NS 1 Exam 1
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=> Florence Nightingale’s Contributions
Professional Nursing and need for nursing education, Respect as a profession
- => Florence Nightingale’s Contributions
- Systematic assessment
- Individualized care
- Client confidentiality
- Nursing education
- Need for theoretical basis for nursing practice
- Recognized 2 components of Nursing: Health and Illness
- Create environment to promote healing
- Maintained accurate records: beginning of nursing research
- Nursing is different from medicine
- Established a respected occupation for women
=> History of Nursing in America
- -Apprenticeship, hospital based
- -Diploma: Hospital-based Nursing Programs; Brown Report - 1948
- -Associate Degree Nursing Programs
- - Post WWII -Practical Nursing Programs
- - Post WWII-1970’s Universities - Nursing theories
- -1970-80 Push for more BSN’s, Nurse Practitioners
- -Master’s degree - 1980’s to 1990’s
- -2011 IOM 80% BSN by 2020
=>Isabel Hampton Robb
- --Helped establish American Nurses Association (ANA) and National League of Nursing (NLN)
- --Advocated rights of nursing students (learner vs. unpaid employee)
Definition of Nursing: Virginia Henderson 1955:
“The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.”
=> CULTURAL ASSESMENT
1. Recognition of own culture and cultural perceptions, beliefs, values, attitudes, and behaviors.
2. Assessment of the patient’s culture
Aspects of care commonly influenced by cultural perspectives:
- Space and distance
- Eye contact
- Observance of holidays
- -What is the client’s affiliation?
- -Health Belief influence behavior
- -Observe how client interacts with others
- -Access to interpreter, phone
- -Use culturally appropriate verbal and non-verbal communication, gesture, tone
- -Learn about different cultures, ask questions
=>Assessing Spiritual beliefs:
- Relationships b/w spiritual beliefs and healt and illness
- -Beliefs about causes of illness
- -Beliefs about causes of illness
- -Beliefs about what heals illness
- -Sources of hope and strength
- -person who provides spiritual guidance-Person who is available in a crisis
=> Psychosocial Assessment
=> Interventions to Increase Sense of Self and Worth:
Behavior appropriate to situation
- Cooperative ?
- Responds appropriately to all questions
- Assess support system
- Past coping behavior
- The more crisis you have successfully faced, the better you can cope
=>Personality Style: Passive, Assertive, Aggressive
- => Interventions to Increase Sense of Self and Worth:
- Respect, Treat with dignity, Demonstrate patience, Explanations prior to procedures, Offer choices in care, Encourage participation in care, Respect privacy
Patient Teaching: Adult Learner
- -Immediate result
- -Desire practical use, meaningful to own life
- -Should be given responsibility for own learning
- -Prioritize when educating: What would my client need to know to prevent life threatening symptoms?
-Goal of the teaching needs to be:
- Goal of the teaching needs to be: *ASMT*
- Time oriented.
-->“By end of instruction, client will demonstrate correct use of the asthma inhaler.”
- -Learning contract: Mutually agreed, realistic relationship, praise
- -Assess cultural beliefs, learning readiness,Visual, auditory, kinesthetic learner?
=> Teaching Techniques
Assess prior knowledge and barriers
Method: Using Photos, videos, equipment, computer, etc.Culturally sensitive, involve family, friendBody language, patience
Use translator if needed
Evaluate: Client verbalizes of returns demonstration
=> ANA Definition of Nursing 1965
--Care: more than “to take care of”; “it is “caring for” and “caring about”. Providing comfort and support.
--Cure Promotion of health and healing. It is clinical judgment whether care plan is working
--Coordination Ensure effective and efficient treatment. Supervising, teaching, and directing all those who give nursing care.
=>ANA Social Policy Statement 1980 -
Nursing practice is the diagnosis and treatment of human responses to actual or potential health problems.”
=> 1974: CA Nurse Practice Act section 2725
-Help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment requires scientific knowledge or technical skill, including:
(1) Services that ensure the safety, comfort, personal hygiene, and protection of patients; and the performance of disease prevention and restorative measures.
(2) Admin of medications, implement a treatment, disease prevention, or rehabilitative regimen ordered by a physician, dentist, podiatrist, or clinical psychologist.
(3) Skin tests, immunization, and withdrawal of human blood.
Orem’s Self-Care Model
=>Definitions: Self Care, Self Care agency, Therapeutic self-care requisites, self-care deficit.
-Self-care - activities the person carries out on his own
-Self-care agency - ability of person to perform self-care
-Therapeutic self-care requisites - what is necessary for the person to maintain or improve present state of health
-Self-care deficit - the person is unable to meet the therapeutic self-care demands
Wholly compensatory - nurse gives total care to meet client needs
-Partly compensatory - nurse and client perform care measures together
-Supportive-educative - client can carry out self-care activities but requires assistance through teaching
=> The Government’s Solution to >$$
-Medicare – Federal health insurance for > 65 yrs old, the disabled, blind, dialysis.
-Medicaid – Help the Poor, MEDI-CAL
-Diagnosis-Related Groups (DRGs) - decrease spending for hospitalized Medicare recipients
-Standardization of care - guidelines to treat high-volume and expensive diseases.Health care reform. Affordable Care Act. Quality measurement and reporting. Health Insurance required 2014. Previous disorder OK.
=> Standardization of Care
- ->National Patient Safety Goals (NPSG)
- -Promote specific improvements in patient safety
- -Highlight problematic areas in health care and describe evidence and expert-based solutions to these problems
Are recommended sets of preventative, diagnostic, and treatment measures. Focus on specific high-risk health events/issues in order to ensure evidence-based care.
=>What are the NPSG (National Patient Safety Goals) that apply to hospitals?
- Identify patients correctly
- Improve staff communication
- Use medicines safely
- Use alarms safely
- Prevent infection
- Identify patient safety risks
- *Universal Protocol: Prevent mistakes in surgery
=> Elements of Therapeutic
- Purposeful and Goal-Directed
- Well-Defined Boundaries
- Non-Judgmental, Active listening
- Caring, honest, empathy
- Encourage verbalization of feelings
- =>Elements of Therapeutic Communication
- 1. Orientation: Establish trust and purpose of relationship. "Hi I'm blah, and I'm your nurse for today"
- 2. Working phase: Set goals and work towards meeting them.
- 3. Termination: Evaluates say good bye “It’s after lunch, I’ll see you next week”
=> Guidelines for Effective Communication
- Introduce yourself by name and title
- State your role in their care
- Assure confidentiality and its parameters
- Give reasons you must ask questions
- Allow for privacy
- Provide enough personal space
- Be attentive to tone of voice
- Be an observant active listener
- Use silence
=>Barriers to Effective Communication
- Giving advice
- False reassurance
- Judgmental comments, “why”
- Offering personal opinion
- Changing the subject
- Failure to listen
- Failure to clarify, obtain relevant data
- Be Genuine
- Self Awareness
- Culturally sensitive
- Speak slowly and clearly
- Include familyVerbal/non-verbal congruent
=> The Nursing Health History: Interview vs. General Survey
Interview: To collect data to identify actual and potential health problems
General Survey: Physical Appearance, Body Structure, mobility, Behavior, Vital Signs
=> Chief Complaint
The signs and symptoms that cause the client to seek health care
The client’s response should be recorded as a direct quote
=> History of Present Illness
- State of health before present problem
- Impact of illness on life style
- Stability of the problem
- Prescribed, OTC medications, herbal and home remedies Effectiveness
- Symptom analysis - PQRST
==>Analyzing symptoms: PQRST
P = Precipitating: immobility, overexertion, fall & Palliating: exercise, rest, heat, massage, muscle relaxants, analgesics
Q= Quality: affect on Activities of Daily Living
R= Region: diffuse or localized
S=Severity: extent of limitation on ROM
T= Timing: onset, time of day, duration
- Home Conditions
- Support Systems
- Cultural Practices
- Spiritual/Religious Preference
- History of mental illness
- Financial Resources
=> General Survey:
Inspection, Ausculation, Palpation, Percussion (I Am Peter Pan)
=>Vital Signs-Goal: Recognize and report changes in a patient that indicate a problem with body function-Most problems show themselves through a change in the patient’s vital signs
- ->vital Signs
- Body temperature
- Blood pressure
- Oxygen saturation
- Pain: levels from 0-10
- Weight & Height--> know BMI
=>Normal Temperature Range
- Oral: 96.8 F – 100.4 F
- Average = 98.6 F
- Axillary: 1 degree less than oral.
- Rectal: 1 degree higher than oral.
**lecture notes: Older people have lower set points, so temp doesn’t tell you if they’re sick or not. Look at how they feel or how they’re behaving. Temperature reflects the balance between heat produced and lost. The neuro and Cardiovascular system work together maintain temp. Core temp is Rectal and tympanic.
Fever usually not harmful unless >101.
- Fever: Blood culture, antipyretic, lab work, fluid and rest.
- Hypothermia <95 F. warm blanket, heated 02. -Age-related changes: Elderly usually have slightly lower normal temperatures, and are less able to generate a fever in response to pathogens
Tachy vs Brady
Adult/Older Adult = 60 – 100 bpm.
Tachycardia = >100
Bradycardia = <60
Taken either apically (heart rate) or at radius.
Oxygen saturation in the blood (“O2 sat.”)
Pulse Oxymetry: >95%
Notify when abnormal <90%
-Adult: Systolic: 100-120, Diastolic: 60-90
-Aging pushes your blood pressure Up.
-The force exerted by the blood in arteries during heart contraction: Systole= heart contraction
Diastole: min pressure on artery. Systolic Hypertension due to increased peripheral resistance.
TREAT WHEN SBP>160. 90% HAVE NO CAUSE. HTN based on highest reading. Diagnosed with 2 separate high reading on 2 separate doctor visits. REST 5 MINUTES, SIT FEET FLAT ON FLOOR, ARM AT HEART LEVEL, SUPPORTED. B/P CUFF 2” ABOVE ANTECUB. -Elderly Systolic HTN
- =>Orthostatic Blood Pressure
- -BP measured 3 times: lying flat, sitting, standing.
- -Remember to support arm at heart level.
- --Also check pulse, dizzyness
- -Postural Hypotension: Drop of 25mmHg in systolic/10mg mmHg when move from lying to sitting, or from sitting to standing.
=>Elderly Client Health History
- Focus on current health problems
- Bring in all medications (“brown bag”)
- Allow time for answers
- Assess Function: ADL’s, role and relationship patterns
- Assess health behaviors, safety precautions, and self-concept
- Support system
- =>Erikson: Ego Integrity vs. Despair
- Life review
- Gain acceptance of their accomplishments
- Accept physiologic decline without fear of death
- Strive to guide the coming generations
- Need love and closeness
- Strong sense of family and community
=>Code of Ethics-
Ethical principles that are accepted by all members of a profession;Ethics is the study of good conduct, character, and motive, guiding principles.
-The Nursing Code of Ethics sets forth ideals of conduct-website http://nursingworld.org/ethics/chcode.htm
=> Universal Moral Principles
- Beneficence- doing good.
- Nonmaleficence-not doing harm
- -Integrity, “I’ll be back in half hr.”Justice
=>Ensuring Public Safety
- Laws, Policy & Procedure'
- Licensing: Medicare, State Public Health agency, State Board of Nursing
Accreditation: NLN, The Joint Commissionwww.jointcommission.org
=>Common Law Legal Actions
-Criminal:Theft, Drug violations,Murder, dependent abuse
- -->Civil torts (unintentional)
- -Negligence: duty, injury, fault. (35 min)
- -Malpractice: fail to meet prof. standard
- -Issues of informed consent
--> Intentional Torts: - Assault - Defamation of character- Battery - Fraud- Invasion of privacy - False imprisonment
=>What Nurses Can Do to Protect Themselves Legally
- Competent practice through continuing education
- Client education
- therapeutic relationship
- When executing physician orders, clarify, BE ASSERTIVE
- Clear, concise, correct documentation
- Risk Management Programs
- Incident or Unusual Occurrence formsHave Liability Insurance
=> Informed Consent
a person’s agreement to allow something to happen, such as surgery, based on a full disclosure of risks, benefits, alternatives. Right to refuse anytime.Obtaining informed consent does not fall within the nursing duty. The nurse is witnessing that signature is voluntary, pt. seems competent to give consent.
=>Right to refuse treatment
- Mentally competent adult
- fully informed about condition and consequences of refusal
- Some refuse because of religious reason
State or hospital: court order can compel parents to get treatment for children.
=>Life Sustaining Procedures
Defined by California Health & Safety Code:“Any medical procedure or intervention which utilizes artificial means to sustain, restore or supplant a vital function which when applied to a qualified patient would only serve to artificially prolong the moment of death.”
=>California Natural Death Act – Living Will (1976)
A competent adult can direct physician in writing to withhold or withdraw life sustaining procedures if no recovery expected.
Living will (Advance Directive) must be signed by the adult and 2 witnesses, and be notarized.
Protects hospital, physician from lawsuit
-POLST (vs. DNR's?)
Living will: Advance care document that specify wishes about medical care if unable to communicate.
Durable Power of Attorney for Health care: Appoint another person to make decision regarding your health care in case you are incompetent.DNR or Allow Natural Death
- =>Do Not Resuscitate Orders
- Most institutions have a policy that resuscitative measures will be initiated unless there is a written DNR order
- DNR orders must be renewed per protocol (usually every 7 days)
- Order must be written in chart and signed by MD.
- =>POLST: “Physician Orders for Life-Sustaining Treatment”
Physician initiates discussion with patient or patient’s surrogate about treatment options.Incorporates preferences for end-of-life treatments into medical orders.
- Is in addition to advanced directives.
- -->Difference from an advanced directive:
- -Involves medical orders, not just documentation of the patient’s wishes.
- -Meant to be portable, and go with the patient from one setting to another.
- Date/time of the assessment, intervention, or evaluationUse military time Follow policy regarding frequency of charting; adjust according to client’s conditionDocument ASAP after an assessment or interventionDocument events in the order in which they occurredDo not document PRIOR TO an assessment or intervention (2:45 min)
- Black ink and LegibleSignatures should include the name and title Example: Irene Smart, MCSNMCSN= Moorpark College Student NurseComputer Documentation: Safeguard user ID & password. Log off when leaving the computer.
- => Accuracy
- Chart facts and observations, rather than opinions or interpretations of an observationAvoid general words, such as large, good, or normal Spell correctly Appropriateness Only information that pertains to the client’s health problems and care should be recorded
=>Completeness Be complete, concise, meaningfulAvoid opinion, cliché, bias, “seems” Use quotes, any instructions, interventions given, client’s response. If it isn’t documented, it didn’t happen.
- =>Confidentiality: HIPAA
- Access to medical record is restricted
- Available to health care professionals providing client care, and for the purposes of education and researchClient gives written permission to share record only with those that need to use it.
- ->Log out of computer charting when doneDo not use names, initials onlyDo not discuss case in public or social media!S.N. MAY NOT PRINT OR PHOTOCOPY RECORDS
The Nursing Process:
THE NURSING PROCESS: Assessment
- => Assessment
- Types of data: Objective = signs (overt data). Use you senses. & Subjective = symptoms. What client SAYS “ “
- => Sources of Data
- ClientFamily and significant others
- Health care team members
- Medical records
- Other records (employment, military, etc.)
- Literature review
- Nurse’s experience
=> These Are Not Nursing Diagnoses
- Medical diagnosis
- Medical pathology
- Diagnostic test
- Therapeutic client need
- Therapeutic nursing goal
- Single sign or symptom
=> Types of Nursing Diagnoses: l
Physical, Psychosocial, Educationa
=> Writing a Nursing Diagnosis: *imp*
PROBLEM related to ETIOLOGY (related factors) manifested by DATA (defining characteristics)
=> Examples of Nursing Diagnoses
-Fluid volume deficit related to decreased fluid intake as evidenced by dry mucous membranes, poor turgor, tachycardia, increased HCT and BUN, no oral fluid intake.
-Activity intolerance r/t insufficient oxygen transport secondary to anemia AEB SOB with transfer from bed to chair, client states “I can’t breathe when I move around” SpO2 92%
-Social isolation R/T contact isolation aeb by client withdrawn, tearful at times, states “I feel all alone”, no visitors, and staff enter room for procedures only
-Knowledge Deficit re: antiembolism measures r/t lack of exposure AEB wearing only one compression hose and asking “what are these for, anyway?”
=>“Risk for” diagnoses
- -Use when the problem has not actually
- happened yet but is of high priority to prevent.
- -Since it has not happened yet, there should not be any defining characteristics.
-Ex: “Risk for impaired tissue integrity related to decreased mobility and thin frame.”
=> Writing Goals/Expected Outcomes
- -Clearly relate to the nsg diagnosis.
- -Involve client and family in making goals
- -Realistic-Goals should indicate time frame for when it’s to be achieved
- -Goals are what the client should accomplish not what the nurse should do
**WHO should do WHAT by WHEN.
"_______ will _____________ by _________."
- =>Examples of Goals/Expected Outcomes
- Goal has a subject, verb, and criteria. MEASURABLE!
ex 1: Pt. will ambulate 100ft with a walker and stand-by assistance by day 3 post-op
ex 2:Mrs. C’s 8 hr fluid intake will total at least 500 ml by 1400.
- ex 3:Mr. D will demonstrate proper incision care by end of shift.
- Types of Nursing Interventions:
- Independent - activities the nurse orders and carries out
- Dependent - activities that require physician orders
- Interdependent - activities carried out in collaboration with other healthcare professionals
- =>Guidelines for Nursing Interventions
- Who, when, how often. Why?
- Make sure they directly relate to the goal that was formulated.
- Involve the client and the family.
- Use hospital protocol.
- Individualize for your patient. Some creativity ok.
- Use action verbs. Assess, ambulate, encourage, refer, etc.
- Write as if making directions for someone else to follow.
- Include when, or time interval for them.
- -ex: “ASSESS LUNG SOUNDS Q 4HR , VS Q SHIFT, TURN Q 2HR, DRESSING Q AM, etc….
- => Examples of Interventions
- Goal: Pt. will have no pressure ulcers during this admission.
- -Keep skin clean and dry throughout shift.
- -Turn patient off of boney prominences q2h.
- -Encourage intake of at least 240 ml of fluids in between meals, and 240 ml of fluids with meals.
- -Ambulate patient three times a day.
=>THE NURSING PROCESS: Evaluation
:Look back at Goal: Was it met or not met?The nurse and client together measure how well the client has achieved the goals
If goal met, celebrate! If the client fails to meet the goals, revise.Decision is made to terminate, continue, or modify the plan
- => Evaluation – what to write
- State if goal was met or not.Make brief statement about what signs or symptoms led you to determine if the goal was met or not.
- -->Do not just put “Goal Met” or “Goal not met.” BUT...“Goal met, patient had no areas of redness or skin breakdown upon discharge.”
- -“Goal in progress, patient had no areas of redness or skin breakdown on 4th day of admission.”
- -“Goal not met, patient with 2cm area of redness on right heel. Float heels off of bed using pillows, and re-evaluate tomorrow.”
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