NUR200 Intro into Nursing Concepts: Unit 2

Implementation: Health Promotion

A. Health promotion -Focus on coping and optimizing health B. Palliative care -Primary goal is to help patients and families achieve the best possible quality of life C. Hospice care -Care of terminally ill patients -Manage pain, provide comfort, ensure quality of life -Adheres to patient wishes •Health promotion in serious chronic illness or death focuses on facilitating successful coping and optimizing physical, emotional, and spiritual health. Many people continue to look for and find meaning even in difficult life circumstances. •Patients and families can benefit greatly from the specialized approach of palliative care. This holistic method to prevention and reduction of symptoms promotes quality of life and whole-person well-being through care of the mind, body, and spirit. •Palliative care focuses on the prevention, relief, reduction, or soothing of symptoms of disease or disorders throughout the entire course of an illness. It can also include, but is not solely, care of the dying. The primary goal of palliative care is to help patients and families achieve the best possible quality of life. •Although it is especially important in advanced or chronic illness, palliative care is appropriate for patients of any age, with any diagnosis, at any time, and in any setting. •The World Health Organization (2015) summarizes palliative care philosophy as follows: i. Affirms life and regards dying as a normal process. ii. Neither hastens or postpones death. iii. Integrated psychological and spiritual aspects of patient care. iv. Offers a support system to help patients live as actively as possible until death. v. Enhances the quality of life. vi. Uses a team approach to meet the needs of patients and families. •When the goals of care change and cure for illnesses becomes less likely, the focus shifts to more palliative care strategies and ideally transition to hospice care, a more specialized form of palliative care for the dying. •Hospice care is a philosophy and model for the care of terminally ill patients and their families at the end of life. It gives priority to managing a patient's pain and other symptoms; comfort; quality of life; and attention to physical, psychological, social, and spiritual needs and resources. •The cornerstone of hospice care is trusting relationship between the hospice team and the patient and family. Knowing expectations, desired location of care, and family dynamics help the hospice team provide individualized care at the end of life. •Unlike traditional care, hospice patients are active participants in all aspects of care, and caregivers prioritize care according to patient wishes. •Hospice programs are built on the following core beliefs and services: i. Patient and family are the unit of care. ii. Coordinated home care with access to inpatient and nursing home beds when needed. iii. Symptom management. iv. Physician-directed services. v. Provision of an interdisciplinary care team. vi. Medical and nursing services available at all times. vii. Bereavement follow-up after patient's death. viii. Use of trained volunteers for visitation and respite support. •To be eligible for home hospice services, a patient must have a family caregiver to provide care when the patient is no longer able to function alone. •Nurses providing hospice care use therapeutic communication, offer psychosocial care and expert symptom management, promote patient dignity and self-esteem, maintain a comfortable and peaceful environment, provide spiritual comfort and hope, protect against abandonment or isolation, offer family support, assist with ethical decision making, and facilitate mourning. A. Use therapeutic communication -Helps earn trust -Use open-ended questions B. Provide psychological care C. Manage symptoms D. Promote dignity and self-esteem E. Maintain a comfortable and peaceful environment •The heart of nursing care is the establishment of a caring and trusting relationship with our patient. This patient-focused approach allows us to respond to patients, rather than react, and encourages the sharing of important information. •Feelings of sadness, numbing, or anger make talking about these situations especially difficult. •If you are reassuring and respectful of a patient's privacy, a therapeutic relationship likely develops. Sometimes patients need to begin resolving their grief privately before they discuss their loss with others, especially strangers. •Do not avoid talking about a topic. When you sense that a patient wants to talk about something, make time to do so as soon as possible. •Above all, remember that a patient's emotions are not something you can "fix." Instead view emotional expressions as an essential part of the patient's adjustment to significant life changes and development of effective coping skills. •Patients at the end of life experience a range of psychological symptoms, including anxiety, depression, powerlessness, uncertainty, and isolation. We can alleviate some worry and fear by providing information to our patients about their condition, the course of their disease, and the benefits and burdens of treatment options. •Managing the multiple symptoms commonly experienced by chronically ill or dying patients remains a primary goal of palliative care nursing. Maintain an ongoing assessment of the patient's pain and response to interventions. Reassure the family repeatedly of the need for pain control even if the patient does not appear in pain. •Remain alert to the potential side effects of opioid administration: constipation, nausea, sedation, respiratory depression, or myoclonus. Education is necessary to helping families understand the need for appropriate use of opioid medications. •A sense of dignity includes a person's positive self-regard, the ability to find meaning in life, to feel valued by others, and by how one is treated by caregivers. Nurses promote patients' self-esteem and dignity by respecting patients as a whole person (i.e., as people with feelings, accomplishments, and passions independent of the illness experience) not just as a diagnosis. •A comfortable, clean, pleasant environment helps patients relax, promotes good sleep patterns, and minimizes symptom severity. Keep a patient comfortable through frequent repositioning, making sure that bed linens are dry, and controlling extraneous environmental noise and offensive odors. Patient-preferred forms of complementary therapies offer noninvasive methods to increase comfort and well-being at the end of life.

State Statutory Issues in Nursing Practice

A. Licensure -BSN - NCLEX - RN B. Good Samaritan Laws C. Public Health Laws •The State Board of Nursing licenses all registered nurses in the state where they practice. The requirements for licensure vary among states, but most states have minimum educational requirements. You will be preparing to take the NCLEX-RN®. The State Board of Nursing suspends or revokes a license if a nurse's conduct violates provisions in the licensing statute on the basis of administrative law rules that implement and enforce the statute. •Nurses act as Good Samaritans when providing care at the scene of an accident. All states have Good Samaritan Acts. Provisions may vary among states; however, these laws limit liability and offer legal immunity for nurses who help at the scene of an accident. At least two states, Minnesota and Vermont, require nurses to stop and help in an emergency. If you perform a procedure exceeding your scope of practice and for which you have no training, you are liable for injury that may result from that act. If you leave the patient without properly transferring or handing him or her off to a capable person, you may be liable for patient abandonment and responsible for any injury suffered after you leave him or her. •It is important for you to understand public health laws. Under the health code, state legislatures enact statutes that describe the reporting laws for communicable diseases, specify necessary school immunizations, and mandate other measures that promote health and reduce health risks in communities. The Centers for Disease Control and Prevention (CDC) and the Occupational Safety Health Administration (OSHA) provide guidelines on a national level for safe and healthy communities and work environments. •Public health laws protect populations, advocate for the rights of people, regulate health care and health care financing, and ensure professional accountability for care provided. •Any health care professional who does not report suspected child abuse or neglect may be liable for civil or criminal legal action. D. The Uniform Determination of Death Act -Cardiopulmonary definition -Whole-brain standard E. Autopsy F. Death with Dignity or Physician-Assisted Suicide -Eight states and District of Columbia •The Uniform Determination of Death Act of 1980 states that health care providers can use the cardiopulmonary definition or the whole brain definition to determine death. The cardiopulmonary standard requires irreversible cessation of circulatory and respiratory functions. The whole-brain standard requires irreversible cessation of all function of the entire brain, including the brainstem. These two definitions facilitate the recovery of organs for transplantation. •An autopsy or postmortem examination may be requested by the patient or patient's family. When the patient's death is not subject to a medical examiner review, consent must be obtained. The priority for giving consent is (1) the patient, in writing before death; (2) durable power of attorney; (3) surviving spouse; and (4) surviving child, parent, or sibling in the order named. •The Oregon Death With Dignity Act (1994) was the first statute that permitted physician-assisted suicide. The statute stipulates that competent-yet-terminal patients could make an oral or written request for medication to end their life in a human and dignified manner. Terminal disease is defined as an incurable and irreversible disease that has been medically confirmed and that will, within reasonable medical judgment, produce death within 6 months. •The ANA has held that nurses' participation in assisted suicide violates the code of ethics for nurses. The American Association of Colleges of Nursing (AACN) supports the International Council of Nurses' mandate to ensure an individual's peaceful end of life.

Legal Limits of Nursing

A. Sources of law: -Statutory law (Nurse Practice Act) i. Criminal law (felonies or misdemeanors) ii. Civil law -Regulatory law (administrative law) -Common law (judicial decisions) •As a professional nurse you need to understand the legal limits of nursing and the professional standards of care that affect nursing practice. •Statutory laws include the Nurse Practice Act found in all states. The Nurse Practice Act describes and defines the legal boundaries of nursing practice in each state. The Nurse Practice Act of each state defines the scope of nursing practice and expanded nursing roles, sets education requirements for nurses, and distinguishes between nursing and medical practice. •Criminal laws are meant to prevent harm to society and to provide punishment for crimes. These are categorized as felonies or misdemeanors. •A felony is a serious offense that results in significant harm to another person or society in general. Felony crimes carry penalties of monetary restitution, imprisonment for greater than 1 year, or death. Examples of Nurse Practice Act violations that may carry criminal penalties include misuse of a controlled substance or practicing without a license. •A misdemeanor is a crime that, although injurious, does not inflict serious harm. For example, parking in a no-parking zone is a misdemeanor violation of traffic laws. A misdemeanor usually has a penalty of a monetary fine, forfeiture, or brief imprisonment. •Civil laws protect the rights of individuals and provide for fair and equitable treatment when civil wrongs or violations occur. The consequences of civil law violations are damages in the form of fines or specific performance of good works such as public service. Nursing negligence or malpractice is an example of a civil law violation. •Regulatory law, also known as administrative law, defines your duty to report incompetent or unethical nursing conduct to the Board of Nursing. Common law results from judicial decisions concerning individual cases. Most of these revolve around negligence and malpractice. B. Standards of care -Legal guidelines for defining nursing practice and identifying the minimum acceptable nursing care -American Nurses Association (ANA) -Set by state and federal laws that govern where nurses work -Joint Commission requires policies and procedures (P&Ps). •Standards reflect the knowledge and skill ordinarily possessed and used by nurses actively practicing in the profession. •The American Nurses Association (ANA) (2010) develops standards for nursing practice, policy statements, and similar resolutions. These standards outline the scope, function, and role of the nurse in practice. •In a malpractice lawsuit, a nurse's actual conduct is compared to nursing standards of care to determine whether the nurse acted as any reasonably prudent nurse would act under the same or similar circumstances. •Nurse Practice Acts define the scope of nursing practice, distinguishing between nursing and medical practice and establishing education and licensure requirements for nurses. •The Joint Commission (TJC) (2014) requires accredited hospitals to have written nursing policies and procedures. These internal standards of care are specific to the agency and need to be accessible on all nursing units. •In a lawsuit for malpractice or negligence, a nursing expert may testify to the jury about the standards of nursing care as applied to the facts of the case. Nurse experts base their opinions on existing standards of practice established by Nurse Practice Acts, federal and state hospital licensing laws, TJC standards, professional organizations, institutional policies and procedures, job descriptions, and current nursing evidence-based literature.

The Dying Person's Bill of Rights

. I have the right to be treated as a living human until I die. • I have the right to maintain a sense of hopefulness, however changing its focus may be. • I have the right to be cared for by those who can maintain a sense of hopefulness, however changing this might be. • I have the right to express my feelings and emotions about my approaching death in my own way. • I have the right to participate in decisions concerning my care. • I have the right to expect continuing medical and nursing attention even though "cure" goals must be changed to "comfort" goals. • I have the right not to die alone. • I have the right to be free from pain. • I have the right to have my questions answered honestly. • I have the right to retain my individuality and not be judged for my decisions that may be contrary to beliefs of others. • I have the right to expect that the sanctity of the human body will be respected after death. • I have the right to be cared for by caring, sensitive, knowledgeable people who will attempt to understand my needs and be able to gain some satisfaction in helping me face my death.

Physical Changes Hours or Days Before Death

. Increased periods of sleeping/unresponsiveness • Circulatory changes with coolness and color changes in extremities, nose, fingers (cyanosis, pallor, mottling) (see Fig. 36.4) • Bowel or bladder incontinence • Decreased urine output; dark-colored urine • Restlessness, confusion, or disorientation • Decreased intake of food or fluids; inability to swallow • Congestion/increased pulmonary secretions; noisy respirations (death rattle) • Altered breathing (apnea, labored or irregular breathing, Cheyne-Stokes pattern) • Decreased muscle tone, relaxed jaw muscles, sagging mouth • Weakness and fatigue

Focus on Older Adults Grief Considerations in Older Adults

. There is little evidence that grief experiences differ because of age alone. Responses to loss are more likely related to the nature of the specific loss experience and individual differences. • Increased age increases the likelihood that older adults have faced multiple losses. Older adults residing in communal living situations experience many losses as friends die. • Many older adults exhibit resilience. Others around them can learn from their courage and ability to respond to life challenges. • Older adults are at risk for complicated grieving as a result of multiple losses, potential for cognitive impairment, or decreased physical resources. The risks include depression (Bruinsma et al., 2015), loneliness, and accompanying functional decline. • Physical decline caused by chronic illness sometimes leads to grief over lost health, function, and roles. • Older adults benefit from the same therapeutic techniques as people in other age-groups. Evidence indicates that positive reappraisal (cognitive restructuring) helps older adults adapt to significant losses (e.g., seeing a cardiac diagnosis as the opportunity to become healthy by eating nutritiously and exercising regularly). Relieving depression and maintaining physical function are therapeutic goals for grieving older adults.

Documentation of End-of-Life Care

. Time and date of death and all actions taken to respond to the impending death • Verification of death according to health care agency policy • Name of health care provider certifying the death • People notified of the death (e.g., health care providers, family members, organ request team, morgue, funeral home, spiritual care providers) and person who declared the time of death • Name of person making request for organ or tissue donation • Special preparations of the body (e.g., desired or required spiritual, religious and cultural rituals) • Medical tubes, devices, or lines left in or on the body • Personal articles left on and secured to the body • Personal items given to the family with description, date, time, to whom given • Location of body identification tags • Time of body transfer and destination • Any other relevant information or family requests that help clarify special circumstances

Malpractice Insurance

A. A contract between the nurse and the insurance company B. Provides a defense when a nurse is in a lawsuit involving negligence or malpractice C. Nurses covered by institution's insurance while working D. The insurance company pays for costs, attorney's fees and settlement, and other related fees generated in the representation of the nurse. E. Nurses employed by health care agencies generally are covered by insurance provided by the agency; however, it is important to remember that the lawyer is representing your employer and not you. The insurance provided by the employing agency only covers nurses while they are working within the scope of their employment. F. Nurses are also investigated by the State Board of Nursing or Nursing Commission to determine whether the alleged breach in care is a violation of civil regulations associated with their nursing license. Without individual insurance coverage, the nurse will be required to personally pay all costs and attorney fees incurred by him or her in the defense against these claims.

Illness

A. A state in which a person's physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished or impaired B. Acute Illness -Short duration and severe C. Chronic Illness -Persists longer than 6 months

Definition of Health

A. A state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity B. A state of being that people define in relation to their own values, personality, and lifestyle

Building a Nursing Team

A. A strong nursing team works together to achieve the best outcomes for patients. B. Effective team development requires team building and training, trust, communication, and a workplace that facilitates collaboration. C. As a nurse it is also important to work in an empowering environment as a member of a solid and strong nursing team. D. Patient care units where teamwork is stronger had fewer reports and incidents of missed nursing care, leading to improved quality and safety of nursing care for patients.

Federal Statutory Issues in Nursing Practice (cont.)

A. Advance directives -Living wills -Health care proxies or durable power of attorney for health care •The Patient Self-Determination Act (PSDA) enacted in 1991 requires health care institutions to provide written information to patients concerning their rights under state law to make decisions, including the right to refuse treatment and formulate advance directives. •For living wills or durable powers of attorney for health care to be enforced, the patient must be declared legally incompetent or lack the capacity to make decisions regarding his or her own health care treatment. •Be familiar with the policies of your institution that comply with the PSDA. Likewise check the state laws to see if a state honors an advance directive that originates in another state. •Living wills represent written documents that direct treatment in accordance with a patient's wishes in the event of a terminal illness or condition. •A health care proxy or durable power of attorney for health care (DPAHC) is a legal document that designates a person or people of one's choosing to make health care decisions when the patient is no longer able to make decisions on his or her own behalf. This agent makes health care treatment decisions on the basis of the patient's wishes. •In addition to federal statutes, the ethical doctrine of autonomy ensures the patient the right to refuse medical treatment. •In addition to patient refusals of treatment, the nurse frequently encounters a "do not resuscitate" (DNR) or "no code" DNR order. Documentation that the health care provider has consulted with the patient and/or family is required before attaching a DNR order to the patient's medical record. •Cardiopulmonary resuscitation (CPR) is an emergency treatment provided without patient consent. Health care providers perform CPR on an appropriate patient unless there is a DNR order in the patient's chart. B. Uniform Anatomical Gift Act C. Health Insurance Portability and Accountability Act (HIPAA) D. Health Information Technology Act (HITECH) E. Restraints •Uniform Anatomical Gift Act i. An individual who is at least 18 years of age has the right to make an organ donation. Donors need to make the gift in writing with their signature. In many states, adults sign the back of their driver's license, indicating consent to organ donation. ii. In most states there is a law requiring that at the time of death a qualified health care provider ask a patient's family members to consider organ or tissue donation. Individuals are approached in the following order: (1) spouse, (2) adult son or daughter, (3) parent, (4) adult brother or sister, (5) grandparent, and (6) guardian. iii. The National Organ Transplant Act (1984) prohibits the purchase or sale of organs, provides civil and criminal immunity to the hospital and health care provider who perform in accordance with the act, and protects the donor's estate from liability. •HIPAA i. This law provides rights to patients and protects employees. It protects individual employees from losing their health insurance when changing jobs by providing portability. ii. It also creates patient right to consent to the use and disclosure of their protected health information, to inspect and copy one's medical record, and to amend mistaken or incomplete information. iii. It limits who is able to access a patient's record. iv. Provides confidentiality of a patient's medical information. •Health Information Technology Act (HITECH) i. HITECH expands the principles extended under the HIPAA, especially when a security breach of personal health information (PHI) occurs. ii. Under the HITECH Act nurses must ensure that patient PHI is not inadvertently conveyed on social media and in particular that protected data are not disclosed other than as permitted by the patient. •Restraints i. The Centers for Medicare and Medicaid Services (CMS), American Nurses Association (ANA), and The Joint Commission (TJC) have set standards for reducing the use of all types of restraints in health care settings. ii. Restraints can be used (1) only to ensure the physical safety of the patient or other patients, (2) when less restrictive interventions are not successful, and (3) only on the written order of a health care provider. The regulations also describe documentation of restraint use and follow-up assessments.

Ethic of Care

A. An ethic of care places caring at the center of decision making. B. In any patient encounter a nurse needs to know what behavior is ethically appropriate. C. The term "ethic" refers to the ideals of right and wrong behavior. D. Ethics and morals are interconnected E. An ethic of care is unique so professional nurses do not make professional decisions based solely on intellectual or analytical principles. F. An ethic of care is concerned with relationships between people and with a nurse's character and attitude toward others.

Clinical Decisions

A. Apply the nursing process B. Know your patient C. Use clinical decision making practices D. Accurate clinical decision-making keeps you focused on the proper course of action -Your ability to make clinical decisions depends on application of the nursing process. -Knowing the patient involves more than gathering formal assessment data. It requires learning a patient's typical patterns of responses and his or her current situation and knowing the patient as an individual. -If you do not make accurate clinical decisions about a patient, undesirable outcomes will probably occur. The patient's condition worsens or remains the same when you lose the potential for improvement. -Never hesitate to ask for assistance when a patient's condition changes.

Use of Resources

A. Appropriate use of resources is an important aspect of clinical care coordination. B. Administration of patient care occurs more smoothly when staff members work together. C. Appropriate use of resources is an important aspect of clinical care coordination. Resources in this case include members of the health care team. D. Never hesitate to have staff help you, especially when there is an opportunity to make a procedure or activity more comfortable and safer for patients. E. Consulting with an experienced RN confirms findings and ensures that you take the proper course of action for the patient. F. A leader knows his or her limitations and seeks professional colleagues for guidance and support.

Caring in Nursing Practice

A. As you deal with health and illness in your practice, you grow in your ability to care and develop caring behaviors. B. Caring is one of those human behaviors that we can give and receive. C. Recognize the importance of self-care. D. Use caring behaviors to reach out to your colleagues and care for them as well.

Basic Terms in Health Ethics

A. Autonomy -Commitment to include patients in decisions B. Beneficence -Taking positive actions to help others C. Nonmaleficence -Avoidance of harm or hurt D. Justice -Being fair -Just Culture E. Fidelity -Agreement to keep promises

Critical Thinking

A. Be familiar with commonly experienced responses to loss. B. Integrate theory, prior experience, subjective experiences, and self-knowledge. C. Use Professional Standards: -Nursing Code of Ethics -Dying Person's Bill of Rights D. ANA Scope and Standards of Hospice and Palliative Nursing E. Grieving people use their own unique history, context, and resources to make meaning out of their loss experiences. Listen as patients share the experience in their own way. F. When developing a plan of care, make sure to access current practice guidelines for assistance.

Impact of Illness on the Patient and Family

A. Behavioral and emotional changes B. Impact on body image C. Impact on self-concept D. Impact on family roles E. Impact on family dynamics

Providing Presence

A. Being with B. Body language C. Listening D. Eye contact E. Tone of voice F. Positive and encouraging attitude

Summary of Theoretical Views

A. Caring is highly relational. B. Caring theories are valuable when assessing patient perceptions of being cared for in a multicultural environment. C. Enabling is an aspect of caring. D. Knowing the context of a patient's illness helps you choose and individualize interventions that will actually help the patient.

Relieving Symptoms and Suffering

A. Caring nursing actions - -patient comfort, dignity, respect, and peace B. Providing comfort and support measures to the family or significant others C. Create an environment that soothes and heals the mind, body, and spirit D. Comforting through a listening, nonjudgmental, caring presence

Theoretical Views on Caring

A. Caring: a universal phenomenon that influences the way we think, feel, and behave. B. Since Florence Nightingale, nurses have studied caring. C. Caring is at the heart of a nurse's ability to work with all patients in a respectful and therapeutic way. D. Caring is primary -Caring determines what matters to a person. -Caring helps you provide patient-centered care. E. Leininger's Transcultural Caring -Caring is an essential human need. -Caring helps an individual or group improve a human condition. -Caring helps to protect, develop, nurture, and sustain people. F. Watson's Transpersonal Caring -Promotes healing and wholeness -Rejects the disease orientation to health care -Places care before cure -Emphasizes the nurse-patient relationship G. Swanson's Theory of Caring -Defines caring as a nurturing way of relating to an individual -States that caring is a central nursing phenomenon but is not necessarily unique to nursing practice

The Challenge of Caring

A. Challenges -Task-oriented biomedical model -Institutional demands -Time constraints -Reliance on technology, cost-effective strategies, and standardized work processes B. Today's health care system presents many challenges for the nurse to provide a caring patient-centered plan of care. Nurses are often torn between the human caring model and the task-oriented biomedical model and institutional demands that consume their practice. C. Nurses have increasingly less time to spend with patients, making it much harder to know who the patients are. D. A reliance on technology and cost-effective health care strategies and efforts to standardize and refine work processes all undermine the nature of caring. E. If health care is to make a positive difference in patients' lives, health care must become more holistic and humanistic. F. Nurses play an important role in making caring an integral part of health care delivery. G. This begins by making it a part of the philosophy and environment in the workplace. H. Incorporating caring concepts into standards of nursing practice establishes the guidelines for professional conduct. I. Finally, during day-to-day practice with patients and families, nurses need to be committed to caring and willing to establish the relationships necessary for personal, competent, compassionate, and meaningful nursing care.

Nurse Executive

A. Chief Nursing Officer (CNO), VP of Patient Services B. Director of ______ C. Transformation Leadership D. TEEAMS

Clinical Care Coordination

A. Clinical Decisions B. Priority Setting C. Organizational Skills D. Use of Resources E. Time Management F. Evaluation -Clinical care coordination includes clinical decision making, priority setting, use of organizational skills and resources, time management, and evaluation. -The activities of clinical care coordination require use of critical reflection, critical reasoning, and clinical judgment. -They are important first steps in developing a caring relationship with a patient. Use a critical thinking approach, applying previous knowledge and experience to the decision-making process.

Professional Nursing Code of Ethics

A. Code of nursing ethics -A set of guiding principles that all members of a profession accept -Helps professional groups settle questions about practice or behavior -Includes advocacy, responsibility, accountability, and confidentiality B. Social networking -Presents ethical challenges for nurses

Responsibilities of a Nurse Manager

A. Collaborate with staff to establish annual goals for the unit and the systems needed to accomplish goals (e.g., assignment methods, quality improvement activities, patient education methods). B. Monitor professional nursing standards of practice on the unit. C. Develop an ongoing staff development plan, including one for new employees. D. Recruit new employees (interview and hire). E. Conduct routine staff evaluations. F. Role model positive customer service (customers include patients, families, and other health care team members). G. Submit staffing schedules for the unit. H. Advocate for the nursing staff to the administration of the organization. I. Conduct regular patient rounds and problem solve patient or family complaints. J. Establish, monitor, and implement a quality improvement (QI) plan for the unit. K. Review and recommend new equipment for the unit. L. Conduct regular staff meetings. M. Make rounds with health care providers. N. Establish and support staff and interprofessional committees.

Listening

A. Creates trust B. Opens lines of communication C. Creates a mutual relationship D. To listen effectively the nurse needs to silence himself or herself and listen with an open mind.

Priority Setting

A. Determine which patient's needs should be addressed first: -High priority: immediate threat to patient survival or safety -Intermediate priority: nonemergent, non-life threatening -Low priority: actual or potential problems may or may not be directly related to patient's illness or disease B. After forming a picture of the patient's total needs, you set priorities by deciding which patient needs or problems need attention first. Classify patient problems in three priority levels: -High priority—An immediate threat to a patient's survival or safety. -Intermediate priority—Nonemergency, non-life-threatening actual or potential needs that a patient and family members are experiencing. -Low priority—Actual or potential problems that are not directly related to a patient's illness or disease. C. Many patients have all three types of priorities, requiring you to make careful judgments in choosing a course of action. Obviously high-priority needs demand immediate attention. D. To identify which patients require assessment first, rely on information from the change-of-shift report, your own most recent assessment of the patient, and information from the medical record.

Knowing the Patient

A. Develops over time B. The core process of clinical decision making C. Factors of knowing include: -Time -Continuity of care -Teamwork of the nursing staff -Trust -Experience

Organizational Skills

A. Do the right things. B. Do things right. C. Inform and prepare patient. D. Clean and organize work area. E. Keep patient's needs at the center of attention. -Implementing a plan of care requires you to be effective and efficient. Effective use of time means doing the right things, whereas efficient use of time means doing things right. -A well-organized nurse approaches any planned procedure by having all of the necessary equipment available and making sure that the patient is prepared. If the patient is comfortable and well informed, the likelihood that the procedure will go smoothly increases.

Factors and Items Constituting the Caring Assessment Tool (CAT)

A. Each item begins with the stem: "Since I have been a patient here, the nurse(s)": Mutual Problem Solving • Help me understand how I am thinking. • Ask me how I think treatment is going. • Help me explore alternative ways of dealing. • Ask me what I know. • Help me figure out questions to ask. Attentive Reassurance • Are available. • Seem interested. • Support sense of hope. • Help me believe in self. • Anticipate my needs. Human Respect • Listen to me. • Accept me. • Treat me kindly. • Respect me. • Pay attention to me. Encouraging Manner • Support my beliefs. • Encourage me to ask questions. • Help me to see some good. • Encourage me to go on. • Help me deal with bad feelings. Appreciation of Unique Meanings • Are concerned with how I view things. • Know what is important to me. • Acknowledge my inner feelings. • Show respect for things having meaning. Healing Environment • Check up on me. • Pay attention to me when I am talking. • Make me feel comfortable. • Respect my privacy. • Treat my body carefully. Affiliation Needs • Are responsive to my family. • Talk openly with my family. • Allow my family to be involved. Basic Human Needs • Make sure I get food. • Help me with routine needs for sleep. • Help me feel less worried.

Caring for Yourself

A. Eat a nutritious diet B. Get adequate sleep C. Engage in exercise and relaxation activities D. Establish a good work-family balance E. Engage in regular nonwork activities. F. Develop coping skills G. Allowing personal time for grieving H. Focus on spiritual health I. Find a mentor

Institutional Resources

A. Ethics committees are usually multidisciplinary and serve several purposes: education, policy recommendation, and case consultation. B. Any person involved in an ethical dilemma, including nurses, physicians, health care providers, patients, and family members, can request access to an ethics committee.

Evaluate

A. Evaluate process. B. Evaluate patient response. C. Evaluate therapy efficacy. D. Evaluate patient and expected outcomes. -Evaluation is ongoing, just like other steps of the nursing process. Once you assess a patient's needs and begin therapies directed at a specific problem area, immediately evaluate whether therapies are effective and the patient's response. -When expected outcomes are not met, evaluation reveals the need to continue current therapies for a longer period, revise approaches to care, or introduce new therapies. -Keeping a focus on evaluation of the patient's progress lessens the chance of becoming distracted by the tasks of care.

Symptoms of Normal Grief

A. Feelings • Sorrow • Fear • Anger • Guilt or self-reproach • Anxiety • Loneliness • Fatigue • Helplessness/hopelessness • Yearning • Relief B. Cognitions (Thought Patterns) • Disbelief • Confusion or memory problems • Problems in making decisions • Inability to concentrate • Feeling the presence of the deceased C. Physical Sensations • Headaches • Nausea and appetite disturbances • Tightness in the chest and throat • Insomnia • Oversensitivity to noise • Sense of depersonalization ("Nothing seems real") • Feeling short of breath, choking sensation • Muscle weakness • Lack of energy • Dry mouth D. Behaviors • Crying and frequent sighing • Distancing from people • Absentmindedness • Dreams of the deceased • Keeping the deceased's room intact • Loss of interest in regular life events • Wearing objects that belonged to the deceased

Principles of Time Management

A. Goal setting: Review a patient's goals of care for the day and any goals you have for activities such as completing documentation, attending a patient care conference, giving a hand-off report, or preparing medications for administration. B. Time analysis: Reflect on how you use your time. While working on a clinical area, keep track of how you use your time in different activities. This helps you become more aware of how well organized you really are and areas you may need to improve upon. C. Priority setting: Set the priorities that you have established for patients within set time frames. For example, determine when is the best time to have teaching sessions, plan ambulation, and provide rest periods based on what you know about a patient's condition. For example, if a patient is nauseated or in pain, it is not a good time for a teaching session. D. Interruption control: Everyone needs time to socialize or discuss issues with colleagues. However, do not let this interrupt important patient care activities such as medication administration (see Chapter 31), ordered treatments, or teaching sessions. Use time during report, mealtime, or team meetings to your advantage. In addition, plan time to help fellow colleagues so that it complements your patient care schedule. E. Evaluation: At the end of each day take time to think and reflect about how effectively you used your time. If you are having difficulties, discuss them with an instructor or a more experienced staff member.

Planning

A. Goals and outcomes B. Setting priorities -Encourage patient to share their priorities for care -Give priority to a patient's most urgent physical or psychological needs -Maintain an ongoing assessment to revise the plan of care according to patient needs and preferences C. Teamwork and collaboration -Interprofessional care D. Setting priorities -Encourage patient to share their priorities for care -Give priority to a patient's most urgent physical or psychological needs -Maintain an ongoing assessment to revise the plan of care according to patient needs and preferences E. Teamwork and collaboration •Nurses provide holistic, physical, emotional, social, and spiritual care to patients experiencing grief, death, or loss. •The use of critical thinking ensures a well-designed care plan that supports a patient's self-esteem and autonomy by including him or her in the planning process. •Consider a patient's own resources such as physical energy and activity tolerance, family support, and coping style. •The goals of care for a patient experiencing loss are either short or long term, depending on the nature of the loss and the patient's condition. •Encourage patients and family members to share their priorities for care at the end of life. Patients at the end of life or with advanced chronic illness are more likely to want their comfort, social, or spiritual needs met than to pursue medical cures. •Give priority to a patient's most urgent physical or psychological needs while also considering his or her expectations and priorities. •When comfort needs have been met, you can address other issues important to the patient and family. •A patient's condition at the end of life often changes quickly; therefore maintain an ongoing assessment to revise the plan of care according to patient needs and preferences. •Use a concept map for multiple diagnoses. •A team of nurses, physicians, social workers, spiritual care providers, nutritionists, pharmacists, physical and occupational therapists, patients, and family members works together to provide palliative care, grief care, and care at the end of life. •As a patient's care needs change, team members take a more or less active role, depending on the patient's shifting priorities. Team members communicate with one another on a regular basis to ensure coordination and effectiveness of care.

Health Promotion, Wellness, and Illness Prevention

A. Health promotion -Helps individuals maintain or enhance their present health. B. Health education -Helps people develop a greater understanding of their health and how to better manage their health risks. C. Illness prevention -Protects people from actual or potential threats to health.

Consent

A. Informed consent -Agreement to allow care based on full disclosure of risks, benefits, alternatives, and consequences of refusal -The nurse's signature as a witness to the consent means that the patient voluntarily gave consent, the patient's signature is authentic, and the patient appears to be competent to give consent •A patient's signed consent form is necessary for admission to a health care agency, invasive procedures such as intravenous central line insertion, surgery, some treatment programs such as chemotherapy, and participation in research studies. •Nurses need to know the law in their states and be familiar with the policies and procedures of their employing agency regarding consent. •Informed consent creates a legal duty for the health care provider to disclose material facts in terms the patient is able to understand to make an informed choice. •Informed consent is part of the health care provider-patient relationship. It must be obtained and witnessed when the patient is not under the influence of medication such as opioids. It is not the nurse's responsibility get informed consent. •Key elements of responsibility for the health care provider include the following: •The patient receives an explanation of the procedure or treatment. •The patient receives the names and qualifications of people performing and assisting in the procedure. •The patient receives a description of the serious harm, including death, that may occur as a result of the procedure and anticipated pain and/or discomfort. •The patient receives an explanation of alternative therapies to the proposed procedure/treatment and the risks of doing nothing. •The patient knows that he or she has the right to refuse the procedure/treatment without discontinuing other supportive care. •The patient knows that he or she may refuse the procedure/treatment even after the procedure has begun. •If patients deny understanding or you suspect that they do not understand, notify the health care provider or nursing supervisor. Health care providers must inform a patient refusing surgery or other medical treatment about any harmful consequences of refusal. •Parents are usually the legal guardians of pediatric patients; therefore they typically are the people who sign consent forms for treatment. •Patients with mental illnesses must also give consent. They retain the right to refuse treatment until a court has determined legally that they are incompetent to decide for themselves.

Variables Influencing Health and Health Beliefs and Practices

A. Internal variables -Developmental stage -Intellectual background -Perception of functioning -Emotional factors -Spiritual factors B. External variables -Family role and practices -Social determinants of health

Illness Behavior

A. Involves how people monitor their bodies and define and interpret their symptoms B. Variables influencing illness and illness behavior -Internal variables: Perception of illness and nature of illness -External variables: Visibility of symptoms, social group, cultural background, economics, and accessibility to health care

Scientific Knowledge Base

A. Loss ◦Actual loss ◦Necessary loss (i.e., Maturational loss) ◦Situational loss ◦Perceived loss B. Each person responds to loss differently ◦Culture, spirituality, personal beliefs, previous experience and degree of social support influences the way a person responds to death C. Grief D. Mourning E. Bereavement F. Types of grief ◦Normal (uncomplicated) ◦Anticipatory ◦Disenfranchised (ambiguous) ◦Complicated (chronic, exaggerated, delayed, masked) G. Theories of grief and mourning ◦Stages of Dying ◦Attachment Theory ◦Grief Tasks Model ◦Rando's "R" Process Model ◦Dual Process Model

Types of Loss

A. Loss of possessions or objects (e.g., theft, deterioration, misplacement, or destruction) -Extent of grieving depends on value of object, sentiment attached to it, or its usefulness. B. Loss of known environment (e.g., leaving home, hospitalization, new job, moving out of a rehabilitation unit) -Loss occurs through maturational or situational events or by injury/illness. Loneliness or uncertainty in an unfamiliar setting threatens self-esteem, hopefulness, or belonging. C. Loss of a significant other (e.g., divorce, loss of friend, trusted caregiver, or pet) -Close friends, family members, and pets fulfill psychological, safety, love, belonging, and self-esteem needs. D. Loss of an aspect of self (e.g., body part, job, psychological or physiological function) -Illness, injury, or developmental changes result in loss of a valued aspect of self, altering personal identity and self-concept. E. Loss of life (e.g., death of family member, friend, co-worker, or one's own death) -Those left behind after a death grieve for the loss of life of a loved one. Dying people also feel sadness or fear pain, loss of control, and dependency on others.

Models of Health and Illness

A. Models help explain complex concepts or ideas, such as health and illness B. Health beliefs C. Health behaviors -Positive -Negative D. Maslow's Hierarchy of Needs -Used to understand the interrelationships of basic human needs E. Holistic Health Model -Attempts to create conditions that promote optimal health

Nursing Point of View

A. Nurses generally engage with patients over longer periods of time than other disciplines. B. Patients may feel more comfortable revealing information to nurses.

Decision Making

A. Nursing manager supports staff through: -Establishing nursing practice through problem-solving committees or professional shared governance councils -Interprofessional collaboration among nurses and health care providers -Interprofessional rounding -Staff communication -Staff education B. Nursing practice is established through problem-solving committees or professional shared governance councils. Chaired by senior clinical staff nurses, these groups establish and maintain care standards for nursing practice on their work unit. Shared governance is a dynamic process that promotes decision making, accountability, and empowerment in staff nurses and enables them to control their nursing practice. The committee establishes methods to ensure that all staff have input or participation on practice issues. Managers do not always sit on a committee, but they receive regular reports of committee progress. C. Interprofessional collaboration among nurses and health care providers is critical to the delivery of quality, safe patient care, and the creation of a positive work culture for practitioners. D. Interprofessional collaboration involves all professions bringing different points of view to the table to identify, clarify, and solve complex patient problems together, providing integrated and cohesive patient care. E. Competencies needed for effective interpersonal collaboration include: F. Work with individuals of other professions to maintain a climate of mutual respect and shared values. G. Use the knowledge of one's own role and those of other professions to appropriately assess and address the health care needs of patients and populations served. H. Communicate with patients, families, communities, and other health care professionals in a responsive and responsible manner that supports patient-centered care and a team approach to the maintenance of health and treatment of disease. I. During rounding, members of the team meet and share patient information, answer questions asked by other team members, discuss patients' clinical progress and plans for discharge, and focus all team members on the same patient goals. This decreases medical errors, decrease patient readmission rates, impact patient satisfaction, and improve quality of care. J. A manager's greatest challenge, especially if a work group is large, is communication with staff. An effective manager uses a variety of approaches to communicate quickly and accurately to all staff, through newsletters, minutes of meetings accessible, conducting staff meetings. K. A professional nursing staff needs to always grow in knowledge. It is impossible to remain knowledgeable about current medical and nursing practice trends without ongoing education.

Risk Factor Modification and Changing Health Behaviors

A. Once identified, implement health education and counseling B. Transtheoretical Model of Change -Precontemplation -Contemplation -Preparation -Action -Maintenance

Nursing Knowledge Base

A. Organizations that assist in end-of-life care ◦End-of-Life Nursing Consortium (ELNEC) ◦American Nurses Association (ANA) ◦American Society of Pain Management Nurses ◦American Association of Critical Care Nurses B. Factors influencing loss and grief ◦Human development ◦Personal relationships ◦Nature of the loss ◦Coping Strategies ◦Socioeconomic loss ◦Culture ◦Spiritual and religious beliefs

Promoting Comfort in the Terminally Ill Patient

A. Pain: Pain has multiple causes, depending on patient diagnosis. Collaborate with team members to identify and implement appropriate pharmacological and nonpharmacological interventions to reduce pain and promote comfort (see Chapter 44). B. Skin discomfort: Any source of skin irritation increases discomfort. Keep skin clean, dry, and moisturized. Monitor for incontinence. C. Mucous membrane discomfort: Mouth breathing or dehydration leads to dry mucous membranes; tongue and lips become dry or chapped. Provide oral care at least every 2 to 4 hours. Apply a light film of lip balm for dryness. Apply topical analgesics to oral lesions prn. D. Corneal irritation: Blinking reflexes diminish near death, causing drying of cornea. Optical lubricants or artificial tears reduce corneal drying. E. Fatigue: Metabolic demands, stress, disease states, decreased oral intake, and heart function cause weakness and fatigue. Provide periods of rest and educate patient about energy conservation. F. Anxiety: Physical, social, or spiritual distress causes anxiety; causes may be situational or event specific. Provide opportunity for patient to express feelings though active listening. Provide calm, supportive environment. Consult members of the health care team to determine whether pharmacological interventions are appropriate. G. Nausea: Nausea is caused by medications, pain, or decreased intestinal blood flow with impending death. Determine the cause of nausea and work to reduce nausea triggers such as strong smells. Administer antiemetics or promotility agents. Encourage patients to lie on their right side. Provide oral care at least every 2 to 4 hours. H. Constipation: Opioids, other medications, and immobility slow peristalsis. Lack of bulk in diet or reduced fluid is a cause. Increase fiber in diet if appropriate. Administer stool softeners or laxatives as needed. If possible, encourage increased liquid intake and regular periods of ambulation. I. Diarrhea: Disease processes, treatment or medications, and gastrointestinal (GI) infections are causes. Consult with members of the health care team to determine the cause and make appropriate changes. Provide skin care and easy accessibility to the toilet or bedside commode. J. Urinary incontinence: Progressive disease and decreased level of consciousness are causes. Provide good skin care and frequent assessment for incontinent urine. Place Foley catheter as appropriate. K. Altered nutrition: Medications, depression, decreased activity, and decreased blood flow to GI tract are causes. Nausea produces anorexia. Encourage patient to eat small, frequent meals of preferred foods. Patients should never be forced to eat. L. Dehydration: Patient is less willing or able to maintain oral fluid intake; has fever. Reduce discomfort from dehydration; give mouth care at least every 2 to 4 hours; offer ice chips or moist cloth to lips. Keep lips and tongue moist. M. Ineffective breathing patterns (e.g., dyspnea, shortness of breath): Anxiety; fever; pain; increased oxygen demand; disease processes; and anemia, which reduces oxygen-carrying capacity, are causes. Treat or control underlying cause. Use nonpharmacological interventions such as elevating the head of the bed to promote lung expansion. Provide oxygen as needed. Keeping the air cool provides ease and comfort for the terminal patient. Using morphine or benzodiazepines to treat tachypnea is sometimes appropriate. N. Noisy breathing ("death rattle")Noisy breathing is the sound of secretions moving in the airway during inspiratory and expiratory phases caused by thick secretions, decreased muscle tone, swallow, and cough. Elevate head to facilitate postural drainage. Turn patient at least every 2 hours. Provide oral care and maintain hydration as tolerated.

Federal Statutory Issues in Nursing Practice

A. Patient Protection and Affordable Care Act (PPACA) -Consumer rights and protections -Affordable health care coverage -Increased access to care -Stronger Medicare to improve care for those most vulnerable in our society •PPACA created a new Patient's Bill of Rights that prohibited patients from being denied health care coverage because of prior existing conditions, limits on the amount of care for those conditions, and/or an accidental mistake in paperwork when a patient got sick. •PPACA is also intended to reduce overall care costs to the consumer by: •Providing tax credits. •Increasing insurance company accountability for premiums and rate increases. •Increasing the choices from which patients can choose the right insurer to meet their needs. •In addition, PPACA was developed to increase access to health care. Patients now receive recommended preventive services, such as screenings for cancer, blood pressure, and diabetes, without having to pay copays or deductibles. •Anyone younger than 26 years of age may now continue to receive coverage under his or her parents' insurance plan. •PPACA improves Medicare coverage for vulnerable populations by improving access to care and prescriptions, decreasing costs of medications, extending the life of the Medicare Trust Fund until 2024, and addressing fraud and abuse in billing practices. B. Americans with Disabilities Act (ADA) -Protects rights of people with physical or mental disabilities C. Emergency Medical Treatment and Active Labor Act -When a patient presents to an emergency department, they must be treated D. Mental Health Parity Act •The ADA prohibits discrimination and ensures equal opportunities for people with disabilities in employment, state and local government services, public accommodations, commercial facilities, and transportation. •As defined by the statute and the U.S. Supreme Court, a disability is a mental or physical condition that substantially limits a major life activity, including seeing, hearing, speaking, walking, breathing, performing manual tasks, learning, caring for oneself, and/or working. •The ADA protects health care workers in the workplace with disabilities such as human immunodeficiency virus (HIV) infection. Likewise, health care workers cannot discriminate against HIV-positive patients. •The Emergency Medical Treatment and Active Labor Act provides that if an emergency condition exists, staff must evaluate the patient and may not discharge or transfer him or her until the patient's condition stabilizes. •PPACA requires parity (the state or condition of being equal) in provision of 10 specific services, including mental health, behavioral health, and substance use services. i. Insurers may not discriminate or deny coverage to patients with mental illness because of preexisting conditions. ii. Patients may remain on their parent's health insurance until they are 26 years old. iii. Currently, admission of a patient to a mental health unit can occur involuntarily or on a voluntary basis. iv. If the patient's history and medical records indicate suicidal tendencies, the patient must be kept under supervision.

Patient's Perspective of Caring

A. Patients value the affective dimension of nursing care B. Caring Assessment Tool C. Connecting with patients and their families D. Being present E. Respecting values, beliefs, and health care choices

Anatomy of a Lawsuit

A. Pleadings Phase -Petition: Elements of the claim. The plaintiff outlines what the defendant nurse did wrong and, because of that alleged negligence, how the plaintiff was injured. -Answer: The nurse admits or denies each allegation in the petition. The plaintiff must establish anything that the nurse does not admit. -Discovery: The process of discovering all the facts of the case involves using interrogatories, full access to the medical records in question, and the depositions. The patient and the health care staff are asked questions by counsel for the defense. They answer under oath, and their testimony is recorded and kept for reference. i. Interrogatories: Written questions requiring answers under oath. Typically opposing counsel requests a list of possible witnesses, insurance experts, and which health care providers the plaintiff saw before and after the event. ii. Requests for productions: Opposing parties request relevant documents, pictures, or related materials such as medical records for treatment before and after the event. iii. Depositions: Questions are posed to opposing parties, witnesses, and experts under oath to obtain all relevant, nonprivileged information about the case. Experts establish the elements of the case and the applicable standard of care. -Medical records: The defendant obtains all the plaintiff's relevant medical records for treatment before and after the event. Everything written by the nurses and the health care provider in the medical record is open to examination by both the plaintiff and the defendants. This includes all e-mails, texts, and other social media communications. -Witnesses' deposition: Questions are posed to the witnesses under oath to obtain all relevant, nonprivileged information about the case. Parties' depositions: The plaintiff and defendants (health care provider, nurse, and hospital personnel) are almost always deposed. -Other witnesses: Factual witnesses, both neutral and biased, are deposed to obtain information about their version of the case. They may include family members on the plaintiff's side and other medical personnel (e.g., nurses) on the defendant's side. -Experts: The plaintiff selects experts to establish the essential legal elements of the case against the defendant. The defendant selects experts to establish the appropriateness of the nursing care. Nursing experts are asked to testify to the reasonableness or inappropriate actions of the health care staff once the patient's condition began to change. The expert is asked to compare the actions of the nursing staff to the standard of care. -Trial: The trial usually occurs 3 years after the filing of the petition. Most are settled before trial.

Three Levels of Prevention

A. Primary Prevention -True prevention that lowers the chances that a disease will develop B. Secondary Prevention -Focuses on those who have health problems or illnesses and are at risk for developing complications or worsening conditions C. Tertiary Prevention -Occurs when a defect or disability is permanent or irreversible

Implementation: Health Promotion (cont.)

A. Promote spiritual comfort and hope B. Protect against abandonment and isolation C. Support the grieving family D. Facilitate mourning -Provide bereavement care •Patients are comforted when they have assurance that some aspect of their lives will transcend death, so helping patients make connections to their spiritual practice or cultural community can be a useful intervention. Draw on the resources of spiritual care providers in an institutional setting or collaborate with the patient's own spiritual or religious leaders and communities. •The spiritual concept of hope takes on special significance near the end of life. Nursing strategies that promote hope are often quite simple: be present and provide whole-person care. •Many patients with terminal illness fear dying alone. Patients feel more hopeful when others are near to help them. Nurses in institutional settings need to answer call lights promptly and check on patients often to reassure them that someone is close at hand. •When family members do visit, inform them of the patient's status and share meaningful insights or encounters that you have had with the patient. •In palliative and hospice care, patients and family members constitute the unit of care. When a patient becomes debilitated or approaches the end of life, family members also suffer. •Family members caring for people with serious life-limiting illness need attention and support early and consistently throughout the experience of illness and death. •Educate family members in all settings about the symptoms that the patient will likely experience and the implications for care. •Family members who have limited prior experience with death do not know what to expect. Whenever possible, communicate news of a patient's declining condition or impending death when family members are together so they can support each other. Provide information privately and stay with the family as long as needed or desired. •Reduce family member anxiety, stress, or fear by describing what to expect as death approaches. Become familiar with common manifestations of impending death (Box 37-8), remembering that patients usually experience some but not all of these changes. •During the dying process check frequently on families offering support, information, and if appropriate encouragement to continue touching and talking with their loved ones. •After death assist the family with decision making such as notification of a funeral home, transportation of family members, and collection of the patient's belongings. A. Assist with end-of-life decision making -Support and educate patients and families as they identify, contemplate, and decide the best journey to the end of life B. Facilitate mourning -Provide bereavement care C. Care after death -Ensure respect for the body -Postmortem care -Organ and tissue donation -Autopsy •Patients and families must decide about which treatments to continue and which treatments to forgo, to enroll in hospice or stay in the hospital, to transfer to a nursing home, in-patient unit, or to go home. •We are able to support and educated patients and families as they identify, contemplate, and ultimately decide how to best journey to the end of life. •Difficult ethical decisions at the end of life complicate a survivor's grief, create family divisions, or increase family uncertainty at the time of death. When ethical decisions are handled well, survivors achieve a sense of control and experience a meaningful conclusion to their loved one's death. •Helpful strategies for assisting grieving persons include the following: i. Help the survivor accept that the loss is real. Discuss how the loss or illness occurred or was discovered, when, under what circumstances, who told the survivor about it, and other factual topics to reinforce the reality of the event and put it in perspective. ii. Support efforts to adjust to the loss. Use a problem-solving approach. Have survivors make a list of their concerns or needs, help them prioritize, and lead them step-by-step through a discussion of how to proceed. Encourage survivors to ask for help. iii. Encourage establishment of new relationships. Reassure people that new relationships do not mean that they are replacing the person who has died. Encourage involvement in nonthreatening group social activities (e.g., volunteer activities or church events). iv. Allow time to grieve. "Anniversary reactions" (i.e., renewed grief around the time of the loss in subsequent years) are common. A return to sadness or the pain of grief is often worrisome. Openly acknowledge the loss, provide reassurance that the reaction is normal, and encourage the survivor to reminisce. v. Interpret "normal" behavior. Being distractible, having difficulty sleeping or eating, and thinking that they have heard the deceased's voice are common behaviors following loss. These symptoms do not mean that an individual has an emotional problem or is becoming ill. Reinforce that these behaviors are normal and will resolve over time. vi. Provide continuing support. Survivors need the support of a nurse with whom they have bonded for a time following a loss, especially in home care or hospice nursing. The nurse has filled an important role in the deceased's life and death and has helped them through some very intimate and memorable times. Attachment for a period of time after the death is appropriate and healing for both the survivor and the nurse. However, it is imperative that professional boundaries always be maintained. vii. Be alert for signs of ineffective, potentially harmful coping mechanisms such as alcohol and substance abuse or excessive use of over-the-counter analgesics or sleep aids. •Federal and state laws require institutions to develop policies and procedures for certain events that occur after death: requesting organ or tissue donation, performing an autopsy, certifying and documenting the occurrence of a death, and providing safe and appropriate postmortem care. In accordance with federal law, a specially trained professional (e.g., transplant coordinator or social worker) makes requests for organ and tissue donation at the time of every death. •Nurses provide support and reinforce or clarify explanations given to them during the request process. •Family members give consent for an autopsy to determine the exact cause and circumstances of death or discover the pathway of a disease. •Documentation of a death provides a legal record of the event. Follow agency policies and procedures carefully to provide an accurate and reliable medical record of all assessments and activities surrounding a death. Documentation also validates success in meeting patient goals or provides justification for changes in treatment or expected outcomes. •When a patient dies in an institutional or home care setting, nurses provide or delegate postmortem care, the care of a body after death. Above all, a deceased person's body deserves the same respect and dignity as a living person's body and needs to be prepared in a manner consistent with the patient's cultural and religious beliefs. •Maintaining the integrity of cultural and religious rituals and mourning practices at the time of death gives survivors a sense of fulfilled obligations and promotes acceptance of the patient's death.

Touch

A. Provides comfort B. Creates a connection -Noncontact touch -Contact touch i. Task-oriented touch ii. Caring touch iii. Protective touch

Issues in Health Care Ethics

A. Quality of life: Central to discussions about end-of-life care, cancer therapy, physician-assisted suicide, and Do Not Resuscitate (DNR) B. Disabilities: Antidiscrimination laws enhance the economic security of people with physical, mental, or emotional challenges C. Care at the end of life: Interventions unlikely to produce benefit for the patient D. Health Care Reform: Facilitated access to care for millions of uninsured Americans

Knowledge Building

A. Remain competent. B. Pursue lifelong learning. C. Share the knowledge. D. To become a leader, actively pursue learning opportunities, both formal and informal, and learn to share knowledge with the professional colleagues you encounter. E. Remaining competent provides the foundation for further skill building. F. Lifelong learning allows you to continuously provide safe, effective, quality care. G. In-service programs, workshops, professional conferences, professional reading, and collegiate courses offer innovative and current information on the rapidly changing world of health care. H. Ongoing development of skills in delegation, communication, and teamwork helps maintain and build competency!

Time Management

A. Remain goal oriented. B. Identify priorities. C. Establish personal goals. -One useful time-management skill involves making a priority to-do list. Good time management also involves setting goals to help you complete one task before starting another. -Time management requires the ability to anticipate the activities of the day and combine activities when possible.

Team Communication

A. Respect others' ideas. B. Share information. C. Stay informed. D. Strive to improve your communication. E. Share expectations of communication. F. Use structured communication techniques -As a part of a nursing team, you are responsible for using open, professional communication. -Strategies you can use to improve your communication with physicians include addressing the physician by name, having the patient and chart available when discussing patient issues, focusing on the patient problem, and being professional and not aggressive. -Part of good communication is clarifying what others are saying and building on the merits of co-workers' ideas. -Sharing expectations of what, when, and how to communicate is a step toward establishing a strong work team. -Examples of communication tools that improve communication include: i. Briefings or short discussions among team members. ii. Group rounds on patients. iii. Callouts to share critical information such as vital signs with all team members at the same time. iv. Check backs to restate what a person has said to verify understanding of information. v. The two-challenge rule that allows concerns to be voiced twice, which allows all team members to voice concerns about safety. vi. "CUS" words, which means "I'm Concerned, I'm Uncomfortable, I don't feel this is Safe". vii. The use of Situation-Background-Assessment-Recommendation (SBAR) when sharing information.

Decision Making of Managing Patient Care

A. Responsibility: duties and activities an individual is employed to perform B. Autonomy: independent decisions about patient care C. Authority: legitimate power to give commands and make final decisions specific to a given position D. Accountability: answerable for the actions E. Decision making is a critical component of an effective leader and manager. F. Decentralization is a component of the hierarchical level of decision making found in health care institutions. G. Decentralized management structure has the advantage of creating an environment in which managers and staff become more actively involved in shaping the identity and determining the success of a health care organization. H. Thus, it is the manager who directs and supports decision making—an important tool for nurses. I. Working in a decentralized structure has the potential for greater collaborative effort, increased competency of staff, increased staff motivation, and, ultimately, a greater sense of professional accomplishment and satisfaction. J. Responsibility reflects ownership. An individual who manages employees has to distribute responsibility, and the employees have to accept the manager's direction. Managers have to be sure that staff clearly understand their responsibilities, particularly in the face of change. K. Autonomy consistent with the scope of professional nursing practice maximizes the nurse's effectiveness. In work autonomy, a nurse makes independent decisions about the work of the unit such as scheduling or unit governance. Autonomy is not an absolute; it occurs in degrees. L. With authority, the nurse is able to choose and recommend appropriate teaching strategies for the patient on behalf of the other health care team members. The nurse has the final authority in selecting the best course of action for the patient's care. M. Accountability means that as a nurse you are responsible for providing excellent patient care by following standards of practice and institutional policies and procedures. You assume responsibility for the outcomes of the actions, judgments, and omissions in providing that care.

The Five Rights of Delegation

A. Right Task B. Right Circumstance C. Right Person D. Right Direction E. Right Supervision -The right task is one that can be delegated for a specific patient, such as tasks that are repetitive, require little supervision, are relatively noninvasive, have results that are predictable, and have potential minimal risk. -Appropriate patient setting, available resources, and other relevant factors are considered in determining the right circumstance. -The right person is delegating the right tasks to the right person to be performed on the right person. -Right direction/communication indicates that a clear, concise description of the task, including its objective, limits, and expectations, is given. -Right supervision/evaluation means that appropriate monitoring, evaluation, intervention as needed, and feedback are provided. F. Steps to Effective Delegation -Assess the knowledge and skills of the delegatee. -Match tasks to the delegatee's skills. -Communicate clearly: i. Task, outcome, time -Listen attentively. -Provide feedback. i. Provide clear instructions and desired outcomes when delegating tasks. These instructions initially focus on the procedure itself, what will be accomplished, when it should be completed, and the unique needs of the patient. ii. Important steps in delegation are evaluation of the staff member's performance, achievement of the patient's outcomes, the communication process used, and any problems or concerns that occurred. iii. As an RN, you may be delegating tasks to NAP. To assess knowledge and skills, ask open-ended questions that elicit conversation and details about what he or she knows. iv. You will need to know which tasks and skills are within the scope of practice and job description for team members to whom you delegate. v. Always provide clear directions by describing a task, the desired outcome, and the time period within which NAP should complete the task. vi. Listen to the response of NAP after you provide directions. Help sort out priorities if needed. vii. Always give NAP feedback regarding performance, regardless of outcome.

Legal Implications in Nursing Practice

A. Safe and competent nursing practice requires clinical reasoning and an understanding of the legal framework of health care, the specific state's Nurse Practice Act, and the scope and standards of nursing care. B. As patient care practice innovations and new health care technologies emerge, the principles of negligence and malpractice liability are being applied to challenging new situations. C. Nurses should practice nursing armed with the skills that are the outcomes of informed critical thinking.

Abandonment and Assignment Issues

A. Short staffing -Legal problems occur if an inadequate number of nurses will provide care. B. Floating -Based on census load and patient acuities. C. Health care providers' orders -Nurses follow orders unless they believe an order is given in error or is harmful. •A nurse may refuse an assignment when (1) the nurse lacks the knowledge or skill to provide competent care; (2) care exceeding the Nurse Practice Act is expected; (3) health of the nurse or her unborn child is directly threatened by the type of assignment; (4) orientation to the unit has not been completed and safety is at risk; (5) the nurse clearly states and documents a conscientious objection on the basis of moral, ethical, or religious grounds; or (6) the nurse's clinical judgment is impaired as a result of fatigue, resulting in a safety risk for the patient. •When refusing an assignment, it is important to give your immediate supervisor specific reasons for the refusal and determine if other alternatives, such as reassignment, are available. •The Community Health Accreditation Program (CHAP) and other state and federal standards require agencies to have guidelines for determining the number (staffing ratios) of nurses required to give care to a specific number of patients. •The ANA in conjunction with professional nursing organizations has supported federal legislation titled the Registered Nurse Safe Staffing Act, which requires Medicare-certified facilities to establish staffing committees comprised of 55% direct-care nurses. •Nurses who float must inform the supervisor of any lack of experience in caring for the type of patients on the nursing unit. They should request and receive an orientation to the unit. •Nurses follow health care providers' orders unless they believe that the orders are in error, violate agency policy, or are harmful to the patient. If the health care provider confirms an order and you still believe that it is inappropriate, use the agency chain of command to inform your direct supervisor. •Make sure that all the health care provider orders are in writing, dated and timed appropriately, and transcribed correctly.

Spiritual Caring

A. Spiritual health is achieved when a person can find a balance between his life values, goals, and belief symptoms and those of others. B. Spirituality offers a sense of intrapersonal, interpersonal, and transpersonal connectedness.

Decision Making -Staff

A. Staff involvement -Transformational leadership and decentralized decision making -All staff benefit from knowledge and skills of entire work group -Requires skilled communication -TEEAMS B. When transformational leadership and decentralized decision making exist on a nursing unit, all staff members actively participate in unit activities. C. Because the work environment promotes participation, all staff members benefit from the knowledge and skills of the entire work group. D. The use of transactional leadership practices positively impacts the work environment, resulting in greater nurse empowerment, improved culture and climate, increased nurses' research utilization, better teamwork between nurses and physicians, greater role clarity, and reduced conflict and ambiguity.

Processing an Ethical Dilemma

A. Step 1: Ask if this is an ethical dilemma. B. Step 2: Gather all relevant information. C. Step 3: Clarify values. D. Step 4: Verbalize the problem. E. Step 5: Identify possible courses of action. F. Step 6: Negotiate the outcome. G. Step 7: Evaluate the action.

Key TeamSTEPPS® Principles

A. Team Structure: Identify the complex parts of the health care system that have to work together effectively to promote patient safety. B. Communication: Use structured processes to clearly and accurately exchange information among members of the health care team. C. Leadership: Ensure that all members of the health care team understand the team's actions, receive information about changes, and have resources needed to perform their jobs. D. Situation Monitoring: Actively assess any situation to gather information, improve your understanding, or maintain awareness to support the functioning of the team. E. Mutual Support: Understand the responsibilities and workload of all team members so that you can anticipate and support their needs.

Risk Management and Quality Assurance

A. The Joint Commission Universal Protocol -Speak Up -Never Events: preventable errors •Occurrence reporting provides a database for further investigation in an attempt to determine deviations from standards of care and to identify corrective measures needed to prevent recurrence and to alert risk management to a potential claim situation. •Risk management also requires complete documentation. A nurse's documentation is often the evidence of care received by a patient and establishes support that the nurse acted reasonably and safely. •One area of potential risk is associated with the use of electronic monitoring devices. Continual assessment of a patient is necessary to help document the accuracy of electronic monitoring. •Nurses on the units are risk managers. •TJC's Universal Protocol principles: i. Preoperative verification that relevant documents and studies are available before the start of the procedure and that these documents are consistent with the patient's expectations. ii. Marking the operative site with indelible ink to mark left and right distinction, multiple structures (e.g., fingers), and levels of the spine. iii. A time-out just before starting the procedure for final verification of the correct patient, procedure, site, and any implants. •Never events are preventable errors, which may include falls, urinary tract infections from improper use of catheters, and pressure ulcers. •Become involved in professional organizations and committees that define the standards of care for nursing practice. The voice of nursing is powerful and effective when the organizing focus is the protection and welfare of the public entrusted to nurses' care. B. Identify possible risks C. Analyze risks D. Act to reduce risks E. Evaluate steps taken •The rationale for risk-management and quality improvement programs is the development of an organizational system of ensuring appropriate, quality health care by identifying potential hazards and eliminating them before harm occurs. •TJC requires the use of quality improvement and risk-management procedures. Both quality improvement and risk management require thorough documentation.

Proof of Negligence

A. The nurse owed a duty of care to the patient. • The nurse did not carry out the duty or breached it (failed to use that degree of skill and learning ordinarily used under the same or similar circumstances by members of the profession). • The patient was physically injured or harmed because the nurse breached the duty. • The patient's injury resulted in compensable damages that can be qualified as medical bills, lost wages, and pain and suffering. B. Common Sources of Negligence . Be aware of the common negligent acts that have resulted in lawsuits against hospitals and nurses. • Failure to assess and/or monitor, including making a nursing diagnosis • Failure to observe, assess, correctly diagnose, or treat in a timely manner • Failure to use, calibrate, or replace equipment required to safely care for the patient • Failure to document care and evaluation of care provided to the patient in a timely manner • Failure to notify the health care provider of significant changes in a patient's status • Failure to respond to or correctly implement new and existing orders • Failure to follow the seven rights of medication administration • Failure to convey discharge instructions to the patient, his or her family, or providers who are assuming responsibility for the patient • Failure to ensure patient safety, especially patients who have a history of falling, are sedated or confused, are frail, are mentally impaired, get up in the night, or are uncooperative • Failure to follow policies and procedures • Failure to properly delegate and supervise

Statutory Guidelines for Legal Consent for Medical Treatment

A. Those who may consent to treatment are governed by state law but generally include the following: I. Adults a. Any competent individual 18 years of age or older for himself or herself b. Any parent for his or her unemancipated minor c. Any guardian for his or her ward d. Any adult for the treatment of his or her minor brother or sister (if an emergency and parents are not present) E. Any grandparent for a minor grandchild (in an emergency and if parents are not present) II. Minors a. Ordinarily minors may not consent to medical treatment without a parent. However, emancipated minors may consent to medical treatment without a parent. Emancipated minors include: 1. Minors who are designated emancipated by a court order 2. Minors who are married, divorced, or widowed 3. Minors who are in active military service b. Unemancipated minors may consent to medical treatment if they have specific medical conditions 1. Pregnancy and pregnancy-related conditions (Various states differ in characterizing a pregnant minor as either emancipated or unemancipated. Know your state rules in this matter.) 2. A minor parent for his or her custodial child 3. Sexually transmitted infection (STI) information and treatment 4. Substance abuse treatment 5. Outpatient and/or temporary sheltered mental health treatment c. The issue of emancipated or unemancipated minors does not relieve the health care provider's duty to attempt to obtain meaningful informed consent.

Evaluation

A. Through the patient's eye -Assess if the patient's goals are being met. -Be alert for signs and symptoms of grief. B. Patient outcomes -Review the goals and expected outcomes of the plan of care to determine if nursing interventions were successful or if modifications are needed. -Continue to evaluate the patient's progress, the effectiveness of interventions and patient and family interactions.

Nursing Process: Assessment

A. Through the patient's eyes ◦Use presence, active listening, silence, therapeutic touch and open, honest communication Grief variables ◦Assess coping style, social support, nature of the loss, beliefs, life goals, grief patterns, self-care, hope Grief reactions ◦Assess grief response; most grieving people show some common outward signs and symptoms

No matter how tough it is, just take it one step at a time

A. Time Management B. Limit non-school screen time C. Personal Health -No stress eating -Move around

Civil and Common Law Issues in Nursing Practice

A. Torts B. Intentional -Assault -Battery -False imprisonment •A tort is a civil wrong made against a person or property. They are classified as intentional, quasi-intentional, or unintentional. •Intentional torts are willful acts that violate another's rights. These include assault, battery, and false imprisonment. •Assault is an intentional threat toward another person that places the person in reasonable fear of harmful, imminent, or unwelcome contact. No actual contact is required for an assault to occur. •Battery is any intentional offensive touching without consent or lawful justification. The contact can be harmful to the patient and cause an injury, or it merely can be offensive to the patient's personal dignity. Battery also results if the health care provider performs a procedure that goes beyond the scope of the patient's consent. •The tort of false imprisonment occurs with unjustified restraint of a person without a legal reason. This occurs when nurses restrain a patient in a confined area to keep the person from freedom. False imprisonment requires that the patient be aware of the confinement. C. Quasi-intentional torts -Invasion of privacy -Defamation of character i. Slander ii. Libel D. Unintentional torts -Negligence -Malpractice •Typically, invasion of privacy is the release of a patient's medical information to an unauthorized person such as a member of the press, the patient's employer, the patient's family, or online. The information that is in a patient's medical record is a confidential communication that may be shared with health care providers for the purpose of medical treatment only. •Do not disclose the patient's confidential medical information without his or her consent. A patient must authorize the release of information. •Defamation of character is the publication of false statements that result in damage to a person's reputation. •Slander occurs when one speaks falsely about another. •Libel is the written defamation of character. •Negligence is conduct that falls below the generally accepted standard of care of a reasonably prudent person. •Malpractice is one type of negligence and often referred to as professional negligence. •Certain criteria are necessary to establish nursing malpractice: •The nurse (defendant) owed a duty of care to the patient (plaintiff). •The nurse did not carry out or breached that duty. •The patient was injured and the nurse's failure to carry out the duty caused the injury. •The best way for nurses to avoid malpractice is to follow standards of care, give competent health care, and communicate with other health care providers. •You are accountable for timely reporting of any significant changes in the patient's condition to the health care provider and documenting these changes in the medical record. If records are lost or incomplete, there is a presumption that the care was negligent and therefore the cause of the patient's injuries.

Nursing Care Delivery Models

A. Total patient care -Registered nurse works directly with patient, family, and health care team members. -RN is responsible for patients during shift of care, although care can be delegated. -Approach may not be cost-effective owing to high number of RNs needed. -Patient satisfaction is high. B. Total patient care emphasizes a high degree of collaboration with other health care professionals. C. Total patient care is when the RN is responsible for all aspects of care for one or more patients during a shift of care, working directly with patients, families, and health team members. D. Case management -Collaborative process of assessing, planning, facilitating, and advocating for options and services to meet an individual's health needs. -Clinicians oversee the management of patients with specific, complex health problems and are usually held accountable for some standard of cost management and quality. -Often the case manager is an advanced practice nurse (APN), who helps improve patient outcomes via specific interventions. E. Case management is a care management approach that coordinates and links health care services to patients and their families while streamlining costs and maintaining quality. F. Communication and use of available resources promote quality cost-effective outcomes in this model. G. The case management model emphasizes supervision, not necessarily providing direct care, but overseeing the care delivered by other staff and health care professionals.

Nursing Care Delivery Methods

A. Traditional models -Team nursing -Primary nursing B. Today's models -Patient-centered care -Total patient care -Case management C. Nursing care delivery models contain the common components of nurse-patient relationship, clinical decision making, patient assignments and work allocation, interprofessional communication, and management of the environment of care. D. In team nursing the registered nurse (RN) is the leader who leads a team of other RNs, practical nurses, and nursing assistive personnel (NAP) who provide direct patient care. E. Primary nursing supports a philosophy regarding nurse and patient relationships. It is typically not practiced today because of the high cost of an all RN staffing model. F. Today's models are discussed on following slides. G. Patient- and family-centered care -Respect and dignity -Information sharing -Participation -Collaboration H. Patient- and family-centered care is a model of nursing care in which mutual partnerships among the patient, family, and health care team are formed to plan, implement, and evaluate the nursing and health care delivered. At the center of patient-centered care is the patient or family member as the source of control and full partner in providing care. Core concepts: I. Respect and dignity, ensuring that the care provided is given on the basis of the patient's and family's knowledge, values, beliefs, and cultural backgrounds. J. Information sharing, meaning that health care providers communicate and share information so patients and families receive timely, complete, and accurate information to effectively participate in care and decision making. K. Participation, whereby the patients and families are encouraged and supported in participating in care and decision making. L. Collaboration, demonstrated by the health care leaders collaborating with patients and families in policy and program development, implementation, and evaluation, and patients who are fully engaged in their health care.

Delegation

A. Transfers responsibility while remaining accountable for outcomes B. Requires knowing which skills are transferable C. Results in improved quality, safe patient care, improved efficiency, increased productivity, an empowered staff, and skill development of others D. The Nurse Practice Act of your state, along with principles of authority, accountability, and responsibility, is the basis for effective delegation. E. Delegation is an essential part of management. F. Never delegate a task that you dislike doing or would not do yourself because this creates negative feelings and poor working relationships. G. As a nurse you are responsible and accountable for providing care to patients and delegating care activities to the nursing assistive personnel (NAP). However, you do not delegate the steps of the nursing process of assessment, diagnosis, planning, and evaluation because these steps require nursing judgment. H. Patient teaching is also the responsibility of an RN and should not be delegated. I. As an RN, you are always responsible for the assessment of a patient's ongoing status; but if a patient is stable, you delegate vital sign monitoring to the NAP. J. Appropriate delegation begins with knowing which skills you are able to delegate. Know your state's Nurse Practice Act. K. As a professional nurse you cannot simply assign the NAP tasks without considering the implications. Assess the patient and determine a plan of care before identifying which tasks someone else is able to perform. L. Efficient delegation requires constant communication.

Values

A. Value -A value is a personal belief about the worth of a given idea, attitude, custom, or object that sets standards that influence behavior. B. Values clarification -Ethical dilemmas almost always occur in the presence of conflicting values. -To resolve ethical dilemmas, one needs to distinguish among values, facts, and opinion.

Risk Factors

A. Variables that increase the vulnerability of an individual or a group to an illness or accident B. Risk factors include: -Nonmodifiable risk factors -Modifiable risk factors -Environment

Nursing Students

A. You are liable if your actions cause harm to patients, as is your instructor, hospital, and college/university. B. You are expected to perform as a professional when rendering care. C. You must separate your student nurse role from your work as a certified nursing assistant (CNA). D. When students work as nursing assistants or nurse's aides when not attending classes, they should not perform tasks that do not appear in a job description for a nurse's aide or assistant. E. If someone requests that a student employed in the agency as a nurse's aide perform tasks that he or she is not prepared to complete safely, the student employee needs to bring this information to the supervisor's attention so the task can be assigned to an appropriate health care professional.

Ethics and Philosophy

A. the study of the fundamental nature of knowledge, reality, and existence, especially when considered as an academic discipline. B. Deontology -Defines actions as right and wrong B. Utilitarianism -Proposes that the value of something is determines by its usefulness C. Feminist Ethics -Focus on differences between genders and look at patient's relationships. D. Ethics of Care -Understanding relationships between people and caring in facilities E. Casuistry -Case-based reasoning - Consensus

You will use the concept of primary prevention when instructing a patient to: A. get a flu shot every year. B. take a blood pressure reading every day. C. explore hiring a patient with a known disability. D. undergo physical therapy following a cerebrovascular accident.

Answer: A. get a flu shot every year.

Sally has decided to set aside 30 minutes a day to walk after work next week. Sally is in what stage of risk factor modification? A. Precontemplation B. Contemplation C. Preparation D. Action E. Maintenance

Answer: C. Preparation -Rationale: Preparation is making small changes in preparation for a change in the next month.

According to Maslow's hierarchy of needs, which of these needs would the patient seek to meet first? A. Self-actualization B. Self-esteem C. Shelter D. Love and belonging

Answer: C. Shelter -Rationale: According to this model, certain human needs are more basic than others (i.e., some needs must be met before other needs [e.g., fulfilling the physiological needs before the needs of love and belonging]).

After evaluating a patient's external variables, the nurse concludes that health beliefs and practices can be influenced by A. emotional factors. B. intellectual background. C. developmental stage. D. socioeconomic factors.

Answer: D. socioeconomic factors. -Rationale: Emotional factors, intellectual background, and developmental stage are internal factors, not external factors.

Nursing Assessment Questions

Nature of Relationships • How long have you known _______ (the deceased person)? • What role did (name person) play in your life? • Tell me about what your relationship with (name person) meant to you. Social Support Systems • In times of loss, who is "there for you"? Absent? Who provides support? • What do others do for you that is most meaningful or helpful? • Are family/friends available when needed? Which friends or relatives do you wish were here? Nature of the Loss • What does this loss mean to you? • What other losses have you experienced? • Was this loss expected or unexpected? Cultural and Spiritual Beliefs • What is your belief about death? Meaning of life? • Which rituals/practices are important to you at the end of life? • How do members of your culture or religious group respond to this type of loss? Life Goals • What are your life goals at this time? • How have your goals changed because of this experience? • Are you able to see what you will do in the future? Family Grief Patterns • How have you/your family dealt with loss in the past? • What are your family's strengths? • How have family relationships changed as a result of your loss? • What role do you assume in your family during stressful situations? Self-Care • Tell me how you're feeling. • What are you doing to take care of yourself now? • What helps you when you feel this sad? What doesn't help? • What can I do for you? Hope • What do you hope for right now? • What helps you to remain hopeful? What causes you to lose hope?