okay so I'm going to pick up where we left off we are moving into talking about what the statutory guidelines are for legal consent for medical treatment and what your responsibilities are in relation to that the primary responsibilities of the nurse as it um surrounds consent is to be a witness to consent to advocate for the patient to ensure that they are making an informed consent that they understand what they are consenting to and to ensure that that patient is competent that you have not just given them narcotics that they are completely Lucid as they are making the decisions that they are making I refer you again to the Cal hospital.org website they have um an outline and it's updated continuously as far as what are the requirements for adults to consent for medical treatment what are the requirements for minors to consent to medical treatment and then again as I mentioned before they have the assault and abuse reporting requirement ments there as well so if this isn't something that you do in your day-to-day job then this is a really good website to have kind of tucked away in the back of your mind so that when these questions come up you know where to find reputable answers the first thing we're going to look at is the guidelines for an adult to consent to medical treatment an adult is considered anyone over the age of 18 also we'll get into this on the next slide but it could be someone who is a parent or an emancipated minor it also includes someone who's the guardian of someone else and any adult who is um consenting to treatment for their minor siblings or a grandparent who is consenting for treatment for M minor grandchildren as the nurse I said your responsibility is to witness it um it is the responsibility of the person who is performing the procedure that would be the nurse practitioner or the physician their responsibility is to um to explain the procedure to them you are just witnessing it so they are actually getting the informed consent you are witnessing the patient's signature on that form and attesting to the fact that they are not under the influence and that they are of sound mind when they are signing that um we require consents for all routine treatment surgery chemotherapy blood transfusions research um so we use consents quite a bit in the hospital it is a patients agreement to allow something to happen and it could be a like I said it could be a surgery an invasive diagnostic procedure and they need to have explained to them the risks benefits Alternatives and the consequences of refusal and again this is the person who is performing whatever that is the the procedure the surgery that's the person who explains to them what are the risks what are the benefits what are the Alternatives and what are the consequences if they refuse um if we have a patient who is is deaf illiterate foreign language um then we need to bring official interpreters so that they have a full understanding of what they're agreeing to and like I said before they can't be under the influence of opioids when they're signing so sometimes that's a little bit tricky um with patients who have had trauma and other type issues um when we talk about miners then um it gets a little bit trickier so even if someone is is a minor um but they have a child they can consent for that child or any child that is in their legal custody and that becomes really tricky but just remember they can consent for their own child um they cannot always however consent for themselves so if they have a child so let's say a 16-year-old has a child they can consent to anything that needs to happen to that child however for most medical treatment if they had a broken arm and the patient themselves the 16-year-old and needed surgery they would probably need their parents to consent for that surgery however um if it is something that has to do with pregnancy or prevention of pregnancy venial disease or treatment of reial disease drug abuse or substance abuse or treatment of drug abuse or substance abuse then they do not need anybody else's permission then they are able to consent for that themselves um and if they are married or a par or emancipated then they can always consent for themselves as well um there's a couple other stipulations and this is not going to be a test question that I just think this is interesting um there's also so even if someone is not legally married a parent or officially emancipated if someone is 15 years old or older and independent meaning they are managing their own money uh then they can also consent for themselves and at first I had to do a little research to figure out what was the reason reasoning behind that because why do we have the whole purpose of being emancipated if someone could just consent themselves at the age of 15 um and what that came around to was that was trying to protect our homeless youth so if someone has run away from home and they now need medical treatment of some sort obviously if they're coming from a bad home situation to call the parents at home to say where the child is and you know get consent from them is not appropriate so most of these laws go to uh to protect so that is to protect again our homeless youth if you look at the laws around pregnancy that's also a protection so the pregnancy venial disease and drug and substance abuse is also looking to protect the minor um I'm hoping you all come from good homes where you know of course it's not the desire that you become pregnant while you're a minor um but if you did come to your parents and say that that they would support you um same thing if you came to your parents and you said you had a venial disease or you had a drug or substance abuse problem I'm hoping that most of you come from homes where again it wouldn't be the first choice but they would support you not everyone does um and so that puts those minors at risk if they can't go to their families let's say you know they go to their family and they tell them they're pregnant and next thing we know we you know they're they're no longer we don't find them anymore um so that's not safe for that child um sometimes it's situations of incest where the father is the father of their child's baby um so in that case we're protecting that Minor by saying that for pregnancy veneral disease drug and substance abuse um or a situation where that child is homeless that they can consent for themselves um however that doesn't work if it is a minor who is um living in a home who again like my example on the bottom here wants to become vaccinated but this is not an independent minor they're not supporting themselves they're not homeless they're living in a home home they have a good family but in this case um and you can click on this when I give you the slides but in this case it was a 15-year-old who really wanted to become vaccinated but his mom was against vaccinations and he had he actually wrote to one of the nursing journals that I read um which I thought was pretty astute for a 15-year-old and just said you know what should I do should I lie about my age how should I how do I get these back vaccines because I really believe in being vaccinated uh but my mother does not um and so of course the the nursing journal editor you know wrote back to the child saying you know no do not lie about your age um but unfortunately unless you can get your mother's consent you do not have a way to legally do that um which is interesting and I don't know if that will change moving forward just because of the climate that we're in um but I thought that was interesting for you guys to to know um all right so we're going to move on and look at your responsibilities as nursing students um so one of the big things that you need to know as a nurs nursing student um with legalities to what we're talking about is that if your actions cause harm to patients it is your liel as is your instructor as is the hospital as is the school um so that's a that's a lot of people that are responsible for you making a mistake which is why when you're in clinical settings as a student you always feel like someone's watching you because we are always watching you um we want to make sure that we're protecting you we want to make sure we're protecting the patient we want to make sure we're protecting ourselves the school the hospital the whole the whole situation um you are any time that you are wearing the Concordia uniform that you are rendering care to patients you are expected to perform as a professional and you have to be very careful to separate your nursing student role from your work role uh so I know I heard from quite a few of you guys that you have work experience some of you are EMTs lbns nursing assistants um you know whatever that is respiratory therapists we've seen it all come through the program and that's great and you have a skill set but when you're in nursing school as a nursing student even if you are the LVN who is the best at starting IVs whatever it is you are not allowed to do that if it has not been taught to you yet in school um so you only allowed to perform skills and tasks which you have been in instructed and checked off to perform in school so if you've been taught it in lab and we've checked off and said you are competent to do this then with your instructor present you are okay to do that with a patient um but otherwise no if it's something you've learned in the course of your job then no um so again you can't perform anything that you would as a nursing assistant or any other medical professional and so if someone comes up to you and they know you're a nursing school and yesterday you were working as um an LVN and you were able to pass Med because that was your job and today you just happen to be on exactly the same unit but you're wearing your nursing school scrubs and the unit is crazy busy and your best friend that you usually work with is like oh my gosh can you give these meds for me 100% no you cannot give those meds for anybody even though you know how because you've been trained in your other role it doesn't matter um as a nursing student you can only do the things that are under your description as a nursing student um even if it's just tile nod doesn't make any difference so make sure that you guys know that there is a very distinct separation between those two um and that's the same thing if you were working as a CNA and you had learned something in school and now you were reverse situation and now you're there as a CNA and the nurse says oh my gosh I know you're a nursing school wouldn't you like to put this catheter in you sure would like to put that catheter in can you no 100% no um so even if someone says oh come on it's okay we do this all the time it is not okay um and the consequences for you on our end would be very very severe so you know please make sure that you respect the difference between your role as a student and your role if you're employed somewhere um that's about all I can say about that um with that I'm going to transition into uh malpractice insurance which to the best of my knowledge well actually I know this um you all are required to have malpractice insurance once you become an RN if you're working for a hospital most hospitals will have malpractice insurance for you which sounds great on the surface um and could be great I have always throughout my entire career and I don't know many people who have not I have always kept my own malpractice insurance and my reasoning for that is that I want someone who's going to fight just for me so if I do something stupid um I want to make sure that I have an attorney who's my attorney it's it's not the hospital's attorney who's looking for a scapegoat um in which case that might be me as the nurse it's my attorney and so that's important to me uh but there's nothing legal that says that you have to have malpractice insurance if you have malpractice insurance through your employer again to me it's just kind of an extra an extra layer of protection that I think is a big deal um when you do have malpractice insurance it is um essentially contract between you and the insurance company and it um they then will defend you if there's any type of negligence or malpractice um complaints placed against you and like I said you are covered by the institution's insurance while you're working um but it's pretty cheap to get malpractice insurance so I have always had it independently just in case um we're going to get into another area here so we're kind of just tying up all the loose ends here um so we also need to talk about abandonment and assignment ment issues so if you are um short staffed on a unit and let's say we come in and um I come into my unit and we're in California so on the medical unit there's ratios of five patients to one nurse and I come in and they say oh my gosh you won't believe it two people just got in a car wreck on their way into work and so you're going to have 15 patients today instead of five I have a decision to make at the point that they tell me that so if they say that and then I say oh that's terrible but okay I'll take care of 15 patients I have accepted responsibility so remember what we talked about the different things that have to be provide that have to be proven for negligence um if I accept responsibility for those patients whatever happens to those patients is my responsibility no matter how ridiculous the assignment is if however I say there's no way that I can care for 15 patients safely we're going to have to call everybody who works on this unit and if we can't get any of them we're going to have to call the manager and have him come in and take care of these patients because I cannot safely take care of 15 patients those are two different scenarios so it might be seen as insubordinate if I say that I don't want to take care of 15 patients but it's not outside of my rights to say that if however I accept the 15 patients and two hours into it I realize there's no way I can do this and I just run and hide I go home whatever that is that's abandonment so at that point I accepted responsibility for the patients and then I just didn't take care of them um and that's a big big legal problem um so be be aware of whatever you step into and take responsibility for is then your responsibility um the other area that can cause a little bit of legal concern is floating which is moving from your home unit so let's say I normally work on the orthopedic unit if I then go to the oncology unit because they're short of nurses there then I need to make sure that um I'm qualified to take care of those patients that the patients they give me are appropriate for my training um that I ask for an orientation to the unit so I know where supplies are I know how to get the medications I know where the educational materials are um so there's some responsibilities that go around that I cannot just there it's not a legal defense to say well it wasn't my home unit so I didn't really understand um so make sure that you guys are aware of that as well um we're going to move into an interesting case um that I was reading recently so this is um a situation where the um the the nurse followed orders even though the orders did not make sense um so we all know that the Physicians are responsible for providing um written orders and that nurses are responsible for um carrying out those orders um and then again if they don't make sense then we have to use our critical thinking to question why the order is what it is um so in this case um let's see so the example that I have is this case with Barbara leforge um she was a 57 yearold woman and again this happened right here in Orange County these are real cases um who went to a Subacute acute rehab facility to recuperate from tendon repair um after surgery by her podiatrist the podiatrist mistakenly ordered 50 Mig of morphine instead of 50 Mig of demol which I don't know how much you guys know about pain medications uh and narcotics but there is a very very very big difference between 50 Mig of morphine and 50 Mig of Demerol um so the farm pharmacist called the nurses on the unit and warned them that the dose was too high so that's red flag number one right I'm always talking about what red flags you have so there's definitely a red flag so the first red actually the first red flag should have been that that's a lot of morphine second red flag should be the pharmacist calls you and says that's too much morphine third red flag should have been that the nurses had to open an emergency kit because they didn't have enough vials of morphine to give the patient the dose as ordered so anytime you don't have enough of it on your unit and you have to open up an emergency kit maybe you need to question that order if it was a valid order wouldn't you have that already stocked on your unit um so again that would be a very very big um red flag so they went ahead they opened up the emergency kit they got scrambled and got enough morphine together to give her this ginormous dose of morphine after they gave it to her she suffered an overdose and was barely breathing but because it was a Subacute rehab unit she was not monitored she was not taken to the hospital until the next morning um the defendant's attorney said that the order was double checked and verified with a physician so I don't know if there was documentation of that I don't think there was because of the way the case went down um but supposedly the nurse called gave an esar to the doctor and said you know you sure you want to give 50 Mig of morphine and apparently the answer to that was yes um and I hope you guys have some questions for me when we meet about that because that should be setting off some bells for you so write yourself a little note if you have a question about that um so as a result of this she suffered an oxic brain injury resulting in deficits in coordination executive function reduced cognitive function and impaired judgment she spent 6 months learn relearning how to walk talk eat and groom herself and she required 24-hour supervision to assist with her ADLs she had been at the facility for 5 and2 hours when this overdose occurred so she had just gotten there um so I want you guys to think back to what we have to have to prove negligence so did the nurses have a duty to her yep did they breach that Duty yep was she injured yep was that injury caused by the nurse's breach of Duty yep um so what the jury found um was that the facility was 90% responsible for damages and the surgeon was 10% um so I want you guys to write down some questions right now that you can bring in with you in class does that make sense to you so the surgeon is the one who wrote the orders um the facility including the nurses are the ones who car carried out those orders supposedly double checked with the physician who said yes that is what I want you to give when the jury passed their verdict they said that the facility was 90% responsible and the surgeon was 10% responsible um so again write down any questions that you have on that we'll have a quick little conversation about that all right I'm going to move into um documentation so we're not going to spend a lot of time on this uh because we have already talked about documentation quite a bit and I know in that I also talked about that being a legal requirement um so you can imagine it would show up here again so when we have any kind of Mal malpractice any kind of a legal case um the patients's chart their medical record becomes the most important piece of evidence so in documentation when I told you if you didn't didn't document it it didn't happen that's 100% true here if ITA is not written in the chart then it doesn't matter how much you said you did it um so in the case that we had on the previous slide where the nurse says that she verified that order with the physician my guess is that that piece of information was not in the chart because otherwise I don't think that verdict would have gone the way that it did um it still would not be okay so even if you verify an order with the surgeon and she tells you 100% I want you to give that dose if your common sense and your nursing knowledge and your critical thinking tell you no you should not give that dose then you need to take it up the chain of command um you don't just do it and say well she told me to and she was the doctor um so make sure you guys are really clear on that um and again that whole that medical record becomes the communication tool that is accessed by all the members of the healthcare team so again it's really really important legally and also as a communication tool um if you make any entries into the doc into the nurses um sorry into the patient electronic medical record that are poorly written either bad grammar bad spelling um you know in the wrong chart whatever that is that is sniffed out by the plain's attorney really really quickly um and that's going to be a problem for you um the the last bullet point on here this was actually something that um one of the attorneys on one of the cases that Janette was on asked a nurse as she was on the witness stand who had it was back when there were pap documentation charts and her writing was really sloppy which I'm guilty of having sloppy writing so you know that I don't think that makes you a bad nurse um but the the attorney then turns to her and says so does your is your care as sloppy as the documentation that you provided in this chart that just puts you in such a bad light and there's no good way to answer that question because you're on the defensive um so be really careful be mindful that it is the patient Pati's medical record it is the piece of evidence that's going to be pulled up if there's any kind of legal considerations um so be really mindful of that as you are documenting even as a student and then some of the things we talked about already as far as documentation goes these are all repeats of what we've already talked about but make sure you document just the facts again it's not a creative writing exercise nobody cares what color hair the patient has or what the sunshine was doing outside um you can skip most of the adjectives and AD verbs and just stick to the facts um so these are some examples again of documentation of clear versus unclear so if you document somewhat agitated what are you trying to say what does that mean whereas if you document exactly the facts of what was happening the patient was pulling at the sheets and spitting out food we can all put a picture in our mind of like whoa that's a really agitated patient if you say something like appears like having a seizure what are you trying trying to say whereas if you say the left side of the face was twitching for 1 minute that's much more clear and concise so because this is the medical legal record of your patient be as clear and specific and concise as you can be um with the facts as you are entering them in there another thing we talked about when we talked about documentation is approved abbreviations so I showed you the Joint Commission list of unapproved abbreviations your hospital may have a list that's more extensive than that if your hospital list says don't use this abbreviation then you don't get to use that abbreviation um and this again is another quote from another case where this is what the attorney asked is if you didn't follow the hospital's policy for Approved abbreviations what other Hospital policies did you fail to follow nobody wants to answer that question that again puts you on the defensive makes you look bad um this also not um pre-charging forward we talked about that in documentation so don't just go down a column that somebody else documented even if you agree 100% that exactly what they documented is what you found you still need to go down your column and click all those things individually because that chart on the backside can tell that you did that um so if we end up in a legal situation and they can tell by looking at the inside of that documentation system that you just took a column and copied it and pasted they're going to question whether or not you did your own independent assessment or you just copied information from the shift before so make sure that you're really careful about that and then we talked about legibility already so that we don't need to repeat again couple other things here um again all of this I've already told you um but you as far as your notes go in any of the electronic documentation they are date stamped they are stamped with your name you couldn't pretend to be somebody else if you wanted to uh paper document mentation is a little bit trickier um and we'll we'll walk you guys through that a little bit in lab as well um if you did make a phone call so let's say you were the nurse who was qu questioning that morphine order you need to make an entry in that chart as the patient's Advocate and say you know Dr Smith um notified regarding concern of order for morphine 50 milligrams do order received to administer 50 Mig of morphine stack um because if that again had been in that chart on that case I think the outcome would have been different um but just saying that you did it and not having anything in there there's nothing to back you up um you shouldn't make any kind of notes and keep them separately because an attorney can ask for those they are discoverable um so you should not be taking notes home you guys as students when you're in clinical may be taking notes home um they need to be deidentified completely so that we cannot see who the patient is and then as soon as you are done with using those for scholarly purposes to writing your care plans doing your write up whatever it is that you're using them for they need to be shredded um so I I'm hoping you guys have shredders I I don't know but they do need to be shredded if that's not possible then you need to be very very very careful about what you take out of the hospital um because it should be very minimal and you should never take anything that is printed at the hospital with you um that's a big no no write down any information that you have but do not take a printed sheet of paper that has uh patient information on it that is not okay um if you are handing your patient over to somebody you should always put an entry in the chart that says report given to sjones at 1352 p.m. or report received from so that it's very clear the chain of command of custody of that patient when they came here when they left there so no one says well I brought the patient up there at one 1:00 and your first entry is at 6:00 that doesn't look good um so making sure that your entry reflects that now you are taking over care of that patient and then we talked about late entries when we talked about documentation but again if you're going to make a late entry make sure you note it as a late entry the next thing we're going to skip on to is talking about risk management um so most of our hospitals have a risk management department and um this is a department that actually um helps in mitigating any risks that are being faced by the hospital so if you had a patient who says oh my gosh I'm going to sue you guys so hard the first thing you should do is pick up the phone and call risk management and say the patient in room such and such seems to be angry about some of her care and she is threatening to sue the hospital because then they can come up and they can have a conversation with her they can investigate and they can see where are we at is it something that we can fix before it gets to that point or do we really have a problem that we need to be aware of um so we also part of what risk management does is they do um root cause analysis so they look at trying to figure out how did mistakes happen so let's say we have a mistake where a patient receives the wrong medication part of it is obviously the nurse because and there's always respons responsibility on the nurse so obviously the nurse did not do the full medication rights did not completely check the medication the armband whatever that was but there's usually some other issues so what risk management looks at is where was that medication located was it located where the other medication was located the day before does that medication look exactly like the other medication are those labels too similar are the colors of the Caps too similar um is there a chance that this could happen to another patient um and so they look at not just the nurse made a mistake and this is kind of like that um culture of safety that we talked about a few weeks ago so obviously a mistake was make made but is there something by analyzing what happened that we can do to reduce the risk of that happening again um and then testing out what those steps are and seeing that's a big part of what risk management does um it requires really good documentation uh so that the risk management can kind of follow the trail of what happened um but it becomes really important again it's part of s patient safety if you guys remind me when we get into class I will tell you guys about um a situation that I had years ago where um I was involved in a root cause analysis um at at the result of you know a patient having events that they never never should have had um so if you ask me about that I'll remember to tell you that so put that on a note somewhere cuz I probably won't remember all right so one of the tools that risk management uses is what we call an incident report um sometimes it's called An Occurrence report but it is it serves as like it says here as a database for further investigation and quality improvement it alerts risk management to the potentiality of there being a lawsuit um and it is separate from the patients charts so I never really understood this I just knew that was the case um and it wasn't until Janette came and co-taught this lecture with me that I had the opportunity to ask her why is it that we're not allowed to put that incident report in the chart and we're not allowed to put any mention in the chart you can't say incident report completed um nothing like that I said and she says well it's because then it's discoverable to the attorneys and I said well don't the attorneys they like they know we fill these out so even if it doesn't say anything in the chart why don't they just say I want to see the incident report and her answer to that was that the incident report has nothing to do with the patient the patient's chart is with the patient so the incident whatever happened is documented in the patient's chart it may not be documented in the same amount of detail as an incident report or occurrence is so what's in the chart is only about the patient what is in the incident report might be all the Minor Details which may not be so minor um as far as what you saw outside the room um where the medication was located was it next to that other medication that looks similar were you rushed did you have a patient assignment that had 15 patients none of that information belongs in the patient's chart because the patient's chart is about the patient not about you and your workday but by putting it on the incident report it helps risk management figure out how to mitigate that risk for the hospital how to mitigate that risk from happening again again to another patient um so it's a really really important tool um but you definitely want to make sure that you do not document anywhere in that patient chart that you completed an incident report because then it is tied to the patient and then their legal team has access to it and now they have all that background information um which is not helpful to the hospital um and if you guys have questions on that you can write you guys you can write down some notes on that and we'll discuss that a little bit when we get into to um into class as well some of the things that I have on here for you um you can click on the links yourself if you're interested in them uh what I wanted just to raise awareness with you is that as a nurse you can jeopardize your license even when you're not at work um so if you are an off-duty nurse you don't have to be in Scrubs you don't have to be on your way home from the hospital it can be any random Friday Saturday night um if you get a DUI that can lead to discipline of your license part of that is that term that we talked about at the beginning of this unprofessional conduct they will absolutely say that's unprofessional conduct they will question your judgment so nurses are supposed to have good critical thinking and good nursing judgment there is no good nursing judgment in drinking more than is the legal limit and getting behind the wheel of a car so even though you are not on duty you do not have name badge on you as a nurse are going to be questioned on that because you are held to a different standard and you are supposed to have good judgment and that is not good judgment um they um the disciplinary process um with the border of Registered Nursing um is pretty intense um you can look at the link that's on here it's I don't think it's California specific um but it does go through what that process looks like I have a little bit of that that I'll show you when we get into class um so we'll have a little bit more conversation about what that looks like I have never been personally in that disciplinary process so I don't have a whole lot of experience with that I do have an example that I want to share with you in class um that I find as a very eye-opening and terrifying example of what can happen to somebody if they make bad decisions as a nurse um but I think it's important for you guys to hear so if you remind me again um to share that with you it is a um a former student of mine who was ACC accused of um diverting drugs and again the most unlikely person that I never would have thought would have done anything like this um but I've had some communication with her since then um and I can share a little bit about what that process was like for her and where she's at in that process now that kind of leads us into impaired practice so I have a few slides that go through um as far as what the board stance on impaired practice is and uh recently in the last 10 years or so the ncsbn the National Council of State Boards of Nursing have not to say they've taken a softer stance on it because impaired practice is not okay under any circumstances um but they are taking the stance of helping impaired nurses um not not condoning the practice but helping them to recover um because it is again their stance is that it is um it's wrong to not support um nurses and um if we are talking about impaired practice usually the any kind of description of that includes um that their professional judgment is impaired due to the use of drugs or alcohol or even mental illness or lack of sleep and that this interferes with their ability um of the nurse to provide safe quality patient care um some studies indicate that 10 to 20% of nurses will um suffer from some type of substance abuse in their lives I sure hope it's not that High um but uh it is a stressful job and if you don't have good coping mechanisms then I can certainly see how that could happen um I'm hoping again that's why we focus in this class on stress on you know coping mechanisms health and wellness all of that um because if you don't have good coping skills for the little things then when the big things come you don't have any coping mechanisms at all and then that's usually when people end up in these um situations some of the things if you were working alongside somebody who is impaired some of the common signs of that U and again this is a big picture this is not necessarily you know you know oh my gosh Sue asked for overtime she must be impaired that's not the case but if you have somebody who's frequently asking for overtime and um frequently making narcotic errors maybe dropping the medication losing the medication um maybe at the same time they really just want to work with the patients who are comos um and then when they kind of are they don't eat lunch with everybody anymore they're kind of socially isolated um maybe they have a dramatic change in their grooming in their appearance all of those things I'm going to use a term that you guys remember from like week three um when you cluster all that data together that is a pretty good picture that somebody may have some types of impairment um chemical impairment so again not just one thing not just that somebody's irritable not just that somebody has a complaint about them from a patient but the big picture of all of that the reason I present it to you um actually comes from this book that was written by Carol Houston a few years ago um and what she talked about was that we don't talk about this and so very often people Overlook these things and don't think that it could be a chemical impairment um and the example that I will share with you in class um is is definitely that because like I said this is someone that I did not think in a million years would be guilty of what she was guilty of and I could easily overlooked this and I think a lot of people overlooked this because they didn't expect it from her um so that's the other reason I want to share that example with you so that you understand that there's not a there's not a prototype just like when we talked about elder abuse there's not a picture of what an abuser looks like same thing for chemical impairment there is not an not a picture not a description of what somebody who um would do this looks like um the next few slides are just um again information that I found as I was researching this topic and you may or may not you know you may or may not agree with it um but what the evidence says is that um that drug addiction is not voluntary that it is a compulsive behavior that affects the brain now you may say well it was their choice to use it was their choice to have a drink and that's true the first one was their choice but there may be some type of chemical imbalance um may be some type of compulsive behavior that after a while it's not a choice anymore um and then I like the statement here as far as losing one nurse to substance abuse is losing one too many um and that because we are a profession of caring then we really need to care for ourselves and for our our group of nurses um so I think that's important um to say and again they focused on how this really isn't talked about in nursing school so that's why I want to make sure to talk about it with you all right we are about to wrap up so I'm kind of bringing it back to all the different things that we saw as far as how you can protect your license so remember that you are an intelligent well-educated person and if you are thinking what you are about to do is not a good idea then you really need to respect yourself with that and question that you are responsible for assessing your patient you are responsible for continuously monitoring your patient you are responsible for communicating any changes concerns about that patient you are responsible for providing a safe environment you are responsible for following appropriate physician orders so again if that order for 50 milligrams of morphine comes through and that doesn't seem appropriate to you then you are not responsible for following that order you're responsible for communicating your concern about that order um you'll learn next next semester in farm about the six rights for medication administration but you are also responsible for that some of the things that you need to do that we already talked about so this is just kind of wrapping it all up um to protect your license making sure that you convey those discharge instructions verbal and written make sure that you follow your Hospital's policy and procedure huge huge huge make sure that if you delegate that you supervise appropriately you don't just delegate it away and forget about it make sure that you um your documentation is accurate clear and concise um and then here's a slide that I got from um a webinar that I did a while back and I just thought this was um again important so you can read this on your own I'm not going to read it to you but I think it makes some good points on here all right and then I just have a couple little bloopers for you here see if you can see the humor in this one here I thought it was funny all right and same thing for the next ones that are coming here again a little bit of nurse humor but I thought these were fairly funny so if you're writing a patient goal we always talked about it being positive so here's a patient goal that's not quite appropriate not quite positive but you know it's a that's a goal patient will not have any fatal dysrhythmias during this admission so basically patient won't die um that's not really a goal uh it is a goal but it's not one that we document in the nursing care plan and oh and then this was documentation this was actually physician documentation um where again it was documented in such a not factual manner you know coming out of anesthesia in a relatively unfavorable manner versus the patient was having generaliz seizures for 2 minutes um every 2 minutes and Lasting 10 seconds each and then the very final one I have here um was one that Janette shared with me not an actual thing that happened but just a little bit of attorney humor all right that's all I have for you guys so hopefully you made some notes and we'll have some rich conversations when we meet in class um I think this there's a lot of opportunity for conversation here and I have a couple things I want to show you as well um and if you remind me then I'll tell you those uh couple stories that I had for you so I will see you in class