NSG 3130 Exam 1 | STUDY GUIDE
General delegation rules to follow for the RN: -Always be familiar with your state board rules and regulations for delegation.
-Refer to you facility policies and procedures for roles and responsibilities for task
delegation.
-NEVER assume! Always ensure those you are delegating to (RN, LVN/LPN and/or
UAP) have the training and skill set to complete the task delegated to them.
-Always validate! If you are unsure if a staff member does not have the
knowledge or skills to complete a task, ask them to demonstrate by stating
"Please show me how you would do this".
UAP Delegation: -Setting bed alarms, VS.
-Check patient status as directed by the RN- must report findings to the RN ("are
you still having pain?").
-Emptying drainage devices (indwelling urinary cats, suprapubic caths, JP drains,
etc).
-Record meals/routines.
-Typically UAPs do not care for chest tubes (even drainage). UAPs cannot give
medication.
LVN/LPN Delegations: -Dressing changes.
-Apply O2.
-Give PO, IM, SQ medications.
-Enemas.
-Urinary catheter insertion.
-Can care for stable patients that are not complex.
-No IVs or IV medications.
, As the RN you MUST complete the following items, they -Assessments/ reassessments.
cannot be delegated: -Evaluation (think nursing process).
-Education/teaching.
-Transfers (on or off the unit-they will need an assessment).
-Post mortem care.
-Abnormal results.
-Plan of care development.
-Going to or coming from surgery (includes pre op check lists and initial post op
assessment).
Things to remember as an RN delegating: -Always remember, as an RN, you will also be delegated too- this means the first
step when a patient assignment or task is delegated to YOU is to figure out what is
needed or required.
-If there are patients/tasks you do not have the knowledge or skill set to care for
or complete, report to your charge nurse.
Documentation must be: -Timely.
-Accurate.
-Complete.
-Factual.
-NO slang or bias language-factual and objective.
-ALL CHARTING IS CONSIDERED LEGAL DOCUMENTATION.
Documentation Standards: -You can't look up a patient that you had the day before (HIPAA violation).
-If you are the interviewing nurse, you can access client's chart.
-You can document meds on the patient you gave meds to: do not document
medications or tasks you did not complete.
-Only need a section witness on required meds.
-You can discuss care of a client with the nurse that is precepting you.
Rules and Regulations with Documentation: -Ethical and Legal Concerns.
-Confidentiality of all patient information.
-HIPAA updated April 14, 2003.
-Ensuring confidentiality of computer records.
Source-oriented: Each profession has a separate section of the record in which to do
narrative charting.
Problem-oriented medical record (POMR): Integrates charting from the entire care team in the same section of the record.
Nurse's notes may be in a narrative format or in a PIE, APIE, SOAP, SOAPIE, SOAPIER, or CBE format.
problem-oriented structure, such as...
Charting by exception: -Agencies develop standards of nursing practice.
-Documentation according to standards involves a check mark.
-Exceptions to standards described in narrative form on nurses' notes. Only chart
what is significant or abnormal.
General delegation rules to follow for the RN: -Always be familiar with your state board rules and regulations for delegation.
-Refer to you facility policies and procedures for roles and responsibilities for task
delegation.
-NEVER assume! Always ensure those you are delegating to (RN, LVN/LPN and/or
UAP) have the training and skill set to complete the task delegated to them.
-Always validate! If you are unsure if a staff member does not have the
knowledge or skills to complete a task, ask them to demonstrate by stating
"Please show me how you would do this".
UAP Delegation: -Setting bed alarms, VS.
-Check patient status as directed by the RN- must report findings to the RN ("are
you still having pain?").
-Emptying drainage devices (indwelling urinary cats, suprapubic caths, JP drains,
etc).
-Record meals/routines.
-Typically UAPs do not care for chest tubes (even drainage). UAPs cannot give
medication.
LVN/LPN Delegations: -Dressing changes.
-Apply O2.
-Give PO, IM, SQ medications.
-Enemas.
-Urinary catheter insertion.
-Can care for stable patients that are not complex.
-No IVs or IV medications.
, As the RN you MUST complete the following items, they -Assessments/ reassessments.
cannot be delegated: -Evaluation (think nursing process).
-Education/teaching.
-Transfers (on or off the unit-they will need an assessment).
-Post mortem care.
-Abnormal results.
-Plan of care development.
-Going to or coming from surgery (includes pre op check lists and initial post op
assessment).
Things to remember as an RN delegating: -Always remember, as an RN, you will also be delegated too- this means the first
step when a patient assignment or task is delegated to YOU is to figure out what is
needed or required.
-If there are patients/tasks you do not have the knowledge or skill set to care for
or complete, report to your charge nurse.
Documentation must be: -Timely.
-Accurate.
-Complete.
-Factual.
-NO slang or bias language-factual and objective.
-ALL CHARTING IS CONSIDERED LEGAL DOCUMENTATION.
Documentation Standards: -You can't look up a patient that you had the day before (HIPAA violation).
-If you are the interviewing nurse, you can access client's chart.
-You can document meds on the patient you gave meds to: do not document
medications or tasks you did not complete.
-Only need a section witness on required meds.
-You can discuss care of a client with the nurse that is precepting you.
Rules and Regulations with Documentation: -Ethical and Legal Concerns.
-Confidentiality of all patient information.
-HIPAA updated April 14, 2003.
-Ensuring confidentiality of computer records.
Source-oriented: Each profession has a separate section of the record in which to do
narrative charting.
Problem-oriented medical record (POMR): Integrates charting from the entire care team in the same section of the record.
Nurse's notes may be in a narrative format or in a PIE, APIE, SOAP, SOAPIE, SOAPIER, or CBE format.
problem-oriented structure, such as...
Charting by exception: -Agencies develop standards of nursing practice.
-Documentation according to standards involves a check mark.
-Exceptions to standards described in narrative form on nurses' notes. Only chart
what is significant or abnormal.
