nursing

helpneeded2016

nursing.docx

It is 3:30 p.m. on a Thursday and Mr. B, a 67-year-old patient, arrives at the six-room emergency department (ED) of a sixty-bed rural hospital. He has been brought to the hospital by his son and neighbor. At this time, Mr. B is moaning and complaining of severe pain to his (L) leg and hip area. He states he lost his balance and fell after tripping over his dog. Mr. B was admitted to the triage room where his vital signs were B/P 120/80, HR-88 (regular), T-98.6, R-32, and his weight was recorded at 175 pounds. Mr. B. states that he has no known allergies and no previous falls. He states, “My hip area and leg hurt really bad. I have never had anything like this before.” Patient rates pain at ten out of ten on the numerical verbal pain scale. He appears to be in moderate distress. His (L) leg appears shortened with swelling (edema in the calf), ecchymosis, and limited range of motion (ROM). Mr. B’s leg is stabilized and then he is further evaluated and discharged from triage to the emergency department (ED) patient room. He is admitted by Nurse J. The admitting nurse finds that Mr. B has a history of impaired glucose tolerance and prostate cancer. At Mr. B’s last visit with his primary care physician, laboratory data revealed elevated cholesterol and lipids. Mr. B’s current medications are atorvastatin and oxycodone for chronic back pain. After the nurse completes Mr. B’s assessment, Nurse J informs the ED physician of admission findings and the ED physician proceeds to examine Mr. B. Staffing on this day consists of two nurses (one RN and one LPN), one secretary, and one emergency department physician. Respiratory therapy is in-house and available as needed. At the time of Mr. B’s arrival, the ED staff is caring for two other patients. One patient is a 43-year-old female complaining of a throbbing headache. The patient rates current pain at four out of ten on numerical verbal pain scale. The patient states that she has a history of migraines. She received treatment, remains stable, and discharge is pending. The second patient is an eight-year-old boy being evaluated for possible appendicitis. Laboratory results are pending for this patient. Both of these patients were examined, evaluated, and cared for by the ED physician and are awaiting further treatment or orders. After evaluation of Mr. B, Dr. T, the ED physician, writes the order for Nurse J to administer diazepam 5 mg IVP to Mr. B. The medication diazepam is administered IVP at 4:05 p.m. After five minutes, the diazepam appears to have had no effect on Mr. B, and Dr. T instructs Nurse J to administer hydromorphone 2 mg IVP. The medication (hydromorphone) is administered IVP at 4:15 p.m. After five minutes, Dr. T is still not satisfied with the level of sedation Mr. B has achieved and instructs Nurse J to administer another 2 mg of hydromorphone IVP and an additional 5 mg of diazepam IVP. The physician’s goal is for the patient to achieve skeletal muscle relaxation from the diazepam, which will aid in the manual manipulation, relocation, and alignment of Mr. B’s hip. The hydromorphone IVP was administered to achieve pain control and sedation. After reviewing the patient’s medical history, Dr. T notes that the patient’s weight and current regular use of oxycodone appear to be making it more difficult to sedate Mr. B. Finally at 4:25, the patient appears to be sedated and the successful reduction of his (L) hip takes place. The patient appears to have tolerated the procedure and remains sedated. He is not currently on any supplemental oxygen. The procedure concludes at 4:30 p.m. and Mr. B is resting without indications of discomfort and distress. At this time, the ED receives an emergency dispatch call alerting the emergency department that the emergency rescue unit paramedics are en route with a 75-year-old patient in acute respiratory distress. Nurse J places Mr. B on an automatic blood pressure machine programmed to monitor his B/P every five minutes and a pulse oximeter. At this time Nurse J leaves his room. The nurse allows Mr. B’s son to sit with him as he is being monitored via the blood pressure monitor. At 4:35, Mr. B’s B/P is 110/62 and his O2 sat is 92%. He remains without supplemental oxygen and his ECG and respirations are not monitored. Nurse J and the LPN on duty have received the emergency transport patient. They are also in the process of discharging the other two patients. Meanwhile, the ED lobby has become congested with new incoming patients. At this time, Mr. B’s O2 saturation alarm is heard and shows “low O2 saturation” (currently showing a sat of 85%). The LPN enters Mr. B’s room briefly and resets the alarm and repeats the B/P reading. Nurse J is now fully engaged with the emergency care of the respiratory distress patient, which includes assessments, evaluation, and the ordering respiratory treatments, CXR, labs, etc. At 4:43, Mr. B’s son comes out of the room and informs the nurse that the “monitor is alarming.” When Nurse J enters the room, the blood pressure machine shows Mr. B’s B/P reading is 58/30 and the O2 sat is 79%. The patient is not breathing and no palpable pulse can be detected. A STAT CODE is called and the son is escorted to the waiting room. The code team arrives and begins resuscitative efforts. When connected to the cardiac monitor, Mr. B is found to be in ventricular fibrillation. CPR begins immediately by the RN, and Mr. B is intubated. He is defibrillated and reversal agents, IV fluids, and vasopressors are administered. After 30 minutes of interventions, the ECG returns to a normal sinus rhythm with a pulse and a B/P of 110/70. The patient is not breathing on his own and is fully dependent on the ventilator. The patient’s pupils are fixed and dilated. He has no spontaneous movements and does not respond to noxious stimuli. Air transport is called and, upon the family’s wishes, the patient is transferred to a tertiary facility for advanced care. Seven days later, the receiving hospital informed the rural hospital that EEG’s had determined brain death in Mr. B. The family had requested life-support be removed, and Mr. B subsequently died. Additional information: The hospital where Mr. B. was originally seen and treated had a moderate sedation/analgesia (“conscious sedation”) policy that requires that the patient remains on continuous B/P, ECG, and pulse oximeter throughout the procedure and until the patient meets specific discharge criteria (i.e., fully awake, VSS, no N/V, and able to void). All practitioners who perform moderate sedation must first successfully complete the hospital’s moderate sedation training module. The training module includes drug selection as well as acceptable dose ranges. Additional (backup) staff was available on the day of the incident. Nurse J had completed the moderate sedation module. Nurse J had current ACLS certification and was an experienced critical care nurse. Nurse J’s prior annual clinical evaluations by the manager demonstrated that the nurse was “meeting requirements.” Nurse J did not have a history of negligent patient care. Sufficient equipment was available and in working order in the ED on this day. Task:

A. Complete a root cause analysis (RCA) that takes into consideration causative factors, errors, and/or hazards that led to the sentinel event (this patient’s outcome).

B. Discuss a process improvement plan that would decrease the likelihood of a reoccurrence of the outcome of the scenario.

1. Discuss a change theory that could be used to implement the process improvement plan developed in B.

C. Use a failure mode and effects analysis (FMEA) to project the likelihood that the process improvement plan you suggest would not fail.

1. Identify the members of the interdisciplinary team who will be included in the FMEA.

2. Discuss steps for preparing for the FMEA.

3. Apply the three steps of the FMEA (severity, occurrence, and detection) to the process improvement plan created in part B.

4. Explain how you would test the interventions from the process improvement plan from part B to improve care in a similar situation.

Note:You are not expected to carry out the full FMEA, but you should explain each step, and how you would apply it to your process improvement plan.

D. Discuss how the professional nurse may function as a leader in promoting quality care and influencing quality improvement activities.

E. When you use sources to support ideas and elements in a paper or project, provide acknowledgement of source information for any content that is quoted, paraphrased or summarized. Acknowledgement of source information includes in-text citation noting specifically where in the submission the source is used and a corresponding reference, which includes:

• Author

• Date

• Title

• Location of information (e.g., publisher, journal, or website URL)

Note: The use of APA citation style is encouraged but is not required for this task. Evaluators will offer feedback on the acknowledgement of source information but not with regard to conformity with APA or other citation style. For tips on using APA style, please refer to the APA Resources web link found under General Information/APA Guidelines in the left-hand panel in TaskStream. Note: No more than a combined total of 30% of a submission can be directly quoted or closely paraphrased from outside sources, even if cited correctly.

2) Introduction: It is essential that nurses understand the issues related to healthcare financing, including local, state, and national healthcare policies and initiatives that affect healthcare delivery. As a patient advocate, the professional nurse is in a position to work with patients and families to access available resources to meet their healthcare needs. Requirements:

A. Compare the U.S. healthcare system with the healthcare system of Great Britain, Japan, Germany, or Switzerland, by doing the following:

1. Identify one country from the following list whose healthcare system you will compare to the U.S. healthcare system: Great Britain, Japan, Germany, or Switzerland.

2. Compare access between the two healthcare systems for children, people who are unemployed, and for people who are retired.

a. Discuss coverage for medications in the two healthcare systems.

b. Determine the requirements to get a referral to see a specialist in the two healthcare systems.

c. Discuss coverage for preexisting conditions in the two healthcare systems.

3. Explain two financial implications for the patient with regard to the healthcare delivery differences between the two countries.

B. When you use sources to support ideas and elements in a paper or project, provide acknowledgement of source information for any content that is quoted, paraphrased or summarized. Acknowledgement of source information includes in-text citation noting specifically where in the submission the source is used and a corresponding reference, which includes:

• Author

• Date

• Title

• Location of information (e.g., publisher, journal, or website URL)

Note: For definitions of terms commonly used in the rubric, see the Rubric Terms web link included in the Evaluation Procedures section. Note: When using sources to support ideas and elements in an assessment, the submission MUST include APA formatted in-text citations with a corresponding reference list for any direct quotes or paraphrasing. It is not necessary to list sources that were consulted if they have not been quoted or paraphrased in the text of the assessment. Note: No more than a combined total of 30% of a submission can be directly quoted or closely paraphrased from outside sources, even if cited correctly. For tips on using APA style, please refer to the APA Handout web link included in the APA Guidelines section.

3) Scenario: Mr. J is a 72-year-old retired rabbi with a diagnosis of mild dementia. He was admitted for treatment of a fractured right hip after falling in his home. He has received pain medication and is drowsy, but he answers simple questions appropriately. A week after Mr. J was admitted to the hospital, his daughter, who lives eight hours away, came to visit. She found him restrained in bed. While Mr. J was slightly sleepy, he recognized his daughter and was able to ask her to remove the restraints so he could be helped to the bathroom. His daughter went to get a certified nursing assistant (CNA) to remove the restraints and help her father to the bathroom. When the CNA was in the process of helping Mr. J sit up in bed, his daughter noticed a red, depressed area over Mr. J’s lower spine, similar to a severe sunburn. She reported the incident to the CNA who replied, “Oh, that is not anything to worry about. It will go away as soon as he gets up.” The CNA helped Mr. J to the bathroom and then returned him to bed where she had him lie on his back so she could reapply the restraints. The diet order for Mr. J was “regular, kosher, chopped meat.” The day after his daughter arrived, Mr. J was alone in his room when his meal tray was delivered. The nurse entered the room 30 minutes later and observed that Mr. J had eaten approximately 75% of the meal. The meal served was labeled, “regular, chopped meat.” The tray contained the remains of a chopped pork cutlet. The nurse notified the supervisor, who said, “Just keep it quiet. It will be okay.” The nursing supervisor then notified the kitchen supervisor of the error. The kitchen supervisor told the staff on duty what had happened. When the patient’s daughter visited later that night, she was not told of the incident. The next night, the daughter was present at suppertime when the tray was delivered by a dietary worker. The worker said to the patient’s daughter, “I’m so sorry about the pork cutlet last night.” The daughter asked what had happened and was told that there had been “a mix up in the order.” The daughter then asked the nurse about the incident. The nurse, while confirming the incident, told the daughter, “Half a pork cutlet never killed anyone.” The daughter then called the physician, who called the hospital administrator. The physician, who is also Jewish, told the administrator that he has had several complaints over the past six months from his hospitalized Jewish patients who felt that their dietary requests were not taken seriously by the hospital employees. The hospital is a 65-bed rural hospital in a town of few Jewish residents. The town’s few Jewish members usually receive care from a Jewish hospital 20 miles away in a larger city. Task:

Analyze the scenario (suggested length of 2–3 pages) by doing the following:

A. Discuss how an understanding of nursing-sensitive indicators could assist the nurses in this case in identifying issues that may interfere with patient care.

B. Analyze how hospital data on specific nursing-sensitive indicators (such as incidence of pressure ulcers and prevalence of restraints) could advance quality patient care throughout the hospital.

C. Analyze the specific system resources, referrals, or colleagues that you, as the nursing shift supervisor, could use to resolve the ethical issue in this scenario.

D. When you use sources to support ideas and elements in a paper or project, provide acknowledgement of source information for any content that is quoted, paraphrased or summarized. Acknowledgement of source information includes in-text citation noting specifically where in the submission the source is used and a corresponding reference, which includes:

• Author

• Date

• Title

• Location of information (e.g., publisher, journal, or website URL)

Note: No more than a combined total of 30% of a submission can be directly quoted or closely paraphrased from outside sources, even if cited correctly.

4) Introduction: More emphasis is being placed on healthier communities as changes are occurring in the fields of healthcare financing, policy, and focus. One of the primary roles of a community health nurse is to assess the community or population in order to determine its health status in relation to its assets and needs. Requirements:

A. Identify an appropriate community for which there is published data available (county, state, or national data) that will support the diagnosis.

B. Assess the health needs and risks of the identified community by utilizing the following tools:

Note: The collection of this data should include a variety of data sources, such as focus groups with older adults and/or youth, epidemiological data from the health department or department of vital statistics, investigations of community resources from stakeholders or faith-based organizations, and/or surveys. You do not have to answer every question listed in the assessment tools. Each of these tools can be found either in the web links section or as an attachment to this task.

• Population Economic Status Assessment

• Neighborhood/Community Safety Inventory

• Cultural Assessment Tool

• Disaster Assessment and Planning Guide

• Windshield Survey

• Population Health Scavenger Hunt

Note: The name of each of the six tools should be identified in the needs assessment summary, along with a brief summary of how each of the six tools was used in the needs assessment.

1. Interpret the collected data using concepts of epidemiology and health determinants (e.g., birth rate, death rate, rates of disease, morbidity).

C. Formulate an appropriate community diagnosis for the selected community by doing the following (suggested length of 4–6 pages):

1. Identify the top three problems for the selected community based on the Healthy People 2020 goals.

a. Discuss the problems in relation to the Healthy People 2020 goals.

2. Select one of the problems identified in part C1 that you would like to investigate further, and do the following:

a. Discuss community resources (e.g., Public Health Department, American Red Cross, American Heart) that are available to address this problem.

3. Formulate a primary prevention topic based on the problem you identified in part C2.

Note: See the attached “Approved Topic List” for guidance in formulating your topic.

D. Include all in-text citations and references in APA format.

5) Introduction: Nursing is a practice discipline that includes direct and indirect care activities that affect health outcomes. As a baccalaureate nursing student, you are developing new competencies in leadership, and in order to achieve mastery, you must apply those competencies to live practice experiences and situations. This Leadership Learning Experience (LLE) is designed to allow you to choose a clinical focus (e.g., practice, policy, education, population) in which you apply your leadership problem–solving skills. The experience requires engagement with other people within the setting to complete the LLE. You will develop a project within a practice setting that allows you to develop these leadership skills. You will identify a problem area in a practice setting that you specifically want to address (e.g., practice, policy, population, education) that aligns with organizational priorities. Example sources for the problem area may include the following:

• Practice: joint commission standards, core measures as quality indicators, other data

• Policy: legislation, staffing ratio, regulations from state boards

• Population: children with diabetes, adult obesity

• Education: future of nursing, Benner’s recommendations about nursing education

You will focus on a real-life solution for the problem. You should choose a topic that is timely, manageable, and realistic to the current healthcare environment. An external resource person (manager, clinical leader, clinical educator, policy expert, or population expert) must confirm the relevance of the selected project and your engagement in the setting as part of project completion. As with all projects, you should think how you, as a nurse, function in the following roles: detective, scientist, and manager of the healing environment. Project Requirements: Note: Any information that would be considered confidential, proprietary, or personal in nature should not be included. Do not include the actual names of people, stakeholders, or other personally identifiable information. Fictional names should be used. Also, agency-specific data, including financial information, should not be included but should be addressed in a general fashion as appropriate. Note: Your submission may be in a variety of formats (e.g., report, multimedia presentation).

A. Develop a written proposal by doing the following:

1. Identify a problem or issue related to practice, policy, population, or education that aligns with organizational priorities that you seek to solve.

Note: You may need to meet with the organization/practice setting, your manager, and/or supervisor to help choose a current problem or issue.

a. Explain the problem or issue, including why it is applicable to the area of practice you chose and the healthcare environment.

2. Discuss your investigation of the problem or issue.

a. Include evidence to substantiate the problem or issue (e.g. organizational assessment, national source documents, evidence from a stakeholder).

3. Analyze the state of the situation using current data.

a. Analyze areas that might be contributing to the problem or issue.

4. Propose a solution or innovation for the problem or issue.

a. Justify your proposed solution or innovation based on the results of your investigation and analysis.

5. Recommend resources to implement your proposed solution or innovation.

a. Include a cost benefit analysis of your proposed solution or innovation.

6. Include a timeline for implementation based on your proposal.

7. Identify key stakeholders and/or appropriate partners that are important for the implementation of your solution or innovation.

a. Discuss why each key stakeholder and/or appropriate partner is important for the implementation of the solution or innovation.

b. Summarize your engagement with the key stakeholders and/or appropriate partners, including the input and feedback you received.

c. Discuss how you intend to work with those key stakeholders and/or appropriate partners in order to achieve success.

8. Discuss how your proposed solution or innovation could be implemented.

a. Discuss how the implementation could be evaluated for success.

B. Explain how you fulfilled the following roles during your process of investigation and proposal development:

1. scientist

2. detective

3. manager of the healing environment

C. Submit the completed attached “Professional Verification Form” from the organizational leader advising you in your leadership experience.

D. When you use sources, include all in-text citations and references in APA format.

Note: For definitions of terms commonly used in the rubric, see the Rubric Terms web link included in the Evaluation Procedures section. Note: When using sources to support ideas and elements in a paper or project, the submission MUST include APA formatted in-text citations with a corresponding reference list for any direct quotes or paraphrasing. It is not necessary to list sources that were consulted if they have not been quoted or paraphrased in the text of the paper or project. Note: No more than a combined total of 30% of a submission can be directly quoted or closely paraphrased from outside sources, even if cited correctly. For tips on using APA style, please refer to the APA Handout web link included in the APA Guidelines section.