Conduct and Accountability
The registered nurse or licensed practical nurse shall have a thorough understanding of the rules and laws by which nursing practice is governed. Both RN’s and LPN’s shall perform their duties within the legal scope of nursing practice. When completing new or unfamiliar procedures, they should seek out instruction and supervision. LPN’s should always be responsible and accountable for the quality of care that their patients receive. This is based on (and limited to) the scope of education, demonstrated, competence, and nursing experience. The LPN should have a thorough understanding of their facility’s policies regarding the right to provide care, and they should understand what their limitations are under their scope of practice.
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Registered Nurses should accept individual responsibility and accountability for recognizing and implementing appropriate interventions related to changes in the patient’s mental or physical health status. They should also be accountable and responsible for delegating certain tasks in certain situations to assistive personnel. RN’s should treat all patients with the same level of care, regardless of age, race, religion, gender, national origin, sexual orientation, diagnosis, or disability. Finally, RN’s must respect both patients’ and their significant others’ dignity and rights. This includes privacy, safety, protection of property, protection of confidential information, therapeutic behavior that prioritizes the patient’s best interests, and freedom from exploitation of physical, mental, sexual, or financial boundaries.
Competence in the practice of the PN and the RN includes:
Registered Nurse (RN)
Licensed Practical Nurse (LPN)
Standards of Documentation
Documentation of nursing care shall be legible, accurate, complete, and timely. Complete documentation includes:
- Patient signs and symptoms
- Patient responses
- Patient treatments
- Patient medications
- Provision of other nursing care
- Communication of information to other health care team members
- Unusual events related to the patient or patient’s care
In order to be complete, a signature of the document’s author is required, whether electronic or written. Documentation should be recorded at the time or after care is provided, including any medications that were administered. A “late entry” is any charting that is not completed in the actual sequence of time in which care was provided. Late entries should include a date and time it was recorded, and they should also state the date and time the care was provided. Any corrections made to an erroneous entry shall not be whited-out, destroyed, or obliterated. The nurse shall place one straight line through the mistake and include his or her initials next to the error that was corrected.
Medication Administration & Safety
Both RN’s and LPN’s shall possess knowledge regarding medication and administration. This knowledge shall include the drug’s action, classification, side effects and their interventions, adverse reactions and their interventions, emergency interventions. The nurse should also recognize contraindications based on the patient’s current health status, including their illnesses, disease processes, or pre-existing conditions. Furthermore, the nurse should be knowledgeable about the reason the patient is taking the medication and its therapeutic effects. Safety precautions, including the rights of medication administration (right patient, medication, time, dose, route, reason, and documentation), should be followed for every patient. The nurse should have competent drug dosage calculation skills. Nurses should also be familiar with their state’s laws related to controlled substances and their facility’s policies on storing medications. Finally, nurses shall educate their patients regarding specific medications, whether it be with verbal teaching, written information, use of videos, or some other method; the nurse should teach according to the patient’s needs.
Moderate sedation is used “for short-term therapeutic or diagnostic procedures,” such as a colonoscopy or wisdom tooth extraction. Moderate sedation permits the patient to be in a state of consciousness in which he or she responds to verbal commands either spontaneously or with gentle tactile stimulation. Moderate sedation retains the patient’s ability to maintain a patent airway, respiratory rate, and rhythm. Physicians, dentists, CRNAs, and registered nurses can administer medications to produce moderate sedation. Although, RNs must do so with some restrictions. They must complete an organized program of study, have supervised clinical practice, and have demonstrated clinical competence. Minimum training for the RN includes “anatomy, physiology, pharmacology, cardiac arrhythmia recognition, and complications related to sedation.” The nurse should also have an advanced cardiac life sport certification. The RN should assess respiratory rate, oxygen saturation, blood pressure, heart rate and rhythm, and level of consciousness. While a patient is receiving moderate sedation, the nurse should not have any other tasks during the procedure that would require leaving the patient unattended. RN’s may not give moderate sedation if a physician, dentist, or CRNA and assistive personnel are not physically present. If monitors, defibrillators, airway devices, and emergency drugs are not available, the registered nurse should refrain from administering moderate sedation.
Comprehensive and focused assessments by the registered nurse should include the following elements: objective and subjective data, physical examinations, verbal interviews, and written records. Each of these elements should be documented accurately and in a timely fashion. After analyzing and reporting the collected information, the data is used to develop a plan of care. The plan of care shall be modified based on patient response. The RN should anticipate and recognize any changes, whether they are actual or potential, in patient’s health status. The RN shall determine any signs and symptoms of changes to the current health status and shall execute intervention modifications as necessary. Focused assessments implemented by the licensed practical nurse should also include subjective and objective data, nursing examinations, interviews, and written records. With the data collected, the LPN should distinguish normal and abnormal data and record and report the data. The LPN, too, anticipates and recognizes changes in patient status by monitoring for signs and symptoms. Focused nursing assessments are reported to the RN, physician, advanced practice nurse, or dentist. The LPN should then implement the plan of care and modify it according to patient responses.
Delegation - Unlicensed Assistive Personnel
Tasks delegated to an unlicensed assistive personnel may not include tasks that require:
- Independent nursing judgment or intervention
- Invasive or sterile procedures (this does not include finger sticks or peripheral venous phlebotomy for laboratory analysis)
IV Therapy – Minimum Requirements
Minimum requirements for a licensed practical nurse to implement IV therapy include: completion of an organized program of study, supervised clinical practice, and demonstrated clinical competence. Minimum training includes: anatomy & physiology, fluid & electrolyte balance, equipment and procedures utilized, complications, prevention, interventions, initiating a peripheral intravenous device, set-up, replacement, and removal of IV tubing, IV fluid calculations and flow rate adjustment, IV piggyback medication administration, procedures for reconstituting and administering IV medications via piggyback, including but not limited to pharmacology, compatibilities, and flow rates. LPN’s may administer medications through a peripheral IV catheter if the medications do not require the skill, judgment, and knowledge of a registered nurse, and if the RN is physically present and immediately available within the facility.
Leadership Styles - ATI
Leadership styles are usually classified as authoritative, democratic, or laissez-faire. Nurses may use any one or a combination of all three leadership styles depending on the circumstances. Authoritative leaders typically make decisions on behalf of the group and encourage the team by using coercion. With authoritative leaders, “communication occurs down the chain of command.” This style is usually the most effective when managing a team of employees that have little to no formal education. Staff’s performance is usually high, which can be useful when handling a crisis or in “bureaucratic settings.” Democratic leaders tend to consider input from members of the group when making decisions and motivates employees by “supporting staff achievements.” Under a democratic leader, employee performance “is usually of good quality,” and these types of teams usually work most efficiently in situations where “cooperation and collaboration are necessary.” Also, communication amongst team members takes place both “up and down the chain of command.” The final leadership style is laissez-faire. These types of leaders do not make very many decisions, and very little amounts of planning usually take place. Individual team members are usually responsible for being self-motivated. Under laissez-faire leadership, “communication occurs up and down the chain of command and between group members.” This type of leadership is usually most efficient when working with professionals because work performance can be low without an “informal leader” that emerges from the group.
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Effective Delegation - ATI
Delegating is defined as relocating the “authority and responsibility” from oneself to another member of the health care team to accomplish a task. Accountability for the completion of such tasks ultimately lies with the individual who did the delegating. In order to delegate appropriately and effectively, the nurse should consider the needs of each individual client, the facility’s policies, state nurse practice acts, and professional standards. The nurse should also consider several other factors when making a decision about delegating a task. The nurse should recognize whether or not the task is something routine (such as putting a client on a bed pan) as well as the predictability of the outcome. The nurse should also assess whether or not there is potential for harm, especially when dealing with unstable clients. Nurses should not delegate complex tasks unless the delegatee has the skills and legal authority necessary to perform such tasks. Client education, the nursing process, or tasks that demand clinical judgment/critical thinking also should not be delegated to neither a licensed practical nurse, nor assistive personnel. Nurses should take into account the five rights of delegation: “what tasks the nurse delegate (right task), under what circumstances (right circumstance), to whom (right person), what information should be communicated (right direction/communication), and how to supervise/evaluate (right supervision/evaluation.”
Ethical Nursing Care
Ethical nursing care promotes autonomy, beneficence, fidelity, justice, nonmaleficence, and veracity. Autonomy allows for clients to make their own personal decisions, even when the nurse disagrees and when the decision is not in the client’s own best interest. Beneficence refers to providing care in which the priority is the client’s best interest. Fidelity involves keeping promises to the client about his or her care. Justice involves fair treatment in issues related to client care. Nonmaleficence refers to the nurse’s responsibility “to avoid causing harm to the client.” Veracity involves the nurse’s obligation to always tell the truth. Ethical issues refer to problems that have more than one possible choice for how to handle them. This choice is influenced by the decision-maker’s values and beliefs. Nurses should consider all options and select the one that best complies with the ethical principles listed above. The nurse should be able to justify why he or she chose the option that he or she did.
- (2016, July 25). ALABAMA BOARD OF NURSING ADMINISTRATIVE CODE CHAPTER 610-X-6 STANDARDS OF NURSING PRACTICE. Retrieved from https://abn.alabama.gov/laws/
- Henry, N.E., MSN/Ed, RN, McMichael, M., DNP, MSN, Johnson, J., MSN, RN, CNE, DiStasi, A., DNP, RN, CNE, Ball, B.S., Med, BSN, RN, & Holman, H. C., MSN, RN. (2016). Managing Client Care. In Nursing Leadership and Management (7.0th ed., pp. 3-18). Assessment Technologies Institute, LLC.
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