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Nursing Delegation/Documentation and more

Student Presentation Regarding Delegation, Documentation, Chain of Command, and LPN and NAP roles
by

Stephanie Givens

on 26 June 2014

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Transcript of Nursing Delegation/Documentation and more

Chain of Command
Documentation
Change of Shift Report Exercise
Delegation
Def: vertical relationships within organization (i.e. Nurse Nurse Manager Nursing Supervisor)
LPN Roles
Administer meds
Perform procedures according to policy
Recognize abnormal findings
Care for stable patients with predictable outcomes
Implement a plan of care
Knowledge of asepsis and dressing changes
Purpose
Legal Record
Third-party reimbursement
Required by regulatory agencies
Promotes Communication
Def: Giving another individual the authority and responsibility to execute a task
You can only hand off authority and responsibility, but
NEVER
accountability
Can only delegate task for which the nurse is responsible.

Delegation/
Chain of Command/
Documentation

Assist with direct client care activities: bathing, feeding, transferring, tolieting, obtaining vital signs, I&Os, height and weight.

Scope of practice is limited

CNA/NAP Roles
ALL VARIANCES, PROBLEMS, AND CONCERNS ARE REPORTED TO THE NEXT PERSON WITH AUTHORITY IN DIRECT LINE.
Objectives
List the Five Rights of Delegation
Explain the Chain of Command
Discuss the role LPN/LVN and CNA/NAP
Outline the characteristics of Good Documentation
Discuss the purpose of good documentation
Examine the importance of a thorough Change of Shift report
Right Task
What is the task to be completed?

Assist patient to the toliet
Provide discharge instructions
Administer IV medications
Reposition patient
Right Person
Who should be the Delegatee? - Match the task with his/her skills and abilities

CNA/NAP
LPN
Another RN
Right Circumstances
Is this a routine task, One you don't have time to accomplish, or with a lower priority

Has all of the patient's needs been assessed?
Right Direction/Communication
What does the task involve?

Specify data to be collected
Explain the activities to be performed
Be sure clear instructions have been given and understood
Right Supervision/Evaluation
Answer any questions regarding the task

Remember accountability remains with YOU!
An RN discusses delegation with a new nurse. Which of the following statements by the new nurse indicates an understanding of the meaning of delegation?

A. Delegation means that the nurse is able to understand nursing actions and results.

B. Delegation occurs when the RN assigns a specific task to be delegated to an LPN or CNA.

C. Delegation occurs when the nurse does not have time to complete the task and tells another nurse to complete the task.

D. Delegation means that another nurse is obligated to complete the task.
Five Rights of Delegation
Resources
The Five Rights of Delegation. (n.d.). . Retrieved June 22, 2014, from https://www.ncsbn.org/fiverights.pdf

Halm, M. A. Nursing Handoffs: Ensuring Safe Passage for Patients.
American Journal of Critical care
, 22, 158-162.

Kærnested, B., & Bragadóttir, H. Delegation of registered nurses revisited: attitudes towards delegation and preparedness to delegate effectively.
Nordic Journal of Nursing Research & Clinical Studies
, 32, 10-15.

LeMone, P., & Burke, K. M. (2011).
Medical-surgical nursing: critical thinking in patient care
(5th ed.). Upper Saddle River, N.J.: Pearson.

Lorenzo, O., & Parsh, B. Improving change-of-shift report.
Nursing
, 43, 68.

NCLEX-RN content review guide
(Second ed.). (2014). New York: Kaplan Nursing.


Accurate and factual, not summarized
Well Organized
Proper
Grammar &
Spelling
Confidential
Use Approved
Abbreviations
Only
Good Documentation
An RN assesses clients for the upcoming shift. The nursing team includes one RN, two LPN/LVNs, and four CNAs. The nurse determines assignments are appropriate if which of the following patients is assigned to a CNA?

A. A patient diagnosed with Addison’s disease needing a sterile dressing change.
B. A patient requiring strict intake and output.
C. A patient with full thickness burns requiring IV morphine.
D. A patient diagnosed with cancer complaining of a headache.
A client admitted for an MI is now stable. Appropriate activities to assign to unlicensed personnel would include all the following except:

A. Teaching about what foods are high in sodium.
B. Recording intake and output.
C. Assisting with ambulation to the restroom.
D. Reporting to the nurse that the pt complained of chest pain.
A. Teaching about what foods are high in sodium
A student nurse discusses good documentation. The student nurse identifies which one of the following statements adheres to the legal guidelines for appropriate documentation?

A. The nurse leaves blank lines in the chart so that other nurses can fill in the blanks.
B. The nurse uses white out in the chart to fix her mistakes.
C. The nurse documents changes in the patients condition.
D. The nurse charts that the physician “made mistakes in the medication administration of the patient.”
C. The nurse documents changes in the patients condition.
B. Delegation occurs when the RN assigns a specific task to be delegated to an LPN or CNA.
B. A patient requiring strict intake and output.
An agitated patient is very upset about the level of care she has received since admission. She is a requesting to speak to the CEO or COO of the hospital to address her dissatisfaction. What is the most appropriate action for the nurse to take at this time?

A. Administer PRN Lorazepam (Ativan).
B. Contact the CEO's secretary to make arrangements to meet the patient.
C. Inform nursing supervisor of the situation.
D. Inform the client that he/she is being unreasonable.
C. Inform nursing supervisor of the situation.
Delegation is done frequently as a nurse but needs to be done with care.
Follow the 5 rights of delegation
Know what task can be delegated and to whom
This includes knowing the roles of LPN/LVN and CNA
Contact your immediate supervisor, for any problems and concerns
Documentation is a legal record of the care that has been provided
Documentation should be concise, appropriate, legible, thorough, and well organized.
If a task is not documented...it did not happen.
Be sure to document all client conditions, assessments, changes, responses, and teaching
Change of shift reports should be thorough and accurate.
Do not include any personal opinions, gossip or judgements in your documentation or change of shift reports
Summary
Any Questions?
Full transcript