Lecture Exam 3

Define nursing theory.

Nursing theory is a conceptualization of some aspect of nursing

Communicated for the purpose of describing, explaining, predicting, and/or prescribing nursing care

Describes, explains, predicts, and/or prescribes nursing care

A theory contains a set of concepts, definitions, and assumptions or propositions that explain a phenomenon.

Describes and links concepts

Theories guide the design of nursing interventions.

Define the value of nursing theory in nursing practice.

Theories guide the design of nursing interventions.

A theory offers a well-grounded rationale or reason for how and why nurses perform specific actions.

Common nursing theories enhance communication and increase autonomy and accountability for patient care

Describe the relationship between theory, the nursing process, and patient needs.

Nurses need a theoretical base to demonstrate the science and art of the profession when they promote health and wellness for their clients, families and communities.

Describe the historical development of nursing theory.

Development of nursing theories and models is relatively recent.

The nursing profession relied on theories from other disciplines such as medicine, psychology, and sociology, as a basis for practice.

In the mid-1950's Teachers College, Columbia University, NY City, began offering master's and doctoral programs in nursing education and administration, resulting in student participation in theory development and testing.

Define selected theories from other disciplines.

Systems Theory

Maslow's Basic Human Needs

Developmental Theories

Psychosocial Theories

Define selected nursing theories.

Nightingale, Peplau, Henderson, Roy, Orem & King, Neuman, Leininger, Watson, Benner & Wrubel

Describe the relationship between theory and knowledge development in nursing.

Nursing knowledge is theoretical and practical.

The goals of theoretical knowledge are to stimulate thinking and create a broad understanding of the "science" and practices of the nursing discipline.

Experiential knowledge, or the "art" of nursing, is based on nurses' experiences in providing care to patients.

Discuss the benefits of evidence-based practice.

A response to societal forces.

A problem-solving approach to practice.

Can be a challenge to obtain the very best and most current information at the right time for patient care

Integrates the conscientious use of best evidence +clinician's expertise + patient preferences & values in making decisions about patient care

Describe the six steps of evidence-based practice.

1. Ask the clinical question (PICOT).

2. Collect the best evidence. (peer reviewed)

3. Critique the evidence.

4. Integrate the evidence.

5. Evaluate the practice decision or change.

6. Share the outcomes of EBP changes with others.

Explain how nursing research improves nursing practice.

Theories provide direction for nursing research.

Nursing theory and nursing research build the knowledge base for nursing, which is then applied to practice.

Theory-generating or theory-testing research refines the knowledge base of nursing.

Nurses incorporate research-based interventions into theory-based practice.

Phenomenon (of nursing and nursing care)

aspect of reality that can be sensed or experienced; caring, self-care, client's responses to stress. Reflects the domain of nursing practice.

Concepts

related ideas, mental images; help to describe or label phenomena.

Definitions

define the general meaning of concepts.

-Define so others know what you mean

Assumptions

Taken for granted or "I believe" statements that describe concepts or connect two concepts that are factual; determine nature of the concepts, definitions, purpose, relationships, and structure of theory.

-back up with evidence and research

Systems Theory

Open and Closed

Closed - not able to interact with surroundings

Open - ex. Nursing process

Patient interact with hospital environment

4 components: input, output, feedback, and content

Nursing Process (open system) Figure 4-3;

client's interaction with the environment and response to nursing interventions

Basic Human Needs (Maslow)

5 Levels, human needs on a tier with the most basic needs as the foundation of the hierarchy

Developmental Theories

Describe and predict behavior and development at various phases of the life continuum.

Maslow's Hierarchy of Needs

Psychosocial Theories

Cultural Diversity

Family as Client/Caregiver

Grieving

Nightingale

mid 1800s (1860)

Environmental Theory

Environment as the focus of nursing care

Descriptive theory

Manipulate the environment to promote healing.

Gave clean sheets

Peplau

1952

Interpersonal Relationships

Focus on interpersonal relations between nurse, patient, and patient's family

Development of nurse-patient relationship

Henderson

1955

14 Basic Needs

14 basic needs of the whole person

Framing nursing care are the needs of the individual.

Roy

1970

Adaptation Model

Views the patient as an adaptive system

When patient cannot adapt to stressors, nursing is needed

Client is adaptive system, nurses help client adapt to changes.

Need for nursing arises when client unable to adapt to environmental demands.

Orem 1971

King 1971

Self-Care Deficit

Goal Attainment

Orem (2001) Self-Care Deficit Theory of Nursing

Focuses on patient's self-care needs

Goal is for patient to manage his or her health problems

Help client attain total self-care; nursing care is necessary when the client is unable to fulfill biological, psychological, developmental, or social needs.

King (1971) Theory of Goal Attainment

3 dynamic/interacting systems: personal, interpersonal, and social.

Nurse/client relationship is vehicle for delivery of nursing care.

Neuman

1974

Stress Systems Model

Based on stress and the patient's reaction to the stressor

Role of nursing is to stabilize the patient or situation.

Leininger

1978

Culture Care/Sunrise

Theory of cultural care diversity and universality

Considers social structure factors

Watson

1979

Transpersonal Caring

Defines the outcome of nursing activity with regard to the humanistic aspects of life

Purpose is to understand the interrelationships among health, illness, and human behavior

Benner and Wrubel 1989

Primacy of Caring

Caring is central

PICOT

P-Patient population of interest

I-Intervention of interest

C-Comparison of interest

O-Outcome

T-Time

Abstract

Summary of what's in the paper

Introduction

Why they wrote what they wrote

Literature review or background

how, purpose, design

Narrative (clinical or research)

Purpose

Methods or design

Clinical implication

Make a difference or not

Further research? - Research is part of EBP -helps and supports EBP

Results and/or conclusion

Clinical implications

After critiquing all articles for a PICOT question,

Synthesize or combine the findings

Consider the scientific rigor of the evidence and

Whether it has application in practice

When you decide to apply evidence, consider:

The setting

Whether support is provided from staff and available resources

Evaluate the change.

Share the information.

Nursing Research

A way to identify new knowledge, improve professional education and practice, and use resources effectively

International Council of Nurses (ICN)

supports the need for nursing research as a means of improving the health and welfare of people.

Define the role that caring plays in building a nurse-patient relationship.

Caring is an inherent feature of nursing practice, whereby nurses help clients recover from illness, give meaning to that illness, and maintain or reestablish a connection.

Caring facilitates a nurse's ability to know a client, allowing the nurse to recognize a client's problems and to find and implement individualized solutions.

Compare and contrast theories on caring.

Caring is a universal phenomenon that influences the way in which people think, feel, and behave in relation to one another.

Florence Nightingale studied caring.

In the 1980s, Patricia Benner and Benner with Judith Wrubel offered another definition of caring. Determines what matters to a person and has a wide range of interactions.

Identify the potential implications when nurses' and patients' perceptions of caring might differ.

Clients have valued nurses' effectiveness in performing tasks, but clients also value the affective dimension of nursing care.

The identification of behaviors that clients perceive as caring helps to emphasize what clients expect from their caregivers.

Clients' satisfaction with nursing care is an important factor in their decision to return to a hospital.

Explain how an ethic of care influences nurses' decision making.

Concerned with the relationship between the patient and the nurse and the attitude of each toward the other

Places the nurse as the patient's advocate who solves ethical dilemmas by creating a relationship

Gives priority to each patient as a unique being

Ethics refers to the ideals of right and wrong behavior.

In any client encounter, a nurse must know

what behavior is ethically appropriate.

An ethic of care is concerned with relationships between people and with a nurse's character and attitude toward others. Places the nurse as the client's advocate, solving ethical dilemmas by attending to relationships and by giving priority to each client's unique personhood.

Describe ways to convey caring through presence and touch.

Providing Presence

-Being there-physically, in communication, and understanding.

-Eye contact, body language, voice tone, listening,

& having a positive and encouraging attitude.

Touch

- Comforting approach which communicates support and concern.

-Contact/noncontact: task-oriented, caring, protective

Define key concepts relevant to cultural diversity in nursing and health care.

Knowing the Client

-Knowing develops over time.

-Avoid assumptions, focus on client, detect changes in client's condition.

Spiritual Caring

-Client's belief system.

Family Care

-Involve family in client's care as appropriate.

-Being honest, give clear explanations, keep family informed, try to make the client comfortable, showing interest in answering questions.

Describe social and cultural influences in health, illness, and caring patterns.

Culture affects how people value, evaluate, and categorize life experiences

The members of a cultural group share values and ways of thinking and acting.

These values and ways of thinking and acting are different from those of people who are outside the group.

Differentiate culturally congruent from culturally competent care.

Culturally congruent care

Goal of transcultural nursing

Fits the person's valued life patterns and set of meanings

Requires specific knowledge, skills, and attitudes in the delivery of care

Culturally competent care

Is the process of acquiring specific knowledge, skills, and attitudes to provide culturally congruent care

the ability of the practioner to bridge cultural gaps in caring, work with cultural differences, and enable clients and families to achieve meaningful and supportive care.

Describe steps toward developing cultural competence.

Cultural Competence: the process of acquiring specific knowledge, skills, and attitudes that ensure delivery of culturally congruent care (5 components...).

Cultural awareness

Cultural knowledge

Cultural skills

Cultural encounters

Cultural desire

Identify major components of cultural assessment.

A systematic and comprehensive examination of the cultural care values, beliefs, and practices of individuals, families, and communities

Gathers information that will enable the nurse to provide culturally competent care

Use cultural assessment to identify significant values, beliefs, and practices critical to nursing care of individuals through life transformations.

Census Data/Demographics

Asking Questions

What is your ethnic identity? or

Which culture or ethnicity do you identify with? or

Describe a cultural group(s) to which you belong and

What values, beliefs, or practices are important for us to

know during your care?

Establishing Relationships

Madeleine Leininger (1991)

studied caring

from a transcultural perspective.

Transcultural Perspective

describes the concept of care as the essence and central, unifying, and dominant domain that distinguishes nursing from other health disciplines.

-Care is an essential human need, necessary for health and survival of all individuals.

-Care, unlike cure, assists an individual or group in improving a human condition.

Jean Watson's Theory of Caring

(1988, 1979)

Conscious intention to care promotes healing and wholeness

Rejects the disease orientation to health care and places care before cure

Looks beyond disease and treatment by conventional means to deeper sources of inner healing

Emphasizes the nurse-patient relationship and forming a connection

Dying at peace

Swanson's Theory of Caring

Swanson (1991) identified five categories/processes of caring following 3 studies performed in a perinatal unit:

Knowing; Being with; Doing for; Enabling; Maintaining belief

Defines caring as a nurturing way of relating to a valued other, toward whom one feels a personal sense of commitment and responsibility

Swanson's Theory of Caring identified five categories:

-Knowing (avoiding assumptions, assessing thoroughly)

-Being With (being there, sharing feelings)

-Doing For (comforting, anticipating)

-Enabling (informing, explaining, supporting, allowing)

-Maintaining Belief (maintaining a hope-filled attitude, offering realistic optimism)

Providing Presence

Being with, Eye contact, Body language, Tone of voice, Listening, Positive and encouraging attitude

Touch

Provides comfort

Creates a connection

Contact touch

Noncontact touch

Protective touch - prevent harm from an incident

Nurse - remove self from situation

Task-oriented touch - ex. shower

Listening

Creates trust

Opens lines of communication

Creates a mutual relationship

Spiritual Care

Spiritual health is achieved when a person can find a balance between his life values, goals, and belief symptoms and those of others.

Spirituality offers a sense of interpersonal and transpersonal connectedness.

Can be related to religion

Family Care

A nurse discusses a patient's health care

needs with his family.

The Challenge of Caring

Nurses are given less time to spend with clients, making it much harder to know who they are; nursing shortage.

Modern technology provides advances, but is often detrimental to providing "nursing care."

Clients have multiple illnesses/diseases that require immediate treatment.

Culture

affects how people value, evaluate, and categorize life experiences

thoughts, communications, actions, customs, beliefs and institutions of racial, ethnic, religious or social groups.

Ethnicity

Ethnic identity is based on the language, geographic area, racial characteristics, and values of the group's heritage (Irish, Polish, Vietnamese, Mexican). Differs from race.

Subcultures

represent various ethnic, religious, and other groups with distinct characteristics from the dominant culture (Appalachian, Missouri Ozark, Amish).

Emic Worldview

insider/native perspective

Etic Worldview

outsider perspective

Enculturation

socialization into one's primary culture as a child.

Acculturation

adapting to and adopting a new culture.

Ex. Raised in the Philippines and then move to the US

Assimilation

(process)

results when an individual gradually adopts and incorporates the characteristics of the dominant culture.

Biculturalism

occurs when an individual identifies equally with 2 or more cultures.

Cultural Backlash: occurs when an individual rejects a new culture because experience with a new or different culture is extremely negative.

Cultural Awareness

in-depth, self-examination of one's own background, recognizing biases and prejudices and assumptions about others.

Cultural Knowledge

obtaining sufficient comparative knowledge of diverse groups, including their indigenous values, health beliefs, care practices, worldview, and biocultural ecology.

Cultural Skills

assessment of social, cultural, and biophysical factors influencing treatment and care of clients.

Cultural Encounters

involve the engagement in cross-cultural interactions that can provide learning of other cultures and opportunities for effective intercultural communication development (researching).

Cultural Desire

the motivation and commitment to caring that moves an individual to learn from others, accept the role of learner, be open and accepting of cultural differences, and build upon cultural similarities.

Ethnocentrism

a tendency to hold one's own life as superior to others.

Cultural Imposition

use of one's own values & lifestyles as the absolute guide in dealing with patients and interpreting their behaviors; exhibited by health care providers who have cultural ignorance or cultural blindness about differences.

Describe the composition of breast granular tissue.

The glandular tissue contains 15 to 20 lobes radiating from the nipple, and these are composed of lobules. Within each lobule are clusters of alveoli that produce milk. Each lobe empties into a lactiferous duct. The 15 to 20 lactiferous ducts form a collecting duct system converging toward the nipple. There, the ducts form ampullae, or lactiferous sinuses, behind the nipple, which are reservoirs for storing milk.

Describe the surface landmarks of the thorax.

...

Describe the anatomic demarcation of the five lobes of the lungs.

Right lung has 3 lobes: Superior, Middle, and Inferior lobe. Apex is nearest the head, and base is near the stomach (opposite of the heart's base and apex)

Left lung has 2 lobes

Describe the IPPA of pulmonary assessment.

Inspection: inspect shape and configuration of chest, position of pt., LOC, use of accessory muscles, location of trachea, skin color and condition, resp. rate, AP/Lateral diameter, barrel chest

Palpation: symmetric expansion, tactile fremitus (vibration), tender areas, lumps or masses

Percussion: should have tympany (hollow) sound

Auscultation: 5 areas in front, 9 areas in back

Describe the normal and adventitious lung sounds.

Crackles, Wheezing, Stridor, Ronchi

Crackles

Due to fluid, mucus or pus; Non-musical, popping sound

Wheezing

High pitched

Due to airway narrowing

Heard louder in lungs than trachea

Stridor

High-pitched during inspiration

Due to obstruction of upper airway

Louder in trachea than lungs

Ronchi

Low-pitched, snore-like

Due to airway narrowing and secretions

Identify auscultatory sites for lung sounds.

While standing behind the person, listen to the following lung areas—posterior from the apices at C7 to the bases (around T10), and laterally from the axilla down to the seventh or eighth rib.

While standing behind the person, listen to the following lung areas—posterior from the apices at C7 to the bases (around T10), and laterally from the axilla down to the seventh or eighth rib.

Abnormal Respiratory Condition: Atelectasis

collapse of alveoli

Collapsed shrunken section of alveoli or an entire lung as a result of (1) airway obstruction (e.g., the bronchus is completely blocked by thick exudate, aspirated foreign body, or tumor), the alveolar air beyond it is gradually absorbed by the pulmonary capillaries, and the alveolar walls cave in; (2) compression on the lung; and (3) lack of surfactant (hyaline membrane disease).

Abnormal Respiratory Condition: COPD

People with COPD often sit in a tripod position, leaning forward with arms braced against their

Bronchitis, emphysema

Abnormal Respiratory Condition: Asthma

accessory muscles used

An allergic hypersensitivity to certain inhaled allergens (pollen), irritants (tobacco, ozone), microbes, stress, or exercise that produces a complex response characterized bybronchospasm and inflammation, edema in walls of bronchioles, and secretion of highly viscous mucus into airways. These factors greatly increase airway resistance, especially during expiration, and produce the symptoms of wheezing, dyspnea, and chest tightness.

Abnormal Respiratory Condition: Pleural Effusion

◦Pneumonia

◦Heart Failure

◦Hemothorax

◦Pneumothorax

Collection of excess fluid in the intrapleural space, with compression of overlying lung tissue. Effusion may contain watery capillary fluid (transudative), protein (exudative), purulent matter (empyemic), blood (hemothorax), or milky lymphatic fluid (chylothorax). Gravity settles fluid in dependent areas of thorax. Presence of fluid subdues all lung sounds.

Abnormal Respiratory Condition: Pneumocystis Carinii Pneumonia (PCP)

◦Pneumocysits Jiroveci fungus - doesn't affect healthy individuals

◦Affects HIV pts. Because immunocompromised

◦If pt comes in with PCP, assume they have HIV

This virulent form of pneumonia is a protozoal infection associated with AIDS. The parasite P. jiroveci (P. carinii) is common in the United States and harmless to most people, except to the immunocompromised, in whom a diffuse interstitial pneumonitis ensues. Cysts containing the organism and macrophages form in alveolar spaces, alveolar walls thicken, and the disease spreads to bilateral interstitial infiltrates of foamy, protein-rich fluid.

Abnormal Respiratory Condition: Tuberculosis

blood in sputum

◦Rust colored sputum, fever, night sweats

◦If pt comes in with signs of TB, are isolated until cultures comes back

Inhalation of tubercle bacilli into the alveolar wall starts: (1) Initial complex is acute inflammatory response—macrophages engulf bacilli but do not kill them. Tubercle forms around bacilli. (2) Scar tissue forms, lesion calcifies and shows on x-ray. (3) Reactivation of previously healed lesion. Dormant bacilli now multiply, producing necrosis, cavitation, and caseous lung tissue (cheeselike). (4) Extensive destruction as lesion erodes into bronchus, forming air-filled cavity. Apex usually has the most damage.

Abnormal Respiratory Condition: Acute Respiratory Distress Syndrome (ARDS)

An acute pulmonary insult (trauma, gastric acid aspiration, shock, sepsis) damages alveolar capillary membrane, leading to increased permeability of pulmonary capillaries and alveolar epithelium and to pulmonary edema. Gross examination (autopsy) would show dark red, firm, airless tissue, with some alveoli collapsed, and hyaline membranes lining the distended alveoli

Describe the correct sequence of examination technique during abdominal assessment.

(IAPP - only in GI)

Inspection

Auscultation - before palpation so no false bowel sounds are heard

Percussion

Palpation

Muscle Testing

•Inspection

•Palpation

•ROM

•Muscle Testing

-Repeat same motions used to test ROM

flex & hold as you apply opposing force

Measures strength

•Grade 0-5

Grading Scale

Have patient perform AROM while you provide resistance

5

Full ROM/against gravity

Full resistance

4

Full ROM/against gravity

Some resistance

3

Full ROM

With gravity/No resistance

2

Full ROM with gravity

Eliminated (PROM)

1

Slight contraction

0

No contraction

Grade 5

Full ROM/against gravity

Full resistance

100%

Assessment: Normal

Grade 4

Full ROM/against gravity

Some resistance

75%

Assessment: Good

Grade 3

Full ROM

With gravity/No resistance

50%

Assessment: Fair

Grade 2

Full ROM with gravity

Eliminated (PROM)

25%

Assessment: Poor

Grade 1

Slight contraction

10%

Assessment: Trace