The Emergent Care Clinic

HESI 01 - Capstone The Emergent Care Clinic Case Study | 54mins Meet the Client The Emergent Care Clinic is a fast-paced, 20-bed, free-standing, acute care facility. The Emergent Care interdisciplinary team includes registered nurses (RN), practical nurses (PN), unlicensed assistive personnel (UAP), physicians, advanced practice registered nurses (APRN), and other collaborative care team members. The facility is located in an urban area and is open for business 24 hours a day, 7 days a week. Important to Know 1. Your first answer is the one that counts towards your score, but you’ll be prompted to try again if you get the wrong answer. When you get the right answer, you’ll go to the next section. 2. If you choose to re-take a Case Study, you will no longer be able to see your previous score. Section 1 Management of Care The first action of the charge nurse for the day shift in the Emergent Care Clinic is to prepare the assignments for the day shift. In addition to the charge nurse, three RNs, one PN, and two UAPs are scheduled from 7 am to 7 pm. Question 1 of 23 Which client should the charge nurse assign to the PN? A 45-year-old male reporting left arm pain and gastrointestinal upset. This client requires frequent assessment by an RN because symptoms may be cardiac in origin. A 20-year-old female who complains of pain to the right lower leg with swelling after tripping on the sidewalk. Because this client is the least acute, she is the most appropriate assignment for the PN. A 55-year old female who woke up with facial drooping, slurred speech, and right sided weakness. This client requires frequent assessment by an RN because she is have symptoms of a transient ischemia attack (TIA) or possible stroke. A 45-year-old male who is vomiting large amounts of coffee-ground emesis. This client requires frequent assessment by an RN and will more than likely require placement of a nasogastric (NG) tube. Section 2 Question 2 of 23 Mr. Jackson, the 45-year-old male client reporting left arm pain and gastrointestinal upset, is assigned to an RN. It is most important for the RN to admit Mr. Jackson to which room in the Emergent Care Clinic? The room farthest from the nurse’s station that is quiet. This is not the best choice. A private room that allows for a more confidential interview of the client’s symptoms. The RN should take measures to ensure confidentiality even in a semiprivate room. The room with the closest proximity to the nurse’s station. Close proximity to the nurse’s station is important, but it does not override obtaining critically needed data. A room with a continuous cardiac telemetry monitor. Reports of left arm pain may indicate myocardial ischemia, and monitoring the ECG is critical. The RN admits Mr. Jackson to a clinic room and connects him to the continuous cardiac telemetry monitor so that his heart rhythm can be monitored in the room and at the nurse' station. Section 3 Management of Care: Delegation The UAP assists the RN in getÝng Mr. Jackson admitted. Question 3 of 23 Which tasks should the RN delegate to the UAP? Select all that apply Enter the obtained vital signs in the medical record. The RN can delegate this task to the UAP. Ask the client to describe his left arm pain and stomach discomfort. Assessment should be done by the RN. Some facilities allow the UAPs to collect data on pain levels, but the RN should do a complete pain assessment. Collect the client’s psychosocial history. Because this is part of the client assessment, the RN should not delegate this task to the UAP. Identify potential nursing diagnoses for the plan of care. The RN is responsible for the development and implementation of the plan of care and cannot delegate it to the UAP. Place a bedside commode in the room. The UAP can bring durable medical equipment into a room as directed by the RN. Section 4 The UAP obtains Mr. Jackson’s vital signs and reports the results to the RN. Reported vital signs for Mr. Jackson are as follows: T 98.8° F P 94 beats/min R 30 breaths/min BP 158/88 mmHg Question 4 of 23 Which action should the RN delegate to the UAP next? Bring oxygen supplies to the room. Although oxygen equipment and supplies may be needed, it is not the first action. Reduce the lighting in the room so the client can relax. This action may help to reduce the client’s anxiety, but it is not the priority action. Ask Mr. Jackson for the name and phone number of the person he wants contacted. Next of kin may need to be contacted, but it is not the priority action. Apply a continuous pulse oximeter monitor to the client. The increased respiratory rate indicates that continuous monitoring is the primary concern for this client. The oxygen saturation level also needs to be monitored continuously. The pulse oximeter may be applied by the UAP, but the monitoring and assessment is done by the RN. The UAP applies the continuous pulse oximeter to Mr. Jackson's finger. The client's Oxygen saturation is 90%. The RN applies an automated blood pressure cuff to assess his BP every 15 minutes. Section 5 Reduction of Potential Risk Mr. Jackson also reports dull, aching pain from his left shoulder radiating to his left arm. He states the pain comes and goes, and he rates the pain as 5 on a pain scale of 0 to 10. The RN applies electrodes from the ECG machine to obtain a tracing of Mr. Jackson's heart function and then analyzes Mr. Jackson's ECG strip, which shows a normal sinus rhythm. Emergent Care Clinic Normal sinus rhythm Question 5 of 23 Which prescription should the RN plan to implement first for Mr. Jackson? Administer sublingual nitroglycerin (NTG). This may be needed but it has not yet been ordered and is not the priority. Draw blood for cardiac enzymes. Lab results will provide important data about the client’s condition, but this prescription does not have the highest priority. Oxygen at 4 liters per nasal cannula. The client has increased respirations and low oxygen saturation. Increasing the client’s oxygen should be addressed first in this case. Administer a nebulizer treatment. There is no indication that the client requires a nebulizer treatment. Question 6 of 23 Which inquiry is most important for the RN to make first? Client’s insurance information. Financial status may be part of the comprehensive assessment, but it is not the first priority. Each client should be treated with the same standard of care regardless of financial status or insurance coverage. Family history of heart disease. Family history of heart disease is important; however, it is not the priority question. List of current prescription and over-the-counter medications. It is essential to obtain information on current medications when the client arrives. Many health problems are caused from side effects or missed doses. Length of time at his current job. Assessment of socio-economic factors should be done during the comprehensive assessment, but it is not the primary concern in this case. Mr. Jackson informs the nurse that he does not take any prescription medications and is not now on any over-thecounter medications or vitamin supplements. He says that he just returned from a long business trip overseas. Furthermore, he states that he has had no previous health problems. Section 6 After oxygen is applied to Mr. Jackson, his oxygen saturation improves to 96% with respirations of 22. The RN draws blood for laboratory analysis, starts an IV saline lock, and calls the UAP to prepare the client for a 12 lead ECG. Emergent Care Clinic Limb leads Limb leads I, II, and III. Leads are located on the extremities. Illustrated are the angles from which these leads view the heart. B, Lead placement for limb leads aVr, aVl, and aVf. These unipolar leads use the center of the heart as their negative electrode. C, Lead placement for the chest electrodes: V1, fourth intercostal space at the right sternal border; V2, fourth intercostal space at the left sternal border; V3, halfway between V2 and V4; V4, fifth intercostal space at the left midclavicular line; V5, fifth intercostal space at the left anterior axillary line; V6, fifth intercostal space at the left midaxillary line. Question 7 of 23 After the RN receives Mr. Jackson’s laboratory results, which data is most important to report to the primary healthcare provider (HCP)? Select all that apply Serum potassium 3.0 mEq/L. Because this is a critically low result that could contribute to cardiac complications, it should be reported immediately. Fingerstick glucose 180 mg/dL. A capillary glucose level of 180 mg/dl is elevated and should be reported. Serum magnesium 2.1 mg/dl. A serum magnesium level of 2.1 mg/dl is normal. Negative cardiac enzymes. Negative cardiac enzymes are normal. Abnormal lab data should be reported first. Sodium 143 mEq/L. Section 7 Management of Care: Establishing Priorities The RN notes that Mr. Jackson is now having occasional premature ventricular contractions (PVCs). The primary HCP prescribes a potassium supplement and sublingual nitroglycerin. Potassium chloride 40 mEq PO Stat is prescribed. The supply is potassium chloride 20 mEq per tablet. The charge nurse notes that Mr. Jackson's primary RN has pulled four tablets from the automated medication delivery system. Question 8 of 23 Fill in the blank How many capsule(s) should the RN give? (Enter numerical value only. If rounding is necessary, round to the whole number.) 2 The primary RN gives the correct dose of the medication. After being treated with potassium and nitroglycerin, Mr. Jackson rates his pain as a 0 on a scale of 0 to 10. His vital signs are stabilized, and his oxygen is discontinued. The RN teaches him about signs and symptoms of electrolyte imbalance and the importance of staying hydrated while traveling. Mr. Jackson is discharged with a referral to a cardiologist for an outpatient stress test later that afternoon. Section 8 Management of Care: Leadership The next day, the nurse manager of the clinic plans a staff meeting with the nurses and UAPs to communicate some changes in the scheduling protocol for the clinic. Question 9 of 23 Which method for scheduling the staff meeting allows for the best continuity of care for the clients and the best communication between management and employees? Schedule a meeting with the nurses in the morning and a meeting with the UAPs in the afternoon. This method would break continuity of care because the clients would not have access to the nurses during their meeting. Assign minimal staff to monitor the clients in the clinic and meet with the rest of the staff regarding the scheduling change. While this provides continuity of care for the clients in the clinic, it excludes some of the staff from participating in the process. Schedule two meeting times during the day to allow the nurses and UAPs to attend one of the sessions and maintain continuity of care in the clinic. Because this method ensures that there are nurses and UAPs monitoring the clients during the meeting, it does not break continuity of care. Unlike a sign in the nurses' lounge, the face-to-face meeting allows for the exchange of ideas and questions and answers. Post a printed sign in the nurse’s lounge with the protocols for the scheduling change. This is a one-way communication method that does not allow for an exchange of ideas or a question/answer session between the nurse manager and the staff. The nurse manager conducts the meetings and presents two different protocols for scheduling. The staff nurses and UAPs vote on the two different options. Question 10 of 23 The nurse manager demonstrates which type of leadership by allowing the nurses and UAPs to vote on the stafÏng protocol? Authoritative. The authoritative leader sets the vision for the team then steps back to allow them to work. Participative. Voting is an example of participative (democratic leadership), which promotes and supports participant involvement. Directive. The directive leader orders the team around, sets high standards, and disciplines those who don’t meet the standard. Coaching. The coaching leader focuses on the learning experience. Section 9 The participative style of leadership is usually the most effective, but there may be times when other styles are more appropriate. Question 11 of 23 In which situations should a directive leadership style be used by the charge nurse? Select all that apply When dealing with a mass casualty situation. When decisions must be made quickly and there is not time for participants to provide input, the directive leadership style is effective. Example: Code team leader. When developing protocols for a new nursing unit. The nurses who are going to be using the protocol should always have input into its creation, so a participative style is more appropriate in this situation. When implementing policy changes at an organizational level. When changes are made at the highest level of administration, middle level managers are obligated to implement the changes. Staff nurses form a committee to develop a protocol to decrease client wait time in the clinic. Authoritative leadership sets the goal for the team and allows them to do the work. When participating in an interdisciplinary team conference. Patriarchal or paternal style is not effective within the interdisciplinary team because all members of the team should participate and have input. Section 10 Psychosocial Integrity: Communication During the staff meeting, the nurse manager asks the nurses and UAPs to provide feedback about the daily operations of the clinic. One of the full-time RNs states, “I am always assigned the most challenging clients in the clinic, and it isn’t fair.” Question 12 of 23 How should the nurse manager respond? “Because you have more experience than most of the others the higher acuity clients are assigned to you.” This response does not address the RN’s feelings. “If you have a complaint, you should take it to me personally.” This dismisses the RN’s comments after the nurse manager asked for feedback. “I am sure that it is not intentional.” This does not address the RN’s concern or allow the RN to elaborate. “I hear your concern. Please elaborate on that.” This is an open-ended statement. It does not sound judgmental, and it gives the RN the chance to voice the concern. After hearing the RN’s response, the nurse manager schedules a one-on-one meeting with the RN to investigate the issue. After the meeting, one of the PNs tells the nurse manager that there is reason to believe one of the nurse practitioners is stealing narcotics. Question 13 of 23 What action should the nurse manager take first? Advise the nurse practitioner to seek counseling. Another action should be taken first. Have the PN describe the situation to include specific observations of the nurse practitioner’s behavior. The nurse manager needs to gather more information prior to confronting the nurse practitioner, asking for a urine or blood sample, or reporting the nurse practitioner to the State Board of Nursing. Specific details will be needed to determine if the report is credible. The board or other authority may be contacted after the report is substantiated. Ask the PN to observe the nurse practitioner for a week and report back with documented observations. This is not a correct action. Report the nurse practitioner to the ethics board of the institution. Another action should be taken first. Section 11 When asked about the specifics of the accusation, the PN states that the nurse practitioner was observed taking out five pre-filled vials of morphine from the automatic drug dispenser and placing them in her pocket. The nurse manager investigates and determines that five vials of morphine sulfate were removed from the automatic drug dispenser using the nurse practitioner’s login identification (ID), but no clients had prescriptions for morphine on this shift. Question 14 of 23 Which approach should the nurse manager use to confront the nurse practitioner? Tell the nurse practitioner that she will be terminated because she is stealing narcotics. This assumes guilt and does not give the nurse practitioner a chance to defend herself if she is not guilty. Call security to report the theft of the narcotics. Although the theft of the narcotics will need to be reported, this is not the first action. Observe the nurse practitioner for the rest of the shift to determine if more narcotics will be taken. This option allows the nurse practitioner to continue to care for clients when she may be under the influence of drugs. Privately meet with the nurse practitioner and inform her that she was observed placing narcotics in her pocket. This is a matter-of-fact approach in which the evidence is presented. If the nurse practitioner is guilty and decides to admit the wrongdoing, it will eliminate the need for an ongoing investigation and will be more therapeutic for the recovery process. The nurse practitioner admits to stealing the narcotics. The nurse manager accompanies the impaired nurse to the employee assistance program ofÏce. After counseling, the impaired nurse voluntarily admits herself to a drug rehabilitation unit. Section 12 Management of Care: Legal Just before the change of shift, Billy Young, a 6-year-old boy, is brought to the clinic by his grandmother, Ms. Washington. The charge nurse asks Ms. Washington what happened to Billy. The grandmother states that Billy fell out of his swing and that she thinks he broke his arm. The charge nurse observes Billy holding his right arm, but he is not crying and is currently playing with a toy car. Question 15 of 23 Which action should the charge nurse take first? Examine Billy’s right arm. Assessing a client’s injury is important, but another action should be taken first. Ask the grandmother if she is Billy’s legal guardian. The priority action for the charge nurse is to determine if the grandmother can legally give consent for the staff at the Emergent Care Clinic to treat Billy. Assess Billy’s pain level. Assessing a client’s level of pain is important, but it is not the priority action in this situation. Ask Billy what he was doing when he fell. The height of the fall may give the HCP information about the injury, but it is not the first priority. Section 13 Billy’s grandmother states that she is the child’s legal guardian, and she gives her consent for him to be treated. The RN asks Ms. Washington if she has any proof of legal guardianship for Billy. Ms. Washington shows the charge nurse her custody papers for Billy. The charge nurse assigns a male RN with 5 years pediatric experience to care for Billy. Question 16 of 23 Under which circumstance can healthcare personnel treat a child even when the legal guardian cannot be contacted? When the child has an obvious physical injury. Physical injury is not a criteria used for legal consent of a minor. When the personnel are unable to contact the legal guardian. Attempting to call the guardian does not provide legal consent. When the child is experiencing a life-threatening condition. If the child’s life is in danger, the child can be legally treated even when consent cannot be obtained. Any adult who brings and injured child can provide consent. Bringing the child to the hospital does not provide legal consent. Billy’s grandmother states that she has had custody of him since he was a baby and his biological mother visits him about once a month. In the examining room, the RN helps Billy take off his shirt and notices that he has bruises in multiple stages of healing on his back. The nurse asks Billy how he got the injuries, and Billy says, “I don’t know.” The grandmother states, “He falls a lot.” Question 17 of 23 Which action should the RN take first? Have the grandmother escorted out of the room. Although the RN may assign a UAP to stay with the client if abuse is suspected, more information needs to be gathered before the grandmother is confronted. Ask the grandmother is there is any other family member who can take care of Billy. There has not been enough information gathered yet to ask that information. Call local law enforcement and report suspected abuse. More information should be gathered before reporting to law enforcement. Continue with the nursing assessment. The RN should complete the assessment, paying close attention to any other signs of injury or abuse. The nurse completes the rest of the assessment and notices what appear to be cigarette burns on the back of Billy's legs. Billy does not cry when his injured arm is assessed. The nurse assigns a UAP to stay with Billy while he notifies the primary HCP. Section 14 Management of Care: Advocacy The HCP calls the grandmother out of the room to ask her a few questions while the RN interviews Billy alone. When asked again about his injuries, Billy says his mother gets mad sometimes when he is not good. Billy says he tells his grandmother, but she doesn't do anything. When the RN reports Billy's statements to the HCP, the HCP states, "I have known this family for a long time and I do not believe what the child is saying.” Question 18 of 23 Which action should the RN take? Contact Child Protective Services to remove Billy from his grandmother’s care. The RN can contact child protective services in abuse situations, but deciding to remove the child from the home is not within the role of the RN. Take the HCP’s word that the grandmother is being truthful. Because the HCP’s view is obviously skewed by the personal involvement with the family, another action should be taken. Assure Billy that authorities will keep his mother away from him. This falls outside of the RN’s realm of expertise. Because the RN does not know what the authorities will do, this information could be inaccurate. Request that the HCP withdraw from the case. The RN must be a client advocate and insist on unbiased continuity of care. Since there is personal involvement with the family, the RN should ask the HCP to withdraw from the case and allow another HCP to be assigned to Billy's care. The RN notifies the nurse manager of the situation and requests help with the problem. CPS is notified since the nurse is ethically and legally bound to report child abuse. The HCP’s behavior is also reported. After CPS and social services are notified, Billy receives treatment for his arm by another HCP. He is discharged to the care of a social worker for the night. Section 15 Management of Care: Performance Improvement Nurse managers have many responsibilities. One of those responsibilities is ensuring the Emergent Care Clinic’s performance improvement (PI) plan is implemented. Question 19 of 23 How should nurse managers use PI programs? Select all that apply Determine root cause of errors in practice. The goal of performance improvement plans is to improve systems and processes, not to assign blame. Implementation of nursing plans of care. Nursing plans of care are for the client, not the facility. Records may be monitored to determine if plans of care are being followed as part of a PI plan. Implement and follow guidelines established by accrediting agencies. The Joint Commission and other accrediting agencies require documentation of performance improvement programs for their participating facilities. Conduct chart reviews to determine the impact of nursing care on patient safety and healthcare outcomes. Client records are confidentially reviewed by nurses for trends and statistics and compared with benchmark standards. Guidelines for the use of the electronic medical record. All PI plans do not provide guidelines for the electronic medical record. An individual facility might include this as part of a review for a PI plan. As part of the PI plan, the nurse manager reviews trends in client satisfaction surveys. It is noted that 76% of clients are dissatisfied with the amount of time they had to wait in the waiting room. Question 20 of 23 Which action should the nurse manager take first? Inform administration that wait time cannot be decreased unless more staff is hired. It is too early to ask for an increase in staff because the nurse manager does not know if the wait time is too long, and if it is too long,the nurse manager does not know whether it is due to short stafÏng or another process. Set average acceptable wait time based on industry averages. More data needs to be obtained before a goal or expected outcome can be established. Schedule a staff meeting to discuss ways to decrease wait time. More data needs to be collected before planning strategies. Conduct a study to determine the current average wait time. Establishing the current wait time will give the nurse manager a frame of reference from which to work. Question 21 of 23 The nurse manager conducts a time study and determines that the average wait time for clients is 55 minutes before being admitted to a room in the Emergent Care Clinic. After the nurse manager decides to conduct a root cause analysis on lengthy wait times, which action should be implemented? Continued analysis and evaluation of services to achieve customer satisfaction. This describes the quality improvement process. Retrospective review of data to determine the cause of the problem. This describes root cause analysis, which is used to investigate the reason for the problem instead of just the effect. Establish measurable outcomes and quality indicators for wait time. This describes the quality improvement process. Compare the emergency center’s performance with that of similar organizations. This describes benchmarking. Section 16 Management of Care: Continuity of Care Upon completion of the root cause analysis, the nurse manager determines that the lengthy wait time is due to the manual processing and duplication of paperwork. After the nurse manager reviews different computerized data systems to help solve this problem, a recommendation is made that a system be purchased as soon as possible. The nurse manager plans to ensure a smooth transition and continuity of care for all clients when the clinic purchases a computerized data system for billing, charting, and medication administration. Question 22 of 23 Which strategy should the nurse manager use with the staff to provide a smooth transition when implementing a computerized data system? Provide the staff with a cost comparison on the computerized system with the current method being used. This may not be valued by every employee. Tell the staff that the agency will benefit from having a computerized system. This does not provide enough information to the staff to help with a smooth transition. Inform the staff that the new system is being purchased and they will have to convert to using computers. This type of strategy is authoritarian and will likely have a negative effect. Explain that the new system will drastically decrease duplication of paperwork and streamline processes and include potential disadvantages. Explaining how the system will benefit those using it and being honest about any flaws will let the staff know what to expect, which should help ensure a smoother transition. Majority of the staff agrees that an electronic data system will allow them to make more efÏcient use of their time and improve client satisfaction. The system is purchased for all departments in the Emergent Care Clinic. Question 23 of 23 After the education and training on the use of the electronic data system has been completed with the staff, which implementation strategy provides the best continuity of care to the clients? Schedule implementation for each department on different dates. Implementing one department at a time will allow for problems to be worked out prior to implementing it in another department and will be less stressful for the staff. Schedule a date for the system to start throughout the agency. If there are problems and the system fails, it will affect all departments and ultimately delay or interrupt continuity of care. Continue to use the paper pencil system for the employees who prefer not to use the computerized system. This is not an effective option as some employees may never want to convert to the new system. Remove all paper charts as soon as the new system is initiated. If the system fails, the paper charts can be used as backup, providing continuity of care. Therefore, they should not be shredded. The system is successfully implemented, and over the next 6 months, the wait time is shortened to 15 minutes. Emergent Care Clinic Emotional Stages of Change Section 17 Case Outcome The nurse manager, charge nurses, RNs, PNs, UAPs, and HCPs continue to work as an interdisciplinary team to improve processes dealing with all aspects of client care in this fast-paced Emergent Care Clinic.