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33 Cards in this Set

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Informed Consent - Requirements
Informed Consent - Requirements

a. Capacity - age (adult), competence (can make choices $ understand consequences)
b. Voluntary - freedom of choice w/o force, fraud, deceit, dures, coercion
c. Info must be given in understandable form (lay terminology_
d. Cannot sign informed consent if client has been drinking alcohol or has been premedicated
Minors who can provide own consent for treatment
Minors who can provide own consent for treatment

a. Married Minors
b. Over a specific age (e.g. 12) for STDs, HIV testing, AIDS treatment, drug & alcohol treatment
c. Emancipated & mature minors
d. Minors seeking birth control services
e. Minors seeking outpatient psychiatric services or inpatient voluntary admissions to a psychiatric facility
f. Pregnant Minor
1. Can sign concent for themselves & the fetus
2. After delivery
a. The mother retains right to provide consent for infant
b. Mother cannot give own consent unless she fits into one of other exemptions
Informed Consent - Legal responsibility
Informed Consent - Legal responsibility

1. Rests with individual who will perform treatment
2. When nurse witnesses a signature, it means that there is reason to believe that the client is informed about upcoming treatment
Confidentiality
Confidentiality

1. Right to privacy of records
2. Info used only for purpose of diagnosis & treatment
3. Not released to others w/o permission
Advanced Directives
Advanced Directives

a. Written statement by competent person that states decisions about individual's treatment in the event of a serious illness or injuiry
b. Designates persons authorized to make decisions on individual's behalf if the individual is unable to make and/or communicate decisions
Living Wills
Living Wills

a. Legal document signed by competent individual indicates treatment or life-saving measures (e.g. surgery, CPR, antibiotics, dialysis, repirator, tube feedings) to be used if individual's ability to make decisions is lost
b. Indicates who is autorized to make health care decisions if individual becomes incapacitated
c. Legally binding in most states
Restraints - Omnibus Budget Reconciliation Act
Omnibus Budget Reconciliation Act

- provides patients/clients with the right to be free from physical & chemical restraints imposed for the purpose of discipline or convenience & not required to treat medical symptoms
Restraints - Requirement
Restraints - Requirement

Informed Consent
Restraints - False Imprisonment
Restraints - False Imprisonment

Restraint of patient w/o informed consent or sufficient justification is false imprisonment
Restraints - Consent of Proxy
Restraints - Consent of Proxy

If client is unable to consent to use restraints, then consent of proxy must be obtained after full disclosure of risks & benefits
Restraints - Chemical Restraints
Restraints - Chemical Restraints

1. Psychotropic drugs cannot be used to control behavior
2. Can be used only for diagnoses-related conditions
3. Inappropriate use causes deep sedation, agitation, combativeness
Negligence
Negligence

- unintentional failure of individual to perform an act that a reasonable person would or would not perform in similar circumstances
- can be act of omission or commission
Malpractice
Malpractice

- professional neglilgence involving misconduct or lack of skill in carrying out professional responsibilties

Reuired elements
a. Duty
b. Breach of Duty
c. Causation
d. Injury
Invasion of Privacy
Invasion of Privacy

- release of info to an unauthorized person without the client's consent
Assault
Assault

- the use of unreasonable force utilized against a client;
Good Samaritan Laws
Good Samaritan Laws

- limit the liability of professionals in emergency situations
Tarasoff Act
Tarasoff Act

- duty to warn of threatened suicide or harm to others
Nursing Accountability
Nursing Accountability

- accept ownership for results or lack of results

1. The nurse is responsible for using reasonable care in practicing nursing
2. To remain competent, nurse needs to participate in lifelong learning programs
Advocacy
Advocacy

The nurse as client advocate should:
1. Actively support client's rights
2. Defend client's participation in decision affecting them
3. Communicate clien's needs to interdisciplinary team (pysician, PT, dietician, social worker, psychologist)
4. Safeguard client's autonomy & independence
5. Provide clients with info about needs & available options so that clients can make informed decisions about health care
LPN/LVN
LPN/LVN

a. Assist with implementation of defined plan of care
b. perform procedures according to protocol
c. Differentiate normal from abnormal
d. Care for physiologically stable patients with predictable conditions
e. Has knowledge of asepsis & dressing changes
f. Ability to administer meds varies with educational bakcground & state practice nurse practice act
Unlicensed Assistive Personnel (UAPs)
Unlicensed Assistive Personnel (UAPs)

a. Assist with direct paient care activities (bathing, transferring, ambulating, feeding, toileting, obtaining vital signs, height, weight, intake & output, housekeeping, transporting, stocking supplies)
b. Nurse includes nurse aides, assistants, technicians, orderlies, nurse extenders
c. Scope of nursing practice is limited
Chain of command
Chain of command

- emphasis on vertical relationships (nurse - nurse manager - nursing supervisor)
Incident Reports - Definition
Incident Reports - Definition

1. Statement of fact & patient's physical response
2. Accurate & comprehensive report on any unexpected or unplanned occurence that affects or could potentially affect a client, family member, or staff person
Incident Reports - Purpose
Incident Reports - Purpose

1. Documentation & follow-up
2. Used to analyze the severity, frequency, & cause of occurence
3. Analysis is the basis for intervention
Incident Reports - Charting
Incident Reports - Charting

1. Don't include a reference to the incident report
2. Don't use words such as "error" or "inappropriate"
3. Don't include inflammatory owds or judgmental statements
4. If there are adverse reactions to incident, chart follow-up note updating client's status
5. Documentation of client's reactions should be included as status changes and should be continued until client reurns to original status
Common Situations that require and incident report
Common Situations that require and incident report

1. Med errors (omitted med, wrong med, wrong dosage, wrong route)
2. Complications from diagnostic or treatment procedures (e.g. blood sample stick, biopsy, x-ray, LP, invasive procedure, bronchoscopy, thoracentesis)
3. Incorrect sponge count in surgery
4. Failure to report change in patient's condition
5. Falls
6. Patient is burned
7. Break in aseptic technique
8. Medical - legal incident
a. Client or family refuses treatment as ordered and refuses to sign consent
b. Client or family voices dissatisfaction with care & situation cannot be or has not been resolved
Ethical Principles of Nursing - Autonomy
Ethical Principles of Nursing - Autonomy

- support of client's independence to make decisions & take action for themselves
Ethical Principles of Nursing - Beneficence
Ethical Principles of Nursing - Beneficence

- duty o help other by doing what is best for them

- for refusal of care, autonomy overrides beneficence
Ethical Principles of Nursing - Nonmaleficence
Ethical Principles of Nursing - Nonmaleficence

- "do not harm"
- act with empathy toward patient & staff without resentment or malice
- violated by acts performed in bad faith or with ill will, or when making false accusations about patient or employee
Ethical Principles of Nursing - Justice
Ethical Principles of Nursing - Justice

- use available resources fairly and reasonable
Ethical Principles of Nursing - Varacity
Ethical Principles of Nursing - Varacity

- communicate truthfully & accurately
Ethical Principles of Nursing - Confidentiality
Ethical Principles of Nursing - Confidentiality

- safeguard the client's privacy
Ethical Principles of Nursing - Fidelity
Ethical Principles of Nursing - Fidelity

- following through on what you say will do; carefully attending to the details of the client's care