Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX-RN® Examination (2021)
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Copyright © 2021, Elsevier Inc. All rights reserved. i YOU’VE JUST PURCHASED MORE THAN A TEXTBOOK! REGISTER TODAY! Place Sticker Here You can now purchase Elsevier products on Evolve! Go to evolve.elsevier.com/shop to search and browse for products. 2019v1.0 Enhance your learning with Evolve Student Resources. These online study tools and exercises can help deepen your understanding of textbook content so you can be more prepared for class, perform better on exams, and succeed in your course. Activate the complete learning experience that comes with each http://evolve.elsevier.com/LaCharity/prioritization/ If your school uses its own Learning Management System, your resources may be delivered on that platform. Consult with your instructor. has already been revealed, the code may have been used and cannot be re-used for registration. To purchase a new code to access these valuable study resources, simply follow the link above.
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Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX- RN ® Examination
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P P P P P P a t t i e e e n n t - Linda A. LaCharity, PhD, RN Formerly, Accelerated Program Director Assistant Professor College of Nursing University of Cincinnati Cincinnati, Ohio Shirley M. Hosler, MSN, RN Formerly, Nursing Instructor School of Nursing National American University Albuquerque, New Mexico Candice K. Kumagai, MSN, RN Formerly, Clinical Instructor School of Nursing University of Texas at Austin Austin, Texas With an introduction by Ruth Hansten, MBA, PhD, RN, FACHE Principal Consultant and CEO Hansten Healthcare Santa Rosa, California 5 th EDITION Prioritization, Delegation, and Assignment Practice Exercises for the NCLEX-RN ® Examination
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Elsevier 3251 Riverport Lane St. Louis, Missouri 63043 PRIORITIZATION, DELEGATION, AND ASSIGNMENT: PRACTICE EXERCISES FOR THE NCLEX- RN® EXAMINATION, FIFTH EDITION ISBN: 978- 0- 323- 68316- 6 Copyright © 2022 by Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions . This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted 2019, 2014, 2011, and 2006. Library of Congress Control Number: 2021936204 Executive Content Strategist: Lee Henderson Senior Content Development Manager: Lisa Newton Senior Content Development Specialist: Tina Kaemmerer Publishing Services Manager: Julie Eddy Senior Project Manager: Abigail Bradberry Design Direction: Margaret Reid Printed in Canada Last digit is the print number: 9 8 7 6 5 4 3 2 1
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v Contributors and Reviewers CONTRIBUTORS Martha Barry, MS, RN, APN, CNM Certified Nurse Midwife OB Faculty Practice Advocate Medical Group Chicago, Illinois; Adjunct Clinical Instructor College of Nursing University of Illinois at Chicago Chicago, Illinois Mary Tedesco- Schneck, PhD, RN, CPNP Assistant Professor School of Nursing University of Maine Orono, Maine REVIEWERS Amber Ballard, MSN, RN Registered Nurse Emergency Department Sparrow Health System Lansing, Michigan Angela McConachie, DNP, MSN-FNP, RN Director, BSN Program Accelerated Option Associate Professor Goldfarb School of Nursing at Barnes Jewish College St. Louis, Missouri
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vi Preface Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX- RN ® Examination has evolved since its first edition from a medical- surgical nursing–focused test preparation workbook to a resource that spans gen - eral nursing knowledge while emphasizing management of care to assist students in preparing for the NCLEX® Examination. Our fifth edition includes many examples of new question types that will be included in the forthcom - ing Next-Generation NCLEX® Examination (NGN). A second and equally important purpose of the book contin - ues to be assisting students, novice nurses, and seasoned nurses in applying concepts of prioritization, delegation, and assignment to nursing practice in today’s patient care settings. TO FACULTY AND OTHER USERS Patient care acuity continues to be higher than ever with the essential added care of COVID- 19 patients, while staffing shortages remain very real. Nurses must use all available patient care personnel and resources compe - tently and efficiently and be familiar with variations in state laws governing the practice of nursing, as well as differences in scopes of practice and facility- specific job descriptions. Nurses must also be aware of the different skill and experience levels of the health care profession - als with whom they work on a daily basis. Which nursing actions can be assigned to an experienced versus a new graduate RN or LPN/LVN? What forms of patient care can the nurse delegate to assistive personnel (AP)? Who should help the postoperative patient who has had a total hip replacement get out of bed and ambulate to the bath - room? Can the nurse ask APs such as nursing assistants to check a patient’s oxygen saturation using pulse oxim - etry or check a diabetic patient’s glucose level? What reporting parameters should the nurse give to an LPN/ LVN who is monitoring a patient after cardiac catheter - ization or to the AP checking patients’ vital signs? What patient care interventions and actions should not be dele - gated by the nurse? The answers to these and many other questions should be much clearer after completion of the exercises in this book. Exercises in this book range from simple to complex and use various patient care scenarios. The purpose of the chapters and case studies is to encourage the student or new graduate nurse to conceptualize using the skills of prioritization, delegation, and assignment, as well as supervision in many different settings. Our goal is to make these concepts tangible to our readers. The questions are written in NCLEX® Examination formats, including new NGN styles to help faculty as they teach student nurses how to prepare for licensure examination. The chapters and case studies focus on real and hypothetical patient care situations to challenge nurses and nursing students to develop the skills nec - essary to apply these concepts in practice. The exercises are also useful to nurse educators as they discuss, teach, and test their students and nurses for understanding and application of these concepts in nursing programs, exam - ination preparations, and facility orientations. Correct answers, along with in- depth rationales, are provided at the end of each chapter and case study to facilitate the learning process, along with the focus/foci for each item. The faculty exercise keys include QSEN (Quality and Safety Education for Nurses) categories, concepts, and cognitive levels for each question, as well as IPEC (Interprofessional Education Collaborative) competen - cies where appropriate. TO STUDENTS Prioritization, delegation, and assignment are essential concepts and skills for nursing practice. Our students and graduate nurses have repeatedly told us of their dif - ficulties with the application of these principles when taking program exit and licensure examinations. Nurse managers have told us many times that novice nurses and even some experienced nurses lack the expertise to effectively and safely practice these skills in real- world settings. Although several excellent resources deal with these issues, there is still a need for a book that incorporates management of these care concepts into real- world practice scenarios. Our goal in writing the fifth edition of Prioritization, Delegation, and Assignment: Practice Exercises for the NCLEX- RN ® Examination is to provide a resource that challenges nursing students, as well as novice and experienced nurses, to develop the knowledge and understanding necessary to effectively apply these important nursing skills: examination preparation and real- world practice. From the original focus on medical- surgical nursing, subsequent editions have expanded to
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PREFACE vii include pediatrics, labor and delivery, psychiatric nursing, and long- term care as well as the role of the nurse in a vari - ety of nonacute care settings. Additionally, we have made changes that reflect the current focus on evidence- based best practices, fundamentals of safe practice, and expan - sion of diabetes care. For the fifth edition, we responded to requests for more questions, especially about medica - tions. New questions, including drug- related questions, have been added to each chapter. We also added questions specific to the needs of the lesbian, gay, bisexual, transgen - der, queer, intersexual, and asexual (LGBTQIA) commu - nity. New questions were added and revised throughout the book to broaden comprehension of key concepts and knowledge areas and to update current knowledge lev - els. Our fifth edition expands on all of these topics and incorporates examples of Next-Generation NCLEX® Examination (NGN) question formats to prepare stu - dents for the upcoming NCLEX® changes. Each new copy of the book comes with a fully interac - tive version of the book content, with scoring, on Evolve at http://evolve.elsevier.com/LaCharity/prioritization . This interactive version of the book helps to simulate the expe - rience of taking the NCLEX® Examination. Students can use this interactive option to create multiple different test versions for practice and self- assessment. ACKNOWLEDGMENTS We would like to thank the many people whose support and assistance made the creation of the fifth edition of this book possible. Thanks to our families, colleagues, and friends for listening, reading, encouraging, and making sure we had the time to research, write, and review this book. We truly appreciate the expertise of our two con - tributing authors, Martha Barry (reproductive health) and Mary Tedesco- Schneck (pediatrics), who each contributed an excellent chapter and case study related to their areas of expertise. Very special thanks to Ruth Hansten, whose expertise in the area of clinical prioritization, delegation, and assignment skills continues to keep us on track. Many thanks to the faculty reviewers, whose expertise helped us keep the scenarios accurate and realistic. Finally, we wish to acknowledge our faculty, students, graduates, and read - ers who have taken the time to keep in touch and let us know about their needs for additional assistance in devel - oping the skills to practice the arts of prioritization, del - egation, and assignment. Linda A. LaCharity Candice K. Kumagai Shirley M. Hosler
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viii Contents PART 1 INTRODUCTION, 1 Guidelines for Prioritization, Delegation, and Assignment Decisions, 1 PART 2 PRIORITIZATION, DELEGATION, AND ASSIGNMENT IN COMMON HEALTH SCENARIOS, 11 Chapter 1 Pain, 11 Chapter 2 Cancer, 25 Chapter 3 Immunologic Problems, 38 Chapter 4 Fluid, Electrolyte, and Acid- Base Balance Problems, 47 Chapter 5 Safety and Infection Control, 54 Chapter 6 Respiratory Problems, 63 Chapter 7 Cardiovascular Problems, 73 Chapter 8 Hematologic Problems, 84 Chapter 9 Neurologic Problems, 92 Chapter 10 Visual and Auditory Problems, 102 Chapter 11 Musculoskeletal Problems, 112 Chapter 12 Gastrointestinal and Nutritional Problems, 120 Chapter 13 Diabetes Mellitus, 133 Chapter 14 Other Endocrine Problems, 141 Chapter 15 Integumentary Problems, 149 Chapter 16 Renal and Urinary Problems, 157 Chapter 17 Reproductive Problems, 166 Chapter 18 Problems in Pregnancy and Childbearing, 176 Chapter 19 Pediatric Problems, 189 Chapter 20 Pharmacology, 201 Chapter 21 Emergencies and Disasters, 211 Chapter 22 Psychiatric/Mental Health Problems, 225 Chapter 23 NCLEX Next Generation, 237 PART 3 PRIORITIZATION, DELEGATION, AND ASSIGNMENT IN COMPLEX HEALTH SCENARIOS, 251 Case Study 1 Chest Pressure, Indigestion, and Nausea, 251 Case Study 2 Dyspnea and Shortness of Breath, 257 Case Study 3 Multiple Clients on a Medical- Surgical Unit, 264 Case Study 4 Shortness of Breath, Edema, and Decreased Urine Output, 271 Case Study 5 Diabetic Ketoacidosis, 276 Case Study 6 Home Health, 283 Case Study 7 Spinal Cord Injury, 289 Case Study 8 Multiple Patients With Adrenal Gland Disorders, 294 Case Study 9 Multiple Clients With Gastrointestinal Problems, 299 Case Study 10 Multiple Patients With Pain, 310 Case Study 11 Multiple Clients With Cancer, 320 Case Study 12 Gastrointestinal Bleeding, 330 Case Study 13 Head and Leg Trauma and Shock, 338 Case Study 14 Septic Shock, 345 Case Study 15 Heart Failure, 351 Case Study 16 Multiple Patients With Peripheral Vascular Disease, 356 Case Study 17 Respiratory Difficulty After Surgery, 363 Case Study 18 Long- Term Care, 370 Case Study 19 Pediatric Clients in Clinic and Acute Care Settings, 377 Case Study 20 Multiple Patients With Mental Health Disorders, 386 Case Study 21 Childbearing, 397 Illustration Credits, 407
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1 Copyright © 2022, Elsevier Inc. All rights reserved. Introduction PART 1 OUTCOMES FOCUS Expert nurses have discovered that the most success - ful method of approaching their practice is to maintain a laser- like focus on the outcomes that the patients and their families want to achieve. To attempt to prioritize, delegate, or assign care without understanding the patient’s preferred results is like trying to put together a jigsaw puzzle with - out the top of the puzzle box that shows the puzzle picture. Not only does the puzzle player pick up random pieces that don’t fit well together, wasting time and increasing frustra - tion, but also the process of puzzle assembly is fraught with inefficiencies and wrong choices. In the same way, a nurse who scurries haphazardly without a plan, unsure of what could be the most important, life- saving task to be done first or which person should do which tasks for this group of patients, is not fulfilling his or her potential to be a channel for healing. Let’s visit a change- of- shift report in which a group of nurses receives information about two patients whose blood pressure is plummeting at the same rate. How would one determine which nurse would be best to assign to care for these patients, which patient needs to be seen first, and which tasks could be delegated to assistive person - nel (APs), if none of the nurses is aware of each patient’s preferred outcomes? Patient A is a young mother who has been receiving chemotherapy for breast cancer; she has been admitted this shift because of dehydration from uncontrolled emesis. She is expecting to regain her nor - mally robust good health and watch her children gradu - ate from college. Everyone on the health care team would concur with her long- term goals. Patient Z is an elderly gentleman, 92 years of age, whose wife recently died from complications of repeated cerebrovascular events and dementia. Yesterday while in the emergency department (ED), he was given the diagnosis of acute myocardial infarction and preexisting severe heart failure. He would like to die and join his wife, has requested a “do not resus - citate” order, and is awaiting transfer to a hospice. These two patients share critical clinical data but require widely different prioritization, delegation, and assignment. A savvy charge RN would make the obvious decisions: to assign the most skilled RN to the young mother and to ask APs to function in a supportive role to the primary care RN. The elderly gentleman needs palliative care and would be best cared for by an RN and care team with excellent people skills. Even a novice nursing assistant could be del - egated tasks to help keep Mr. Z and his family comfortable and emotionally supported. The big picture on the puzzle box for these two patients ranges from long- term “robust good health” requiring immediate emergency assessment and treatment to “a supported and comfortable death” requiring timely palliative care, including supportive emotional and physical care. Without envisioning these patients’ pictures and knowing their preferred outcomes, the RNs cannot prioritize, delegate, or assign appropriately. There are many times in nursing practice, however, when correct choices are not so apparent. Patients in all care set - tings today are often complex, and many have preexisting comorbidities that may stump the expert practitioners and clinical specialists planning their care. Care delivery sys - tems must flex on a moment’s notice as an AP arrives in place of a scheduled LPN/LVN and agency, float, or travel - ing nurses fill vacancies, while new patients, waiting to be admitted, accumulate in the ED or wait to be transferred to another setting. APs arrive with varying educational prepa - ration and dissimilar levels of motivation and skill. Critical thinking and complex clinical judgment are required from the minute the shift begins until the nurse clocks out. In this book, the authors have filled an educational need for students and practicing nurses who wish to hone their skills in prioritizing, assigning, and delegating. The scenar - ios and patient problems presented in this workbook are practical, challenging, and complex learning tools. Quality and Safety Education for Nurses (QSEN) competencies are incorporated into this chapter and throughout the ques - tions to highlight patient- and family- centered care, quality and safety improvement, and teamwork and collaboration concepts and skills ( QSEN Institute, 2019 ). Patient stories will stimulate thought and discussion and help polish the higher- order intellectual skills necessary to practice as a successful, safe, and effective nurse. The Interprofessional Collaboration Competency Community and Population Oriented Domains from the Interprofessional Education Collaborative (IPEC) are applied to the questions in this book as appropriate ( Interprofessional Education Collaborative, 2016 , https://ipecollaborative.org ). Domains include Interprofessional Teamwork and Team- Based Practices, Interprofessional Teamwork Practices, Guidelines for Prioritization, Delegation, and Assignment Decisions Ruth Hansten, PhD, MBA, BSN, RN, FACHE
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Guidelines for Prioritization, Delegation, and Assignment Decisions 2 Copyright © 2022, Elsevier Inc. All rights reserved. Introduction PART 1 Roles and Responsibilities for Collaborative Practice, and Values/Ethics for Interprofessional Practice. As reflected in the IPEC sub- competencies, especially crucial for patient outcomes is the role of the RN, armed with knowledge of scopes of practice, successfully communicating with team members to delegate, assign, and supervise ( IPEC, 2016 ). DEFINITION OF TERMS The intellectual functions of prioritization, delegation, and assignment engage the nurse in projecting into the future from the present state. Thinking about what impact might occur if competing decisions are chosen, weigh - ing options, and making split- second decisions, given the available data, is not an easy process. Unless resources in terms of staffing, budget, time, or supplies are unlimited, nurses must relentlessly focus on choosing which issues or concerns must take precedence. Prioritization Prioritization is defined as “ranking problems in order of importance” or “deciding which needs or problems require immediate action and which ones could tolerate a delay in action until a later time because they are not urgent” ( Silvestri, 2018 ). Prioritization in a clinical setting is a pro - cess that involves clearly envisioning patient outcomes but also includes predicting possible problems if another task is performed first. One also must weigh potential future events if the task is not completed, the time it would take to accomplish it, and the relationship of the tasks and outcomes. New nurses often struggle with prioritization because they have not yet worked with typical patient progressions through care pathways and have not expe - rienced the complications that may emerge in association with a particular clinical condition. In short, knowing the patient’s purpose for care, current clinical picture, and picture of the outcome or result is necessary to be able to plan priorities. The part played by each team member is designated as the RN assigns or delegates. The “four Ps”— purpose, picture, plan, and part—become a guidepost for appropriately navigating these processes ( Hansten, 2008a, 2011, 2014b ; Hansten and Jackson, 2009 ). The four Ps will be referred to throughout this introduction because these concepts are the framework on which RNs base decisions about supporting patients and families toward their pre - ferred outcomes, whether RNs provide the care themselves or work closely with assistive team members. Prioritization includes evaluating and weighing each competing task or process using the following criteria ( Hansten and Jackson, 2009 , pp. 194–196): • Is it life threatening or potentially life threatening if the task is not done? Would another patient be endangered if this task is done now or the task is left for later? • Is this task or process essential to patient or staff safety? • Is this task or process essential to the medical or nursing plan of care? In each case, an understanding of the overall patient goals and the context and setting is essential. 1. In her book on critical thinking and clinical judg - ment, Rosalinda Alfaro- Lefevre (2017) suggests three levels of priority setting: The first level is a ir - way, b reathing, c ardiac status and circulation, and v i - tal signs and l ab values that could be life threatening (“ABCs plus V and L”). 2. The second level is immediately subsequent to the first level and includes concerns such as mental sta - tus changes, untreated medical issues, acute pain, acute elimination problems, and imminent risks. 3. The third level comprises health problems other than those at the first two levels, such as more long- term issues in health education, rest, coping, and so on (p. 171). Maslow’s hierarchy of needs can be used to prioritize from the most crucial survival needs to needs related to safety and security, affiliation (love, relationships), self- esteem, and self- actualization ( Alfaro- Lefevre, 2017 , p. 170). Delegation and Assignment The official definitions of assignment have been altered through ongoing dialogue among nursing leaders in various states and nursing organizations, and terminology distinc - tions such as observation versus assessment, critical thinking versus clinical reasoning, and delegation versus assignment continue to be discussed as nursing leaders attempt to describe complex thinking processes that occur in various levels of nursing practice. Assignment has been defined as “the distribution of work that each staff member is responsible for during a given work period” ( American Nurses Association [ANA], Duffy & McCoy, 2014 , p. 22). In 2016, the National Council of State Boards of Nursing (NCSBN) published the results of two expert panels to clarify that assignment includes “the routine care, activi - ties, and procedures that are within the authorized scope of practice of the RN or LPN/LVN or part of the routine functions of the UAP (Unlicensed Assistive Personnel)” ( NCSBN, 2016b , pp. 6–7), and this definition was adopted by the ANA in 2019 in a joint statement with the NCSBN with the addition of the acronym AP (assistive personnel) ( ANA & NCSBN 2019 National Guidelines for Nursing Delegation, p. 2). Delegation was defined traditionally as “transferring to a competent individual the authority to perform a selected nursing task in a selected situation” ( NCSBN, 1995 ), and similar definitions are used by some nurse practice statutes or regulations. Both the ANA and the NCSBN describe delegation as “allowing a delegate
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Guidelines for Prioritization, Delegation, and Assignment Decisions 3 Copyright © 2022, Elsevier Inc. All rights reserved. Introduction PART 1 to perform a specific nursing activity, skill, or procedure that is beyond the delegatee’s traditional role and is not routinely performed” ( ANA & NCSBN 2019 , p. 2). Nevertheless, the delegatee must be competent to perform that delegated task as a result of extra training and skill validation. The ANA specifies that delegation is a transfer of responsibility or assignment of an activity while retain - ing the accountability for the outcome and the overall care ( ANA, 2014 ; Duffy & McCoy , p. 22). Some state boards have argued that assignment is the process of directing a nursing assistant to perform a task such as taking blood pressure, a task on which nurs - ing assistants are tested in the certified nursing assistant examination and that would commonly appear in a job description. Others contend that all nursing care is part of the RN scope of practice and therefore that such a task would be delegated rather than assigned. Other nursing leaders argue that only when a task is clearly within the RN’s scope of practice, and not included in the role of an AP, is the task delegated. Regardless of whether the alloca - tion of tasks to be done is based on assignment or delega - tion, in this book, assignment means the “work plan” and connotes the nursing leadership role of human resources deployment in a manner that most wisely promotes the patient’s and family’s preferred outcome. Although states vary in their definitions of the functions and processes in professional nursing practice, including that of delegation, the authors use the NCSBN and ANA’s definition, including the caveat present in the sentence following the definition: delegation is “transferring to a competent individual the authority to perform a selected nursing task in a selected situation. The nurse retains the accountability for the delegation” ( NCSBN, 1995 , p. 2). Assignments are work plans that would include tasks the delegatee would have been trained to do in their basic educational program; the nurse “assigns” or distributes work and also “delegates” nursing care as she or he works through others. In advanced personnel roles, such as when certified medication aides are taught to administer medi - cations or when certified medical assistants give injections, the NCSBN (2016) asserts that because of the extensive responsibilities involved, the employers and nurse lead - ers in the settings where certified medication aides are employed, such as ambulatory care, skilled nursing homes, or home health settings, should regard these procedures as being delegated and AP competencies must be assured ( NCSBN, 2016b , p. 7). ANA designates these certified but unlicensed individuals as APs rather than UAPs ( ANA & NSCBN 2019 ). The differences in definitions among states and the differentiation between delegation and assignment are perplexing to nurses. Because both processes are simi - lar in terms of the actions and thinking processes of the RN from a practical standpoint, this workbook will merge the definitions to mean that RNs delegate or assign tasks when they are allocating work to competent trained indi - viduals, keeping within each state’s scope of practice, rules, and organizational job descriptions. Whether assigning or delegating, the RN is accountable for the total nursing care of the patient and for making choices about which compe - tent person is permitted to perform each task successfully. Whether the RN is delegating or assigning, depending on their state regulations, the expert RN will not ask a team member to perform a task that is beyond the RN’s own scope of practice or job description, or a task outside of any person’s competencies. In all cases the choices made to allocate work must prioritize which allocation of work is optimal for the patient’s safe and effective care ( Hansten 2020 , in Kelly Vana and Tazbir). Delegation or Assignment and Supervision The definitions of delegation and assignment offer some important clues to nursing practice and to the composition of an effective patient care team. The person who makes the decision to ask a person to do something (a task or assignment) must know that the chosen person is com - petent to perform that task. The RN selects the particular task, given his or her knowledge of the individual patient’s condition and that particular circumstance. Because of the nurse’s preparation, knowledge, and skill, the RN chooses to render judgments of this kind and stands by the choices made. According to licensure and statute, the nurse is obli - gated to delegate or assign based on the unique situation, patients, and personnel involved and to provide ongoing follow- up. Supervision Whenever nurses delegate or assign, they must also super - vise. Supervision is defined by the NCSBN as “the pro - vision of guidance and direction, oversight, evaluation, and follow up by the licensed nurse for accomplishment of a nursing task delegated to nursing assistive person - nel” and by the ANA as “the active process of directing, guiding, and influencing the outcome of an individual’s performance of a task” ( ANA, 2014 ; Duffy & McCoy , p. 23). Each state may use a different explanation, such as Washington State’s supervision definition: “initial direction … periodic inspection … and the authority to require corrective action” (Washington Administrative Code 246- 840- 010 Definitions, https://app.leg.wa.gov/w ac/default.aspx?cite=246- 840- 010 ). The act of delegating or assigning is just the beginning of the RN’s responsibil - ity. As for the accountability of the delegatees (or people given the task duty), these individuals are accountable for a) accepting only the responsibilities that they know they are competent to complete, b) maintaining their skill proficiency, c) pursuing ongoing communication with the team’s leader, and d) completing and documenting the task appropriately ( ANA and NCSBN, 2019 , p. 9). For exam - ple, nursing assistants who are unprepared or untrained to complete a task should say as much when asked and can then decline to perform that particular duty. In such a situ - ation, the RN would determine whether to allocate time
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Guidelines for Prioritization, Delegation, and Assignment Decisions 4 Copyright © 2022, Elsevier Inc. All rights reserved. Introduction PART 1 to train the AP and review the skill as it is learned, to del - egate the task to another competent person, to do it herself or himself, or to make arrangements for later skill train - ing. The RN’s job continues throughout the performance and results of task completion, evaluation of the care, and ongoing feedback to the delegatees. Scope of Practice for RNs, LPNs/LVNs, and APs Heretofore this text has discussed national recommendations for definitions. National trends suggest that nursing is mov - ing toward standardized licensure through mutual recogni - tion compacts and multistate licensure, and as of April 2019, 31 states had adopted the nurse license compact allowing a nurse in a member state to possess one state’s license and practice in another member state, with several states pend - ing ( NCSBN, 2019a ). Standardized and multistate licensure supports electronic practice and promotes improved practice flexibility. Each RN must know his or her own state’s regu - lations, however. Definitions still differ from state to state, as do regulations about the tasks that nursing assistants or other APs are allowed to perform in various settings. For example, APs are delegated tasks for which they have been trained and that they are currently competent to perform for stable patients in uncomplicated circum - stances; these are routine, simple, repetitive, common activities not requiring nursing judgment, such as activi - ties of daily living, hygiene, feeding, and ambulation. Some states have generated statutes and/or rules that list specific tasks that can or cannot be delegated. Nevertheless, trends indicate that more tasks will be delegated as research sup - ports such delegation through evidence of positive out - comes. Acute care hospital nursing assistants have not historically been authorized to administer medications. In some states, specially certified medication assistants administer oral medications in the community (group homes) and in some long- term care facilities, although there is substantial variability in state- designated certi - fied nursing assistant (CNA) duties ( McMullen et al., 2015 ). More states are employing specially trained nurs - ing assistants as CMAs (certified medication assistants) or MA- Cs (medication assistants- certified) to administer routine, nonparenteral medications in long- term care or community settings with training as recommended by the NCSBN’s Model Curriculum ( NCSBN, 2016 , p. 7). For over a decade, Washington state has altered the statute and related administrative codes to allow trained nursing assis - tants in home or community- based settings, such as board - ing homes and adult family homes, to administer insulin if the patient is an appropriate candidate (in a stable and predictable condition) and if the nursing assistant has been appropriately trained and supervised for the first 4 weeks of performing this task ( Revised Code of Washington, 2012 ). Nationally, consistency of state regulation of AP medication administration in residential care and adult day- care settings has been stated to be inadequate to ensure RN oversight of APs ( Carder & O’Keeffe, 2016 ). This research finding should serve as a caution for all prac - ticing in these settings. Other studies of nursing homes and assisted living facilities show evidence of role confu - sion among RNs, LPN/LVNs, and APs ( Mueller et al., 2018 ; Dyck & Novotny, 2018 ). In ambulatory care set - tings, medical assistants (MAs) are being used extensively, supervised by RNs, LPNs (depending on the state), physi - cians, or other providers, and nurses are cautioned to know both the state nursing and medical regulations. In some cases (Maryland, for example), a physician could delegate peripheral IV initiation to an MA with on-site supervision, but in some states an LPN is prohibited from this same task ( Maningo and Panthofer, 2018 , p.2). In all states, nursing judgment is used to delegate tasks that fall within, but never exceed, the nurse’s legal scope of practice, and an RN always makes decisions based on the individual patient situation. An RN may decide not to delegate the task of feeding a patient if the patient is dysphagic and the nursing assistant is not familiar with feeding techniques. A “Lessons Learned from Litigation” article in the American Journal of Nursing in May 2014 describes the hazards of improper RN assignment, del - egation, and supervision of patient feeding, resulting in a patient’s death and licensure sanctions ( Brous, 2014 ). The scope of practice for LPNs or LVNs also differs from state to state and is continually evolving. For exam - ple, in Texas, LPNs are prohibited from delegating nurs - ing tasks; only RNs are allowed to delegate ( Texas Board of Nursing, 2019 , http://www.bon.texas.gov/faq_delegati on.asp#t6 ), whereas in Washington state an LPN could delegate to nursing assistants in some settings (listed as hospitals, nursing homes, clinics, and ambulatory surgery centers) ( Washington Nursing Care Quality Assurance Commission 2019 , https://www.doh.wa.gov/Portals/1/ Documents/6000/NCAO13.pdf ). Although practicing nurses know that LPNs often review a patient’s condition and perform data- gathering tasks such as observation and auscultation, RNs remain accountable for the total assess - ment of a patient, including the synthesis and analysis of reported and reviewed information to lead care planning based on the nursing diagnosis. In their periodic review of actual practice by LPNs, the NCSBN found that assign - ing client care or related tasks to other LPNs or APs was ranked sixth in frequency, with monitoring activities of APs ranked seventh ( NCSBN, 2019 , p. 156). IV therapy and administration of blood products or total parenteral nutrition by LPNs/LVNs also vary widely. Even in states where regulations allow LPNs/LVNs to administer blood products, a given health care organization’s policies or job descriptions may limit practice and place additional safe - guards because of the life- threatening risk involved in the administration of blood products and other medications. The RN must review the agency’s job descriptions as well as the state regulations because either is changeable. LPN/LVN practice continues to evolve, and in any state, tasks to support the assessment, planning, interven - tion, and evaluation phases of the nursing process can be
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Guidelines for Prioritization, Delegation, and Assignment Decisions 5 Copyright © 2022, Elsevier Inc. All rights reserved. Introduction PART 1 allocated. When it is clear that a task could possibly be delegated to a skilled delegatee according to your state’s scope of practice rules and is not prohibited by the organi - zation policies, the principles of delegation and/or assign - ment remain the same. The totality of the nursing process remains the responsibility of the RN. Also, the total nursing care of the patient rests squarely on the RN’s shoulders, no matter which competent and skilled individual is asked to perform care activities. To obtain more information about the statute and rules in a given state and to access decision trees and other helpful aides to delegation and supervi - sion, visit the NCSBN website at http://www.ncsbn.org . The state practice act for each state is linked at that site. ASSIGNMENT PROCESS In current hospital environments, the process of assigning or creating a work plan is dependent on who is available, present, and accounted for and what their roles and compe - tencies are for each shift. Assignment has been understood to be the “work plan” or “the distribution of work that each staff member is responsible for during a given work period” (American Nurses Association (ANA), Duffy & McCoy, 2014 , p. 22). Classical care delivery models once known as total patient care have been transformed into a combination of team, functional, and primary care nursing, depending on the projected patient outcomes, the present patient state, and the available staff. Assignments must be created with knowledge of the following issues ( Hansten and Jackson, 2009 , pp. 207–208, Hansten, 2020 in Kelly Vana and Tazbir): • How complex is the patient’s required care? • What are the dynamics of the patient’s status and their stability? • How complex is the assessment and ongoing evaluation? • What kind of infection control is necessary? • Are there any individual safety precautions? • Is there special technology involved in the care, and who is skilled in its use? • How much supervision and oversight will be needed based on the staff ’s numbers and expertise? • How available are the supervising RNs? • How will the physical location of patients affect the time and availability of care? • Can continuity of care be maintained? • Are there any personal reasons to allocate duties for a particular patient, or are there nurse or patient pref - erences that should be taken into account? Factors such as staff difficulties with a particular diagnosis, patient preferences for an employee’s care on a previ - ous admission, or a staff member’s need for a particu - lar learning experience will be taken into account. • Is there an acuity rating system that will help distrib - ute care based on a point or number system? For more information on care delivery modali - ties, refer to the texts by Hansten and Jackson (2009) or access Hansten’s webinars related to assignment and care delivery models at http://learning.hansten.com/ and Alfaro- LeFevre (2017) listed in the References section. Whichever type of care delivery plan is chosen for each particular shift or within your practice arena, the rela - tionship with the patient and the results that the patient wants to achieve must be foremost, followed by the plac - ing together of the right pieces in the form of compe - tent team members, to compose the complete picture ( Hansten, 2019 ). DELEGATION AND ASSIGNMENT: THE FIVE RIGHTS As you contemplate the questions in this workbook, you can use mnemonic devices to order your thinking pro - cess, such as the “five rights.” The right task is assigned to the right person in the right circumstances. The RN then offers the right direction and communication and the right supervision and evaluation ( Hansten and Jackson, 2009 , pp. 205–206; NCSBN, 1995 , pp. 2–3; Hansten, 2014a , p. 70; NCSBN, 2016b , p. 8; ANA & NCSBN, 2019 , p. 4). Right Task Returning to the guideposts for navigating care, the patient’s four Ps (purpose, picture, plan, and part), the right task is a task that, in the nurse’s best judgment, is one that can be safely delegated for this patient, given the patient’s current condition (picture) and future preferred outcomes (purpose, picture), if the nurse has a competent willing individual available to perform it. Although the RN may believe that he or she personally would be the best person to accomplish this task, the nurse must prioritize the best use of his or her time given a myriad of factors, such as: What other tasks and processes must I do because I am the only RN on this team? Which tasks can be delegated based on state regulations and my thorough knowledge of job descriptions here in this facility? How skilled are the personnel working here today? Who else could be avail - able to help if necessary? In its draft model language for nursing APs, the NCSBN lists criteria for determining nursing activities that can be delegated. The following are recommended for the nurse’s consideration. It should be kept in mind that the nursing process and nursing judgment cannot be delegated. • Knowledge and skills of the delegatee • Verification of clinical competence by the employer • Stability of the patient’s condition • Service setting variables such as available resources (including the nurse’s accessibility) and methods of communication, complexity and frequency of care, and proximity and numbers of patients relative to staff
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Guidelines for Prioritization, Delegation, and Assignment Decisions 6 Copyright © 2022, Elsevier Inc. All rights reserved. Introduction PART 1 APs are not to be allocated the duties of the nursing process of assessment (except gathering data), nursing diagnosis, planning, implementation (except those tasks delegated/assigned), or evaluation. Professional clinical judgment or reasoning and decision making related to the manner in which the RN makes sense of the patient’s data and clinical progress cannot be delegated or assigned ( ANA & NCSBN, 2019 , p. 3). Right Circumstances Recall the importance of the context in clinical decision making. Not only do rules and regulations adjust based on the area of practice (i.e., home health care, acute care, schools, ambulatory clinics, long- term care), but patient conditions and the preferred patient results must also be considered. If information is not available, a best judgment must be made. Often RNs must balance the need to know as much as pos - sible and the time available to obtain the information. The instability of patients immediately postoperatively or in the intensive care unit (ICU) means that a student nurse will have to be closely supervised and partnered with an experi - enced RN. The questions in this workbook give direction as to context and offer hints to the circumstances. For example, in long- term care skilled nursing facilities, LPNs/LVNs often function as “team leaders” with ongo - ing care planning and oversight by a smaller number of on- site RNs. Some EDs use paramedics, who may be reg - ulated by the state emergency system statutes, in different roles in hospitals. Medical clinics often employ “medical assistants” who function under the direction and supervi - sion of physicians, other providers, and RNs. Community group homes, assisted living facilities, and other health care providers beyond acute care hospitals seek to create safe and effective care delivery systems for the growing number of older adults. Whatever the setting or circum - stance, the nurse is accountable to know the specific laws and regulations that apply. Right Person Licensure, Certification, and Role Description One of the most commonly voiced concerns during work - shops with staff nurses across the nation is, “How can I trust the delegatees?” Knowing the licensure, role, and preparation of each member of the team is the first step in determining competency. What tasks does a patient care technician (PCT) perform in this facility? What is the role of an LPN/LVN? Are different levels of LPN/LVN des - ignated here (LPN I or II)? Nearly 100 different titles for APs have been developed in care settings across the coun - try. To effectively assign or delegate, the RN must know the role descriptions of co- workers as well as his or her own. Strengths and Weaknesses The personal strengths and weaknesses of everyday team members are no mystery. Their skills are discovered through practice, positive and negative experiences, and an ever- present but unreliable rumor mill. An expert RN helps create better team results by using strengths in assigning personnel to make the most of their gifts. The most compassionate team members will be assigned work with the hospice patient and his or her family. The super - vising nurse helps identify performance flaws and develops staff by providing judicious use of learning assignments. For example, a novice nursing assistant can be partnered with an experienced oncology RN during the assistant’s first experiences with a terminally ill patient. When working with students, float nurses, or other tem - porary personnel, nurses sometimes forget that the assign - ing RN has the duty to determine competency. Asking personnel about their previous experiences and about their understanding of the work duties, as well as pairing them with a strong unit staff member, is as essential as provid - ing the ongoing support and supervision needed through - out the shift. If your mother was an ICU patient and her nurse was an inexperienced float from the rehabilitation unit, what level of leadership and direction would that nurse need from an experienced ICU RN? Many hospitals delegate only tasks and not overall patient responsibility, a functional form of assignment, to temporary personnel who are unfamiliar with the clinical area. Right Direction and Communication Now that the right staff member is being delegated the right task for each particular situation and setting, team members must find out what they need to do and how the tasks must be done. Relaying instructions about the plan for the shift or even for a specific task is not as simple as it seems. Some RNs believe that a written assignment board provides enough information to proceed because “everyone knows his or her job,” but others spend copious amounts of time giving overly detailed directions to bored staff. The “four Cs” of initial direction will help clarify the salient points of this process ( Hansten and Jackson, 2009 , pp. 287–288; Hansten, 2021 in Zerwekh and Garneau, p. 316). Instructions and ongoing direction must be clear, concise, correct, and complete. Clear communication is information that is understood by the listener. An ambiguous question such as: “Can you get the new patient?” is not helpful when there are several new patients and returning surgical patients, and “getting” could mean transporting, admitting, or taking full respon - sibility for the care of the patient. Asking the delegatee to restate the instructions and work plan can be helpful to determine whether the communication is clear. Concise statements are those that give enough but not too much additional information. The student nurse who merely wants to know how to turn on the chemical strip analyzer machine does not need a full treatise on the tran - sit of potassium and glucose through the cell membrane. Too much or irrelevant information confuses the listener and wastes precious time.
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Guidelines for Prioritization, Delegation, and Assignment Decisions 7 Copyright © 2022, Elsevier Inc. All rights reserved. Introduction PART 1 Correct communication is that which is accurate and is aligned to rules, regulations, or job descriptions. Are the room number, patient name, and other identifiers correct? Are there two patients with similar last names? Can this task be delegated to this individual? Correct communi - cation is not cloudy or confusing ( Hansten and Jackson, 2009 , pp. 287–288; Hansten, 2021 in Zerwekh and Garneau, p. 318). Complete communication leaves no room for doubt on the part of supervisor or delegatees. Staff members often say, “I would do whatever the RNs want if they would just tell me what they want me to do and how to do it.” Incomplete communication wins the top prize for creat - ing team strife and substandard work. Assuming that staff “know” what to do and how to do it, along with what information to report and when, creates havoc, rework, and frustration for patients and staff alike. Each staff member should have in mind a clear map or plan for the day, what to do and why, and what and when to report to the team leader. Parameters for reporting and the results that should be expected are often left in the team leader’s brain rather than being discussed and spelled out in sufficient detail. RNs are accountable for clear, concise, correct, and com - plete initial and ongoing direction. Right Supervision and Evaluation After prioritization, assignment, and delegation have been considered, determined, and communicated, the RN remains accountable for the total care of the patients throughout the tour of duty. Recall that the definition of supervision includes not only initial direction but also that “supervision is the active process of directing, guiding, and influencing the outcome of an individual’s performance of a task. Similarly, NCSBN defines supervision as “the provi - sion of guidance or direction, oversight, evaluation and fol - low- up by the licensed nurse for the accomplishment of a delegated nursing task by assistive personnel” ( ANA, 2014, in Duffy and McCoy, p. 23). RNs may not actually per - form each task of care, but they must oversee the ongoing progress and results obtained, reviewing staff performance. Evaluation of the care provided, and adequate documenta - tion of the tasks and outcomes, must be included in this last of the five rights. On a typical unit in an acute care facility, assisted living, or long- term care setting, the RN can ensure optimal performance as the RN begins the shift by holding a short “second report” meeting with APs, out - lining the day’s plan and the plan for each patient, and giving initial direction at that time. Subsequent short team update or “checkpoint” meetings should be held before and after breaks and meals and before the end of the shift ( Hansten, 2005, 2008a, 2008b, 2019 ). During each short update, feedback is often offered, and plans are altered. The last checkpoint presents all team members with an opportunity to give feedback to one another using the step- by- step feedback process ( Hansten, 2008a , pp. 79–84; Hansten, 2021 , in Zerweck and Garneau, pp. 301–302). This step is often called the “debriefing” checkpoint or huddle, in which the team’s processes are also examined. In ambulatory care settings, this checkpoint may be toward the end of each patient’s visit or the end of the shift; in home health care, these conversations are often conducted on a weekly basis. Questions such as, “What would you recommend I do differently if we worked together tomor - row on the same group of patients?” and “What can we do better as a team to help us navigate the patients toward their preferred results?” will help the team function more effectively in the future. 1. The team member’s input should be solicited first. “I noted that the vital signs for the first four patients aren’t yet on the electronic record. Do you know what’s been done?” rather than “WHY haven’t those vital signs been recorded yet?” At the end of the shift, the questions might be global, as in “How did we do today?” “What would you do differently if we had it to do over?” “What should I do differently tomorrow?” 2. Credit should be given for all that has been accom - plished. “Oh, so you have the vital signs done, but they aren’t recorded? Great, I’m so glad they are done so I can find out about Ms. Johnson’s temperature before I call Dr. Smith.” “You did a fantastic job with cleaning Mr. Hu after his incontinence episodes; his family is very appreciative of our respect for his dignity.” 3. Observations or concerns should be offered. “The vital signs are routinely recorded on the electron - ic medical record (EMR) before patients are sent for surgery and procedures and before the doctor’s round so that we can see the big picture of patients’ progress before they leave the unit and to make sure they are stable for their procedures.” Or, “I think I should have assigned another RN to Ms. A. I had no idea that your mother recently died of breast cancer.” 4. The delegatee should be asked for ideas on how to resolve the issue. “What are your thoughts on how you could order your work to get the vital signs on the EMR before 8:30 AM?” Or, “What would you like to do with your work plan for tomorrow? Should we change Ms. A.’s team?” 5. A course of action and plan for the future should be agreed upon. “That sounds great. Practice use of the handheld computers today before you leave, and that should resolve the issue. When we work to - gether tomorrow, let me know whether that resolves the time issue for recording; if not, we will go to an - other plan.” Or, “If you still feel that you want to stay with this assignment tomorrow after you’ve slept on it, we will keep it as is. If not, please let me know first thing tomorrow morning when you awaken so we can change all the assignments before the staff arrive.”
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Guidelines for Prioritization, Delegation, and Assignment Decisions 8 Copyright © 2022, Elsevier Inc. All rights reserved. Introduction PART 1 PRACTICE BASED ON RESEARCH EVIDENCE Rationale for Maximizing Nursing Leadership Skills at the Point of Care If the skills presented in this book are used to save lives by providing care prioritized to attend to the most unsta - ble patients first, optimally delegated to be delivered by the right personnel, and assigned using appropriate language with the most motivational and conscientious supervisory follow- up, then clinical outcomes should be optimal and work satisfaction should flourish. Solid cor - relational research evidence has been lacking related to “the best use of personnel to multiply the RN’s ability to remain vigilant over patient progress and avoid failures to rescue, but common sense would advise that better delegation and supervision skills would prevent errors and omissions as well as unobserved patient decline” ( Hansten, 2008b , 2019 ). In an era of value- based purchasing and health care reimbursement based on clinical results with linkages for care along the continuum from site to site, an RN’s accountability has irrevocably moved beyond task orienta - tion to leadership practices that ensure better outcomes for patients, families, and populations. The necessity of efficiency and effectiveness in health care means that RNs must delegate and supervise appropriately so that all tasks that can be safely assigned to APs are completed flawlessly. Patient safety experts have linked interpersonal commu - nication errors and teamwork communication gaps as major sources of medical errors and The Joint Commission associated these as root causes of 70% or more of serious reportable events ( Grant, 2016 , p. 11). Severe events that harm patients (sentinel events) can occur through inad - equate hand- offs between caregivers and along the health care continuum as patients are transferred ( The Joint Commission, 2017 ). Nurses are accountable for processes as well as out - comes measures so that insurers will reimburse health care organizations. If hospital- acquired conditions occur, such as pressure injuries falls with injury, and some infections, reimbursement for the care of that condition will be nega - tively impacted. • Nurses have been reported to spend more than half their time on tasks other than patient care, including searching for team members and internal communi - cations ( Voalte Special Report, 2013 ). Shift report at the bedside, along with better initial direction and a plan for supervision during the day, all ultimately decrease time wasted when nurses must attempt to connect with team members when delegation and assignment processes do not include the five rights. At one facility in the Midwest, shift hand- offs were reduced to 10 to 15 minutes per shift per RN as a result of a planned approach to initial direction and care planning, which thus saved each RN 30 to 45 minutes per day ( Hansten, 2008a , p. 34). Better use of nursing and AP time can result in more time to care for patients, giving RNs the opportunity to teach patients self- care or to maintain functional status. • When nurses did not appropriately implement the five rights of delegation and supervision with assis - tive personnel, errors occurred that potentially could have been avoided with better RN leadership behav - iors. Early research about the impact of supervision on errors showed that about 14% of task errors or care omissions related to teamwork were because of lack of RN direction or communication, and approxi - mately 12% of the issues stemmed from lack of su - pervision or follow- up ( Standing, Anthony, & Hertz, 2001 ). Lack of communication among staff members has been an international issue leading to care that is not completed appropriately ( Diab & Ebrahim, 2019 ). Errors can result in uncompensated condi - tions or readmissions; unhappy patients and provid - ers; disgruntled health care purchasers; and a disloyal, anxious patient community ( Hansten, 2019 ). • Teamwork and job satisfaction have been found to be negatively correlated with over- delegation and a hierarchical relationship between nurses and assis - tive personnel ( Kalisch 2015 , p. 266–227), but of - fering feedback effectively has been shown to im - prove team thinking and performance (Mizne, D., 2018, https://www.15five.com/blog/7- employee- engagement- trends- 2018/ ). Workplace injuries, expensive employee turnover, and patient safety have been linked with employee morale. Daily or weekly feedback has been requested by a majority of teams and this could be achieved by excellent delegation, assignment, and supervision shift routines ( McNee, 2017 , https://www.mcknights.com/blogs/guest- columns/nurse- morale- and- its- impact- on- ltc/ ). Best practices for deployment of personnel include a connection to patient outcomes, which can oc - cur during initial direction and debriefing supervi - sion checkpoints ( Hansten, 2021 in LaCharity and Garneau). • Unplanned readmissions to acute care within 30 days of discharge are linked to potential penal - ties and reduced reimbursement. Inadequate RN initial direction and supervision of APs can lead to missed mobilization, hydration, and nutrition of pa - tients, thereby discharging deconditioned patients, and can be traced to ED visits and subsequent read - missions. Reimbursement bundling for specific care pathways such as total joint replacements or acute exacerbation of chronic obstructive pulmonary disease requires that team communication and RN supervision of coworkers along the full continuum must be seam - less from ambulatory care to acute care, rehabilitation, and home settings ( Kalisch, 2015 ; Hansten, 2019 ). • As public quality transparency and competition for best value become the norm, ineffective delegation has been a significant source of missed care, such
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Guidelines for Prioritization, Delegation, and Assignment Decisions 9 Copyright © 2022, Elsevier Inc. All rights reserved. Introduction PART 1 as lack of care planning, lack of turning or ambula - tion, delayed or missed nutrition, and lack of hygiene ( Bittner et al., 2011 ; Kalisch, 2015 , pp. 266– 270). These care omissions can be contributing factors for the occurrence of unreimbursed “never events” (events that should never occur), such as pressure ul - cers and pneumonia, as well as prolonged lengths of stay. Other nurse- sensitive quality indicators such as catheter- associated urinary tract infections could be correlated to omitted perineal hygiene and inatten - tion to discontinuation of catheters. Useful models that link delegation with care omissions and ensu - ing care hazards such as thrombosis, pressure inju - ries, constipation, and infection, combined with a Swiss Cheese Safety Model showing defensive steps against health care–acquired conditions and errors through excellence in RN leadership, can be ac - cessed in the August 2014 Nurse Leader at https://d oi.org/10.1016/j.mnl.2013.10.007 ( Hansten, 2014a ; Hansten, 2020 in Kelly Vana and Tazbir). • In perioperative nursing, such omissions as lack of warming, oral care, head elevation and deep breath - ing, can lead to postoperative pneumonia and lack of optimal healing ( Ralph and Viljoen, 2018 ). Many of these interventions could be delegated or assigned. Evidence does indicate that appropriate nursing judg - ment in prioritization, delegation, and supervision can save time and improve communication and thereby improve care, patient safety, clinical outcomes, and job satisfaction, potentially saving patient- days and absenteeism and recruit - ment costs. Patient satisfaction, staff satisfaction, and clinical results decline when nursing care is poor. Potential reim - bursement is lost, patients and families suffer, and the health of our communities decays when RNs do not assume the leadership necessary to work effectively with all team mem - bers ( Bittner et al., 2011 , Kalisch, 2015 , Hansten, 2019 ). PRINCIPLES FOR IMPLEMENTATION OF PRIORITIZATION, DELEGATION, AND ASSIGNMENT Return to our goalposts of the four Ps (purpose, picture, plan, and part) as a framework as you answer the questions in this workbook and further develop your own expertise and recall the following principles: • The RN should always start with the patient’s and family’s preferred outcomes in mind. The RN is first clear about the patient’s purpose for accessing care and his or her picture for a successful outcome. • The RN should refer to the applicable state nursing practice statute and rules as well as the organization’s job descriptions for current information about roles and responsibilities of RNs, LPNs/LVNs, and APs. (These are the roles or the parts that people play.) • Student nurses, novices, float nurses, and other infre - quent workers also require variable levels of supervi - sion, guidance, or support (The workers’ abilities and roles become a piece of the plan.) ( NCSBN, 2016b ). • The RN is accountable for nursing judgment deci - sions and for ongoing supervision of any care that is delegated or assigned. • The RN cannot delegate the nursing process (in particular the assessment, planning, and evaluation phases) or clinical judgment to a non- RN. Some in - terventions or data- gathering activities may be del - egated based on the circumstances. • The RN must know as much as practical about the patients and their conditions, as well as the skills and competency of team members, to prioritize, delegate, and assign. Decisions must be specifically individual - ized to the patient, the delegatees, and the situation. • In a clinical situation, everything is fluid and shift - ing. No priority, assignment, or delegation is written indelibly and cannot be altered. The RN in charge of a unit, a team, or one patient is accountable to choose the best course to achieve the patient’s and family’s preferred results. Best wishes in completing this workbook! The authors invite you to use the questions as an exercise in assem - bling the pieces to the puzzle that will become a picture of health- promoting practice. REFERENCES Alfaro- Lefevre R: Critical thinking, clinical reasoning, and clinical judgment: a practical approach , ed 6, St Louis, 2017, Saunders. American Nurses Association. National Guidelines for Nursing Delegation. Effective 4/1/2019, by ANA Board of Directors/ NCSBN Board of Directors. Retrieved April 12, 2019 from https://www.nursingworld.org/practice- policy/nursing- excellence/official- position- statements/id/joint- statement- on- delegation- by- ANA- and- NCSBN/ [file available to members only at https://www.nursingworld.org/globalassets/practiceand policy/nursing- excellence/ana- position- statements- secure/ana- ncsbn- joint- statement- on- delegation.pdf , accessed April 12, 2019.] American Nurses Association, Duffy M, Fields McCoy S: Delegation and YOU : when to delegate and to whom , Silver Springs, MD, 2015. ANA. Bittner N, Gravlin G, Hansten R, Kalisch B: Unraveling care omissions, J Nurs Adm 41(12):510–512, 2011. Brous E: Lessons learned from litigation: the case of Bernard Travaglini, Am J Nurs (114):5:68–70, 2014 5. Carder PC, O’Keeffe J: State regulation of medication administration by unlicensed assistive personnel in residential care and adult day services settings, Res Gerontol Nurs 7:1–14, 2016. Diab G, Ebrahim R: Factors leading to missed nursing care among nurses at selected hospitals, Am J Nurs Res 7 (2): 136- 147, 2019. Dyck M, Novotny N: Exploring reported practice habits of registered nurses and licensed practical nurses at Illinois nursing homes, J Nurs Reg 9 (2): 18- 30, 2018. Grant V: Sharpening your legal IQ: safeguarding your license, Viewpoint 38(3):10–12, 2016.
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Guidelines for Prioritization, Delegation, and Assignment Decisions 10 Copyright © 2022, Elsevier Inc. All rights reserved. Introduction PART 1 Hansten R: Relationship and results- oriented healthcare: evaluate the basics, J Nurs Adm 35(12):522–524, 2005. Hansten R: Leadership at the point of care: nursing delegation, 2011. Retrieved May 31, 2012, from http://www.MyFreeCE .com . Hansten R: Relationship and results oriented healthcare™ planning and implementation manual , Port Ludlow, Wash, 2008a, Hansten Healthcare PLLC. Hansten R: Why nurses still must learn to delegate, Nurse Leader 6(5):19–26, 2008b. Hansten R, Jackson M: Clinical delegation skills: a handbook for professional practice , ed 4, Sudbury, Mass, 2009, Jones & Bartlett. Hansten R: The master coach manual for the relationship & results oriented healthcare program , Port Ludlow, Wash, 2014b, Hansten Healthcare PLLC. Hansten R: Coach as chief correlator of tasks to results through delegation skill and teamwork development, Nurse Leader , 12 (4):69–73, 2014a. Hansten R: Another Look at RN leadership skill level and patient outcomes. LinkedIn Pulse . Retrieved April 21, 2019 from https://www.linkedin.com/pulse/anoth er- look- rn- leadership- skill- level- patient- hansten- rn- mba- phd . Hansten R: Delegation, assignment, and supervision in Kelly Vana P & Tazbir J, ed. Nursing leadership and management , 4th Ed. Hoboken, NJ. 2020 (in press), Wiley. Hansten R: Delegation in the clinical setting. In Zerwekh J, Garneau A, editors: Nursing today: transitions and trends , ed 10, St Louis, 2021, Elsevier. Interprofessional Education Collaborative. Core competencies for interprofessional collaborative practice: 2016 update. Washington, DC: Interprofessional Education Collaborative. Retrieved April 16, 2019 from 780E69ED19E2B3A5&dispos ition=0&alloworigin=1 . Kalisch B: Errors of Omission: How missed nursing care imperils patents . Silver Springs, MD., 2015, ANA. Kalisch B: Missed nursing care, J Nurs Care Qual 21(4):306–313, 2006. Maningo MJ, Panthofer N: Appropriate delegation in an ambulatory care setting AAACN Viewpoint 40 (1): 1- 2, 2018. McMullen TL, Resnick B, Chin- Hansen J, et al: Certified nurse aide scope of practice: state- by- state differences in allowable delegated activities, J Am Med Dir Assoc 6(1):20–24, 2015. Mizne D. 7 fascinating employee engagement trends for 2018. 15Five.com . Retrieved April 21, 2019 from https://www.15five.com/blog/7- employee- engagement- trends- 2018/ , pp. 1- 11, 2018. McNee B. Nurse morale and its impact on LTC, McKnights Long - Term Care News, June 28, 2017. Retrieved April 21, 2019 from https://www.mcknights.com/blogs/guest- columns/nurse- morale- and- its- impact- on- ltc/ , pp. 1- 2, 2017 Mueller C, Vogelsmeier A, Anderson R, McConnell E, & Corazzini K. Interchangeability of licensed nurses in nursing homes: perspective of directors of nursing. The End to End Journal , 1, 1- 27, 2018. National Council of State Boards of Nursing: Delegation: concepts and decision- making process, Issues December:1–4, 1995. National Council of State Boards of Nursing. 2018 LPN/VN Practice Analysis: Linking the NCLEX- PN Examination to Practice. NCSBN Research Brief vol. 75: March 2019. Retrieved April 17, 2019 from https://www.ncsbn.org/13443.htm.m 2019 . National Council of State Boards of Nursing: National guidelines for nursing delegation. J Nurs Reg 7(1):5–14, 2016b. Accessed April 21, 2019 at https://www.ncsbn.org/NCSBN_Delegation _Guidelines.pdf National Council of State Boards of Nursing: Participating states in the nurse licensure compact implementation. Retrieved April 17, 2019 from https://www.ncsbn.org/compacts.htm. , 2019. QSEN Institute: QSEN Institute Website: QSEN Competencies. Retrieved April 19, 2019 from http://qsen.org/competencies/ graduate- ksas/ . Ralph N, Viljoen B. Fundamentals of missed care: Implications for the perioperative environment, ACORN Journal of Perioperative Nursing 31 (3): Spring, 3- 4, 2018. Revised Code of Washington, Title 18, Chapter 18.79, Section 18.79.260, Registered nurse—activities allowed—delegation of tasks. Retrieved April 18, 2019 from http://apps.leg.wa.gov/ RCW/default.aspx?cite=18.79.260 . Silvestri L, Silvestri A. Saunders 2018- 2019 Strategies for Test Success: p. 63. St Louis, 2018, Elsevier. Standing T, Anthony M, Hertz J: Nurses’ narratives of outcomes after delegation to unlicensed assistive personnel, Outcomes Manag Nurs Pract 5(1):18–23, 2001. The Joint Commission. Inadequate hand- off communication. Sentinel Event Alert Issue 58, September 12, 2017. Texas Board of Nursing 2013. “Frequently Asked Questions: Delegation:” P. 2 (1- 7), 2013. Retrieved April 21, 2019 from http://www.bon.texas.gov/faq_delegation.asp#t6 . Voalte: Special Report top 10 clinical communication trends 2013 pp. 1- 16. Retrieved April 24, 2019 from https://www.voalte.com/press- releases/new- survey- finds- hospital- nurses- spend- half- shift- tasks- patient- care . Washington State Administrative Code 246- 840- 010 Definitions. Retrieved April 19, 2019 from https://app.leg.wa.gov/wac/defau lt.aspx?cite=246- 840- 010 , 2019. Washington State Department of Health Nursing Care Quality Assurance Commission Advisory Opinion 13.01 2019 Registered Nurse and Licensed Practical Nurse Scope of Practice, 3- 8- 2019: p. 4 (1- 12). Retrieved April 25, 2019 from https://www.doh.wa .gov/Portals/1/Documents/6000/NCAO13.pdf . RECOMMENDED RESOURCES Alfaro- Lefevre R: Critical thinking, clinical reasoning, and clinical judgment: a practical approach , ed 6, St Louis, 2017, Saunders. Hansten R: The master coach manual for the relationship & results oriented healthcare program , Port Ludlow, Wash, 2014, Hansten Healthcare PLLC. Hansten R: Relationship and results oriented healthcare™ planning and implementation manual , Port Ludlow, Wash, 2008, Hansten Healthcare PLLC. Hansten R, Jackson M: Clinical delegation skills: a handbook for professional practice , ed 4, Sudbury, Mass, 2009, Jones & Bartlett. Hansten R. Coach as chief correlator of tasks to results through dele - gation skill and teamwork development. Nurse Leader 12(4): 69–73. Hansten Healthcare PLLC website, http://www.Hansten.com or http://www.RROHC.com . Check for new delegation/ supervision resources, online delegation, and assignment education modules at http://learning.Hansten.com/. National Council of State Boards of Nursing website, http://www.ncsbn.org . Contains links to state boards and abundant resources relating to delegation and supervision. Also download the ANA and NCSBN Joint Statement on Delegation. The decision trees and step- by- step process through the five rights are exceptionally clear and a great review to prepare for the NCLEX at https://www.ncsbn.org/NCSBN_Delegation_ Guidelines.pdf and https://www.ncsbn.org/Delegation_joint_st atement_NCSBN- ANA.pdf
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Copyright © 2022, Elsevier Inc. All rights reserved. 11 Prioritization, Delegation, and Assignment in Common Health Scenarios PART 1 CHAPTER 1 Pain Questions 1. Based on the principles of pain treatment, which con - sideration comes first ? 1. Treatment is based on patient goals. 2. A multidisciplinary approach is needed. 3. Patient’s perception of pain must be accepted. 4. Drug side effects must be prevented and managed. 2. According to Centers for Disease Control and Prevention (CDC) guidelines for opioid use for pa - tients with chronic pain, which actions are part of the nurse’s responsibility related to the current opioid cri - sis? Select all that apply. 1. Recognize that negative attitudes toward substance abusers is a barrier to patient compliance. 2. Access electronic prescription drug monitor - ing program whenever patients receive an opioid prescription. 3. Learn to recognize the signs and symptoms of opi - oid overdose and the proper use of naloxone. 4. Use a tone of voice and facial expression that con - vey acceptance and understanding of patients who are addicted. 5. Report health care providers who fail to safely pre - scribe opioids according to the guidelines. 3. On the first day after surgery, a patient who is on a patient- controlled analgesia pump reports that the pain control is inadequate. Which action would the nurse take first ? 1. Deliver the bolus dose per standing order. 2. Contact the health care provider (HCP) to increase the dose. 3. Try nonpharmacologic comfort measures. 4. Assess the pain for location, quality, and intensity. 4. The team is providing emergency care to a patient who received an excessive dose of opioid pain medica - tion. Which task is best to assign to the LPN/LVN? 1. Calling the health care provider (HCP) to re - port SBAR (situation, background, assessment, recommendation) 2. Giving naloxone and evaluating response to therapy 3. Monitoring the respiratory status for the first 30 minutes 4. Applying oxygen per nasal cannula as ordered 5. What is the best way to schedule medication for a patient with constant pain? 1. As needed at the patient’s request 2. Before painful procedures 3. IV bolus after pain assessment 4. Around- the- clock 6. Which patient is at greatest risk for respiratory de - pression when receiving opioids for analgesia? 1. Older adult patient with chronic pain related to joint immobility 2. Patient with a heroin addiction and back pain 3. Young female patient with advanced multiple myeloma 4. Opioid- naïve adolescent with an arm fracture and cystic fibrosis 7. The home health nurse is interviewing an older patient with a history of rheumatoid arthritis who reports “feeling pretty good, except for the pain and stiffness in my joints when I first get out of bed.” Which mem - ber of the health care team would be notified to aid in the patient’s pain? 1. Health care provider to review the dosage and fre - quency of pain medication 2. Physical therapist for evaluation of function and possible exercise therapy 3. Social worker to locate community resources for complementary therapy 4. Home health aide to help patient with a warm shower in the morning 8. A patient with diabetic neuropathy reports a burn - ing, electrical- type pain in the lower extremities that is worse at night and not responding to nonsteroidal antiinflammatory drugs. Which medication will the nurse advocate for first ? 1. Gabapentin
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C HAPT e R 1 Pain 12 Copyright © 2022, Elsevier Inc. All rights reserved. Answer Key for this chapter begins on p. 19 Common Health Scenarios PART 2 2. Corticosteroids 3. Hydromorphone 4. Lorazepam 9. When an analgesic is titrated to manage pain, what is the priority goal? 1. Titrate to the smallest dose that provides relief with the fewest side effects. 2. Titrate upward until the patient is pain free or an acceptable level is reached. 3. Titrate downward to prevent toxicity, overdose, and adverse effects. 4. Titrate to a dosage that is adequate to meet the patient’s subjective needs. 10. According to recent guidelines from the American Pain Society in collaboration with the American Society of Anesthesiologists, which pain management strategies are important for postsurgical patients? Select all that apply. 1. Acetaminophen and/or nonsteroidal anti- inflammatory drugs (NSAIDs) for management of postoperative pain in adults and children without contraindications 2. Surgical site–specific peripheral regional anesthetic techniques in adults and children for procedures 3. Neuraxial (epidural) analgesia for major thoracic and abdominal procedures if the patient has risk for cardiac complications or prolonged ileus 4. Multimodal therapy that could include opioids and nonopioid therapies, regional anesthetic tech - niques, and nonpharmacologic therapies 5. IV administration of opioids, rather than oral opi - oids, for postoperative analgesia 6. Pain specialists to manage the postoperative pain for all surgical patients 11. When a patient stoically abides with his parent’s en - couragement to “tough out the pain” rather than risk an addiction to opioids, the nurse recognizes that the sociocultural dimension of pain is the current pri ority for the patient. Which question will the nurse ask? 1. “Where is the pain located, and does it radiate to other parts of your body?” 2. “How would you describe the pain, and how is it affecting you?” 3. “What do you believe about pain medication and drug addiction?” 4. “How is the pain affecting your activity level and your ability to function?” 12. Which patient is most likely to receive opioids for ex - tended periods of time? 1. A patient with fibromyalgia 2. A patient with phantom limb pain in the leg 3. A patient with progressive pancreatic cancer 4. A patient with trigeminal neuralgia 13. The nurse is caring for a postoperative patient who re - ports pain. Based on recent evidence- based guidelines, which approach would be best ? 1. Multimodal strategies 2. Standing orders by protocol 3. Intravenous patient- controlled analgesia (PCA) 4. Opioid dosage based on valid numerical scale 14. A newly graduated RN has correctly documented dose and time of medication, but there is no docu - mentation regarding nonpharmaceutical measures. What action should the charge nurse take first ? 1. Make a note in the nurse’s file and continue to ob - serve clinical performance. 2. Refer the new nurse to the in- service education department. 3. Quiz the nurse about knowledge of pain manage - ment and pharmacology. 4. Give praise for documenting dose and time and discuss documentation deficits. 15. Which patients must be assigned to an experienced RN? Select all that apply. 1. Patient who was in an automobile crash and sus - tained multiple injuries 2. Patient with chronic back pain related to a work - place injury 3. Patient who has returned from surgery and has a chest tube in place 4. Patient with abdominal cramps related to food poisoning 5. Patient with a severe headache of unknown origin 6. Patient with chest pain who has a history of arteriosclerosis 16. Which postoperative patient is manifesting the most serious negative effect of inadequate pain management? 1. Demonstrates continuous use of call bell related to unsatisfied needs and discomfort 2. Develops venous thromboembolism because of im - mobility caused by pain and discomfort 3. Refuses to participate in physical therapy because of fear of pain caused by exercises 4. Feels depressed about loss of function and hopeless about getting relief from pain 17. The nurse is considering seeking clarification for sev - eral prescriptions of pain medication. Which patient circumstance is the priority concern? 1. A 35- year- old opioid- naïve adult will receive a basal dose of morphine via IV patient- controlled analgesia.
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C HAPT e R 1 Pain 13 Copyright © 2022, Elsevier Inc. All rights reserved. Answer Key for this chapter begins on p. 19 Common Health Scenarios PART 2 2. A 65- year- old adult will be discharged with a pre - scription for nonsteroidal antiinflammatory drugs (NSAIDs). 3. A 25- year- old adult is prescribed as-needed intra - muscular (IM) analgesic for pain. 4. A 45- year- old adult is taking oral fluids and foods and has orders for IV morphine. 18. Which patient has the most immediate need for IV access to deliver analgesia with rapid titration? 1. Patient who has sharp chest pain that increases with cough and shortness of breath 2. Patient who reports excruciating lower back pain with hematuria 3. Patient who is having an acute myocardial infarc - tion with severe chest pain 4. Patient who is having a severe migraine with an elevated blood pressure 19. A patient received as-needed morphine, lorazepam, and cyclobenzaprine. The unlicensed assistive person - nel (AP) reports that the patient has a respiratory rate of 10 breaths/min. Which action is the priority ? 1. Call the health care provider to obtain a prescrip - tion for naloxone. 2. Assess the patient’s responsiveness and respiratory status. 3. Obtain a bag- valve mask and deliver breaths at 20 breaths/min. 4. Double- check the prescription to see which drugs were prescribed. 20. The patient is diagnosed with an acute migraine by the health care provider (HCP). For which situation is it most important to have a discussion with the HCP before medication is prescribed? 1. The HCP is considering dexamethasone, and the patient has type 2 diabetes. 2. The HCP is considering subcutaneous sumatriptan, and the patient took ergotamine 3 hours ago. 3. The HCP is considering valproate sodium, and the patient recently started birth control pills. 4. The HCP is considering prochlorperazine, and the patient drove himself to the hospital. 21. A patient is crying and grimacing but denies pain and refuses opioid medication because “my brother is a drug addict and has ruined our lives.” Which inter - vention is the priority for this patient? 1. Encourage expression of fears and past experiences. 2. Respect the patient’s wishes and use nonpharma - cologic therapies. 3. Explain that addiction is unlikely when opioids are used for acute pain. 4. Seek family assistance to support the prescribed therapy. 22. A patient’s opioid therapy is being tapered off, and the nurse is watchful for signs of withdrawal. What is one of the first signs of withdrawal? 1. Fever 2. Nausea 3. Diaphoresis 4. Abdominal cramps 23. In the care of patients with pain and discomfort, which task is most appropriate to delegate to unli - censed assistive personnel (AP)? 1. Assisting the patient with preparation of a sitz bath 2. Monitoring the patient for signs of discomfort while ambulating 3. Coaching the patient to deep breathe during pain - ful procedures 4. Evaluating relief after applying a cold compress 24. The health care provider (HCP) prescribed a placebo for a patient with chronic pain. The newly hired nurse feels very uncomfortable administering a placebo. Which action would the new nurse take first ? 1. Prepare the prescribed placebo and hand it to the HCP. 2. Check the hospital policy regarding the use of a placebo. 3. Follow a personal code of ethics and refuse to participate. 4. Contact the charge nurse for advice and suggestions. 25. For a cognitively impaired patient who cannot accu - rately report pain, which action would the nurse take first ? 1. Closely assess for nonverbal signs such as grimac - ing or rocking. 2. Obtain baseline behavioral indicators from family members. 3. Note the time of and patient’s response to the last dose of analgesic. 4. Give the maximum as-needed dose within the minimum time frame for relief. 26. A patient with chronic pain reports to the charge nurse that the other nurses have not been responding to requests for pain medication. What is the charge nurse’s initial action? 1. Check the medication administration records for the past several days. 2. Ask the nurse educator to provide in- service train - ing about pain management. 3. Perform a complete pain assessment on the patient and take a pain history. 4. Have a conference with the staff nurses to assess their care of this patient.
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C HAPT e R 1 Pain 14 Copyright © 2022, Elsevier Inc. All rights reserved. Answer Key for this chapter begins on p. 19 Common Health Scenarios PART 2 27. According to recent guidelines from the Center for Disease Control and Prevention for prescribing/us - ing opioid medication for chronic pain, which pre - scriptions would the nurse question because of the increased risk for opioid overdose? Select all that apply. 1. Extended- release/long- acting (ER/LA) transder - mal fentanyl for a patient with fibromyalgia 2. Time- scheduled ER/LA oxycodone for a patient with chronic low back pain 3. As-needed (PRN) morphine for arthritis pain for an elderly patient with sleep apnea 4. 90 morphine milligram equivalents/day for a pa - tient who has a hip fracture 5. ER/LA methadone PRN for a patient with head - ache pain 6. Patient- controlled analgesia (PCA) morphine for a patient with postsurgical abdominal pain 28. Which patients can be appropriately assigned to a newly graduated RN who has recently completed ori - entation? Select all that apply. 1. Anxious patient with chronic pain who frequently uses the call button 2. Patient on the second postoperative day who needs pain medication before dressing changes 3. Patient with acquired immune deficiency syndrome who reports headache and abdominal and pleuritic chest pain 4. Patient with chronic pain who is to be discharged with a new surgically implanted catheter 5. Patient who is reporting pain at the site of a pe - ripheral IV line 6. Patient with a kidney stone who needs frequent as-needed pain medication 29. A patient’s spouse comes to the nurse’s station and says, “He needs more pain medicine. He is still having a lot of pain.” Which response is best ? 1. “The medication is prescribed to be given every 4 hours.” 2. “If medication is given too frequently, there are ill effects.” 3. “Please tell him that I will be right there to check on him.” 4. “Let’s wait 40 minutes. If he still hurts, I’ll call the health care provider.” 30. A patient with pain disorder and depression has chronic low back pain. He states, “None of these doc - tors has done anything to help.” Which patient state - ment is cause for greatest concern? 1. “I twisted my back last night, and now the pain is a lot worse.” 2. “I’m so sick of this pain. I think I’m going to find a way to end it.” 3. “Occasionally, I buy pain killers from a guy in my neighborhood.” 4. “I’m going to sue you and the doctor; you aren’t do - ing anything for me.” 31. A patient has severe pain and bladder distention re - lated to urinary retention and possible obstruction; insertion of an indwelling catheter is prescribed. An experienced unlicensed assistive personnel (AP) states that she is trained to do this procedure. Which task can be delegated to this AP? 1. Assessing the bladder distention and the pain as - sociated with urinary retention 2. Inserting the indwelling catheter after verifying her knowledge of sterile technique 3. Evaluating the relief of pain and bladder distention after the catheter is inserted 4. Measuring the urine output after the catheter is in - serted and obtaining a specimen 32. The nurse is caring for a young man with a history of substance abuse who had exploratory abdominal surgery 4 days ago for a knife wound. There is a pre - scription to discontinue the morphine via patient- controlled analgesia and to start oral pain medication. The patient begs, “Please don’t stop the morphine. My pain is really a lot worse today than it was yesterday.” Which response is best ? 1. “Let me stop the pump; we can try oral pain medi - cation to see if it gives relief.” 2. “I realize that you are scared of the pain, but we must try to wean you off the pump.” 3. “Show me where your pain is and describe how it feels compared with yesterday.” 4. “Let’s take your vital signs; then I will call the health care provider.” 33. The nurse is working with a health care provider who prescribes opioid doses based on a specif - ic pain intensity rating (dosing to the numbers). Which patient circumstance is cause for greatest concern? 1. A 73- year- old frail female patient with a history of chronic obstructive pulmonary disease is pre - scribed 4 mg IV morphine for pain of 1 to 3 on a scale of 0 to 10. 2. A 25- year- old postoperative male patient with a history of opioid addiction is prescribed one tablet of oxycodone and acetaminophen for pain of 4 to 5 on a scale of 0 to 10. 3. A 33- year- old opioid- naïve female patient who has a severe migraine headache is prescribed 5 mg IV morphine for pain of 7 to 8 on a scale of 0 to 10. 4. A 60- year- old male with a history of rheumatoid arthritis is prescribed one tablet of hydromorphone for pain of 5 to 6 on scale of 0 to 10.
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C HAPT e R 1 Pain 15 Copyright © 2022, Elsevier Inc. All rights reserved. Answer Key for this chapter begins on p. 19 Common Health Scenarios PART 2 34. Which nursing action is the best example of the prin - ciple of nonmaleficence as an ethical consideration in pain management? 1. Patient seems excessively sedated but continues to ask for morphine, so the nurse conducts fur - ther assessment and seeks alternatives to opioid medication. 2. Patient has no known disease disorders and no objective signs of poor health or injury, but re - ports severe pain, so nurse advocates for pain medicine. 3. Patient is older, but he is mentally alert and dem - onstrates good judgment, so the nurse encourages the patient to verbalize personal goals for pain management. 4. Patient repeatedly refuses pain medication but shows grimacing and reluctance to move, so the nurse explains the benefits of taking pain medication. 35. The nurse is assessing a patient who has been receiving opioid medication via patient- controlled analgesia. Which early sign alerts the nurse to a possible adverse opioid reaction? 1. Patient reports shortness of breath. 2. Patient is more difficult to arouse. 3. Patient is more anxious and nervous. 4. Patient reports pain is worsening. 36. The charge nurse of a long- term care facility is review - ing the methods and assessment tools that are being used to assess the residents’ pain. Which nurse is using the best method to assess pain? 1. Nurse A uses a behavioral assessment tool when the resident is engaged in activities. 2. Nurse B asks a resident who doesn’t speak English to point to the location of pain. 3. Nurse C uses the same numerical rating scale every day for the same resident. 4. Nurse D asks the daughter of a confused patient to describe the resident’s pain. 37. For which of these patients is IV morphine the first- line choice for pain management? 1. A 33- year- old intrapartum patient needs pain re - lief for labor contractions. 2. A 24- year- old patient reports severe headache re - lated to being hit in the head. 3. A 56- year- old patient reports breakthrough bone pain related to multiple myeloma. 4. A 73- year- old patient reports chronic pain associ - ated with hip replacement surgery. 38. The patient is prescribed a fentanyl patch for persis - tent severe pain. Which patient behavior most ur - gently requires correction? 1. Frequently likes to sit in the hot tub to reduce joint stiffness 2. Prefers to place the patch only on the upper ante - rior chest wall 3. Saves and reuses the old patches when he can’t af - ford new ones 4. Changes the patch every 4 days rather than the prescribed 72 hours 39. The home health nurse discovers that an older adult patient has been sharing his pain medication with his daughter. He acknowledges the dangers of sharing, but states, “My daughter can’t afford to see a doctor or buy medicine, so I must give her a few of my pain pills.” Which member of the health care team would the nurse consult first ? 1. Health care provider to renew the prescription so that the patient has enough medicine 2. Pharmacist to monitor the frequency of the pre - scription refills 3. Social worker to help the family locate resources for health care 4. Home health aide to watch for inappropriate med - ication usage by family 40. For a postoperative patient, the health care provider (HCP) prescribed multimodal therapy, which includes acetaminophen, nonsteroidal antiinflammatory drugs, as-needed (PRN) opioids, and nonpharmaceutical in - terventions. The patient continuously asks for the PRN opioid, and the nurse suspects that the patient may have a drug abuse problem. Which action by the nurse is best ? 1. Administer acetaminophen and spend extra time with the patient. 2. Explain that opioid medication is reserved for moderate to severe pain. 3. Give the opioid because the patient deserves relief and drug abuse is unconfirmed. 4. Ask the HCP to validate suspicions of drug abuse and alter the opioid prescription. 41. An inexperienced new nurse compares the medication ad - ministration record (MAR) and the health care provider’s (HCP’s) prescription for a patient who has a patient- controlled analgesia (PCA) pump for pain management. Both the MAR and prescription indicate that larger doses are prescribed at night compared with doses throughout the day. Who would the new nurse consult first ? 1. Ask the patient if he typically needs extra medica - tion in the evening. 2. Ask the HCP to verify that the larger amount is the correct dose. 3. Ask the pharmacist to confirm the dosage on the original prescription. 4. Ask the charge nurse if this is a typical dosage for nighttime PCA.
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C HAPT e R 1 Pain 16 Copyright © 2022, Elsevier Inc. All rights reserved. Answer Key for this chapter begins on p. 19 Common Health Scenarios PART 2 42. Which instruction would the nurse give to the unli - censed assistive personnel (AP) related to the care of a patient who has received ketamine for analgesia? 1. Keep the environment calm and quiet. 2. Watch for and report respiratory depression. 3. Offer frequent sips of noncaffeinated fluids. 4. Keep the bed flat and frequently turn patient. 43. The health care provider (HCP) prescribes 7 mg mor - phine IV as needed. The nursing student prepares the medication and shows the syringe (see figures below) to the nursing instructor. Which action would the nursing instructor take first? 1. Tell the student to review the HCP’s prescription before administering medication. 2. Waste the medication and tell the student that re - mediation is required for serious error. 3. Ask the student to demonstrate the calculations and steps required to prepare the dose. 4. Accompany the student to the patient’s room and observe as the medication is administered. 10 mL 2 4 1 3 6 8 9 5 7 Scenario: The nurse is caring for a patient who had abdominal surgery yesterday. The patient is restless and anxious and reports that the pain is getting worse (8 out of 10) despite morphine via patient- controlled an - algesia. Physical assessment findings include: T 100.3°F (37.9°C), P 110 beats/min, R 24 breaths/min, and BP 110/70 mmHg. The abdomen is rigid and tender to the touch with hypoactive bowel sounds. The nurse tries to make the patient comfortable, and he is willing to wait until the next scheduled dose of pain medication. However, the nurse decides to notify the patient’s health care provider (HCP) because the pain warrants evaluation, possible diagnostic testing, and additional therapies. Which information would the nurse include in the assessment compo - nent of the SBAR (situation, background, assessment, recommendation) report to the HCP? Instructions: Underline or highlight the information the nurse would include in the assessment component of the SBAR report. 44. Expanded Hot Spot ____________________________________________________________________________
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C HAPT e R 1 Pain 17 Copyright © 2022, Elsevier Inc. All rights reserved. Answer Key for this chapter begins on p. 19 Common Health Scenarios PART 2 45. Extended Multiple Response _____________________________________________________________________ Question: Based on the American Society for Pain Management Nursing recommendations for “As needed” (PRN) range prescriptions for opioid analgesics, for which prescriptions, does the nurse need to seek clarification from the health care provider? Instructions: Place an X in the space provided or highlight each patient situation where the nurse would seek clarification for the prescrip-tion. Select all that apply. The nurse is reviewing the PRN (as-needed) pain prescriptions for the following patients: 1. ______ Ms. A is a 35-year old female admitted for an acute episode of cholelithiasis. Prescribed: Morphine 1 to 15 mg IV every 2 hours PRN pain 2. ______ Mr. B is a 75-year old male who had hip surgery yesterday. He has chronic obstructive pulmonary disease. Prescribed: Morphine 2 to 3 mg IV every 2 hours PRN pain 3. ______ Mr. C is a 55-year old male with acute pancreatitis. He has a history of alcohol and substance abuse. Prescribed: Morphine 1 to 3 mg IV every 4 hours PRN pain 4. ______ Mrs. D is an 83-year old female with an ankle fracture. She has dementia and is unable to maintain elevation of the ankle. Prescribed: Meperidine 25 to 50 mg PO PRN pain 5. ______ Mr. E is a 46-year old male admitted for bacterial meningitis. He reports severe headaches. Prescribed: Codeine 15 mg PO 1-2 tablets every 4 to 6 hours PRN pain 6. ______ Mr. F is a 25-year old male. He has extensive abrasions on the left side of the body sustained in a motorcycle accident. No other obvious trauma detected in the emergency department. Prescribed: Oxycodone 9 mg PO every 12 hours; Hydrocodone with acetaminophen 5/325 PO 1 to 2 tablets every 4 to 6 hours PRN pain; acetaminophen 500 mg 2 tablets PO every 6 to 8 hours PRN pain 7. ______ Ms. G is a 57-year old female who had a hysterectomy yesterday for uterine prolapse. She is opioid naive and has no preexisting health conditions other than prolapse of the uterus. Prescribed: Fentanyl 50 to 100 mcg IV every 2 hours PRN for severe pain 8. ______ Mr. H is a 68-year old male; he has pain associated with postherpetic neuralgia. Prescribed: Morphine 2 to 3 mg IV every 4 hours PRN pain Scenario: The nurse is caring for a 73-year old patient who was admitted for dehydration and observation for compartment injury. The patient fell between the toilet and the wall. His right arm was pinned underneath his body, for several hours before he was discovered by a neighbor. Fractures and other obvious injuries were ruled out in the emergency department. Patient received 400 mg ibuprofen for pain in the right arm. Which nursing actions would the nurse take for suspicion of compart - ment syndrome? Instructions: For each potential nurs - ing action listed below, check to specify whether the action is anticipated, non- essential or contraindicated. Vital signs: Temperature 98.7F° (37°C) Pulse 120 beats/min Respirations 24 breaths/min Blood pressure 140/70 mmHg Oxygen saturation 95% (on room air) Body Mass Index (BMI) 30 Assessment findings: Patient is anxious and tearful. He reports stiff - ness and soreness in his right leg, but “My leg is okay compared to my arm. My arm really hurts (9/10 on pain scale). Stretching makes the pain worse and there is burning and tingling in my fingers. When is that pain medication supposed to start working?” 46. Matrix ______________________________________________________________________________________
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C HAPT e R 1 Pain 18 Copyright © 2022, Elsevier Inc. All rights reserved. Answer Key for this chapter begins on p. 19 Common Health Scenarios PART 2 47. Drag and Drop ________________________________________________________________________________ Scenario: The oncoming day shift nurse has received the shift report from the night nurse. The day shift nurse has done a quick check on all of the patients and has deter - mined that all are stable and not in acute distress. In which order would the nurse care for these patients? Instructions: Patients are listed in the left-hand column. In the right- hand column write in the number to indicate the order of priority for care; 1 being the first and 5 being the last. Patients Order of priority 1. 17-year-old adolescent who is alert and oriented. He was admitted 2 days ago for treatment of meningitis. He reports a continuous headache that is partially relieved by medication. 2. 65-year-old man who underwent total knee replacement surgery 2 days ago. He is using the patient- controlled analgesia (PCA) pump frequently and occasionally asks for a bolus dose. 3. 53-year-old woman who is demanding and frequently calls for assistance. She was admitted for investigation of functional abdominal pain and is scheduled for diagnostic testing this morning. 4. 82-year-old woman with advanced Alzheimer disease who requires total care for all activities of daily living. She will be transferred to a long- term care facility in a few days after arrangements are finalized. 5. 26-year-old man who was admitted with chest pain secondary to a spontane - ous pneumothorax. Today, the chest tube will be removed and the PCA pump will be discontinued. Potential Nursing Actions Anticipated Nonessential Contraindicated Assess the location, quality, and intensity of pain Assess for 5Ps (pain, pallor, pulselessness, paralysis, paresthesia) Elevate right arm above the level of the heart Apply an ice pack wrapped in a towel Assess urine color and output Wrap the forearm with an elastic bandage Obtain an order for an x- ray of the arm Notify health care provider for unrelieved pain and paresthesia
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Copyright © 2022, Elsevier Inc. All rights reserved. Introduction PART 1 18.e1 Answers 1. Ans: 3 The patient must be believed, and his or her experience of pain must be acknowledged as valid. The data gathered via patient reports can then be applied to the other options in developing the treatment plan. Focus: Prioritization; QSEN: PCC; Concept: Pain; Cognitive Level: Applying. 2. Ans: 1, 3, 4 The widespread use of opioids and the increase in mortality and morbidity make it essential for nurses to recognize any personal negative bias and work toward conveying acceptance and understand - ing. This increases the likelihood of patient engage - ment and success in treatment programs. Learning about the signs and symptoms of an opioid overdose and the proper use of naloxone is also a nursing re - sponsibility. Electronic prescription drug monitoring programs show promise but are not currently available nationwide and checking the database for all opioid prescriptions may be time- consuming and unneces - sary (short- term opioid prescriptions for acute pain are less problematic). The nurse would question a health care provider if an opioid prescription did not seem safe; however, the CDC recommendations are not legally binding and deviations are not report - able. Focus: Prioritization; QSEN: EBP, S; Concept: Pain; Cognitive Level: Analyzing. 3. Ans: 4 Assess the pain for changes in location, quality, and intensity, as well as changes in response to medication. This assessment will guide the next steps. Focus: Prioritization; QSEN: EBP; Concept: Pain; Cognitive Level: Applying. Test Taking Tip: During clinical rotations, you may observe nurses giv - ing pain medication without performing an adequate pain assessment. This is an error in clinical perfor - mance. In postoperative patients, pain could signal complications, such as hemorrhage, infection, or de - creased perfusion related to tissue swelling. Always assess pain first, then make a decision about giving medication, using nonpharmacologic methods, or contacting the HCP. 4. Ans: 4 The LPN/LVN is well trained to administer oxygen per nasal cannula. This patient is considered unstable; therefore the RN should take responsibil - ity for administering drugs and monitoring the re - sponse to therapy, which includes the effects on the respiratory system. The RN should also take respon - sibility to communicate with the HCP for ongoing treatment and therapy. Focus: Assignment; QSEN: TC; Concept: Clinical Judgment; Cognitive Level: Analyzing; IPEC: R/R. 5. Ans: 4 If the pain is constant, the best schedule is around- the- clock to provide steady analgesia and pain control. The other options may require higher dosages to achieve control. Focus: Prioritization; QSEN: EBP; Concept: Pain; Cognitive Level: Applying. 6. Ans: 4 At greatest risk are older adult patients, opioid- naïve patients, and those with underlying pul - monary disease. The adolescent has two of the three risk factors. Focus: Prioritization; QSEN: EBP; Concept: Pain; Cognitive Level: Applying. 7. Ans: 4 One of the common features of rheumatoid arthritis is joint pain and stiffness when first rising. This usually resolves over the course of the day. A non - pharmaceutical measure is to take a warm shower (or apply warm packs to joints if pain is limited to one or two joints). If pain worsens, then the nurse may elect to contact other members of the health care team for additional interventions. Focus: Delegation; QSEN: TC; Concept: Pain; Cognitive Level: Applying; IPEC: R/R. 8. Ans: 1 Gabapentin is an antiepileptic drug, but it is also used to treat diabetic neuropathy. Corticosteroids are for pain associated with inflam - mation. Hydromorphone is a stronger opioid, and it is not the first choice for chronic pain that can be managed with other drugs. Lorazepam is an anxiolyt - ic that may be prescribed as an adjuvant medication. Focus: Prioritization; QSEN: EBP; Concept: Pain; Cognitive Level: Applying. 9. Ans: 1 The goal is to control pain while minimizing side effects. For severe pain, the medication can be ti - trated upward until the pain is controlled. Downward titration occurs when the pain begins to subside. Focus: Prioritization; QSEN: EBP; Concept: Pain; Cognitive Level: Applying. 10. Ans: 1, 2, 3, 4 The recommendations of the American Pain Society, in collaboration with the American Society of Anesthesiologists, for postopera - tive patients include: acetaminophen and/or NSAIDs if there are no contraindications; surgical site–specific peripheral regional anesthetic for procedures; neuraxi - al analgesia (also known as epidural analgesia) for ma - jor thoracic and abdominal procedures, if patient has risk for cardiac complications or prolonged ileus; and multimodal therapy, which includes use of different types of medications and other therapies. Oral opioids are preferred in the postoperative period. Pain special - ists should be consulted if patients have inadequately controlled postoperative pain. Focus: Prioritization; QSEN: EBP; Concept: Pain; Cognitive Level: Understanding . Test Taking Tip: Passing a test and working as a competent nurse requires keeping up to date with current practice guidelines. 11. Ans: 3 Beliefs, attitudes, and familial influence are part of the sociocultural dimension of pain. Location
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18.e2 Copyright © 2022, Elsevier Inc. All rights reserved. C HAPT e R 1 Pain Introduction PART 1 and radiation of pain address the sensory dimension. Describing pain and its effects addresses the affective dimension. Activity level and function address the be - havioral dimension. Asking about knowledge address - es the cognitive dimension. Focus: Prioritization; QSEN: PCC; Concept: Pain; Cognitive Level: Analyzing. 12. Ans: 3 Cancer pain generally worsens with disease progression, and the use of opioids is more generous. Fibromyalgia is more likely to be treated with non- opioid and adjuvant medications. Trigeminal neu - ralgia is treated with antiseizure medications such as carbamazepine. Phantom limb pain usually sub - sides after ambulation begins. Focus: Prioritization; QSEN: EBP; Concept: Pain; Cognitive Level: Applying. 13. Ans: 1 Multimodal therapies for postoperative pa - tients include opioids and nonopioid therapies, re - gional anesthetic techniques, and nonpharmacologic therapies. This approach is thought to be the most im - portant strategy for pain management for most post - operative patients. Standing orders are less optimal because there is no consideration of individual needs or characteristics. PCA is one important element, but not all patients can manage PCA devices. Assessment tools are an important part of overall manage - ment, but basing opioid dose on a numerical scale does not consider individual patient circumstances. Focus: Prioritization; QSEN: EBP; Concept: Pain; Cognitive Level: Understanding. 14. Ans: 4 When supervising a new RN, good per - formance should be reinforced first and then areas of improvement can be addressed. Asking the nurse about knowledge of pain management is also an op - tion; however, it would be a more indirect and time- consuming approach. Making a note and watching does not help the nurse to correct the immediate problem. In- service training might be considered if the problem persists. Focus: Supervision; QSEN: TC, QI; Concept: Leadership; Cognitive Level: Applying. 15. Ans: 1, 3, 5, 6 Patients with acute conditions that require close monitoring for complications should be assigned to an experienced RN. Abdominal cramps secondary to food poisoning is an acute condition; however, cramping, vomiting, and diarrhea are usu - ally self- limiting. The patient with chronic back pain would be considered physically stable. Although all patients will benefit from care provided by an experi - enced RN, the patient with abdominal cramps and the patient with back pain could be assigned to a new RN, an LPN/LVN, or a float nurse. Focus: Assignment; QSEN: TC; Concept: Clinical Judgment; Cognitive Level: Analyzing; IPEC: T/T. Test Taking Tip: To determine acuity of patients, use nursing con - cepts, such as gas exchange and perfusion. Patients 1, 3, 5, and 6 could have potential problems related to perfusion. The patient with the chest tube could also have a potential problem related to gas exchange. 16. Ans: 2 Inadequate pain management for postsurgi - cal patients can affect quality of life, function, recovery, and postsurgical complication; thus all the manifes - tations are examples of negative results. Nevertheless, venous thromboembolism is the most serious because it can lead to pulmonary embolism, which is an imme - diate life- threatening concern. The nurse also needs to implement interventions to resolve unsatisfied needs, fear of pain, and hopelessness related to pain and function. Focus: Prioritization; QSEN: PCC, S; Concept: Pain; Cognitive Level: Analyzing. Test Taking Tip: Physiologic needs are the first concern. In this case, venous thromboembolism is the most serious physiologic outcome secondary to inadequate pain management. 17. Ans: 1 The nurse would consider questioning all of the medication prescriptions, but the opioid- naïve adult has the greatest immediate risk because use of a basal dose has been associated with an increased in - cidence of respiratory depression in opioid- naïve pa - tients. Older adults are frequently prescribed NSAIDs; however, they are used with caution, and the patient’s history should be reviewed for potential problems, such as a history of gastrointestinal bleeding, cardiac disease, or renal dysfunction. Many medications such as anticoagulants, oral hypoglycemics, diuretics, and antihypertensives can also cause adverse drug–drug interactions with NSAIDs. IM injections cause pain, absorption is unreliable, and there are no advantages over other routes of administration. If a patient is able to tolerate oral foods and fluids, oral medications are preferred because the efficacy of the oral route is equal to the IV route. Focus: Prioritization; QSEN: EBP, S; Concept: Pain; Cognitive Level: Analyzing. Test Taking Tip: It is worthwhile to study the purposes, pharmacologic actions, and side effects of commonly used medications. Morphine is considered the proto - type of the opioid medications. For opioid- naïve pa - tients, the priority concern is respiratory depression. For patients who need opioids for long- term pain management, the primary side effect is constipation. 18. Ans: 3 The patient with an acute myocardial infarc - tion has the greatest need for IV access and is likely to receive morphine, which will relieve pain and in - crease venous capacitance. The other patients may also need IV access for delivery of pain medication, other drugs, or IV fluids, but the need is less urgent. Focus: Prioritization; QSEN: EBP; Concept: Clinical Judgment; Cognitive Level: Analyzing. 19. Ans: 2 The AP has correctly reported findings, but the nurse is ultimately responsible to assess first and then determine the correct action. Based on assess - ment findings, the other options may also be appro - priate. Focus: Prioritization; QSEN: EBP; Concept: Clinical Judgment; Cognitive Level: Applying.
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