LEADERSHIP & MANAGEMENT –
MANAGEMENT/CONCEPTS
CHILD NEGLECT
• Child neglect occurs when a caregiver
purposely withholds or does not adequately
provide necessary resources to fulfill the
basic needs of a child (eg, adequate
nutrition, security, hygiene). Supervisory
neglect, leaving children without
adequate guardianship to ensure safety,
is one form of child neglect
• Children age <12 lack formal operational
reasoning and cannot anticipate safety risks
or respond appropriately to emergencies,
and should therefore not be left to
supervise other children.
• It is a priority for the nurse to intervene, as
this is an unsafe situation for the young
children. The nurse, or social services,
should report the situation to an
appropriate government child protective
service and/or law enforcement.
• Potential job loss indicates that the parent
may be overwhelmed. The nurse should
alert a social worker about the situation at a
later time to discuss potential assistance.
• Transitioning to the role of a single parent
can present mental and financial stressors,
possibly requiring assistance from a social
worker. However, this does not require
immediate intervention.
• A parent stealing food may warrant calling
the police or security, but the children's
safety is a priority requiring immediate
action.
REPOSITIONING AND TRANSFERRING
• Repositioning and transferring clients can
be delegated to unlicensed assistive
personnel (UAP) when it is deemed safe
and appropriate.
• The nurse must provide UAPs with
detailed instructions, including when to
move the client, which techniques to use,
and when to use assistive persons or
devices.
• The nurse must also notify UAPs of any
client mobility restrictions. Unstable clients
and spinal cord stabilization require the
presence of a nurse for repositioning or
moving
• The client who is 8 hours postoperative
total hip replacement requires assessment
prior to repositioning as the client is at risk
for hip dislocation. A wedge may be
needed to maintain abduction; nursing
judgment is required
• To reduce the risk of client and staff injury,
safe transfers and repositioning are
achieved using the following guidelines:
o Use a gait/transfer belt to transfer a
partially weight-bearing client to a chair
o Use 2 or more caregivers to reposition
clients who are uncooperative or unable
to assist (eg, comatose, medicated)
o Use a full-body sling lift to move/transfer
nonparticipating clients.
o Use 2-3 caregivers to move cooperative
clients weighing less than 200 lb (91
kg).
o Use 3 or more caregivers to move
cooperative clients weighing more than
200 lb (91 kg)
INTERDISCIPLINARY TEAM
• Several adjunctive professional services
assist clients in the post-acute phase of
their illness as part of an
overall interdisciplinary team.
• Speech therapy focuses on speech and
communication but also on
swallowing/eating issues
• A client with a stroke will need to be
evaluated for any aspiration risks and
taught how to minimize those risks (eg,
chin-down positioning, chewing on the non-
affected side of the mouth).
• Social workers assist with developing
coping skills, securing adequate financial
resources or housing, and making referrals
to volunteer organizations
• Wound care is a resource for assessing
and planning the optimal care of any
wound
• Occupational therapy emphasizes the
skills necessary for activities of daily living
(eg, dressing, bathing, cognitive or
perception issues); however, walker training
is performed by a physical therapist. An
 overly broad generalization is that
occupational therapy is for "above the
waist."
• Physical therapy focuses on mobility,
ambulation, ability to transfer, and use of
related equipment. An overly broad
generalization is that physical therapy is for
"below the waist." Dressing skills would be
taught via occupational therapy.
• The case manager and social worker on the
interdisciplinary team have expertise in
discharge planning and health care
finance. They can assess the adequacy of
the discharge setting and support systems,
arrange for resources at home, or
discharge to an alternate setting, such as a
rehabilitation facility. They can also help
advocate for safe, effective discharge
planning.
• The clinical psychologist's role is to assess
the client's psychological issues and assist
with counseling and coping strategies.
CASE MANAGER
• Case management involves assessing,
planning, facilitating, and advocating for
client health services to accomplish cost-
effective quality client outcomes. This is
done through communication and use of
available resources.
• A professional nurse often serves in the
case manager role. The case manager in
the hospital setting assesses client needs,
decreases fragmentation of care, helps to
coordinate care and communication
between HCPs, makes referrals, ensures
quality standards are being met, and
arranges for home health or placement
after discharge
• Case managers typically do not provide
direct client care. Medication reconciliation
should be done between the primary nurse
directly caring for the client and the HCP.
• Case managers often make daily rounds to
the nursing department to review
documentation in the client's chart but do
not necessarily visit the client personally.
LATERAL VIOLENCE (HORIZONTAL
VIOLENCE)
• Lateral violence (also known as horizontal
violence) can be defined as acts of
aggression carried out by a co-worker
against another co-worker and designed to
control, diminish, or devalue a colleague.
• These behaviors usually take the form of
verbal abuse such as name-calling,
unwarranted criticism, intimidation, and
blaming. However, other acts, such as
refusing to help someone, sabotage,
exclusion, and unfair assignments, also fall
under the category of lateral violence.
• Violence in the workplace should not be
tolerated or ignored by either staff or
management. Actions that staff members
can take if they become victims of lateral
violence include:
o Documenting and keeping a file of all
incidents
o Reporting the incidents to the immediate
supervisor
o Letting the bully know that the behavior
will not be tolerated
o Observing interactions between the
bully and other colleagues (may validate
the victim's experiences and serve as a
source of support)
o Seek support from within the facility or
from an external source
UNPROFESSIONAL CONDUCT
• The stress of bullying and workplace
violence impairs clinical judgment and
creates an unsafe environment for
clients.
• In response to unprofessional conduct, the
nurse should shift the focus of the
conversation back to the client's needs,
especially in situations that may result in
client injury
• Discussing facility policies does not direct
the conversation to the client's needs and
fails to address the urgency of the
situation. The priority is for the nurse to
advocate for the client's needs because the
client is experiencing a serious, limb-
threatening, postsurgical complication.
• Confrontational statements are more likely
to provoke a fight than result in appropriate
intervention for the client.
• Incidents of bullying and workplace violence
should be reported to a nursing supervisor,
but the priority is to ensure that the client's
needs are addressed.
SBAR (SITUATION-BACKGROUND-
ASSESSMENT-
RECOMMENDATION/REQUEST)
• The SBAR (Situation-Background-
Assessment-Recommendation) provides a
framework for communicating information
about a change in client status to the health
care provider (HCP). It includes the
following information:
1. S = Situation – what prompted the
communication
2. B = Background – pertinent information,
relevant history, vital signs
3. A = Assessment – the nurse's
assessment of the situation
4. R = Recommendation – request for
prescription or action from the HCP
• The report given by the nurse contains the
most appropriate and complete
information. The nurse includes pertinent
data related to history, admission, and
present treatment (background); indicates
when and what changes occurred
(situation, assessment); and requests a
prescription from the HCP
(recommendation).
SUBDURAL HEMATOMA
• A subdural hematoma is caused by
bleeding into the subdural space and is the
result of blunt force head trauma. It is life-
threatening, as increased pressure from the
hematoma on the brain can lead to
decreased cerebral perfusion
and herniation (mid-line shift).
• Assessing for signs of increased
intracranial pressure, including change in
level of consciousness, Cushing triad
(hypertension, bradycardia, and irregular
respirations), ipsilateral pupil dilation,
headache, and vomiting, is critical as
surgery to evacuate the hematoma and
relieve the pressure may be necessary.
MEDICAL INTERPRETER
• The nursing role in advocating for the client
includes ensuring the use of interpreters for
clients who speak a different language,
particularly during the informed consent
process. The person interpreting for the
client should ideally possess the following:
o Training in medical terminology and
procedures
o Ability to protect the client's rights in a
medical setting
o Fluency in the language
o Understanding of cultural beliefs and
nuances
• For these reasons, and to protect client
confidentiality, family members should not
be used as medical interpreters unless the
situation is urgent and a family member is
the only one available to fill this role.
• An interpreter's job is to literally translate
the words/concepts spoken (as much as
possible).
• The role does not include personally
editorializing or embellishing with advice
beyond what the health care provider
(HCP) said.
• It is important to find out if there was any
discussion related to the procedure or if the
follow-up conversation was about other
topics (eg, social).
• The nurse needs to obtain feedback to be
certain that the client understands about the
procedure and had no additional questions
that the interpreter personally answered.
• The nurse can ask the client additional
questions using this interpreter or use a
different interpreter/a language line.
• After the nurse is satisfied that no additional
information was provided and the client
understands what the client is signing, the
nurse (as the hospital employee) should
then witness the signature. The nurse
should indicate that an interpreter was used
in the process.
• Gestures/pantomime may be adequate for
basic actions, such as obtaining a blood
pressure. In this case, there is specific
information that must be clear and should
be communicated with interpretation.
• Federal law requires accommodations for
people with limited English proficiency. The
Joint Commission indicates that clients'
rights include translation.
• Clarifying the content of the conversation is
the priority. The nurse (as an employee of
the hospital) should be the witness
whenever the signature is
obtained. However, the name and the
contact information of the interpreter should
be documented.
• The consent should not be signed until it is
clearly established that no additional
information/advice was given by or asked of
the interpreter after the HCP left.
TRANSFORMATIONAL NURSE MANAGER
• The transformational nurse manager
provides a supportive culture in which
learning is valued and best practices are
implemented to ensure the appropriate skill
level and experience of each staff member.
• A workshop would provide the graduate
nurses with an opportunity to learn and ask
questions about the cultures represented
on their unit. It would also help develop
cultural awareness and sensitivity, leading
to respect for the diverse cultures
represented on the unit.
• Cultural diversity is present in every clinical
unit; therefore, it is not feasible to assign
the graduate nurses to a unit without
cultural diversity.
• To provide culturally competent care, the
graduate nurses must know about the
various cultures represented on their unit.
• Culturally competent care is first attained
through education. Afterward, the graduate
nurses are ready to implement best
practices in the care of clients from diverse
cultures.
• Although researching various cultures
would assist the graduate nurses in
learning, the new graduates are novices
and have not fully developed cultural
competency; therefore, they are not the
best individuals to provide an in-service on
this topic.
STANDARDS OF NURSING PRACTICE AND
CARE
• Standards of nursing practice and
care are universal criteria that are used
when determining if appropriate,
professional care has been delivered. The
definition of this minimum acceptable level
of care reflects what reasonable, prudent,
and careful nurses would do in specific
circumstances. The state or
province/territory boards of nursing help to
regulate these standards.
• Sources used to define standard of care
include statements from professional
organizations, agency policies and
procedures, textbooks, current literature,
expert consensus, the Nurse Practice Act,
and statutes from regulatory organizations
• The standard of care includes objective
criteria and does not consider
intention. Guidelines are used in
 determining if duties were performed in an
appropriate manner. A nurse can have
good intentions but still fail to meet the
standards of professional nursing practice.
• Standard of care is determined by
objective, third-party
authoritative/reasonably reliable sources.
• Nurses who are suspected of negligence,
yet cannot provide documentation of the
event in question, can testify about their
interpretation of usual custom and practice
as it relates to the incident. However, an
individual's typical actions are not
authoritative in determining the universal
standard of nursing care and cannot
replace the use of objective, authoritative,
and predetermined standards of care.
UNIT QUALITY IMPROVEMENT COMMITTEE
• A unit quality improvement committee
assesses process standards (guidelines,
systems, and operations) and clinical
issues on a specific unit that
affect delivery of client care and client
outcomes.
• The committee implements a process to
improve performance if the standards are
not being met.
• Examples requiring unit quality
improvement include the following:
1. Medications prescribed STAT are not
available in a timely manner
2. Catheter-associated bacterial infections
are increasing within the unit
SEXUAL HARASSMENT
• Sexual harassment, including soliciting
sexual favors in exchange for favorable job
benefits, is prohibited. Other behaviors that
could be defined as sexual harassment
include asking someone for a date after the
other person expressed disinterest or
making remarks about a person's gender or
body.
• The receiving nurse should first
immediately and clearly indicate that the
attention is unwanted and the offending
HCP should stop. The offending HCP may
have erroneously perceived a mutual
attraction. If that is not effective, additional
action should be taken. The American
Nurses Association cites 4 tactics to fight
workplace sexual harassment: confront,
report, document, and support.
• The incident should be reported, especially
if the offending HCP does not stop. If the
harasser is the immediate supervisor, the
receiving nurse should go up the chain of
command. However, the nurse should first
simply tell the offending HCP to stop and
see if that resolves the issue.
• The nurse should respond with
assertiveness, not avoidance. Ignoring the
situation may imply that the nurse does not
mind the HCP's attention.
• The receiving nurse should document what
occurred and how the nurse
responded. The presence of witnesses
should be documented. Documentation
should be stored somewhere other than the
workplace. However, the nurse should
initially communicate assertively that the
actions are to stop before documenting
them.
HANDOFF REPORT
• Current respiratory status is essential to
include in handoff report, as it is objective
information related to the client's current
condition.
• Information communicated during report
should allow the oncoming nurse
to prioritize care and obtain baseline
measurements of the client's current
status and response to treatment. It is
especially important to include information
that may not be documented in the medical
record.
• Respiratory status can change rapidly, and
the most current measurements may not be
documented, as vital signs are often
documented every 4, 8, or 12 hours
• Handoff report typically includes:
o Client's name, location, age, gender,
health care provider, and diagnoses
o Client's current baseline measurements,
treatment plan, goals, and response to
treatment
 o Priority and outstanding tasks and ROOM ASSIGNMENT
changes from previous days

• A handoff of care report is the critical

communication that occurs when
transferring client care to another nurse (eg,
shift change, department
transfer). Transitions of care
require thorough, precise communication
to ensure client wellness
and safety. Appropriate handoff
communication allows for continuity of care
and provides a synopsis of client needs and
details of the client's care.
• To ensure appropriate and effective handoff
• When clients must be housed together in
communication, the nurse should:
less than ideal circumstances, those
infected with the same causative pathogens
o Provide identifying information (eg,
can be placed together. However, a client
client's name and room number).
who is infectious should not be placed with
o Note care priorities and upcoming or
an immunosuppressed client (eg, on
outstanding tasks (eg, time to replace a
steroids/chemotherapy, HIV positive, new
medication infusion bag, need to perform
post-operative, multiple chronic co-
delayed wound care and cause of delay)
morbidities, splenectomy, diabetes, very
o Provide exact, pertinent
young/elderly).
information (eg, medication dose, time,
measurable outcomes) (Option 3). • Every client in the hospital is on universal
o Include multidisciplinary plans (eg, precautions; therefore, there should be no
radiology examinations, family meetings, concern about placing a vulnerable post-
physical therapy) operative client in the same room where
o Relay significant client changes in a clear standard precautions are being taken for
manner (ie, assessment, interventions, another client. In a disaster setting, clients
outcomes, evaluation). of different age groups can be placed in the
same room together so long as both are
stable and noninfectious (even if this is not
• Report statements should include exact
socially acceptable).
information (ie, time medication is
administered, measurable outcome using a • (Option 1) Though both clients are on
pain scale). "Good relief" is a vague term. contact isolation, they are infected with
different organisms and this places them at
• Handoff should not include biased
risk for cross-infection.
information or personal opinions (eg,
"rude") and should include visitor • (Option 3) By around age 4, clients with
information only if the visitor is involved in sickle cell disease have some level of
client care and/or teaching. It is appropriate immunosuppression as their spleens are
dysfunctional due to infarctions from the
to include information about a client's
medication list. sickling episodes. The spleen then fails to
carry out protective phagocytosis,
especially to encapsulated bacteria (eg,
streptococcus pneumoniae).
TRIAGE
Chest pain
WRITTEN CONSENT
• Written consent is required for invasive
procedures and surgery. Clients must be
informed of and competent to understand
information about the procedure, alternate
treatments, and risks. They must also be
informed that they have the right to refuse
the procedure or surgery.
• The nurse's role in informed consent is
to witness that the client signed the
consent voluntarily and was competent at
the time of signing
• The nurse should ensure that the client
received necessary information and has no
remaining questions about the
procedure. After obtaining the signature,
the nurse should document in the client's
medical record that the informed consent
was given and the date/time of the
signature
• The health care provider is responsible for
explaining all aspects of the procedure,
ensuring that the client has a correct
understanding of the procedure and its
potential risks, providing the
names/qualifications of those who will be
involved, describing available alternate
treatments, and reinforcing that the client
has the right to refuse the procedure.
• The health care provider should be
contacted if the client does not have a
correct understanding of the
procedure. The nurse should not try to
explain procedures as he/she could be held
liable for giving incorrect/incomplete
information.
RADIATON EXPOSURE
• The key aspects related to radiation
exposure are time and distance. The
greater the distance, the less dosage
received.
• Acute radiation syndrome has the following
phases: prodromal, latent, manifest, and
recovery or death. Initially, all victims will
appear well; however, the damage is mainly
internal, leads to cell destruction, and
manifests later on.
• Victims farthest away from the radiation
source are the most salvageable. In this
scenario, the principle of disaster nursing is
to do the most good for the most people
with the available resources.
• Nerve agents used as biological weapons
(eg, sarin) inhibit acetyl-cholinesterase, and
their effects are caused by the resulting
excess acetylcholine. Common symptoms
are miosis, rhinorrhea, copious secretions,
shortness of breath, and flaccid
paralysis. Treatment is with suction and
support ventilation and
circulation. However, these symptoms are
not related to radiation contamination.
• Damage from radiation affects the most
radiosensitive cells first; these are the
hematopoietic, digestive, central nervous
system, and cutaneous cells. The
presence of severe symptoms indicates
extensive internal damage and that the
victims are less salvageable in the long
term.
• Neurologic symptoms such as symmetrical
descending flaccid paralysis with cranial
nerve palsies (ptosis, diplopia, dysphagia,
dysphonia) are classic of botulism, which is
caused by toxins from the spore-forming
anaerobic bacillus Clostridium
botulinum. Treatment includes ventilator
 assistance and the heptavalent botulism
antitoxin.
ADVERSE EVENT
• Adverse event is an injury to a client
caused by medical management rather
than a client's underlying condition. It may
or may not be preventable. The Institute of
Medicine (2000) recognizes 4 types of
errors. They are:
o Diagnostic (delay in diagnosis, failure to
employ indicated tests, failure to act on
results of monitoring)
o Treatment (error in performance of
procedure, treatment, dose; avoidable
delay)
o Preventive (failure to provide
prophylactic treatment, inadequate
follow-up/monitoring of treatment)
o Other (failure of communication,
equipment failure, system failure)
SENTINEL EVENT
or “near-misses”
• A sentinel event is any unanticipated event
in a health care setting that results in death
or serious physical or psychological injury.
• Warfarin is an anticoagulant often used in
clients with the following:
o Atrial fibrillation (to prevent clot
formation and reduce the risk for
stroke)
o Deep venous thrombosis and
pulmonary embolism (to prevent
additional clots)
o Mechanical heart valves (to prevent clot
formation on valves)
• The International Normalized Ratio (INR) is
a blood test used to monitor the
effectiveness of warfarin therapy. The
typical target INR is 2-3. In some instances
(eg, mechanical heart valves), the
therapeutic INR target is as high as
3.5. The higher the INR, the higher the
bleeding risk. The nurse should not
administer warfarin if the INR is over 4.
• (Option 1) Flumazenil is the appropriate
antidote for a benzodiazepine overdose.
• (Option 2) Insulin quickly lowers serum
potassium by pushing it
intracellularly. Dextrose is given to prevent
hypoglycemia. This is an appropriate
action.
• (Option 4) Nitroprusside is a potent
vasodilator often used for hypertensive
urgencies.
NURSE’S ROLE
• The role of the nurse as advocate is to
protect the rights of the client, including the
right to adequate pain control. The nurse
acting as advocate speaks up for clients
when they cannot easily speak for
themselves.
• In the role of caregiver, the nurse promotes
healing and well-being by helping the client
and family set and achieve goals through
the nursing process.
• In the role of educator, the nurse helps the
client and family learn about topics relevant
to their health.
• In the role of manager, the nurse
coordinates the care of the client among
different members of the interdisciplinary
team and across care settings.
ANTI-EMBOLISM STOCKINGS
• Anti-embolism stockings are part
of venous thromboembolism (VTE)
prophylaxis in hospitalized clients. Anti-
embolism stockings improve blood
circulation in the leg veins by applying
graduated compression. When fitted
properly and worn consistently, the
stockings decrease VTE risk.
• The stockings should not be rolled down,
folded down, cut, or altered in any
way. If stockings are not fitted and worn
 correctly, venous return can actually be
impeded.
• Anti-embolism stockings should be applied
before ambulating while the client is in bed;
this maximizes the compression effects of
the stockings and promotes venous return.
• Wrinkles should be smoothed out to avoid
impeding venous return.
• The toe opening should be located on the
plantar side of the foot/under the toes.
MEDICAL ABBREVIATIONS
• (Option 3) A zero must precede the
decimal dose. If the decimal point is
missed, ".5" could be mistaken for 5 mg.
ANTICIPATORY GUIDANCE
• Anticipatory guidance prepares clients
and caregivers for future health needs and
is useful throughout life, from pediatric
growth and development to anticipated
changes related to disease processes.
• This type of education promotes health and
helps to reduce client/caregiver stress and
anxiety, which heighten with unexpected
cognitive, physical, and emotional
changes.
• Anticipatory guidance educational goals
should be client-oriented, realistic,
objective, measurable, and focused on
preparing for future needs specific to the
client.

• The Joint Commission (2004) and Institute

for Safe Medication Practices prohibit error-
prone or "dangerous" abbreviations,
descriptions of symptoms, and dose
designations in medical documentation.
• "Cm" (centimeters) and "II" (2) (eg,
decubitus staging) are acceptable
abbreviations/notations (Option 1).
• The abbreviations "ac" (before meals), "pc"
(after meals), and "c/o" (complains of) are
acceptable (Option 4).
• "QID" (4 times a day) is
acceptable. Abbreviations that are not
acceptable include "qd" (daily) and "q1d"
(daily), which can be mistaken for "qid" (4
times a day), and "qod" (every other day),
which can be mistaken for "qd"
(daily) (Option 5).
• (Option 2) A trailing zero after the decimal
point is not acceptable as it could be
interpreted as 40 instead of 4 if the decimal
point is not noted. The use of "u" for unit is
not acceptable as it can be mistaken for the
number 0 or 4 (eg, 4u seen as 40). "SSRI"
(sliding-scale regular insulin) is not
acceptable to indicate insulin as it can be
mistaken for selective serotonin reuptake
inhibitor. "Mg" for milligrams is acceptable.