Professional Issues Study Guide for the CEN

Patient

Patients will come from myriad backgrounds and represent a range of races, ethnicities, families, life experiences, religions, genders, ages, and other factors that impact their care. Each factor must be considered carefully. Some patients rarely seek healthcare and are not well-versed in the healthcare system, while others are frequent flyers, so to speak. Every patient should be treated with respect and receive considerate, compassionate care no matter who they are or what their background is. The CEO of the hospital and someone who is homeless should receive the same level of care.

Discharge Planning

Discharge planning is a team effort between the doctor, nurse, case manager, patient, and their family/caregivers to ensure that an appropriate plan is in place to care for a patient upon discharge from a facility. Depending on the nature of their health condition, the patient may work with physical, occupational, or speech therapy to evaluate their capabilities. The patient may be discharged to an assisted living facility or nursing home or, if the patient struggles with performing daily living tasks independently, to a skilled nursing facility or subacute rehab. Sometimes the patient’s family can care for them with external resources, if needed, such as home healthcare or physical therapy.

End-of-Life and Palliative Care

End-of-life and palliative care are essential elements of comprehensive care for patients. A patient may be on palliative care for chronic long-term complex health conditions. Hospice care applies to patients expected to have less than six months left to live.

The patient’s family has the right to be with their loved one at the end of life unless legal documentation or an advance directive is in place that indicates otherwise. Advance directives are legally binding documents that the patient uses to indicate their healthcare preferences if they are incapacitated, state their preferences for end-of-life care, and/or choose a healthcare durable power of attorney to make medical decisions on their behalf if they are incapacitated.

Withholding care or lifesaving measures is a complex situation. The healthcare provider must consider the patient’s wishes, as indicated by an advanced directive, and the family’s wishes, while also avoiding unnecessarily prolonging patient suffering when there is little to no chance of recovery. Ethics committees are instrumental in situations such as these, providing external guidance.

Organ and Tissue Donation

Organ and tissue donation is a highly regulated process, the specifics of which vary by state. Please remember that as a nurse caring for the patient near the end of life, you cannot discuss or suggest organ donation to the patient’s family. Instead, refer them to the organ donation coordinator associated with your state, who is not employed by your healthcare facility. This helps prevent conflicts of interest and ensures that the patient’s healthcare providers are solely focused on their care.

Forensic Evidence Collection

Forensic evidence collection in the emergency room is most commonly performed by a certified sexual assault nurse examiner (SANE), who cares for victims of sexual assault. The nurse performs a specialized medical and forensic exam that includes performing a head-to-toe assessment, collecting samples for a rape kit and other physical evidence for potential forensic evidence in court, taking pictures, and gathering a detailed history of the assault. A generalized forensic nurse will perform the same duties for victims of other crimes, such as gunshot wounds or assaults. The nurse will also provide emotional support to the victim and assist with any treatment as dictated by the nature of the victim’s injuries.

Pain Management and Procedural Sedation

Nurses must follow designated medication orders and standing protocols in providing pain management and can administer oral, intravenous, and intramuscular pain medications. Pain medication can be dosed on a sliding scale guided by the patient’s level of pain on a 1 to 10 scale (or behavioral scale if they cannot communicate) and their sedation level as rated using a tool such as the Pasero Opioid-Induced Sedation Scale (POSS). Nurses must also be versed in non-medication pain management techniques such as appropriate use of hot and cold, repositioning, abdominal splinting, and deep breathing, as well as allowing friends and family to sit with the patient.

Registered nurses can administer procedural sedation under the supervision of an attending healthcare provider, but they cannot administer monitored anesthesia care (MAC) or general anesthesia. For instance, the nurse can administer fentanyl and Versed® but cannot administer a propofol bolus. However, an ICU nurse can titrate a propofol drip within the parameters indicated in the infusion order to manage a patient’s sedation. Depending on state law, certified registered nurse anesthetists (CRNAs) who provide MAC sedation or general anesthesia can work independently or under the supervision of a supervising anesthesiologist.

Patient Safety

Patient safety is the top nursing priority. Make sure that every type of care the patient receives is appropriate, and do not be afraid to question the healthcare provider if something does not seem right. If there is ever any situation in which you are uncertain about the ordered drug dosage or any other information regarding the ordered drug, check with the hospital pharmacist. To reduce medication errors, always practice the five rights of medication administration: right patient, right medication, right route, right dose, and right time.

Use caution when ambulating patients and assisting with transfers, and always use appropriate mobility aids and gait belts when needed. Identify patients who are high fall risks, and take appropriate precautions such as providing them with a bed or chair alarm, supervising while they’re ambulating or in the bathroom, and making the call light easily accessible.

Patient Satisfaction

Patient satisfaction is another critical component of care. It is essential to recognize that you need to work with the patient to provide care whenever possible, involve them in the decision-making process, and explain what is happening. However, in emergent situations, you have to move quickly to save their life. Such actions take priority over ensuring patient satisfaction. Allowing a patient to have a family member present (when appropriate) can help to increase their satisfaction. Many healthcare facilities use patient surveys to track patient feedback. If a patient is dissatisfied, they should always be offered the option to contact the patient liaison to discuss their concerns and find a solution.

Transfer and Stabilization

Transfer and stabilization is a process that most often occurs in rural areas when the capacity and services of the healthcare facility are somewhat limited. Patients who are seriously ill or injured will frequently be stabilized and receive lifesaving measures in the emergency room of a community hospital and then be transferred to a tertiary facility for further care. Consider a patient who was severely injured in a farming accident. This polytrauma patient will require multiple complex surgeries. He will be stabilized initially at the hospital closest to his home and then will be transferred to a large facility to undergo what will likely be complicated surgical interventions.

Transitions of Care

A transition of care occurs whenever a patient transfers to a different level of care or facility. Such transitions differ from transfer and stabilization because they are planned in advance and facilitated by the patient’s healthcare provider or case manager. The patient’s medical history and health requirements must be carefully assessed to ensure that the receiving facility is an appropriate setting for them. The receiving facility must also receive all of the patient’s medical history, current medications, treatments, and other needs to ensure continuity of care.

Cultural Considerations

Cultural considerations also come into play when caring for patients. Interpreting services must be available to patients who speak different languages or who have disabilities such as hearing impairments that affect their ability to communicate. Having a friend or family member translate for anything other than basic needs is not sufficient. The interpreter must be a trained professional. An in-person interpreter is always best, but remote interpreters are also available using different apps that can be accessed on an iPad or other tablet. Furthermore, due to religious or cultural concerns, some patients may prefer a nurse of the same gender.

Abuse and Neglect

Abuse and neglect can affect patients of all ages. The young, elderly, and patients with physical or mental disabilities are at the greatest risk of being abused. Recognize signs of abuse such as unexplained cuts, bruises, or fractures, an unkempt appearance, weight loss, acting withdrawn, or apparent fear of an accompanying caregiver. Screen all patients when they are alone and ask whether they feel safe at home. All nurses and other licensed healthcare workers are mandated reporters who need to report any suspected abuse or neglect. The exact way reporting occurs varies by state, so familiarize yourself with the steps your state follows.

Human Trafficking

Human trafficking is a global problem that involves the use of coercion, lies, or force to elicit a commercial sex act or some type of labor. Signs of human trafficking include the victim being overly anxious, acting submissive, not having control of their legal documents, being supervised closely, and living and working in isolated conditions. Many states require nurses to take continuing education classes on human trafficking to stay informed.

Gender Equity

Patients need to be treated equally, no matter their gender identity, the most common of which are cisgender, transgender, and nonbinary. The nurse must be sensitive to issues affecting the LGBTQ+ population and ask the patient what pronouns/names they prefer. Remember that the patient’s legal name may not match the name they prefer if they are in the middle of their transition. Accept patients regardless of what they look like or who they are married to, and be open to a wide range of lifestyles.