JURSING LEADERSHIP Leadership Styles ‘Authoritative: Leader dictates decisions for the team, uses penalties andior coercion to promote behavior change Democratic: Leader involves team members in decision-making process. Characterized by team ‘cooperation, resulting in higher quality results Laissez-faire: (hint = lazy") Leader provides litle irection, planning. Emphasis is on group decision- making, Team results may be lacking Prioritize interventions using ABCDE framework * Ex Administering O2 as ordered fra patient wih ‘yspnea is prorized OVER giving a patient pain ‘medication HINT: Administering pain medication is RARELY the priority! Prioritize using Maslow’s hierarchy of needs + Ex Physiological needs take precedence over need for sete, lve, sel-esteem, ec (Choose LEAST invasive interventions FIRST + Ex: Move patient al rsk fr fais near nursing station {and use bed alarm) instead of placing restraints, NURSING LEADERSHIP ABCDE Principle in Nursing Efficient Nursing Practice ‘A (Airway): Ensure patent airway. Stabilize cervical spine if neck/nead trauma is suspected. B (Breathing): Assess for respirations. C (Circulation): Check heart rate, blood pressure, ‘capillary refil D (Disability): Assess patient's level of consciousness, E (Exposure): Assess patient's body for trauma, exposure to heaticold > Make time to provize and plan at the Beginning of each shit + Complete charting as soon as possible afer intervention ‘Do NOT wait unt the end of you shift to chat your fassosemonts or mervertions + Group tasks fora single patent (or for multiple patents in {he same locaton) to prevent repeated bis to supply room. + Complcte sitet or time-consuming tasks early mn the shift (when energy is igh. + Perfoum nor-essantal asks later inthe day. ‘Complete tasks before staring new ones. Know when to delegate and ask for help. Donot ep other team members with ow pont tasks. when you Stl have custanding tasks, NURSING LEADERSHIP Prioritization of Patient Care NURSING LEADERSHIP Delegation ‘ASSESS before taking ACTION: ASE Patient Toporis dyspnea. Check 02, listen to breath sounds BEFORE notifying provider. + Ex: Chack patient's blood sugar BEFORE giving insulin, Prioritize UNSTABLE over STABLE patients Patienis with expected findings for their medical diagnoses are stable. They are NOT the priority. + Ex COPD patient with $p02 in low 90s, stroke patient with facial drooping, MS patient with ‘ataxia are all STABLE (i.e. NOT the priority), RN should not delegate: Patient education, any task that requires nursing judgment, nursing assessment, blood transfusions, OK to delegate to PN: Medication administration, enteral feedings, urinary catheter insertion, suctioning, tracheostomy care, wound care, reinforcement of patient teaching ‘OK to delegate to CNA: Bathing, dressing, ambulating, toileting, feeding patients without swallowing precautions, positioning, vital signs, bed making, specimen collection, 1&Os, basic CPR. NURSING LEADERSHIP Prioritization of Patient Care 5 Rights of Delegation Prioritize ACUTE over CHRONIC conditions: + Ex: A patient with an acute condition (ex abnormal vital signs or urine output < 30mll hr takes prionty over a patient with a chronic ‘medical condition (ex: pressure ulcer). Prioritize SYSTEMIC over LOCAL issues Ex: A patient with systemic symptoms (ex: fever, hypotension, tachypnea, tachycardia) takes priority over a patient experiencing local symptoms (ex: leg pain and erythema). ight task: Repetitive, noninvasive, doesnt require much ‘superision [Right cumstances: Do not assign a patient whois unstable. ‘Bight person: Make sure deogate fs competent and operating ‘within fei Se0p@ of pracioe, Check fais job descipon or the indivduas skil competency checklist. Right dieetion and communication: Communicate spectic elas of tas, timeline for completion, and expectation for ‘communicating the incings back o you. Right supervision and evaluation Interven if needed. provide feedback. I Selegte epors resus ouside the expected ange, assess patient and re-check yourselfNURSING LEADERSHIP Quality Improvement Conflict, ‘Gualay improvement Process used 1o improve quay of care andor corect performance defclendes ona unit or team. Steps: 1. Establish BEST PRACTICE GUIDELINES or benchmark! {goal against which nursing care will be measured, 2. Develop plan for collection of data 3. Collec data ‘4 Compare data agaist benchmark. I benchmarks not met, perlom root cause analysis ‘entylanalyze potential sluions, select one to implement Implement souton (ex: cortectve action, educaton). ‘Reevaluaie issue at predetermined bme io evaluate cefleciveness of solu, Intrapersonal Conflict: An individual's internal ‘struggle'conflict ‘+ Ex: "Should | apply for an ICU position even if it ‘means | will have to work nights for a while..." Interpersonal Conflict: Conflict between two or more people. ‘© Ex: Bullying is 2 form of interpersonal conflict that may result in lateral violence (ex: a more experienced nurse verbally abuses, sabotages, and/or undermines a newly licensed nurse). NURSING LEADERSHIP Quality Improvement NURSING LEADERSHIP Conflict ‘* Unusual trends on the unit should be reported tothe. {quality improvement team + Ifthere is @ quality issue on the unit (ex: increased infection rates, insufficient nursing documentation, poor meeting attendance), the frst step Is to ASSESS ‘causative factors before taking any action. ‘Stage 1 (Latent conflict No conflict yet, but high likelihood it will occur. Stage 2 (Perceived conflict): An individual believes that a problem exists, but the other party is unaware of a problem. Stage 3 (Felt conflict): An individual has an « Audits area good way ocbtan quafatve dataon |g __| emotional response fo a confi. is factors related toa quality issue | Stage-4 Manifest conflict! Goin partis are aware | + ifapaienthes acomplant about nursing care on your |? | of the conflict, and-acton i taken fo resolve confict.—_|é Unt frst ASSESS the patents feetngsendcientyns’ |i | Stage §(Conflet aftermath): Confctis resolved, ter expectations before taking acon wh ether postive!negative results H (aS dass dala \ INS Performance Reviews: Key points Negotiation Strategies " Ayoiding/Withdrawing: aries refuse to acknowl oF + Collect data over time (throughout year) eT eT ee, + Allow for employee self-appraisal before review Eng rps hoy tm pace + Include peer evaluations (other RN). eng te ter pay Cont emai race. N Sompaingsarcng’ Wee souton One pal gow sere * Go though a performance checklist See ieceren me ee + Compare RN against standards (not other RNs) Seoperiaiactomodaing; Lose soliton, On pay ges Discuss employee goals ; | Seay caves ond alow oom pro |e *+ An employee who does not agree with the i ‘Sompromising: Bom pares give up somthing and come toa |p evaluation can make writen comments on the ff | Sammtam H evaluation andlor make an appecl | tbsratag we-tvn sokton. Bt pares pu ase eins! |B jg | Seaesnsetctoetarta dete susty pret soson. | Is Sa Disciplinary Action: Key points Interprofessional Team Responsibilities ‘+ Serious offenses (ex: working under the influence Of alcohol or drugs) should result in immediate dismissal + Forless serious offenses, provide progressive discipline: Verbal reprimand FIRST, THEN written reprimand, THEN suspension, THEN termination. ‘Gase manager Does not provide direct patient care Its as care coordinator for healthcare team to safely transition patient from acute care to SNF, home, or LTAC. Arranges Home Health services, referrals, and equipment needs Occupational therapist: Helps patints regain their ily fo perform ADLs (actives of daly Wing) ech language pathologist Assists wth patient issues related to speech, language, and swallowing Physical therapist: Helps patient improve mobility End strengthNURSING LEADERSHIP Critical Pathways NURSING LEADERSHIP. Refusal of Treatment Critical Pathways are used to promote cost- ‘effective care and shorten a patient's length of stay by standardizing care for patients with a specific, common diagnosis, ‘Critical pathways are developed using evidence-based strategies and include: time-bound activities, interventions, and outcomes. ousal of teatment Competent also emancipated minors have the ight to ‘eluse treatment: This includes patients Involumtanly fsmited Patios who are NOT compote etude aus fir dementa ads ner the uence of acon (= 0.08% Ac) or drugs, sehizphene pants expedeneng command + Rekine patent to sign a document indeating hat they Understand the rsks of refusing veatment Steps to fake when patient wants fo leave AMA 1. Not powder 2. Decl rks of eaving win pation. 3 Flve pate’ sign ANA orm (or dasument retusa to ign). NOTE: Vou do not cal security NURSING LEADERSHIP Patient Transfer: Nursing hand-off NURSING LEADERSHIP. Informed Consent DO include in report * Invmediate needs and pies. 1 Alergies, advance directives dietlactvty resricions. {Recent changes related to the patents condition 1 Time ofthe patents last dose of pan medication, DO .NOT include in report: Provider responsiiliies: * Communale purpose and complete description of procedure In the patents prmary language (use medical interpreter if reece) Explain sks vs. benefits * Descite other options io treat te condition BN responsibilities: ‘+ Tformation about routine care found in the medical Gon patient understands information provided by provider, | fox, FE Nai ponte patourasmere queens orsomsat [E + Information about the patient's visitors (unless it dectly | ‘understand information provided. i secs te lent ere) + NGhjputent campo i veiomed consent (e. —[P «Subjective comments Gr negative statements abouta | patent is an adult of emanopeted minor nol impaited) f patent «_Eteure patet son ona nce vy s SINS aS IRSING LEADERSHI Discharge Planning Informed Consent Discharge planning starts at ADMISSION’ The following people can give consent for another ‘Discharge instructions: person: Setar canmeceun + Parent or egal guardian ofa minor. i parent or bel cnguceanel-preieunnoipencumame op ayer echy aman legal guardian is unavailable, another family 2 nud cressng changes} Aw or eum sonst member or elatve may ge concent nan + Ustof medications, when to take them, precautions egarcing | ee, val . rneatere k ; + Sons and symptoms of complications, whentoseekmedial |b + Durable power of attorney. f searice ae ee Hy '* Spouse or closest relative, based on state law. H «Felon ppcinmentnrmatn, oad ‘+ Names, numbers of providers and community resources. | |Court.speciied reprocentzives ls NURSING LEADERSHIP ‘Therapeutic Communication ‘Advance Directives wRonG: ‘Asking closed ended questions Changing the subject. Minimizing the patient’ feeings. RIGHT: > Reking relevant, open-ended questions (ex: “Tell me ‘move..”) to clay the patients thoughtsifealings + Offering of self (personal information), but return focus. to patient as soon as possible. ing will: Communicates patient's wishes regarding ‘medical treatment if patient becomes incapacitated Note: Evidence that the client was incompetent at the time of making a living will could result in the living will being revoked. DPOA: Patient designates a health care proxy to ‘make medical decisions for him/her i they become incapacitated Provider's orders: Prescription for DNR (do not resuscitale) or AND (allow natural death).NURSING LEADERSHIP. Information Security NURSIN Patient Protection and Affordal Esse ble Care Act HIPPA: Ensures the confidentiality of a patient's health information, ‘+ Only those responsible for patients care may ‘access the patient's medical record. Employers can {tack staff access to patient records! ‘+ Patient has the right to obtain a copy of their Protects the patient from annual and lifetime coverage limits ‘Allows parents to insure dependents until the age of 26. States that an insurance provider cannot deny prcton rene state hats pao he Nae feensuce Compact) + Nurses should refuse to practice beyond their legal scope of prative prescriptions. medical record. Follow facility protocol. if icovereg 28 Petient Cus so presicatng i + Copies of the patient's medical record should NOT {é conditions. li Sool peterte west rcmed shoud MOT 1127. peaacts a pen form canccuton ot icher =f between health care facilities. ls insurance due to illness. iB + _Donot use patient names on public display boards. H NUR Information Security Impaired Coworkers Communication about a patient should happen ina Huss esponsibties: Nurses who suspect a coworker of beng prt pace : it sess esata ena SON «Set pbrtson rom pall hae a ts Susteomel Sag, eer cam sone Marotteyfeceaty ary nenoar besten tesa shaver patient information wth unauthorized peopl Slang otimpatment imped coorsnaton, eft focusing, « Prsowrd pace decree nese Bea ahace See sare meas a orem F Feeguere toy oft compue bets lente SameREeT ones ron von | Cention | | Seaaeeeie creas | + Repobreahes of clntconetaliyomurseranaper|? | Selahed ae cit Shorea |E {ex overearing others discussing patent information in a | \neonidental manner (donot ascuss win nurses coworners) | Cares tS ere ets ESSE Torts ‘Mandatory Reporting Uninenonl Tons Suspicion af buse: Chil, elder, domestcvence Here ee eyeing setbed tar or apt Halatatyaotae communicable dessous eS) Hisnoaed ate Resor cats neath Sesetiment «Matti madcaon oor hat harms pater) Kerrettabe caeitons nese tie nenioral Tort = rer * ASsaul (ex nurse threatens patient) . Saute te Saroneta + Battery (ex: nurse hits patient, or administers f Sarna tj anane Sass rE ‘mecication against pationt’s wil) Sem sila ae + Fase meesonmat ox nuaelnppropnaayrsrans [f | | S62, a aee See I ‘a patient or administers a chemical restraint such asa |? ‘Haemophius infuenzae Mumps Tuberculosis is men iS = i NURSING LEADERSHIP. JRSING LEADERSHIP Nursing Practice ‘Telephone Orders ‘State Board of Nursing: + Have second RN listen in on call, “wares wienanors govern rus ne + Make sure to get ALL components of prescription ‘+ Ensures health care providers comply with state regulations. dose, frequency, route. enema re «Repeat prescription back othe provider to "+ Nurses need to know the laws/regulations that govern confirm the information obtained is correct. wanes naam ann aeeenee |= Mako ewe ponder sign procritin in ime + Nurses musth sense inevery state in which they | frame required by facility (usually 24 hours) le + Question inappropriate or contraindicatedNURSING LEADERSHIP Nursing Ethical Principles eS Sterile Field ‘Autonomy: Patient has right to make his/her own decision, even if itis not his/her best interest. If patient wants to discontinue treatment or decline surgery, ‘you need to respect and support that decision! Beneficence: Do what is best for the patient (do good), Fidelity: Keep your promises. Justice: Provide faimess in care and allocation of || resources. li Nonmaleficence: Do no harm i Veracity Tell the truth. Setting up a sterile eld: Position package with op flap facing way fom you. Open top Nap away fom You. Open right side tap ‘ih right hand, open lt sde Nap wih let hand. Open ast Nap towards you Maintaining a sterile etd MAM Be nt cough, sneeze or ak ove fl 2 tedge offild ie NOT ster: ciscard ny tem that comes in contact wth tis area + Any object held below the waist or above the chests comarinated. + Kad objects othe stoke fild at LEAST 6" above the fed Never tun your back on a sterile Meld or reach across Sterile elas NURSING LEADERSHII Ethical Decision-Making NURSING LEADERSHIP. Safety Measures Ethical dilemma: + Problem cannot be solved by reviewing scientific data, + Involves confict between 2 moral imperatives. ‘© Decision has major impact on patient Ethies committee: + Ethics committee is an interprofessional team that ‘examines facts and supports patients/caregivers + The ethics committee does not offer legal support ‘+ The ethics commitee does NOT impose adecision |? ‘or recommend the best course of action. The decision | ‘maker's the patient andior fami! lg edieal equipment safety: Equipment should be inspected by engineering dept on a reguiar basis. Make ‘ure equipment is grounded. Unplug equipment by plug, not cord, Tag malfunctioning equipment as broken, take out of use immediately, and notify the appropriate dept! Needlestick injuries: Use retractable needles, needles with ‘capping mechanisms, or needless connections to avoid needlestick injures ‘+ For neetlestick injuries, noty supervisor right away. ‘Test patient and nurse for bloodborne ilinesses. (hepatitis, HIV) File incident report NURSING LEADERSH Contact Precautions Preventing Falls Contact Precautions: Impetigo, scabies, shiglla, herpes, MRSA, ‘VRE, COIFF (and other enteric infections), RSV, wound infections + Private room or with another patient with the same infection + Gloves and gowns for caregivers and visitors, Airborne Precautios * Infections: Measles, varicella (chickenpox), tuberculosis, + Private, negative airflow room. ‘+ N95 masks for caregivers and visitors, + Advise patents with orthostatic hypotension o st at he: side ofthe bed before standing up. + Provide regular tolling to patients requiring + Provide skid proot socks. + Place patents at risk for falls near nurses’ station, + Round on your patents hourly. ‘+ Make sure frequently used items are within reach, + Postion be in loves poston, lock beaks, se bed + Do not put up all 4 side rails for patients who will ry to get out of bed on their own, Droplet precautions, Radiation Therapy NURSING LEADE! Seizures Droplet Precautions cians Wibca, preuronia, pertussis, mumps, ‘sepsis, rubella, bacteral meningis, ‘+ rivate room or wth another patent with the same infection, ‘+, Masks for caregivers and visitors. Radiation Theray ‘Limit vistors f0 30 minute visits. Instruct visitors to maintain distance of >= 6 from patient. ‘+ Weara lead apron wien caring for the patient and always face the apron toward the radiation source. + Keep the door to the patient's room closed. Implement seizure precautions: Pad side rails, have ‘suction and oxygen equipment available. During seizure: Turn patient to the side (prior), ‘lear area of hazardous objects, loosen restrictive clothing, do not insert airway or restrain patient, ‘administer 02, note onsetduration of seizure. Post seizure: Keep in lateral position, check vital ‘signs, reorient patient, NPO until patient is fully awake ‘and swallow reflex has relumed.RUSS EaSle Restraints NURSING LEADERS! Injury prevention: Schoo! age children ‘Types of restraints: Physical (vest, belt, mitten) or ‘chemical (sedative or antipsychotic medication) Alternatives: Reorientation, supervision, diversions, Key points when administering restraints: nan emergency, the RN can place a patient in restraints, but must get prescription from doctor ASAP per facility policy (usually one hour). + Provider must rewrite the prescription every 24 hours. PRN prescriptions NOT allowed + Apply the padded portion ofthe restraint tothe client's wrist (to prevent skin breakdown) + Use car booster seat while child is under 40 tbs or under 4'9". Keep child in backseat until 12 years old + Use protective gear (ex: helmets, pads) for bicycling, sports + Reduce water heating set degrees F. + Keep guns locked up, bullets stored in separate location, + Enclose pools with locked fence, supervise children near poo'siwater. 1g to less than 120, Key points when administering restraints NURSING LEADERSHIP. Injury prevention: Adolescents NURSING LEADERSHIP. PPeform neurovascular checks every 2 hours, Assess skin integrity, Provide ROM exercises. Use least restrictive restraint to correct problem (mittens are less restrictive than wist restraints), + Apply restraints 50 2 fingers can ft between restraint {and patent. Use quick release knot (ex: slipknot. + Place restraints on a movable part ofthe bed frame (NOT the side rails) + Apply belt restraints over the patient's gowniclothing, I ‘+ Educate teens on risks associated with smoking, drugs, alcohol, unprotected sex. ‘+ Wam against distracted or impaired driving, + Reinforce the need to wear seat belts. “+ Monitor teens for mental health issues (depression, anxiety). Fire Safety NURSING LEADERSHIP Injury prevention: Older Adults NURSING LEADERSHIP. RAGE sequence + R (Rescue): Move patients to safer location. Horizontal evacuation frst, then lateral evacuation I needed + Ralarm) Activate alarm system + € (Contain): Close doorsiwindows, tun of oxygen +_E (Extinguish): Use fre extinguisher. PASS sequence: * P:Pul the pin. + ALAlm atthe base of the fire. + $ Squeeze tne handle. +S Sweep ftom side to side i i + Remove trip hazards from home: scatter rugs, loose carpet. + Place electrical cords against wall (behind furniture) ‘+ Install grab bars in bathroomishower, use nonskid ‘mat in shower. + Ensure adequate lighting in home. Use colored tape on step edges. ‘+ No wheeled chairs (as they pose a fall risk). NURSING LEADERSHIP Injury Prevention: infants and toddlers NURSING LEADERSHIP. Injury prevention: Oxygen safety ‘Avoid foods that ean cause choking: popcorn, raisins, Peanuts, grapes, raw carrots, hotdogs, celery, peanut butter, candy, tough meat + Place infants on back to sleep. Do not place anything in the crib with the baby. Make sure erib slats are < 2 3/8 inches apart. + Keep plastic bags, houseplants, cleaning agents out of, reach. Lock up medications. ‘+ Use rear facing car seat unti 2 years old. Use car seats nth 5 point harness, place in back seat. ‘+ Turn pot handles away from front of stove + Close bathroom doors, keep tolet ids down, ‘+ Oxygen equipment increases sk of combustion. Place ‘xygen-dalvery system auay fom wats and n'a wel ‘ertlated (and clterree) environment. ‘+ Keep oxygen tank in standrack (not on floor!) ‘Place “no smoking” sgn a font door of home. ‘Make sure elocineal equipment fs grounded, and in good ‘shape: No extension cares. + Use COTTON bedding and clothes. Do NOT use ‘synthetic Tabrics or wool. + Keep flammable tems away rom oxygen equipment. No petroleum jelly! Use water-based lubricant instead. + Mentor oxygen delivery rate daly to make sue oxygen Is being delivered at the peserbed ateNURSING LEADERSHIP Injury prevention: Wheelchairs NURSING LEADERSHIP Incident Reports ‘Stand between the wheelchair and the bottom of an incline to provide better control of the wheelchair by keeping weight close to the body. * Back the wheelchair into the elevator with the ‘ear wheels first to prevent injury, * Lock the brakes on both wheels when transferring the patient. * Raise the footplates of the wheelchair before transferring the patient to prevent injury Incident reports: Created when an accident or unexpected vent occurs (ex: medication error, fall, needlestck injury). Used for quality improvement at facity. ‘+ When an incident occurs, provide immediate care to the patient to decrease further injury. Notify provider. ‘+ Nurse is responsible for completing an incident report. Complete within 24 hours of incident. ‘Incident reports are confidential facility documents and are not shared with patient. + Description of the event should be included in patient's ‘medical record, but DO NOT include the incident report (or reference existence of incident report) Injury prevention: Carbon monoxide I weiss Mass Casualty Event ‘Carbon monoxide: Odorless, tasteless gas. Carbon ‘monoxide binds to hemoglobin, reducing 02 supplied to the body. Prevention of carbon monoxide poisoning: ‘= Use carbon monoxide detectors. + Maintain proper ventilation when using fuel-burning items (ex: wood stoves, gas fireplaces), ‘+ Know symptoms of carbon monoxide poisoning nausea, vomiting, headache, loss of Tea + Class | (red tag}: immediate threat to life (ex: sucking ‘est wound, pneumothorax, major bur) + Class (yellow tag) Major injury that requires ‘prompt treatment, within 2 hrs (ex: bone fracture) + Class il (green tag): Minor injury does not require {teatment wihin 2 fr (ex: laceration, sprain) + Class IV (black tag): Expected and allowed to cie {(©x penetrating head wound, chest crush injury) Discharge/Relocation of patients: Discharge/relocate ‘ambulatory patiens requinng minimal care. Transfer stable Patients out of PACU tothe surgical unt, Injury prevention: Food poisoning Nursing actions during disasters *+ Perform frequent hand hygiene. ‘+ Immunocompromised individuals (at higher risk for {food poisoning) should consume a low microbial diet. + Refrigerate perishable products within 2 hours (or within 1 hour when temperature is 90 degrees or ‘more). + Donnot consume unpasteurized dairy products or untreated water. + Prevent cross-contamination during food preparation (handle raw and fresh food separately). + Cook foods to recommended temperatures. ‘Tomados: Close shades, move patents away fom windows iiealy in naway), place blankets over patents who ae bedbound, ‘Chemical exposure’ Undress patent, migate profusely. For cry ‘hemieals, rush chemical of patents cothing/skn, Hazardous material accident: Locate safety data sheet (SDS), Waters the unversal antdot (inmost cases). Use bleach to clean blood spills. Radiological incident: Wear dosimety badge (fo monitor raion exposure). Deconiaminate patients wih Soap, water, and ‘disposable towels, Contain water run (as tis contaminated). Bomb threat Keep calle onthe pone as log as posse. Listen for background noses, ives. Ergonomics ‘+ Spread feet apart to lower center of gravity, which increases stabilty ‘+ Distribute your weight between the major muscle {groups in your arms and legs when iting ‘+ When iting an object, hold it as close to your body as possible. Tighten abdominal muscles, ‘+ Avoid twisting or bending at the waist. ‘+ Get help when repositioning a patient. ‘+ Use smooth movements when moving patients.