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- 2. The Culture of Health Care Nursing Care Processes Lecture c This material (Comp 2 Unit 6) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.
- 3. Nursing Care Processes Learning Objectives • Describe what nurses do and how they are trained (Lecture a). • Discuss the role of certified nursing assistants (Lecture a). • Describe how nurses make clinical decisions and assess patients (Lecture b). • Identify the settings where nurses work (Lectures a, c). • Discuss the procedures that nurses perform (Lecture c). • Identify nursing career opportunities, including those not involved with direct patient care (Lectures a, b, c). 3
- 4. Nursing Routines and Procedures • This lecture explains – Where nurses work – What kind of invasive procedures nurses perform – How nurses administer medication – How nurses document procedures – How nurses use technology 4
- 5. Acute Care Nursing • Acute care nurses – Treat urgent problems – Work in emergency departments, urgent care clinics, and surgical centers – Work in inpatient settings and skilled medical care settings o Includes critical care nurses 5
- 6. Ambulatory Care Nursing • Ambulatory care nurses – Treat and educate patients about non-urgent problems – Focus on health promotion – Might treat patients via telecommunications – Work in public and community health centers, doctors’ offices, diagnostic centers, the military 6
- 7. Long-Term-Care Nursing • Long-term-care nurses – Provide ongoing care for chronic illness or disability – Help patients with daily living, non-medical needs, medical problems, and emergencies – Work in assisted-living facilities, nursing homes, or skilled nursing facilities 7
- 8. Home Health Care Nursing • Home health care nurses – Provide care in the patient’s home – Might provide short-term or long-term care – Monitor the patient – Work for private or nonprofit agencies and health care systems • Also called visiting nurses 8
- 9. Public Health Nursing • Public health nurses – Promote health within a community – Help create public health policies – Might work for clinic or health maintenance organization (HMO) – Often work for government agencies, such as the Centers for Disease Control and Prevention 9
- 10. School Nursing • School nurses – Provide preventive care and health education to students – Help treat students’ health problems, such as food allergies and asthma – Work for school districts and other organizations 10
- 11. Occupational Health Nursing • Occupational nurses – Focus to keep workers healthy – Might treat workers, monitor the workplace, or advise business leaders – Understand topics such as toxicology – Work for companies, organizations, and government agencies 11
- 12. Invasive Procedures that Nurses Perform • Give injections: – Inject medications and therapies – Start intravenous (IV) lines • Insert Foley catheters • Suture cuts • Manage patient airways • Insert nasogastric tubes 12
- 13. Medication Administration Procedures • Nurses are the health care professionals most likely to administer medication • The five “rights” of medication administration: – Right patient: Check patient’s wristband – Right drug: Check label – Right time: Check prescription – Right dose: Check prescription – Right route: Check prescription 13
- 14. Common Medication Errors • Common ordering and prescribing errors: – Prescriber is overworked or distracted – Prescriber is unaware of patient’s allergies and potential drug interactions – Prescription is incomplete or illegible • IV administration is especially error-prone • Common administration errors: – Nurse is tired, distracted, or interrupted – Equipment failure 14
- 15. Preventing Administration Errors • To reduce medication administration errors: – Standardize medication labeling – Pre-measure standard doses of medication – Provide drug safety training to nurses – Provide dose calculation worksheets to nurses – Use barcodes on medication – Use technology to track and report timing of medications 15
- 16. Documentation Procedures • Nurses must document every step of the nursing process: – Patient information: Symptoms, observations, medications, treatments, patient response – Contact with other health care providers: When primary care provider saw chart or patient, appointments, consultations – Nurse’s actions: What the nurse did for the patient 16
- 17. Rules for Filling Out the Patient’s Chart • Make the record clear and comprehensible by others • Record data accurately: – Use approved abbreviations – Be objective, clear, specific, descriptive, and concise • Indicate errors or late entries appropriately • Electronic health records facilitate the complete and accurate patient record 17
- 18. Technologies That Nurses Use • Examples of patient care technologies: – Feeding pumps – Suction equipment – Barcoded medication – Oxygen and regulators – Telemetry – Automated leg compression devices – Protection of nurses: Mechanical lifts • Examples of technologies: RFID tags, video conferencing, electronic medical records 18
- 19. Technology Challenges for Nurses • Potential problems with technology: – Poor design – Poor implementation or system integration – Poor maintenance • Solutions: – Involve nurses in technology selection – Implement in stages, train nurses in use – Teach nurses how to monitor technology 19
- 20. Nursing Care Processes Summary – Lecture c • Nurses work in a wide variety of settings and have a wide range of responsibilities • Regardless of where they work, all nurses must give medication safely, document the nursing process carefully, and learn to use technology 20
- 21. Nursing Care Processes Summary – Unit 6 • Summary Lecture a: – Three types of nurses: LPNs, RNs, and APNs – Nursing roles: Patient care, teaching, research, and administration – All nurses must have formal training, pass a national exam, and meet state requirements • Summary Lecture b: – Nurses use clinical judgment when following five-step nursing process – Nurses can also play important roles in protecting patients’ legal rights and improving the quality of patient care • Summary Lecture c: – Nurses work in a wide variety of settings and have a wide range of responsibilities – Regardless of where they work, all nurses must give medication safely, document the nursing process carefully, and learn to use technology 21
- 22. Nursing Care Processes References – Lecture c References American Academy of Ambulatory Care Nursing. (2016). About AACN. Retrieved from https://www.aaacn.org/about-aaacn American Academy of Ambulatory Care Nursing. (2016). What is ambulatory care nursing? Retrieved https://www.aaacn.org/what-ambulatory-care-nursing American Public Health Association. (2016). What is public health? Retrieved from http://www.apha.org/what-is-public-health Blair, W., & Smith, B. (2012). Nursing documentation: Frameworks and barriers. Contemporary Nurse, 41(2), 160-168. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22800381 Bureau of Labor Statistics, U.S. Department of Labor. (2015). Registered nurses, in Occupational Outlook Handbook, 2014–15 Edition. Retrieved from http://www.bls.gov/ooh/healthcare/registered-nurses.htm Collins, S. A., Cato, K., Albers, D., Scott, K., Stetson, P. D., Bakken, S., & Vawdrey, D. K. (2013). Relationship between nursing documentation and patients’ mortality. American Journal of Critical Care, 22(4), 306-313. Retrieved from http://ajcc.aacnjournals.org/content/22/4/306.full.pdf+html Donald, F., Martin‐Misener, R., Carter, N., Donald, E. E., Kaasalainen, S., Wickson‐Griffiths, A., DiCenso, A. (2013). A systematic review of the effectiveness of advanced practice nurses in long‐term care. Journal of Advanced Nursing, 69(10), 2148-2161. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/jan.12140/epdf 22
- 23. Nursing Care Processes References – Lecture c Continued References Gugerty, B., Maranda, M. J., Beachley, M., et al. (2007). Challenges and opportunities in documentation of the nursing care of patients. Maryland Nursing Workforce Commission. Retrieved from http://mbon.maryland.gov/Documents/documentation_challenges.pdf Hughes R. G., & Blegen, M. A. (2008). Medication administration safety. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality. Kleinpell, R. (2005). Acute care nurse practitioner practice: Results of a 5-year longitudinal study. American Journal of Critical Care, 14 (3), 211–219. Kim, J., & Bates, D. W. (2013). Medication administration errors by nurses: adherence to guidelines. Journal of Clinical Nursing, 22(3-4), 590-598. Kulbok, P., Thatcher, E., Park, E., & Meszaros, P. (2012). Evolving public health nursing roles. Online Journal on Issues Nursing, 17 (2). LongTermCare.gov. (2016). What is long-term care? Retrieved from https://longtermcare.acl.gov/the- basics/what-is-long-term-care.html 23
- 24. Nursing Care Processes References – Lecture c Continued 2 References Powell-Cope, G., Nelson, A. L., & Patterson E. S. (2008). Patient care technology and safety. In R.G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality. Rapin, J., D’Amour, D., & Dubois, C. A. (2015). Indicators for evaluating the performance and quality of care of ambulatory care nurses. Nursing research and practice. Retrieved from http://www.hindawi.com/journals/nrp/2015/861239/abs/ South Carolina Department of Disabilities and Special Needs. (2006). Nursing documentation. Retrieved from http://www.ddsn.sc.gov/providers/manualsandguidelines/Documents/HealthCareGuidelines/Nursin gDocumentation.pdf Study.com. (2016). How to become a home care nurse: A step-by-step career guide. Retrieved from http://study.com/articles/How_to_Become_a_Home_Care_Nurse_Step-by- Step_Career_Guide.html Tunlind, A., Granström, J., & Engström, Å. (2015). Nursing care in a high-technological environment: Experiences of critical care nurses. Intensive and Critical Care Nursing, 31(2), 116-123. Westbrook, J. I., Rob, M. I., Woods, A., & Parry D. (2011). Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience. BMJ Quality and Safety, 20, 1027–1034. 24
- 25. The Culture of Health Care Nursing Care Processes Lecture c This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015. This material was updated in 2016 by Bellevue College under Award Number 90WT0002. 25
Editor's Notes
- No audio. Recording preparation.
- Welcome to The Culture of Health Care, Nursing Care Processes. This is Lecture c. The component, The Culture of Health Care, addresses job expectations in health care settings. It discusses how care is organized within a practice setting, privacy laws, and professional and ethical issues encountered in the workplace.
- By the end of this unit, Nursing Care Processes, students will be able to: Describe what nurses do and how they are trained Discuss the role of certified nursing assistants Describe how nurses make clinical decisions and assess patients Identify the settings where nurses work Discuss the procedures that nurses perform Identify nursing career opportunities including those not involved with direct patient care
- This lecture describes the many different places where nurses work. It also explains the invasive procedures that nurses perform. The word invasive means that the procedure involves going inside the patient’s body with a needle, tube, device, or scope. This lecture also explains how nurses administer medication and document procedures, and it describes the technology that nurses commonly use.
- Nurses provide a wide range of services to patients and their families in many different settings. This slide and the following slides describe where many nurses work and what they do there. Acute care nurses treat patients who need immediate treatment or monitoring. Depending on their qualifications, acute care nurses might screen, diagnose, or treat patients in an emergency department, an urgent care clinic, or at a surgical clinic. Acute care nurses manage a wide range of patient injuries and illnesses, both medical and surgical. These nurses may care for patients who are recovering from surgery or an invasive procedure at independent surgical centers and hospital surgical departments. Acute care nurses care for patients whose problems are not life threatening but require skilled medical care in the inpatient setting. Critical care nurses, on the other hand, care for patients with ongoing life-threatening problems, often in hospital settings such as intensive care units where they provide highly skilled nursing care. Larger health care organizations may have specialty intensive care units such cardiac intensive care, medical intensive care, or surgical intensive care units.
- Ambulatory [am-byoo-luh-torr-ree] care nurses care for patients with non-urgent problems, usually over multiple visits. They treat and educate patients about a wide range of medical problems, with the goal of improving the patient’s long-term health. Many ambulatory care nurses also use telecommunications tools to provide long-distance care, monitoring, and medical advice. Because they focus on health promotion, many ambulatory care nurses work in public health settings, occupational health settings, or community health clinics. Ambulatory care nurses also work in doctors’ offices, diagnostic centers, and in the military.
- Long-term-care nurses work with patients who need substantial ongoing care for a chronic illness or disability. They often provide this care in assisted-living facilities or nursing homes. Long-term-care nurses might help patients with daily activities, such as getting dressed, or help manage a patient’s medical problems, such as by giving medication. They also handle emergency situations. They must follow the regulatory requirements of the facility where they work. Long-term-care nurses often get to know their patients well as they care for them. These nurses take care of each patient’s medical needs but also consider the patient’s non-medical needs, such as their social needs.
- Home health care nurses provide care in a patient’s home. They might provide short-term care over days or weeks, such as helping a patient recover from an injury after being released from the hospital. Or they might provide long-term care for a patient with a serious chronic illness or disability who can live at home. Hospice care may also be conducted in a home setting as well as the inpatient setting. A home health care nurse monitors and evaluates the patient regularly. Like long-term-care nurses, home health care nurses often get to know their patients well. Many home health care nurses work for a private or nonprofit nursing agency, such as the Visiting Nurse Association. These agencies send nurses to the home at the request of a health care provider, patient, or patient’s family. They may also work for a health care system that has home health and hospice care as part of their service offering. Home health care nurses are sometimes called visiting nurses.
- Like ambulatory care nurses, public health nurses focus on health promotion and education. The difference is that public health nurses look at the health of an entire community or population. They look at how community health is affected by cultural, economic, and other forces, and they help create public policies to make the community healthier. An example would be working to pass a statewide law against smoking in restaurants. Public health nurses might also help assess how effective a health care system is. Some public health nurses are employed by clinics or health maintenance organizations where they work with individual patients and their families to educate them about community health needs, wellness, and prevention. Public health nurses may work for organizations at the county and state levels. Also, they may work for state or federal government agencies such as the Centers for Disease Control and Prevention.
- School nurses are employed by school districts and private schools to help students stay healthy and thrive academically. School nurses might provide preventive care such as vaccinations, administer student medication, or provide health education to students. School nurses also provide medical care when needed for special education students and for students with complex health needs, such as those who use a ventilator to breathe. They also help care for students who have behavioral problems or chronic medical conditions such as diabetes, food allergies, asthma, and epilepsy. They provide this care while the school is in session.
- Occupational health nurses help keep workers healthy and help prevent injuries and illnesses at the workplace. They usually work for companies that have hazardous worksites, such as manufacturing companies, construction companies, nuclear power plants, and public utilities. Occupational health nurses might independently evaluate and treat workers, coordinate the care and rehabilitation of workers, or monitor and assess workplace safety. Some of these nurses advise company leaders on workplace health and safety. Occupational health nurses need to understand topics relevant to hazardous workplaces, such as toxicology, which is the study of toxic substances, and epidemiology [ep-pih-dee-mee-ol-oh-gee], which is the study of how diseases spread. Some occupational health nurses work for government agencies such as the Occupational Safety and Health Administration.
- Nurses perform a range of procedures to manage and treat injuries and illnesses. The types of invasive procedures they do depend on their training. Nurses often inject patients with medications, vaccinations, and other therapies. They also start intravenous lines, or IVs, [I-Vs] to deliver fluids, medications, blood products, or other treatments directly to the patient’s vein through a thin tube called a catheter [cath-uh-tur]. Nurses might also insert catheters elsewhere in the body. The Foley [fo-lee] catheter, for example, is inserted into the urinary tract to drain urine. Nurses also clean and bandage wounds, and some nurses can suture [sue-chir], or stitch, cuts on the skin. Some nurses provide airway management by inserting a breathing tube. Some nurses insert nasogastric [nay-zo-gas-strick] tubes that run from the nose to the stomach. Nasogastric tubes are used to deliver food and liquids to the stomach or to pump substances out of the stomach.
- Before a medication reaches a patient in a hospital or other institution, it must be ordered, and the prescription information must be transcribed and verified. The medication is then dispensed and delivered to the patient. Next, the medication is administered to the patient, usually by a nurse, and the patient’s response to the medication is monitored and recorded. To make sure medication is given safely, nurses use a checklist called the five “rights” of medication administration. The five rights are right patient, right drug, right time, right dose, and right route. The right dose includes factors such as the amount of the medication and the speed of any IV infusion. Examples of routes for medication administration are oral, rectal, and intravenous.
- Researchers have found that many errors begin early in the medication administration process, when the drug is ordered. The health care provider who prescribes the medication might be overworked and distracted. Or, the provider might be unaware of a patient’s allergies to a medication or of interactions between medications. The prescription might be incomplete or illegible. Medications with similar names are often mixed up, as well. A number of errors can occur during medication administration itself. The administration of IV medication is especially error-prone. For example, sometimes nurses need to mix an IV drug with a diluting agent before they start it, and this can lead to contamination or errors in measurement. Other medication administration problems involve equipment failure, such as a defective infusion pump. Nurses can also be tired, distracted, or interrupted while giving medication, which increases the risk of errors.
- Fortunately, researchers have found ways to decrease the medication administration errors that nurses face. Hospitals can standardize medication labeling and pre-measure standard doses of medication. They can provide training in drug safety for nurses. Some hospitals provide worksheets to help nurses calculate the correct doses of medication. To prevent interruptions, other hospitals have used signs or given nurses special vests to wear when they are administering medication. Technological solutions include using bar-coding technology on medication and using a computer program to report when medications are given late.
- Good documentation of patient care is vital because it makes it easier to provide consistent care across health care providers and shifts. Third-party payers also expect accurate documentation in order to reimburse health care providers for the cost of care. Furthermore, the patient record is an important legal document. Every step of the nursing process needs to be documented and updated in a timely way for each patient. The nurse must record the patient’s symptoms and the nurse’s observations and any new symptoms or problems that occur while the nurse cares for the patient. The patient’s response to medications and other treatments also must be recorded by the nurse. If the patient is hospitalized, the nurse also needs to record any information received from the patient’s primary care provider and note any time the provider sees the patient or reviews the patient’s chart. The nurse should also record the details of any consultation about the patient. The nurse must record what he or she does for the patient; however, the nurse should not record what other health care providers do for the patient unless the nurse notes the name of the provider.
- Documentation in the patient’s chart, which is typically done electronically, needs to be clear and thorough. Nurses need to record data accurately and indicate errors or late entries appropriately. Date and time of each action they take for a patient needs to be documented. Information systems typically automatically track the date and time of data entry, which can be used for auditing purposes. For any handwritten records, the nurse should write legibly in permanent black ink and sign every entry. If an entry is written late, the nurse should mark it as a late entry and record when the entry was written. Although electronic health record systems include numerous drop-down menu items, some fields are unstructured and allow providers to enter text. So that others can read the chart accurately, the nurse should use only approved and recognized medical abbreviations and symbols. Unless he or she is quoting someone, the nurse should not use slang. All entries should be objective, and the nurse should use details to support his or her interpretations. To prevent any unauthorized additions to the record, the nurse should draw a line through any blank lines or spaces in handwritten records. This is not an issue with clinical systems. To correct the chart, the nurse should draw one line through an error, write the correct information, and date and initial the correction. Clinical systems should have a process by which to provide an addendum and corrections for the record. Electronic medical records have greatly impacted the ability of clinicians to effectively document patient care and have improved overall accessibility and management of the record. But researchers have found that nurses have three main frustrations with electronic documentation. Some systems are designed poorly, some systems are not integrated well with each other, and some systems create redundant documentation. These frustrations usually link back to the overall success of the electronic health record implementation and how well the system is aligned with workflow processes. Ideally, system implementations should be considered a three-legged stool that comprises technology, people, and process. These three pieces must be addressed for overall success of any system implementation.
- Nurses use technology when providing direct patient care, to protect patients from harm, to monitor patients, and to protect themselves from harm. Nurses also use technology to communicate, gain training in new skills, and manage staff and inventory. Examples of direct patient care technologies include feeding pumps, suction equipment, bar-coded medication, oxygen tanks and regulators, telemetry, and automated leg compression devices. An example of technology used to protect nurses is the mechanical lift used to move patients from bed to chair to toilet. Also, nurses use radio frequency identification tags, or RFIDs [Are-fids], video conferencing technology, and other communication devices. Software systems used by nurses include the electronic health record and other clinical information systems specific to the provider setting they work in. They may also use smart phone applications and may access information from an electronic health information exchange and a patient portal. They may access information provided from patient wearable devices, such as a blood pressure monitoring device, or they may remotely retrieve information from devices that are located in the patient’s home. These are just a few examples of technology and systems that nurses use in providing patient care across multiple provider settings.
- Some of the technologies that nurses use are poorly designed. Examples of design problems that researchers have found with hospital technologies include ergonomic flaws, usability issues, and interfaces that are not aligned with provider workflow processes. Other potential problems with health care technology are poor implementation, poor integration into existing systems, and poor maintenance. It’s important to include nurses in the process of selecting new technologies and equipment, looking at factors such as ergonomics, safety, and usability. New technology should be implemented in stages so that nurses can get used to it. They should be trained in how to use the technology and evaluated on how well they learn it. Once the technology or equipment is in use, nurses can monitor it for problems. They can also conduct risk modeling to predict how to respond to potential equipment failure. Nurses should provide feedback on how well the technology or equipment works with patients. As already mentioned, technology professionals typically understand the importance of having clinicians as part of their team in designing, developing, and implementing health care technology solutions. Nurses are valuable assets in ensuring that effective and efficient clinical systems and technology are implemented in all provider settings.
- This concludes Lecture c of Nursing Care Processes. In summary, nurses work in a wide variety of settings, from emergency departments to patient homes, and have a broad range of responsibilities, which vary according to the care setting and their specific training.
- This also concludes Nursing Care Processes. In summary, the first lecture discussed the three types of nurses: licensed practical nurses, registered nurses, and advanced practice nurses. The four types of advanced practice nurses are certified registered nurse anesthetists [uh-ness-thu-tists], certified nurse-midwives, nurse practitioners, and clinical nurse specialists. Nursing roles include direct patient care, teaching, research, and administration. Specialization enables nurses to gain expertise in specific areas of health care. All nurses must have formal training, pass a national exam, and meet state requirements. Nurses stay licensed and build their careers by pursuing continuing education, certification, and advanced degrees. The second lecture discussed how nurses use clinical judgment skills when following the five-step nursing process. Those five steps are to assess the patient, diagnose the problem, create a plan of care, implement the plan, and evaluate the plan. Nurses can also play important roles in protecting patients’ legal rights and improving the quality of patient care. The third lecture discussed how nurses work in a wide variety of settings, from emergency departments to patient homes. Within those workplaces, nurses have a wide range of responsibilities, including, for those with appropriate training, performing invasive procedures such as giving injections, placing catheters, and suturing cuts. Regardless of where they work, all nurses must give medication safely, document the nursing process carefully, and learn to use technology.
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