Management of Care Study Guide for the NCLEX-RN Exam

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:

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:

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 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:

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 health records. You need to learn, understand, and maintain all the privacy requirements for confidential patent information that are specific to the facility in which you work.

Legal Rights and Responsibilities

As a nurse, you are responsible for understanding the legal limitations and scope of practice of your nursing license. Many of these parameters are mandated by both federal and state laws, as well as by general guidelines such as the Nurse Practice Acts (NPAs). Each state will have a state Board of Nursing that will serve as your credentialing body and source of information on the confines of laws applicable to the state in which you practice.

Negligence

Negligence is an unintentional act or failure to act that results in harm to a patient. It involves the failure to act in the same way that a reasonable person would, given the same set of circumstances. Failure to give a medication, or give it in an untimely manner, could be examples of negligence if the patient experiences a consequential adverse reaction. In each case, the nurse exhibits a breach of duty of care that is an essential component of negligence.

Malpractice

Malpractice differs from negligence in that malpractice includes the element of intent. Often, the individual state Boards of Nursing set the requirements for determining malpractice. In general, malpractice occurs when a nurse fails to competently perform his or her duties and the patient suffers harm as a result. Examples include giving the wrong medication to the wrong patient or giving an incorrect medication dosage.

A Nurse’s Role

The nurse is responsible for proper, timely care of patients. Any incorrect, inappropriate, or lack of action (as set by the standard of care) could result in legal action against the nurse if the patient suffers harm as a result. Be familiar with your legal rights and responsibilities.

Response to legal issues—You must be able to identify and respond appropriately to legal issues relating to patient care. Examples include a patient’s refusal of care and privacy rights of minors.
Seeking assistance—You must be able to identify tasks and assignments that you are not qualified to perform and seek help or guidance when necessary.
Patient valuables—Your facility or practice will have specific guidelines to know and follow with regard to handling valuables. Many facilities offer lock boxes and security regulations concerning patient valuables.
Patient and staff education—Participating in required and elective education events helps ensure you understand and are prepared to respond appropriately to potential legal and ethical issues.
Regulations for reporting—Certain health conditions (communicable disease, dog bites, etc.) have both state and federal regulations that must be followed. You will need to be familiar with regulations that apply to you as a mandated reporter of suspected child abuse and other crimes.

Organ Donation

Organ donation is the process of harvesting an organ or tissue from one person and transplanting it on or into another. Internal organs, skin, bone, bone marrow, and corneas may all be donated/transplanted. While many organ donations take place after the donor is deceased, some are done with a living donor (e.g., kidney, bone marrow).

Nurse Roles

Specialized nurses, called procurement nurses, are involved in the care of organ donation/transplantation patients. Nurses who counsel patients and their families on the specifics of organ donation must have special training under federal law. As an entry-level nurse, your involvement in the process will likely be ensuring that your patients over the age of 18 have copies of their advance directives in the medical record.

Advance Directives and Donation

Advance directives are legal documents that specify the patient’s wishes if he or she should become incapacitated and not able to express them for him or herself. The patient’s wishes for organ donation, specifically, should be obtained and documented within the medical record if the patient is legally able to provide this information.

Performance Improvement

Different medical institutions each have specific definitions of quality, but generally, the term refers to meeting or exceeding the patient’s expectations, meeting or exceeding the standards for care, and achieving the planned outcomes for all patients. Quality improvement refers to the process of identifying and improving quality issues with regard to nursing care. This may include:

TQM (Total Quality Management)— a long-term management approach to success that is centered on patient satisfaction
CQI (Continuous Quality Improvement)— a management approach that is centered on ongoing evaluation and improvement of the processes that lead to success
Evidence-based decision making—This approach focuses on adjusting policies and processes according to the most recent research evidence.
Quality management plan and benchmarks— This approach uses performance measures to adjust processes accordingly. Benchmarks are points of comparison that can be used to identify problems in the process. This approach encourages competition as it typically seeks to identify the best practices at the best cost.
Reporting issues— Nurses play a critical role in quality improvement. By reporting patient care problems or issues to the appropriate personnel, you ensure proper management evaluation of why they occur and facilitate correction.
Resources— You may also serve as a quality improvement resource for your institution, practice, or agency. You may be a source of data collection or participate in a group or team that is involved in the performance improvement process. You may also be asked to evaluate the impact of procedural or process changes to your nursing practice.
Nurse-sensitive indicators— Nurse-sensitive indicators are measurements of patient care that are directly impacted by nursing interventions. Examples of these are skin breakdown (decubiti), falls, and the use of restraints.

Referrals

As you care for your patients, you will often play a role in helping to coordinate care with other healthcare providers or community agencies. This may be as simple as recommending a particular provider (dietician, physical therapist, wound care center), but it may also require you to obtain prior authorization for your patients via their insurance company. Your job is to appropriately assess your patient’s needs and then assist him or her in the referral process to get the care needed. You will also be responsible for providing the appropriate documentation to the provider or facility your patient has been referred to (i.e., referral form or copy of the medical record).