Md. Code Regs. 10.27.10.02

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.27.10.02 - Nursing Process

A. In a team relationship the licensed practical nurse contributes to the nursing process. The nursing process shall include, but is not limited to, the following elements listed in §B"C of this regulation.

B. Nursing Assessment. The LPN contributes to the nursing assessment by:

(1) Collecting data for the assessment of the client:

(a) Through direct observation;

(b) From interviews with the client, client's family, and significant others;

(c) From the review of the client's medical records including, but not limited to:

(i) Past history;

(ii) Laboratory studies;

(iii) Medications; and

(iv) Consultations; and

(d) By assessing the environment;

(2) Performing a focused nursing assessment of the client's current conditions and problems or needs which includes:

(a) The nursing interview;

(b) A physical assessment;

(c) The client's common predictable, chronic, routine, recurrent health problems; and

(d) Identification of any changes in the client's symptoms and behavior;

(3) Communicating the assessment on records that reflect:

(a) Changes in the client's health status; and

(b) A continuous collection of data by updating and revising of the nursing assessment; and

(c) Data recorded in a manner which is:

(i) Complete, timely, and accurate;

(ii) Consistent with general standards of nursing practice, and

(iii) Consistent with the facility's policies and procedures.

C. Nursing Plan of Care.

(1) Development. The LPN contributes to the development of the nursing plan of care by:

(a) Reporting ongoing data collection;

(b) Reporting changes that include, but are not limited to, the client's;

(i) Condition;

(ii) Changed goals; and

(iii) Changed priorities;

(c) Making recommendations to individualize interventions specific to the client;

(d) Reporting communication with;

(i) The client;

(ii) The client's family;

(iii) Significant others; and

(iv) Other members of the health care team; and

(e) Documenting in appropriate records.

(2) Implementation. The LPN participates in the implementation of the nursing plan of care by:

(a) Continuing to collect and report data;

(b) Assisting in the coordination of client care with other health care team members as directed by the RN;

(c) Implementing standardized or RN developed teaching plans under the direction of the RN;

(d) Contributing to the nursing case management by:

(i) Implementing assigned components of the nursing care plan; and

(ii) Continuing to collect and report data regarding the implemented plan including the client's response to intervention and problem identification;

(e) Contributing to nursing management and supervision of the certified nursing assistant and unlicensed personnel by:

(i) Assuring nursing functions are performed competently and timely; and

(ii) Reporting to the leader of the nursing team; and

(f) In accordance with the nursing team's plan of care for the client and with COMAR10.27.11, delegating acts of the LPN's practice to:

(i) The certified nursing assistant;

(ii) The certified medication technician; and

(iii) Unlicensed personnel;

(g) Performing nursing interventions in a competent safe manner appropriate to the LPN's scope of practice including:

(i) Administration of medications and treatments;

(ii) Administration of infusion therapy consistent with COMAR 10.27.20; and,

(iii) Nursing intervention consistent with any declaratory rulings and regulations issued by the Board;

(h) Documenting implementation of nursing care timely, completely, and accurately; and

(i) Utilizing identified nursing approaches which include, but are not limited to:

(ii) Reflecting knowledge of scientific principles;

(iii) Recognizing the rights of the client, the client's family, and significant others; and

(iv) Providing a safe and therapeutic environment.

(3) Evaluation. The LPN contributes to the evaluation of the nursing plan of care by:

(a) Collecting and communicating data on the client's goal achievement;

(b) Assisting in identifying barriers to the client's meeting any identified goal;

(c) Reporting to other members of the health care team in a timely, accurate, and complete manner on data collected from;

(i) The client;

(ii) The client's family;

(iii) Significant others; and

(iv) Other health care providers;

(d) Assisting in evaluating the client's competency in performing any treatment and self administering medication by utilizing established competency based evaluation tools;

(e) Making recommendations regarding modification of the teaching nursing plan based on the client's response;

(f) Making recommendations regarding any revision to the nursing plan of care; and

(g) Documenting the evaluation data on appropriate records.

(4) Nursing Team Relationship.

(a) The LPN as a part of the nursing team:

(i) Functions as a team member under the leadership of the RN who is the team leader;

(ii) Participates in providing care for the client; and

(iii) Provides care for the client to the fullest extent allowed by the LPN's scope of practice.

(b) Each licensed nurse has responsibility for oversight or supervision of nursing practice appropriate to his or her level of licensure which includes critically watching, instructing, directing, and evaluating another's nursing practice.

Md. Code Regs. 10.27.10.02

Regulations .02 adopted effective May 2, 2011 (38:9 Md. R. 553)