Chapter 1: The Past, Present, and Future

Key Terms

- American Health Care Act: A law designed to improve access to health insurance and reduce health care costs.

- Clinical Pathways: Standard plans that guide health care providers in treating common health problems.

- Connected Care: Using technology to link patients with health care providers for better communication and care coordination.

- Clinical Judgment Model: A framework nurses use to assess patients and make safe, informed decisions.

- Critical Thinking: The ability to think clearly and carefully to make good decisions in nursing.

- Cultural Awareness: Being aware of your own cultural beliefs and recognizing that others have different cultures.

- Cultural Competence: Having the skills and knowledge to care respectfully for patients from different cultural backgrounds.

- Cultural Sensitivity: Showing respect and understanding toward different cultures in health care.

- Culture: The shared beliefs, customs, and behaviors of a group of people.

- Documentation: Recording all patient care information clearly and accurately.

- Evidence-Based Practice: Using the best research and data to guide nursing care decisions.

- Family Care Plan: A nursing care plan that includes the needs and roles of the whole family.

- Global Nursing: Nursing focused on improving health care around the world.

- Health Information Portability and Accountability Act (HIPAA): A law protecting patients private health information.

- Healthy People 2030: A government initiative setting health goals to improve the well-being of Americans by 2030.

- Nursing Care Plan: A written plan outlining nursing goals and actions for a patient.

- Nursing Process: A 5-step method nurses use to care for patients: assess, diagnose, plan, implement, and evaluate.

- QSEN: Quality and Safety Education for Nurses; a program teaching nurses to provide safe and effective care.

- SBAR (or S-BAR): A communication tool used by nurses and health care teams:

Situation, Background, Assessment, Recommendation.

- Telemedicine: Providing health care remotely using technology like video calls or phone.

Introduction to Obstetrics, Pediatrics, and Family-Centered Care

Obstetrics

Derived from the Latin word obstetrix, meaning “stand by.”

A medical specialty focused on the care of women during:

• Pregnancy

• Childbirth

• Postpartum period (also called puerperium)

Maternity nursing: Nursing care given to the expectant family before, during, and after birth.

Obstetrician

A doctor who specializes in:

• Caring for women during pregnancy, labor, birth, and postpartum

• Performs cesarean deliveries and manages obstetric problems.

Other providers who deliver babies include:

• Family physicians

• Certified nurse-midwives

Pediatrics

Medical branch dealing with:

• The development and care of children

• Diseases of childhood and their treatment

The word comes from Greek:

• pais, paidos = child

• iatreia = cure

Family-Centered Care

Recognizes the strength and importance of the family in health care.

Places the family at the core of planning and implementing care.

Family members act as:

• Caregivers

• Decision makers

Family’s philosophy, goals, culture, and ethnic practices influence their healthcare.

This control over health decisions is called empowerment.

The nurses role is to form a partnership (or contract) with the family to help achieve health goals.

The Past

Obstetrics

Early History

Obstetrics origins trace back to ancient times, recorded in Egyptian papyruses (~1550 BC).

Soranus (2nd century, Rome), known as the father of obstetrics, developed the podalic version technique:

• This procedure rotates a fetus to a breech (feet-first) position.

• Important for vaginal delivery of the second twin.

Today, planned cesarean births have largely replaced podalic version for safety.

Medical Progress Halted: The Dark Ages

After the fall of the Roman Empire, medical science, including obstetrics, stagnated in Western Europe.

Breakthroughs in the 19th Century

Karl Credé (1819-1892):

• Introduced instilling 2% silver nitrate into newborns eyes to prevent blindness caused by gonorrhea.

• This simple innovation has saved countless babies eyesight worldwide.

Ignaz Semmelweis (1818-1865):

• Worked in Vienna’s maternity ward in the 1840s.

• Discovered that puerperal fever (childbed fever) was spread by doctors who did not wash their hands after cadaver dissections.

• Advocated for strict handwashing to reduce infections.

Published The Causes, Understanding, and Prevention of Childbed Fever (1861).

• His life-saving ideas were ignored until decades later.

Louis Pasteur (1822-1895):

• Proved that bacteria caused puerperal fever.

• Emphasized the importance of hand hygiene and avoiding contact with contaminated objects to stop infections.

Joseph Lister (1827-1912):

• Applied Pasteur’s discoveries to surgery.

• Pioneered antiseptic surgical techniques, greatly reducing infections and revolutionizing surgery.

Key Takeaways:

- Handwashing became a critical practice in preventing infections during childbirth.

- Innovations in infection control drastically improved maternal and newborn safety.

- Obstetrics evolved from ancient practices through scientific breakthroughs, especially in the 19th century.

Pediatrics

Early Child Care in History

• Child care depended on the culture of each society.

• Primitive tribes (nomadic):

  • Only strong children survived.

  • Infanticide (killing weak infants) was used to protect the group.

• As tribes settled, children were treated better but were mainly valued for their productivity.

Ancient Civilizations

• Egyptians and Greeks had more advanced views on child care.

• Hippocrates (460–370 BC):

  • Greek physician.

  • Wrote about illnesses specific to children.

Middle Ages

• No real concept of childhood.

• Children were treated like mini-adults by age 7.

  • Wore adult clothes and wigs.

• Christianity began to influence child care:

  • Saint Vincent de Paul (1600s) started children’s asylums.

  • These later turned into hospitals for abandoned children.

Modern Developments

• 1802: First children’s hospital in Paris.

• 1853: Children’s Aid Society founded in New York City.

• 1855: First pediatric hospital in the U.S. — Children’s Hospital of Philadelphia.

Abraham Jacobi

• Known as the “father of pediatrics”.

• Helped create:

  • Pediatric departments in medical schools.

  • Children’s hospitals.

  • Separate units for children in general hospitals.

Pediatric Nursing and Hospital Care

• Pediatric nursing became a specialty alongside the rise of children's hospitals.

• By the 1960s, most hospitals had separate pediatric units.

• Parents had limited visiting hours.

  • Breastfeedingmothers were allowed 1-hour visits when needed.

Obstetric and Pediatric Care in the United States

US Early Childbirth Practices in America

• Immigrants and Native American nations brought diverse birth practices.

• Midwives or relatives usually helped with births.

• Samuel Bard (1807): Wrote the first American midwifery textbook.

Medical Discoveries

• Oliver Wendell Holmes (1809–1894):

  • Harvard physician who showed puerperal fever was contagious.

  • Faced criticism, like Semmelweis.

  • Helped support the germ theory, which improved survival rates.

Shift from Home to Hospital Births

• Before 1900s:

  • Most babies were born at home.

  • Lying-in hospitals for very ill patients had high maternal and infant death rates due to crowding and poor care.

• Hospitals began training nurses.

• Doctors built closer ties with hospitals.

• Instruments and anesthesia led to hospital childbirth becoming popular.

• By 1950s, hospital births were standard.

• By 1960, over 90% of births happened in hospitals.

Problems in Early Hospital Births

• Lacked family-centered care:

  • Fathers waited in separate rooms.

  • Mothers were sedated (e.g., “twilight sleep”) and not active in labor.

  • Babies were not reunited with parents for hours → delayed bonding.

Professional Organizations

Legal and Ethical Considerations

• ANA sets standards of nursing practice for guidance and policies.

• Each state has its own Nurse Practice Act:

  • Defines roles of RNs, LPNs/VNs, CNAs.

  • Scope of practice varies by state.

  • Nurses must know the laws in their state.

Government Influences in Maternity and Pediatric Care

Important U.S. Laws and Programs (Chronological Order)

Legal and Ethical Considerations

HIPAA (2003)

• Keeps patient info private.

• Names and personal info must be stored securely.

• Applies to all health care workers.

HITECH (2009)

• Adds protections for electronic medical records.

• Tracks:

  • Who accessed the record

  • When it was accessed

  • What was reviewed

Affordable Care Act (ACA)

• Signed by President Obama (2010).

• Focused on preventive health care.

• Expanded coverage starting in 2014.

• Upheld by the Supreme Court in 2012.

• Challenged in 2017 by President Trump with AHCA (still evolving).

The Children’s Bureau & Community Programs

The Children’s Bureau

• Founded in 1912, thanks to Lillian Wald (a nurse focused on child welfare).

• Main Focus:

  • First: Infant mortality.

  • Then: Maternal mortality.

• Led to birth registration in all U.S. states.

• In the 1930s, investigations led to hot lunch programs in schools.

• Now part of the Department of Health and Human Services (HHS).

Nursing Tip: Helpful Community Programs

These are valuable resources for families that are:

• Dysfunctional

• Isolated

• In need of extra support

Examples:

• Foster grandparents programs – Older adults helping children.

• Home health aides / Parent aides – Provide in-home help.

• Hotlines – Support for children left alone after school (important for safety and emotional support)

White House Conferences & Children’s Charter

Major White House Conferences on Children

• 1909 – President Theodore Roosevelt holds the 1st Conference on Children & Youth.

  • Aim: Meet every 10 years under the President’s lead.

• 1930 – Under President Hoover, the Conference on Child Health & Protection writes the Children’s Charter (see summary below).

• 1971 – President Nixon splits the Conference into two parts:

  1. Children’s needs

  2. Teen health & social issues

• Late 1970s–’80s – Under Presidents Carter and Reagan, smaller/state events keep the spirit alive.

• 1993 – Authorized under Clinton, but not funded.

• 1990s–2000s – Clinton & G.W. Bush host small gatherings on early childhood, missing/exploited kids, and school safety.

• 2010 – President Obama pushes a bill to renew national Children’s Conferences, sparking a new conversation on child welfare.

The Children’s Charter (1930) – Key Themes

The main ideas grouped by theme:

1. Health & Safety

   • Care before, during, and after birth

   • Regular health checks, dental care, and disease prevention

   • Safe homes, schools, and communities

2. Family & Home

   • Love, security, and family stability

   • Foster care that feels as close to home as possible

3. Education & Development

   • Early education (nursery, kindergarten)

   • Schools that fit each child’s needs and prepare them for life

   • Training for future parents and citizens

4. Protection & Rights

   • Guard personality, spiritual and moral growth

   • Protect against child labor, accidents, abuse, and moral hazards

   • Special care for handicapped or troubled children

5. Equality & Access

   • Same services for rural and city children

   • Public support when families can’t pay

International Year of the Child & UN Rights of the Child

International Year of the Child (1979)

• Purpose:
  - Focus world attention on the needs of 1.5 billion children
  - Encourage governments and individuals to improve care and services for children

• Led by:
  - The United Nations (UN)
  - Supported by UNICEF and World Health Organization (WHO)

• Outcome:
  - Reaffirmed the Declaration of the Rights of the Child (originally adopted in 1959)

UN Declaration of the Rights of the Child (1959)

Top 10 Rights Children Should Have:

1. Equal rights for all children — regardless of race, gender, religion, background, etc.

2. Full development — physically, mentally, morally, spiritually, and socially

3. A name and nationality at birth

4. Healthy growth — with access to food, shelter, play, health care, and social security

5. Special care for children with disabilities

6. Love and support, ideally within a family

7. Free education and recreation, to develop talents

8. First to be protected in times of trouble (like war or disaster)

9. Protection from abuse, neglect, and harmful labor

10. No discrimination, and the right to a peaceful and friendly environment

Department of Public Health & Legal Responsibilities

Department of Public Health

• Works at the national, state, and local levels to prevent childhood disease and death.

• Key roles:

  • Inspects water, milk, and food supplies.

  • Makes sure sewage and garbage are handled safely.

  • Investigates epidemics.

  • Isolates people who may spread dangerous diseases.

  • Inspects housing conditions.

  • Supports mother and infant health with programs like WIC (Women, Infants, and Children).

Legal and Ethical Considerations for Nurses

Reportable Situations (What Nurses Must Report)

Nurses must report the following:

• Communicable diseases that could harm the public:

  • Examples: Tuberculosis (TB), STIs, foodborne illnesses

• Suspected child abuse

• Suicidal behavior

How to Report:

• Use forms from your employer or the public health department.

• Act immediately to help protect the child or patient.

Important Note:

• Nurses must understand:

  • Legal duties

  • Ethical guidelines

  • Their role in the health care team

• This helps them think clearly, act quickly, and give families the best support.

The Present

Family-Centered Care in Maternity

• Family as a system: Birth affects every family member. Family involvement during pregnancy and birth is important for bonding and support.

• Modern birth settings:

  • Alternative birth centers and birthing rooms have been created.

  • Traditional separate areas for labor, delivery, postpartum, and newborn nursery are merging into one.

  • Many hospitals use LDR rooms (Labor, Delivery, Recovery) where the mother stays in one room throughout labor, delivery, and postpartum care. This avoids moving the mother and fragments in care.

  • These rooms are often designed to be home-like to increase comfort.

• Freestanding birthing centers:

  • Popular for low-risk pregnancies.

  • Offer complete care: antepartum, labor/delivery, postpartum, classes (mother’s and lactation), and family planning follow-up.

• Home births:

  • Not very common currently.

  • Reasons: High malpractice insurance costs, and lack of emergency equipment for unexpected problems.

Financial Considerations

• Cost containment means using resources efficiently and managing the budget carefully.

• Initially, cost containment led to early discharge of mothers and newborns—within 24 hours after delivery.

• Due to problems with early discharge, laws now allow:

  • 48-hour hospital stay for vaginal births

  • 4-day hospital stay for cesarean sections

Changing Perceptions of Childbearing

• Childbirth is now viewed as a normal, healthy event, not a medical problem.

• Focus is on providing a high-quality family experience.

• Parents are prepared for:

  • Physical changes during pregnancy, labor, and delivery

  • Emotional and family dynamic changes after birth

• Care is individualized to fit each family’s unique needs.

• In the 1950s, hospital stays were about 1 week after birth.

• Now, stays average 1–2 days for uncomplicated deliveries.

• Newborn follow-up is routine within 48–72 hours after discharge.

• Nurses provide home visits for high-risk mothers and infants.

Midwives

• Women have long served as birth attendants or midwives throughout history.

• The first nurse-midwifery school in the U.S. opened in 1932 in New York City.

• Many accredited midwifery programs exist, mostly linked to colleges or universities.

• A Certified Nurse-Midwife (CNM) is:

  • A registered nurse (RN)

  • Graduated from an accredited midwife program

  • Nationally certified by the American College of Nurse-Midwives

• CNMs provide comprehensive prenatal and postnatal care and attend uncomplicated deliveries.

• They ensure patients have a backup physician in case complications arise.

Role of the Consumer

• The natural childbirth movement in the early 1960s encouraged parents to seek education and active involvement.

• Prepared childbirth, La Leche League (breastfeeding support), and Lamaze classes became widely accepted.

• Parents began questioning routine anesthesia use and fathers’ exclusion from delivery.

• Now, fathers commonly attend births, visiting hours are flexible, and extended newborn contact is encouraged.

• Consumers (parents) continue to drive change in maternity care policies.

• Evidence shows educated and supported parents make wise care decisions during childbirth.

Cultural Considerations

• Culture means the shared values, beliefs, and practices passed down through generations. It shapes how people think and act—called traditions.

• Culture can affect how patients respond to health care and childbirth.

• The U.S. is culturally diverse, so nurses need to develop:

  • Cultural awareness (recognizing differences)

  • Cultural sensitivity (respecting others’ values and practices)

  • Cultural competence (adapting care to meet cultural needs)

• These skills are important especially in global health nursing.

• A family’s cultural background strongly influences how they handle pregnancy and birth.

• To provide culturally sensitive care, nurses should ask pregnant women about their views and practices, such as:

  • How does she see her pregnancy? (illness, vulnerable time, or healthy time)

  • Does she think birth is dangerous? Why?

  • Is birth a private or public event for her?

  • What delivery position does she expect or prefer?

  • What kind of help does she want before and after birth?

  • What role does her family play in pregnancy and birth?

Medical Technology and Specialty Expertise

• Advances in medical technology have greatly improved survival rates for infants who previously might not have survived, especially extremely premature babies (as small as 1 lb).

• Specialized care includes:

  • High-risk prenatal clinics

  • Neonatal Intensive Care Units (NICUs)

  • Specialists like pediatric cardiologists, surgeons, and psychiatrists who treat children with complex medical or emotional issues.

• Advanced laboratory tests, such as chromosomal studies and biochemical screenings, help identify health risks early and allow for family counseling.

• Perinatal biology is a leading field in pediatric medicine, including prenatal surgeries to correct defects before birth.

• Medical professionals and allied health teams collaborate to provide expert diagnosis, treatment, and ongoing care.

• Many children with chronic disabilities or complex needs are cared for at home using advanced medical equipment (ventilators, monitors).

• Home nursing care may require highly technical skills like suctioning tracheostomies or central line care.

• Parents need thorough education and continuous support to manage this care effectively.

• Respite care is crucial because 24/7 caregiving is physically and emotionally demanding for families.

Genomics

• Genomics studies all the genes in the human body and how they interact with each other and the environment.

• The Human Genome Project mapped all human genetic material.

• Researchers have identified genes that cause certain birth defects.

• Gene therapy can replace missing genes or fix faulty ones.

• This knowledge helps with:

  • Earlier diagnosis

  • Earlier treatment

  • Using genomics in patient education and therapy

Health Care Delivery Systems

• Cost containment is a key concern because health care costs have risen without lowering illness or death rates.

• Insurance reimbursement affects how health care is delivered, especially with government programs like Medicare and Medicaid.

• Diagnosis-related groups (DRGs) are a Medicare payment system based on the patient’s diagnosis, encouraging shorter hospital stays and more care at skilled nursing facilities or at home.

• Nurses often act as case managers, coordinating care and helping to control costs while ensuring quality.

• Nurses need to be flexible and demonstrate their value and cost-effectiveness.

Alternative Delivery Systems

• Health Maintenance Organizations (HMOs): Provide health care for a fixed monthly fee (premium).

• Preferred Provider Organizations (PPOs): Make contracts with providers to offer discounted services on a fee-for-service basis.

• These systems aim to hold down costs while competing for patients.

Two-tiered System

• People with more financial resources typically use private insurance, HMOs, and PPOs.

• People with fewer resources rely on Medicare and Medicaid.

• The Affordable Care Act (ACA) of 2010 expanded coverage for many uninsured people. The effects of the later AHCA of 2017 are uncertain.

Key Terms from Box 1.3:

• Managed care: Combines financing and health care; members pay a monthly fee, and the system contracts with providers to control costs via strict utilization review.

• Utilization review: Evaluates if health care services are necessary and guides physicians on treatment, helping control costs.

Coordination of Care

• Shorter hospital stays mean patients go home needing continued support, education, and follow-up care.

• Nurses coordinate care between different health care providers to:

  • Improve quality of care

  • Support a smooth transition (such as from pediatric to adult care)

  • Help families find financial help and community resources

  • Avoid repeating services unnecessarily

• Care coordination helps prevent gaps or confusion in care and makes sure care goals are met.

• Community nurses may:

  • Work with schools to meet a child’s health and educational needs

  • Support families in understanding their ill child’s needs

  • Promote positive parenting

  • Use cultural awareness to better meet family needs

  • Connect families to local resources

• Good care includes both hospital care and community follow-up.

Technology and Patient Teaching

• Mobile apps help teach parents about infant care, diet, exercise, and general health.

• Nurses must check that the information in the apps is:

  • Accurate

  • From a reliable source

  • Right for the patient’s needs

• Nurses help create and use these tools to improve health behaviors and educate patients globally.

Telemedicine and Connected Care

• Telemedicine (telehealth or digital health) allows patients to get care from home.

  • Became widely used during the COVID-19 pandemic

  • Especially helpful for people in rural or remote areas

• Benefits of telemedicine:

  • Saves money and time (no need to travel)

  • Increases patient autonomy and satisfaction

  • Improves access to preventive care, family planning, follow-ups, well baby/woman visits, and lactation support

  • Helpful for high-risk patients and personalized care

• Connected Care:

  • Combines telehealth with electronic health records (EHRs)

  • Allows doctors and nurses to make better decisions with real-time data

  • Uses texts, apps, and even tools like live ultrasounds or AirStrip OB (an app that separates mother and baby heart sounds)

• Future trends:

  • Use of AI to predict disease and suggest treatments

  • Better data sharing, workflow updates, and insurance support

  • Will reshape how we deliver care in obstetrics and pediatrics

Interprofessional Nursing Care

• Nurses must follow CDC precautions during labor, delivery, cord care, and while working in the nursery.

• Electronic health records (EHRs) allow nurses to view notes from the whole health care team—but require nurses to be computer literate.

• Social changes (like smaller families, more single parents, and working mothers) present new challenges for nurses.

  • Nurses must:

    • Watch for signs of abuse

    • Know about community support services

    • Be flexible to help working parents

    • Tailor teaching and care plans to each family's cultural background

• The nurse plays a key role on the interprofessional health care team.

Cultural Considerations: Perception of Health and Illness

• Cultural beliefs shape how families view health, illness, and care.

• Holistic nursing means being aware of cultural differences and using that knowledge to adapt nursing care.

• Nurses should include the patient’s culture and values in the care plan.

Pediatric Nurses as Advocates

• An advocate speaks up for someone who can't speak for themselves.

• Pediatric nurses often advocate for children and their families.

  • This is important because hospitalized children may not be able to express their needs.

• If a nurse believes a child’s needs are not being met, they must:

  • Take the issue to the health care team.

  • Document all actions and efforts to get help from supervisors or doctors.

Nursing Tip:
Nurses must collect and document data, take action for abnormal findings, and refer patients for follow-up when needed.

Health Promotion

• Health promotion means preventing illness before it starts.

  • It saves money and reduces family stress.

• More children are treated in outpatient settings or at home instead of long hospital stays.

• Many chronically ill children now live into adulthood, which increases the need for:

  • In-home care

  • Education

  • Support services

• Nurses often help by:

  • Teaching families

  • Referring them to services

  • Helping children live as independently as possible

Important Terms:

• Mainstream: Including children with disabilities in everyday activities

• Full inclusion: Expands on mainstreaming to include all areas of life

• Early intervention: Helping young children with developmental disabilities early to improve outcomes

• Advance directives: Plans made with older children and families in case of serious illness

• Nurses must keep learning to stay up to date with new technology and care methods.

  • Continuing education is required to keep a nursing license.

Nursing Tip:
Nurses can expand their roles and become:

• Clinical Nurse Specialists (CNS)

• Pediatric Nurse Practitioners (PNP)

• School Nurse Practitioners

• Family Nurse Practitioners (FNP)

• Certified Nurse-Midwives (CNM)

Advanced Practice Nurses

• The focus today is preventing illness and keeping people healthy rather than only treating illness.

• Pediatric Nurse Practitioners (PNPs):

  • Provide primary care and treat children in outpatient (ambulatory) settings.

  • Work with well children, not just sick ones.

• School nurses and child life specialists help by teaching health in schools and supporting children’s development.

Nursing Tip:
Being a patient advocate is one of the most important jobs of a nurse.

Clinical Nurse Specialists (CNS)

• CNSs care for patients in hospitals or communities with special needs (like heart, brain, or cancer care).

• They:

  • Do research

  • Help improve care plans

  • Work with more complex cases

• CNSs and PNPs are types of Advanced Practice Nurses (APNs).

  • They are registered nurses (RNs) with advanced degrees.

  • They can specialize in:

    • Obstetrics

    • Pediatrics

    • Neonatal care

Advanced Practice Nursing Specialties

Health Promotion – Healthy People 2030

School nurses will take on more roles to improve children’s health:

1. Check physical education programs (for all students)

2. Teach nutrition

3. Oversee school meals

4. Support drug- and tobacco-free environments

5. Educate about STIs (sexually transmitted infections)

6. Help prevent injuries

7. Teach oral (dental) health

8. Provide age-appropriate HIV education

9. Make sure students have up-to-date immunizations

10. Review and adjust how they meet students' health needs through prevention, teaching, and follow-up

Nursing Tools

The Nursing Process

A step-by-step method used by nurses to care for patients. It helps identify, treat, or prevent health problems. It uses critical thinking and problem-solving.

Steps of the Nursing Process (by ANA):

1. Assessment – Gather patient information (what they say and what you observe).

2. Diagnosis – Identify patient problems that nursing can treat.

3. Planning – Make a care plan with goals to solve those problems.

4. Outcomes Identification – Set specific, expected results for the patient.

5. Implementation – Carry out the care plan (nursing interventions).

6. Evaluation – Check if the goals were met. If not, revise the plan.

It is goal-directed, individualized, and focused on solving real or possible problems.

Nursing vs. Medical Diagnosis

Nursing Care Plans

• A written plan that helps nurses provide personalized care.

• It’s made using the nursing process.

• Used by the whole health care team.

• Helps everyone understand the patient’s problems, goals, and what to do.

Common Terms in Care Plans

How the Care Plan Works:

1. Collect clues (assessment)

2. Figure out problems (diagnosis)

3. Prioritize the most important problem

4. Plan what to do

5. Do the interventions

6. Set goals/outcomes

7. Check if it worked (evaluate)

Clinical Pathways

• Definition: A step-by-step team-based care plan that outlines what care should happen, when, and by whom — based on research.

• Goal: To make sure all health care team members work together efficiently to help the patient recover on time.

Key Points:

• Set daily recovery goals for the patient.

• Help track expected progress and outcomes.

• If the patient falls behind, it's called a variance:

  • Negative variance = slower progress → may delay discharge.

• Based on research, not tradition.

• Helps improve care quality and reduce hospital stays.

• A key tool in managed care (keeping care efficient and coordinated).

Vital Statistics

• Definition: Numerical data that help track births, illnesses, and deaths.

• Used to:

  • Spot trends in health

  • Identify at-risk groups

  • Measure care quality

  • Compare data by state or country

Example:

• SIDS (Sudden Infant Death Syndrome) was the top cause of infant death in 2014 but dropped to third in 2015.

• Respiratory Distress Syndrome dropped from the 3rd cause of infant death in 1980 to 8th by 2015.

Healthy People 2030 Goal (Table 1.2):

• Reduce preterm births by 2030.

  • Preterm birth rates went from 11.32% to 9.85% (2014–2016).

  • Late preterm births (34–37 weeks) dropped from 7.93% to 7.09%.

Critical Thinking

• Critical thinking = purposeful, goal-directed thinking based on facts and science, not just memorization.

• Helps nurses make smart, patient-specific decisions that aren’t always in a textbook.

• Example: Teaching about eating meat won’t help a vegetarian with protein deficiency. The nurse must think critically and offer other protein sources.

Why It Matters

• Nurses care for real people, each with their own background, culture, and needs.

• Critical thinking lets nurses:

  • Solve unique problems

  • Prevent mistakes

  • Provide safe, effective care

  • Adjust care to the individual

Steps in Preparing a Nursing Care Plan

1. Collect data from the chart, labs, notes, etc.

2. Review the medical diagnosis.

3. Talk to the patient and gather info directly.

4. Pick the right nursing diagnosis with clear causes and signs.

5. Set measurable goals and list specific nursing actions.

6. Check if the goals were met; change the plan if needed.

Critical Thinking vs. General Thinking

The Nursing Process = A Tool for Critical Thinking

Use it to make good decisions for each patient:

1. Assessment – Gather data

2. Diagnosis – Find the problem

3. Outcomes Identification – Set patient goals

4. Planning – Choose interventions

5. Implementation – Do the care

6. Evaluation – See if the plan worked

Steps in the Critical Thinking Process

1. Identify the problem.

2. Separate facts from guesses.

3. Check if the data is accurate and reliable.

4. Focus on what’s relevant.

5. Think of possible solutions or outcomes.

6. Set priorities and goals.

7. Watch how the patient responds.

What Can LPNs Do?

• Always follow your state’s scope of practice.

• Know what you can do on your own vs. when to call the RN or doctor.

NCSBN Clinical Judgment Model (CJM)

• Created by the National Council of State Boards of Nursing (NCSBN).

• A framework for measuring how well students make decisions using clinical judgment.

• Used in the NCLEX-PN exam to test real-world thinking, not just memorized facts.

What’s Different in the NCLEX?

Starting in 2023, the NCLEX will:

• Focus more on clinical scenarios (like real patient cases).

• Use new question types, not just multiple choice:

  • Unfolding case studies

  • Drag and drop (to rank steps or reasons)

  • Highlighting important info in charts or tables (called cues)

  • Select-all-that-apply (SATA) questions with more depth

➡ Goal: See how well you can assess, analyze, and decide what to do next — just like in real nursing situations.

Connection to the Nursing Process:

• The nursing process (Assessment, Diagnosis, Planning, Implementation, Evaluation) is built into this model.

• Helps guide the “next best step” in patient care decisions.

Using Critical Thinking to Improve Test Scores

Critical thinking helps you understand, remember, and apply what you study — which is key for tests and real-life nursing.

Study Smarter with Critical Thinking:

Example:

To answer a test question about abnormal lung sounds:

• You must first recall normal sounds.

• Then, use critical thinking to decide what the abnormal sound means.

• Choose the best intervention based on what you know and what the patient needs.

Documentation

• Also called charting.

• It is a legal responsibility for nurses.

• Required by The Joint Commission (TJC) as part of patient safety standards.

What Should Be Documented?

• Medications given

• Treatments performed

• Head-to-toe assessments

• Patient’s response to care

• Any important data related to diagnosis or changes in condition

🛑 If it’s not documented, it’s considered not done — this is important in legal situations.

Legal & Ethical Responsibility

• Documentation must be:

  • Detailed

  • Accurate

  • Timely

Electronic Documentation

Benefits:

• Reduces errors caused by bad handwriting

• Allows multiple team members to access records at the same time

• Includes built-in alerts for abnormal values

• Uses barcodes to scan meds and patients for safety

• Often done using computers in rooms or mobile carts (“computers on wheels”)

• Used in hospitals and community care (iPads, etc.)

📲 All nurses must now be computer literate to use electronic documentation systems.

Healthy People 2030

Healthy People 2030 is the latest update to the U.S. government’s national health goals, focusing on improving health and quality of life for Americans in the 21st century.

Key Focus Areas:

• Health Promotion

• Health Protection

• Preventive Services

• Development of Surveillance and Data Systems

Main Goals:

• Increase the length of healthy life

• Reduce health disparities among different groups

• Ensure access to preventive health care for everyone

Priority Topics Include:

• Maternal and infant health

• Immunizations

• Prevention of sexually transmitted infections (STIs)

• Oral health

• Nutrition

• Physical fitness

Important Fact:

• The previous goal (Healthy People 2010) aimed to reduce maternal mortality to 3.3 per 100,000 births but actually increased to 17.4 per 100,000 in 2018. More coordinated efforts are needed to meet this goal by 2030.

The Future

Health Care Reform

Key Issues:

• Balancing Cost and Quality:
  Health care became a big business, so controlling costs while maintaining quality became a major challenge.

• Managed Care:
  This system continuously monitors care quality and cost, especially focusing on prevention and routine management.

Government Efforts:

• The federal government passed major health care reforms in 2010 and 2017 to lower health care costs and increase access for everyone.

• Even with health insurance, access to care can be limited because insurance companies may need to approve tests or treatments first.

Challenges:

• Families without health insurance often skip preventive care, such as prenatal visits and immunizations.

• The Affordable Care Act (ACA) of 2010 helped increase access to preventive and follow-up care for many people.

• Despite high U.S. health care spending per person, inefficiencies and waste limit improvements in cost and access.

• Health care reform is ongoing, with nurses playing a vital role as patient advocates to maintain quality care.

Safety Alert:

Pregnant women should have about 13 prenatal visits during a normal full-term pregnancy, according to the American College of Obstetricians and Gynecologists (ACOG).

Global Health Nursing

Importance of Global Awareness:

• Nurses need to be aware of global health to improve care worldwide.

• The Global Nursing Caucus (GNC) was created in 2011 to share global health information and raise awareness among nurses.

Interprofessional Collaboration:

• Working together with other professionals helps improve care for people around the world.

• Nurses must learn how different cultures and health beliefs affect care, both locally and globally.

Trauma-Informed Care (TIC):

• TIC focuses on sharing responsibility instead of one person being in charge.

• It includes both physical and emotional care.

• Nurses follow the "ABCDE" approach for emergency care:

  • Airway

  • Breathing

  • Circulation

  • Disability

  • Exposure

• Recovery also needs "DEF":

  • Distress

  • Emotional support

  • Family

• Cultural beliefs, the child’s age, and past experiences all affect recovery.

Preventing Disease Spread:

• Nurses must understand how diseases spread globally and how travel plays a role.

• Nurses help prevent pandemics and reduce health disparities (differences in health care access and quality between groups).

Nurses as Leaders:

• Nurses are not only caregivers but also leaders, advocates, mentors, and educators.

• They can help improve global health by sharing knowledge and skills to reduce illness and death worldwide.

Future Roles for Nurses

Historical Background:

• Lillian Wald started home health care for poor children.

• Margaret Sanger helped poor pregnant women, leading to the creation of Planned Parenthood.

Community as the New Health Setting:

• Most health care now takes place in the community rather than the hospital.

• Nurses help provide safe, caring, and cost-effective care to mothers, infants, and families.

• Nurses advocate for patients and work with governments and businesses to support preventive care.

Nurse as Educator and Advocate:

• Nurses teach and support the community through:

  • Schools

  • Churches

  • Health fairs

  • Websites

  • Media

• Nurses can work as private practitioners, such as lactation consultants.

Expanding Role in the Home:

• Care now includes the whole family, not just the patient.

• Nurses in the home must:

  • Use creativity and problem-solving

  • Coordinate care

  • Handle case management and referrals

Types of Care at Home:

• Includes both preventive and therapeutic care:

  • Fetal monitoring

  • Apnea monitoring

  • Diabetes management

  • Heparin therapy

  • IV nutrition

• Nurses may support care by phone or computer.

Home Health Care Team:

• Includes:

  • Doctors

  • RNs and LPNs

  • Therapists (occupational, physical, respiratory, speech)

  • Teachers, social workers, aides

Looking Ahead:

• Nurses will work in many setings around the world.

• Future nurses will be:

  • Caregivers

  • Teachers

  • Collaborators

  • Advocates

  • Managers

  • Researchers

• Nurses must be competent and accountable to the patient, family, and community.

• The Institute of Medicine (IOM) encourages nurses to expand their practice to make health care more accessible globally.

Influence of Prenatal Care on the Adult Health of the Newborn

Key Idea:

What happens during pregnancy can affect a child’s health into adulthood.

Important Points:

• Many adult diseases can begin before birth (during pregnancy).

• Early prenatal care and technology (like fetal surgery and NICU care) help babies survive and be healthier.

What Affects Adult Health from the Womb:

• This is called “gestational programming”, meaning the baby’s body and genes are shaped by:

  • Mother’s nutrition

  • Hormones

  • Stress

  • Toxins and drugs

  • Overall environment in the womb

Examples of Prenatal Factors and Later Health:

• Poor nutrition or low birth weight → higher risk of heart disease, stroke, or high blood pressure later in life.

• Folic acid during pregnancy → prevents neural tube defects like spina bifida.

• Iodine during pregnancy → prevents cretinism (a growth and mental development issue).

• Steroid drugs given during pregnancy:

  • Help prevent premature birth.

  • But may cause future heart, kidney, learning, or behavior problems in the child.

• Eating too much licorice → may lead to verbal or behavior issues in the child later.

• Antibiotics and C-sections → may change gut bacteria and raise the risk of obesity in adulthood.

Prevention Through Prenatal Care:

• Good diet and exercise during pregnancy improve insulin sensitivity and reduce obesity risk.

• Avoiding smoking, stress, and harmful substances helps babies grow into healthier adults.

• The goal is not just a healthy baby at birth, but also a healthier adult in the future.