MODULE UNO
Chapter Two - Nursing Process
Definition of the Nursing Process
Organized sequence of problem-solving steps used to identify and manage the health problems of clients.
Framework for nursing practice in all healthcare settings.
Basis of accountability as per the Nurse Practice Act and foundation for national licensing examinations; questions categorized as Assessment, Diagnosis, etc.
Serves as a framework for nursing documentation in medical records.
Legally, it determines standards of care met.
Characteristics of the Nursing Process
Legal Scope of Nursing
Familiarity with state-specific Nurse Practice Act is required.
Based on Knowledge
Emphasizes the use of critical thinking, reasoning, problem-solving, and evidence-based practice for interventions.
Planned
Organized steps where one step leads to another.
Client-Centered
Unique care plan for each client, involving the client in the process.
Goal-Directed
Collaboration between client and nursing team aimed at achieving desired outcomes.
Prioritized
Resolution of problems based on the greatest risk to client health.
Dynamic
Health status is fluid; reevaluation is continuous, adjusting plans as needed.
Steps of the Nursing Process
Assessment: Collection of subjective and objective data.
Diagnosis: Identification of health-related problems through analysis of data.
Planning: Prioritize nursing diagnoses and develop a plan of care.
Implementation: Execution of the nursing care plan.
Evaluation: Assessment of the effectiveness of the care plan.
Assessment
Data Collection Types:
Subjective Data: Client-reported symptoms (e.g., pain).
Objective Data: Observable and measurable signs (e.g., blood pressure).
Primary and Secondary Sources:
Primary: Actual client.
Secondary: Family, medical records, reports, healthcare providers.
Types of Assessments
Database Assessment: Initial data at admission.
Focus Assessment: Detailed information on specific issues.
Functional Assessment: Comprehensive evaluation of activities of daily living, cognitive and social functioning; conducted within 14 days of admission.
Diagnosis
Process: Identify and analyze data to propose nursing diagnoses; indicative of health issues that can be prevented or improved through nursing measures.
Nursing diagnosis categories:
Problem-focused, risk, syndrome, health promotion.
NANDA International (NANDA I): Authoritative body for nursing diagnoses.
Diagnostic Statements - PES Format
P: Problem (health-related issue).
E: Etiology (related factors).
S: Signs and Symptoms (evidence).
Example:
Disturbed Sleep Pattern (P)
Related to excessive caffeine intake (E)
As evidenced by difficulty falling asleep, feeling tired, irritability (S).
Collaborative Problems
Nurse monitors certain problems needing collaboration with healthcare providers (e.g., hemorrhage).
Planning
Include:
Setting priorities for nursing diagnoses.
Identifying measurable and realistic outcomes; essential in developing care plans.
Setting Priorities
Use Maslow's Hierarchy of Needs to prioritize physiological needs over others.
Setting Goals
Goals should be specific, measurable, and client-centered with short-term and long-term criteria.
Short Term Goal Example: Client ambulate independently with a walker 100 feet in 4 days.
Long Term Goal Example: Client to feed independently with assistive devices within 3-6 months.
Selecting Nursing Interventions
Choose strategies to address etiology of identified problems; must comply with safety and legal standards.
Documenting the Plan of Care
Documentations must reflect planned interventions in the medical record as per Joint Commission standards.
Implementation
Execute care plan involving medical and nursing orders; participation from clients and healthcare team.
Evaluation
Determine if client goals were met; adjust plans based on assessment outcomes.
Discuss findings with the client, revise care goals as necessary.
Nursing Care Plans & Concept Mapping
Basic nursing care plan examples available in texts; concept maps as tools for understanding disease processes.
Chapter Three - Laws and Ethics
Overview: Legal and ethical considerations in nursing; understanding of the legal system is crucial for nurses.
Types of Laws
Constitutional Law: Basis for federal system and rights of citizens.
Statutory Laws: Enacted by legislatures (e.g., Nurse Practice Act).
Administrative Laws: Enforced by agencies (e.g., State Board of Nursing).
Common Law: Established through court decisions.
Criminal Law: Addresses crimes, defines felonies and misdemeanors.
Civil Laws: Protect rights in personal disputes.
Key Legal Aspects
Intentional Torts: Include assault, battery, false imprisonment, invasion of privacy, defamation.
Unintentional Torts: Include negligence and malpractice; four elements necessary to prove malpractice: duty, breach of duty, causation, injury.
Example: Administration of medication despite known allergies.
Liability Insurance
Importance of obtaining personal liability insurance, as institutional coverage may not protect individuals.
Good Samaritan Laws
Privilege to provide aid in emergencies outside of healthcare settings.
Ethical Considerations
Wellspring of ethical dilemmas where values and laws may conflict (e.g., assisted suicide).
Ethical Theories
Teleologic Theory: Outcome-focused decisions.
Deontologic Theory: Morality of actions emphasized over outcomes.
Patients’ Rights
Right to information for decision-making.
Right to choose trusted providers.
Right to immediate access to emergency care.
Right to know options and participate in health decisions.
Right to respectful treatment and non-discrimination.
Right to private medical consultations and access to personal records.
Right to timely review of complaints.
Ethical Principles
Beneficence and Nonmaleficence: Promoting good, avoiding harm.
Autonomy: Clients’ right to make informed choices.
Veracity: Honesty in client interactions.
Fidelity: Professional commitments.
Justice: Equal treatment regardless of differences.
Ethical Decision-Making Guidelines
Client welfare as priority.
Protect clients’ rights.
Collaborate with clients and care teams.
Abide by ethics, policies, and laws.
Conscience-guided actions.
Ethics Committees
Established to advise on ethical dilemmas and protect client interests.
Common Ethical Issues
Truth-telling regarding diagnoses.
Confidentiality and HIPAA considerations.
Withholding and withdrawing treatment decisions.
Advance Directives
Legal documents outlining medical care preferences in advance.
Chapter Four - Health and Illness
Shift towards preventative care in healthcare practice, focusing on early diagnosis and disease prevention.
Definitions of Health
World Health Organization defines health as complete well-being beyond disease absence.
Wellness Concept
Holistic integration of physical, emotional, social, and spiritual health.
Holism and Holistic Care
Treat the whole person considering all aspects of health.
Maslow's Hierarchy of Needs
Categorization of human needs essential to prioritize care, beginning with physiological requirements.
Common Illness Classifications
Acute Illness: Sudden onset, e.g., influenza.
Chronic Illness: Long-lasting conditions, e.g., COPD.
Terminal Illness: Conditions with no cure, inevitably fatal.
Primary vs. Secondary Illness: Primary develops independently; secondary results from primary illness.
Remissions and Exacerbations
Remission: Disappearance of disease symptoms; duration varies.
Exacerbation: Return or worsening of disease symptoms.
Illness Types
Hereditary: Genetic disorders, e.g., cystic fibrosis.
Congenital: Present at birth, e.g., fetal alcohol syndrome.
Idiopathic: Unknown origins; focus on symptom relief.
Health Care System Overview
Primary, Secondary, Tertiary, and Extended care definitions.
Access to Care
Challenges like lack of insurance affecting access to healthcare.
Government-Funded Programs: ACA, Medicare, Medicaid, and CHIP programs addressing insurance access.
Financing Health Care
Prospective Payment System: Fixed-rate hospital reimbursements, incentivizing discharge after stabilization.
Managed Care: Prevention-focused care and cost management strategies.
HMO vs. PPO Differences: Types of health plans and costs.
Healthy People 2020
A national initiative to improve health goals through data-driven approaches.
Chapter Six - Culture and Ethnicity
Importance of culturally sensitive nursing practices in diverse patient populations.
Cultural Competence in Nursing
Emphasizes individualized care considering cultural beliefs and practices.
Cultural Differences in Nursing
Avoid assumptions based on stereotypes and generalizations
Importance of transcultural nursing, which respects the various cultural contexts.
Transcultural Nursing
Understanding and integrating cultural beliefs into effective nursing care strategies.
Chapter Seven - The Nurse-Client Relationship
Trust established through effective communication between the nurse and client.
Nursing Roles
Four Basic Roles:
Caregiver: Emotional and physical support.
Educator: Sharing health information and empowering client decisions.
Collaborator: Working as part of the healthcare team.
Delegator: Assigning tasks appropriately and legally.
Therapeutic Relationships
Phases: Introductory (acquaintance), Working (care planning), Termination (goal review).
Chapter Nine - Recording and Reporting
Emphasizes the importance of accurate, thorough documentation as a legal record of care.
Components of Medical Records
Uses include quality assurance, legal evidence, and facilitating communication among healthcare providers.
Charting Methods
Various formats (SOAP, PIE, Narrative) that aid in organizing client data.
Importance of Accuracy
Critical for legal protections and effective client care; emphasize the saying, "If it wasn't documented, it wasn't done."
Protecting Client Information
Emphasizes HIPAA regulations and client privacy measures.
Conclusion
Comprehensive understanding of the nursing process, legal and ethical implications, and the importance of holistic, culturally sensitive care in nursing practice is essential for effective patient care and professional development.