mr. Jamisen, 69, admitted this a.m. Diagnosis: coronary artery disease Surgery at 10 a.m.: triple bypass-- will go to ICU following surgery Pre-op checklist and client teaching has been completed Pre-op meds on call to OR. IV medications IV #1 1000 mL D5/0.2NS at 75 mL/hr. RM 602A Mrs. Jones, 59, admitted 2 days ago Diagnosis: cholelithiasis Surgery 2 days ago: Laparoscopic cholecystectomy Ambulate ad lib., self care Oral medications for pain IV discontinued at 8 a.m. To be discharged today with discharge teaching RM 602B Not occupied RM 603A Mrs. Henderson, 38, admitted yesterday Diagnosis: metastatic cancer to the brain CAT scan scheduled for 12 noon IV #2 1000 mL D5W with 20mEq. potassium chloride at 50 mL/hr. Assist with ADLs Vital signs and neuro checks every 4 hrs., I&O oral medications for pain RM 603B Miss Johnson, 70, admitted 3 days ago Diagnosis: pancreatic cancer with metastasis to the lungs Chair three times a day, and ambulate to bathroom Vital signs every 4 hrs. Spirometry every 4 hrs. with RT Deep breathing and coughing exercises every 4 hrs, Nasotracheal suction PRN. IV #5 1000 mL D5W at 50 mL/hr. PCA pump for pain medication Chemotherapy IV daily RM 604A Mr. Scott, 64, admitted this a.m. Diagnosis: benign prostatic hypertrophy Surgery: TURP scheduled for 1 p.m. to return to the nursing unit Needs pre-op teaching and a surgical checklist completed RM 604B Mr. Jackson, 37, admitted last night Diagnosis: torn ACL Surgery this a.m. at 7:30--will return to unit by 10:30 a.m. Continuous passive motion (CPM) ordered postop RM 605A Mrs. Price, 89, admitted 1 week ago Diagnosis: terminal heart failure, semi-comatose Complete ADLs, keep comfortable, turn and position every 2 hrs. Vital signs every 8 hrs., I&O, Indwelling urinary catheter to drainage IV #8 D5/0.45 NS with 40mEq potassium chloride at KVO (keep vein open) rateRM 605B Not occupied RM 606A Mrs. Fellipe, 28, admitted last evening Diagnosis: gastroenteritis for last 4 days Ambulate to bathroom, chair as tolerated Independent in ADLs Vital signs every4 hrs., NPO, I&O IV #3 1000 mL NS with 40mEq potassium chloride at 125 mL/hr. RM 606B Mrs. Blake, 48, admitted yesterday Diagnosis: sickle cell crisis Bedrest until pain subsides Vital signs every 4 hrs., I&O, diet as tolerated Oral medications, folic acid, non-steroidal anti-inflammatory drug Narcotic analgesic medication for pain IV #3 1000 mL D5/0.2NS with 40mEq potassium chloride at 125 mL/hr. 1. Determine the appropriate staff assignment for this client roster. What information do you need to complete this assignment? 2. How would you as team leader make client assignments for each individual staff member? 3. How do the theory of delegation and the facility/state policies of delegation impact on your assignment? 4. What additional factors would you need to consider in making these assignments? Scenario 2 You are assigned to provide nursing care for Mr. Fred Smith, 39 years of age. He is admitted to the hospital for severe dehydration due to the effects of chemotherapy. On your initial rounds at 7:30 A.M., you find him sleeping. His respirations are labored and stertorous. His color is ashen, eyes sunken, and skin dry. At 8 A.M. you enter the room and find him awake. He complains of being very thirsty and wants a glass of water. He cannot tolerate oral fluids and is receiving IV fluids with potassium chloride (KCI) added because of his nausea and vomiting on admission the day before. After taking his vital signs (T: 100.6; P: 100; R: 32) you give him his bath and make his bed. You notice he has reddened areas over his coccyx and on his elbows and heels, each area about the size of a quarter. His skin is dry and peeling. Drainage from his Foley catheter is a dark amber color with a very strong odor. You measure the urine at 8 A.M. The total is 75 mL. The last output was measured at 6 A.M. 1. How would you chart the information obtained from the simulated situation? What would be appropriate forms to use? 2. What assessment information (that you just charted) would require nursing interventions? If you were assigning this client to a team member, who would be most appropriate—RN, LPN/LVN, or CNA? Scenario 3 You have just received your client care assignment. There are two stages of preparation. The first is obtaining all the necessary information you will need to provide safe care. The second stage is reviewing your reference materials to gain an understanding of the client’s diagnosis, medications, lab values, and diagnostic tests that will be done during his/her hospitalization. 1. If you have only limited time to review the client’s chart, what sections of the chart will provide you with sufficient information to render you safe to care for the client? 2. In preparing for clinical practice, what information is essential to review in addition to the data you have obtained from the client’s record? Where is the most appropriate place to find this information? 3. List the priority interventions you will carry out within the first hour of the clinical experience. Explain the rationale for your answers. Resolution Possibilities for Scenario 1 1. Review each client and determine the appropriate staff assignment based on the skill level and Nurse Practice Act, and hospital policies and procedures. 2. An LPN/LVN cannot be assigned to do an initial complete physical assessment; it would be assigned to an RN. Depending upon state practice act regulations an RN may be required to administer intravenous medications. 3. Ensure that the rationale for the assignment follows the principles of delegation. 4. The team approach should be used when assigning clients. Each staff member may be assigned to a certain skill for a specific client. Examples follow: a. The RN will initiate PCA medications. b. The RN will be the team leader and other staff will report to the RN, who assumes responsibility for client care. c. The LPN/LVN or RN can give oral meds. Depending upon state practice act the LPN/LVN may or may not complete discharge teaching. d. The RN must complete the initial physical assessment. e. The UAP can assist clients with ADLs, ambulation, baths, and beds. f. The UAP may take basic vital signs and accompany clients to surgery or discharge. The Nurse Practice Act provides guidelines for the different tasks each staff member may perform. While making assignments, it is important to remember that the more experienced and educated staff (RN or LPN/LVN) should care for the most critically ill clients. Clients who are not new admissions (who have already been assessed by an RN) and those about to be discharged may be assigned to UAPs. Resolution Possibilities for Scenario 2 1. Appropriate forms should be used, i.e., I & O Record includes IV (intake), indwelling urinary catheter drainage output, vomiting. 2. Fluid intake—can client take fluids PO now? Pressure ulcer—interventions to prevent from developing. 3. RN or LPN/LVN—continued assessment needs to be made and interventions made to prevent complications. Resolution Possibilities for Scenario 3 1. Client’s medical diagnosis, medications to be given during clinical, essential lab values for medication tests, if client has any allergies. 2. Information on medications from PDR and Drug reference texts. Information on medical diagnosis from textbooks. Nursing skills protocols and procedures from skills text. Lab information from lab diagnostic text. 3. Complete hand hygiene, receive oral report from nurse, check Kardex or computer generated care plan for new client information, introduce yourself to your client, take vital signs, complete a focus assessment, and check that all medications are available in cart if not using Pyxis machine. Each of these tasks is designed to provide safe client care. Hand hygiene prevents the spread of microorganisms to the client. Checking medications and new orders is essential to provide accurate care for the client. The focus assessment provides the baseline information on the client’s condition and promotes individualized client care. Clinical Nursing Skills, 9e Smith, Duell, Martin, Aebersold, and Gonzalez © 2017, Education Inc.