Lesson 1 Management of Care

I. Concepts of Management and Supervisiono

A. Review standards and/or position statements of the following agencies before delegating any nursing tasks

1. Board of nursing (U.S.)/regulatory body (Canada)

2. National Council of State Boards of Nursing (NCSBN)

3. Nursing organizations

a. American Nurses Association (ANA)

b. Canadian Nurses Association (CNA)

4. Health care institutions

Don't Confuse these! ✓Scope of Practice - determined by a state's nurse practice act (or province/territory's nursing act) ✓Standards of Practice - established by the nursing profession (such as the ANA or CNA) ✓Standard of Care - institutional policy and procedure documents

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B. Use critical thinking in management situationso

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C. Nurses must understand the legal aspects of the nursing profession

1. Provide safe competent care

2. Advocate client's rights

3. Provide care that is within their scope of practice

4. Provide care that is consistent with established standards of care

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Learn more about the National Council of State Boards of Nursing  (NCSBN) and follow the links to find your state's nurse practice act. Click on the links to discover more about the American Nurses Association  (ANA) and the Canadian Nurses Association  (CNA).

D. Use the six Quality and Safety Education for Nurses (QSEN) competencies as a guide for managing and supervising care

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1. Patient-centered care - the patient (or designee) is recognized as the source of control and full partner; care that is provided is based on respect for patient's preferences, values, and needs

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2. Teamwork and collaboration - open communication, mutual respect, and shared decision-making are used to achieve quality patient care

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3. Evidence-based practice - health care delivery is the integration of best current evidence with clinical expertise and patient/family preferences and values

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4. Quality Improvement - data is used to monitor the outcomes of care processes;

improvement methods continuously improve the quality and safety of health care systems

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5. Safety - risk of harm to clients and providers is minimized through both system effectiveness and individual performance

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6. Informatics - information and technology is used to communicate, manage knowledge, mitigate error, and support decision-making

E. Establishing prioritieso

1. Prioritizing involves decisions of which needs or problems require immediate attention or action and which ones can be delayed until a later time if they are not urgent

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2. Needs that are life-threatening or could result in harm to the client if left untreated are high priorities

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3. Actual problems or needs have higher priority than potential problems or needs

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4. Problems or needs identified by client are of a higher priorityo

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5. Consider Maslow's principles (hierarchy of needs) or the ABCs (airway, breathing, circulation) of emergency care to guide decisions

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6. Mutual decision-making for priorities may be made with the client based on the client's physiologic needs, desires, and safety

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Learn more about the Quality and Safety Education for Nurses  (QSEN) project.

F. Communication skills and conflict resolutiono

1. Communication

a. involves perception to receive a message

b. involves expectation - the unexpected may be ignored

c. makes demands on nurses to think and respond

d. is different than information

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2. Types of communication

a. downward - used to relate organizational policy such as position description and rules and regulations

b. upward - include such things as staff meetings

c. lateral - between staff members, i.e. to coordinate activities

d. diagonal - staff from different levels work together on a project

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3. Causes of conflict

a. inadequate communication

b. incorrect facts

c. unstable leadership or inadequate action plans

d. misunderstood roles or responsibilities

e. receiving directions from two or more delegators

f. lack of or limited staff input into decisions

g. inability to accept change

h. power issues

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4. Prevention of conflict includes

a. allocating resources fairly

b. avoiding unexplained changes

c. clearly stating expectations

d. addressing staff fears

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5. Dealing with conflict

a. take prompt action

b. help parties resolve conflict among themselves (communicate trust that parties can achieve resolution)

c. maintain an objective approach

d. avoid criticism

e. use problem solving approach

f. provide privacy for sensitive issues

g. negotiate for agreements - not winning or losing

h. focus on patient care interests

i. avoid emotional outbursts

j. include a third party when mediation seems the best choice

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G. Communication and collaboration techniqueso

1. SBAR technique - provides a standardized framework for communication between members of the health care team

a. S = situation (a concise statement of the problem)

b. B = background (pertinent and brief information related to the situation)

c. A = assessment (analysis and considerations of options - what you found/think)

d. R = recommendation (action requested/recommended - what you want)

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2. "I PASS the BATON" - used to improve "handoffs" and transitions in

health care, with opportunities to ask questions, clarify, and confirm

a. I = introduction (introduce yourself and your role/job)

b. P = patient (name, identifiers, age, gender, location)

c. A = assessment (presenting chief complaint, vital signs and symptoms and diagnosis)

d. S = situation (current status/circumstances, including code status, recent changes, response to treatment)

e. S = safety concerns (critical lab values/reports, socioeconomic factors, allergies, alerts such as falls, isolation, etc.)

f. B = background (co-morbidities, previous episodes, current medications, family history)

g. A = actions (what actions were taken or are required and provide brief rationale)

h. T = timing (level of urgency and explicit timing, prioritization of actions)

i. O = ownership (who is responsible - nurse/doctor/team and patient/family responsibilities)

j. N = next (what will happen next? anticipated change? what is the PLAN? what is the contingency plan?)

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3. CUS - a process used to more effectively advocate for clients when there is a concern

a. C = concern ("I am concerned...")

b. U = uncomfortable ("I am uncomfortable...")

c. S = safety ("this is unsafe...")

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The SBAR technique was originally developed by Kaiser Permanente. Read more about SBAR from the federal Agency for Healthcare Research and Quality .

II. Delegationo

A. Definitions

1. Delegation: a process by which responsibility and authority for performing tasks are transferred from one individual to another who accepts that authority and responsibility

2. Delegation involves

a. responsibility: an obligation to accomplish a task

b. accountability: accepting ownership for the results or lack of

c. authority: right to act or empower over others

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B. Delegation overview

1. A nurse can only delegate those tasks for which that nurse is responsible

2. The delegator remains accountable for the task

3. Along with responsibility for a task, the nurse who delegates must also transfer the authority necessary to complete the task

4. The delegator knows how to perform the task being delegated

5. Delegation is a contractual agreement that is entered into voluntarily

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Remember the steps in the Nursing Process - A Delicious PIE

A = AssessmentD = Diagnosis

P = PlanningI = ImplementationE = Evaluation

C. Scope of practice, training and education of nursing personnel o

1. Registered Nurses (RNs)

a. baccalaureate prepared nurses are equipped to care for individuals, families, groups and communities in both structured and unstructured health settings

b. associate degree prepared nurses are equipped to care for individuals in a structured health care environment

c. RNs cannot delegate the following activities to unlicensed assistive personnel (UAP)

i. assessment of clients

ii. evaluation of client data

iii. nursing judgment

iv. client/family education/counseling and evaluation

v. nursing diagnosis/nursing care planning

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2. Licensed Practical or Vocational Nurses (LPN/VN)

1. assist in implementing a defined plan of care and to perform procedures according to protocol

2. assessment skills involve collecting data and are directed at differentiating normal from abnormal

3. may reinforce information that has been given to the client by the RN

4. competence to care for physiologically stable clients with predictable conditions

5. the scope of practice for LPN/VNs is not the same in every jurisdiction

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3. Unlicensed Assistive Personnel (UAP)

1. because they are unlicensed, they have no scope of practice

2. in general, nursing tasks that may be delegated include non-invasive and non-sterile treatments

a. assist in a variety of direct client care activities or tasks, e.g., bathing, transferring, ambulating, feeding,

toileting, and obtaining measurements (vital signs, height, weight, intake and output, blood glucose levels)

b. perform indirect activities such as housekeeping, transporting people and stocking supplies

3. some states allow for the practice of medication administration in specific settings by medication aides - refer to your jurisdiction's laws for specific information

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D. Steps of delegationo

1. Right task - define the task and determine if it can be safely delegated

a. match the delegatee to the task

b. determine if the task is within the scope of practice for the delegatee

c. determine agency policies, procedures, and standards

d. understand standards of practice, e.g., the American Nurses Association (ANA) Standards of Practice and the Canadian Nurses Association (CNA) Position Statements

e. remember - nursing tasks that be delegated to unlicensed assistive personnel (UAP) are intended to assist, but not replace, the nurse

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2. Right circumstances

a. determine if there is anything about the client's condition or the environment which would preclude this delegatee from performing the task as delegated

b. determine if staff members have the resources, equipment, and supervision needed to work safely

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3. Right person - is the right person delegating the right task to the right person to be performed on the right patient?

a. determine if staff members have the necessary knowledge, skills, and abilities (KSA) to perform the delegated tasks and if this information is documented

b. determine if the client's condition is stable with predictable outcomes prior to delegating care

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4. Right direction/communication - clearly communicate the specific steps of the task, expectation about performance, reporting, and documentation of the task

a. potential problems and solutions are discussed

b. the nurse intervenes if necessary

c. staff members must be able to decline without jeopardizing their jobs

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5. Right supervision/evaluation - appropriate monitoring, intervention, evaluation, and ongoing feedback

a. the nurse must have the appropriate skills to assist, teach and guide the individual who is completing the task

b. the nurse will determine if client needs were met

c. the nurse can continue or withdraw the delegation

d. problems, particularly and sentinel events, are clarified or reported to supervisors

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Five Rights of Delegation

✓Right Task✓Right Circumstances✓Right Person✓Right Direction/Communication✓Right Supervision/Evaluation

E. Client care assignments

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1. Assign the right task o

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2. Assign the task to the right persono

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3. The LPN may assign tasks to the unlicensed assistive personnel or nursing assistants (if allowed by the jurisdiction's laws)

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4. Unlicensed assistive persons (UAP) or nursing assistants cannot delegate to other UAPs or nursing assistants

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The 4 C's of Communication

1. Clear - Does the team member understand what I am saying?2. Concise - Have I confused the direction by giving too much unnecessary information? 3. Correct - Is the direction given according to policy, procedures, job description & the law? 4. Complete - Does the team member have all the information necessary to complete the task?NCSBN Learning Extension offers an online continuing education course called Delegating Effectively .

Read NCSBN's Working with Others: A Position Paper  (2005). Use the decision tree to help you to understand the concept of delegation and how to better manage and supervise others.

III. Performance Improvement (Quality Assurance) o

A. Quality: the degree to which client care services increase the probability of desired outcomes and reduce the probability of undesired outcomes given the current state of knowledge

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B. Performance improvement/assurance: the process of attaining a new level of performance or quality that is superior to any previous level of performance or quality

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C. Total quality management: a philosophy that emphasizes a commitment to excellence throughout the organization

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D.Six characteristics of total quality management  

1. Focus on customer, i.e., client

2. Focus on outcomes

3. Total organizational involvement

4. Multi-professional approach

5. Use of quality tools and statistics for measurement

6. Identification of key areas for improvement with an emphasis on SAFETY

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E. Mandated by the Joint Commissiono

Learn more about the Joint Commission's accreditation survey process .

View the Joint Commission's 2014 National Patient Safety Goals .

Review information about the Canadian Patient Safety Institute .

IV. Nursing Care Delivery Systemso

A. Functional nursing (task nursing)

1. Needs of clients are broken down into tasks

2. Tasks are assigned to various levels of health care workers according to licensure and skill

3. Example: RN gives medications and UAP give bed baths for one group of clients

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B. Team nursing

1. Most common nursing care delivery system

2. A team of nursing personnel provides total care to a group of clients

3. Team leaders supervise client care teams, which usually consist of an RN, LPN, and UAP

4. Team leader reviews the client's plan of care and progress with team members during team conference

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C. Total client care (case method)

1. An RN is responsible for all aspects of care of one or more clients

2. The LPN may be assigned to assist the RN

3. This type of care is usually provided in areas requiring high level of nursing expertise, such as the critical care unit (CCU) or the post-anesthesia recovery unit (PACU)

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D. Primary nursing

1. The RN maintains a client load of primary clients

2. The primary nurse designs, implements and is accountable for the nursing care of those clients during their entire stay on the unit

a. has the benefit of continuity of care but may not be feasible with varying schedules

b. has been found to result in greater nurse satisfaction, more personalized care, less turn over, and fewer negative outcomes for patients

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E. Practice partnerships

1. An RN and an assistant (UAP, LPN, less-experienced RN, graduate nurse, or nurse intern) agree to be practice partners

2. Partners work together on same schedule with same group of clients

3. Senior partner directs the work of the junior partner within the scope of each partner's practice

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F. Case managemento

1. Model for identifying, coordinating, and monitoring the implementation of services needed to achieve desired client outcomes within a specified period of time

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2. Organizes client care by major diagnosis or Diagnosis Related Group (DRG)

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3. A collaborative health care team defines the expected outcomes of care and care strategies for a client population by defining critical paths

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4. A registered nurse manager is assigned to coordinate, communicate, collaborate, problem solve, facilitate and evaluate client care for a group of clients

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5. Case manager usually does not provide direct client care but coordinates care provided by licensed and unlicensed nursing personnel according to a critical path

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6. Critical pathways are plans for providing care to the client and family

a. identify desired outcomes

b. state expected amount of time and resources to be used

c. focus on specific diagnoses or procedures that are high volume and or high resource use (and therefore costly)

d. promote collaboration among disciplines (health care professionals)

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7. The essential components of case management include

a. collaboration of all health care team members

b. identification of expected patient outcomes with time frames

c. use of principles of continuous quality improvement (CQI) and variance analysis

d. promotion of professional practice

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8. Client involvement and participation is key to successful case managemento

The Case Management Resource Guide  is a free, searchable database of health care services, facilities, businesses and organizations.

G. Differentiated practiceo

1. Identifies distinct levels of nursing practice based on defined abilities that are incorporated into job descriptions

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2. Structures nursing roles according to education, experience, and competency

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H. Client-centered careo

1. The RN coordinates a team of multi-functional unit-based caregiverso

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2. All client care services are unit-based, including admission, discharge, diagnostic testing and support services

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3. Uses UAPs to perform delegated client care taskso

Arrive at the testing center early on exam day  so you have time to register, become accustomed to your surroundings, and relax. Bring the proper identification and your Authorization To Test (ATT) email.

V. Information & Documentationo

A. Types of patient records

1. Problem-oriented medical record (POMR)

a. a decision is made on the nature of the client's problem or problems and these problems are assessed regularly

b. recorded using a standardized format, by narrative notes in the S.O.A.P. format or by flow sheets

c. discharge summary relates the overall assessment of progress during treatment and plans for follow-up care, encouraging continuity of care

d. four parts

i. data base: the client's present health status

ii. problem list: numbered list of health problem(s)

iii. initial plan: plan to help overcome health problem(s)

iv. progress notes: all disciplines chart on the same page

2. Source-oriented

a. most traditional type of charting, with different disciplines charting on separate forms

b. drawback: records become very bulky, very quickly

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Documentation has six key components (CO-ACTS) 

ConfidentialOrganized (chronologically)AccurateCompleteTimelySubjective and objective data

B. Methods (styles) of chartingo

1. Narrative charting

a. the nurse records observations, data (including reactions from the client) in a sequential and chronological order

b. baseline charted every shift

c. source-oriented

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2. S-O-A-P: problem-oriented charting; comes from a medical model

a. S = subjective; what client tells you

b. O = objective; what you observe, see, etc.

c. A = assessment; what you think is going on based on the data

d. P = plan; what you are going to do

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3. D-A-R

a. D = data - collecting information about a problem

b. A = action - the task to be completed about the problem

c. R = response - the client's response to the problem

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4. Focus charting

a. charting on an acute condition, a potential problem, a treatment or procedure, or a client behavior

b. components of this type of charting include: information about the condition/problem, action, and client's responses

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5. A P-I-E charting - uses the nursing process

a. A = assessment

b. P = problem

c. I = intervention

d. E = evaluation

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6. Charting by exception

a. uses flowsheets

b. emphasis on abnormal (or what is abnormal for this particular client); normal routine is presumed as having been done, without any problems

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C. Documentation guidelineso

1. General

a. check that you have the correct chart

b. record the facts as accurately as possible

c. chart as you go

d. never chart for another person

e. do not mention incident reports

f. avoid the use of abbreviations - when in doubt, write it out!

i. all health care institutions have a list of accepted abbreviations

ii. refer to the Joint Commission's official "Do Not Use" list of abbreviations

g. never alter a client's record (altering a client chart is a criminal offense)

h. six things that nurses must document

i. assessment

ii. nursing diagnosis and client needs

iii. interventions

iv. care provided

v. client response to care

vi. client's ability to manage continuing care after discharge

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NCSBN Learning Extension offers several continuing education courses, including Documentation: A Critical Aspect of Client Care .

The American Recovery and Reinvestment Act  (ARRA) requires all health care facilities to use electronic medical records.

Review the U.S.'s Institute for Safe Medication Practices (ISMP) List of Error-Prone Abbreviations, Symbols, and Dose Designations . and the dangerous abbreviations list from the Institute for Safe Medication Practices Canada .

2. Legal guidelines for charting

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a. electronic health record (EHR) charting

i. never share access or password with another person

ii. change your password frequently

iii. maintain confidentiality of documented information printed from the computer

iv. carefully check your information before you press enter

v. access information for clients under your care only

vi. log off when you are finished

vii. date and time are automatically recorded

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b. paper-ink

i. do write in chronological order

use permanent black ink

chart the time and date for each entry

include consent for or refusal of treatment, client

responses to interventions, calls made to other health care professionals

write legibly

cross through the error once, date and initial the change

correct any errors in a timely manner

ii. do not erase, scratch out or use correction fluid (Liquid Paper

or White Out®)

document for others or change documentation by others

leave blank spaces

recopy any charting form

make photocopies without permission

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VI. Legal Responsibilitieso

A. Sources of law

1. Federal Regulations in the U.S.

a. American Recovery and Reinvestment Act (ARRA)

i. The Health Insurance Portability and Accountability Act (HIPAA)

ii. Health Information Technology for Economic and Clinical Health Act (HITECH Act)

b. The Americans with Disabilities Act (ADA)

c. The Mental Health Parity Act (MHPA)

d. The Patient Self-Determination Act (PSDA)

e. The Uniform Anatomical Gift Act and the National Organ Transplant Act

2. State law (U.S.) - nurse practice act

a. passed by each state legislature to regulate the practice of nursing in that state

b. administered by the board of nursing in each state or jurisdiction

c. scope and responsibilities vary state-to-state, therefore nurses are responsible for knowing regulatory requirements for nursing in each state where they are practicing

d. nurse practice acts define:

i. scope of practice (what the nurse is allowed to do)

ii. nursing titles that are allowed to be used

iii. qualifications for licensure

iv. actions that can or will happen if a nurse does not follow the nursing law

3. Regulatory bodies (Canada) - College of Nurses

a. establishes requirements for entry to practice

b. articulates and promotes practice standards

c. administers a Quality Assurance program

d. enforces standards of practice and conduct

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NCSBN Learning Extension offers continuing education (CE) courses on Professional Accountability and Legal Liability for Nurses  and Disciplinary Actions: What Every Nurse Should Know . 

B. Types of lawo

1. Criminal Law

a. deals with acts of intentional harm to individuals and society as a whole

b. categorized as a felony or misdemeanor

c. the defendant is either guilty or not guilty

d. the burden of proof is "beyond a reasonable doubt"

In cases of malpractice, the (former) client must prove that the nurse not only committed a breach of duty but that this breach of duty was the cause of any damage or injury to the client.

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2. Civil Law

a. deals with disputes between parties or negligent acts that cause harm to others protects the individual rights of people

b. deals with tort law - unintentional, quasi-intentional or intentional torts

c. the burden of proof is "preponderance of the evidence"

d. negligence and malpractice are examples of unintentional torts

i. negligence: a breach of the duty to provide nursing care to the client

ii. malpractice is professional negligence; the unintentional failure of an individual to perform or not perform an act that a reasonable person would or would not perform in a similar set of circumstances

iii. negligence involves four legal concepts duty: nurses have a legal obligation to

provide nursing care to clients

must meet a reasonable and

prudent standard of care under the circumstances

must deliver care as any other

reasonable and prudent nurse of similar education and experience would, under similar circumstances

breach of duty: failure to provide expected,

reasonable standard of care under the circumstances (includes errors of omission or commission)

proximate cause relationship between the breach of

duty and the resulting injury

the injured party must prove that

the nurse's action or omission led to the injury

damages: the injury and the monetary award

to the plaintiff

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C. Legal rights and responsibilitieso

1. Comply with state and/or federal regulations for reporting client conditions, e.g., abuse, neglect, communicable diseases, gunshot wounds, dog bites

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2. Report unsafe practice of health care personnel and intervene as appropriate (for example, with suspected substance abuse, improper care) - mandatory reporting is required by most nurse practice acts

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3. Identify and manage client valuables according to facility/agency policyo

VII. Professional Misconducto

A. The impaired professional

1. Remember that the impaired nurse compromises client care

2. Be sure that the problem exists and can be proven

3. Communicate specific concerns to appropriate persons such as a nurse manager or risk manager

4. Document incidents in terms of behaviors, specific times, dates - be objective

5. File a report according to the policies and procedures of the institution

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B. Boundary violations

1. Definition: actions that overstep established interpersonal boundaries and meet the needs of the nurse rather than the client.

2. Guiding principles in determining professional boundaries

a. nurse is responsible for setting and keeping boundaries

b. nurse must avoid simultaneous professional and

personal relationship with a client

c. nurse must avoid flirtation

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C. Consequence of professional misconduct

1. A board of nursing must protect the public and is required to take action against the licenses of nurses who have exhibited unsafe nursing practice

2. A state board of nursing may imposes penalties for professional misconduct, ranging from probation, censure, and reprimand, to suspension or even revocation of licensure

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NCSBN Learning Extension offers continuing education (CE) courses for Understanding Substance Use Disorder in Nursing  and Professional Boundaries in Nursing .

Review the Canadian Nurses Association's position statements on Problematic Substance Use by Nurses . and Nurses' Involvement in Screening for Alcohol or Drugs in the Workplace .

VIII. Client Rightso

A. Privacy

1. Confidential information may only be released by signed consent of the client

2. Unauthorized release of client data may be an invasion of privacy

3. Health Insurance Portability and Accountability Act of 1996 (HIPAA)

a. provides individuals with access to their medical records and more control over how their personal health information is used

b. provides privacy protection for consumers of health care

4. Health care workers must release information when a court orders it or when statutes require it (as in child abuse or communicable diseases)

5. Special regulations apply to release of information about psychiatric illness or HIV

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Learn more about HIPAA  from the U.S. Department of Health & Human Services.

Read more about Privacy Legislation in Canada .

NCSBN Learning Extension offers a continuing education course called Patient Privacy .

B.Advance directives  

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1. As part of the Omnibus Budget Reconciliation Act (OBRA) of 1990, the U.S. Congress established the Patient Self-Determination (PSDA); this requires states to provide written information to clients outlining their rights to make health care decisions

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2. These rights include:

a. the right to refuse or accept treatment

b. the right to formulate advance directives

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3. Nurses and other members of the health care team are required to

a. assess the clients knowledge of advance directives and their status regarding the advance directive process

b. provide information and assistance to the client in developing advance directives

c. plan care that incorporates the clients decisions regarding advance directives Three common advance directives are:

i. living will - identifies what a client wishes for his care should he become unable to communicate these wishes

ii. durable power of attorney for health care decisions - the client has appointed a person to make decisions about their care if they are unable to do so.

iii. do not resuscitate (DNR) status - this has been expanded to include identification of medications that

may be given without any defibrillation attempts (comfort measures only)

follow the facility policy on obtaining and implementing DNR orders

generally, the order must be written by a

physician; some facilities may have a policy to allow verbal orders under specific conditions

the order must be communicated clearly to all personnel caring for the client

the client or her or his health care proxy can withdraw the order at any time

a nurse who attempts to resuscitate a client

with a valid DNR order may be committing battery

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C. Refusal of treatment - competent clients may refuse treatment, even life-sustaining treatment

D. Freedom from safety devices/restraintso

1. Physical restraints/safety devices require a signed, dated physician's order specifying the type of restraint/safety device and a time limit for its use

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2. Types of restraints/safety devices

a. drug or medication - central nervous system depressants, paralytics

b. any manual methoc (physical or mechanical device, material or equipment) - vest restraints, side rails

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3. Use the least restrictive form of restraint/safety deviceo

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4. Know agency guidelines for use of restraints  

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5. The nurse must document three factors

a. why restraints/safety devices were used

b. how the client responded

c. whether the client needs continued restraints/safety devices

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6. Restraining clients without consent or sufficient justification may be interpreted as false imprisonment

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Get a good night's sleep the night before the test.

E.Informed consent    

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1. Basic requirements

a. capacity

b. voluntariness

c. information

i. health care provider is legally obligated to provide a complete description of the treatment/procedure, description of the potential harm, pain, and discomfort that may occur, options for other treatments, and the right to refuse treatment

ii. the nurse should verify client comprehends and consents to care

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2. The client must understand

a. purpose of the procedure and expected results

b. anticipated risks and discomforts

c. potential benefits

d. any reasonable alternatives

e. that consent may be withdrawn at any time

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3. Requirements for signing an informed consent form

a. must be signed by a competent adult

b. individual who is signing must be able to understand the information given by the health care professional (if the person is unable to understand the information due to language barrier or hearing impairment, a trained medical interpreter must be present)

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F. Transition planning - recognizes that clients are not discharged from care but moved across the continuum to another level of care

Become familiar with the NCLEX Test Plan's distribution of questions and use this to make notes, like “I can recall” or “I need to review.” Use the “I need to review” list to help you to select the questions where you need more practice.

Rejuvenation Station: Triangle Breathinghttps://www.youtube.com/watch?v=xHXDwggp4hM