ANA's
Position Statement on Unlicensed Assistive Personnel
Susan Jones, RN is a team leader on a busy adult oncology unit. There are 30 patients on the unit. On evening shift, the staffing includes two RNs and two LPNs and a nurse's aide. The nurses' aide, Beth, is a junior student enrolled in a nearby baccalaureate program. The nurse's aide is assigned eight patients from the assignment of the RNs and LPNs. One of Susan's patients complained to Beth that her nephrostomy tube was leaking at the insertion site. Beth reported the matter to Susan. The patient meanwhile was saying that if someone didn't get in there as fix her nephrostomy tube, she was going to call administration. Susan, meanwhile was administering a vesicant, IV push, to a patient. She also had to monitor the patient's vital signs afterwards. She informed Beth that since she learned how to change a dressing and irrigate the nephrostomy tube in nursing school, that she go ahead and change the dressing and irrigate the nephrostomy tube. Susan instructed Beth to be careful not to pull the nephrostomy tube out of place. Beth went into the patient and took off the dressing for the nephrostomy tube. She prepared 10 ccs of saline and using sterile technique, she instilled the 10ccs and gently pulled back on the syringe. The patient screamed with pain and pulled away from Beth, whereupon the nephrostomy tube slipped out about an inch. Not knowing what to do, Beth pushed to tube back the inch it had slipped out. She apologized to the patient, redressed the nephrostomy tube and told Susan what happened. An hour later, Susan went into the room to assess the patient and noticed that the patient's nephrostomy tube was not draining any urine. The patient was complaining of flank pain and looked flushed. She took her temperature and it was 102.4o F. Upon inspection of the nephrostomy tube, it was observed that the stopcock was in the off position. Susan opened the stopcock, but nothing drained. Subsequently, the patient had to go to x-ray for the replacement of the nephrostomy tube. The patient developed a pyelonephritis which had to be treated with antibiotics.
Answer the following questions true or false based upon the above situation:
1. _____ The RN correctly delegated the task of irrigating the nephrostomy tube and cleaning the nephrostomy dressing to the nurse's aide.
2. _____ The RN committed malpractice when she allowed the aide to irrigate the nephrostomy tube and change the nephrostomy dressing.
3. _____ The nurse=s aide was negligent in the manner in which she irrigated the nephrostomy tube and changed the dressing.
4. _____ The Board of Nursing could refuse to allow the aide to sit for the licensure examination once she completes her baccalaureate program.
5. _____ Susan adequately instructed Beth when she cautioned her about not pulling the nephrostomy tube out.
6. _____ Susan should have clarified the interpretation of irrigation for a nephrostomy tube.
7. _____ The patient could take legal action against the following for developing pyelonephritis:
8. _____ Since Susan was in the midst of a procedure that could not be interrupted, she was correct in directing the nurse's aide in irrigating the nephrostomy tube.a. the hospitalb. the registered nurse
c. the nurse's aide
d. the evening supervisor
e. all of the above
Delegation Issues
Check all that apply:
1. A new graduate noticed that a newly hired LPN who just moved here from another state, telephoned a physician to report that a patient's potassium level was low and received order for two doses of KCL elixir (20 meq) and electrolytes to be drawn in the morning. This is not part of the LPN's role in the hospital. Which of the following is true?
a. The LPN might not be familiar with the institution's policy or the state board of nursing regulations2. The secretary who floated to the unit made several errors in transcribing medications today. As the charge nurse, which of the following are appropriate actions?b. The LPN may have phoned physicians in her previous jobs and feels that she is competent to do so.
c. The LPN probably won't do it again, so there is no need to mention it to her
d. The LPN will need to be told about it and depending upon her response, you might have to tell the nurse manager
a. Assess the unit secretary's understanding of the orders to be transcribed.3. Julie, a newly licensed RN just completed the IV therapy course and according to the hospital policy, needs to be supervised for three successful IV starts. She is one of two RNs on the evening shift on a unit and is almost done with her orientation. She has successfully started two IVs. She was unsuccessful with a third patient who had difficult veins. A patient's IV became infiltrated and Julie removed the IV. However, now the patient needs to receive her two 6:00 P.M. antibiotics and the other RN just went to dinner and won't be back until after 7:00 P.M.. The unit has been very busy. Julie called the supervisor to supervise her while starting the IV. The supervisor said she was too busy and that she would have to start the IV herself. Which of the following are appropriate actions?b. Wait until the head nurse comes back from vacation
c. Assume that the errors were probably just a function of working on a different unit with patients having different clinical conditions.
d. Complete an incident report for each of the transcription errors.
e. Recommend action to the supervisor following discussion of the situation with the unit secretary.
a. Start the IV4. A staff nurse is in charge while the head nurse is off today. A housekeeper who has been on the job for many years has now been assigned to an environmental services team which includes transfer of patients as well as housekeeping tasks. She often talks with patients and their families. However, she groans when she bends over and makes a face when she is asked to complete another task. Everyone on the unit is very busy, however, she is often found in an empty room watching a soap opera. Today, a patient was opening a container of prune juice and accidently sprayed it all over the wall. The student nurse assigned to the patient asked the housekeeper to clean up the wall. The housekeeper went into the room and started yelling at the patient whereupon she started to cry. Which of the following is the most appropriate action for the staff nurse?b. Report the supervisor to the assistant director of nursing the next day
c. Wait until the other RN returns from dinner
d. Tell the patient that she can't get her antibiotics because no one wants to supervise her starting the IV.
e. Ask the medical resident to supervise her in starting the IV.
f. Ask the supervisor if there is another RN who would be free to supervise her with the IV if she has everything ready to go when she arrives on the floor.
g. Clarify the conflict between the supervisor's direct order and the hospital policy.
a. Ask the student why she didn't clean up the wall herself5. An RN is working for a temporary staffing agency. Usually she is assigned to a medical-surgical unit in a hospital. However, the agency received a desperate call from a nursing home that they need to have an RN for a Saturday night. Rita, an RN with six years of medical-surgical experience takes the shift. The LPN for the shift did not show up for work. Rita is busy with medications and making rounds. A patient with a CVA and a continuous gastrostomy feeding needs suctioning. The aide who has worked in the nursing home for a very long time tells Rita that she knows how to suction and that routine suctioning of stable patients is part of the job description of aides in the nursing home. She adds that she has suctioned the patient before. Which of the following are appropriate actions?b. Let it go, and let the head nurse deal with it when she comes back
c. Call the supervisor of the environmental services to discuss the housekeeper's behavior.
d. Discuss the situation with the housekeeper
e. Discuss the situation with the housekeeper as well as the observation that she is always sitting around
f. Review the housekeeper's job description with her
g. Discuss the housekeeper's understanding of her job
h. Demand that the housekeeper go into the patient and apologize
a. Call the nurse administrator on call for a clarification of the aide's responsibilities6. Ellen, an RN who is recovering from substance abuse, had a restriction placed on her license by the Board of Nursing. She is allowed to complete all of the nursing care for a patient, however, she is not permitted to administer any controlled substances to patients. A code is called on a patient who was admitted with unstable angina. While the code is in progress, Ellen comes into the room and reports to Marie, the charge nurse, that a postoperative patient is in severe pain rating it at a 10. Marie knows that the rating is probably accurate since the patient had a thoracotomy for lung cancer and his medication has not been very effective. Ellen asks for the keys and tells Marie that she will bring the unopened tubex to her so that Marie can administer the medication. Which of the following are appropriate actions?b. Allow the aide to go ahead and suction the patient
c. Observe the aide once to determine if she is using correct technique.
d. Tell the aide that she can't suction the patient, that she never heard of an
aide suctioning and that she can't take the responsibility for it.
e. Ask the aide if she can show her the relevant policy or job description
f. Suction the patient herself all night
a. Ask Ellen to call the surgeon to report the ineffectiveness of the medication7. Alice, a RN on the night shift, is caring for a patient who needs to get two units of packed cells on the night shift. She ordered the packed cells from the Blood Bank and they were delivered to the unit in the midst of a crisis when a patient was being transferred to the ICU. Once the crisis was over, the other RN on the unit took her dinner break. After about a half hour, Alice noticed the unit of packed cells sitting on the counter. She knows that this particular patient cannot tolerate much of an increase in fluid intake and is worried that she won't be able to get the administer the blood in a timely fashion. The hospital policy states that two RNs need to verify the numbers on the packed cells. How should the situation be handled?b. Tell Ellen to take over her responsibilities in giving the meds for the code while administering the medication
c. Tell Ellen to bring her the unopened pain medication tubex
d. Report Ellen's inappropriate behavior to the head nurse in the morning.
e. Discuss Ellen's understanding of her licensure restriction with her after the code is over
a. Checks the numbers with the LPN who is certified to start IVs8. A patient who had a coronary artery stent placed is being discharged. She going home with a prescription for Coumadin 1 mg. po each evening. The patient lives alone and does not drive. The physician asks the nurse to give the patient one tablet of Coumadin 1 mg. to take home so that the patient does not have to make arrangements to go to a pharmacy when she gets home. Which of the following are appropriate actions:b. Wait until the other RN returns to the unit
c. Call the supervisor and ask if she can check the blood with her
d. Call an RN who is on another unit
e. Ask the intern to check the numbers
a. Prepare the Coumadin as long as it is in a unit dose package and labeled with the name and dose.9. A nurse's aide in pediatrics is assigned to feed a one-year old who is in a crib. Following the feeding, the aide changes the baby's diaper and puts her to sleep in her crib. She walked across the room to get a clean nightgown without putting the side rail of the crib up. The baby fell out of the crib and is crying. The aide picked up the baby and put her back into the crib and put the side rail up. Later on, when the RN comes into to do her assessment, the mother of the baby in the next crib tells the RN what happened.b. Tell the doctor that nurses are not allowed to dispense medications because it is hospital policy
c. Tell the doctor that dispensing of medications by nurses would violate the nurse practice act
d. Call the discharge planning nurse to see what arrangements may be made to get the prescription filled.
e. Give the patient her Coumadin 1 mg. before she goes home this afternoon.
What is the RN accountable for in this example?10. Check the box if the caregiver is allowed to perform the specific task.Was the task of feeding the baby and changing the baby's diaper delegated correctly?
Is the RN's license in jeopardy for working with an incompetent aide?
What is the nurse's aide responsible for?
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| Oral medication | |||
| IM or SC meds | |||
| IV meds | |||
| Chemotherapy | |||
| Epidural meds | |||
| Changing sterile dressings | |||
| Gastrostomy tube feeding | |||
| Irrigating the ng tube of a postoperative patient | |||
| Enemas | |||
| Colostomy Irrigation | |||
| Inhalers | |||
| Insulin | |||
| Blood glucose monitoring | |||
| Suctioning | |||
| Administering cardiac drugs for arrhythmias |
Reference: Hansten, R. I. & Washburn, M. J. (1994). Clinical delegation skills: A handbook for nurses. Gaithersburg, MD: Aspen.
Copyright © 2004 Margarete Lieb Zalon
University of Scranton
Weinberg Memorial Library
Dr. Margarete
Zalon's
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