Nursing Fundamentals

Unit 1

care provider

primary professional responsibility is to people requiring nursing care

educator

ensures patients receive sufficient information on care and tx

advocate

interprets info/provides education. Respects patient decision even when differ

leader

provides a direction and purpose to others

change agent

can provide in a leadership role

manager

manages all activities and tx for patients

researcher

critique research studies and apply to practice

collaborator

two or more people working together to a common end

delegator

entrusting or transferring responsibility to others to complete

Maslow's Hierarchy of Needs Level One: Physiological

breathing, food, water, sex, sleep, homeostasis, excretion

Maslow's Hierarchy of Needs Level Two: Safety

security of body, of employment, of resources, of morality, of the family, of health, of property

Maslow's Hierarchy of Needs Level Three: Love/Belonging

friendship, family, sexual intimacy

Maslow's Hierarchy of Needs Level Four: Esteem

self esteem, confidence, achievement, respect of others, respect by others

Maslow's Hierarchy of Needs Level Five: Self Actualization

morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts

respect of autonomy

people have freedom of choice; up to individual

veracity

truthfulness

justice

fairness and equality

accountability

taking responsibility for your actions

advocacy

supporting or promoting the interests of others or of a cause greater than oneself

confidentiality

secure all information relating to a patient unless the patient gives consent for disclosure

fidelity

keeping one's promise to the client about care that was offered

responsibility

being dependable and reliable

beneficence

doing good without self interest

non-maleficence

avoidance of harm or hurt

Scope of practice for AP

activities of daily living, vital signs, weight, measure input and output, safety

Scope of practice for LPN

stable client, data collection, reinforce teaching

Scope of practice for RN

unstable client, assess, teach, plan care

euthanasia

the act of painlessly ending the life of another

ethical dilemma

two or more clear moral principles apply but support mutually inconsistent courses of action

ethical distress

occurs when the nurse knows the right thing to do but either personal or institutional factors make it difficult to follow the correct course of action

moral distress

the anguish that healthcare professionals experience when their basic beliefs of what is right and wrong or ethical principles are challenged

moral resilience

the capacity of an individual to sustain or restore integrity in response to moral complexity, confusion, distress, or setbacks

misdemeanor

any minor misbehavior or misconduct jail time up to one year

felony

a crime, typically one involving violence, regarded as more serious than a misdemeanor, and usually punishable by imprisonment for more than one year or by death.

assault

threat or attempt to injure

battery

unlawful touching of another person without consent

defamation of character

wrongfully hurting a person's good reputation

libel

written defamation

slander

spoken defamation

false imprisonment

unlawful restraint or restriction of a person's freedom of movement

invasion of privacy

unwelcome and unlawful intrusion into one's private life so as to cause outrage, mental suffering, or humiliation

neglience

creating a risk of harm to others by failing to do something that a reasonable person would ordinarily do or doing something that a reasonable person would ordinarily not do

malpractice

negligence by a professional person

duty

must be proved that nurse owed a duty of care

dereliction

evidence that nurse's actions did not meet the standard of care

damages

actual harm or injury resulting to the patient

direct cause

a causal relationship must be established between harm to the accusing patient and the actions or omitted acts of the nurse.

burden of proof

the obligation to present evidence to support one's claim

litigation

the process of taking legal action

plantiff

a person who brings a case against another in a court of law

defendant

person being accused of crime

altruism

puts the patient's interests above her own and tries to care for the welfare of others

Five rights of safe delegation

right task, right circumstances, right person, right direction or communication, right supervision

First principle of delegation

nurses must have knowledge of the nurse practice act in the state where they are licensed

Second principle of delegation

the RN cannot delegate assessment, planning, evaluation, or accountability for the assigned task

Third principle of delegation

the person to whom the assignment was delegated cannot delegate that assignment to someone else

Information contained in incident reports

complete name of person and names of witnesses

factual account of incident

date, time, and place of incident

pertinent characteristics of person involved

any equipment or resources being used

any other important variables

documentation by physician of medical examination of person involved

Concepts of Delegation

the responsibility of the task is transferred

accountability remains with the delegator

delegation may be direct or indirect

Criteria for a Profession

altruism

body of knowledge and research

accountability

higher education

autonomy

code of ethnics

professional organization

licensure

diversity

Intentional torts

assault

battery

defamation of character

false imprisonment

invasion or privacy

Unintentional torts

malpractice

negligence

Health Insurance Portability and Accountability Act (HIPAA)

to see and copy their health record

to update their health record

to request correction of any mistakes

to get a list of disclosures a health care institution has made independent of disclosures for the purpose of treatment, payment, and health care operations

to request a restriction on certain uses or disclosures

to choose how to receive health information

Good Samaritan Laws

all 50 states have enacted these laws

allows protection for Physicians and other HCP

protect HCP from charges of negligence providing emergency health care

Direct Delegation

usually verbal direction

RN decides which staff member is capable of performing a specific task

the RN may assign a more skilled individual to perform a task

the RN may not assign an individual to perform an activity outside of a job description of the scope of practice

Nurse Practice Act

defines functions of nursing and sets standards for licensure \n grants a nurse the authority to carry out those functions \n each state has its own NPA, but all must be consistent w/ provisions or statues established at the federal level

Four Functions of Ethnics Committees

education

policy making

case review

consultation occasionally research

civil tort law

disputes between people in which a person is harmed because of another person's actions or failure to act

Categories of Malpractice Claims

failure to follow standards of care

failure to use equipment in responsible matter

failure to assess and monitor

failure to communicate

failure to document

failure to act as a patient advocate

Standards of care

the minimum requirements for providing safe nursing care

informed consent

permission granted by a patient after discussing each of the following topics with physician, surgeon, or advanced practice nurse who will perform the surgery or procedure

5 Topics Discussed with HCP about Informed Consent

exact details of the treatment

necessity of the treatment

all known benefits and risks involved

available alternatives

risks of treatment refusal

advance directives

consist of two types of documents living wills and documents appointing a health care proxy

living will

specifies the treatment a person wants to receive when a patient is unconscious or no longer capable of making decision independently

DNR

directions given by patients who are faced with life threatening illness, or their designed family member acting as health care proxies, to refuse or limit extraordinary measures that may delay natural death

health care proxy

the specific durable power of attorney for medical care

Conducting Evidence-Based Research

assessing the problem

developing a question

searching for and evaluating evidence

critically appraising information

synthesizing the evidence and developing a plan

maintaining the change and re-evaluating

Health Care documentation

any written or electronically generated information about a patient that describes the patient, the patient’s health, and the care and services provided, including dates of care

Nursing Documentation

standardized nursing terminologies

do not use abbreviations

narrative charting

formative charting

Nursing Documentation

charting by exception

case management documentation

flow sheets

Nursing Documentation

bar coded medication administration

kardex

admission and discharge summaries

legal issues of documentation

Handoff Reports

passing patient-specific information from one caregiver to another

may be oral, written, or recorded

promotes continuity of care

provides opportunity for collaborative problem solving

several sentinel events could occur because of incomplete handoff reports

Incident Reports

generated when usual and unexpected event involving a patient, visitor, or staff member occurs

purpose to document the details of the incident immediately to ensure accuracy

it is not part of medical report and the fact that an incident report was completed is not recorded in the patient’s medical record

verbal and telephone orders

often limited to emergency situations

must be taken by an RN who repeats the order verbatim, enters order into paper of electric system, documents it as verbal/phone order, includes date, time, physician name, and RN signature

most facility policies require the physician to cosign a verbal or telephone order within a defined time period

transfers

level of care has changed

another setting is required

facility does not do that type of care

no longer needs care and returns home

discharges

type of discharge

date and time, who left with client and transportation

where they went

summary of clients condition at discharge

description of follow up

disposition of valuables

document understanding of instructions by client

discharge education

use clear, concise language will understand

verify understanding

identify safety concerns

review clinical manifestations of complications and when to contact emergency care

phone number of provider

community resources

step by step instructions and provide info on medications

Admission

provides baseline data for nursing plan of care

assess and collect data

inventory personal items

orient family and patient to room and facility

share information

nursing process

foundation of professional nursing practice

framework within which nurses provide care to patients in an organized and effective manner

requires critical thinking

systematic method of critical thinking to develop individualized plans of care to provide care for clients

ANA definition of nursing

nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence. Nursing is the diagnosis and treatment of human responses and advocacy in the care individuals, families, groups, communities, and populations in recognition of the connections of all humanity

First step of nursing process: asessment

the organized and ongoing appraisal of a patient’s well-being involving collecting data from a variety of sources that is needed to care for patients

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holistic approach

nurses assess the state of a patient’s physical, psychological, emotional, environmental, cultural, and spiritual health to gain a better understanding of the patient’s overall condition

assessment data can be collected from

patients

family members

friends

communities

health care professionals

medial records

lab results

diagnostic test results

primary data

contains information obtained directly from a patient

secondary data

collected from family members, friends, other health care professionals, or written sources, such as medical records and test results

subjective data

spoken information such as patient’s feelings about a situation or comments about how they are feeling

gathered during a patient interview or health history

typically recorded using quotations

objective data

data collected from medical records, laboratory, and diagnostic test results, or physical assessments

consist of observable information that a nurse gathers based on what can be seen, measured, or tested

inspection

involves the use of vision, hearing, and smell to closely look over the physical characteristics of a whole person and individual body systems

palpation

uses touch to access body organs and skin texture, temperature, moisture, turgor (skin elasticity), tenderness, and thickness

can determine organ location and size

percussion

tapping patient’s skin with short, sharp stokes to see if any blood or air is present

auscultation

listening with the assistance of a stethoscope to sounds

breath sounds, hearts sounds, and bowel sounds are routinely assessed this way