Cardiovascular drugs quizlet

Cardiovascular drugs quizlet DEFAULT

Practice - Texas Board of Nursing Position Statements

 



15.1 Nurses Carrying out Orders from Physician Assistants

The purpose of this position statement is to provide guidance to nurses with regard to carrying out orders from Physician Assistants (PAs).

The Nursing Practice Act (NPA) includes the "administration of medications or treatments ordered by a physician, podiatrist or dentist" as part of the practice of nursing.1,2 There are no other healthcare professionals listed thus leading to questions regarding nurses carrying out orders from other licensed healthcare providers. Although PAs are not included in the NPA, the Board recognizes that nurses work collaboratively with PAs to provide patient care in various practice settings.

The PA is licensed and regulated by the Texas Physician Assistant Board.3 PAs may provide medical aspects of care, including ordering or prescribing medications and treatments, as delegated by a physician consistent with laws, rules and regulations applicable to the PAs’ practice including those of the Texas Medical Board (TMB) Chapter 193.4 A physician is not required to be present at all times at the location where the PA is providing care and orders are not required to be countersigned by the physician. A nurse may carry out these orders. As with any order, the nurse must seek clarification if he/she believes the order or treatment is inaccurate, non-efficacious or contraindicated by consulting with the PA and physician as appropriate.5 A list of physician assistants credentialed by the medical staff and policies directing their practice should be available to the nursing staff.

References

1 Nursing Practice Act, TOC §301.002(2)

2 Texas Board of Nursing (2017). Position statement 15.25,Administration of Medication & Treatments by LVNs.

3 Physician Assistant Licensing Act, TOC Chapter 204 and 22 TAC Chapter 185

4 22 TAC §§185.2(17); 185.10, 193.2(17) & 193.2(18)

5 22 TAC §217.11(1)(N)

(Board Action: 01/1994; Revised: 01/2005; 01/2006; 01/2010; 01/2012; 01/2016; 01/2017; 01/2018)
(Reviewed: 01/2007; 01/2008; 01/2009; 01/2011; 01/2013; 01/2014; 01/2015; 01/2019 ;01/2020; 01/2021)

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15.2 The Role of the Licensed Vocational Nurse in the Pronouncement of Death

Licensed vocational nurses (LVNs) do not have the authority to legally determine death, diagnose death, or otherwise pronounce death in the State of Texas. Regardless of practice setting, the importance of initiating cardiopulmonary resuscitation (CPR) in cases where no clear do-not-resuscitate (DNR) orders exist is imperative. The Board of Nursing (BON) has investigated cases involving the failure of a LVN to initiate CPR in the absence of a DNR order. Position Statement 15.20, Registered Nurses in the Management of an Unwitnessed Arrest in a Resident in a Long Term Care Facility, has additional information in regards to initiating CPR.

It is within the LVN scope of practice as defined by 22 TAC §217.11(1)-(2) (effective 9/28/2004) and Position Statement 15.27, The Licensed Vocational Nurse Scope of Practice, for a LVN to gather data and perform a focused assessment regarding a patient, to recognize significant changes in a patient’s condition, and to report said data and observation of significant changes to the physician. The LVN’s focused assessment should include nursing observations to determine the presence or absence of the following presumptive or conclusive signs of death:

Presumptive Signs of Death

  • The patient is unresponsive,
  • The patient has no respirations,
  • The patient has no pulse,
  • The patient’s pupils are fixed and dilated,
  • The patient’s body temperature indicates hypothermia: skin is cold relative to the patient’s baseline skin temperature,
  • The patient has generalized cyanosis, and

Conclusive Signs of Death

  • There is presence of livor mortis (venous pooling of blood in dependent body parts causing purple discoloration of the skin).
  • While these signs of irreversible death would not be expected to be seen in most practice settings, the American Heart Association also includes the following irreversible signs of death:
    • decapitation (separation of the head from the body)
    • decomposition (decay or putrification of the body)
    • rigor mortis (stiffness of the limbs and body that develops 2 - 4 hours after death and may take up to 12 hours to fully develop).

Upon reporting clinical findings to the physician, and in accordance with facility policy, the LVN may accept reasonable physician’s orders regarding the care of the client; i.e.: notification of family, postmortem care, contacting the funeral home or appropriate legal authority, documentation; however, a LVN may not accept an order that would require the LVN to “pronounce death,” or to complete the state-required “medical certification” of a death that occurs without medical attendance.

The BON has no jurisdiction over physician practice, facility policies, or the laws regulating pronouncement of death in Texas. Additional information on Texas regulations regarding pronouncement of death may be found in Chapters 193 and 671 of the Texas Health and Safety Code, as well as through the Department of State Health Services. A LVN is not responsible for the actions of a physician who elects to pronounce death by remote-means. Physicians are licensed by, and must comply with, rules promulgated by the Texas Medical Board as well as other laws applicable to the physician’s practice setting.

References

American Heart Association (2020). American Heart Association CPR & ECC guidelines. Retrieved from https://eccguidelines.heart.org/circulation/cpr-ecc-guidelines/

Texas Health and Safety Code Chapters 193 and 671: http://www.statutes.legis.state.tx.us/

(BVNE Statement adopted 06/1999; Revised BON statement: 01/2006)
(Revised: 01/2007; 01/2008; 01/2009; 01/2011; 01/2012; 01/2013; 01/2014; 01/2015; 01/2016; 01/2018; 01/2019; 01/2021)
(Reviewed: 01/2010; 01/2017)

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15.3 LVNs Engaging in Intravenous Therapy, Venipuncture, or Peripherally Inserted Central Catheter (PICC) Lines

The basic educational curriculum for Licensed Vocational Nurses (LVNs) does not mandate teaching of principles and techniques for insertion of peripheral intravenous (IV) catheters, or the administration of fluids and medications via the IV route. Knowledge and skills relating to maintaining patency and performing dressing changes of central line IV catheters is also not mandated as part of basic LVN education. As such, it cannot be presumed that all LVN licensees possess basic competency in the management of IV lines/IV therapy.

Applicable Nursing Standards

LVN practice is guided by the Nursing Practice Act (NPA) and Board Rules.  22 TAC §217.11, Standards of Nursing Practice, is the Board rule most often applied to nursing practice issues. Two standards applicable in all practice scenarios include:

  • §217.11(1)(B) Implement measures to promote a safe environment for clients and others, and
  • §217.11(1)(T) Accept only those nursing assignments that take into consideration client safety and that are commensurate with the nurse’s educational preparation, experience, knowledge, and physical and emotional ability.

Additional standards in 22 TAC §217.11 that may be applicable when an LVN chooses to engage in an IV therapy related task include (but are not limited to):

  • (1)(C) Know the rationale for and the effects of medications and treatments and correctly administer the same,
  • (1)(D) Accurately and completely report and document: (i) client status...(ii) nursing care rendered...(iii) physician, dentist or podiatrist orders...(iv) administration of medications and treatments...(v) client response(s)...,
  • (1)(G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices,
  • (1)(H) Make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations,
  • (1)(R) Be responsible for one’s own continuing competence in nursing practice and individual professional growth,
  • (2)(A) Utilize a systematic approach to provide individualized, goal-directed nursing care...[(i)-(v)], and
  • (2)(C) ...perform other acts that require education and training as prescribed by board rules and policies, commensurate with the LVN’s experience, continuing education, and demonstrated LVN competencies.

Position Statement 15.27, The Licensed Vocational Nurse Scope of Practice, provides additional clarification of the Standards of Nursing Practice Rule as it applies to LVN scope of practice. Instruction and skill evaluation relating to LVNs performing insertion of peripheral IV catheters and/or administering IV fluids and medications as prescribed by an authorized practitioner may allow a LVN to expand his/her scope of practice to include IV therapy.

It is the opinion of the Board that the LVN shall not engage in IV therapy related to either peripheral or central venous catheters, including venipuncture, administration of IV fluids, and/or administration of IV push medications, until successful completion of a validation course that instructs the LVN in the knowledge and skills applicable to the LVN’s IV therapy practice. The BON does not define or set qualifications for an “IV Validation Course” or for "LVN IV certification." The LVN who chooses to engage in IV therapy must first have been instructed in the principles of IV therapy congruent with prevailing nursing practice standards.

Insertion and Removal of PICC Lines or Midline Catheter

The Board has further determined that vocational nursing programs do not provide the LVN with the educational foundation to assure client safety in insertion and removal of Peripherally Inserted Central Catheters (PICC lines) or midline catheters, inclusive of vein selection, insertion/advancement/retraction of the catheter, determining placement, and monitoring of the client for untoward reactions in relation to catheter insertion and removal.  The LVN scope of practice is a directed scope of practice utilizing a focused assessment for patients with predictable healthcare needs. Patients having PICC lines either inserted or removed are at risk for complications, e.g., air embolism, nerve damage, infection1, and could potentially become unpredictable needing a comprehensive assessment, as well as changes to nursing diagnoses and plan of care to ensure vascular access.  This position of the Board aligns with boards of nursing across the nation2,3,4,5,6,7,8,9.Position Statement 15.27, The Licensed Vocational Nurse Scope of Practice, and Position Statement 15.10, Continuing Education: Limitations for Expanding Scope of Practice, further maintains that continuing education that falls short of an educational program of study leading to a degree and licensure as a registered nurse would be insufficient to assure vocational nurse competency and patient safety with regard to insertion and removal of PICC lines or midline catheters. Therefore, it is the Board’s position that insertion and removal of PICC lines or midline catheters is beyond the scope of practice for LVNs.1

Administration of IV Fluids and Medications

The ability of an LVN to administer specific IV fluids or drugs, to prepare and/or administer IV “piggy-back” or IV “push” medications, or to monitor and titrate “IV drip” medications of any kind is up to facility policy. The LVN’s practice relative to IV therapy must also comply with any other regulations that may exist under the jurisdiction of other regulatory agencies or entities. The LVN who accepts an assignment to engage in any aspect of IV therapy is responsible for adhering to the NPA and Board rules, particularly 22 TAC §217.11, Standards of Nursing Practice, including excerpted standards listed above and any other standards or rules applicable to the individual LVN’s practice.

All nursing actions related to peripheral and/or central intravenous lines, as well as IV administration of medications, must be completed in accordance with the orders of the prescribing practitioner, as well as written policies, procedures and job descriptions approved by the health care employer.

References

1 Gorski, L., Hadaway, L., Hagle, M. E., McGoldrick, M., Orr, M., & Doellman, D. (2016). Infusion therapy: Standards of practice. Journal of Infusion Nursing 39(1S).

2 Alabama Board of Nursing. (2016). Alabama Board of Nursing approved standardized procedures. Retrieved from https://www.abn.alabama.gov/wp-content/uploads/2016/03/Approved-Standardized-Procedures.pdf

3 Connecticut Board of Examiners for Nursing. (1997). Suggested guidelines for registered nurses in the insertion and removal of specialized intravenous catheters. Retrieved from https://portal.ct.gov/-/media/Departments-and-Agencies/DPH/dph/phho/Nursing_Board/Guidelines/Specialcathpdf.pdf?la=en

4 Iowa Board of Nursing. (2011). Chapter 6: Nursing practice for registered nurses/licensed practical nurses. Retrieved from https://www.legis.iowa.gov/docs/iac/chapter/09-27-2017.655.6.pdf

5 Massachusetts Board of Registration in Nursing. (2015). Peripherally inserted central catheters (PICC). Retrieved from http://www.mass.gov/eohhs/gov/departments/dph/programs/hcq/dhpl/nursing/nursing-practice/advisory-rulings/peripherally-inserted-central-catheters.html

6 Mississippi Board of Nursing. (2000). Insertion, maintenance and removal of peripherally inserted central catheters (PICC). Retrieved from http://www.msbn.ms.gov/Documents/PICC_2000.pdf

7 South Dakota Board of Nursing. (2012). IV therapy education. Retrieved from https://doh.sd.gov/documents/LPNintravenousTherapy.pdf

8 Vermont Board of Nursing. (2012). The role of the license practical nurse in intravenous infusion therapy. Retrieved from https://www.sec.state.vt.us/media/369316/ps-role-of-the-lpn-in-iv-therapy.pdf

9 Wyoming State Board of Nursing. (2017). Advisory Opinion LPN IV certified (IV-C) scope of practice. Retrieved from https://nursing-online.state.wy.us/Resources/AO_LPN%20IV-C%20Scope%20of%20Practice.pdf

(Board Action: 06/1995; Revised: 09/1999; 01/2005; 01/2011; 01/2012; 01/2014; 01/2015; 01/2018; 01/2019; 01/2020) (Reviewed: 01/2006; 01/2007; 01/2008; 01/2009; 01/2010; 01/2013; 01/2016; 01/2017; 01/2021)

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15.4 Educational Mobility

The Texas Board of Nursing (Board or BON) supports educational mobility for nurses prepared at the VN, ADN, Diploma and BSN levels and encourages the elimination of needless repetition of experiences or time penalties.  Furthermore, the Board encourages existing nursing education programs approved by the Texas Board of Nursing to develop articulation arrangements that specify their policies regarding transfer of academic credits to facilitate educational mobility, especially in underserved areas of the state.

The Board honors and supports military personnel and veterans and their educational mobility. Several Board approved education programs offer articulated credit or other options for military personnel with healthcare training and/or experience.

(Board Action 01/1989)
(Revised: 01/1992; 01/2005; 01/2008; 01/2015; 01/2018)
(Reviewed: 01/2006; 01/2007; 01/2009; 01/2010; 01/2011; 01/2012; 01/2013; 01/2014; 01/2016; 01/2017; 01/2019; 01/2020; 01/2021)

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15.5 Nurses with Responsibility for Initiating Physician Standing Orders

According to the Texas Nursing Practice Act [Tex. Occ. Code Ann. §301.002(3)], the term "Nurse" means, “a person required to be licensed under this chapter to engage in professional or vocational nursing.” The practice of either professional or vocational nursing frequently involves implementing orders from a physician, podiatrist, or dentist. Timely interventions for various patient populations can be facilitated using physician’s standing orders that authorize the nurse to carry out specific orders for a patient presenting with or developing a condition or symptoms addressed in the standing orders.

The specifics of how authorization occurs for a LVN or RN to implement a set of standing physician’s orders are defined in the Texas Medical Board’s (TMB) Rule 193 (22 Tex. Admin. Code §§193.1-193.20) relating to physician delegation. This rule delineates two methods by which nurses may follow a pre-approved set of orders for treating patients:

    1. Standing Delegation Orders; and/or
    2. Standing Medical Orders

These terms are defined in 22 Tex. Admin. Code §193.2 as follows:

(19) Standing delegation order -- Written instructions, orders, rules, regulations, or procedures prepared by a physician and designed for a patient population with specific diseases, disorders, health problems, or sets of symptoms. Such written instructions, orders, rules, regulations or procedures shall delineate under what set of conditions and circumstances action should be instituted. These instructions, orders, rules, regulations or procedures are to provide authority for and a plan for use with patients presenting themselves prior to being examined or evaluated by a physician to assure that such acts are carried out correctly and are distinct from specific orders written for a particular patient, and shall be limited in scope of authority to be delegated as provided in §193.4 of this title (relating to Scope of Standing Delegation Orders). As used in this chapter, standing delegation orders do not refer to treatment programs ordered by a physician following examination or evaluation by a physician, nor to established procedures for providing of care by personnel under direct, personal supervision of a physician who is directly supervising or overseeing the delivery of medical or health care. As used in this chapter, standing delegation orders are separate and distinct from prescriptive authority agreements as defined in this chapter. Such standing delegation orders should be developed and approved by the physician who is responsible for the delivery of medical care covered by the orders.

Such standing delegation orders, at a minimum, should:

      1. include a written description of the method used in developing and approving them and any revision thereof;
      2. be in writing, dated, and signed by the physician;
      3. specify which acts require a particular level of training or licensure and under what circumstances they are to be performed;
      4. state specific requirements which are to be followed by persons acting under same in performing particular functions;
      5. specify any experience, training, and/or education requirements for those persons who shall perform such orders;
      6. establish a method for initial and continuing evaluation of the competence of those authorized to perform same;
      7.  provide for a method of maintaining a written record of those persons authorized to perform same;
      8.  specify the scope of supervision required for performance of same, for example, immediate supervision of a physician;
      9. set forth any specialized circumstances under which a person performing same is to immediately communicate with the patient's physician concerning the patient's condition;
      10. state limitations on setting, if any, in which the plan is to be performed;
      11. specify patient record-keeping requirements which shall, at a minimum, provide for accurate and detailed information regarding each patient visit; personnel involved in treatment and evaluation on each visit; drugs, or medications administered, prescribed or provided; and such other information which is routinely noted on patient charts and files by physicians in their offices; and
      12. provide for a method of periodic review, which shall be at least annually, of such plan including the effective date of initiation and the date of termination of the plan after which date the physician shall issue a new plan.

(20) Standing medical orders -- Orders, rules, regulations or procedures prepared by a physician or approved by a physician or the medical staff of an institution for patients which have been examined or evaluated by a physician and which are used as a guide in preparation for and carrying out medical or surgical procedures or both. These orders, rules, regulations or procedures are authority and direction for the performance for certain prescribed acts for patients by authorized persons as distinguished from specific orders written for a particular patient or delegation pursuant to a prescriptive authority agreement.

A third term, "Protocols", is defined narrowly by the TMB and applies to RNs with advanced practice licensure (APRN) by the BON, or to Physician Assistants only:

(18) Protocols -- Written authorization delegating authority to initiate medical aspects of patient care, including delegation of the act of prescribing or ordering a drug or device at a facility-based practice. The term protocols is separate and distinct from prescriptive authority agreements as defined under the Act and this chapter. However, prescriptive authority agreements may reference or include the terms of a protocol(s). The protocols must be agreed upon and signed by the physician, the physician assistant and/or advanced practice registered nurse, reviewed and signed at least annually, maintained on site, and must contain a list of the types or categories of dangerous drugs and controlled substances available for prescription, limitations on the number of dosage units and refills permitted, and instructions to be given the patient for follow-up monitoring or contain a list of the types or categories of dangerous drugs and controlled substances that may not be prescribed. Protocols shall be defined to promote the exercise of professional judgment by the advanced practice registered nurse and physician assistant commensurate with their education and experience. The protocols used by a reasonable and prudent physician exercising sound medical judgment need not describe the exact steps that an advanced practice registered nurse or a physician assistant must take with respect to each specific condition, disease, or symptom.

By definition, both vocational and professional nursing excludes “acts of medical diagnosis or the prescription of therapeutic or corrective measures” [Tex. Occ. Code Ann. §301.002(2) and (5)].  Based on the above definitions in the TMB rules, RNs who do not have advanced practice licensure from the BON may not utilize "protocols" to carry out physician orders. Likewise, LVNs are also prohibited from utilizing protocols as defined by the TMB, as neither LVNs nor RNs may engage in acts that require independent medical judgment.

A nurse responsible for initiating physician's standing medical orders or standing delegation orders may select specific tasks or functions for patient management, including the administration of a medication required to implement the selected order provided such selection be within the scope of the standing orders. The selection of such tasks or functions for patient management constitutes a nursing decision that may be carried out by a LVN or RN. In addition, this position statement should not be construed to preclude the use of the term “protocol” for a standard set of orders covering the monitoring and treatment of a given clinical condition (e.g., insulin protocol, heparin protocol, ARDS protocol, etc.) provided said standard orders meet the requirements for standing delegation or standing medical orders as defined by the TMB.

The written standing orders under which nurses function shall be commensurate with each nurse’s educational preparation and experience. The nurse initiating any form of standing orders must act within the scope of the Nursing Practice Act, Board Rules and Regulations, and any other applicable local, state, or federal laws.

(Board Action 07/1988; Revised: 01/1992; 07/2001; 01/2005; 01/2006; 01/2007; 01/2009; 01/2011; 01/2014; 01/2016; 01/2018)
(Reviewed: 01/2008; 01/2010; 01/2012; 01/2013; 01/2015; 01/2017; 01/2019; 01/2020; 01/2021)

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15.6 Board Rules Associated with Alleged Patient "Abandonment"

The Texas Board of Nursing (BON or Board), in keeping with its mission to protect public health, safety, and welfare, holds nurses accountable for providing a safe environment for patients and others over whom the nurse is responsible [22 TAC §217.11(1)(B)]. Though the Nursing Practice Act (NPA) and Board rules do not define the term “abandonment,” the Board has investigated and disciplined nurses in the past for issues surrounding the concept of abandonment as it relates to the nurse’s duty to a patient. The Board’s position applies to all licensed nurses (LVNs, RNs, and APRNs), including RN’s with advanced practice licensure (Nurse Practitioners, Clinical Nurse Specialists, Nurse Midwives, and Certified Registered Nurse Anesthetists) in Texas.

Nurse’s Duty to a Patient

All nurses, regardless of practice setting or position title/role, are required to adhere to the NPA and Board rules. The “core” rules relating to nursing practice are 22 TAC §217.11, Standards of Nursing Practice, and 22 TAC §217.12, Unprofessional Conduct. The standard upon which all other standards are based is 22 TAC §217.11(1)(B) “...promote a safe environment for clients and others.” This standard supersedes a physician’s order or facility’s policy and has previously been upheld in a landmark case, Lunsford v. Board of Nurse Examiners, 648 S.W. 2d 391 (Tex. App. -- Austin 1983). The concept of the nurse’s duty to promote patient safety also serves as the basis for determining behavior that could be considered unprofessional conduct by a nurse. 

Patients under the care of a nurse are vulnerable by virtue of illness, injury, and/or the dependent nature and unequal power base of the nurse-patient relationship. Persons who are especially vulnerable include the elderly, children, the mentally ill, sedated and anesthetized patients, those whose mental or cognitive ability is compromised, and patients who are physically disabled, immobilized, restrained, or secluded. The nurse’s duty to protect the patient is created by the patients' vulnerability and the nurse's power base.  The distinction between a nurse leaving employment versus a nurse violating a duty to a patient through leaving an assignment is often confused. The first is an employment issue; the other is potentially a licensure issue.

There is also no routine answer to the question, “When does the nurse’s duty to a patient begin?”  The nurse’s duty is not defined by any single event such as clocking in or taking report.  From a BON standpoint, the focus for disciplinary sanctions is on the relationship and responsibility of the nurse to the patient, not to the employer or employment setting.

Employment Issues

Though the Board has no jurisdiction over employers or employment-related issues, other laws regulating facility licensure may apply certain responsibilities to the employer for provision of patient safety, such as development of effective patient care systems or provision of adequate numbers of qualified staff. Specific requirements for a given facility may be obtained by contacting the applicable licensing authority for the institution.

The Board believes that the following additional examples of employment issues would not typically involve violations of the NPA or Board Rules:

  • resignation without advance notice, assuming the nurse’s current patient care assignment and/or work shift has been completed;
  • refusal to work additional shifts, either “doubles” or extra shifts on days off; and/or
  • other work-related issues, such as frequent absenteeism or tardiness, or conflicts between staff/employees.

The Board believes nurses should be vigilant and exercise sound professional judgment when accepting assignments that may be requested by employers who need nurses to fill vacant shifts for licensed nursing staff or other staffing-related situations. Clear communication between staff and supervisors is essential to arrive at solutions that best focus on patient care needs without compromising either patient safety or a nurse’s license. 

Licensure Issues

As previously noted, the rules most frequently applied to nursing practice concerns are 22 TAC§217.11, Standards of Nursing Practice, and 22 TAC §217.12, Unprofessional Conduct. In relation to questions of "abandonment,” standard 22 TAC §217.11(1)(I) holds the nurse responsible to “notify the appropriate supervisor when leaving a nursing assignment.” This standard should not be misinterpreted to mean a nurse may simply notify the supervisor that he/she is leaving the premises, regardless of whether or not another qualified licensed nurse is available to assume care of the nurse’s patients. Specific procedures to follow in a given circumstance (i.e., nurse becomes ill, family emergency, etc.) should be delineated in facility policies (which the Board does not regulate).

Some actions may be more obvious examples of unprofessional conduct that could result in sanctions on the nurse’s license. Examples of conduct that could lead to Board action on the nurse’s license may include:

  • sleeping on the job, which effectively makes the nurse unavailable to observe the patient or respond to the patient’s needs, even though the nurse is physically present;
  • simply walking off the job in mid-shift without notifying anyone and without regard for patient safety;
  • failing to initiate or complete an agreed assignment when the nurse is the sole care provider, and/or the nurse is a consultant or supervisor in a home or homelike setting; and/or failing to notify a supervisor in a timely manner that the assignment will not be done, and/or falsifying records to the effect that the missed nursing visit was indeed completed; and/or
  • leaving the assigned patient care area and remaining gone or unavailable for a period of time such that the care of any/all patients may be compromised due to lack of available licensed staff.

The Board may impose sanctions on a nurse’s license for actions that potentially place patients at risk for harm or when harm has resulted because a nurse violated his or her duty to the patient by leaving a patient care assignment in a manner inconsistent with the Board rules.

Emergency Preparedness

A nurse may have to choose between the duty to provide safe patient care and protecting the nurse’s own life during an emergency, including but not limited to disasters, infectious disease outbreaks or acts of terrorism. The Board believes nurses should be vigilant and exercise sound professional judgment when accepting assignments that may be requested by employers who need nurses to fill vacant shifts for licensed nursing staff or other staffing-related situations.  These situations are challenging for all nurses and their employers, therefore the Board recommends policies and procedures be developed, and periodically reviewed, to provide clear guidance and direction to nurses in order for patients to receive safe and effective care. A nurse may have to choose between the duty to provide safe patient care and protecting the nurse's own life during a violent situation that may occur in the workplace. For example, when an active shooter is present in the workplace, the nurse should take steps to protect the patients if there is time and using a method that does not jeopardize the nurse's personal safety or interfere with law enforcement personnel. These steps may include evacuating the area or preventing entry to an area where the active shooter is located. However, during an active shooter situation a nurse may find there is not sufficient time to do anything but to ensure his or her own safety. In this instance, as soon as the situation has resolved the nurse should promptly resume care of patients. Clear communication between staff and supervisors is essential to arrive at solutions that best focus on patient care needs without compromising either patient safety or a nurse’s license.

Board Disciplinary Actions

Complaints of “patient abandonment” when it is obvious from the allegation that it is an employment issue will not be investigated by the Board. In these circumstances, however, both parties (the nurse and the employer) may be advised to strive for alternate solutions to avoid similar situations in the future.

Some general factors that would be considered in investigating a complaint alleging a nurse left an assignment by a nurse would include, but not be limited to:

  • the extent of dependency or disability of the patient;
  • stability of the patient;
  • the length of time the patient was deprived of care;
  • any harm to the patient/level of risk of harm to the patient;
  • steps taken by the nurse to notify a supervisor of the inability to provide care;
  • previous history of leaving a patient-care assignment;
  • emergencies that require nurses to respond, including but not limited to disasters, disease outbreaks, and bioterrorism;
  • workplace violence, including but not limited to an active shooter situation;
  • other unprofessional conduct in relation to the practice of nursing;
  • nurse's general competency regarding adherence to minimum nursing standards.

As with all allegations received by the Board, the alleged conduct by a nurse will be thoroughly investigated to determine what, if any, violations of the NPA and rules have occurred. Depending upon the case analysis, Board actions may range from the case being closed with no findings or action all the way to suspension and/or revocation/voluntary surrender of the nurse’s license. If evidence of violations exists, the Board must then determine what level of sanction is appropriate to take on the nurse’s license and what specific stipulation requirements will be applied. 

Safe Harbor Nursing Peer Review

If a nurse feels he/she is being asked to accept an assignment that would potentially cause the nurse to violate his/her duty to a patient, the nurse may be able to invoke “safe harbor,” depending on whether or not the nurse’s employer meets requirements that would make it mandatory for the employer to have a nursing peer review plan in place.  This is established Chapter 301, Nursing Practice Act; Chapter 303, Nursing Peer Review, and in 22 TAC §217.20, Safe Harbor Peer Review and Whistleblower Protections. Safe harbor has two effects related to the nurse’s license:

    1. it is a means by which a nurse can request a nursing peer review committee determination of a specific situation in relation to the nurse’s duty to a patient; and
    2. it affords the nurse immunity from Board action against the nurse’s license if the nurse invokes Safe Harbor in accordance with 22 TAC §217.20.  For the nurse to activate this immunity status, the nurse must notify the assigning supervisor at the time the assignment request is made, and the nurse must submit the required information in writing (or verbally if due to immediate patient care needs) to this supervisor, as specified in 22 TAC §217.20(d)(2)(B) & (3) or on the Board’s Safe Harbor Quick Request Form. Do not submit this form to the Board.

Links to related resources:

(Adopted 01/2005; Revised: 01/2006; 01/2007; 01/2009; 01/2011; 01/2014; 01/2015; 01/2017; 01/2018; 01/2019; 01/2021)
(Reviewed: 01/2008; 01/2010; 01/2012; 01/2013; 01/2016; 01/2020)

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15.7 The Role of LVNs & RNs in Management and/or Administration of Medications via Epidural or Intrathecal Catheter Routes

Role of the LVN

The LVN can provide basic nursing care to patients with epidural or intrathecal catheters. It is the opinion of the Board that the LVN shall not be responsible for the management of a patient's epidural or intrathecal catheter, including administration of any medications via either epidural or intrathecal catheter routes. Management of epidural or intrathecal catheters requires the mastery of complex nursing knowledge and skills that are beyond the competencies of the vocational nursing program or a continuing education course.

Role of the RN

The Board has determined that it may be within the scope of practice of a registered professional nurse to administer analgesic and anesthetic agents via the epidural or intrathecal routes for the purposes of pain control. As with all areas of nursing practice, the RN must apply the Nursing Practice Act (NPA) and Board Rules to the specific practice setting and must utilize good professional judgment in determining whether to engage in a given patient-care related activity.

The Board believes that only licensed anesthesia care providers, as described by the American Society of Anesthesiologists and the American Association of Nurse Anesthetists, as authorized by applicable laws, should perform insertion and verification of epidural or intrathecal catheter placement. Consistent with state law, the attending physician or the qualified provider must order the drugs, dosages, and concentrations of medications to be administered to the patient through the catheter. These interventions are beyond the scope of the registered professional nurse in that independent medical judgment and formal advanced education, skills and training are required to achieve and maintain competence in performing these procedures.

RNs who choose to engage in administration of properly ordered medications via the epidural or intrathecal routes must have documentation that the RN has participated in educational activities to gain and maintain the knowledge and skill necessary to safely administer and monitor patient responses, including the ability to:

  • Demonstrate knowledge of the anatomy, physiology, and pharmacology appropriate for administration of medications via the epidural or intrathecal routes;
  • Know the medication and medication concentrations approved for use for the specific type of pump;
  • Maintain awareness that certain medications are not U.S. Food & Drug Administration (FDA) approved for intrathecal administration (e.g., hydromorphone, bupivacaine, fentanyl, and clonidine);
  • Recognize that mixtures of two or more different kinds of medications and compounded medications are not FDA approved for intrathecal administration;
  • Anticipate and recognize potential complications of the analgesia relative to the type of infusion device and catheter used;
  • Recognize emergency situations and institute appropriate nursing interventions to stabilize the patient and prevent complications;
  • Implement appropriate nursing care of patients to include:
    • observation and monitoring of sedation levels and other patient parameters;
    • administration of medications and monitoring of effectiveness of medication, and catheter monitoring;
    • applicable teaching for both patients and their family/significant others related to expected patient outcomes/responses and possible side effects of the medication or treatment; and
    • maintenance of the knowledge and skill to remove catheters, when applicable.

Appropriate nursing policies and procedures that address the education and skills of the RN and nursing care of the patient should be developed to guide the RN in the administration of epidural and/or intrathecal medications. RNs and facilities should consider evidence-based practice guidelines put forth by professional specialty organizations(s), such as the American Association of Nurse Anesthetists and the American Society of Anesthesiologists, when developing appropriate guidance for the RN in a particular practice setting. For example, the Association of Women’s Health, Obstetric and Neonatal Nurses’ (AWHONN) has a clinical position statement on "Role of the Registered Nurse in the Care of the Pregnant Woman Receiving Analgesia and Anesthesia by Catheter Techniques." This nationally recognized practice guideline states that it is beyond the scope of practice of the obstetrical nurse to institute or change the rate of continuous infusions via epidural or intrathecal catheters. The American Association of Nurse Anesthetists has a similar position. Nurses should also be aware of FDA safety communications regarding intrathecal administration of pain medication.

The Board encourages the use of the BON’s Scope of Practice Decision-Making Model (DMM) . Finally, standing medical orders approved by the medical and/or anesthesia staff of the facility should include, but not necessarily be limited to, the following:

  • The purpose and goal of treatment;
  • The dosage range of medication to be administered, including the maximum dosage;
  • Intravenous access;
  • Treatment of respiratory depression and other side effects, including an order for a narcotic antagonist;
  • Options for inadequate pain control; and
  • Physician/CRNA availability and backup.
References

American Association of Nurse Anesthetists. (2017). Care of patients receiving analgesia by catheter techniques.  Retrieved from https://www.aana.com/docs/default-source/practice-aana-com-web-documents-(all)/care-of-patients-receiving-analgesia-by-catheter-techniques.pdf?sfvrsn=d30049b1_2

Association of Women’s Health, Obstetric, and Neonatal Nurses. (2020). Role of the registered nurse in the care of the pregnant woman receiving analgesia and anesthesia by catheter techniques. Retrieved from https://www.jognn.org/article/S0884-2175(20)30012-5/fulltext

US Food and Drug Administration. (2018). Implanted Pumps: Safety Communication—Use Caution When Selecting Pain Medicine for Intrathecal Administration. Retrieved from:
https://www.fda.gov/medical-devices/safety-communications/use-caution-implanted-pumps-intrathecal-administration-medicines-pain-management-fda-safety

(LVN role: BVNE 1994; Revised BON 01/2005)
(RN role: BON 06/1991; Revised: 01/2003; 01/2004; 01/2005; 01/2011; 01/2014; 01/2016; 01/2018; 01/2019; 01/2020; 01/2021)
(Reviewed: 01/2006; 01/2007; 01/2008; 01/2009; 01/2010; 01/2012; 01/2013; 01/2015; 01/2017)

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15.8 Role of the Nurse in Moderate Sedation

Note: This position statement is not intended to apply to:

    1. The practice of the registered nurse who holds licensure as an advanced practice registered nurse in the role and population focus of nurse anesthetist (CRNA) functioning within his/her authorized scope of practice;
    2. The registered nurse practicing in an acute care setting, such as critical care, where the patient in question is intubated, receiving mechanical ventilatory support, and continuously monitored by the patient care RN; or
    3. Adjunct or off label use of low dose agents for pain management or other indications.

Role of the LVN

The administration of pharmacologic agents via intravenous or other routes for the purpose of achieving moderate sedation requires mastery of complex nursing knowledge, advanced skills, and the ability to make independent nursing judgments during an unstable and unpredictable period for the patient.  It is the opinion of the Board that the one-year vocational nursing program does not provide the Licensed Vocational Nurse (LVN) with the educational foundation to assure patient safety for optimal anesthesia care inclusive of both the administration of pharmacologic agents intended to induce moderate sedation and/or assessment and monitoring of the patient receiving moderate (conscious) sedation.

In alignment with 22 TAC §217.11, Standards of Nursing Practice, Board Position Statement 15.27, The Licensed Vocational Nurse Scope of Practice, and Board Position Statement 15.10, Continuing Education: Limitations for Expanding Scope of Nursing Practice, the Board also maintains that continuing education that falls short of achieving licensure as a registered nurse would be insufficient to assure vocational nurse competency and patient safety with regard to both medication administration and patient monitoring associated with moderate sedation.

Though the Board cannot dictate physician practice, it is the Board’s position that a LVN cannot administer medications or monitor patients receiving moderate sedation as a delegated medical act.

Role of the RN or non-CRNA Advanced Practice Registered Nurse

Though optimal anesthesia care is best provided by qualified certified registered nurse anesthetists (CRNAs) or anesthesiologists, the Board recognizes that the demand in the practice setting necessitates provision of moderate sedation by registered nurses and non-CRNA advanced practice registered nurses in certain practice situations.

All licensed nurses practicing in Texas are required to “know and comply” with the Nursing Practice Act (NPA) and Board Rules. 22 TAC §217.11(1)(B) requires the nurse to “promote a safe environment for clients and others.” This standard establishes the nurse’s duty to the patient/client, which supersedes any physician order or any facility policy. This “duty” to the patient requires the nurse to use informed professional judgment when choosing to assist or engage in a given procedure. [See Position Statement 15.14, Duty of a Nurse in Any Practice Setting].

As the NPA and Board rules are not prescriptive to specific tasks a nurse may or may not perform, a RN or non-CRNA advanced practice registered nurse should consider evidence-based practice guidelines put forth by professional organizations with clinical expertise in the administration of pharmacologic agents used for sedation/anesthesia as well as advanced airway management and cardiovascular support.  A number of professional specialty organizations have well-defined standards and recommendations for ongoing nursing education and competency assessment related to administration and monitoring of patients receiving moderate sedation.

These organizations include the American Association of Nurse Anesthetists (AANA)1, the American Nurses Association (ANA)2, the Association of periOperative Registered Nurses (AORN)3, and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN).4 Statements published by the American Society of Anesthesiologists (ASA) also support the positions of the above nursing organizations.5  The Board advises the nurse use caution in applying moderate sedation standards of any individual or specialty group who are not also experts in the field of advanced airway management/anesthesia. The Board encourages the use of the BON’s Scope of Practice Decision-Making Model (DMM)

Employing institutions should develop policies and procedures to guide the RN or non-CRNA advanced practice registered nurse in administration of medications and patient monitoring associated with moderate sedation. Policies and procedures should include but not be limited to:

  • Performance of a pre-sedation health assessment by the individual ordering the sedation and the RN or non-CRNA advanced practice registered nurse administering the sedation;
  • Guidelines for patient monitoring, drug administration, and a plan for managing potential complications or emergency situations developed in accordance with currently accepted standards of practice;
  • Accessibility of emergency equipment and supplies;
  • Documentation and monitoring of the level of sedation and physiologic measurements (e.g. blood pressure, oxygen saturation, cardiac rate and rhythm); and
  • Documentation/evidence of initial education and training and ongoing competence of the RN or non-CRNA advanced practice registered nurse administering and/or monitoring patients receiving moderate sedation

Use of Specific Pharmacologic Agents

It is up to facilities and physicians to determine specific pharmacologic agents to be used to induce moderate sedation. The Board advises the RN or non-CRNA advanced practice registered nurse use caution, however, when deciding whether s/he has the competency to administer the specific pharmacologic agents ordered by the physician. What is within the scope of practice for one RN is not necessarily within the scope of practice for another RN. (See references to 22 TAC §217.11 & Scope of Practice Decision-Making Model (DMM) above). With regard to this issue, the Board recommends the RN also take into consideration:

  1. Availability of and knowledge regarding the administration of reversal agents for the pharmacologic agents used; and
  2. If reversal agents do not exist for the pharmacologic agents used or the criteria outlined in (1) above are not met, then the nurse must consider his/her individual knowledge, skills, and abilities to rescue a patient from un-intended deep sedation/anesthesia using advanced life support airway management equipment and techniques.

RNs or non-CRNA Advanced Practice Registered Nurses Administering Propofol, Ketamine, or Other Anesthetic Agents to Non-Intubated Patients

Of concern to the Board is the growing number of inquiries related to RNs and non-CRNA advanced practice registered nurses administering Propofol, Ketamine, or other drugs commonly used for anesthesia purposes to non-intubated patients for the purpose of moderate sedation in a variety of patient care settings. It is critical for any RN who chooses to engage in moderate sedation to appreciate the differences between moderate sedation and deep sedation/anesthesia.

Moderate Sedation versus Deep Sedation Anesthesia

According to the professional literature, "moderate sedation" is defined as a medication-induced, medically controlled state of depressed consciousness. Included in the literature from various professional organizations is the caveat that, while under moderate sedation, the patient at all times retains the ability to independently and continuously maintain a patent airway and cardiovascular function, and is able to respond meaningfully and purposefully to verbal commands, with or without light physical stimulation. Reflex withdrawal to physical stimulation is not considered a purposeful response. Loss of consciousness for patients undergoing moderate sedation should not be the goal and thus pharmacologic agents used should render this result unlikely. If the patient requires painful or repeated stimulation for arousal and/or airway maintenance, this is considered deep sedation.

In a state of deep sedation, the patient’s level of consciousness is depressed, and the patient is likely to require assistance to maintain a patent airway. Deep sedation occurring in a patient who is not appropriately monitored and/or who does not have appropriate airway support may result in a life-threatening emergency for the patient.  This is not consistent with the concept of moderate sedation as defined in this position statement or the professional literature and is generally considered to be beyond the scope of practice of the RN.

Although Propofol is classified as a sedative/hypnotic/anesthetic, according to the FDA product information, it is intended for use as an anesthetic agent or for maintaining sedation of an intubated, mechanically ventilated patient. The product information brochure for Propofol further includes a warning that “only persons trained to administer general anesthesia and not involved in the conduct of the surgical/diagnostic procedure should administer Propofol for purposes of general anesthesia or for monitored anesthesia care/sedation.” The clinical effects for patients receiving anesthetic agents such as Propofol may vary widely within a negligible dose range. Though reportedly “short-acting”, it is also noteworthy that there are no reversal agents for Propofol.

As the US Food and Drug Administration (FDA) approves computer-assisted personalized sedation systems, a nurse is encouraged to use the Scope of Practice Decision-Making Model (DMM) to reach a sound decision whether to engage in nursing practice utilizing such a device in accordance with the US FDA approval requirements. US FDA approval requirements for computer-assisted personalized sedation systems include requirements for completion of training in addition to safety requirements, such as the immediate availability of anesthesia providers. A nurse is required to complete training prior to using any computer-assisted personalized sedation system and is encouraged to retain proof of training.

The patient receiving anesthetic agents is at increased risk for loss of consciousness and/or normal protective reflexes, regardless of who is administering this medication. The loss of consciousness and/or protective reflexes may indicate progression into deep sedation and this is not consistent with the concept of moderate sedation outlined in the professional literature.

Though the RN or non-CRNA advanced practice registered nurse may have completed continuing education in advanced cardiac life support (ACLS) and practiced techniques during the training program, this process does not ensure ongoing expertise in airway management and emergency intubation. The American Heart Association (AHA)6 has identified factors that contribute to misplacement of the endotracheal tube during resuscitation including: “inadequate training, lack of experience” and patient characteristics such as physiology and movement. It is also important to note that no continuing education program, including ACLS programs, will ensure that the RN or non-CRNA advanced practice registered nurse has the knowledge, skills and abilities to rescue a patient from deep sedation or general anesthesia.  Furthermore, it is the joint position of the AANA and ASA that, “because sedation is a continuum, it is not always possible to predict how an individual patient will respond.”  These organizations state only qualified anesthesia providers who are trained in the administration of general anesthesia should administer anesthetic agents, including induction agents.

Therefore, it is the position of the Board that the administration of anesthetic agents (e.g. propofol, methohexital, ketamine, and etomidate) is outside the scope of practice for RNs and non-CRNA advanced practice registered nurses except in the following situations:

  • when assisting in the physical presence of a CRNA or anesthesiologist (the CRNA or anesthesiologist may direct the RN to administer anesthetic agents in conjunction with the CRNA or anesthesiologist intubating or otherwise managing the patient’s airway)
  • when administering these medications as part of a clinical experience within an advanced educational program of study that prepares the individual for licensure as a nurse anesthetist (i.e. when functioning as a student nurse anesthetist)
  • when administering these medications to patients who are intubated and mechanically ventilated in critical care settings
  • when assisting an individual with current competence in advanced airway management, including emergency intubation procedures
  • when utilizing a US FDA approved computer-assisted personalized sedation system in accordance with the US FDA approval requirements, where appropriate safety requirements are met (such as immediate availability of anesthesia providers) after completing appropriate training.

While the physician or other health care provider performing the procedure may possess the necessary knowledge, skills and abilities to rescue a patient from deep sedation and general anesthesia, it is not prudent to presume this physician will be able to leave the surgical site or abandon the procedure to assist in rescuing the patient.  In the case of an appropriately licensed practitioner performing a procedure that can be safely abandoned to rescue or intubate the patient, the RN may administer the anesthetic agent when directed. In this instance, the RN is responsible for accepting the assignment and for knowing the rationale, effects, and correctly administering the medication [22 TAC §217.11 (1)(T) & (1)(C)].

The Board again stresses that the nurse’s duty to assure patient safety [22 TAC §217.11(1)(B)] is an independent obligation under his/her professional licensure that supersedes any physician order or facility policy.7 It is important to note that the nurse’s duty to the patient obligates him/her to decline orders for medications or doses of medications that have the potential to cause the patient to reach a deeper level of sedation or anesthesia.  The nurse’s duty is outlined in detail in Board Position Statement 15.14, Duty of a Nurse In Any Practice Setting.

 

Recommended Reference Document:  The American Association of Nurse Anesthetists developed an informational advisory document in 2016 to guide policy development for the safe administration of procedural sedation by a non-anesthesia sedation team in a hospital, ambulatory surgical center, or office setting.1 The anesthetic agents Ketamine and Propofol are both mentioned within the document in the context of procedural sedation.

References

1 The American Association of Nurse Anesthetists. (2016). Non-anesthesia Provider Procedural Sedation and Analgesia: Policy Considerations. Retrieved from https://www.aana.com/docs/default-source/practice-aana-com-web-documents-(all)/non-anesthesia-provider-procedural-sedation-and-analgesia.pdf?sfvrsn=670049b1_

2 American Nurses Association. (2008). Procedural Sedation Consensus Statement. Retrieved from https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/procedural-sedation-consensus-statement

3 The Association of periOperative Registered Nurses. (2017). Patient Care Guidelines: Care of the Patient Receiving Moderate Sedation Analgesia. Retrieved from https://aornguidelines.org/guidelines/content?sectionid=173733727&view=book.

4 Association of Women's Health, Obstetric and Neonatal Nurses. (2020). Role of the registered nurse in the care of the pregnant woman receiving analgesia and anesthesia by catheter techniques. Retrieved from http://www.jognn.org/article/S0884-2175(20)30012-5/fulltext

5 American Association of Nurse Anesthetists and American Society of Anesthesiologists. (2013) AANA–ASA Joint Position Statement Regarding Propofol Administration. Retrieved fromhttps://www.aana.com/docs/default-source/practice-aana-com-web-documents-(all)/aana-asa-propofol-joint-ps.pdf?sfvrsn=f80049b1_2

6 American Heart Association (2020). American Heart Association CPR & ECC guidelines. Retrieved from https://eccguidelines.heart.org/circulation/cpr-ecc-guidelines/

7 Lunsford v. BNE,  648 S.W. 391, (Tex. App–Austin 1983)

Additional Resources

Texas Board of Nursing. (2012). Nurses on guard- best practices in patient safety: Off-label administration of Ketamine for pain management by a nurse. Texas Board of Nursing Bulletin, 43(4), 5-6.

Texas Board of Nursing. (2017). FAQ: Off Label Use of Medication.

(Board Action 01/1992; Revised: 01/2003; 01/2004; 01/2006; 01/2007; 01/2009; 01/2012; 01/2013; 01/2014; 01/2016; 01/2017; 01/2018; 01/2019; 01/2020; 01/2021)
(Reviewed: 01/2008; 01/2010; 01/2011; 01/2015)

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15.9 Performance of Laser Therapy by RNs or LVNs

The Board of Nursing (BON) recognizes that the use of laser therapy and the technology of laser use have changed rapidly since their introduction for medical purposes. Nurses fulfill many important roles in the use of laser therapies. These roles and functions change based upon the type of treatment and the setting in which the treatment occurs. It may be within the scope of nursing practice to perform the delivery of laser energy on a patient with a valid order providing the nurse has the education, experience, and knowledge to perform the assignment [22 TAC §217.11 (1) (T)]. RNs (including Advanced Practice Registered Nurses practicing within their educated role and population focus) or LVNs, with an appropriate clinical supervisor, who choose to administer laser therapy must know and comply with all applicable laws, rules, and regulations, as well as the Nursing Practice Act (NPA) and Rules of the BON [22 TAC §217.11 (1)(A)].

Additional criteria applicable to the nurse who elects to follow an appropriate order in the use of nonablative laser therapy (such as laser hair removal) include:

  1. Appropriate education related to use of laser technologies for medical purposes, including laser safety standards of the American National Standards Institute and FDA intended-use labeling parameters;
  2. The nurse’s education and skill assessment is documented in his/her personnel record;
  3. The procedure has been ordered by a currently licensed physician, podiatrist, or dentist or by an Advanced Practice Registered Nurse (APRN) or Physician Assistant working in collaboration with one of the aforementioned practitioners; and
  4. Appropriate medical, nursing, and support service back up is available, since remedies for untoward effects of laser therapy may go beyond the scope of practice of the nurse performing the procedure; and
  5. Specific regulations related to laser hair removal, including educational requirements for a certificate, may be accessed on the Texas Department of Licensing and Regulation website at  https://www.tdlr.texas.gov/las/lasrules.htm

Registered Nurses, including APRNs, cannot delegate any aspects of the use of lasers to unlicensed persons. The nurse is expected to comply with the Nursing Practice Act and Board’s Rules and regulations when carrying out any delegated medical act.

Additional regulations potentially applicable to laser use may include Texas Health and Safety Code, Chapter 401, Subchapter M and the Texas Medical Board Rule 193.17 related to Nonsurgical Medical Cosmetic Procedures.

An additional reference in relation to physician delegation: Position Statement 15.11, Delegated Medical Acts.

(Board Action, 05/1992)
(Revised: 11/1997; 01/2003; 04/2004; 01/2006; 01/2008; 01/2009; 01/2011; 04/2013; 01/2014; 01/2017; 01/2018)
(Reviewed: 01/2005; 01/2007; 01/2010; 01/2012; 01/2015; 01/2016; 01/2019; 01/2020; 01/2021)

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15.10 Continuing Education: Limitations for Expanding Scope of Practice

Foundation for Initial Licensure and/or APRN licensure

The Board’s Advisory Committee on Education states in its “Differentiated Essential Competencies (DECs)of Graduates of Texas Nursing Programs Evidenced by Knowledge, Clinical Judgements, and Behaviors, October 2010" that: “The curricula of each of the nursing programs differ, and the outcomes of the educational levels dictate a differentiated set of essential competencies of graduates.  The competencies of each educational level build upon the previous level.”  The National Council of State Boards of Nursing (NCSBN) develops and administers two national nurse licensure examinations; the National Council Licensure Examination for Practical Nurses (NCLEX-PN®) and the National Council Licensure Examination for Registered Nurses (NCLEX-RN®). These two examinations are used by all U.S. state and territorial boards of nursing to test entry-level nursing competence of candidates for licensure as Registered Nurses and as Licensed Practical/Vocational Nurses.

Licensure as an Advanced Practice Registered Nurse (APRN) in Texas requires completion of a master’s or postmaster’s advanced practice program, as well as national certification in the advanced role and population focus. To gain licensure as an APRN in Texas, the nurse must first be licensed as a RN in Texas or have privilege to practice in Texas using a valid, unencumbered RN multistate license from a compact state. The nurse must then submit an application to the Board for licensure in the advanced practice role and population focus.

Limitations of “Continuing Education”

The nursing shortage is creating ever-greater challenges for those who must fill nursing vacancies at all levels of licensure and in various specialties. As efforts to invent new ways to fill this growing void expand, the Board is receiving a growing number of calls to clarify the term “continuing education” in relation to how far a nurse can expand his/her practice with informal continuing education offerings.

The formal education for entry into nursing practice in Texas is differentiated between vocational and professional (registered) nursing. Formalized education for advanced practice also requires completion of a formal program of education in the advanced practice role and population focus at the master’s or postmaster’s level.

The Board believes that for a nurse to successfully make a transition from one level of nursing licensure to the next requires the completion of a formal program of education as defined in the applicable board rule [Board Rules 217.2 and 221.4]. The Board also believes that completion of on-going, informal continuing education offerings, such as workshops or online offerings in a specialty area, serve to expand and maintain the competency of the nurse at the current level of licensure. No amount of informal or on-the-job-training can qualify a LVN to perform the same level of care as the RN. Likewise, the RN cannot engage in aspects of care that require independent medical judgement in a given APRN role and population focus without the formal education, national certification, and proper licensure in that APRN role and population focus.

For example, a LVN with 10 years of home care experience cannot perform the comprehensive assessment and initiate the nursing care plan on a patient newly admitted to the services of a home care agency where the LVN is employed. This is precluded in both BON 22 TAC §217.11 as well as in the home care regulations.  Attending a workshop and/or spending time under the supervision of a RN does not qualify the LVN to engage in practice that is designated in statue or rule as being exclusive to the next level of licensure.

Therefore, any nurse, regardless of experience, who engages in nursing practice that would otherwise require a higher level of licensure or a APRN licensure type is practicing outside of his/her scope of practice and may be subject to disciplinary action congruent with the NPA and Rules applicable to LVNs, RNs, and/or RNs with APRN licensure in a given role and population focus. 

In summary, a nurse functions under his/her own nursing license and, as such, has a duty to patients that is separate from any employment relationship. In other words, a nurse's duty is to keep a patient safe and uphold the standards of nursing practice. A nurse never works under the license of another provider. The nurse must individually assess his/her own education, training, experience, knowledge, abilities, and employment setting policies to determine if the act or task is within his/her scope of practice, and take accountability for acceptance of the assignment and the resultant patient outcomes. 

(Adopted 01/2005; Revised: 01/2009; 01/2011; 01/2013; 01/2014; 01/2017; 01/2018; 01/2020)
(Reviewed: 01/2006; 01/2007; 01/2008; 01/2010; 01/2012; 01/2015; 01/2016; 01/2019; 01/2021)

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15.11 Delegated Medical Acts

In carrying out orders from physicians, podiatrists, or dentists for the administration of medications or treatments, nurses are usually engaged in the practice of vocational or professional nursing in accordance with the applicable licensure of the individual nurse. In carrying out some physician orders, however, LVNs or RNs may perform acts not usually considered to be within the scope of vocational or professional nursing practice, respectively. Such tasks are delegated and supervised by physicians, podiatrists, or dentists. RNs who lack licensure as advanced practice registered nurses in a specified role and population focus, and LVNs may not engage in "acts of medical diagnosis or prescription of therapeutic or corrective measures" [NPA, Section 301.002(2) and (5)] as these acts require independent medical judgment, which is beyond the scope of practice of the vocational or registered nurse.

In carrying out the delegated medical function, the nurse is expected to comply with the Standards of Nursing Practice just as if performing a nursing procedure. The Board's position is that a LVN or RN may carry out a delegated medical act if the following criteria are met:

  1. The nurse has received appropriate education and supervised practice, is competent to perform the procedure safely, and can respond appropriately to complications and/or untoward effects of the delegated medical act [refer to Standards in 22 TAC §217.11 (1)(C), (1)(G), (1)(M), (1)(N), (1)(R), and (1)(T)];
  2. The nurse’s education and skills assessment are documented in his/her personnel record;
  3. The nursing and medical staffs have collaborated in the development of written policies/procedures/practice guidelines for the delegated acts, these are available to nursing staff practicing in the facility, and the guidelines are reviewed annually, if applicable;
  4. The procedure has been ordered by an appropriate licensed practitioner; and
  5. Appropriate medical and nursing support is available.

The Board recognizes that nursing practice is dynamic and that acts which today may be considered delegated medical acts may in the future be considered within the scope of either vocational or professional nursing practice. The Board, therefore, advises nurses that they must comply with the Board's Standards of Nursing Practice and any other applicable regulations when carrying out nursing and/or delegated medical acts.

(Board Action 09/1993)
(Revised: 03/1994; 01/2001; 01/2003; 01/2004; 01/2005; 01/2011; 01/2014; 01/2017; 01/2018)
(Reviewed: 01/2006; 01/2007; 01/2008; 01/2009; 01/2010; 01/2012; 01/2013; 01/2015; 01/2016; 01/2019; 01/2020; 01/2021)

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15.12 Use of American Psychiatric Association Diagnoses by LVNS, RNs, or APRNs

The Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses are multi-disciplinary psychiatric diagnoses used for the purpose of applying objective criteria, establishing a practice framework and communicating findings with other health care professionals. The current version is the DSM-5 (Fifth Edition).

In accordance with the Nursing Practice Act (NPA), Section 301.002(2) and (5), acts of medical diagnosis or prescription of therapeutic or corrective measures are beyond the scope of practice for licensed vocational nurses as well as registered nurses who are not licensed in an appropriate advanced practice registered nurse (APRN) role and population focus.

The use of DSM-5 diagnoses by a registered nurse licensed by the Board as an APRN in the role and population focus of either a Clinical Nurse Specialist (CNS) in Psychiatric/Mental Health Nursing or as a Psychiatric/Mental Health Nurse Practitioner is authorized provided he/she is acting within the scope of his/her advanced practice role and population focus and that the diagnoses utilized are appropriate for the individual APRN’s advanced education, experience, and scope of practice. APRNs must utilize protocols or other written authorization when providing medical aspects of patient care in compliance with 22 TAC §221,Advanced Practice Nurses. When psychiatric patient conditions are identified that are outside the psychiatric mental health CNS'/NP's scope of practice or expertise, a referral to the appropriate psychiatric mental health or medical provider is indicated.

(Board Action: 09/1996)
(Revised: 01/2005; 01/2006; 01/2008; 01/2009; 01/2010; 01/2011; 01/2014; 01/2015; 01/2016; 01/2017; 01/2018)
(Reviewed: 01/2007; 01/2012; 01/2013; 01/2019; 01/2020; 01/2021)

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15.13 Role of LVNs and RNs in School Health

The Board of Nursing (BON of Board) recognizes the complexity of nursing in the school health setting and the need to protect the youth of Texas. Although students come to school with complex and diverse health care needs, they should be provided an education in the least restrictive environment. The BON recognizes that the school children of Texas have the right to receive safe, appropriate, and specialized health services that may be required to assure the child's inclusion in the school environment.

Registered Nurses in the School Setting

The Texas Education Agency defines a school nurse in 19 Texas Administrative Code (TAC) § 153.1022 (a) (1) (D) as “… an educator employed to provide full-time nursing and health care services and who meets all the requirements to practice as a registered nurse (RN) pursuant to the Nursing Practice Act and rules and regulations relating to professional nurse education, licensure, and practice and has been issued a license to practice professional nursing in Texas.” The BON believes that school nursing is a professional registered nursing (RN) specialty. School nursing requires comprehensive assessment skills to promote student health, prevent illness and intervene in accordance with the nursing care plan. The RN has the educational preparation and critical thinking skills as well as clinical expertise that are essential to nursing in the school setting. These activities involve the comprehensive assessment of the nursing/health care needs of the student, the development of a nursing plan of care, implementation of the plan, and evaluation of the outcomes. The provision of these services by the RN contributes directly to the students' education and to the successful outcome of the educational process. These essential components of professional nursing practice are the responsibility of the RN in compliance with 22 TAC §217.11(3)(A).

Vocational Nurses in the School Setting

The licensed vocational nurse (LVN) has a directed scope of practice under supervision of a registered nurse, advanced practice registered nurse, physician, physician assistant, podiatrist, or dentist. 1 The provision of nursing care when provided by an LVN in a school setting should be under the supervision of an RN. The RN, in compliance with the BON's Standards of Nursing Practice [22 TAC §217.11], assigns those aspects of care and activities to the LVN that are within the LVN's educational preparation and demonstrated competency to provide. The RN monitors, coordinates, and evaluates the provision of health services necessary to meet individual student health needs essential in achieving educational objectives.

When LVNs are utilized in the school setting and are supervised by the RN, the RN needs to consider how closely they can supervise the LVN and how the RN will direct, guide, and influence the outcome of the LVN’s performance4 and respond to any situations where the LVN needs onsite supervision.2

RN Delegation to Unlicensed Personnel

Due to the growing number of students entering the school system with special health care needs, the BON recognizes that not all health-related services can be provided by a RN or LVN. Therefore, the RN may delegate tasks in the school setting in compliance with the BON's Delegation Rules located in Chapters 224 and 225. School is considered an independent living environment as defined in Chapter 2253; however, acute or emergency situations in the school setting may be delegated in accordance with the rules in both Chapter 224 and Chapter 225. The RN may decide to delegate to an unlicensed person the emergency administration of medications or treatments. Examples include, but are not limited to, Epi-pens, Glucagon, Diastat, oxygen, metered dose inhalers or nebulizer treatments for the relief of acute respiratory symptoms, and the use of a hand held magnet to activate a vagus nerve stimulator to prevent or control seizure activity. All delegation of this nature must be in compliance with 22 TAC §224.6(4) in order to stabilize the child and prevent complications from delaying treatment. The decision to delegate a specific task is always at the discretion of the RN in accordance with 22 TAC §224.8(b)(1)(C) or 22 TAC §225.9(d). Additional delegation resources for RNs can be found in the School Nurse Delegation section of the Delegation Resource Packet of the BON website.

Other Laws Impacting School Health Care

In a school setting, the administration of medication may be assigned to an unlicensed person by the public school official in accordance with the Texas Education Code. The RN's obligation under 22 TAC §225.14 is to verify the training of the unlicensed person, verify the competency of the unlicensed person to perform the task safely, and provide adequate supervision. If the RN is unable to assure these criteria have been met, the RN must notify the public school official.

Summary

Given the complexity, the current number, and the future projections of increasing numbers of children entering the school system with complex nursing and health-related needs, the BON believes that the RN must establish an individualized nursing care plan for each child as applicable. The RN may be assisted by LVNs and unlicensed assistive personnel in the delivery of services to ensure the delivery of safe, effective health care to the school children of Texas.

References

1 Nursing Practice Act, TOC §301.353 and 22 TAC§ 217.11(2)

2 22 TAC§217.11(2)

3 22 TAC §225.4(9)

(Adopted 11/1996; Revised: 11/1997; 01/2003; 01/2005; 01/2008; 01/2009; 01/2011; 01/2013; 07/2013; 01/2016; 01/2018; 1/2019) (Reviewed: 01/2006; 01/2007; 01/2010; 01/2012; 01/2014; 01/2015; 01/2017; 01/2020; 01/2021)

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15.14 Duty of a Nurse in any Practice Setting

In a time when cost consciousness and a drive for increasing productivity have brought about the reorganization and restructuring of health care delivery systems, the effects of these new delivery systems on the safety of clients/patients have placed a greater burden on the licensed vocational nurse (LVN) and the registered professional nurse (RN) to consider the meaning of licensure and assurance of quality care that it provides.

In the interest of fulfilling its mission to protect the health, safety, and welfare of the people of Texas through the regulation of nurses, the Board of Nursing (Board or BON), through the Nursing Practice Act and Board Rules, emphasizes the nurse’s responsibility and duty to the client/patient to provide safe, effective nursing care.

Specifically, the following portions of the Board Rules and supporting documents underscore the duty and responsibilities of the LVN and/or the RN to the client/patient:

  • The Standards of Nursing Practice differentiate the roles of the LVN and the RN in accepting nursing care assignments, assuring a safe environment for patients, and obtaining instruction and supervision as needed (22 TAC §217.11); and
  • In Lunsford v. Board of Nurse Examiners, 648 S.W. 2d 391 (Tex. App.--Austin, 1983), the court in affirming the disciplinary action of the Board, held that a nurse has a duty to the patient which cannot be superseded by hospital policy or physician's order.
    • This landmark case involved a gentleman who arrived to a rural hospital via private vehicle. The gentleman was experiencing severe chest pain, nausea, and sweating—all hallmark symptoms of myocardial infarction (heart attack). Nurse Lunsford was summoned to the ER waiting room by this gentleman’s friend. Upon seeing the acute distress the man was experiencing and hearing his symptoms, she instructed his friend to drive the man to the nearest facility equipped to handle heart attack victims. This facility was 24 miles away. The man succumbed to the heart attack 5 miles away from the small hospital.
    • When the Board sought to sanction the nurse’s license, the nurse maintained that the ER physician (who never saw the man) told her the man needed to be transported to the larger facility. The facility policy was also to transfer patients experiencing heart attacks (via ambulance) to the larger facility that was equipped to provide the broad range of therapies that might be needed.
    • The court sided with the BON and agreed that the nurse had the knowledge, skills and abilities to recognize the life-threatening nature of the man’s symptoms. Because of this knowledge, the court maintained that it was the nurse’s duty to act in the best interest of the client by assessing the man, taking measures to stabilize him and to prevent complications, and communicating his condition to other staff (such as the physician) to enlist appropriate medical care.
  • The Board’s Disciplinary Sanction Policies discuss expectations of all nurses regarding behaviors that are consistent with the Board’s rules 22 TAC §§213.27-213.29. These policies explain the client’s vulnerability and the nurse’s “power” differential over the client by virtue of the client’s status (with regard to age, illness, mental infirmity, etc.) and by the nature of the nurse client relationship (where the client typically defers decisions to the nurse, and relies on the nurse to protect the client from harm).
  • The delegation rules guide the RN in delegation of tasks to unlicensed assistive personnel who are utilized to enhance the contribution of the RN to the client's/patient's wellbeing. When performing nursing tasks, the unlicensed person cannot function independently and functions only under the RN's delegation and supervision. Through delegation, the RN retains responsibility and accountability for care rendered (22 TAC Chapters 224 and 225). The Board may take disciplinary action against the license of a RN or RN administrator for inappropriate delegation.
  • RNs with advanced practice licensure from the Board must comply with the same rules applicable to other RNs. In addition, rules specific to advanced practice nursing Chapters 221 & 222, as well as laws applicable to the APRN’s practice setting that are outside of the BON’s jurisdiction must also be followed.
  • Each nurse must be able to support how his/her clinical judgments and nursing actions are aligned with the NPA and Board Rules. The Board recommends nurses use the Scope of Practice Decision-Making Model (DMM) when trying to determine if a given task is within the individual nurse’s abilities. Congruence with standards adopted by national nursing specialty organizations may further serve to enhance and support the nurse’s decision to perform a particular task.

The nurse, by virtue of a rigorous process of education and examination leading to either LVN or RN licensure, is accountable to the Board to assure that nursing care meets standards of safety and effectiveness.

Therefore, it is the position of the Board that each licensed nurse upholds his/her duty to maintain client safety by practicing within the parameters of the NPA and Board Rules as they apply to each licensee.

Position Statement 15.14 - Duty of a Nurse - DADS QMP poster 

(Adopted 01/2005; Revised: 01/2007; 01/2009; 01/2014; 01/2018)
(Reviewed: 01/2006; 01/2008; 01/2010; 01/2011; 01/2012; 01/2013; 01/2015; 01/2016; 01/2017; 01/2019; 01/2020; 01/2021)

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15.15 Board's Jurisdiction Over a Nurse's Practice in Any Role and Use of the Nursing Title

An individual who holds licensure as a licensed vocational nurse (LVN) or as a registered professional nurse (RN) or as an advanced practice registered nurse (APRN) in Texas is responsible and accountable to adhere to the Nursing Practice Act and Board Rules which have the force of law with regard to licensed nursing practice in the state of Texas. Standards of Nursing Practice [22 TAC§217.11(1)(T)] require that each nurse practice within the level of his/her educational preparation, experience, knowledge, and physical and emotional ability. The Standards of Nursing Practice establish the nurse’s duty to the client. This “duty” requires the nurse to intervene appropriately to protect and promote the health and wellbeing of the client or others for whom the nurse is responsible [22 TAC§217.11(1)(B)].

RNs or LVNs Functioning in Unlicensed Positions/Nurse Functioning in another Role

The Nursing Practice Act (NPA) and Board Rules do not preclude a LVN or RN, including a RN/APRN, from seeking employment in unlicensed or technical positions, or in roles the nurse has the knowledge, education, experience, and a valid certificate or license to perform. However, a nurse, who is also licensed by another state agency, is required to comply with the NPA and Board Rules for any acts that are also within the scope of nursing practice [Tex. Occ. Code Ann. § 301.004 (a) (5)]. The Board holds a licensed registered professional nurse, who is working in an unlicensed or technical position, or other role, responsible and accountable to the level of education and competency of a RN. Likewise, a LVN working as an unlicensed or technical person, or in another role, is responsible and accountable to the educational preparation and knowledge of a LVN. This expectation does not apply to individuals formerly licensed as LVNs or RNs or APRNs whose nursing license has been retired, placed on inactive status, surrendered, or revoked.

Use of the Title “LVN” or "RN" when Providing Related Services

The use of the titles “Licensed Vocational Nurse,” or “LVN,” or "Registered Nurse," “RN,” or any designation tending to imply that one is a licensed nurse is limited to those individuals appropriately licensed by the Board. The use of titles implying that an individual holds licensure as a nurse in the State of Texas is restricted by law (Tex. Occ. Code Ann. § 301.351, and Board Rule, 22 Tex. Admin. Code § 217.10). A RN is not automatically a LVN and may not use the title LVN unless the RN also holds an active LVN license. The dually licensed RN/LVN will be held to the standards of the RN license even when working as an LVN. The dually licensed RN/APRN will be held to the nursing standards applicable to the APRN role and population focus when working as an RN in that role and population focus. Use of any protected nursing title by an individual who is not licensed to practice either licensed vocational nursing or professional nursing in accordance with the licensing requirements in Texas, or who does not hold a valid compact license to practice nursing poses a potential threat to public safety related to this act of deception and misrepresentation to the public who may be seeking the services of a licensed nurse.

In the opinion of the Board, the expressed or implied use of the title “LVN,” or "RN," or any other title that implies nursing licensure requires compliance with the NPA and Board Rules. As stated in Rule 217.11(1)(A), the nurse is accountable to adhere to any state, local, or federal laws impacting the nurse’s area of practice.

(Board Action 09/1998)
(Revised: 01/2001; 01/2003; 01/2004; 01/2005; 01/2008; 01/2013; 01/2014; 01/2018)
(Reviewed: 01/2006; 01/2007; 01/2009; 01/2010; 01/2011; 01/2012; 01/2015; 01/2016; 01/2017; 01/2019; 01/2020; 01/2021)

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15.16 Development of Nursing Education Programs

Approval of nursing education programs is one of the primary functions of the Texas Board of Nursing (Board or BON) in fulfilling its mission to protect and promote the welfare of the people of Texas. The Texas BON has the responsibility and legal authority to decide whether a proposed new nursing education program meets the Board’s established minimum standards for education programs. These standards require adequate human, fiscal, and physical resources, including qualified nursing faculty and clinical learning facilities, to initiate and sustain a program that prepares graduates to practice competently and safely as nurses.

The Texas BON recognizes that when health care facilities experience difficulties in recruiting and retaining sufficient nurses, education institutions and facilities within the affected geographical region frequently respond to this workforce need by proposing new nursing education programs. 

Guidelines for Establishing a New Vocational or Professional Nursing Education Program

Entities desiring to start a nursing education program that are not approved as a school/college, must establish a school/college identity and be approved by the Texas Workforce Commission (TWC) as a career school or college (proprietary school) prior to seeking approval for the proposed nursing education program.

All new pre-licensure vocational and professional nursing education programs in Texas must be approved/licensed by either the TWC or the Texas Higher Education Coordinating Board (THECB), as applicable, unless deemed exempt from approval/licensing by the TWC or the THECB; and must also be approved by the Texas BON before enrolling students in the program.  A new nursing education program that is deemed exempt from approval/licensing by the TWC or THECB, must still be approved by the Texas BON before enrolling students in the program.

Process for Proposal Approval/Denial

A proposal to establish a new vocational nursing education program or a new professional nursing education program must follow Texas BON Rules & Regulations in Chapter 214 for Vocational Nursing Education or Chapter 215 for Professional Nursing Education.  The entity seeking to establish the new program must have the appropriate accreditation/approval and the proposal must be prepared by an individual qualified and designated as the proposed program director. The proposal should include, but not be limited to, extensive rationale which supports establishing the new program with demographic and community data, employment needs for nurses in the area, evidence of support from stakeholders, established agreements with clinical affiliating agencies, adequate qualified nursing administrator and faculty to begin the program, and an acceptable curriculum as identified in the guidelines.  The Texas BON Education Guidelines for developing a proposal to establish a new program and a New Proposal Resource Packet are available on the Texas BON web site under the Nursing Education link.  An initial approval fee shall be submitted with the proposal [Rule 223.1(a)(9)].

The process for proposal approval/denial begins when the Board staff receives a letter of intent or an initial proposal from the school/college.  A program is allowed up to one year from the date of receipt of the proposal in the Board office to finalize all aspects of the proposal for presentation to the Board.  The actual length of time until Board approval depends upon the completeness of the proposal and compliance with Board standards. A timeline is included in the Resource Packet.  The proposed director should attend at least one Informal Information Session for Proposal Development.  The Informal Information Session is provided by board staff several times each year. Representatives from the institution should also attend at least one regularly scheduled Board meeting in order to gain familiarity with Board proceedings.

After the proposal is determined to be ready to be presented to the Board, a preliminary survey visit will be conducted by board staff.  The equipment and educational spaces in the physical facility should be ready for the program to begin at this time.

A public hearing will be held at the Board meeting prior to the Board’s discussion of the proposal and the Board’s decision. The Board may approve the proposal and grant initial approval to the new program, may defer action on the proposal, or may deny further consideration of the proposal.

(Board Action 07/2000)
(Revised: 01/2004; 01/2005; 01/2006; 01/2008; 10/2008; 01/2011; 01/2013; 01/2017; 01/2018)
(Reviewed: 01/2007; 01/2009; 01/2010; 01/2012; 01/2014; 01/2015; 01/2016; 01/2019; 01/2020; 01/2021)

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15.17 Texas Board of Nursing/Board of Pharmacy, Joint Position Statement, Medication Errors

Medication errors occur when a drug has been inappropriately prescribed, dispensed, or administered. Medication errors are a multifaceted problem that may occur in any health care setting. Consistent with their common mission to promote and protect the welfare of the people of Texas, the Board of Nursing and the Board of Pharmacy issued this joint statement for the purpose of increasing awareness of some of the factors which contribute to medication errors.

The Boards note that there are numerous publications available which examine the many facets of this problem, and agree that all elements must be examined in order to identify and successfully correct the problem. This position paper has been jointly developed because the Boards acknowledge the interdisciplinary nature of medication errors and the variety of settings in which these errors may occur. These settings may include hospitals, community pharmacies, doctors' offices/clinics, long-term care facilities, clients' homes, and other locations.

Traditionally, medication errors have been attributed to the individual practitioner. However, reports such as the Institute of Medicine's 1999 report entitled "To Err Is Human: Building a Safer Health System," suggest the majority of medical errors do not result from individual recklessness, but from basic flaws in the way the health system is organized. It is the joint position of the Boards that a comprehensive and varied approach is necessary to reduce the occurrence of errors. The Boards agree that a comprehensive approach includes three major elements: (1) the individual professional's knowledge of practice; (2) resources available to the professional; and (3) systems designs, problems and failures. Each of these three elements of this comprehensive approach are discussed below.

Professional competence has long been targeted as a source of health care professional errors. To reduce the probability of errors, all professionals must accept only those assignments for which they have the appropriate education and which they can safely perform. Professionals must continually expand their knowledge and remain current in their specialty, as well as be alerted to new medications, technologies and procedures in their work settings. Professionals must be able to identify when they need assistance, and then seek appropriate instruction and clarification. Professionals should evaluate strengths and weaknesses in their practice and strive to improve performance. This ultimate accountability on the part of individual practitioners is a critical element in reducing the incidence of medication errors.

The second element (resources available to all professionals) centers on the concept of teamwork and the work environment. The team should be defined as all health care personnel within any setting. Health care professionals must not be reluctant to seek out and utilize each other as resources. This is especially important for the new professional and/or the professional in transition. Taking the time to learn about the resources available in any practice setting is the individual professional's responsibility, and can help decrease the occurrence of medication errors. Adequate staffing and availability of experienced professionals are key factors in the delivery of safe effective medication therapy. In addition, health care organizations have the responsibility to develop complete and thorough orientation for all employees, maintain adequate and updated policies and procedures as guidelines for practice, and offer relevant opportunities for continuing staff development.

Analysis of the third element (systems designs, problems and failures) may demand creative and/or innovative thinking specific to each setting as well as a commitment to guarantee client safety. Systems which may have been in place for a long period of time may need to be re-examined for effectiveness. New information and technological advances must always be taken into account, and input should be solicited from all professionals. In addition, the system should contain a comprehensive quality program for the purpose of detecting and preventing problems and failures. The quality program must encourage all health care professionals to be alert for problems encountered in their daily tasks and to advocate for changes when necessary. In addition, the quality program should include a method of reporting all errors and problems within the system, a system for tracking and analysis of the errors, and an interdisciplinary review of the incident(s). Eliminating systems problems is vital in promoting optimal performance. The table on the following page, while not an exhaustive list, specifies areas that can be reviewed when medication errors occur. These areas encompass all three of the aforementioned contributing elements to the problem of medication errors and can be applied to individuals or systems. Communication is a common thread basic to all of these factors. Effective verbal or written communication is fundamental to successfully resolving breakdowns, either individual or system wide, that frequently contribute to medication errors.

The Boards agree that health care regulatory entities must remain focused on public safety. It is imperative that laws and rules are relevant to today's practice environment and that appropriate mechanisms are in place to address medication errors. The complex nature of the problem requires that there be a comprehensive approach to reducing these errors. It is vital to the public welfare that medication errors be identified, addressed, and reduced.

To view and print the Table: Factors Contributing to Medication Errors in PDF format, click here.


Diagram showing factors contributing to medication errors
References

Institute of Medicine. (1999). To err is human: Building a safer health system.  Washington, D.C.: National Academy Press.

Joint Commission on Accreditation of Healthcare Organizations. (1999, November 19). High-alert medications and patient safety. Sentinel Event Alert, 11, [On-line]. Retrieved from  https://www.jointcommission.org/assets/1/18/SEA_11.pdf

Leape, L. L. (1994). Error in medicine. Journal of the American Medical Association, 272(23), 1851-1857.

Nursing Practice Act, TOC Chapters 301 and 303. Texas Pharmacy Act.

TOC, Chapters 551 - 566.

(Board Action 10/2000; 01/2017; 01/2018) (Reviewed: 01/2005; 01/2006; 01/2007; 01/2008; 01/2009; 01/2010; 01/2011; 01/2012; 01/2013; 01/2014; 01/2015; 01/2016; 01/2019; 01/2020; 01/2021)

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15.18 Nurses Carrying out Orders from Advanced Practice Registered Nurses

Advanced practice registered nurses (APRNs) are registered nurses who hold licensure from the Texas Board of Nursing to practice as advanced practice registered nurses based on completion of an advanced educational program acceptable to the Board. The term includes a nurse practitioner, nurse-midwife, nurse anesthetist, and a clinical nurse specialist. The advanced practice registered nurse is prepared to practice in an expanded role to provide health care to individuals, families, and/or groups in a variety of settings, including, but not limited to, homes, hospitals, institutions, offices, industry, schools, community agencies, public and private clinics, and private practice. The advanced practice registered nurse acts independently, under the delegated authority of a physician and/or in collaboration with other health care professionals in the delivery of health care services. Advanced practice registered nurses utilize mechanisms, including Protocols, prescriptive authority agreements, or other written authorization, that provide them with the authority to provide medical aspects of care, including the ordering of dangerous drugs, controlled substances, or devices that bear or are required to bear the legend: "Caution: federal law prohibits dispensing without a prescription" or "RX only" or any other legend that complies with federal law.  The Protocols, prescriptive authority agreements, or other written authorization may vary in complexity based on the educational preparation and advanced practice experience of the individual advanced practice registered nurse. Protocols, prescriptive authority agreements, or other written authorization are not required to describe the exact steps that an advanced practice registered nurse must take with respect to each specific condition, disease, or symptom. Protocols, prescriptive authority agreements, or other written authorizations are not required for nursing aspects of care.

The Board recognizes that in many settings, nurses and advanced practice registered nurses work together in a collegial relationship. A nurse may carry out an advanced practice registered nurse’s order in the management of a patient, including, but not limited to, the administration of treatments, orders for laboratory or diagnostic testing, or medication orders. A physician is not required to be physically present at the location where the advanced practice registered nurse is providing care. The order is not required to be countersigned by the physician. The advanced practice registered nurse must function within the accepted scope of practice of the role and population focus in which he/she has been licensed by the Board.

As with any order, the nurse must seek clarification if he/she believes the order is inappropriate, inaccurate, non-efficacious or contraindicated by consulting with the advanced practice registered nurse or the physician as appropriate. The nurse carrying out an order from an advanced practice registered nurse is responsible and accountable for his/her actions just as he/she would be with any physician order.

(Board Action: 01/2001)
(Revised: 01/2005; 01/2009; 01/2012; 01/2014; 01/2018)
(Reviewed: 01/2006; 01/2007; 01/2008; 01/2010; 01/2011; 01/2013; 01/2015; 01/2016; 01/2017; 01/2019; 01/2020; 01/2021)

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15.19 Nurses Carrying out Orders from Pharmacists for Drug Therapy Management

In response to Senate Bill 659 enacted in 1995 during the 74th Legislative Session, the Texas State Board of Pharmacy and the Texas Medical Board (TMB) entered into a joint rule-making effort to delineate the processes by which a pharmacist could engage in drug therapy management (DTM) as delegated by a physician. The result of this joint effort was the adoption of rules by both the Pharmacy Board [22 TAC §295.13, 1997], and the Texas Medical Board [22 TAC §193.7, 1999]. The TMB amended its rules subsequent to the adoption of §157.101 Delegation to Pharmacist, in the Medical Practice Act during the 76th Legislative Session (1999).

According to definitions listed in the Pharmacy Act [Tex. Occ. Code Ann. §551.003], the “Practice of Pharmacy" includes "(F) performing for a patient a specific act of drug therapy management delegated to a pharmacist by a written protocol from a physician licensed in this state in compliance with Subtitle B." The Pharmacy rules further define DTM as ""the performance of specific acts by pharmacists as authorized by a physician through written protocol. Drug therapy management does not include the selection of drug products not prescribed by the physician, unless the drug product is named in the physician initiated protocol or the physician initiated record of deviation from a standing protocol. Drug therapy management may include the following:

    (A) collecting and reviewing patient drug use histories;

   (B) ordering or performing routine drug therapy related patient assessment procedures including temperature, pulse, and respiration;

    (C) ordering drug therapy related laboratory tests;

    (D) implementing or modifying drug therapy following diagnosis, initial patient assessment, and ordering of drug therapy by a physician as detailed in the protocol; or 

    (E) any other drug therapy related act delegated by a physician” [22 TAC §295.13(b)(4)].

Rule 295.13(b)(6) further adds the clarification that a written protocol is

a physician’s order, standing medical order, standing delegation order, or other order or protocol as defined by rule of the Texas Medical Board under the Medical Practice Act.

   (A) A written protocol must contain at a minimum the following:

      (i) a statement identifying the individual physician authorized to prescribe drugs and responsible for the delegation of drug therapy management;

      (ii) a statement identifying the individual pharmacist authorized to dispense drugs and to engage in drug therapy management as delegated by the physician;

      (iii) a statement identifying the types of drug therapy management decisions that the pharmacist is authorized to make which shall include:

           (I) a statement of the ailments or diseases involved, drugs, and types of drug therapy management authorized; and

          (II) a specific statement of the procedures, decision criteria, or plan the pharmacist shall follow when exercising drug therapy management authority;

      (iv) a statement of the activities the pharmacist shall follow in the course of exercising drug therapy management authority, including the method for documenting decisions made and a plan for communication or feedback to the authorizing physician concerning specific decisions made. Documentation shall be recorded within a reasonable time of each intervention and may be performed on the patient medication record, patient medical chart, or in a separate log book; and

      (v) a statement that describes appropriate mechanisms and time schedule for the pharmacist to report to the physician monitoring the pharmacist's exercise of delegated drug therapy management and the results of the drug therapy management.

   (B) A standard protocol may be used or the attending physician may develop a drug therapy management protocol for the individual patient. If a standard protocol is used, the physician shall record what deviations, if any, from the standard protocol are ordered for that patient.

The TMB Rule [22 TAC §193.15] reflects similar language to the Pharmacy Board rules.

Nurses frequently communicate and collaborate with both the client’s physician and the pharmacist in providing optimal care to clients. It is, therefore, the Board’s position that a nurse may carry out orders written by a pharmacist for DTM provided the order originates from a written protocol authorized by a physician. Any nurse carrying out DTM orders from a pharmacist may wish to review the TMB Rule193, Physician Delegation, in its entirety. The components of the rule related to physician delegation for a pharmacist to engage in DTM are set forth in §193.15(e) as follows:

  1. A written protocol must contain at a minimum the following listed in subparagraphs (A)-(E) of this paragraph:
    1. a statement identifying the individual physician authorized to prescribe drugs and responsible for the delegation of drug therapy management;
    2. a statement identifying the individual pharmacist authorized to dispense drugs and to engage in drug therapy management as delegated by the physician;
    3. a statement identifying the types of drug therapy management decisions that the pharmacist is authorized to make which shall include:
      1. a statement of the ailments or diseases, drugs, and type of drug therapy management authorized; and
      2. a specific statement of the procedures, decision criteria, or plan the pharmacist shall follow when exercising drug therapy management authority;
    4. a statement of the activities the pharmacist shall follow in the course of exercising drug therapy management authority, including the method for documenting decisions made and a plan for communication or feedback to the authorizing physician concerning specific decisions made. Documentation shall be recorded within a reasonable time of each intervention and may be performed on the patient medication record, patient medical chart, or in a separate log book; and
    5. a statement that describes appropriate mechanisms and time schedule for the pharmacist to report to the physician monitoring the pharmacist’s exercise of delegated drug therapy management and the results of the drug therapy management.
  2. A standard protocol may be used, or the attending physician may develop a drug therapy management protocol for the individual patient. If a standard protocol is used, the physician shall record, what deviations if any, from the standard protocol are ordered for that patient [22 TAC §193.15(e)].

The protocol under which a pharmacist initiates DTM orders for a patient should be available to the nurse at the facility, agency, or organization in which it is carried out. As with any order, the nurse must seek clarification if he/she believes the order is inappropriate, inaccurate, non-efficacious, or contraindicated by contacting the pharmacist and/or the physician who authorized the DTM protocol as appropriate [22 TAC §217.11(1)(N)]. The nurse carrying out an order for DTM written by a pharmacist is responsible and accountable for his/her actions just as he/she would be with any physician order.

(Board Action 01/2002; Revised: 01/2005; 01/2006; 01/2007; 01/2011; 01/2014; 01/2017; 01/2018; 01/2020)
(Reviewed: 01/2008; 01/2009; 01/2010; 01/2012; 01/2013; 01/2015; 01/2016; 01/2019; 01/2021)

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15.20 Registered Nurses in the Management of an Unwitnessed Arrest in a Resident in a Long Term Care Facility

The Texas Board of Nursing (BON) has approved this position statement, only applicable to long term care settings, in an effort to provide guidance to registered nurses (RNs) in long-term care facilities and to clarify issues of compassionate end-of-life care. In 2002, The Texas Nurses Association (TNA) through its Long Term Care (LTC) Committee identified that RNs were concerned about the inappropriate initiation of cardiopulmonary resuscitation (CPR) when a resident without a "do-not-resuscitate" order (DNR) experiences unwitnessed arrest. There is a growing sentiment on the part of the long-term care nurse community that the initiation of CPR would appear futile and inappropriate given the nursing assessment of the resident.

The nursing community generally considers that initiation of CPR in such cases is not compassionate, and is not consistent with standards requiring the use of a systematic approach to provide individualized, goal directed nursing care [BON Standards of Nursing Practice, 22 TAC §217.11(3)]. This position statement is intended to provide guidance for RNs in the management of an unwitnessed resident arrest without a DNR order in a long-term care (LTC) setting. This position statement also addresses the related issues of:

  • Obligation (or duty) of the RN to the resident;
  • Expectation of supportive policies and procedures in LTC facilities; and
  • The RN role in pronouncement of death.

These related issues are addressed in this position statement because the BON is often required to investigate cases of death where it appears there is a lack of clarity about a RN's obligation when there is no DNR order. The BON will evaluate cases involving the failure of a RN to initiate CPR in the absence of a DNR based on the following premise:

A DNR is a medical order that must be given by a physician and in the absence thereof, it is generally outside the standard of nursing practice to determine that CPR will not be initiated.

However, there may be instances when LTC residents without a DNR order experience an unwitnessed arrest, and it is clear according to the comprehensive nursing assessment that CPR intervention would be a futile and inappropriate intervention given the condition of the resident. In the case of an unwitnessed resident arrest without DNR orders, determination of the appropriateness of CPR initiation should be undertaken by the RN through an assessment of the resident, and interventions appropriate to the findings should be initiated.

Assessment of death in which CPR would be a futile and inappropriate intervention requires that all seven of the following signs be present and that the arrest is unwitnessed:

Presumptive Signs of Death

    1. The resident is unresponsive;
    2. The resident has no respirations;
    3. The resident has no pulse;
    4. The resident's pupils are fixed and dilated;
    5. The resident's body temperature indicates hypothermia: skin is cold relative to the resident’s baseline skin temperature;
    6. The resident has generalized cyanosis; and

Conclusive Sign of Death

    1. There is presence of livor mortis (venous pooling of blood in dependent body parts causing purple discoloration of the skin).

There may be other circumstances and assessment findings that could influence a decision on the part of the RN not to initiate CPR. However, evaluation of the prudence of such a decision would occur on a case-by-case basis by the BON.

Documentation

After assessment of the resident is completed and appropriate interventions are taken, documentation of the circumstances and the assessment of the resident in the resident's medical record is required. The rules of the BON establish legal documentation standards, [BON Standards of Nursing Practice, 22 TAC §217.11 (1)(D)]. Examples of important documentation elements include:

  • Description of the discovery of the resident
  • Any treatment of the resident that was undertaken
  • The findings for each of the assessment elements outlined in the standards
  • All individuals notified of the resident's status (e.g., 9-1-1, the health care provider, the administrator of the facility, family, coroner, etc.)
  • Any directions that were provided to staff or others during the assessment and/or treatment of the resident
  • The results of any communications
  • Presence or absence of witnesses

Documentation should be adequate to give a clear picture of the situation and all of the actions that were taken or not taken on behalf of the resident.

Even if the RN's decision not to initiate CPR was appropriate, failure to accurately and completely document can result in an action against a nurse's license by the BON. Furthermore, lack of documentation places the nurse at a disadvantage should the nurse be required to explain the circumstances of the resident's death. RNs should be aware that actions documented at the time of death provide a more credible and accurate clinical description. Documentation that is absent, incomplete or inaccurate reveals gaps in care, requiring the nurse to prove actions not appropriately documented were actually taken. As stated in Position Statement 15.2, The Role of the Licensed Vocational Nurse in the Pronouncement of Death, it is beyond the scope of practice of the LVN to legally determine death, diagnose death, or otherwise pronounce death in the State of Texas. Therefore, the LVN cannot make a determination to withhold CPR.

Obligation (“Duty”) of the Nurse to the Resident

Whether CPR is initiated or not, it is important for the nurse to understand that the nurse may be held accountable if the nurse failed to meet standards of care to assure the safety of the resident, prior to the arrest such as:

  • Failure to monitor the resident's physiologic status;
  • Failure to document changes in the resident's status and to adjust the plan of care based on the resident assessment;
  • Failure to implement appropriate interventions which might be required to stabilize a client's condition such as: reporting changes in the resident's status to the resident's primary care provider and obtaining appropriate orders; and/or
  • Failure to implement procedures or protocols that could reasonably be expected to improve the resident's outcome.

Care Planning and Advanced Directives

Proactive policies and procedures, that acknowledge the importance of care planning with the inclusion of advanced directives, are also important. Evidence indicates that establishing the resident's wishes at the end of life and careful care planning prevents confusion on the part of nursing staff and assures that the resident's and family's wishes in all aspects of end of life care are properly managed.

The admission process to long-term care facilities in Texas requires that residents be provided information on self-determination and given the option to request that no resuscitation efforts be made in the event of cardiac and/or respiratory arrest. Facilities are required to have policies and adequate resources to assure that every resident and resident's family upon admission to a long term care facility not only receive such information, but have sufficient support to make an informed decision about end of life issues.

It is further expected that advanced care planning is an ongoing component of every resident's care and that the nursing staff should know the status of such planning for each resident.

The Board recognizes that end of life decisions on the part of residents and families can be difficult. However, the Board believes that principled and ethical discussion about CPR with the resident and family, is an essential element of the resident care plan.

RN Role in Pronouncement of Death

Texas law provides for RN pronouncement of death [Health & Safety Code §§ 671.001-.002]. The law requires that in order for an RN to pronounce death, the facility must have a written policy that is jointly developed and approved by the medical staff or medical consultant and the nursing staff specifying under what circumstances an RN can make a pronouncement of death.

It is important that nurses understand that the assessment that death has occurred and that CPR is not an appropriate intervention are not equivalent to the pronouncement of death. Texas statutory law governs who can pronounce death, and only someone legally authorized to pronounce death may do so. If the RN does not have the authority to pronounce death, upon assessment of death the RN must notify a person legally authorized to pronounce death.

Conclusion

This position statement is intended to guide RNs in long-term care facilities who encounter an unwitnessed resident arrest without a DNR order. It is hoped that by clarifying the responsibility of the RN, and using supportive facility policies and procedures, registered nurses will be better able to provide compassionate end of life care.

Qualifier to Position Statement

The BON evaluates "failure to initiate CPR cases" based on the premise that in the absence of a physician's DNR order it is generally outside the standard of nursing practice not to initiate CPR. Consequently, RNs who decide not to initiate CPR must assure themselves that not initiating CPR complies with their respective standards of practice, when their assessment determines that not all seven signs of death are present. Depending on the circumstances, a nurse's failure to initiate CPR when not all seven signs are present may constitute failure to comply with standards of nursing care. This position statement is limited to situations when all seven signs are present and should not be construed as providing guidance on the appropriateness of not initiating CPR when not all seven signs are present.

References

Texas Health and Safety Code §§ 671.001-671.002 https://statutes.capitol.texas.gov/Docs/HS/htm/HS.671.htm

American Heart Association. (2020). American Heart Association CPR&ECC guidelines. Retrieved from https://eccguidelines.heart.org/circulation/cpr-ecc-guidelines/

(Approved by the Board of Nursing on October 24, 2002; Revised: 01/2005; 01/2007; 01/2008; 01/2011; 01/2012; 01/2013; 01/2014; 01/2016; 01/2018; 01/2019; 01/2020; 01/2021)
(Reviewed: 01/2006; 01/2009; 01/2010; 01/2015; 01/2017)

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15.22 APRNs Providing Medical Aspects of Care for Individuals with whom there is a Close Personal Relationship

Advanced Practice Registered Nurses (APRN) often find themselves in situations where they may feel compelled to provide medical aspects of care or prescribe medications for themselves, their family members, or other individuals with whom they have a close personal relationship. APRNs are prohibited from ordering, prescribing or dispensing both medications and devices for personal use [22 TAC §222.10 (a) (2)]. When ordering, prescribing, or dispensing a medication or a device for any person, the APRN is expected to meet all standards of care including assessment, documentation of the assessment, diagnosis, and documentation of the plan of care prior to ordering, prescribing, dispensing, or administering a medication or device [22 TAC 222.10(a)(3)].

The practice of providing medical aspects of care for individuals with whom an APRN has a close personal relationship raises a number of ethical questions. The Board is concerned that APRNs in these situations risk allowing their personal feelings to cloud their professional judgment and objectivity. It is the opinion of the Board of Nursing that APRNs should not provide medical treatment or prescribe medications for any individual with whom they have a close personal relationship.

(Board Action 10/2003)
(Revised: 01/2009; 01/2014; 01/2018)
(Reviewed: 01/2006; 01/2007; 01/2008; 01/2010; 01/2011; 01/2012; 01/2013; 01/2015; 01/2016; 01/2017; 01/2019; 01/2020; 01/2021)

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15.23 The Use of Complementary Modalities by the LVN or RN

Nursing is a dynamic profession. The scope of practice for one nurse may differ from the scope of practice for another nurse; therefore, it is impractical to create an exhaustive list of tasks that may or may not be performed by a nurse in any setting.

A number of complementary therapeutic modalities have long been incorporated into standard nursing practice to assist patients in meeting identified health needs and goals. Educational preparation to practice complementary modalities may be acquired through formal academic programs or continuing education.

Differentiating the Roles of the LVN and RN

The Licensed Vocational Nurse (LVN) and the professional or Registered Nurse (RN) have different roles within the nursing process. The nursing practice of an LVN requires supervision with oversight from an RN, advanced practice registered nurse, physician, physician assistant, podiatrist, or dentist. The LVN performs focused assessments and contributes to care planning, interventions, and evaluations. The RN is responsible for the overall coordination of care and performs comprehensive assessments, initiates the nursing care plan, and implements and evaluates care of the client or patient.

Additional references related to the topics of supervision, assessment, and the nursing process may be found in the following resources on the BON web site:

  1. Nursing Practice Act (NPA):
    1. 301.002, Definitions, and
    2. 301.353, Supervision of Vocational Nurse
  2. Board 22 TAC §217.11, Standards of Nursing Practice
  3. Position Statement 15.27, The Licensed Vocational Nurse Scope of Practice
  4. Frequently Asked Question: LVN's "Supervision of Practice"
  5. Frequently Asked Question: LVNs Performing Initial Assessments

Complementary Modalities

Depending upon the practice setting and modality considered, complementary modalities may be used alone or in conjunction with conventional modalities. Regardless of the practice setting, the LVN or RN who wishes to incorporate the use of complementary modalities into his/her nursing practice is accountable and responsible to adhere to the NPA and the Board Rules and Regulations Relating to Nursing Education, Licensure and Practice.

Rules that are particularly relevant to LVNs or RNs who integrate complementary therapies into nursing practice include 22 TAC §217.10, Restrictions to Use of Designations for Licensed Vocational or Registered Nurse, which requires a nurse who uses the title, either “LVN” or "RN" whether expressed or implied, to comply with the NPA and Board Rules. In addition, 22 TAC §217.11, Standards of Nursing Practice, forms the foundation for safe nursing practice and establishes the LVN’s or RN’s duty to his/her clients. While all standards apply when engaging in the practice of nursing, those standards most applicable to the nurse who engages in complementary modalities include 22 TAC §217.11(1)(A)-(D), (1)(F), (1)(G), (1)(R), and (1)(T). Additional standards may apply depending upon the specific practice situation. In order to show accountability when providing integrated or complementary modalities as nursing interventions, the LVN or RN should be able to articulate and provide evidence of:

  1. Educational activities used to gain or maintain the knowledge and skills needed for the safe and effective use of such modalities;
  2. Knowledge of the anticipated effects of the complementary therapy and its interactions with other modalities, including its physiological and/or emotional/spiritual impact;
  3. Selection of appropriate interventions, whether complementary, conventional, or in combination, to meet the client’s needs. The interventions and rationale for selection should be documented in the client’s nursing care plan. The demonstrated ability of the LVN or RN to properly perform the chosen intervention(s) should be maintained by the LVN or RN and/or his/her employer;
  4. Appropriate medical diagnosis and a valid order from a licensed provider as indicated.
  5. Instruction/education provided regarding the purpose of the selected intervention, e.g., how it is performed and its potential outcomes;
  6. Collaboration with other health care professionals and applicable referrals when necessary;
  7. Documentation of interventions and client responses in a client’s record;
  8. Development and/or maintenance of policies and procedures relative to complementary modalities when used in organized health care settings;
  9. Abstinence from making unsubstantiated claims about the therapy used; and
  10. Acknowledgment that, as with conventional modalities, each person’s response to the therapy will be unique.

While some complementary therapies, such as massage, have long been within the realm of nursing, there is a much broader connotation applied when an LVN or RN holds himself/herself out as a registered or certified practitioner of such a therapy. "Registered" or "certified" titles, in relation to a complementary modality, imply a degree of mastery above those basic skills acquired through a pre-licensure nursing program. The LVN or RN is accountable to hold the proper credentials (e.g., license, registration, certificate) to safely engage in the specific practice.  Scope of Practice Decision-Making Model (DMM) (accessible on the Texas Board of Nursing (BON) web page) may be a useful tool for the LVN or RN who is uncertain whether a given modality is within his/her scope of practice. The nurse who wishes to integrate complementary modalities when engaging in the practice of nursing should be familiar with not only the NPA, BON rules, and any applicable Federal or State regulations, but also any prevailing standards published by national associations, credentialing bodies, and nursing organizations related to the LVN’s or RN’s area of practice.

(Board Action 01/2004)
(Revised: 01/2005; 01/2009; 04/2010; 01/2012; 01/2013; 01/2018; 01/2019)
(Reviewed: 01/2006; 01/2007; 01/2008; 01/2011; 01/2014; 01/2015; 01/2016; 01/2017; 01/2020; 01/2021)

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15.24 Nurses Engaging In Reinsertion of Permanently Placed Feeding Tubes

The Board of Nursing (Board or BON) approved curriculum for both licensed vocational nurses (LVNs) and registered nurses (RNs) does not provide graduates with sufficient instruction to provide the nurse with the necessary knowledge, skills and ability to re-insert and determine correct placement of a permanently placed feeding tube (such as gastrostomy or jejunostomy tubes). The Board does allow LVNs and RNs to expand their practice beyond the basic educational preparation through post-licensure continuing education and training for certain tasks and procedures. One of the main considerations in determining whether a nurse should consider re-insertion of a gastrostomy, jejunostomy or similar feeding tube, is how long the original tube was in place before becoming dislodged. Though sources vary, most give a range of 8-12 weeks for maturation/healing of the fistulous tract and stoma formation. The method of initial insertion (surgical, endoscopy, or radiographic guidance) may affect the length of healing. Orders should be obtained from the patient’s physician regarding re-insertion guidelines.

It is the opinion of the Board that LVNs and RNs should not engage in the reinsertion of a permanently placed feeding tube through an established tract until the LVN or RN successfully completes a competency validation course congruent with prevailing nursing practice standards. Training should provide instruction on the nursing knowledge and skills applicable to tube replacement and verification of correct and incorrect placement. The BON does not define nor set qualifications for competency validation courses; however, inclusion of the following factors is encouraged:

  • The nurse should complete training designed specifically for the type or types of permanent feeding tubes the nurse may need to replace, including overall patient assessment, verification of proper tube placement, and assessment of the tube insertion site.
  • A registered nurse or a physician who has the necessary expertise with regard to the specific feeding tube provides supervision during the training process.
  • The nurse demonstrates competency in all appropriate aspects (knowledge, decision-making, and psychomotor skills) of performing the procedure.
  • The patient has an established tract. The established tract is not determined by the nurse.
  • The facility has resources available to develop an educational program for initial instruction of LVNs and/or RNs, as well as for ongoing competency validation.
  • Documentation of each nurse’s initial education and ongoing competency validation should be maintained by the nurse and/or the employer in accordance with facility policies.
  • Regardless of training, policies and procedures of the facility must also permit the nurse to engage in the procedure.

The nurse who accepts an assignment to engage in care and/or replacement of permanently placed feeding tubes is responsible to adhere to the NPA and Board rules, particularly 22 TAC §217.11, Standards of Nursing Practice, as well as any other standards or rules applicable to the nurse’s practice setting. Two standards applicable in all practice scenarios include:

  • 22 TAC §217.11(1)(B) “implement measures to promote a safe environment for clients and others;” and
  • 22 TAC §217.11(1)(T) “accept only those assignments that take into consideration client safety and that are commensurate with the nurse’s educational preparation, experience, knowledge, and physical and emotional ability.”

Additional standards in 22 TAC §217.11 that may be applicable when a nurse chooses to engage in replacement of a permanently placed feeding tube include (but are not limited to):

  • (1)(D) “accurately and completely report and document: (i) ...client status...(ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s)...,”
  • (1)(G) “obtain instruction and supervision as necessary when implementing nursing procedures or practices,”
  • (1)(H) “make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations,”
  • (1)(R) “be responsible for one’s own continuing competence in nursing practice and individual professional growth.”
  • Standards specific to LVNs may be found in 22 TAC §217.11(2); standards specific to RNs may be found in 22 TAC §217.11(3).

Regardless of facility policy or physicians’ orders, the nurse always has a duty to maintain the safety of the patient [Reference 22 TAC §217.11(1)(B) above]; this standard has previously been upheld in a landmark case [Lunsford v. Board of Nurse Examiners, 648 S.W. 2d 391 (Tex. App. -- Austin 1983)].

(Adopted 01/2005)
(Revised: 01/2008; 01/2009; 01/2011; 01/2013; 01/2018)
(Reviewed: 01/2006; 01/2007; 01/2010; 01/2012; 01/2014; 01/2015; 01/2016; 01/2017; 01/2019; 01/2020; 01/2021)

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15.25 Administration of Medication & Treatments by LVNs

The definition of “Vocational Nursing” in the Texas Occupations Code states:

“Vocational Nursing” means a directed scope of nursing practice, including the performance of an act that requires specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of vocational nursing.  The term does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures.

Vocational nursing involves:

    • collecting data and performing focused nursing assessments of the health status of an individual;
    • participating in the planning of the nursing care needs of an individual;
    • participating in the development and modification of the nursing care plan;
    • participating in health teaching and counseling to promote, attain, and maintain the optimum health level of an individual;
    • assisting in the evaluation of an individual’s response to a nursing intervention and the identification of an individual’s needs; and
    • engaging in other acts that require education and training, as prescribed by board rules and policies, commensurate with the nurse’s experience, continuing education, and demonstrated competency [TOC 301.002(5)].

Educational preparation leading to initial licensure as a nurse in Texas is described in the DifferentiatedEssential Competencies of Graduates of Texas Nursing Programs Evidenced by Knowledge, Clinical Judgements, and Behaviors (DECs)(Oct 2010). This document lists the minimum competency expectations for graduates of Vocational (VN), Diploma/Associate Degree (Diploma/ADN), and Baccalaureate Degree (BSN) nursing programs.  According to the DECs, educational preparation for Vocational Nurses includes the following related to administration of medications:

Knowledge:

    • Common medical diagnoses, drug and other therapies and treatments.

Clinical Behavior/Judgments:

    • Administer medications and treatments and perform procedures safely, and
    • Monitor, document, and report responses to medications, treatments, and procedures and communicate the same to other health care professionals clearly and accurately.

The Standards of Nursing Practice (22 TAC §217.11) applicable to LVNs (as well as RNs) includes the following standards that specifically relate to medication administration:

  • (1)(C) Know the rationale for and effects of medications and treatments, and shall correctly administer the same;
  • (1)(D) Accurately and completely report and document: (iv) administration of medications and treatments;
  • (1)(N) Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment.

[Note that other standards may apply to administration of medications within a given practice circumstance.]

Sours: https://www.bon.texas.gov/practice_bon_position_statements_content.asp

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Jan 25, 2016 · Hi eyery body, i am doing health assesment class right now and i am having some tough time with shadow health - Tina Jones. Health Details: Health Details: Health Details: Health-final Tina Jones is a 28-year-old female who comes to the Shadow Health. Free and Paid: NR 509 Week 5 Shadow Health Abdominal Pain Physical Assessment Assignment | NR509 Course, Assignments and Exam for Chamberlain Students United States NR 509 Shadow Health Physical Assessment Assignments Weeks 1, 2, 3 and 4 9. Apply theoretical foundations and clinical skills in comprehensive health assessment across the lifespan. Thank you. , only at work or after mowing lawn). She seeks medical attention on a scrap on her right foot. Kelley Equipment: EXAMINATION GOWN AND DRAPE GLOVES STETHOSCOPE LIGHTSOURCE MASK SKIN MARKER METRIC RULER Assessment Procedure Normal finding Abnormal finding General Inspection Inspect for nasal flaring and pursed lip breathing. Park is an elderly female from Korean descend that comes into the clinic complaining about belly pain and having difficulties using the bathroom for a couple of days". NB: We have all the questions and documented answers in the SUBJECTIVE DATA, OBJECTIVE DATA, ASSESSMENT AND CARE PLAN format. 45 Start studying Esther Park-Shadow Health-Abdominal Pain. - Many problems may be identified if this question is worded correctly and properly followed up. tina jones abdominal assessment interview › Verified 4 days ago tina Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved. RN-BSN Student / Ohio University I enjoy Shadow Health because I am able to incorporate what I learn here in the clinical environment. Park's bowel sounds are normoactive in all quadrants, with no bruits or friction sounds. The interview portion of a comprehensive assessment is intended to obtain a as this could cause disruption to sounds such as those in the abdomen. tina jones heent assessment quizlet NR509 Shadow Health Abdominal Pain Physical Assessment Assignment Week 5 2018 May - 00590828 Tutorials for Question of General Questions and General General Questions View Notes - Focused Exam Cognition Notes Shadow Health. Details: Jarvis: Health Assessment Online for Physical Examination and Health Assessment, Version 4, 7. Note the similarities. Shadow Health: Conversation Concept Lab (Rachel Adler) Fri, June 19 25. ADPIE The Undergraduate Pharmacology DCE is built from the ground up to integrate the ADPIE process into students' learning, centering the steps of assessment, diagnosis, planning, implementation, and evaluation in Focused Exam: Abdominal PainEsther Park shadow health assignmentEsther Park is a 78-year-old Korean woman presenting with abdominal pain in the ED. pdf from NURS 201 at West Coast University. Associated symptoms: ¾ Tina Jones shadow health. Get that perfect score in your NCLEX or NLE exams with this questionnaire. It is a very common and nonspecific complaint that can be difficult to diagnose, especially for the family nurse practitioner student. Shadow Health's patient cases are designed for both novice and expert students to practice communicating with and examining patients. When assessing the abdomen, inspection is often overlooked. She noticed the pain about a month ago. In family practice, you are generally allocated a total of 15-minutes for an entire patient visit, which includes taking a history, performing a physical examination, and developing/implementing a treatment plan. Esther Park is a 78-year-old Korean woman presenting with abdominal pain in the ED. Specific areas with problems are covered in the separate articles Left Upper Quadrant Pain , Right Upper Quadrant Pain , Right Iliac Fossa Pain , Left Iliac Fossa Pain and Loin Pain . 00 NR 509 Shadow Health Physical Assessment Assignments Weeks 5, 6 and 7 NR 509 Tina Jones HEENT Interview Completed Shadow Health 1| Advanced Health Assessment - Spring 2019 ( ) Studies, courses, subjects, and textbooks for your search: Self-Assessment: Given Mr. Shadow Health - Focused Exam Chest Pain PrepU Quizzes Mastery Level 5 Week 13 04/18/2019 Assessing Older Adults Chapter 32 Assessing Families Chapter 33 Assessing Communities Chapter 34 Pulling It All Together Chapter 28 Shadow Health Focused Exam ? Abdominal Pain Shadow Health Comprehensive Assessment (Due at the end of week 14) Free and Paid: NR 509 Week 5 Shadow Health Abdominal Pain Physical Assessment Assignment | NR509 Course, Assignments and Exam for Chamberlain Students United States BSN437 HEALTH ASSESSMENT. DOWNLOAD ANSWERS = $ 39. The reports that the pain started almost one week ago, and has gotten progressively worse. Abdominal bruit Revised Problem List 1. At that time she used her albuterol inhaler and her symptoms decreased although they did not completely resolve. Jul 5, 2016 . Focused Exam: Abdominal Pain Esther Park Shadow Health Complete Assignment SolutionEsther Park is a 78-year-old Korean woman presenting with abdominal pain in the ED. As you complete the case study this week, be cognizant of the time that it takes you to conduct the history and physical. NR 509 Week 5 Assignment: Shadow Health Abdominal Pain Physical Assessment Assignment Pre Brief Ms. NR 509 Week 7 Immersion; Physical Assessment Questions-Answers: Summer 2020. assessment. For abdominal pain, be sure to ask about bowel and urinary habits. Browse. 35 terms. The comprehensive abdominal assessment varies slightly from the typical assessment of the body systems, because auscultation is completed after inspection but before percussion and palpation since they can disturb bowel sounds and alter the collected data (Holmgren, 1992, p. Students who do not pass the performance-based assessment by scoring within the Proficiency level in three attempts will receive a failing grade (68 points). OTHER SETS BY THIS CREATOR. • Shadow Health Focused. shadow health abdominal assessment questions › Verified 2 days ago The QSEN Institute advises and lends expertise to the Shadow Health team as they build virtual patient …Unformatted text preview: 5/22/2018 Focused Exam: Chest Pain | Completed | Shadow Health Focused Exam: Chest Pain Results | Turned In Advanced Health Assessment - Chamberlain, NR509-April-2018 Return to Assignment Your Results Overview Lab Pass Transcript Transcript Subjective Data Collection Started: May 21, 2018 | Patient Exam Time: 185 min All Lines (225) Interview Questions (76) Statements Diana Shadow: In this assessment, you will become familiarized with the structure and content of a health history exam so that with real-life patients, you can: º ask effective and comprehensive questions º obtain a thorough health history º evaluate the patient's risk of disease, infection, injury, and complications º educate and Focused Exam_ Abdominal Pain _ Completed _ Shadow Health . Anatomy Notes-Nursing Program 2017 Syl CISC 502 Assignment 3 Health assesment book C12 - 10 edition TB U World Respiratory - nuclex resp review Shadow health focused chest pain shadow health , respiratory Health assessment Class 11 Hemorrhagic Stroke Chapter 8 and 9 LectureNotes SET 9 - Fund Accounting course taught by Professor Zachary M. lonnagriffith. Assessment Exercise: Gastrointestinal 'Tina. Test your knowledge with this 30-item exam. 00 NR 509 Shadow Health Physical Assessment Assignments Weeks 5, 6 and 7 Upload, store, showcase and manage your HD videos. Patient is a 78 year old Korean female who was just admitted into the ER for abdominal pain and difficulty having a bowel movement. Jul 29, 2020 · Brian Foster Chest Pain Shadow Health Assessment. This usually indicates additional fat around the abdominal area. Dyspnea 5. Module 6 Discussion. Health Details: Details: Current Health Status (Comprehensive Assessment of Tina Jones) Tina Jones comes into the clinic for a general physical exam. Jan 13, 2017 · Shadow Health will grade you on what you ask and will deduct points for what you omitted. Amanda_Lemus6. Neurological Shadowhealth 40 terms. NR 509 Week 5 Shadow Health Abdominal Pain Physical Assessment Assignment. Exacerbating/alleviating factors: Look for triggers (e. Amanda Start studying Shadow Health Questions. This assignment provides the opportunity to conduct a focused exam on Brian Foster, who presents with recent episodes of chest pain in a non-emergency setting. HESI Prep - Health Assessment Practice Questions. 21 Abdomen Subjective Data & Examinations. Nov 13, 2016 · By slowing down assessment and giving the abdomen the time and attention it needs, nurses can notice problems that may get past even the most experienced doctors. Recent onset HTN 6. Week 8 assignmentTina Jones Comprehensive Assessment Quizlet Health. Learn faster with spaced repetition. 0% Focused Exam: Abdominal Pain Esther Park Shadow Health Complete Assignment Solution Esther Park is a 78-year-old Korean woman presenting with abdominal pain in the ED. Patho Ch. 00 NR 509 Shadow Health Physical Assessment Assignments Weeks 5, 6 and 7 Core Questions to ask The are 10 core questions that should be included on any medical history form. Understanding when a patient’s body is not acting in a way that is consistent with what is “normal” (for him or her) can NR 509 Shadow Health Assignment Week 1 2 3 and 4; NR 509 Shadow Health Physical Assessment Assignmen NR 509 Course Discussions SOAP Note and Reflection NR 509 SOAP Note Weeks 1 to 7; NR 509 Shadow Health REVIEW QUESTIONS; NR 509 APEA Exam Multiple Subject Areas Advanced P NR 509 Focused Exam Cough Assignment Completed Sha NR 509 Week 5 Shadow Health Gastrointestinal Physi NR 509 Week 5 Shadow Health Abdominal Pain Physica NR 509 Week 5 Quiz 2 Practice Versions Advanced Ph NR 509 Week 6 Assignments plus Quiz; NR 509 Week 6 Alternative Writing Assignment Abdomen; NR 509 Week 6 Shadow Health Mental Health Physical NR 509 Week 6 Shadow Health Pediatric This nursing exam covers the concepts of Nursing Health Assessment and Pain. Park is an elderly female from Korean descend that comes into the clinic complaining about belly pain and having difficulties using the bathroom for a couple of days”. Health Details: HPI: Ms. Gallagher. 00 NR 509 Week 2 Shadow Health Respiratory Assessment Ms. Join our community and get tons of storage, customizable HTML5 player, and professional workflow tools. Are you under a physicians care or have you been during the past 5 years, including hospitalization, and surgery. Focused Exam: Abdominal Pain. The aim is to provide fundamental and personalized knowledge of a patient and also to create promotion of a health A flat abdomen is commonly seen in a person of normal weight. Confirming the name of Tina's birth control pill will solicit information about her health history and current treatment plan. 2. The describes the pain as dull and crampy. i heard that we have to ask lot of questions to the patient inoder to pass the shadow health part of health assesment. ” Interview Questions (40) NR 509 Week 5 Shadow Health Abdominal Pain Physical Assessment Assignment. Fosters symptoms, I believe an adequate health history and physical examination was performed. 00 NR 509 Shadow Health Physical Assessment Assignments Weeks 5, 6 and 7 Anatomy Notes-Nursing Program 2017 Syl CISC 502 Assignment 3 Health assesment book C12 - 10 edition TB U World Respiratory - nuclex resp review Shadow health focused chest pain shadow health , respiratory Health assessment Class 11 Hemorrhagic Stroke Chapter 8 and 9 LectureNotes SET 9 - Fund Accounting course taught by Professor Zachary M. Health Details: Start studying Shadow Health- Tina Jones- Abdominal. … Shadow Health. 0% The Quality and Safety Education for Nurses (QSEN) Institute has partnered with Shadow Health to infuse QSEN competencies into the Digital Clinical Experiences. Epigastric pain 9. After successful completion of this course, the participant will be able to: 1. pdf . 124 terms. (HEENT Physical Assessment Assignment) Pre-Brief: For the last week, Tina has experienced sore, itchy throat, itchy eyes, and runny nose. 45 Shadow Health Partners Working together at the forefront of nursing and educational simulation. Jun 23, 2019 · [ad_1] Esther Park is a 78-year-old Korean woman presenting with abdominal pain in the ED. 00 NR 509 Shadow Health Physical Assessment Assignments Weeks 5, 6 and 7 13. We have experts in subjects of maths, science and many more. Jones is a pleasant 28-year-old African American woma who presented to the clinic with complaints of upper stomach pa after eating. 28). 0% Assessment Techniques: The order of techniques is as follows (A-D) except for the abdomen where you inspect then auscultate A. NR 509 Week 6 Shadow Health Pediatric Physical Assessment Nov 17, 2016 · So I have to do a care plan for a virtual patient on a cite called Shadow Health. Points will be deducted from the rubric if the site does not demonstrate scholarship or quality. ADPIE The Undergraduate Pharmacology DCE is built from the ground up to integrate the ADPIE process into students' learning, centering the steps of assessment, diagnosis, planning, implementation, and evaluation in Focused Exam: Abdominal Pain | Esther Park shadow health assignment. Health Details: Focused Exam: Abdominal Pain Esther Park shadow health assignment answers | Rated A+ Esther Park is a 78-year-old Korean woman presenting with abdominal pain in the ED. the abdominal pain is a 6 and described as a constant dull, crampy feeling low low in her abdomen that began as a general discomfort about 5 days ago when the patient states she began having difficulties going to the bathroom and has not had a bowel mo NR509 Shadow Health Abdominal Pain Physical Assessment Assignment Week 5 2018 May - 00590828 Tutorials for Question of General Questions and General General Questions Cal 3 - Exam 1 (Questions) Diversity hw n - bell Chapter 11 Week 4 - Respiratory Disorders Week 6 - Anemia - Lecture notes 6 Entire Cardiac System CP2 SOAP 2 - SOAP note requirement for class glass calibration table Workout for Diabetes RQ11 Blank Spr 18 - RQ 11 Lab Exam 1 Study Guide- BIO 446L Poem Comparison Essay - Grade: 85 Titan Project Proposal Low back pain - notes Solns 07 Final Exam View Notes - Focused Exam Cognition Notes Shadow Health

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Cardiotonic-inotropicdrugs are particularly useful for patients with heart failure (HF), wherein the heart is not able to effectively pump the blood towards different body organs. As a result, cells of the body are deprived of oxygen and nutrients. Cardiotonic agents are drugs used to increase the contractility of the heart. Included below is a pharmacology guide for nurses on the various effects of cardiotonic-inotropic agents.

Generic and Brand Names

Here is a table of commonly encountered cardiotonic-inotropic drugs, their generic names, and brand names:

Disease Spotlight: Heart Failure (HF)

Heart failure is a syndrome characterized by dysfunction of cardiac muscles.

  • It can occur in a number of heart conditions which can overwork the heart muscles. Some of these conditions include:
  • Coronary artery disease (CAD), which leads to insufficient blood supply for the myocardium and is also the most common cause of HF;
  • Cardiomyopathy, which leads to enlargement of the heart and myocardial fatigue; and
  • Valvular heart diseases, which can cause reflux and overloading of blood to the ventricles which consequently over stretches the myocardium.
  • Clinical manifestations depend on the side of the heart which failed:

Left-sided HF

  • Primarily reflects pulmonary manifestations because the left ventricle cannot push blood towards the peripheral systems.
  • As a result, there is engorgement of pulmonary veins, which leads to difficulty of breathing.
  • Other manifestations include: tachypnea (rapid breathing), dyspnea (discomfort associated with breathing), and orthopnea (increased difficulty of breathing when lying down). Patient also experiences coughing and hemoptysis (coughing up of blood). In severe cases, pulmonary edema (filling up of fluid in the lung spaces) occurs which is life-threatening because it interferes with gas exchange.

Right-sided heart failure

  • Occurs when the right side of the heart has the need to exert more force in order to push blood towards the pulmonary circulation.
  • This side is usually a low-pressure system so when this happens, the pressure in this side rises and venous return can’t enter.
  • Neck veins become distended and central venous pressure is increased. Organs like liver and spleen are enlarged because they are congested with blood.
  • Also, dependent areas like the limbs develop pitting edema because fluid pools in these areas.

Cardiac Glycosides

  • Cardiac glycosides are cardiotonic agents from foxglove or digitalis plants. They exert their effects on the cardiac muscles by affecting levels of intracellular calcium. In turn, the contractility of the muscles is increased.

Therapeutic Action

  • Allows more calcium to enter during contraction, therefore increasing the force of contraction – positive inotropic effect.
  • Consequently, there is increased cardiac output and renal perfusion. A good blood supply to the kidney decreases renin release. This downplays the activity of renin-angiotensin-aldosterone system (RAAS) which causes more fluid to be excreted in the body through urine. A decrease in blood volume eases the workload of the heart.
  • Another mechanism of this drug is to decrease the workload of the heart and slow down relaxation of the cells. Therefore, this drug can increase the strength of contractility without increasing the rate of contraction (negative chronotropic effect).

Indications

  • Primarily indicated for decreasing workload of the heart and relieving HF.
  • Digoxin is especially indicated for atrial flutter, atrial fibrillation, and paroxysmal atrial tachycardia.

Children

  • Widely used in the treatment of heart defects in children but the margin of safety for drug dosage is small so the nurse should recalculate and re-validate the dose with another nurse before administration.
  • Serum level of digoxin and signs of digitalis toxicity should be monitored carefully.

Adults

  • This age group should be educated on manifestations that should be reported signifying drug toxicity.
  • Also, adults are cautioned against utilization of different brands of digoxin as differences in bioavailability can increase the chance of toxicity.
  • It is important for these patients to be taught how to take their own heart rate and assess its regularity.
  • Safety of this drug for pregnant women is not established. As for lactating women, although digoxin enters breast milk, it has not been associated with adverse effects in neonates but caution is still exercised.

Older adults

  • Older adults are more susceptible to drug toxicity because of underlying conditions that would interfere with metabolism and excretion of drug.
  • Renal and hepatic function should always be monitored.
  • Relatives should be instructed on how to take heart rate and assess its regularity.
  • Careful attention should be given to other drugs taken by older adult patients as well as their alternative therapies.

Pharmacokinetics

RouteOnsetPeakDuration
Oral30-120 min2-6 h6-8 d
IV5-30 min1-5 h4-5 d
T1/2: 30-40 h
Metabolism: N/A
Excretion: urine (unchanged)

Contraindications and Cautions

  • Allergy to any component of digitalis preparation. Prevent severe hypersensitivity reactions.
  • Ventricular tachycardia or fibrillation. These are potentially fatal arrhythmias and should be treated with another drug.
  • Heart block (sick sinus syndrome). Can be worsened by drug’s effect on slowing conduction through AV node
  • Idiopathic hypertrophic subaortic stenosis(IHSS). Obstruction of outflow tract to the aorta can result from increasing the force of contraction and this can lead to other severe problems.
  • Acute myocardial infarction (MI). Increasing the force of contraction can damage the heart muscles more.
  • Renal insufficiency. Drug is excreted through urine and the existing renal insufficiency can contribute to development of drug toxicity.
  • Pregnancy and lactation. Can cause potential adverse effects to the fetus or neonate.

Adverse Effects

  • CNS: headache, weakness, drowsiness, vision changes (most commonly reported is seeing yellow halo around objects)
  • CV: arrhythmias
  • GI: GI upset, anorexia
  •  NURSING ALERT! Signs and symptoms of digitalis toxicity: anorexia, nausea, vomiting, malaise, depression, irregular heart rhythms (e.g. heart block, heart arrhythmias, and ventricular tachycardia)

Interactions

  • Digoxin immune Fab or DigiFab: antidote; these antibodies bind molecules of digoxin, making them unavailable at site of action. Used when serum digoxin is >10 ng/mL and serum potassium is >5 mEq/L.
  • Verapamil, amiodarone, quinine, erythromycin, tetracycline, cyclosporine: increased therapeutic and toxic effects of digoxin. Combination of digoxin with any of these drugs would warrant decrease in dose of digoxin to prevent toxicity.
  • Potassium-losing diuretics: increased risk of cardiac arrhythmias
  • Thyroid hormones, metoclopramide, penicillamine: decreased therapeutic effects of digoxin. Increasing the dose of digoxin is important.
  • Cholestyramine, charcoal, colestipol, antacids, bleomycin, cyclophosphamide, methotrexate: decreased absorption of digoxin. In this case, digoxin must be taken 2-4 hours after taking any of these drugs.
  • St. John’s wort, psyllium: decreased therapeutic effect of digoxin
  • Ginseng, hawthorn, licorice: increased risk of digoxin toxicity

Nursing Considerations

Here are important nursing considerations when administering cardiac glycosides:

Nursing Assessment

These are the important things the nurse should include in conducting assessment, history taking, and examination:

  • Assess for the mentioned contraindications to this drug (e.g. renal insufficiency, acute MI, hypersensitivity, etc.) to prevent potential adverse effects.
  • Conduct thorough physical assessment before beginning drug therapy to establish baseline status, determine effectivity of therapy and evaluate potential adverse effects.
  • Obtain baseline status for weight while noting recent manifestations that increase or decreases to determine patient’s fluid status.
  • Assess closely patient’s heart rate and blood pressure to identify cardiovascular changes that may warrant a change in digoxin drug dose.
  • Auscultate heart sounds to note the presence of abnormal sounds and possible conduction problems.
  • Determine urinary pattern and output to assess gross indication of renal function.
  • Obtain baseline electrocardiogram (ECG) to identify heart rate and rhythm.
  • Monitor serum electrolyte and renal function test results to determine whether changes in drug dose is needed or not.

Nursing Diagnoses

Here are some of the nursing diagnoses that can be formulated in the use of this drug for therapy:

Implementation with Rationale

These are vital nursing interventions done in patients who are taking cardiac glycosides:

  • Check drug dose and preparation carefully to avoid medication errors because drug has narrow safety margin.
  • Do not administer drug with food and antacids to prevent decreased in drug absorption.
  •  IMPORTANT!  Count apical pulse for one full minute before administering drug to monitor for adverse effects.
    • Drug is withheld if pulse is less than 60 beats per minute in adults and 90 beats per minute in infants.
    • Apical pulse is taken after one hour and if it remains low, nurse must document it, withhold the dose, and inform doctor.
  • Assess pulse rhythm to detect arrhythmias which are early signs of drug toxicity.
  • Weigh the patient daily to monitor for fluid retention and HF. Assess dependent areas for presence of edema and note its degree of pitting to assess severity of fluid retention.
  • Monitor serum digoxin level as ordered (normal: 0.5-2 ng/mL) to evaluate therapeutic dosing and development of adverse effects.
  • Provide comfort measures (e.g. small frequent meals for GI upset, instituting safety measures for drowsiness and weaknesses, and providing adequate room lighting for patients with visual disturbances) to help patient tolerate drug effects.
  • Promote rest periods and relaxation techniques to balance supply and demand of oxygen.
  • Ensure maintenance of emergency drugs and equipment at bedside (e.g. potassium salts and lidocaine for arrhythmias, phenytoin for seizures, atropine in case of clinically significant low heart rate, and cardiac monitor) to promote prompt treatment in cases of severe toxicity.
  • Educate patient on drug therapy including drug name, its indication, and adverse effects to watch out for to enhance patient understanding on drug therapy and thereby promote adherence to drug regimen.

Evaluation

Here are aspects of care that should be evaluated to determine effectiveness of drug therapy:

  • Monitor patient response to therapy through assessing manifestations of HF, arrhythmia, and serum level of digoxin.
  • Monitor for adverse effects (e.g. visual changes, HF, and arrhythmias).
  • Evaluate patient understanding on drug therapy by asking patient to name the drug, its indication, and adverse effects to watch for.
  • Monitor patient compliance to drug therapy.

Phosphodiesterase Inhibitors

  • Phosphodiesterase inhibitors aid in increasing force of myocardial contractility through their enzyme-blocking effect. This in turn, increases the flow of calcium into the myocardial cells.

Therapeutic Action

  • By blocking the enzyme phosphodiesterase, cyclic adenosine monophosphate (cAMP) increases. cAMP stimulates flow of calcium towards the myocardium and thereby, increases force of cardiac contractility.
  • Increases intracellular calcium and prolongs effect of sympathetic stimulation. This leads to three major effects: vasodilation, increased oxygen consumption, and arrhythmias.

Indications

  • Only indicated for short-term treatment of patients not responding to cardiac glycosides, vasodilators, and diuretics.
  •  Drug use is only limited to severe situations because it is associated with fatal ventricular arrhythmias.

Children

  • Drug is not recommended for this age group

Adults

  • This age group should be educated on manifestations that should be reported signifying drug adverse effects.
  • It is important for these patients to be taught how to take their own heart rate and assess its regularity.

Pregnant women

  • Safety of this drug for pregnant and lactating women is not established.

Older adults

  • Are more susceptible to drug toxicity because of underlying conditions that would interfere with metabolism and excretion of drug.
  • Renal and hepatic function should always be monitored. Relatives should be instructed on how to take heart rate and assess its regularity.
  • Careful attention should be given to other drugs taken by older adult patients as well as their alternative therapies.

Pharmacokinetics

RouteOnsetPeakDuration
OralImmediate10 min8 h
T1/2: 2.3-3.5 h
Metabolism: liver
Excretion: urine and feces

Contraindications and Cautions

  • Allergy to phosphodiesterase inhibitors and bisulfites. Prevent severe hypersensitivity reactions.
  • Severe aortic or pulmonary valvular disease. Exacerbated by increased contraction.
  • Acute MI. Exacerbated by increased contraction and oxygen demand.
  • Conditions with fluid volume deficit. Exacerbated by increased renal perfusion which ultimately leads to increased urine output.

Adverse Effects

  • CV: ventricular arrhythmias, ventricular fibrillation, hypotension, chest pain
  • GI: nausea, vomiting, GI upset, abdominal pain
  • Hema: thrombocytopenia
  • Associated hypersensitivity reactions: vasculitis, pericarditis, pleuritis, and ascites
  • Burning at intravenous injection site

Interactions

  • In solution together with furosemide: precipitate formation

Nursing Considerations

Here are important nursing considerations when administering phosphodiesterase inhibitors:

Nursing Assessment

These are the important things the nurse should include in conducting assessment, history taking, and examination:

  • Assess for the mentioned contraindications to this drug (e.g. fluid volume deficit, acute MI, hypersensitivity, etc.) to prevent potential adverse effects.
  • Conduct thorough physical assessment before beginning drug therapy to establish baseline status, determine effectivity of therapy, and evaluate potential adverse effects.
  • Obtain baseline status for weight while noting recent manifestations that increases or decreases to determine patient’s fluid status.
  • Assess closely patient’s heart rate and blood pressure to identify cardiovascular changes that may warrant change in drug dose.
  • Determine urinary pattern and output to assess gross indication of renal function.
  • Obtain baseline electrocardiogram (ECG) to identify heart rate and rhythm.
  • Monitor serum electrolyte, complete blood count, and renal and hepatic function test results to determine whether changes in drug dose is needed or not.

Nursing Diagnoses

Here are some of the nursing diagnoses that can be formulated in the use of this drug for therapy:

  • Risk for fluid volume deficit related to increased renal perfusion as effect of the drug
  • Decreased cardiac output related to inefficient myocardial contractility and hypotension
  • Risk for injury related to easy bruising 20 thrombocytopenia
  • Ineffective tissue perfusion related to decreased blood flow to different parts of the body

Implementation with Rationale

These are vital nursing interventions done in patients who are taking phosphodiesterase inhibitors:

  • Protect drug from light to prevent drug from degradation.
  • Ensure patency of intravenous access to promote safe administration of drug.
  • Weigh patient daily and fluid intake and output to evaluate resolution of HF.
  • Assess skin condition, noting presence of petechiae and other manifestations of easy bruising and bleeding to assess presence of thrombocytopenia.
  • Monitor intravenous injection site to promote prompt interventions in cases of burning sensation and/or irritation.
  • Provide comfort measures (e.g. small frequent meals for GI upset, instituting safety measures for drowsiness and weaknesses, and providing adequate room lighting for patients with visual disturbances) to help patient tolerate drug effects.
  • Educate patient on drug therapy including drug name, its indication, and adverse effects to watch out for to enhance patient understanding on drug therapy and thereby promote adherence to drug regimen.

Evaluation

Here are aspects of care that should be evaluated to determine effectiveness of drug therapy:

  • Monitor patient response to therapy through assessing for manifestations of resolution of HF.
  • Monitor for adverse effects (e.g. thrombocytopenia, HF, and arrhythmias).
  • Evaluate patient understanding on drug therapy by asking patient to name the drug, its indication, and adverse effects to watch for.
  • Monitor patient compliance to drug therapy.

Practice Quiz: Cardiotonic-Inotropic Agents

Quiz time! Take our 8-item quiz about cardiotonic-inotropic agents!

Questions

1. The primary treatment for heart failure (HF) is ___________.

A. Increasing the heart rate so the heart can pump more blood
B. Decreasing the heart rate so the heart can rest
C. Increasing contractility so the heart will be able to pump more blood
D. Decreasing contractility to prevent muscle fatigue

2. The most common cause of HF is ______________.

A. Hypertension
B. Valvular heart diseases
C. Cardiomyopathy
D. Coronary artery disease (CAD)

3. Digoxin was prescribed to a patient with ventricular tachycardia. What should the nurse do?

A. Administer the drug as ordered.
B. Discuss the order with the doctor.
C. Discontinue other intravenous medications before administering digoxin.
D. Count apical pulse for one full minute before administering.

4. What is the antidote for digoxin intoxication?

A. Diphenhydramine
B. Atropine sulfate
C. Digoxin immune fab (Digibind, DigiFab).
D. Phosphodiesterase inhibitors

5. An infant who is receiving cardiac glycosides has an apical pulse of 80 beats per minute. Which is the best nursing intervention for this assessment finding?

A. Administer drug as ordered.
B. Withdraw the drug and notify doctor.
C. Assess apical pulse every hour for the next five hours.
D. Decrease drug dose and administer.

6. What signals the novice nurse that intravenous milrinone was combined to furosemide in management of patients with heart failure?

A. Presence of bubbles
B. Pink discoloration of the solution
C. Formation of precipitates
D. No obvious sign. Solution is clear.

7. What is the therapeutic level for digoxin?

A. 0.5-2 ng/mL
B. 1.5-2 ng/mL
C. 0.5-1.5 mg/mL
D. 0.5-2 mg/mL

8. In severe cardiac glycoside toxicity, all of the following should be in the bedside, except _________.

A. Lidocaine
B. Phenytoin
C. Calcium channel blocker
D. A and B only

Answers and Rationale

1. Answer: C. Increasing contractility so the heart will be able to pump more blood.

The complete answer would be to make the heart beat efficiently, that is to increase its force of contraction without increasing the heart rate. Through this, more blood is pumped every beat without overwhelming the heart because rate of contraction is not increased.

2. Answer: D. Coronary artery disease (CAD).

It accounts for 95% of HF cases. CAD results to insufficient supply of blood in the heart. This leads to hypoxia and loss of function of heart muscles.

3. Answer: B. Discuss the order with the doctor.

Digoxin is contraindicated in patients with ventricular tachycardia and fibrillation because these are potentially fatal arrhythmias and need to be treated with other medications.

4. Answer: C. Digoxin immune fab (Digibind, DigiFab).

Digoxin Immune Fab or DigiFab, DigiBind should be administered for serum digoxin levels of >10 ng/mL and serum potassium level of >5 mEq/mL.

5. Answer: B. Withdraw the drug and notify doctor.

A low apical pulse (less than 90 for infants and less than 60 for adults) can signal drug toxicity.

6. Answer: C. Formation of precipitates.

Phosphodiesterase inhibitor-furosemide combination should be avoided. Alternate lines should be used if both of these drugs are given intravenously.

7. Answer: A. 0.5-2 ng/mL.

8. Answer:  C. Calcium channel blockers.

Lidocaine and potassium salts are used to treat arrhythmias. Phenytoin is for the treatment of seizures. Other medications and equipment at the bedside include atropine for treatment of increased heart rate, and a cardiac monitor.

References and Sources

References and sources for this pharmacology guide for Cardiotonic-Inotropic Agents:

  • Karch, A. M., & Karch. (2011). Focus on nursing pharmacology. Wolters Kluwer Health/Lippincott Williams & Wilkins. [Link]
  • Katzung, B. G. (2017). Basic and clinical pharmacology. McGraw-Hill Education.
  • Lehne, R. A., Moore, L. A., Crosby, L. J., & Hamilton, D. B. (2004). Pharmacology for nursing care.
  • Smeltzer, S. C., & Bare, B. G. (1992). Brunner & Suddarth’s textbook of medical-surgical nursing. Philadelphia: JB Lippincott.

See Also

Here are other nursing pharmacology study guides:

Gastrointestinal System Drugs

Respiratory System Drugs

Endocrine System Drugs

Autonomic Nervous System Drugs

Immune System Drugs

Chemotherapeutic Agents

Reproductive System Drugs

Nervous System Drugs

Cardiovascular System Drugs

Further Reading and External Links

Recommended resources and reference books. Disclosure: Includes Amazon affiliate links.

  1. Focus on Nursing Pharmacology - Easy to follow guide for Pharmacology
  2. NCLEX-RN Drug Guide: 300 Medications You Need to Know for the Exam - Great if you're reviewing for the NCLEX
  3. Nursing 2017 Drug Handbook (Nursing Drug Handbook) - Reliable nursing drug handbook!
  4. Lehne's Pharmacology for Nursing Care- Provides key information on commonly used drugs in nursing
  5. Pharmacology and the Nursing Process - Learn how to administer drugs correctly and safely!
  6. Pharm Phlash Cards!: Pharmacology Flash Cards - Flash Cards for Nursing Pharmacology
Categories Nursing PharmacologyTags cardiac glycosides, cardiovascular drugs, digitalis, digitoxin, digoxin, Drug Study, lanoxin, nursing pharmacology, phosphodiesterase inhibitorsSours: https://nurseslabs.com/cardiotonic-inotropic-drugs/
Major classes of cardiovascular medications

Physical Assessment - PA head to toe cheat sheet Tina Jones Heent Interview Completed Shadow Health 1 WEEK 2 PA Studyguide - Skin WEEK ONE crossword puzzles Report (15) Report (14) Other related documents. Tina Jones, a 28 years old female, presents herself for a pre-employment assessment in. Cough Daniel Danny Rivera is an 8-year-old boy who comes to the clinic with a cough. Then listen with your stethoscope for 15 seconds in each quadrant. The Advanced Health Assessment patient case is a series of single-system examinations of Tina Jones during several clinic visits over the course of a simulated year, which students have found useful in preparing for their clinical. NR 509 Shadow Health Focused Exam Case. 5) Divide abdomen in four regions. The plan developed above reflects his personal chief complaint as well as both subjective and objective findings of my examination and assessment. pdf from HS MISC at Capella University. It is occasionally productive, producing a clear, "slimy" mucous without odor. Park is an elderly female from Korean descend that comes into the clinic complaining about belly pain and having difficulties using the bathroom for a couple of days”. Look at their belly first. Focused Gastrointestinal Assessment. º ask effective and comprehensive questions º obtain a thorough health history º evaluate the patient’s risk of disease, infection, injury, and complications º educate and. She reports that the pain isn't severe, but that her daughter was. Esther's Focused Health Assessment "Mrs. The cost is $99. BSN437 HEALTH ASSESSMENT. Cough Completed Shadow Health 14 Focused Exam. Esther Park is a 78-year-old woman who comes to the clinic complaining of abdominal pain. The aim is to provide. Aug 20, 2021 · Comprehensive Assessment Tina Jones Shadow Health Transcript …. The following details are facts of the patient’s case. Essential Environment: The Science Behind the Stories Jay H. Ashley_Golay. Biology Mary Ann Clark, Jung Choi, Matthew Douglas. It is occasionally productive, producing a clear, "slimy" mucous without odor. (HEENT Physical Assessment) Overview. 1 lists abnormalities that may be discovered in the musculoskeletal system. com DA: 16 PA: 50 MOZ Rank: 77. Module 1 - History. Many viruses and bacteria can cause acute pharyngitis. Your instructor has chosen to scale your Student Performance Index score so that the average. Tina Jones, a 28 years old female, presents herself for a pre-employment assessment in. Interview the patient to elicit subjective health information about her health and health history Ask relevant follow-up questions to evaluate patient condition Demonstrate empathy for patient perspectives, feelings, and sociocultural background. Exam Mode - Questions and choices are randomly arranged, time limit of 1min per question, answers and grade will be revealed after finishing the exam. Has 15 years experience. 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During the debriefing process, students reflect upon their simulation experience and. the abdominal pain is a 6 and described as a constant dull, crampy feeling low low in her abdomen that began as a general discomfort about 5 days ago when the patient states. Shadow Healths patient cases are designed for both novice and expert students to practice communicating with and examining patients. The simulated electronic health record (EHR) helps students to perfect electronic charting, demonstrate clinical judgment in patient care, and thrive in today's modern healthcare environment. The causes of abdominal pain can range from simple (mild constipation) to life-threatening (abdominal aortic aneurysm or acute MI). Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data. Assess gait and posture. This quiz may be helpful and it may just be a way to confirm you. Description. Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved. 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Thank you Question 06/27/20 3:27 PM […]. External Inspection 1. History of Present Illness. References: Bickley, L. Start studying Health Assessment Test 2 - Abdominal Assessment and Pain As. Biology Mary Ann Clark, Jung Choi, Matthew Douglas. · occurs when you have a strong, sudden need to urinate that i…. FusionShadow Health Tina Jones Cardiovascular ALL Subjective Shadow health comprehensive assessment Flashcards | NR 509 Tina Jones Comprehensive Health Assessment An abdominal examination is a portion of the physical examination which a physician or nurse uses to clinically observe the abdomen of a OTHER QUIZLET SETS. The book/lab manual also have some practice questions that are very similar if you would like extra practice. 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A thorough history and physical exam is required to identify other signs and symptoms to lead to a diagnosis. Adults over 30 years of age with non-traumatic chest pain should prompt the triage nurse to consider the possibility of ACS. Shadow Health provides immediate feedback to students, which includes two-strike scoring and worked examples for each question. com Get All. Patients with lung disease often complain of the following symptoms: dyspnea/shortness of breath, cough, sputum production, fatigue, exercise intolerance, chest tightness or chest pain. Example of a Complete History and Physical Write-up Nursing assessment is an important step of the whole nursing process. Rogers is a 56 y/o WF Define the reason for the patient's visit as who has been having chest pains for the last week. Unformatted text preview: Gastrointestinal Results | Turned In Advanced Health Assessment - Spring 2019, NSG516 Online Return to Assignment Your Results Overview Reopen Lab Pass Experience Overview Transcript Subjective Data Collection Patient: Tina Jones Student Performance Index 49 out of 52 Objective Data Collection Education & Empathy Documentation Self-Reflection Student Survey. Assessing the Musculoskeletal System Health Perception-Health Management. NUR 3069C Health Assessment and Communication - May '18 (Gannon - Jacksonville Only), 3069C. Sep 10, 2021 · Tina jones heent assessment quizlet tina jones heent answers. Note: Patients may call chest symptoms pressure, discomfort, tightness, funny feeling, etc. No tenderness to light or deep palpation. Aug 18, 2020 - Musculoskeletal Results | Completed Health Assessment Laboratory - Fall 2019, NUR 305L Return to Assignment Your Results Turn In Lab Pass Subjective Data Collection: 22 of 23 (95. Appetite has al-ways been "healthy. Start studying Abdominal Subjective Assessment. Learn vocabulary, terms, and more with flashcards, games, and other study tools. Have you had any neck stiffness? Question 03/18/20 11. Equipment: 1) Stethoscope 2) Centimeter ruler and nonstretchable measuring tape. Otoscope assignment with ND Human Phys Study Outline Shadow health focused chest pain sleep stress analysis Chapt 5 - Lecture notes 5. Look at their belly first. B) the absence of disease. Thanks for your feedback! When assessing the assessment, assess him to determine the services or not? How Can You Prevent Diabetes?. Advanced physical assessment Advanced Physical Assessment Assignment 3 American Sentinel University Introduction This student will present a patient from the shadow health environment. When palpating the abdomen, begin at light palpation. Exactly what I do. pain rating of 7/10 pain rating of 7/10 Pain is subjective and can only truly be evidenced by a patient's. 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Comprehensive assessment tina jones shadow health transcript, subjective, objective & documentation. Description. , Szilagyi, P. Comments and Help with shadow health focused exam abdominal pain esther park quizlet. Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved Ask your instructor before using any site if you are unsure Points will be deducted from the rubric if the site does not demonstrate scholarship or quality. Shadow-health-abdominal-assessment-quest is used by aradswathtic in Shadow-health-abdominal-assessment-questions-quizlet. 9 hours ago NR509 Shadow Health Abdominal Pain Physical Assessment Assignment Week 5 2018 May. As abdominal complaint or focused exam abdominal assessment student experiences a review. Can you verify your name Question 06/27/20 3:27 PM CDT Tina Jones. Did the cough medicine make you feel better. Subjective data of Esther Park; The patient reports a decrease in appetite and activity over the last week, and lack of regular bowel movements after mild diarrhea three days ago. It may increase in heent: what is a prerequisite knowledge and was within each type in. Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved. Subjective Data Collection: 31 of 31 (100. Chapters 4 to 17 detail the anatomy and physiology, health history, guide-lines for health promotion and counseling, techniques of examination,. Hi eyery body, i am doing health assesment class right now and i am having some tough time with shadow health - Tina Jones. Within each portion of the HEENT exam the regular examination order is followed. The following is sample documentation from abdominal health assessment of a healthy adult. We write high quality term papers, sample essays, research papers, dissertations, thesis papers, assignments, book reviews, speeches, book reports, custom web content and business papers. I'm going to be an Accounting Clerk at Smith, Stevens, Stewart, Silver & Company. Bladder may still, nurses offers a radioisotope is. The nurse is aware that the following. Interview the patient to elicit subjective health information about her health and health history Ask relevant follow-up questions to evaluate patient condition Demonstrate empathy for patient perspectives, feelings, and sociocultural background. Diplomate, American Board of Ophthalmology Diplomate, American Board of Ophthalmology 5620 E. Subjective findings are obtained from the health history and body systems review. cardiovascular health such as high blood cholesterol, cigarette use, diabetes, or hypertension (CDC, 2011). Categories. Although I'll leave a few things off so it isn't blatantly obvious. on Vimeo, the home for high quality videos and the people who love them. Esther Park is a 78-year-old woman who comes to the clinic complaining of abdominal pain. May 24, 2020 - NSG 516 Gastrointestinal _ Completed _ Shadow Health 1 - River University Gastrointestinal Results | Turned In Advanced Health Assessment - Spring 2019, NSG516 Online Experience Overview Patient: Tina Jones Student Performance Index 49 out of 52 Subjective Data Collection 30 out of 30 Objective Data Collection 17 out of 18 Education and Empathy 2 out of 4 Interaction with. She reports that the pain isn't severe, but that her daughter was concerned and brought her in. Shadow-health-abdominal-assessment-quest is used by aradswathtic in Shadow-health-abdominal-assessment-questions-quizlet. Unformatted text preview: Gastrointestinal Results | Turned In Advanced Health Assessment - Spring 2019, NSG516 Online Return to Assignment Your Results Overview Reopen Lab Pass Experience Overview Transcript Subjective Data Collection Patient: Tina Jones Student Performance Index 49 out of 52 Objective Data Collection Education & Empathy Documentation Self-Reflection Student Survey. Maternal Health History A maternal health history. Subjective Data Collection; Objective Data Collection; NR 509 Week 4 Shadow Health Chest Pain Physical Assessment Assignment. com Get All. Today we are talking all about how to assess the cardiac system. NURS550 Focused Note Esther Park Nursing assignment Patient Name or initials: Esther Park Informant:The informant is a 78-year-old woman who is a reliable historian. Bowel habits—once daily, formed brown stool, change with diet change or travel. Nursing has an expanded concept of health; holistic health includes the mind, body, and spirit as interdependent and functioning as a whole within the environment. About Press Copyright Contact us Creators Advertise Developers Terms Privacy Policy & Safety How YouTube works Test new features Press Copyright Contact us Creators. Diplomate, American Board of Ophthalmology Diplomate, American Board of Ophthalmology 5620 E. Shadow Health Tina Jones Focused Exam: Abdominal Pain. HEENT Ecadimi. Some students may need longer. Model Documentation. These questions provide two scenarios about performing a head-to-assessment on a patient, and requires you to use nursing knowledge in how you will proceed with the assessment along with identifying lymph nodes in the neck. Shadow Homeworkjoy. The nursing health assessment is an incredibly valuable tool nurses have in their arsenal of skills. 0%) Daniel "Danny" Rivera is an 8-year-old boy who has had a cough for several days, especially at night. Shadow Health's patient cases are designed for both novice and expert students to practice communicating with and examining patients. The describes. She maintains eye contact throughout the interview. NR 509 Week 3 Shadow Health: Neurological Physical Assessment – REVIEW QUESTIONS To assess spinal levels L2 L3 and L4 in Tina which deep tendon reflexes would have to … tested? Imagine that you were preparing to irrigate a Foley catheter of a patient with a spinal cord injury at T4 in a urology clinic. Module 3 - Respiratory Exam. Exam Mode - Questions and choices are randomly arranged, time limit of 1min per question, answers and grade will be revealed after finishing the exam. , Szilagyi, P. You conciliate insufficiency to consummate either a debriefing conference or the vacillate adaptation enactment! WE ARE THE SHADOW HEALTH EXPERTS, LET'S HELP WITH YOUR ASSESSMENT. Examining your fingers and lips to see whether the skin has a blue tint (cyanosis). She reports that the pain isn't severe, but that her daughter was. Students who do not pass the performance-based assessment by scoring within the Proficiency level in three attempts will receive a failing grade (68 points). Oct 17, 2016 · Assessment of the cardiovascular system involves evaluating the adequacy of the heart’s ability to pump blood and perfuse tissues. Sep 10, 2021 · Tina jones heent assessment quizlet tina jones heent answers. Otoscope assignment with ND Human Phys Study Outline Shadow health focused chest pain sleep stress analysis Chapt 5 - Lecture notes 5. College Physics Raymond A. Objectives & Instructions. Patient denies any gallbladder or liver disease. Lewis's Medical-Surgical Nursing Diane Brown, Helen Edwards, Lesley Seaton, Thomas. abdominal pain and abdominal migraine may can present under this a group. Foster and be sure to thoroughly assess the cardiovascular system as well as related body systems in order to compile a. Please note this is an average time. The interview portion of a comprehensive assessment is intended to obtain a as this could cause disruption to sounds such as those in the abdomen. Question CDT Auscultated breath sounds in posterior left mid-back (lower lobe) Exam Action CDT I'm allergic to cats. Details: Health exists when all aspects of the person are in perfect balance. Esther Park is a 78-year-old Korean woman presenting with abdominal pain in the ED. The purposes of the Shadow Health Physical Assessment Assignments are to: (a) increase knowledge and understanding of advanced practice physical assessment skills and techniques, (b) conduct focused and comprehensive histories and physical assessments for various patient populations, (c) adapt or modify your physical assessment skills and techniques to suit the individual needs of the patient, (d) apply assessment skills and techniques to gather subjective and objective data, (e. shadow health esther park subjective quizlet. Nr 509 week 2 shadow health respiratory physical assessment assignmentpre brief: Complete transcript of conversation for subjective data collection along with a list of the subjective data. REVIEW OF SYSTEMS: GENERAL, CONSTITUTIONAL Recent weight loss [ No ][ Yes ] Fever [ No ][ Yes ] Chills [ No ][ Yes ] EYES, VISION. Group A strep pharyngitis is an infection of the. A focused cardiovascular assessment is usually indicated after a comprehensive assessment indicates a. 1 hours ago by Onlinenursingpapers. Nursing has an expanded concept of health; holistic health includes the mind, body, and spirit as interdependent and functioning as a whole within the environment. Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. Complete the Digital Experience. When Speaking with Digital Standardized Patients: Ask simple and direct. shadow health gastrointestinal subjective, Crohn’s disease is a chronic, … and disease prevention needs Students will use the information found in Tina’s. quizlette87695878. Am sorry to hear that you are having headaches. Nirenberg, MD, FACS East Valley Ophthalmology, Ltd. Shadow Health’s patient cases are designed for both novice and expert students to practice communicating with and examining patients. esther park shadow health answers Best Cheap Online. A Subjective assessment factors are those that are reported by the patient. pdf from NURSING 305 at California State University, Long Beach. Data_ Shadow Health. Preparation: 1) Use good source of light. A general question about the person’s thoughts and feelings about living is frequently a recommended start to this discussion: Sometimes people feel that life is not worth living. Note the patient's movements when performing the range of motion maneuvers. History taking, HEENT, cardiovascular, mental health, etc. She states that her sleep is "shallow and not restful". References: Bickley, L. The Advanced Health Assessment patient case is a series of single-system examinations of Tina Jones during several clinic visits over the course of a simulated year, which students have found useful in preparing for their clinical. A focused cardiovascular assessment is usually indicated after a comprehensive assessment indicates a. NR 509 Shadow Health Focused Exam Case. Patient is a 78 year old Korean female who was just admitted into the ER for abdominal pain and difficulty having a bowel movement. Assess gait and posture. WHEN YOU PERFORM a physical assessment, you'll use four techniques: inspection, palpation, percussion, and auscultation. For example, palpation can increase the frequency of bowel sounds, so auscultation following palpation ; Records 1 - 459 of 459 — shadow health comprehensive assessment quizlet Esther Park is a 78-year-old Korean woman presenting with abdominal pain in. The purposes of the Shadow Health Physical Assessment Assignments are to: (a) increase knowledge and understanding of advanced practice physical assessment skills and techniques, (b) conduct focused and comprehensive histories and physical assessments for various patient populations, (c) adapt or modify your physical assessment skills and techniques to suit the individual needs of the patient, (d) apply assessment skills and techniques to gather subjective and objective data, (e. It is very important to determine whether or not the situation is. Details: Health exists when all aspects of the person are in perfect balance. Patient voids regularly, and claims normal stool color and shape. Use them in sequence—unless you're performing an abdominal assessment. Chapter 12 Abdominal Assessment. Objective especially with abdominal assessment. quizlette87695878. B) the absence of disease. Jan 25, 2016. Text Mode - Text version of the exam 1. Shadow health is useless, time consuming material IMO. Points will be deducted from the rubric if the site does not demonstrate scholarship or quality. Shadow Health Graduate Nursing Modules 1-3. Some students may need longer. Eating spicy foods Assessment - shadow health tina jones gastrointestinal transcript 509 Shadow Health question 05/29/18 12:11 PM CDT No, just inhalers! 'M so sorry to hear that Empathize 05/29/18 12:03 PM CDT is the name. Esther Park is a 78-year-old Korean woman presenting with abdominal pain in the ED. She complains of difficulty falling asleep at least 5 nights per week, but states that she is able to stay asleep without difficulty. Esther's Focused Health Assessment "Mrs. Adults over 30 years of age with non-traumatic chest pain should prompt the triage nurse to consider the possibility of ACS. Park in order to assess her condition and transfer her care. Patient is a 78 year old Korean female who was just admitted into the ER for abdominal pain and difficulty having a bowel movement. Identify areas for focused physical assessment based on findings from the health history. Skin, hair, and nails completed shadow health objective data collection Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. Skin Assessment •Explain to the patient and family that you will be checking the patient's entire skin. Students must register to attend the debriefing session. The reports that the pain started almost one week ago and has gotten progressively worse. Discuss specific assessment findings that are determined by the history and examination, including inspection, palpation, percussion, and auscultation. Comprehensive assessment tina jones shadow health transcript, subjective, objective & documentation. His cough is getting progressively worse. Chronic constipation is one of the commonest lower gastrointestinal disorders affecting people in the western world. · occurs when you have a strong, sudden need to urinate that i…. Transcript Started: Jun 27, 2020 | Total Time:109 min Hello my name is Danielle I will be your provider today Greet 06/27/20 3:27 PM CDT Hey. Esther park abdominal pain focused shadow health assessment transcript, objective, This assignment provides the opportunity to conduct a focused exam on a Brian Foster Chest Pain Shadow Health Assessment Shadow Health Tina Nov 22, 2020 — Focused Exam: Chest Pain k. The cost is $99. Shadow Health Care Plan. You have a maximum of two (2) attempts per Shadow Health assignment to improve your performance. · occurs when you have a strong, sudden need to urinate that i…. Pressing or tapping on your abdomen (abdominal palpation). Please note, this is an average time. Because so many diseases can present with abdominal pain, the. She is the primary source of the health information and freely provides the information. com Get All. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation(Found) Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. After successful completion of this course, the participant will be able to: 1. 7%) Notice: The detailed results o f your assignment attempt are now a. Shadow-health-abdominal-assessment-quest is used by aradswathtic in Shadow-health-abdominal-assessment-questions-quizlet. Foster and be sure to thoroughly assess the cardiovascular system as well as related body systems in order to compile a. 06/11/1431 9 17 Subjective Data Collection •Headache. Shadow Health Comp Assessment. (Especially for Tina Jones' focused abdominal assessment). The interview portion of a comprehensive assessment is intended to obtain a as this could cause disruption to sounds such as those in the abdomen. Has 15 years experience. This quiz may be helpful and it may just be a way to confirm you. No personal or family history of abdominal disease. Each of you will be completing a Shadow Health Assessments each week. The describes. Subjective Data Collection; Objective Data Collection; NR 509 Week 4 Shadow Health Chest Pain Physical Assessment Assignment. FOCUSED HISTORY. Move their gown back down. Course: Primary Concepts Of Adult Nursing II (NUR 4110) W eek 5: SBAR Focused Exam: Chest Pain Results | T ur ned In. Transcript Started: Jun 27, 2020 | Total Time:109 min Hello my name is Danielle I will be your provider today Greet 06/27/20 3:27 PM CDT Hey. obtaining specific information that will influence your assessment and plan for the patient. Apr 11, 2020 · chest pain shadow health assessment Education & Empathy Esther park abdominal pain focused shadow health assessment transcript, objective, subjective solved Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data. Then percuss with your fingers. Because so many diseases can present with abdominal pain, the. 7%) Notice: The detailed results o f your assignment attempt are now a. Cough Completed Shadow Health 14 Focused Exam. from lack of sleep. 0%) Hover To Reveal. Nur 210 shadow health cardiovascular objective data collection (100% correct) Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. Assignment 4. Retur n to Assignment. Indicates an item that is available to be found. Patient is a 78 year old Korean female who was just admitted into the ER for abdominal pain and difficulty having a bowel movement. Thank you Question 06/27/20 3:27 PM […]. She is the primary source of the history. Your patient is Esther Park, a 78-year-old Korean-American woman presenting with abdominal pain in Shadow General Hospital's Emergency Department. Rachel Adler Shadow Health Quizlet. Danny Rivera is a cooperative, pleasant 8 year old Puerto Rican male who presents to the clinic with a chief complaint of cough with fatigue. NR 509 Week 3 Shadow Health: Neurological Physical Assessment – REVIEW QUESTIONS To assess spinal levels L2 L3 and L4 in Tina which deep tendon reflexes would have to … tested? Imagine that you were preparing to irrigate a Foley catheter of a patient with a spinal cord injury at T4 in a urology clinic. is graded as "shallow" if a shadow is cast over ½ of opposite iris. Acute Coronary Syndrome (ACS) One of the greatest impacts on triage processes has been the ability to rapidly identify patients at risk for STEMI (ST elevation myocardial infarction) and other acute coronary syndromes. Amanda_Lemus6. 5 Signs & Symptoms 0. NR 509 Week 5 Shadow Health Focused Exam: Abdominal Pain Assignment latest. Esther Parks Focused Exam Abdominal Pain Care PlanCourseMerit is a marketplace for online homework help and provide tutoring service. College Physics Raymond A. Did the cough medicine make you feel better. Description. Although I'll leave a few things off so it isn't blatantly obvious. 9 hours ago NR509 Shadow Health Abdominal Pain Physical Assessment Assignment Week 5 2018 May. This quiz may be helpful and it may just be a way to confirm you. 8 hours ago Onlinenursingpapers. Shadow health focused exam cough subjective quizlet JCSS. Jan 25, 2016. She has had a couple of moles removed in the past because they were questionable, but she notes they were benign. SUPPORTIVE CARE As an alternative to the term palliative care , the National Cancer Institute defines supportive care as care given to improve the quality of life of patients with a serious or. If you're a nurse practitioner student or new grad NP, documenting a patient encounter can be a bit of a struggle. Did the cough medicine make you feel better. Withgott, Matthew Laposata. A comprehensive patient assessment yields both subjective and objective findings. Specializes in Case mgmt. from lack of sleep. Subjective & Objective Assessment • Subjective assessment: – to gather relevant information about the site, nature, and onset of symptoms – review the patient’s general health and past treatments • Objective assessment: – to determine abnormalities using special tests (without bias). Adler Life-healthy. Focused exam abdominal pain completed shadow health5. His cough does not get worse when he is active. Module 3 - Respiratory Exam. 00 Add to Cart. His cough is getting progressively worse. View Gastrointestinal _Subjective Data_ Shadow Health. (HEENT Physical Assessment) Overview. You've already rated students with this rubric. She notes the pain is generalized across her entire abdomen however hurts more along the left lower quadrant. May 10, 2020 | total time: Cough/nr 509 shadow health focused exam case:. Equipment: 1) Stethoscope 2) Centimeter ruler and nonstretchable measuring tape. She achieved her Bachelor in Nursing through FNP175435 GO. cardiovascular health such as high blood cholesterol, cigarette use, diabetes, or hypertension (CDC, 2011). Comprehensive assessment tina jones shadow health transcript, subjective, objective & documentation. Shadow Healths patient cases are designed for both novice and expert students to practice communicating with and examining patients. No tenderness to light or deep palpation. 06/11/1431 9 17 Subjective Data Collection •Headache. Park in order to assess her condition and transfer her care. Comprehensive Assessment Tina Jones Shadow Health Transcript, Subjective, Objective & Documentation(Found) Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with. I'll be helping a more experienced accountant with her clients, and then eventually I'll get more responsibility, and build my own client list. Model Documentation. If the patient chooses to start at the present, let it happen. Withgott, Matthew Laposata. FusionShadow Health Tina Jones Cardiovascular ALL Subjective Shadow health comprehensive assessment Flashcards | NR 509 Tina Jones Comprehensive Health Assessment An abdominal examination is a portion of the physical examination which a physician or nurse uses to clinically observe the abdomen of a OTHER QUIZLET SETS. pdf from NURSING 305 at California State University, Long Beach. Indicates an item that is available to be found. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of upper stomach pain after eating. External auditory canal - Look for redness, swelling, large amounts. 1 hours ago by Onlinenursingpapers. Students who do not pass the performance-based assessment by scoring within the Proficiency level in three attempts will receive a failing grade (68 points). She reports that the pain isn't severe, but that her daughter was. (Especially for Tina Jones' focused abdominal assessment). He states that the cough began five days ago. , & Hoffman, R. Complete the Digital Experience. Shadow Health Rachel Adler Quizlet LifeHealthy. Interview Mr. Shadow Health’s patient cases are designed for both novice and expert students to practice communicating with and examining patients. The Advanced Health Assessment patient case is a series of single-system examinations of Tina Jones during several clinic visits over the course of a simulated year, which students have found useful in preparing for their clinical. Some students may need longer. Shadow Health Subjective Data Collection: 29 of 30 96. A quick example: Our textbook listed the correct steps in an exam as Inspection, Auscultation, Palpation, Percussion. Subjective Data Collection: 29 of 30 (96. Shadow Health has you percuss third, then palpate last. Maternal Health History A maternal health history. Exactly what I do. The reports that the pain started almost one week ago and has gotten progressively worse. MS Jones reports that she recently landed an employment and thus. Title: Find Rubric. Unformatted text preview: Gastrointestinal Results | Turned In Advanced Health Assessment - Spring 2019, NSG516 Online Return to Assignment Your Results Overview Reopen Lab Pass Experience Overview Transcript Subjective Data Collection Patient: Tina Jones Student Performance Index 49 out of 52 Objective Data Collection Education & Empathy. Components may include: • Chief complaint • Present health status • Past health history • Current lifestyle • Psychosocial status • Family history • Physical assessment. She complains of difficulty falling asleep at least 5 nights per week, but states that she is able to stay asleep without difficulty. Serway, Chris Vuille. Inspection. Subjective Data Collection: 29 of 30 (96. TAACCCT provides community colleges and other eligible institutions of higher education with funds to expand and improve their ability to deliver education and career training programs. And lastly, palpate by pressing lightly around their belly. Retur n to Assignment. Maybe it was, but I totally skipped the course of study. Description. Has 15 years experience. abdominal pain and abdominal migraine may can present under this a group. A thorough history and physical exam is required to identify other signs and symptoms to lead to a diagnosis. Abdomen, Rectum and Breast and Axillae Assessment Abdomen and Rectum. 0%) Daniel "Danny" Rivera is an 8-year-old boy who has had a cough for several days, especially at night. º ask effective and comprehensive questions º obtain a thorough health history º evaluate the patient’s risk of disease, infection, injury, and complications º educate and. Assess gait and posture. Am sorry to hear that you are having headaches. Some students may need longer. Adults over 30 years of age with non-traumatic chest pain should prompt the triage nurse to consider the possibility of ACS. Patient denies pain upon voiding. Objective findings are collected from the physical examination. Sep 07, 2021 · Shadow-health-abdominal-assessment-quest is used by aradswathtic in Shadow-health-abdominal-assessment-questions-quizlet. Within each portion of the HEENT exam the regular examination order is followed. Subjective Data Collection; Objective Data Collection; NR 509 Week 4 Shadow Health Chest Pain Physical Assessment Assignment. Focused exam abdominal pain completed shadow health5. Categ ory Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. The plan developed above reflects his personal chief complaint as well as both subjective and objective findings of my examination and assessment. Nursing has an expanded concept of health; holistic health includes the mind, body, and spirit as interdependent and functioning as a whole within the environment. Comprehensive Assessment Tina Jones Shadow Health. Patient denies any gallbladder or liver disease. Digital Clinical Experience (DCE) scores do not round up. shadow health respiratory assessment transcript. Focused exam abdominal pain completed shadow health5. Students also viewed Physical Assessment - PA head to toe cheat sheet Tina Jones Health History Care Plan Shadow Healthpdf WEEK 2 PA. Shadow Health Focused Exam: Pediatric GAS Pharyngitis Results. She denies any pain acute illness, pain or. Title: Find Rubric. Cough Daniel Danny Rivera is an 8-year-old boy who comes to the clinic with a cough. Within each portion of the HEENT exam the regular examination order is followed. Cough Completed Shadow Health 14 Focused Exam. 9 hours ago NR509 Shadow Health Abdominal Pain Physical Assessment Assignment Week 5 2018 May. Developed with nursing students in mind, SimChart provides a realistic, yet controlled way to help students master their practice. NR 509 Advanced Physical Assessment. The following is sample documentation from abdominal health assessment of a healthy adult. Learn vocabulary, terms, and more with flashcards, games, and other study tools. Esther stated that she went to the clinic more because her daughter (Jennifer) is very concerned about her health. Within each portion of the HEENT exam the regular examination order is followed. Respiratory Concept Lab Notes - Shadow health study guide by scullionnicole includes 13 questions covering vocabulary, terms and more. Tina Jones Gastrointestinal Physical Assessment Results_Tabs. No personal or family history of abdominal disease. Students also viewed Physical Assessment - PA head to toe cheat sheet Tina Jones Health History Care Plan Shadow Healthpdf WEEK 2 PA. Inspection:. NR 509 Week 7 Shadow Health Comprehensive Health History and Physical Assessment Assignment. , Szilagyi, P. The updated Social history section on the patient Summary includes improvements to smoking status, which has been renamed "Tobacco Use", and additional data elements to support recording alcohol use, financial resources, education, physical activity, stress, social isolation and connection, and exposure to violence. Shadow Health’s patient cases are designed for both novice and expert students to practice communicating with and examining patients. Get the answer for NURS 751 Health Assessment-Shadow Health Answer Key. Comprehensive Assessment Tina Jones Shadow Health. 30-967-2021 4 hours ago Shadow Health Tina Jones Focused Exam: Abdominal Pain Results - Holistic Assessment in Nursing - January 2019, NUR 275. Categories. NURS 4520- Esther Park Shadow Health Abdominal Assessment. Everything's an Argument with 2016 MLA Update University Andrea A Lunsford, University John J Ruszkiewicz. And lastly, palpate by pressing lightly around their belly. 9 hours ago NR509 Shadow Health Abdominal Pain Physical Assessment Assignment Week 5 2018 May. NR 509 Advanced Physical Assessment. (Abdominal Pain) Pre Brief: Ms. Upon moving the leg bag the patient became suddenly flushed and. Categories. With a weak or incorrect assessment,. º ask effective and comprehensive questions º obtain a thorough health history º evaluate the patient’s risk of disease, infection, injury, and complications º educate and. Thanks for your feedback! When assessing the assessment, assess him to determine the services or not? How Can You Prevent Diabetes?. Jul 4, 2020 - Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data Danny Rivera Pediatric Cough Shadow Health Assessment Subjective Data Subjective Data Collection: 20 of 20 (100. During the debriefing process, students reflect upon their simulation experience and. Comprehensive Assessment Tina Jones Shadow Health. Fill shadow health abdominal pain esther park quizlet: Try Risk Free Form Popularity esther park shadow health nursing diagnosis quizlet form Get, Create, Make and Sign focused exam abdominal pain shadow health. Subjective & Objective Assessment • Subjective assessment: – to gather relevant information about the site, nature, and onset of symptoms – review the patient’s general health and past treatments • Objective assessment: – to determine abnormalities using special tests (without bias). It is occasionally productive, producing a clear, "slimy" mucous without odor. This assignment provides the opportunity to conduct a focused exam on Brian Foster, who presents with recent episodes of chest pain in a non-emergency setting. Subjective Data Collection: 31 of 31 (100. Cashback Offer from 25th to 31st August 2021. Shadow Health's patient cases are designed for both novice and expert students to practice communicating with and examining patients. NR 509 Week 2 Shadow Health HEENT Physical Assessment Assignment. Shadow Healths patient cases are designed for both novice and expert students to practice communicating with and examining patients. Note the patient's movements when performing the range of motion maneuvers. The purposes of the Shadow Health Physical Assessment Assignments are to: (a) increase knowledge and understanding of advanced practice physical assessment skills and techniques, (b) conduct focused and comprehensive histories and physical assessments for various patient populations, (c) adapt or modify your physical assessment skills and. Friend, I am so glad you're here! We are just rockin' and a rollin' on this nursing head-to-toe assessment study guide. The reports that the pain started almost one week ago and has gotten progressively worse. Essential Environment: The Science Behind the Stories Jay H. Nursing has an expanded concept of health; holistic health includes the mind, body, and spirit as interdependent and functioning as a whole within the environment. Shadow-health-abdominal-assessment-quest recommended by. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. Maternal Health History A maternal health history. esther park shadow health nursing diagnosis quizlet. Pre Brief: Ms. NURS550 Focused Note Esther Park Nursing assignment Patient Name or initials: Esther Park Informant:The informant is a 78-year-old woman who is a reliable historian. You must also provide sufficient documentation so that you can. She reports that the pain isn't severe, but that her daughter was. Subjective Data Collection: 31 of 31 (100. Faculty will lead virtual debriefing sessions during Weeks 1-6. Shadow Health Graduate Nursing Modules 1-3. Module 6 Discussion. She reports that the pain isn't severe, but that her daughter was concerned and brought her in. Aug 20, 2021 · Comprehensive Assessment Tina Jones Shadow Health Transcript …. Patients with lung disease often complain of the following symptoms: dyspnea/shortness of breath, cough, sputum production, fatigue, exercise intolerance, chest tightness or chest pain. Brian foster chest pain objective. 30-967-2021 4 hours ago Shadow Health Tina Jones Focused Exam: Abdominal Pain Results - Holistic Assessment in Nursing - January 2019, NUR 275. Pinna - Check for skin changes that may represent skin cancer, nodules that may indicate gout. Your date of birth Question 06/27/20 3:27 PM CDT February 17th. A comprehensive head-to-toe assessment is done on patient admission, at the beginning of each shift, and when it is determined to be necessary by the patient's hemodynamic status and the context. , Szilagyi, P. The perfusion process is similar to a plumbing system: the heart acts as the pump to deliver oxygenated blood to the cells, and the vascular network functions as the pipes. Some students may need longer. shadow Ofdesign. This instance con-balance succeed investigate you to. No tenderness to light or deep palpation. Get the answer for NURS 751 Health Assessment-Shadow Health Answer Key. Category Scored Items Experts selected these topics as essential. Jones presents to the clinic complaining of back pain that began 3 days ago after she "tweaked it" while lifting a heavy box while helping a friend move. Health Assessment - Exam I quiz. Module 3 - Respiratory Exam. Park is an elderly female from Korean descend that comes into the clinic complaining about belly pain and having difficulties using the bathroom for a couple of days”. Assess gait and posture. The following is sample documentation from abdominal health assessment of a healthy adult. com Get All. Discuss specific assessment findings that are determined by the history and examination, including inspection, palpation, percussion, and auscultation. Students determine if Danny is in distress, explore the underlying cause of his cough, and look for related symptoms in other body systems. Topic 3: Health Assessment During the Adolescent and Prenatal Periods. Tina Jones' Comprehensive Assessment. Each of you will be completing a Shadow Health Assessments each week. Students who do not pass the performance-based assessment by scoring within the Proficiency level in three attempts will receive a failing grade (68 points). His cough does not get worse when he is active. A comprehensive patient assessment yields both subjective and objective findings. Shadow Health Graduate Nursing Modules 1-3. Asking tina how she is treating her cough might reveal her current symptom management and health literacy. on Vimeo, the home for high quality videos and the people who love them. Shadow Health Tina Jones Focused Exam: Abdominal Pain. Your date of birth Question 06/27/20 3:27 PM CDT February 17th. Constipation also has cost implications in terms of. Sep 10, 2021 · Tina jones heent assessment quizlet tina jones heent answers. co DA: 6 PA: 50 MOZ Rank: 88. Tina Jones tweaked her back lifting a box Week 3 Shadow Health Assessment Musculoskeletal Subjective: HPI: Ms; Jones presents to the clinic complaining of back pain that began 3 days ago after she "tweaked it" while lifting a heavy box while helping a friend move. Foster and be sure to thoroughly assess the cardiovascular system as well as related body systems in order to compile a. We have experts in subjects of maths, science and many more. Can you please state your name for me please Question 03/15/20 11:31 AM PDT Tina Jones. The date, time, and duration of the weekly debriefing session will be posted by the course faculty. Jones is a pleasant, 28-year-old African American single woman who presents for a pre-employment physical. esther park shadow health nursing diagnosis quizlet. com Get All. Lewis's Medical-Surgical Nursing Diane Brown, Helen Edwards, Lesley Seaton, Thomas. Shadow Homeworkjoy. 4) Comfortable relaxed position. health history completed shadow health if you are using safari and have issues with audio in your assignment, please click here for assistance. Focused Exam: Abdominal Pain Esther Park Shadow Health Complete Assignment Solution. com Get All. Start studying Esther Park-Shadow Health-Abdominal Pain. Foster and be sure to thoroughly assess the cardiovascular system as well as related body systems in order to compile a. Points will be deducted from the rubric if the site does not demonstrate scholarship or quality. Each of you will be completing a Shadow Health Assessments each week. 2/11-2/17 Module 2: Abdomen Shadow Health Abdominal Concept Lab Shadow Health Abdominal Quiz 2/18-2/24 Module 3: Chest and Lungs Shadow Health Respiratory Concept Lab Shadow Health Respiratory 2/25-3/3 Module 3: Continued - Heart, & Blood Vessels Concept Lab Cardiovascular Tina Jones Shadow Health Cardiovascular Videoed Assessment Checkoff #1 Quiz. First inspect all skinsurfaces or assess the skingradually as you examineother body systems. Steatorrhea. Esther Park is a 78-year-old woman who comes to the clinic complaining of abdominal pain. Interview Mr. Assessment on Skin, Hair & Nails / HEENT. Exam Mode - Questions and choices are randomly arranged, time limit of 1min per question, answers and grade will be revealed after finishing the exam. The head-to-toe assessment includes all the body systems, and the findings will inform the health care professional on. health assessment, we lack material for advanced practice graduate nursing students. Choose from 490 different sets of shadow health flashcards on Quizlet. from lack of sleep. Within each portion of the HEENT exam the regular examination order is followed. Equipment: 1) Stethoscope 2) Centimeter ruler and nonstretchable measuring tape. Withgott, Matthew Laposata. Learn vocabulary, terms, and more with flashcards, games, and other study tools.




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15. to prevent reproduction of proteins History. Why is it important to hematology lab Flashcards Quizle. Wait about one second for the liquid to flow into the tip. Prior steps for creating recombinant plasmids are described in traditional cloning basics and involve insertion of a DNA sequence of interest into a vector backbone. c 2. Use the Answers link to check your answers. Some examples include: diagnosis of HIV infection, pregnancy tests, and measurement of cytokines or soluble receptors in cell supernatant or serum. No contact lenses should be worn around hazardous chemicals – even when wearing safety glasses. Hand washing is 99. Score at least Must score at least to complete this module item Scored at least Module item has been completed by scoring at least View Must view in order to complete this module item Viewed Module item has been viewed and is complete Mark done Must Labster pipetting quizlet 11 . The growth of bacteria can be observed over the solid nutrient medium, in the liquid broth medium and Using a pH indicator you will determine how much acid/base is needed for the solution to be neutralized. ) d Do not put down the cap/ cotton wool plug. Why is it important to Pigment Extraction Labster Quiz Questions: Directions: Highlight the correct answer for each question. They're an essential part of the  How accurate is a volumetric pipette? Why do we use a volumetric flask Labster? Why do we use a volumetric flask quizlet? What do you do if you add too much . Using a pH indicator you will determine how much acid/base is needed for the solution to be neutralized. • Use the two stops of the pipette. Once you master the art of pipetting, you will dilute your protein solution 10. ELISA is a rapid test used for detecting or quantifying antibodies (Ab) against viruses, bacteria, and other materials or antigens (Ag) . 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His clinical reasoning questions helped my students achieve a deeper understanding of their complex medical patients. Become a Registered Nurse (RN). Each case study allows readers to develop their own approaches to the resolution of ethical. 24 - 1-1 & 1-2 Exam January 25, questions and answers Respiratory System 1 is a virtual anatomy lab study and practice tool that provides students 24/7 it's great for students of biology, nursing, medicine, and massage therapy; but it. Nov 18, 2020 — Keith rn case study answers copd. As an outpatient department nurse, she is a seasoned nurse in providing health teachings to her patients making her also an excellent study guide writer for student nurses. Keith rn case studies answers quizlet Keith rn case studies answers quizlet. Until recently, Leo and Nancy had always been active in the community. 1 Spending on federal healthcare programs continues to grow significantly. Anticipatory and Advance care planning ( ACP), in practical terms, are both about adopting a "thinking ahead" philosophy of care that allows practitioners and their teams to work with people and those close to them to set and achieve common goals that. post the entire writeable PDF for a student to complete and then send back for feedback. The paramedics relate the above story of why he is being admitted. Nosocomial infective endocarditis commonly manifests with elements of a sepsis syndrome (ie, hypotension, metabolic acidosis fever, leukocytosis, and multiple organ failure). To gain knowledge about the specific disease, it’s pathology, etiology, sign and symptoms and management process. an upcoming nurse must incorporate safety standards into daily nursing practice. Strauss is a 24 year-old college student. The United States finds itself at a pivotal moment in the history of medicine when the annual growth in US healthcare spending increased to 5. Whether you Nurslng just starting your course, preparing for your first placement, writing an Essay, or revising for your end-of-year Care, this book will support you through it all, with interactive activities, real. This article presents some of the unique aspects of SLT, along with observations from years of experience from the world’s leading experts in the procedure. A 12-week pilot study of acceptance of a computer-based chronic disease self-monitoring system among patients with type 2 diabetes mellitus and/or hypertension 18 August 2017 | Health Informatics Journal, Vol. There have been and are numerous studies assessing the financial cost of hard-to-heal, chronic wounds, of many different types. Congenital heart defects: Clinical practice Videos, Flashcards, High Yield Notes, & Practice Questions. Case Study 3: Hyde Tools — Doug DeVries 11-97 3. Essay on yoga in sanskrit language! Wegmans culture case study. 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The ruling comes after a steep rise in the number of coronavirus cases in Bnei Brak, a mostly haredi city in Israel, and following a funeral early on Sunday morning, March 21, for Rabbi Tzvi Shinker, attended by hundreds of people in violation of Health Ministry directives allowing 20 people at a funeral. Whether your course uses our book or not, you can reinforce your understanding of many topics related to the study of algorithms by browsing the excerpts, code, and exercises here, watching the lecture videos, and/or using our book. As soon as the historian seeks to study colour, he must grapple with a host of factors all at once: physics. Find best-selling books, new releases, and classics in every category, from Harper Lee's To Kill a Mockingbird to the latest by Stephen King or the next installment in the Diary of a Wimpy Kid children’s book series. Student Directors Amanda Williams Sarah Williams (Alternate) AAFP Delegates Larry Rues, MD Darryl Nelson, MD Bruce Preston, MD (Alternate) Keith Ratcliff, MD (Alternate) MAFP Staff Executive. Rogers is directly admitted to the medical unit with a stage II non-healing ulcer on his right heel. Inflammation represents an important additional. 23 out of 10 average quality score. We encourage you to read the case study and really through the "critical thinking checks" as this is where the real learning occurs. This makes it easy to post any Case studies suited for intermediate nursing students. These unfolding cases combine the power of storytelling with the experiential nature of simulation scenarios. NUR 2868 / NUR2868: Role, Scope, Quality, and Leadership in Professional Nursing Exam 2 Study Guide (Latest 2021/2022) Rasmussen College College. A 12-week pilot study of acceptance of a computer-based chronic disease self-monitoring system among patients with type 2 diabetes mellitus and/or hypertension 18 August 2017 | Health Informatics Journal, Vol. Hypertension. evolve_case_study_answers_hypertension 2/4 Evolve Case Study Answers Hypertension [EPUB] Evolve Case Study Answers Hypertension Medical-Surgical Nursing - E-Book-Sharon L. All of coupon codes are verified and tested today! KeithRN's innovative case studies bring clinical to your cla. As members of a democratic society, individuals face complex decisions about whether to support climate change mitigation, vaccinations, genetically modified food, nanotechnology, geoengineering, and so on. 48 hours $18/page. Our Keith Rn Case Study Answers Dka operators are always ready to assist and work for you 24/7. Blood pressure is determined both by the amount of blood your heart pumps and the amount. As soon as the historian seeks to study colour, he must grapple with a host of factors all at once: physics. It has been one hour from the onset of his neurologic symptoms when he. MSG is used at levels much lower than salt. Thereafter, oral agents, such as phospho- diesterase inhibitors (sildenafil), can be used for. To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy to help you see that you are progressing to clinical analysis. Students may participate in fieldwork, learning expeditions, projects or case studies to be able to apply knowledge learned in the A student in a big city, for example, might study statistics about pollution, read information about its effects, and travel to sites in. Brain Awareness Video Contest Submit a short video about any neuroscience topic for a chance to win $1,000 and a trip to SfN's Annual Meeting!. 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Pharmacology case studies for nurse prescribers Authors Donna Scholefield, Alan Sebti and Alison Harris Medium Text Class Copies Usage Title Available (l) o Handbook of systemic drug treatment in dermatology Authors Sarah H Wakelin, Howard I Maibach and Clive B Archer Medium Text Class Copies Usage Title QV 60 ailable (2) o. Planeta-host. I just reverted this text an NPOV and unencyclopedic: A number of advocate groups (e. Comparison of single-use and reusable metal laryngoscope blades for orotracheal intubation during rapid sequence induction of anesthesia: a multicenter cluster randomized study. com an e-business case study , technology ka essay, media and information literacy as expression of freedom of speech essay, my school ka essay bataiye case study of dependency theory byu. is to reduce death and disability as a result of accidents and give children basic first aid skills. 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My research falls into three broad areas: (1) social factors and the onset, course, and outcome of mental and physical illness, (2) social factors and aging, and (3) the organization and delivery of health services. Though the company only recently applied to the US Food and Drug Administration, the SRP is already a valuable tool for surgical residents using a library of images from typical case studies. We only got answers like. " Walensky said that the Cape Cod. Please email [email protected] com, also read synopsis and reviews. Assessment & Reasoning. Let’s look at a case study of an “Expert Interview” published on-line June 9, 2008 under the tagline Medscape Perspectives on the American Psychiatric Association (APA) 161st Annual Meeting, May 3-8, 2008, Washington, DC. 100 Case Studies In Pathophysiology by Harold Jr Bruyere available in Trade Paperback on Powells. Which form of reasoning is the 3. Keith rn case study answers" Keyword Found Websites Keyword-suggest-tool. 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Case Study: A Patient With Uncontrolled Type 2 Diabetes and Complex Comorbidities Whose Diabetes Care Is Managed by an Advanced Practice Nurse Geralyn Spollett, MSN, C-ANP, CDE The specialized role of nursing in the care and education of people with diabetes has been in existence for more than 30 years. ), the Program in Medical Education for the Latino Community (PRIME-LC), Leadership Education to Advance Diversity-African, Black and Caribbean (LEAD-ABC), Health Education to Advance Leaders in Integrative Medicine (HEAL-IM), an M. All Chromebooks have accessibility features built in, including screen readers and magnifiers, to make getting things done easier. While evaluating George's understanding, which statements indicate that George understands the nurse's instructions about his medications?. Darlene has no significant medical history and no obstetric history. - Nursing Student Allnurses. It is a member of the Kentucky state university system. Your client, Mr. Expatica is the international community’s online home away from home. The American Nurse Education and Career Guide, provides you with facts, figures, other nurses’ experiences, and tons of other resources to help you in your journey. Marie-Eve Poitras, Maud-Christine Chouinard, Martin Fortin, Ariane Girard, Sue Crossman & Frances Gallagher - 2018 - Nursing Inquiry 25 (4):e12250. Even more familiar was the description of subjects in each study. Request a specific writer – choose an academic writer from the dropdown list in the order’s form (optional for returning customers). is to reduce death and disability as a result of accidents and give children basic first aid skills. These cases describe common and challenging care dilemmas. NUR 2868 / NUR2868: Role, Scope, Quality, and Leadership in Professional Nursing Exam 2 Study Guide (Latest 2021/2022) Rasmussen College College. Too often people imagine that long hours of studying are the best path to being a model, straight-A student. Goyal, Hafiz Ansar Rasul Suleria, Ademola Olabode Ayeleso, T. A case report of ventricular septal defect in a calf 284 BJVM, 15, No 4 A male Holstein calf weighing 40 kg, 90 days of age, was presented to the Ve-terinary Teaching Hospital at Azad Uni-versity of Shahrekord, with a history of depression, low weight gain and hyper-pnoea. Essay of the impact of climate change on the economy of south africa /mozambique. This could be derived 1%m study or from working abroad. VIReC Series. This volume is made by the same people who made the graphics for Gray's for Students, but is just pure anatomy without the textbook explanations. Were watching. John is a 45-year-old male with hyperthyroidism. cases per 100,000 person-years Incidence of acute respiratory distress syndrome (ARDS): 13. As an outpatient department nurse, she is a seasoned nurse in providing health teachings to her patients making her also an excellent study guide writer for student nurses. When I really look back on it, there were some changes during pregnancy. 57,58,59,60,61,62,63,64,65,66,67 These assessed parameters including nursing time and length of stay in hospital, along with how severity increases costs, some examples are shown in Table 1. Mood enhancement. The nurse should also ask Jonathan if he has hypertension, another primary underlying condition Heart Failure Clinical Reasoning Case Study Keith Rischer, RN, MA, CEN, CCRN Review of Terms. MASTER CLASS: Sensor-Based CRT Optimisation: New Insights from the Respond-CRT Clinical Trial - Sponsored by LivaNova. Utilizing a series of scenarios encourages the development and application of critical thinking and clinical judgement skills. Patient Overview. There's an edit war brewing on the controversy section. So, nursing school is behind you and all that's left is to pass the NCLEX-RN® and you're off to the career of your dreams. In a year’s time, Dixons Carphone’s benefits package could look completely different. Thereafter, oral agents, such as phospho- diesterase inhibitors (sildenafil), can be used for. For example, computer-tailoring studies have found that behavior feedback resulted in better awareness of personal behavior and a greater intention to change (de Bourdeaudhuij and Brug, 2000; Oenema et al. We have included more than 1,000+ NCLEX practice questions covering different nursing topics for this nursing test bank!We’ve made a significant effort to provide you with the most challenging questions along with insightful rationales for each question to reinforce learning. 1 Spending on federal healthcare programs continues to grow significantly. Case study emerging industry, sample of essay why i want to be a nurse. Hypertension Clinical Reasoning Case Study. 2020 APEX Award of Excellence for Health & Medical Writing ("Nicotine toxicity: Protecting children from e-cigarette exposure," January 2020). Rock active learning as an educator or if you are a student, use this written case study with fully developed answer key to understand this essential content. Waqar Khan, MD , provider of state-of-the-art cardiology services to the Houston area for over 20 years, and author of “Be Heart Smart: Understand, Treat, and Prevent Coronary Heart Disease. Reference this. An analysis of 27,000 patients in the INTERSTROKE study including those in the UK showed that hypertension was the most important modifiable risk factor for stroke. Nursing - Medical - Surgical Nursing 5. Powered by www. Oxford Medicine Online is a digital platform hosting Oxford University Press' prestigious medical titles. Ecological Knowledge and Environmental Problem-solving : Concepts and Case Studies Social Sciences: General 1986. Please make sure that you've entered a valid question. In his new book, Dr. Singapore: Springer Singapore. According to the American sociologist Earl Robert Babbie, "research is a systematic inquiry to describe, explain, predict, and control the observed phenomenon. edition test bank, question bank of biology questions and answers 3, essential cell biology 4th edition chapter 1 cells the, essential cell biology flashcards and study sets quizlet, hello old friend my how you ve changed, test bank for essential cell biology 4th edition by, test bank for. Case Study 3 Congestive Heart Failure Essay. International Journal of Clinical Case Studies, 1. Paper presented at the annual meeting of the International Conference on Applied Human Factors and Ergonomics, Orlando, FL. Heart failure represents a significant burden for patients and the Canadian health care system. This study will help inform our plans for the future. • Former smoker and drinks 1-2 drinks per night approximately 4 days per week. Utilizing a series of scenarios encourages the development and application of critical thinking and clinical judgement skills. Essay on yoga in sanskrit language! Wegmans culture case study. Exam results. “The general idea in the past was, you treat it, and it’s over. Get instant access to all materials. These unfolding cases combine the power of storytelling with the experiential nature of simulation scenarios. Pregnancy Induced Hypertension (PIH) is a condition in which vasospasms occur during pregnancy in both small and large arteries. heres the case study and the questions below it (my answers were in orange though im not surethanks in advance ! h. Are living. Case rn study hypertension Keith answers Greek gods and goddesses essay describing a person essay my father. With VCA's 6,000+ compassionate veterinarians, more than 600 board-certified specialists, and 1,000+ animal hospitals located in 46 US states and 5 Canadian provinces, you are always in good hands. The facilitator should also print out growth charts for both sexes for display and questions. Clinical forethought can be introduced using unfolding case studies that encourage students to make a patient’s values, preferences and beliefs an important factor in their care. My career as a university professor emphasizes teaching and mentoring students from diverse backgrounds in anthropology (sociocultural, medical and applied) and social science research methods, as. Hypertension Case Study. As in the case-study, CHF is associated with hypertension, which is one of the causes for heart failure caused by excessive stretching of the heart muscles. Case Study 2: Ontario Hydro — Corinne Boone 11-69 c. In light of these elements, it is interesting to describe. Keith Rn Case Studies Answers Hypertension. 3 %, which was similar to the national prevalence of 10. Strauss is a 24 year-old college student. For the latest government information, visit https://www. 5 Case Study: Small World. Additionally, it also depends on how well these studies have controlled for other factors, which in case studies is not generally the case. Biology Forums - Study Force is the leading provider of online homework help for college and high school students. Ella Yu (VL) Pressure Ulcer Decubitus ulcers, pressure sores or bedsores Caused by unrelieved pressure Etiology Due to localized ischemia Deficiency in the blood supply to the tissue Reactive hyperemia (bright red flush) Vasodilation- compensate for the preceding period of impeded blood flow Two factors: Friction Shearing force Pressure Ulcers Risk factors: Immobilty Inadequate. Case Study On Acute Pancreatitis Prepared by: De Castro, Richelle Sandriel C. In case of safety concerns nursing staff could overrule the advice. SAGE is a global academic publisher of books, journals, and a growing suite of library products and services. Research from JAMA Ophthalmology — Classification of Visual Field Abnormalities in the Ocular Hypertension Treatment Study ACUTE RENAL FAILURE: CASE. Example questions and answers. These designs can reconcile scholarship on race and causation and offer a clear framework for future research. Anxiety related to the uncertainty of. All nursing CE courses are ANCC accredited. Di Lorenzo L, De Pergola G, Zocchetti C, et al. CreditJohnny Milano for The New York Times. Answers about Lung Transplantation for PULMONARY HYPERTENSION. These case are part of the Department of Justice's China Initiative, which reflects the strategic priority of countering Chinese national security threats and reinforces the President's overall national security strategy. Expert authorship from Dr. Black Eye for America How Critical Race Theory Is Burning Down The House Paperb. 978-1-4511-8525-6. GeorgeProfessor Emerita of Sociology. Chlorpyrifos background 827 3. During the whole life 6% of the planet's population have. Rock active learning as an educator or if you are a student, use this written case study with fully developed answer key to understand this essential content. Check out this case study on hyperthyroidism & learn everything you will need to about to ace your View Answer. Counsel diabetic patients on lifestyle modifications, including blood glucose control, weight control, smoking cessation, diet, and exercise. He first presented with chest pain in March 2010 where he was diagnosed with ischemic heart disease. It is known as the 'study of the particular' for its thorough investigation of particular, real-life situations and is gaining increased attention in nursing and. January 2014. - Nursing Student Allnurses. She also states that she has noticed her hair. In order to complement the results of the statistical analysis, case studies were developed for the two selected states (New York and Indiana), using semi-structured interviews and document analysis. We only got answers like. Pregnancy Induced Hypertension (PIH) is a condition in which vasospasms occur during pregnancy in both small and large arteries. 1 million children in the US under 18 years of age, making it one of the most common chronic childhood disorders (American Lung Association, 2021). He first presented with chest pain in March 2010 where he was diagnosed with ischemic heart disease. Keyword-suggest-tool. COVID-19-related studies. He describes the quality of the abdominal pain as sharp, originating in the epigastric region and. Reference this. provide only a yes-no answer to infection, and will identify as positive patients with low amounts of virus in their bodies. Home telemonitoring is proposed as an intervention that can improve heart failure outcomes by identifying opportunities for earlier clinical intervention and by providing patients with self-management support between scheduled clinic visits. This essay is based on a case study and will discuss the underlying pathophysiology, management and psychosocial aspects a patient faces when diagnosed with pre-eclampsia. Mr Alan Chari(pseudonym used to protect the identity of a patient),was admitted over night in my department. Wrenda's younger child is an infant who feeds every 3 hours. Utilizing a series of scenarios encourages the development and application of critical thinking and clinical judgement skills. It is unique to pregnancy and occurs in 5% to 7% of pregnancies in the united states. Each case study topic comes with a student writable PDF and a separate fully developed answer key. She has been a member of the BMS for many years and has served as a previous Council Member. While some sections of a job application form only. A longitudinal study on the effect of shift work on weight gain in male Japanese workers. Case study 1 - Mrs Patel. Ramon Ortega, a 42-year old farm laborer with a history of hypertension, had been experiencing headaches on an almost daily basis for 2 to 3 weeks. Download Now. Below is a collection of donated scenarios for you to use or modify. Different evidence obtained from various controlled trials has highlighted the significance of using antihypertensive drugs to treat and reduce the health outcomes in patients suffering from the. These designs can reconcile scholarship on race and causation and offer a clear framework for future research. Meet the Client: Leo WhiteLeo White, a 64-year-old male, was diagnosed with Parkinson's disease 4 years ago. - Nursing Student Allnurses. Objectives: At the end of this module Outcome studies with isolated systolic hypertension have shown that decreasing systolic BP by. Keith rn case study answers 21. com Books has the world’s largest selection of new and used titles to suit any reader's tastes. Professor Frances Kay-Lambkin is a registered Psychologist and mental health researcher. coronavirus. You must get at least 12 answers correct on these practice tests to pass your citizenship test. Keith rn case studies answers quizlet Keith rn case studies answers quizlet. You can cancel anytime within the 30-day trial, or continue using Nursing Central to begin a 1-year subscription ($39. Thanks for helping me and my friends with college papers! You have the best essay writers really. The opportunity to manage studies and free time in an enjoyable manner. Students are given different types of Promote And Provide Healthy Food And Drinks case studies just like the one shown below: This is the CHCECE004 case study that we got from a student, whom we helped with a high-quality reference assignment solution. Info: 3633 words (15 pages) Nursing Case Study. "Your Guide to Lowering Your Blood Pressure with DASH. --Military policy,Nuclear arms control--Case studies. Slideshow 2395702 by kagami. multiple-choice questions - though these are rarely used. Whenever their shifts connected, they would compare notes on their experience. 8%) the mean fasting glucose was 138. Keith rn heart failure case study answers quizlet. An estimation on the basis of the results of previous epidemiological studies showed that hypertension is the most important factor of. Benaroch's 24 lectures, experience for yourself the high-stakes drama and medical insights of life in an everyday emergency department: the most intense department in any hospital and home to the kind of split-second decision making, troubleshooting, and detective work that can make the difference between a patient's life and death. Rogers is directly admitted to the medical unit with a stage II non-healing ulcer on his right heel. Head Office and Distribution Centre Unit E1, 3-29 Birnie Avenue, Lidcombe NSW 2141 ABN 24 096 845 126. Ten SCEs provide fundamental nursing concepts, skills and techniques of nursing practice and the foundation for more advanced areas of study. Free Meningitis Case Study Resource Nursing Case Studies is Nurse inspired and is Nurse driven. Access Google Docs with a free Google account (for personal use) or Google Workspace account (for business use). Nursing Activities for Patients with Chronic Disease in Family Medicine Groups: A Multiple-Case Study. This case study discusses the management of a 68 year old male who presented with chest palpitations secondary to rapid trial fibrillation. You never know if this writer is an honest person who will deliver a paper on time. With over 1,000 books available, many of which include exclusive digital tools such as videos to further enrich your learning. Search for: HOME. 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It provides 24/7 emergency access to consultant-delivered care for a wide range of specialist clinical services and expertise. it HESI Hypertension Flashcards Quizlet A persistent case is a stud factor for strokes, case attacks, and heart failure[2] Even a moderate elevation in blood pressure could lead to a Benefits of Exercise on Hypertension Essay There is a direct relationship between. Research paper on management techniquesDissertation ghostwriter kosten ted bundy case study worksheet. Hi, Please if anyone have can help me with this case study I'll appreciated so much!!! Darlene Hall is a married 25-year-old female who works as an attorney. A was obese, incontinent, visually impaired, had degenerative joint disease, a history of hypertension, anemia, significant gait and balance instability, and severe 52 JOURNAL OF AGING STUDIES Vol. i am a nursing student and i have a case study that i need to answer but im having a hard time figuring out the answers. Apply for a study permit. Sustaining nurse-led task-shifting strategies for hypertension control: A concept mapping study to inform evidence-based practice Worldviews on Evidence-based Nursing , 14 ( 5 ) ( 2017 ) , pp. Elaine Drew. Challenge: Competing QI initiatives may impact the ability to measure the primary outcome8. Jones) Nursing Care Plan Area(s): Nutrition and Hydration Nursing diagnosis (1). 12:15 - 13:00. - Ann, English Graduate. Case examples: Active Bathing to Eliminate (ABATE) Infection study. This is a case study on a 76 year old man. Blood pressure lowering efficacy of coenzyme Q10 for primary hypertension. The cases studied occurred in people vaccinated primarily with Pfizer and Moderna shots, with a smaller number having received Johnson & Johnson's The study itself is less alarmist, stating that "microbiological studies are required to confirm these findings. Her Oldest Child Is 3% Years Old. 324 In addition, there are state laws that govern the use of health data tend to go beyond the protections provided by HIPAA. The two main situations where a case Esay is Care are commerce and Care pursuits. • Past medical history of hypertension that is well controlled with hydrochlorothiazide. ### Case 1 R. Travel exemptions and restrictions for international students. If you need professional help with completing any kind of homework, Solution Essays is the right place to get it. Sign in with your university email. An analysis of 27,000 patients in the INTERSTROKE study including those in the UK showed that hypertension was the most important modifiable risk factor for stroke. All nursing CE courses are ANCC accredited. Search across a wide variety of disciplines and sources: articles, theses, books, abstracts and court opinions. This resource brings together authoritative texts by world-renowned authors available online for the first time. 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Li, Lusi (2021) Multi-View Robust Representation Learning. Case Studies in Gerontological Nursing for the Advanced Practice Nurse, John Wiley & Sons, Ltd, 2012 Case Studies in Nursing : Clinical Case Studies for the Family Nurse Practitioner, Wiley-Blackwell, 2011 Case Studies in Palliative and End-of-Life Care, Wiley-Blackwell, 2012. In 2 studies, 1 in the United States48 and 1 in Linxian, China,50 no association was seen. Get Nursing top-quality online case study assignment questions and answers help series Essay an ideal provider in the Study. Amour J, Le Manach YL, Borel M, Lenfant F, Nicolas-Robin A, Carillion A, et al. Clinical forethought can be introduced using unfolding case studies that encourage students to make a patient’s values, preferences and beliefs an important factor in their care. Every ACE unfolding case uses the highly regarded unfolding case model developed for Advancing Care Excellence for Seniors (ACE. 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These case are part of the Department of Justice's China Initiative, which reflects the strategic priority of countering Chinese national security threats and reinforces the President's overall national security strategy. He was transported to the emergency department (ED) where these symptoms continue to persist. 978-1-4511-8526-3. Obaseki, Ayodeji Michael, and Emeto, Theophilus Ikenna (2015) Management of eclampsia in an unbooked primigravida: a case report showing the impact of cultural and socio-economic factors on health outcomes. an upcoming nurse must incorporate safety standards into daily nursing practice. If you've ever gone for a run after a stressful day, chances are you felt better afterward. Answers provided by 260 participants who work as football, male basketball and female basketball coaches in National Collegiate Athletic Association (NCAA) were analysed using the original scale that…. He was resuscitated and given 5 nanograms/kg/min of. Hypertension, obesity, history of congestive heart failure (CHF), chronic kidney disease (CKD) and age put this patient at risk for a CV event. We also incorporate functionality from other websites, such as video, social media feeds and Browsealoud (text-to-speech and translations services) which may set cookies. We looked at it from the perspective of an. Download Now. , stressful. Study hypertension Keith rn answers case How to introduce college essay, essay my future profession lawyer. See step-by-step how to solve tough problems. Study rn hypertension answers case Keith. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?. Blood pressure is determined both by the amount of blood your heart pumps and the amount. Darwin Skeptics A Select List of Science Academics, Scientists, and Scholars Who are Skeptical of Darwinism Compiled by Jerry Bergman PhD. 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Utilizing a series of scenarios encourages the development and application of critical thinking and clinical judgement skills. Presently, the two federal laws most relevant to the use of electronic health data for research are the Health Insurance Portability and Accountability Act (HIPAA) and the Common Rule. , nobody said purification was not a necessary step. In order to complement the results of the statistical analysis, case studies were developed for the two selected states (New York and Indiana), using semi-structured interviews and document analysis. Research on the relationships among religion, spirituality and health has grown dramatically over the past decade. Apart from the clinical presentation of dyspnea, the patient also has 8 pound weight gain, which points out to another etiological factor of obesity which results in the causation of CHF. Rachel Swain, Editorial manager. 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Chapter-ending Think Critically questions return to the patient in the case study and ask you to explore options and make clinical judgments related to the. Case Study on Copd 4135 Words | 17 Pages. And it’s amazing how you deal with urgent orders!. In 2016, Vermont saw a large spike in drug overdose deaths — from 108 in 2015 to 148 in 2016. On March 11, 2020, the World Health Organization (WHO) declared a global pandemic. It is a specialist hospital responsible for the care of the most severely injured patients involved in major trauma. an acute appendicitis. Wayne Oates (1917-1999) produced an extensive, pioneering body of work and research in the field of pastoral care and counseling. MASTER CLASS: Sensor-Based CRT Optimisation: New Insights from the Respond-CRT Clinical Trial - Sponsored by LivaNova. Dietary supplements to enhance exercise and athletic performance come in a variety of forms, including tablets, capsules, liquids, powders, and bars. A patient in his 70s presents to the emergency department with a 1-day history of intermittent epigastric abdominal pain that radiates into his back. The nursing history may repeat some of the same items that the medical history has obtained but the nurse will have different objectives in mind when asking questions and gathering data, The following guide can be used to obtain information from the patient and nursing-related information. "Anyone who's studied infectious diseases knows that a PCR test cannot be used to diagnose anything. Nursing - Nursing Pathophysiology 2. #YouCanLearnAnything Subscribe to Khan Academy's NCLEX-RN channel Unfortunately that it didn't answer my question. And she has not yet responded to our rapid response post on her article But not a single team could answer that question with "yes" — and NB. We hoped that he treats biblical texts. Female: 36% – 44%. m −2 (median BMI of PWH without diabetes who were also HCV negative and HIV negative). Every ACE unfolding case uses the highly regarded unfolding case model developed for Advancing Care Excellence for Seniors (ACE. The case history for Martha will then guide you through the assessment, nursing action and evaluation of a patient with heart failure. Summarize the health issue based on the Conduct nutrition education Promote physical activity in daily living. It is unique to pregnancy and occurs in 5% to 7% of pregnancies in the united states. The Diabetes Community Exercise and Education Programme (DCEP) is an interprofessional, patient-centred, whānau (family)-supported. I received high grade and positive feedback from my instructor. Evidence review of EHR transitions: Implications for VA's implementation of Cerner Millennium (intranet only). Davis's Comprehensive Handbook of Laboratory and Diagnostic Tests with Nursing Implications, 8th Ed. 7 The overall evaluation allowed for the. program in cooperation with The Paul Merage School of Business, an M. Utilizing a series of scenarios encourages the development and application of critical thinking and clinical judgement skills. Halogenated 18:40, 22 January 2008 (UTC) Agreed. The issue of type II diabetes is significant in my nursing practice, as I often encounter patients with hypertension, hyperlipidemia and hyperglycemia. 1 /1994 memory and concentration problems that pointed to progressive dementia. He is a retired teacher and his son is permanently employed by a local company as an electrician. Exam results. Get Nursing top-quality online case study assignment questions and answers help series Essay an ideal provider in the Study.

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