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refusal of treatment
The Patient Self-Determination Act (PSDA) stipulates that on admission
to a health care facility, all clients must be informed of their right to accept or
refuse care. Competent adults have the right to refuse treatment, including the
right to leave a health care facility without a discharge order from the provider.
If the client refuses a treatment or procedure, the client is asked to sign a
document indicating that he understands the risk involved with refusing the
treatment or procedure and that he has chosen to refuse it.
When a client decides to leave the facility without a discharge order, the
nurse notifies the provider and discusses with the client the risks faced by leaving
the facility prior to discharge.
The nurse carefully documents the information that was provided to the
client and that notification of the provider occurred.
The client is asked to sign an Against Medical Advice form.
If the client refuses to sign the form, this is also documented by the
nurse. standards of Care (Practice)
Nurses base practice on established standards of care or legal guidelines for care. These
standards of care can be found in:
The nurse practice act of each state. Its legal guidelines for practice are established and
enforced through a state board of nursing or other government agency.
Nurse practice acts vary from state to state, making it obligatory for the nurse to be
informed about her states nurse practice act as it defines the legal parameters of practice.
Published standards of nursing practice developed by professional organizations and
specialty groups, including the American Nurses Association (ANA), the American
Association of Critical Care Nurses (AACN), and the American Association of
Occupational Health Nurses (AAOHN).
Health care facility policies and procedures maintained in the facilitys policy and
procedure manual.
Policies and procedures establish the standard of practice expected to be maintained by
employees of that institution.
These manuals provide detailed information about how the nurse should respond to or
provide care in specific situations and while performing client care procedures.
Nurses should be familiar with their facilitys policies and procedures and provide
client care in accordance with these policies. For example:
Assess and document client findings postoperatively according to
institutional policy.
Change IV tubing and flush saline locks according to
institutional policy.
Standards of care define and direct the level of care that should be given
by practicing nurses, and they are used in malpractice lawsuits to determine if
that level was maintained.
Nurses should refuse to practice beyond the legal scope of practice
and/or outside of their areas of competence regardless of reason (staffing
shortage, lack of appropriate personnel).
Nurses should use the formal chain of command to verbalize concerns
related to assignment in light of current legal scope of practice, job description,
and area of competence.
seclusion and restraints
Nurses must know and follow federal/state/facility policies that govern
the use of restraints.
Use of seclusion rooms and/or restraints may be authorized for clients in
some cases.
In general, seclusion and/or restraints should be ordered for the shortest
duration necessary and only if less restrictive measures are not sufficient. It is for
the physical protection of the client or the protection of other clients or staff.
A client may voluntarily request temporary seclusion in cases where the
environment is disturbing or seems too stimulating.
Restraints can be either physical or chemical, such as neuroleptic
medication to calm the client.
Seclusion and/or restraint must never be used for:
Convenience of the staff
Punishment for the client
Clients who are extremely physically or mentally unstable
Clients who cannot tolerate the decreased stimulation of a
seclusion room
Restraints should:
Never interfere with treatment
Restrict movement as little as is necessary to ensure safety
Fit properly
Be easily changed to decrease the chance of injury and to provide
for the greatest level of dignity
When all other less restrictive means have been tried to prevent a client
from harming self or others, the following must occur in order for seclusion or
restraint to be used:
The treatment must be prescribed by the provider in writing, based on a face-to-face
assessment of the client.
In an emergency situation in which there is immediate risk to the client or others, the
nurse may place a client in restraints. The nurse must obtain an order from the primary
care provided as soon as possible in accordance with agency policy (usually within 1 hr).
The prescription must include the reason for the restraint, the type of restraint, the
location of the restraint, how long the restraint may be used, and the type of behaviors
demonstrated by the client that warrant use of the restraint.
The provider must rewrite the prescription every 24 hr or the frequency
of time specified by facility policy.
PRN prescriptions for restraints are not allowed.
Nursing responsibilities must be identified in the protocol, including
how often the client should be:
Assessed Including neurosensory checks of affected extremities (circulation,
sensation, mobility). These checks are usually done at least every 2 hr.
Offered food and fluid.
Provided with means for hygiene and elimination.
Monitored for vital signs.
Offered range of motion of extremities. Frequency of client assessments in
regard to food, fluids, comfort, and safety should be performed and
documented every 15 to 30 min. Other responsibilities include:
Always explain the need for the restraint to the client and family, emphasizing that the
restraint is need to ensure the safety of the client and will be used only as long as it is
Obtain signed consent from client or guardian, if required. Review the manufacturers
instructions for correct application.
Remove or replace restraints frequently to ensure good circulation to the area and allow
for full range of motion to the limb that has been restricted.
Pad bony prominences.
Use a quick-release knot to tie the restraint to the bed frame (loose knots that are easily
removed) where it will not tighten when the bed is raised or lowered.
Ensure that the restraint is loose enough for range of motion and with enough room to fit
two fingers between the device and the client to prevent injury.
Regularly assess the need for continued use of the restraints to allow for discontinuation
of the restraint or limiting the restraint at the earliest possible time while ensuring the
clients safety.
Never leave the client unattended without the restraint. Complete documentation includes
a description of the following:
Precipitating events and behavior of the client prior to seclusion or restraint Alternative
actions taken to avoid seclusion or restraint The time restraints were applied and
removed (if discontinued) Type of restraint used and location
Clients behavior while restrained
Type and frequency of care (range of motion, neurosensory checks, removal,
integumentary checks)
Clients response when the restraint is removed
Medication administration
An emergency situation must be present for the charge nurse to use seclusion or
restraints without first obtaining a providers written order. If this treatment is initiated,
the nurse must obtain the written order within a specified period of time (usually within 1
Psychosocial interventions to improve self-concept and alleviate social isolation
for older adults include:
Therapeutic communication
Reality orientation
Validation therapy
Reminiscence therapy
Attending to physical appearance
Assistive devices (canes, walkers, hearing aids)
Use the major muscle groups to prevent back strain, and tighten the
abdominal muscles to increase support to the back muscles.
Distribute the weight between the large muscles of the arms and legs to
decrease the strain on any one muscle group and avoid strain on smaller muscles.
When lifting an object from the floor, flex the hips, knees, and back. Get
the object to thigh level, keeping the knees bent and the back straightened. Stand up
while holding the object as close as possible to the body, bringing the load to the center
of gravity to increase stability and decrease back strain.
Use assistive devices whenever possible, and seek assistance whenever it
is needed.
Transfers and Use of Assistive Devices
Assess the clients ability to help with transfers (balance, muscle
strength, endurance).
Determine the need for additional personnel or assistive devices (transfer
belt, hydraulic lift, sliding board).
Assess and monitor the clients proper use of mobility aids (canes,
walkers, crutches).
Include assistance or mobility aids needed for safe transfers and
ambulation in the plan of care.
establish a therapeutic relationship with the client. a caring and nonjudgmental
manner puts the client at ease and fosters meaningful communication.
ensure privacy and confidentiality. let the client know that sensitive issues are
safe to discuss.
identify individuals who may be at risk for body image disturbances.
acknowledge anger, depression, and denial as feelings to be expected when
adjusting to body changes.
encourage the client to participate in the plan of care.
arrange for a visit from a volunteer who has experienced a similar body image
Using an Interpreter
Use only a facility-approved medical interpreter. Do not use the clients
family or friends to interpret.
Inform the interpreter about the reason for and the type of questions that
will be asked, the expected response (brief or detailed), and with whom to converse.
Allow time for the interpreter and the family to be introduced and
become acquainted before starting the interview.
Refrain from making comments about the family to the interpreter, as
the family may understand some of the discussion.
Ask one question at a time.
Direct the questions to the family, not to the interpreter.
Use lay terminology if possible, knowing that some words may not have
an equivalent word in the clients language.
Do not interrupt the interpreter, the client, or the family as they talk.
Do not try to interpret answers.
Following the interview, ask the interpreter for any additional thoughts
about the interview and the clients and familys responses, both verbal and nonverbal.
Care of the Body
Provide care with respect and compassion while attending to the desires of the
client and family per their cultural, religious, and social practices.
Recognize that the provider certifies death by pronouncing the time and
documenting therapies used, and actions taken prior to the death.

Preparing the body for viewing includes:
Maintaining privacy. Shaving facial hair if applicable and/or desired by the
Removing all tubes and soiled linens (unless organs are to be donated or this is a
medical examiners case).
Removing all personal belongings to be given to the family.
Cleansing and aligning the body with a pillow under the head, arms outside the
sheet and blanket, dentures in place, and eyes closed.
Applying fresh linens and a gown. Brushing/combing the clients hair, replacing
any hair pieces.
Removing excess equipment and linens from the room.
Dimming the lights and minimizing noise to provide a calm environment.
Viewing considerations include:
Asking the family if they would like to visit with the body, honoring any
Clarifying where the clients personal belongings should go With the body or
to a designated person.
Adhering to the same procedures when the client is an infant, with the
exception of:
Swaddling the infants body in a clean blanket.
Transporting the infant in the nurses arms or in an infant
Offering mementos of the infant (identification bracelets,
footprints, the cord clamp, a lock of hair, photos).
Post Viewing
Apply identification tags according to facility policy.
Complete documentation.
Remain aware of visitor and staff sensibilities during transport.
Cane instructions
maintain two points of support on the ground at all times.
Keep the cane on the stronger side of the body.
support body weight on both legs, move the cane forward 6 to 10 inches, then move the
weaker leg forward toward the cane.
next, advance the stronger leg.
injectable dosage
Example: The provider prescribes heparin 8,000 units subcutaneously, Q12H. The
amount available is 5,000 units/mL. How many mL should the nurse administer?
Follow the steps:
STEP 1: What is the dose needed? Dose needed = Desired
8,000 units
STEP 2: What is the dose available? Dose available = Have
5,000 units
STEP 3: Do the units of measurement need to be converted?
no (units = units)
STEP 4: What is the quantity of the dose available?
1 ml
STEP 5: Set up an equation and solve:
desire Quantity X
5,000 units
8,000 units 1 ml X
Cross multiply and solve for X:
5,000X = 8,000
Isolate X by dividing both sides by 5,000.
8,000 5,000 5,000
X = 1.6 ml
STEP 6: Reassess to determine if the amount to be given makes sense. If there are
5,000 units/mL and the prescribed amount is 8,000 units, it makes sense to give
1.6 mL.
The nurse should administer heparin 1.6 mL subcutaneously every 12 hr.
Preventing IV Infections
Use standard precautions.
Change IV sites according to facility policy (usually 72 hr).
Remove catheters as soon as they are no longer clinically indicated.
Change the catheter if any break in surgical aseptic technique is suspected, such as
emergency insertions.
Use a sterile needle/catheter for each insertion attempt.
Avoid writing on IV bags with pens or markers, because ink could contaminate the
Change tubing immediately if contamination is known or suspected.
Fluids should not hang more than 24 hr unless it is a closed system (pressure bags
for hemodynamic monitoring).
Wipe all ports with alcohol or an antiseptic swab before connecting IV lines or
inserting a syringe to prevent the introduction of micro-organisms into the system.
Never disconnect tubing for convenience or to position the client.
Do not allow ports to remain exposed to air.
Perform hand hygiene before and after handling the IV system.
Pallor, local swelling at the site, decreased skin temperature around the site, a damp
dressing, a slowed infusion
stop the infusion and remove the catheter.
elevate the extremity.
encourage active range of motion.
apply warm compresses three to four times/day.
restart the infusion proximal to the site or in another extremity.
Carefully select the site and catheter.
secure the catheter.
Suctioning can be accomplished orally, nasally, or
Potential Diagnoses Hypoxemia Client Presentation Early signs of
hypoxemia, such as restlessness, tachypnea, tachycardia, decreased SaO
adventitious breath sounds, visualization of secretions, cyanosis, absence of
spontaneous cough Client Outcomes
The client maintains a patent airway.
The client maintains an SaO
of 95% to 100%.
Nursing Actions
Perform hand hygiene, provide privacy, and explain the procedure to the client.
Don the required personal protective equipment.
Assist the client to high-Fowlers or Fowlers position for suctioning if
Encourage the client to breathe deeply and cough in an attempt to clear the
secretions without artificial suction.
Obtain baseline breath sounds and vital signs, including SaO
by pulse
oximeter. May monitor SaO
continually during the procedure.
Oropharyngeal suctioning
Obtain baseline assessment data.
Use a Yankauer or tonsil-tipped rigid suction catheter.
Nasopharyngeal and nasotracheal suctioning
Suctioning is performed with a flexible catheter.
Catheter size is based on the diameter of the clients nares and
the thickness of the secretions.
Hyperoxygenate the client with an FiO
of 100% during
equipment preparation.
Lubricate the distal 6 to 8 cm (2 to 3 in) of the suction catheter
with a water-soluble lubricant.
Remove the oxygen delivery device with the nondominant hand,
if applicable.
Endotracheal suctioning (ETS)
Perform ETS through a tracheostomy or an endotracheal tube.
Ask for assistance if necessary.
Obtain a suction catheter with an outer diameter of no more than
1 cm (0.5 in) of the internal diameter of the endotracheal tube.
Hyperoxygenate the client using a bag-valve-mask (BVM) or
specialized ventilator function with an FiO
of 100%.
Client Education Explain the procedure to all clients, conscious or unconscious.
NG placement- pt sit in high fowlers position if available