Professional Development

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Bukidnon State University
College of Nursing
Malaybalay City, Bukidnon

In Partial Fulfillment
of the Requirements for the Course
NCM 107-B
Nursing Leadership and Management

A Case Study on:
PROFESSIONAL DEVELOPMENT
Improper Delegation

Submitted by:
Auguis, Fe
Cagulada, Lharra Mae
Casite, Nielmark
Doydora, Ma. Zusette
Gomez, Junfelm
Homamoy, Frances Joy
Palado, Marcher
Robosa, Joshua
Santillan, Cheerille
Telin, Marvin
Tortola, Loweelyn
Torayno, Imelda
Villamor, Rachelle

Submitted to:
Dr. Violeta B. Juan

TABLE OF CONTENTS

I.

II.
III.

INTRODUCTION
a. Objectives/Statement of the Problem
b. Theoretical Framework
c. Significance of the Study
d. Definition of Terms
REVIEW OF RELATED LITERATURE
CASE

IV.

PROBLEMS IDENTIFIED AND NURSING CARE PLAN

V.

SUMMARY, EVALUATION, AND RECOMMENDATION

VI.

APPENDICES

I.

INTRODUCTION

A changing health care environment is impacting on the role of practice nurses. As a result of
fundamental changes taking place in both health care and nurse education, the clinical role of the
practice nurse will need to extend and expand (Paxton et al 1996). New knowledge and skills
will be a necessity. In the future, one of the greatest challenges to practice nurses will be the
attainment, maintenance and advancement of their professional development.
The importance of continuing professional development (CPD) for nurses has been
increasingly emphasized in the past few years. An Bord Altranais, in its Review of Scope of The
Commission on Nursing, saw the need to develop and strengthen the availability of professional
development for all nurses and suggested that it might be helpful to consider continuing
professional development three broad headings: in service training, continuing education and
specialist training (Commission on Nursing, 1998).CPD has been shown to improve job
performance, quality of care, organizational performance and service delivery across
employment sectors with consequential reduction in costs.

Continuing Professional Development-Definitions
The National Council for the Professional Development of Nursing and Midwifery
(2003) defines CPD as: a lifelong process, which includes both structured and informal activities
that may include formal educational programmes. This definition is in keeping with an earlier
one provided by the English National Board (1990) which states continuing professional
education is any post-basicprofessional education which is directed at maintaining and
improving the quality of care provided to the public (ENB 1990 p. 3). There is a general
consensus that continuing professional development for practice nurses should be purposeful,
patient centered and educational effective (Jenkins-Clarke and Carr-Hill 2001). Resource
constraints should not be used as an excuse for neglecting continuing professional development
for this group of community based nurses-inequalities between practice nurses and other based
community nurses should go and participation should be both encouraged and integrated.

Continuing Professional Development in Practice
Nursing quality care requires considerable knowledge and skills from its practitioners.
Through time, challenges in the health field will continue to occur. The knowledge and skills
needed by practice nurses will also need to change to meet the challenges posed by this changing
health care environment.
Continuing Professional Development creating the right environment
Kemp (2003) believes that professional development occurs where professionals see their
task in a new light, with the aim of maintaining or improving the quality of professional
performance. The vast majority of practice nurses are conscientious about the art and science of
nursing Mackereth (1995), and have always recognized the importance of CPD for the
maintenance of up-to-date practice, while others may be less enthusiastic.

Dengue Hemorrhagic Fever
Dengue hemorrhagic fever is a severe and sometimes fatal infection that occurs tropical
regions. It is most common in Southeast Asia and the western Pacific islands. The dengue virus
is transmitted by mosquitoes. A more severe version of the infection called dengue hemorrhagic
fever can involve significant bleeding and a drop in blood pressure that can cause shock and
death. This condition is sometimes known as dengue shock syndrome.
Dengue hemorrhagic fever can occur when a person is bitten by a mosquito and exposed
to blood infected with the dengue virus. Those who are repeatedly exposed to the dengue virus
often experience more acute symptoms and are at risk for dengue hemorrhagic fever.
People at risk of contracting the dengue virus include people living in or traveling to
Southeast Asia, South and Central America, Sub-Saharan Africa, and parts of the Caribbean.
These patients are also at higher risk:infants and small children, the elderly, and those with
compromised immune systems.

The symptoms of the dengue virus generally include mild, moderate, or high fever,
headaches, nausea, vomiting, pain in the muscles, bones, or joints, and rashes on the skin. In the
case of dengue hemorrhagic fever, other disturbing symptoms can develop. These may
include:restlessness, acute fever, bleeding or bruising under the skin, and cold or clammy skin.
Philippine Hemorrhagic Fever was first reported in 1953. In 1958, hemorrhagic fever
became a notifiable disease in the country and was later reclassified as Dengue Hemorrhagic
Fever. The morbidity rate of dengue fever in 2003 is much lower at 13 cases per 10,000
population compared to the highest ever recorded rate of 60.9 per 100,000 in 1998. The case
fatality ratio for dengue fever and dengue hemorrhagic fever in 2003 is also lower at 0.8%
compared to the highest recorded ratio of 2.6% in 1998.
A Dengue Hemorrhagic Fever patient, having a lethal disease must be strictly watched for
the signs and symptoms as this could turn to life-threatening situation.
The presenters being student nurses sought to know and understand delegation, tasks that
are not to be delegated, laws relating to improper delegation in relation to the case identified, and
professional development activities to improve knowledge on delegation.

A. Objectives/ Statement of the Problem
General Objectives:
At the end of 2 hours of discussion, the facilitators will be able to impart knowledge to
the participants that they will be able to understand proper delegation and apply the nurse
manager's actions/interventions in their professional development when they become future
nurse staffs and nurse managers.
Specific Objectives:
At the end of 2 hours of discussion,
 The facilitators will be able to discuss briefly delegation, tasks that are not to be
delegated, and laws relating to improper delegation;
 The facilitators will be able to discuss the job descriptions of the nurse staff, nurse
manager, and nursing attendant;
 The facilitators will be able to present a case study based on the facilitator's hospital
experience regarding delegation;
 The facilitators will be able to present a conceptual framework based on the theory of
Knowles;
 The facilitators will be able to present a Nursing Care Plan for a critical patient in the
case study;
 The facilitators will be able to determine the Nurse Manager's actions to be done with the
staff nurse who improperly delegated the task;
 The participants will be able to understand and relate their own experiences to the case
study;
 The Clinical Instructors will be able to provide additional information on delegation and
professional development.

B. Theoretical Framework

Knowles’ Adult Learning
Knowles’

Theory

(1978)

Adult Learning Theory claims

that adults learn differently

from children. This difference

should be identified and

addressed

development for health care

workers.

Learning

applicable to the development

Theory

is

of learning opportunities for

registered

in

professional

Knowles’
nurses.

Adult
Knowles

labeled the differences in adult learning andragogy. Andragogy deals with how science and art
assist adult learners in a special way. The goal of educators should be to guide adult learners to
meeting their learning needs and reaching their goals.
There are six basic assumptions of andragogy (Knowles, 1978). The first assumption is
called self-concept. This means that adults need to be self-directed. The second assumption
addresses the issue of experience. Adults bring their past experiences to the learning
environment. The third assumption is readiness to learn. Adults are ready to learn when they feel
that they need to know the information or when they feel the increase in knowledge will help
them accomplish a task more effectively. The fourth assumption is orientation to learning. As
adults mature, they apply knowledge learned immediately. Adults learn based on an immediate
problem or task, and this is related to the fifth assumption—motivation. As adults mature, the
motivation to learn becomes intrinsic. The sixth assumption is the need to learn. To be motivated,
adults must know the reason why they should learn something. These six assumptions are
essential to the creation of the milestone pathway tool. They drive the creation of the tool that
helps facilitate forming professional development goals that are significant to the individual and
specific to the nursing unit. The tool encourages self-direction and takes into account experience
level. Understanding the assumptions allows creation of a tool that is appropriate for adult
learners.

Conceptual Framework

1. Selfconcept

2. Issue of
experience

KNOWLES ADULT
LEARNING
THEORY

3. Readiness

PROFESSIONAL
DEVELOPMENT

4.
Orientation
to learning

5. Motivation
The first assumption is called self-concept. This means that adults need to be selfdirected. As a Registered nurse you need to think first the welfare of others before yourself. To

6. Need
to you.
grow professionally this kind of attitude must
be within
The second assumption addresses the issue of experience. Adults bring their past
experiences to the learning environment. If you are an experienced nurse you already know if
how to assess your patients thoroughly. You know what are the task need to done and need to be
delegated. As a RN you learn based on an immediate problem or task and you will know what to
do. You already know how to weigh the situation to what will be prioritize.
The third assumption is readiness to learn. Adults are ready to learn when they feel
that they need to know the information or when they feel the increase in knowledge will help

them accomplish a task more effectively. For professional development, nurses need to have
continuing education to be updated and has an attitude to learn and accept opinions from others.
The fourth assumption is orientation to learning. As adults mature, they apply
knowledge learned immediately. When you are in this stage you will apply all your
learningsfrom the new updates that you learned.
The fifth assumption is motivation. As adults mature, the motivation to learn becomes
intrinsic. Registered nurses must have the motivation for continuing professional development as
this will help them enhance their knowledge, skills, and attitude towards nursing.
The sixth assumption is the need to learn. To be motivated, adults must know the
reason why they should learn something. T
These six assumptions are essential to the creation of the milestone pathway tool. They
drive the creation of the tool that helps facilitate forming professional development goals that are
significant to the individual and specific to the nursing unit. The tool encourages self-direction
and takes into account experience level. In order for you to be a competent nurse and to grow
professionally you should not stop learning. You should have continuing education. To be more
efficient and effective nurse, you should be updated to the new trends and development in
nursing profession so that you can provide quality care to your clients.

C. Significance of the Study
This study is significant to the following:


Staff Nurses and Nursing Attendants. The staff nurses and nursing attendants
will be presented and updated regarding their roles and responsibilities as a
nurse/nurse attendant, the tasks that are not to be delegated, and laws relating to



improper delegation;
Chief Nurses. The study will present the Chief Nurse the actual scenarios
observed by student nurses in the hospital, and will be able to further conduct
continuing professional development activities for the nurses and nurse
attendants.



Dean of College of Nursing of Bukidnon State University. This study can be
used as a basis for providing training programs, workshops, and conferences



regarding professional development.
Student Nurses of Bukidnon State University- the students will be able to know
what delegation is, the tasks that are not to be delegated, laws relating to improper

delegation; and also will serve as a source for further studies;
 Researchers. This study will serve as a related literature to future researchers who
would like to pursue a similar study.

D. Definition of Terms
 Delegation is the assignment of responsibility or authority to another person to carry


out specific activities..
Improper Delegationis the improper assignment of responsibility to another person



to carry out specific activities.
Primary care is the day-to-day health care given by a health care provider. Typically
this provider acts as the first contact and principal point of continuing care for
patients within a health care system, and coordinates other specialist care that the



patient may need.
Nursing process is a modified scientific method. The nursing process uses clinical
judgement to strike a balance of epistemology between personal interpretation and
research evidence in which critical thinking may play a part to categorize the clients



issue and course of action. Nursing offers diverse patterns of knowing.
Head nurses can work in any variety of medical facilities such as hospitals, treatment
centers or nursing homes. In general, they work in larger facilities where coordination
of nursing teams is needed. Head nurses carry out the same functions as any other
nurse, but they are in a managerial position and often are responsible for whole



sections of facilities as well as communication with upper management and doctors.
Staff Nurse evaluates assigned patients and plans, implements and documents



nursing care. Assists physicians during examinations and procedures.
Nurse practitioner (NP) is an advanced practice registered nurse (APRN) who has
completed advanced coursework and clinical education beyond that required of the
generalist registered nurse (RN) role.



Nursing aidesometimes called a nursing assistant, assists medical staff in providing
care for residents of long-term care facilities, such as nursing homes, as well as for



short-term hospital patients.
Andragogya specific theoretical and practical approach, based on a humanistic
conception of self-directed and autonomous learners and teachers as facilitators of





learning.
Need to know: Adults need to know the reason for learning something.
Foundation: Experience (including error) provides the basis for learning activities.
Self-concept: Adults need to be responsible for their decisions on education;



involvement in the planning and evaluation of their instruction.
Readiness: Adults are most interested in learning subjects having immediate





relevance to their work and/or personal lives.
Orientation: Adult learning is problem-centered rather than content-oriented.
Motivation: Adults respond better to internal versus external motivators.
Errand is an oral message entrusted to a person.

II.

REVIEW OF RELATED LITERATURE

Nurses have authority to assign selected activities of care to other qualified and competent
helpers while protecting the health, safety, and welfare of every patient. Registered Nurses (RNs)
determine the tasks that can be delegated; they rely on other assistive caregivers as a necessary
component of safe staffing. Organizations rely on assistive workers to provide a cost-effective
skill mix. Threats of nursing shortages, mandates for reportable quality outcomes, and data
supporting greater RN presence as improving nurse-sensitive measures have increased the
urgency to ensure appropriate RN staffing inclusive of effective delegation.
Delegation unburdens the RN from unnecessary work others can do, while the RN retains
accountability for care and outcomes. With increased complexity of patients, nurses increasingly
must use critical thinking skills to evaluate the type of care, circumstances, and competence of
assistive caregivers prior to delegation. Delegation remains an underdeveloped skill among
nurses, and one that is difficult to measure. It relies on personality, communication style, and
cooperation. The success or failure of delegation depends on a positive two-way relationship of
mutual respect and trust between the RN and the helper who assumes responsibility for specific
tasks. This dynamic exchange between the RN and the helper requires constant evaluation,
feedback, and modification to achieve the results needed to meet patient care goals.
The six initial articles in this topic address a variety of considerations that are important in
successful delegation. These considerations include traditional and emerging thought about the
common skills necessary for delegation and the unique challenges across practice settings. A
number of common themes emerge in this topic. First is the importance of understanding the
legal authority to delegate to other qualified individuals. In the United States (US) each state
issues its own definitions and regulations regarding delegation, whereas there is no legal
definition of nursing in the United Kingdom (UK), making delegation even more challenging.
Additionally, in any practice setting, developing trust is a fundamental requirement for successful
delegation. Nurses’ delegation skills develop over time, building on critical thinking, and
growing from being uncomfortable delegating to others to being confident in this delegation
process. Competence in delegation is as important for the nurse as are other cognitive or
psychomotor skills. This competence requires ongoing education and development. The
influence of delegation on quality and safety outcomes should not be underestimated. Growing
sophistication in our ability to measure nurse-sensitive outcomes creates an imperative to assess
the contributions of all who contribute to care under the direction of the RN.

Building delegation skills starts with all nurses understanding the provisions of their nurse
practice acts, and also understanding of the concepts of responsibility, accountability, and
authority. In Developing Delegation Skills, Weydt walks the reader through the fundamental five
rights of delegation as articulated by the National Council of State Boards of Nursing (NCSBN).
These include the right task; circumstance; person; direction and communication; and
supervision and evaluation. She points out two major ways delegation occurs, by simple task
assignment based on job descriptions or matching a staff member’s expertise to a patient’s needs.
Weydt stresses the need for: (a) clarity in delegation, (b) ongoing development of delegation
skills, (c) assuring that the person to whom a task is delegated is qualified to perform the task,
and (d) assuring the RN retains final accountability.
Anthony and Vidal describe how the right communication, one of the five rights of
Delegation, influences effective delegation. In Mindful Communication: A Novel Approach to
Improving Delegation and Increasing Patient Safety, they explore ‘mindful’ communication
which requires individuals to recognize the significance of facts and how the facts relate to a
current patient condition or situation. Scenarios amplify the relationship of delegation to safety
and quality outcomes. Some of the tasks typically delegated, for example turning, ambulating,
providing personal care, and/or glucose checking, are directly associated with nurse-sensitive
outcomes, such as preventing complications and maintaining physiologic balance. The right
communication transmitted via timely and clear messages makes communication meaningful.
Reflecting on the communication concepts of ‘information decay’ and ‘information saliency,’
RNs must emphasize to the assisting caregiver what information is important and clarify any
information that can be interpreted in more than one way. Just as communication breakdown is
responsible for sentinel events, it also has a significant effect on effective delegation in our daily
practice.
In Delegation in the School Setting: Is it a Safe Practice?, Resha points out that school
nurses are providing more care than ever before, with limited numbers of providers. In many
locations the ratio of RN to students is five times the recommended 1 to 750 well students.
Nurses are called upon to perform health screenings, immunizations and reporting, health
teaching, case management, and management of medically fragile children with complex needs,
including ventilators, pacemakers, and insulin pumps. Safe delegation can occur for some of
these activities if there is adequate training of assistive personnel and close supervision.
However, for school nurses assigned to multiple buildings and locations, close supervision is a
myth. In some schools there is no support for a nurse helper. When the RN is not present, other
substitutes, for example administrators, teachers, and/or parents, may step in to provide care; this
presents a risk to safe patient care as well as to the school nurse. School nursing practice includes

playing a role in development of school policies, being competent in the five rights of delegation,
educating assistive personnel, and building relationships to ensure proper delegation.
Delegation is a universal nursing skill. With the looming world-wide nursing shortage, any
change in skill mix will undoubtedly lead to an increase in the amount of delegation of certain
aspects of care. In the UK delegation is recognized as an important skill at all levels of practice.
Gillen and Graffin describe the authority, accountability, and responsibility for delegation in the
UK, along with facilitators and barriers in their article Delegation in Nursing in the United
Kingdom. With no legal definition of a nurse in the UK it is imperative that there be clarity in
procedures for delegation as well as clarity between the RN and Health Care Assistant. Many
delegation similarities exist between the UK and the US. In both countries the RN retains
accountability and responsibility for care, but the person who accepts the assigned work also
accepts responsibility for performing the work. Appropriate delegation assumes that prior to
assignment of tasks, the RN uses judgment and demonstrates critical thinking to assess the skill,
competence, attitude, and experience of the helper, as well as the patient requirements and nature
of the circumstances. Building of trust, effective communication, and mutual support contribute
to success in the US and the UK, and around the world. (Delegation Dilemmas: Standards and
Skills for Practice by: Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN; Retrieved February 24,
2015)
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) defines
negligence as a "failure to use such care as a reasonably prudent and careful person would use
under similar circumstances." JCAHO defines malpractice as "improper or unethical conduct or
unreasonable lack of skill by a holder of a professional or official position; often applied to
physicians, dentists, lawyers, and public officers to denote negligent or unskillful performance of
duties when professional skills are obligatory. Malpractice is a cause of action for which
damages are allowed." Malpractice is defined variously under state nurse practice acts,
institutional policies, and federal guidelines such as JCAHO standards, all of which may be taken
into consideration in court.
Several factors have contributed to the increase in the number of malpractice cases
against nurses:


Delegation. As a result of cost-containment efforts in hospitals and HMOs, nurses are
delegating more of their tasks to unlicensed assistive personnel. Delegation of some
of these tasks may be considered negligence according to a given facility's standards
of care or a state's nurse practice act.



Early discharge. Patients are being discharged from hospitals at earlier stages of
recovery and with conditions requiring more acute and intensive nursing care.Nurses
may be sued for not providing care or not making referrals appropriate to the patient's
condition.



The nursing shortage and hospital downsizing have contributed to greater
workloads for nurses, increasing the likelihood of error.



Advances in technology require nurses to have knowledge of a variety of
technologies' capabilities, limitations, and safety features.



Increased autonomy and responsibility of hospital nurses in the exercise of
advanced nursing skills have also brought about greater risk of error and liability.



Better-informed consumers are more likely to be aware of malpractice issues and to
recognize insufficient or inappropriate care.



Expanded legal definitions of liability have held all professionals to higher
standards of accountability. For example, because of the expanded scope of practice
of advanced practice nurses, courts have held them to a medical standard of care.

Republic Act 9173, also known as the Philippine Nursing Act of 2002 states in Article 6,
Section 28 that it shall be the duty of the nurse to “undertake nursing and health human resource
development training and research, which shall include, but not limited to, the development of
advance nursing practice.” Nurses really must continue professional development in accord to
the law, in order to provide the best possible care to patients.

IIII.

CASE

Nurse Z has been working at Bukidnon Hospital with competitive service of caring and
love for patients for almost five years. He is currently assigned as a charge nurse at the Pediatric
Ward, supervising three nurses under his shift. One fine day in the hospital, the ER staff was
extremely busy caring for urgent patients arriving. A male infant named BABY was brought to
the ER by his mother who is 14 months old with a high fever of 40.1°C, and red patch rashes all
over the body. The mother said that it was the 6th day of his fever, he does not drink his milk, has
been having diarrhea, bleeding on gums, vomiting, epistaxis, swelling around the eyes, irritable
with a blood pressure of 80/60 mmHg, pulse pressure of 20 mmHg, PR-147bpm, RR-51cpm.
While in the ER, after the admitting physician examined the child, he diagnosed him of
having a Dengue Hemorrhagic Fever Degree III, the charge nurse carried out the order and asked
the nursing attendant “Could you please start IVF on pt. BABY? I’m very busy carrying out
orders here.” The nursing attendant did insert the IV cannula but the first attempt was
unsuccessful. After several times of reinsertion of the IV cannula to the same vein, she finally
was able to insert it. She left the child and attended to next patients without informing the charge
nurse regarding the several attempts of IV cannula insertion. After a while, the mother
complained to the nurses and said,: “Hey my baby’s hand is starting to swell and blood is coming
out from his nails!”, but the nurses did not pay much attention not until the mother screamed for
help. Suddenly, all staff gave their attention and transferred the patient to the Pediatric Ward. The
patient’s mother told Nurse Z about the situation that have happened at the ER that her baby’s
IVF was not infusing well and that the site has become swollen. After a few hours, lab results
were in and the CBC showed thrombocytopenia (90,000mm3). Nurse Z knew that the patient
must be strictly watched for complications of Dengue Hemorrhagic Fever such as extensive
bleeding, LOC and pleural effusion. However, the bedside nurse delegated the task to the nursing
attendant to discontinue and reinsert a new IV cannula to another site because she was busy
attending other patients and carrying out doctor’s orders.

V.

SUMMARY, EVALUATION, AND RECOMMENDATION

At the Emergency Ward, the nursing attendant inserted the IV cannula but the first
attempt was unsuccessful. After several times of reinsertion of the IV cannula to the same vein,
she finally was able to insert it. She left the child and attended to next patients without informing
the charge nurse regarding the several attempts of IV cannula insertion. At the Pediatric Ward,
Nurse Z knew that the patient must be strictly watched for complications of Dengue
Hemorrhagic Fever such as extensive bleeding, LOC and pleural effusion. However, the nurse
delegated the task to the nursing attendant to discontinue and reinsert a new IV cannula to
another site because she was busy attending other patients and carrying out doctor’s orders. The
identified problem from the case was: Non-compliance to hospital protocol related to improper
delegation. Inserting an IV cannula is not in the job description of a nursing attendant, therefore,
the charge nurse, though she was busy carrying out the Doctor's Orders, should not have
delegated the task to the attendant. Only Registered Nurses who are trained for IVF insertion can
do the task.

Recommendation:
As aspiring future nurse staffs and nurse managers, we recommend the following:
1. The hospital must precisely formulate a comprehensive scope of practice for the
Registered Nurse and Nursing Attendants, including the specific tasks which are
delegable.
2. Registered Nurses must consider the set of tasks he/she would delegate, that fit with the
nursing assistant’s skill and are in accord to the hospital protocols.
3. Advance Life Support and knowledge updates through seminars on delegation.
Although it is costly, these activities will help not just the staff nurses but also the nurse
managers to enhance their management skills.
2. Seminar on Philippine Nursing Act of 2002.
Republic Act 9173 encompasses the Scope of Nursing Practice on Article VI. It must be
presented to all the Registered Nurses as well to remind them of their legal tasks, and
their duty of continuing professional development.

ASSESSMENT
Subjective data:
“gamayrakaayoiyanggakaihi. Ga whole day
nalangiyang diaper,
gamayragyudangbasadayun nay
dugogapanggawassaiyangtudlouglagus.” as
verbalized by the mother
Objective data:
 Tachycardia (PR-147bpm)
 Tachypnea (RR-51cpm)
 Hypotension (80/60 mmHg)
 Decreased urine output
 Bleeding on gums
 Delayed clotting time
 Thrombocytopenia Platelet count –
90,000mm3

NURSEING
DIAGNOSIS
Deficient fluid
volume r/t
hemorrhage

OBJECTIVES

INTERVENTION

Nursing Outcome
Classification
(Expected
Outcomes)

Independent Nursing
Intervention
Classifications:

Short term:
At the end of 30
minutes of several
interventions, the
patient’s vital signs
will be stable and
bleeding will be
minimal.
Long term:
At the end of few
hours of
interventions, the
patient’s platelet
count will improve.

Bedside Nurse
1. Asses initial vital
signs
2. Monitor vital signs
every 15-30
minutes.
3. Put pressure on the
bleeding areas
Dependent Nursing
Intervention
Classifications:
Medication Nurse
4. Start IVF PNSS 1
L upon doctor’s
order.
5. Blood transfusion
(platelet)
Charge Nurse
6. Monitor platelet
count together
with the med tech.
7. Refer the pt. to the
physician.

R
-

F

-

T
v
T
n
d

-

-

T
th
a

-

T
p
T
b

-

-

T
p
re
o

ASSESSMENT
Subjective cues:
“Could you please
start IVF on pt.
BABY? I’m very busy
carrying out orders
here.” As verbalized
by the charge nurse to
the nursing attendant.
Objective cues:
The nursing attendant
inserted the IV
cannula but the first
attempt was
unsuccessful. After
several times of
reinsertion of the IV
cannula to the same
vein, she finally was
able to insert it. She
left the child and
attended to next
patients without
informing the charge
nurse regarding the
several attempts of IV
cannula insertion.

IV.

PROBLEM
Improper
Delegation

OBJECTIVES
Nursing Outcome
Classifications
(Expected Outcomes)
At the end of nurse
manager’s action, the
staff nurse and
nursing attendant will
comply with hospital
protocols.

ACTION
1. Call the attention
of the staffs on
duty and the
nursing attendant
on that shift.
2. Have them make
incident report.
3. Review to them
the consequences
and sanctions of
their action.
4. Evaluate their
previous
performances
whether they
have committed
the same action
on their previous
duties.
5. Decide whether
to give them a
second chance or
terminate them
immediately.

-

RATIONALE
To have them
explain their side
of the issue.

-

For
documentation

-

To remind them
of the hospital
protocols.

-

So that the nurse
manager will
have her basis on
her decision.

-

To reduce the risk
dragging the
Hospital’s name
on the wrongful
actions that the
staff nurses
commits.

PROBLEMS IDENTIFIED AND NURSING CARE PLAN

Definition: HYPERTHERMIA the body temperature rises above the normal range.
ASSESSMENT
PROBLEM
OBJECTIVES
ACTION
Subjective cues:
Nursing Outcome
Independent Nursing
“He has been feverish for
Hyperthermia related Classifications:
Interventions

RATI

the past days. He cries a
lot, too” as verbalized by
the patient’s mother.
Objective cues:









High fever (Temp.
– 40.1°C)
Irritable
Cries a lot
Has no appetite
Tachypnea
Tachycardia
Warm skin
Skin redness

to the process of
dengue virus infection

(Expected Outcomes)

Classification:

Short term:
That during 30mins1hour of nursing
interventions, patient
will experience
normothermia with a
temperature of 3637°C.

Charge Nurse:
1.Carry-out Doctor’s
orders
2. Make and follow-up
laboratory results (e.g
WBC- 15/L
3.Assess possible
etiology of increased
temperature

Long term:
At the end of our duty,
patient will be able to
maintain a core body
Bedside Nurse:
temperature of 36-37°C 1. Provide/ encourage
even without RTC
patient to drink
antipyretic.
plenty of fluid as
tolerated (colostrum)
2.Instruct the significant
other to let the
patient wear
clothing that is thin
and not the cotton
and silk ones.
Medication Nurse:
1.Inform patient
regarding the side
effects of the drugs to
be administered
2.Considers the nursing
precautions in drugs to
be given
Nursing Aide:
1.Monitor V/S every
30mins.
2.Provide and increase
air circulation

Bedside Nurse:
1.Intake and output

1.To facilitat
of care
2.To determi
regimen. To
and other me
3.To monitor
causes of the
condition

1.To replace
evap

2.To provide
comfort and
clothing abso
does not stim
increase in bo

1.To educate
effects and le

2.To prevent
upon adminis

Nursing Aide
1.Vital signs
determine the
general cond
2. Serves as a
measure to lo
heat

Bedside Nurs
1.Detecting e
dehydration a
balance of flu

every 3hours once or
more often.
Dependent Nursing
Interventions
Classification:
Nursing Aide:
1.Application of Tepid
Sponge Bathe
Remove excess
blankets when the client
feels warm; provide
extra warmth when the
client feels chilled.
Medication Nurse:
1.Administer
antipyretics as ordered.
Paracetamol Syrup
2.5mL PRN PO

ASSESSMENT
Subjective cues:
“There was blood coming
out from his gums since
this morning,” as
verbalized by the
patient’s mother.
Objective cues:








Bright red blood
on gums
Petechiae
Has no appetite
Pale skin
Pale nail beds
Capillary refill
less than 2secs
V/S are as
follows:BP-80/60

PROBLEM

OBJECTIVES

Risk for
hemorrhage related
to altered clotting
factor

Nursing Outcome
Classification:
After 3 hours of
nursing
interventions, the
client will be able
to demonstrate
behaviors which
reduce the risk of
bleeding.

ACTION
Independent NIC:
Charge Nurse:
1.Carry-out Doctor’s orders
2. Make and follow-up
laboratory results (e.g Platelet
Ct: 90,000mm3)
Bedside Nurse:
1. Assess the signs and
1.
symptoms of GI bleeding.
Check for secretions.
Observe color and
consistency of stools or
vomitus.
2. Observe for presence of
petechiae, ecchymosis,
bleeding from one more
sites.

electrolytes i

1.To enhance
evaporation a

2.Removing
cooling meas
providing of
promotes hea

1.To lower d
temperature.

RATIO

1.To facilitate c
care
2.To determine
regimen

1.The GI tract i
source of bleed
mucosal fragili

2.Sub-acute dis
intravascular co
develop second
clotting factor.

mmHg, pulse
pressure of 20
mmHg, PR147bpm, RR51cpm

Nursing Aides:
3. Monitor vital signs hourly
or more often.
Medication Nurse:
4. Use small needles for
injections. Apply pressure
to venipuncture sites for
longer than usual.
Collaborative:
1. Administration of
PNSS 1L 50cc/hr as
per Physician’s order

3.An increase in
decrease BP can
of circulating bl

4. Minimize dam
reduce risk for b
hematoma.

1. To repla
can go
transfus
isotonic

VI.

APPENDICES

Duties and Responsibilities of a Head Nurse:
 Head nurses can work in any variety of medical facilities such as hospitals, treatment
centers or nursing homes. In general, they work in larger facilities where coordination of
nursing teams is needed. Head nurses carry out the same functions as any other nurse,
but they are in a managerial position and often are responsible for whole sections of
facilities as well as communication with upper management and doctors.
a. Head nurses manage all the administrative duties of the departments which theyare
assigned to work in
b. They schedule shifts for the nurses and assign duties to them.
c. They collect work reports from all the nurses regarding their day-to-day activitiesand
maintain a record of them.
d. They present the records collected from all the nurses to the respective doctorswho are
handling cases of those patients.
e. They assist and conduct training programs for the nurses who are new and need help.
f. They also solve any issues related to the patients.
g. Head nurses also come in direct contact with the patients and diagnose their health
problems
h. Inventory management is also one of the responsibilities of the head nurses.
i. Head nurses review and supervise the pre-operative settings made by the nurses in the
operating room and make sure that they have provided required equipment’s to the
doctors.
j. Head nurses often accompany the doctors when they go on their rounds to checkthe
patients where they present the reports collected by them.
k. They provide necessary help to the doctors such as carrying diagnostic equipment’s, etc.,
to the doctors while they are on round for check-up.
l. They maintain a log of the entries of the patients in their wards and their health reports.
m. Head nurses also look for the hygiene in the hospital and in the rooms and makesure that
the patients are provided with enough facilities and entertain all typesof complaints from
the patients.
Skills Required in a Head Nurse:
a. A head nurse should have expert management, administration and planning skills.
b. Ability to assist the nurses and manage the team properly by motivating theemployees to
work.
c. Should have good communication skills to understand the problems and resolve them.
d. In-depth knowledge of all the procedures used in the management of the hospital.
e. Sound knowledge of the equipment’s used in the surgical process.

f. Ability to use various diagnostic methods in diagnosis and provide primarytreatment to
the patients in emergency.
g. Good presentation skills to conduct training programs.
h. Enthusiastic, enduring, and willing to work for extra hours.
i. Should be focused and willing to help the patients.
j. Profound written skills and should have proficiency in handling basic computerprograms
used in hospital management.

Educational Qualifications Required in Head Nurse:
a. To become a nurse one has to purse a 4 year degree program in nursing and should
undergo training programs in the same.
b. There are various nursing programs that offer licensure for the nurses. Certified and
licensed nurses are in great demand these days. Head nurses should also have serviced as
nurses for more than 4-5 years.

DUTIES & RESPONSIBILITIES OF STAFF NURSE:
 The Staff Nurse is the first level professional Nurse in the hospital set up. Therefore by
appearance and by word she will be professional at all time.
 She will be skilled nurse, giving expert bed side care to patient and executing special
technical duties in the special areas like operation theatres, intensive care unit, highly
dependent unit etc. She also acts as ‘de facto’ sister as and when situation arises in the
ward or department.
DUTIES & RESPONSIBILITIES IN RELATION TO PATIENT CARE
a. She will assess the needs of the patients in the ward and make nursing care plan for all
patients consulting with ward sister.
b. She will give direct patient care (bed making, changing of bed sheets, mouth care, back
care, bed bathing, hair wash, changing of position etc.) and allotted care to her by the
ward sister.
c. She will fulfill all basic needs (hygienic need, nutritional need etc.) of the patients.
d. She will provide comfort to the patient and maintain safety of the patient.
e. She will take over the charge from duty nurse of previous shift, regarding patients (bed to
bed), instrument supplies, drugs etc. and handed over the same to the next shift.

RESPONSIBILITY IN RELATION TO WARD ADMINISTRATION
a. She will ensure to make the ward clean and tidy including bed.

b. She will keep all articles well-arranged and maintain the inventory.
c. She will take the report, make bed to bed round at the time of changing of the shift of the
unit.
d. She will orient the new patient with ward.
e. She will help the ward sister for supervision of work of Group D allotted in the ward for
maintenance of cleanliness and sanitation.
f. She will make list of patients belongings and keep in safe custody, according to laid down
policy of the hospital.
g. She will keep a sub stock of drugs, linen and other supplies for ward maintenance.
h. She will maintain poisonous drugs registered.
i. She will sterilize all articles; maintain all equipment’s, gadgets, electrical connections
Sight, fan etc.
j. She will indent drugs, diet, and other supplies if necessary.
k. She will vigilant to protect the patient from injury or accident by providing side rail.
l. She will write report of each shift and sign the report after checking properly.
m. She will assist the ward sister in orientation programme of new staff and students.
n. She will make round with doctors and senior nursing officers.
o. She will help ward sister in indenting and checking of drugs, supplies and maintaining
inventories.
p. She will be deputed for the ward sister during her absent.
q. She will keep herself up to date with nursing knowledge by taking part in -service
education programme.

Duties and Responsibilities of a NURSING ATTENDANT:
 A nursing aide, sometimes called a nursing assistant, assists medical staff in providing
care for residents of long-term care facilities, such as nursing homes, as well as for shortterm hospital patients. During a typical workday, they perform a wide variety of nonmedical duties. Because nursing aides spend a large part of each day interacting with
patients, many of whom may not be able to provide for themselves, it is important that
nursing aides be caring, compassionate and patient individuals.
Basic Needs
a. Nursing aides work with patients who require assistance to perform even the most basic
tasks. They are often called upon to feed, bathe or move patients.
b. Nursing aides help reposition bedridden patients so they do not develop bedsores.
c. They help patients who need assistance going to the bathroom. Because frequent lifting
of patients is required in this job, the Bureau of Labor Statistics reports that workplace
injuries are more common among nursing aides than among most other types of workers.

Medical Duties
In addition to helping patients care for themselves, nursing aides provide very basic medical
care.
a. They monitor vital signs, such as blood pressure, pulse and temperature. Nursing aides
report any irregularities in vital signs or health concerns expressed by patients to
supervising nurses or doctors.
b. In some states, nursing aides who have been specially trained and certified are
responsible for administering medication to patients and residents.
Cleaning Responsibilities
a. While hospitals and nursing homes almost always employ a custodial staff for the big
jobs, nursing aides are expected to maintain cleanliness to a certain extent while on the
job.
b. For instance, it is often the responsibility of the nursing aide to clear the dishes and
silverware of residents after meals.
c. Nursing aides also may remove soiled bedpans; sweep and wipe down furniture; and
change bedding.

Activities That May be Delegated
The nursing process can be utilized as a framework to support the RN in delegating patient care
activities to support and assistive personnel. Prior to delegating, the RN assuming care of the
patient is responsible for completing an assessment of the patient as well as reviewing the
patient’s individualized plan of care. The RN should also verify proper training and competency
evaluation of UAP before a task is delegated. Regardless of how simple the delegated task may
seem, the RN is responsible for patient outcomes. Institutional policy and regulations from state
boards of nursing and state departments of health may govern the activities of support personnel.
(Appendix A) The following lists are examples of patient care activities that might be delegated
Direct Patient Care Activities
Vital Signs






Take and record blood pressure, respirations, temperature, and pulse rate
Obtain daily weight
Apply leads and connect to cardiac monitor
Obtain 12-lead ECG
Perform chest compressions in life support situations

Intake and Output
 Measure and record intake and output
 Collect specimens
Activities of Daily Living







Perform total or partial bed bath ƒ
Perform perineal care
Shave
Wash hair
Perform mouth care
Change linen and assist with making occupied bed

Nutrition
 Feed patient
 Calculate and record calorie count
Skin Care
 Perform back care
 Prepare skin for procedure
 Perform skin prep for operative procedure

Activity and Mobility






Assist in ambulating patient
Perform passive and active range of motion
Position
Turn and reposition patient
Assist with transfers

Respiratory Support





Set up oxygen
Assist patient with using an incentive spirometer ƒ
Assist patient with coughing and deep breathing exercises
Perform oral suctioning using an oral suction device

Procedures
 Set up patient room (suction canisters, cables for continuous cardiac monitoring, tubing
for chest tubes)
 Orient patient to room environment
 Set up and calibrate hemodynamic monitoring equipment
 Obtain necessary supplies for sterile procedure
 Discontinue peripheral intravenous catheter
 Perform postmortem care
Indirect Patient Care Activities
Cleaning












Clean equipment in use and stored equipment
Clean environment, including counter tops and desk tops
Clean and defrost food refrigerators
Clean patient care area after transfer or discharge
Clean patient care area after procedures are completed
Empty waste baskets in patient rooms and unit
Empty linen hampers
Remove meal trays
Clean supply carts
Clean and restock procedure rooms
Make unoccupied beds

Errands
 Deliver meal trays
 Obtain and deliver supplies






Obtain and deliver equipment
Obtain and deliver blood products
Check laboratory specimens for appropriate labeling
Deliver specimens to clinical laboratory

Clerical Tasks














Place pages
Place and answer phone calls
Assemble, disassemble, and maintain patient chart
Transcribe physician and nursing patient care orders
Schedule diagnostic tests and procedures
Order necessary office supplies and forms
Sort and deliver mail
Assist with unit orientation for float and registry ancillary personnel
Prepare charges for unit-based billing
Problem solve and locate lost charges
Keep unit log books up to date with patient admissions, transfers, and discharges
Maintain awareness of nursing bed assignments
Update and retrieve information systems data

Stocking and Maintenance








Stock patient bedside supplies
Stock unit supplies
Stock utility rooms
Stock treatment, examination, and procedure rooms
Stock nourishments and kitchen supplies
Check electrical equipment for inspections due dates
Stock linen cart

Activities That May Not Be Delegated
Nursing activities that may not be delegated include:
 Performing an initial patient assessment and subsequent assessments or nursing
interventions that require specialized nursing knowledge, judgment, and/or skill
 Formulating a nursing diagnosis
 Identifying nursing care goals and developing the nursing plan of care in conjunction
with the patient and/or family
 Updating the patient’s plan of care
 Providing patient education to patient and/or family
 Evaluating a patient’s progress, or lack thereof, toward achieving desired goals and
outcomes

 Discussing patient issues with physician
 Communicating with physicians or implementing orders from physician
 Documenting the patient’s assessment, response to therapeutic interventions, in the
patient’s plan of care
 Administering medications
 Providing direct nursing care
Guidelines/Situation for Delegation










Delegable task. The nurse first should determine if the task is properly delegable. For
example, giving medications or interpreting clinical data cannot be delegated because
these are licensed functions. However, it is generally agreed that routine tasks (e.g..,
taking vital signs) or personal care activities (e.g.., bathing) for stable patients with
predictable outcomes can be assigned to UAP
Patient’s needs. The nurse is responsible for individual patient assessment and
determination of nursing care needs. Therefore, even though an intervention such as
giving a bath may be a routine, the nurse may need to complete this task for certain
patient’s if further assessment or health teaching is needed. The nurse should refuse to
delegate any task that would jeopardize patient safety.
Competency of UAP. Job description for UAP should have clearly specify their
responsibilities. UAP should have a record of documented competencies to perform tasks
and should have participated in a formalized educational program that provided
instruction. However, it is the duty of the nurse to ensure that UAP are competent in
particular situations (e.g.., they may not be able to measure blood pressure properly even
though there is documentation that they can). It is the nurse’s responsibility to determine
ability and provide proper instruction for UAP or complete the task himself or herself.
The nurse must provide supervision for UAP and serve as a resource. The sole criterion
for determining who should complete a task in a particular situation in patient safety, as
determined by the nurse.
Communication. Clear directions must be given to UAP so that the task can be completed
properly. For example, the nurse should say, “ I need a finger stick done on Mr. Jones.” A
better instruction would indicate the immediate need for blood glucose measure and to
report the value to the nurse immediately, who will determine if insulin is needed. It is
suggested that the nurse obtain “minireports” throughout the shift, to clarify data obtained
and to provide any supervision necessary for UAP.
Evaluation. As part of the nurse’s duty to supervise UAP, the nurse is responsible for
evaluating their performance. This is an opportunity to provide positive and negative
feedback as well as supervised practice of a skill if needed. The ability to set priorities for
completion of task is an essential skill needed by UAP and often requires guidance by the
nurse.

Liability Issues in Delegation








Improper Delegation and Nurse Liability. The nurse can be liable for improper
delegation in several circumstances. One example is when a task should not be delegated
(e.g.., medication administration) assigned to UAP. Another example is when the nurse
delegates a task to UAP who are not competent to perform the task. While nurses can
generally rely on documented competencies of UAP, there may be information that the
nurse knows or should have known to indicate UAP are not competent in a particular
situation. Another example of improper delegation occurs when the nurse does not
provide the required supervision for UAP. The nurse should always be available foe
questions or further instruction.
Proper Delegation without Nurse liability. If the has delegated properly, UAP can be
individually liable for this actions. One example is when UAP do not inform the nurse of
an liability to perform a task or when UAP perform a task incorrectly, even after
instruction and supervision. UAP who perform tasks that are beyond those delegated o re
outside their competencies are liable for their own actions and for mistakes or adverse
patient outcomes
as a result of their actions. The liability of UAP is generally shifted to the situation, as
the employer.
Staffing Issues. Inadequate staffing is not a rationale for delegating tasks. In such an
instance the nurse needs to documents him or her refusal to delegate a tasks as based on
concern for patient safety and its effect on patient care. This should be forwarded to a
supervisor who has the power to correct the staffing .by taking these steps, the nurse is
shifting the liability to the institution for any outward outcomes resulting from the
situation..
Proper Delegation. Proper Delegation involves (1) the right task, (2) the right
circumstances, (3) the right person, (4) the right direction/communication, and (5) the
right supervision. In all situations, the nurse’s professional judgment determines what can
be delegated safely to UAP. (Retrieved: February 22, 2015)

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