if a new patient problem is within the medical scope, who does the nurse report it to?

What do new nurses need to know about nursing scope of practice?

New nurses need to be aware that physicians don’t necessarily understand nursing scope of practice, and some may issue orders that stretch the boundaries of practice past the comfort zone.

What does the nurse care planning literature say about patient outcomes?

In summary, the nurse care planning literature indicates several things. First, when thought goes into the care planning process, better patient outcomes are possible. Second, altering the care planning process has thus far been done in an ad hoc manner and most of the evidence is from case studies.

What is a possible nursing diagnosis?

Possible nursing diagnosis. While not an official type of nursing diagnosis, possible nursing diagnosis applies to problems suspected to arise. This occurs when risk factors are present and require additional information to diagnose a potential problem.

Do nurses have real concerns about the new computerized healthcare system?

In closing Dillon and coworkers noted that “these results clearly show that the nurses have real concerns about the new impending computer system and that the new system may be risky and might remove the human component of what they do”45(p. 144).

Who is responsible for reporting and documenting a medication error?

The U.S. Food and Drug Administration (FDA) receives more than 100,000 U.S. reports each year associated with a suspected medication error. FDA reviews the reports and classifies them to determine the cause and type of error.

What is the process for reporting errors in patient care?

There are several steps to appropriately dealing with a medical error that are relatively straightforward:Let the patient and family know. ... Notify the rest of the care team. ... Document the error and report it to the hospital safety committee.

Who is responsible for determining the scope of practice for registered nurses?

As the professional organization for all registered nurses, the American Nurses Association (ANA) has assumed the responsibility for developing the scope and standards that apply to the practice of all professional nurses and serve as a template for nursing specialty practice.

What are the 5 stages of the nursing process?

The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective.

What do you do if you make a medical error?

Taking ownership of the error and doing the right thing by putting the patient first is the only realistic course of action. Take immediate corrective measures. Inform the patient's doctor of the mistake so that action can be taken as soon as possible to counteract the effects of the incorrect medication.

What is medical error reporting system?

The MER program is a voluntary medication error reporting system originated by the Institute for Safe Medication Practice (ISMP) in 1975 and administered today by U.S. Pharmacopeia (USP). The MER program receives reports from frontline practitioners via mail, telephone, or the Internet.

Who defines scope practice?

Scope of practice is established by the practice act of the specific practitioner's board, and the rules adopted pursuant to that act.” “establish[ing] which professionals may provide which health care services, in which settings, and under which guidelines or parameters.”

Which organization provides scope and practice guidelines on the roles and responsibilities for nursing and nursing specialists?

The American Nurses Association develops and publishes scope and standards of practice guidelines for nursing and nursing specialties.

What is within a nurse's scope of practice?

Among the scope of services for RNs in most states is administering and monitoring medications; developing care plans; taking vital signs and recognizing abnormalities; caring for wounds; performing basic life support.

How do you assess a patient?

Assessing patients effectivelyInspection. Inspect each body system using vision, smell, and hearing to assess normal conditions and deviations. ... Palpation. Palpation requires you to touch the patient with different parts of your hands, using varying degrees of pressure. ... Percussion. ... Auscultation.

What is the nursing assessment process?

An RN uses a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well.

What are the five steps of patient assessment?

emergency call; determining scene safety, taking BSI precautions, noting the mechanism of injury or patient's nature of illness, determining the number of patients, and deciding what, if any additional resources are needed including Advanced Life Support.

What is an example of a nursing diagnosis?

A nursing diagnosis is something a nurse can make that does not require an advanced provider’s input. It is not a medical diagnosis. An example of...

What is the most common nursing diagnosis?

According to NANDA, some of the most common nursing diagnoses include pain, risk of infection, constipation, and body temperature imbalance.

What is a potential nursing diagnosis?

A potential problem is an issue that could occur with the patient’s medical diagnosis, but there are no current signs and symptoms of it. For insta...

How is a nursing diagnosis written?

Nursing diagnoses are written with a problem or potential problem related to a medical condition, as evidenced by any presenting symptoms. There ar...

What is the clinical diagnosis?

A clinical diagnosis is the official medical diagnosis issued by a physician or other advanced care professional.

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What is a possible nursing diagnosis?

Possible nursing diagnosis. While not an official type of nursing diagnosis, possible nursing diagnosis applies to problems suspected to arise. This occurs when risk factors are present and require additional information to diagnose a potential problem.

Why is it so hard to write a nursing diagnosis?

Problem-focused and risk diagnosis are the most difficult nursing diagnoses to write because they have multiple parts. According to NANDA-I, the simplest ways to write these nursing diagnoses are as follows:

Why are there discrepancies in nursing diagnosis?

Discrepancies may occur when the translation of a nursing diagnosis into another language alters the syntax and structure. However, since there are NANDA-I offices around the world, the non-English nursing diagnoses are essentially the same.

Why is it important to develop a nursing diagnosis?

They are developed with thoughtful consideration of a patient’s physical assessment and can help measure outcomes for the patient’s care plan.

What is NANDA diagnosis?

NANDA diagnoses help strengthen a nurse’s awareness, professional role, and professional abilities. Formed in 1982, NANDA is a professional organization that develops, researches, disseminates, and refines the nursing terminology of nursing diagnosis.

How many types of nursing diagnosis are there?

There are 4 types of nursing diagnosis according to NANDA-I. They are:

What is risk nursing?

Risk nursing diagnosis. A risk nursing diagnosis applies when risk factors require intervention from the nurse and healthcare team prior to a real problem developing. Examples of this type of nursing diagnosis include: This type of diagnosis often requires clinical reasoning and nursing judgement.

What is scope of practice in nursing?

Nursing scope of practice occurs on a continuum that is continually evolving. Remain aware and vigilant, understand the scope of practice that applies to you, and keep your finger on the pulse of changes to scope of practice as they occur.

How to stay tuned into scope of practice issues?

Another good way to stay tuned into scope of practice issues is to become a member of your state or regional nursing association. Many of these organizations utilize lobbyists to push back against groups who want to limit our scope of practice (e.g.: physicians wanting nurse practitioners to have less autonomy), and they train nurses to advocate for the profession and get involved in the legislative process.

What is the NPA?

The National Council of State Boards of Nursing is an excellent resource for nursing scope of practice throughout the United States, and wise nurses familiarize themselves with the NPA in the state (or states) where they are licensed.

Why is understanding scope of practice important?

Whether you’re a nurse just graduating with an ADN or BSN, or you’re a nurse with decades of experience and an advanced degree under your belt, understanding your scope of practice is essential to safe patient care and effective nursing, as well as protecting your license from liability.

Do nurses need to be aware of scope of practice?

New nurses need to be aware that physicians don’t necessarily understand nursing scope of practice, and some may issue orders that stretch the boundaries of practice past the comfort zone. Every state has a set of laws governing the scope of practice of nurses in that state, and a state nurse practice act ...

How many patients did Naylor and colleagues 19 study?

Naylor and colleagues 19 conducted a randomized clinical control trial with 276 patients and 125 caregivers to show the effects of a comprehensive discharge planning protocol. The discharge planning protocol was specifically designed for elderly medical and surgical patients and implemented by a gerontological CNS. From the initial discharge until 6 weeks after discharge, the medical intervention group had fewer readmissions, fewer total days of rehosptilization, lower readmission charges, and lower charges for all health care services after discharge compared to the control group and the surgical intervention group.

Why is research needed for APNs?

While the summary of research related to the safety and quality of APNs validates them as competent and comparable to physicians in many aspects, more research is needed to reduce errors and enhance patient safety. Threshold improvement cannot be accomplished without interdisciplinary practice approaches—which are going to require revolutionary change to flatten the educational and cultural silos between medicine and nursing education. 29 It is crucial that APNs are separated out as distinct provider types in all interdisciplinary research and administrative and clinical datasets. It has taken the nursing profession decades to untangle nursing’s unique role and value within the hospital and decouple professional registered nursing from the “hotel costs” of a hospital stay. RNs have historically been characterized as a cost center rather than a highly valued revenue source within hospitals. If all professional nursing activity was billed for separately, such as is done with physician care, nursing’s value would not have to be debated. As the evidence base on interdisciplinary teams is built, APNs must not become invisible on the health care team. Building a research portfolio on APN practice will require adherence to methodological quality that explores APN practice within an interdisciplinary context. Practice Implications—Barriers to APN Practice

What is the AHRQ?

The Agency for Healthcare Research and Quality (AHRQ) has emerged as the premier funder for HSR, and this funding source should be explored to a far greater degree by APN researchers. While the National Institutes of Health focus on the biomedical aspect of diseases, AHRQ focuses on patient outcomes, cost, use of services, access disparities, quality of care, and patient safety. The focus of AHRQ is becoming increasingly important as the delivery system undergoes transformation, driven by transparency and quality. AHRQ’s goal is to ensure that the knowledge gained through HSR is translated into measurable improvements in the health care system and better care for patients. 42 This goal could be shared by members of the APN community by sharpening and aligning the APN research focus on systems of care.

What is direct clinical practice?

Direct clinical practice is a core competency of any APN role, although the actual skill set varies according to the needs of the patient population. 3 APNs build on the competence of the RN skill set and demonstrate a greater depth and breadth of knowledge, a greater synthesis of data, increased complexity of skills and interventions, and significant role autonomy. The APN is prepared to assume responsibility and accountability for health promotion and the assessment, diagnosis, and management of patient problems, including the use and prescription of pharmacologic and nonpharmacologic interventions. 4

Why is the American health care system in need of fundamental change?

According to Crossing the Quality Chasm, 7 the American health care system is in need of fundamental change because health care frequently harms and fails to deliver its potential benefits. The preceding literature compared APNs to physicians within the context of a health care system that is not necessarily patient safety focused. Comparing APN to physician outcomes was an important validation of APN practice as these professions evolved. Given the current mandate for fundamental system change, new research questions on APN practice as they relate to patient safety have emerged. Most outcome studies to date have focused on acute care nurse staffing and nursing-sensitive outcomes such as decubitus ulcers. 28 The research to measure APN outcomes with valid tools has yet to be developed.

What is an advanced practice nurse?

Advanced practice registered nurse is a term used to encompass certified nurse-midwife (CNM), certified registered nurse anesthetist (CRNA), clinical nurse specialist (CNS), and nurse practitioner (NP). Advanced practice nursing is broadly defined as nursing interventions that influence health care outcomes, including the direct care of individual patients, management of care for individuals and populations, administration of nursing and health care organizations, and the development and implementation of health policy. 1 In 2004, the number of registered nurses (RNs) prepared to practice in at least one advanced practice role was estimated to be 240,461, or 8.3 percent of the total RN population. As noted in figure 1 below, the largest group among the APNs was NPs, followed by CNSs. The APN movement has been growing exponentially with APNs employed in every health care sector. According to the Bureau of Labor Statistics, 2 the demand for APNs is expected to continue to increase over the next decade and beyond, as the need and demand for effective health care increases, especially in rural, inner-city, and other underserved areas.

How do health professionals work together?

Health professionals work together in small groups providing care, be it oncology, the operating room, end of life, or primary care. These team members, however, are educated in their health professional silo and likely have little knowledge of their team members’ skill sets. The IOM report, To Err is Human, 6 suggested that health professionals should be educated in teams using evidenced-based methods employed in aviation such as simulation and checklists. People make fewer errors when they work in teams because it forces processes to be planned and standardized, forces team members to have a clear role and to look out for one another, noticing errors before they become an accident. In an effective interdisciplinary team, members come to trust one another’s judgments and attend to one another’s safety concerns.

What are the tensions surrounding nursing documentation?

These include: the amount of time spent documenting;13–15the number of errors in the records;9,16,17the need for legal accountability;18–20the desire to make nursing work visible;21and the necessity of making nursing notes understandable to the other disciplines. 22, 23For the purposes of this review, we confine ourselves to discussions of either manual or automated nursing systems of documenting patient care, primarily in hospitals. As we have found, while there are good and well-designed individual studies, the different methodologies, populations studied, and variables analyzed have led to little generalizability across the research, making comparisons between them impossible.

How much time do nurses spend on documentation?

Other studies have exposed the overall documentation burden carried by nurses. Hardey and colleagues31found that recordkeeping was given lower status and priority than was direct patient care. It was also viewed as excessively time consuming. Nurses regularly copied data from the medical record and other documents to create personal records that guided their activities. Korst and colleagues13conducted a work-sampling study over a 14-day period. Out of 2,160 observations, the average percent of time nurses spent on documentation was 15.8 percent; 10.6 percent for entry on paper records and 5.2 percent on the computer. The percentage of time spent on documentation was independently associated with day versus night shifts (19.2 percent vs. 12.4 percent, respectively). Time of day is also a factor in retrieving information.

What is nursing documentation?

Nursing documentation covers a wide variety of issues, topics, and systems. Researchers, practitioners, and hospital administrators view recordkeeping as an important element leading to continuity of care, safety, quality care, and compliance.4–7Studies, however, reveal surprisingly little evidence of the linkage between recordkeeping and these outcomes. The literature features multiple exhortations and case studies aimed at improving nurses’ recordkeeping in general8–10or for specific diagnoses.11, 12

What is information work in nursing?

Information work is a critical part of the medical endeavor. Strauss and Corbin3note that trajectory work, as they view medical care, requires information flow before and after each task or task sequence to maintain continuity of care. Tasks are not isolated but are intertwined and build on one another to achieve patient goals. Nurses bear a large burden in both managing and implementing the interdisciplinary team’s plan for the patient, as well as documenting the care and progress toward goals. As a result, nurses spend considerable amounts of time doing information work. There are several genres of nursing documentation studies: those that examine recordkeeping practices as a whole, those that examine issues relating to the documentation (time, content, completeness), and comparative evaluations of different types of changes in the documentation regime including automation versus paper. Taken together, these provide both detailed and broad knowledge of nurses’ recordkeeping practices and highlight the reasons why any change (manual or computerized) is so difficult to integrate into nursing practice.

Why is documentation important in healthcare?

A primary purpose of documentation and recordkeeping systems is to facilitate information flow that supports the continuity, quality, and safety of care. Since recordkeeping systems serve multiple purposes (e.g., legal requirements, accreditation, accountability, financial billing, and others), a tension has arisen and is undermining the primary purpose of the record and instead fueling discontinuity of care, near-misses, and errors. Among the more specialized types of documentation is the plan of care, a requirement of the Joint Commission.1, 2Though planning and plans should facilitate information flow across clinician providers there is little generalizable evidence about their effectiveness.

What are the issues with EHR records?

In several more targeted studies, the central issues of concern were how well the records reflected the care given and accuracy of the patient’s condition. Tornvall and colleagues33audited EHR records and found that reports of medical status and interventions were more prevalent than nursing status. The authors concluded that nursing documentation was limited and inadequate for evaluating the actual care given. Ehrenberg and Ehnfors’34triangulation between data from a chart review and interviews of nurses revealed little agreement between the records and the care nurses reported as having given. The researchers went so far as to state in their findings (p. 303) that “there are serious limitations in using the patient records as a data source for care delivery or for quality assessment and evaluation of care.”34

How does care planning improve outcomes?

In research where the intervention has focused on changing the care planning process, findings have shown that patient outcomes can be improved. Implementation of a care pathway for post surgical patients , to streamline nursing care of postoperative colon resection patients, resulted in a statistically significant shorter length of stay.52In another controlled study, From and colleagues53found that new care planning forms, as opposed to a narrative written in the medical record, could be associated with earlier recognition of patient problems, a shorter length of stay, and a higher accuracy in planning the discharge time.

Can you use a nurse practitioner title without a BRN?

No. You cannot use the title nurse practitioner until you have been certified by the BRN as a nurse practitioner. Furthermore, registered nurses who use the title NP without BRN certification may subject their RN license to possible discipline. (BPC §2836.1)

Can a nurse practitioner use a category of drug to meet the furnishing requirements?

The nurse practitioner cannot use a category of drug to meet the furnishing requirements The law BPC 2836.1 Furnishing or ordering of drugs and devices by a nurse practitioner requires the identification of the drugs and devices in standardized procedure or protocol

Do you need to maintain two furnishing numbers for BRN?

The BRN does not require you to maintain two furnishing numbers. NPs and CNMs are required to have approved furnishing standardized procedures. However, the furnishing laws are different in their authorizations. (BCP §2836.1)

Who is responsible for a patient's consent?

The nurse is responsible and accountable for the verification of and witnessing that the patient or the legal representative has signed the consent document in their presence and that the patient, or the legal representative, is of legal age and competent to provide consent. They also confirm that the patient has sufficient knowledge to make a knowledgeable decision.

Who provides complete information about the treatment or procedure?

The physician, or another licensed independent practitioner such as a nurse practitioner or a physician's assistant, provides the client with complete information about the treatment or procedure, the potential risks including pain and complications, the benefits of the treatment or procedure, who will perform the planned treatment or procedure, and any possible alternatives to the treatment or procedure including their benefits and risks.

What is Informed Consent?

Informed consent is defined as the patient's choice to have a treatment or procedure which is based on their full understanding of the treatment or procedure, its benefits, its risks, and any alternatives to the particular treatment or procedure. All clients have the legal right to autonomy and self-determination to accept or reject all treatments and interventions.

What are the components of informed consent?

The components of informed consent include the person's knowledgeable consent to a treatment or procedure after they have been given, and understand, complete, unbiased information about: 1 The proposed treatment or procedure 2 Who will perform the treatment or procedure 3 The purpose of the proposed treatment or procedure 4 The expected outcomes of the proposed treatment or procedure 5 The benefits of the proposed treatment or procedure 6 The possible risks associated with the proposed treatment or procedure 7 The alternatives to the particular treatment or procedure 8 The benefits and risks associated with alternatives to the proposed treatment or procedure 9 The client's right to refuse a proposed treatment or procedure

What is the right of a client to refuse treatment?

The client's right to refuse a proposed treatment or procedure. Again, all clients have the legal right to autonomy and self-determination to accept or reject all treatments, procedures, and interventions without any coercion or the undue influence of others.

Can consent be obtained from an adult patient?

Informed consent can only be obtained from an adult patient who is mentally competent to do so except under some circumstances and situations. When consent, for any reason including the lack of majority, mental incompetence, and unconsciousness, cannot be obtained, other people can provide legal consent for the patient.

Do nurses have to confirm a complete consent?

There are also times, such as during the preoperative period of time, which nurses must recognize, identify and confirm that a complete surgical consent was obtained and placed in the patient's medical record.