NUR200 Intro into Concepts: Unit 4

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.

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.

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]).

1. Vulnerable populations of patients are those who are more likely to develop health problems as a result of: A. living at home. B. abusive habits. C. citizenship. D. middle age.

B. abusive habits

Self-concept

-An individual's view of self -Subjective -Complex mixture of unconscious and conscious thoughts, attitudes, and perceptions -Directly affects self-esteem -Thinks v. feels about oneself

Nursing Metaparadigm

-Person -Health -Environment/Situation -Nursing

Steps of Evidence-Based Practice

0. Cultivate a spirit of inquiry. 1. Ask a clinical question in PICOT format. 2. Search for the most relevant evidence. 3. Critically appraise the evidence you gather. 4. Integrate all evidence with your clinical expertise and patient preferences and values. 5. Evaluate the outcomes of practice decisions or changes using evidence. 6. Share the outcomes with others. -Consistently following a step-by-step approach ensures that you obtain the strongest available evidence to apply in patient care. -There are seven steps to EBP, which are numbered from zero to six. Collect the Best Evidence

Traditional Chinese Medicine

A. "Life in balance" B. Health promotion C. Yin and yang are opposing, complementary forces that exist in dynamic equilibrium D. Therapeutic modalities -Moxibustion -Cupping -Tai chi -Qi gong E. TCM is a whole system of medicine that began approximately 3600 years ago. Chinese medicine views health as "life in balance," which manifests as lustrous hair, a radiant complexion, engaged interactions, a body that functions without limitations, and emotional balance. F. Health promotion encourages healthy diet, moderate regular exercise, regular meditation/introspection, healthy family and social relationships, and avoidance of environmental toxins such as cigarette smoke. G. Yin represents shade, cold, and inhibition; whereas yang represents fire, light, and excitement. Yin also represents the inner part of the body, specifically the viscera, liver, heart, spleen, lung, and kidney; whereas yang represents the outer part, specifically the bowels, stomach, and bladder. Harmony and balance in every aspect of life are the keys to health, including yin-yang balance. H. Imbalance ultimately leads to disruption of vital energy, qi, which then compromises the body-mind-spirit of the person, causing "disease." Disruptions in qi along the meridians can be systematically evaluated and treated by TCM practitioners. I. TCM practitioners use four methods to evaluate a patient's condition: observing, hearing/smelling, asking/interviewing, and touching/palpating. J. Therapeutic modalities include acupuncture, Chinese herbs, tui na massage, moxibustion (burning moxa, a cone or stick of dried herbs that have healing properties on or near the skin) cupping (placing a heated cup on the skin to create a slight suction), tai chi (originally a martial art that is now viewed as a moving meditation in which patients move their bodies slowly, gently, and with awareness while breathing deeply), qi gong (originally a martial art, now viewed as a series of carefully choreographed movements or gestures that are designed to promote and manipulate the flow of qi within the body), lifestyle modifications, and dietary changes. K. Evidence about its effectiveness is limited. Some evidence shows that TCM is helpful in treating fibromyalgia and in addressing symptoms associated with menopause. L. There is some concern about the safety of Chinese herbal treatments that are used in teas, remedies, and supplements. Recent reports about these products suggest that many Chinese herbs are contaminated with drugs, toxins, or heavy metals or that many ingredients may not be clearly listed or labeled. Further, these herbs can be very powerful, interacting with drugs and causing serious complications. M. When assessing a person using TCM, you need to ask your patient about the therapies he or she receives, including the types of herbs that the patient is using. Some patients consider these as teas or dietary additives, powders, or supplements and not as over-the-counter medications.

Nursing Code of Ethics

A. A code of ethics is the philosophical ideals of right and wrong that define principles used to provide care. -It is important for you to incorporate your own values and ethics into your practice. -Ask yourself: How do your ethics, values, and practice compare with established standards?•Provision 1: The nurse practices with compassion and respect for inherent dignity, worth and unique attributes of every person. •Provision 2: The nurse's primary commitment is to the patient, whether an individual, family group, community or population •Provision 3: The nurse promotes, advocates for, and protects the rights, health, and safety of the patient. •Provision 4: The nurse has authority, accountability, and responsibility for nursing practice: makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care. •Provision 5: The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth. •Provision 6: The nurse, through individual and collective effort, establishes, maintains , and improves the ethical environment of the work settings and conditions of employment that •Provision 7: The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy. •Provision 8: The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities. •Provision 9: The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.

Biofeedback

A. A mind-body technique that uses instruments to teach self-regulation and voluntary self-control over specific physiological responses. B. Instruments measure, process, and provide information about neuromuscular and autonomic nervous system activity. C. Immediate feedback is provided in physical, physiological, auditory, and/or visual signals. D. Electronic or electromechanical instruments give information to patients about their muscle tension, cardiac activity, respiratory rates, brain-wave patterns, and autonomic nervous system activity. E. Feedback increases a person's awareness of internal processes that are linked to illness and distress. F. Biofeedback therapies are used to change thinking, emotions, and behaviors, which in turn support beneficial physiological changes, resulting in improved health and well-being. G. Biofeedback is an effective addition to more traditional relaxation programs because it immediately demonstrates to patients their ability to control some physiological responses and the relationships among thoughts, feelings, and physiological responses. H. Biofeedback provides immediate feedback about which stress relaxation behaviors work most effectively. I. Biofeedback is helpful in stroke recovery, smoking cessation, attention-deficit/hyperactivity disorder (ADHD), epilepsy, headache disorders, and a variety of gastrointestinal (GI) and urinary tract disorders. Patients who are compliant have more positive results. J. Several precautions have been put forth, particularly for those with psychological or neurological conditions. -During biofeedback sessions, repressed emotions or feelings for which coping is difficult sometimes surface. Thus practitioners need to be trained in more traditional psychological methods or have qualified professionals available for referral. -Long-term use of biofeedback sometimes lowers blood pressure, heart rate, and other physiological parameters. As with other biobehavioral interventions, monitor patients closely to determine the need for medication adjustments.

Imagery

A. A mind-body therapy that uses the conscious mind to create mental images to stimulate physical changes in the body, improve perceived well-being, and/or enhance self-awareness B. Clinical applications -Pain control C. Limitations -Relatively few side effects -Not recommended for patients with PTSD or COPD D. Frequently imagery, combined with some form of relaxation training, facilitates the effect of the relaxation technique. E. Imagery may be self-directed, in which individuals create their mental images, or guided, during which a practitioner leads an individual through a particular scenario. F. Imagery often evokes powerful psychophysiological responses such as alterations in gastric secretions, body chemistry, internal and superficial blood flow, wound healing, and heart rate/heart rate variability. Although most imagery techniques involve visual images, they also include the auditory, proprioceptive, gustatory, and olfactory senses. G. Creative visualization is self-directed imagery based on the principle of mind-body connectivity. H. Imagery helps control or relieve pain, decrease nightmares, and improve sleep. It also aids in the treatment of chronic conditions such as asthma, cancer, sickle cell anemia, migraines, autoimmune disorders, atrial fibrillation, functional urinary disorders, menstrual and premenstrual syndromes, gastrointestinal disorders such as irritable bowel syndrome and ulcerative colitis, and rheumatoid arthritis. I. Imagery has relatively few side effects. -Yet increased anxiety and fear sometimes occur when imagery is used to treat posttraumatic stress disorders and social anxiety disorders. -Some patients with chronic obstructive pulmonary disease (COPD) and asthma experience increased airway constriction when using guided imagery. Thus you need to closely monitor patients when beginning this therapy.

Natural Products and Herbal Therapies

A. A natural product is a chemical compound or substance produced by a living organism. B. Herbal medicines are not approved for use as drugs and are not regulated by the FDA. C. "Natural" does not equal "Safe." D. Look for U.S. Pharmacopeia (USP)-verified dietary supplement mark. E. As the oldest form of medicine, archeological evidence suggests that herbal remedies have been used for more than 60,000 years. Herbal medicines are a prominent part of health care among indigenous populations worldwide. F. Nonvitamin, nonmineral natural products are used by almost 20% of the U.S. population to prevent disease and illness and to promote health and well-being. Natural products include herbal medicines (also known as botanicals), dietary supplements, vitamins, minerals, mycotherapies (fungi-based products), essential oils (aromatherapy), and probiotics. G. The most frequently used products are garlic, cranberry, Echinacea, saw palmetto, ginkgo biloba, soy, ginseng, black cohosh, St. John's wort, glucosamine, peppermint, fish oil/omega 3, soy, and milk thistle. H. Many are sold as foods or food supplements. The Dietary Supplement Health and Education Act (1994) allows companies to sell herbs as dietary supplements as long as no health claims are written on their labels. I. A number of herbs are safe and effective for a variety of conditions. J. Simply because a product is "natural" does not make it "safe." K. Because they are not regulated, concentrations of the active ingredients vary considerably. Contamination with other herbs or chemicals, including pesticides and heavy metals, is also problematic. Not all companies follow strict quality control and manufacturing guidelines that set standards for acceptable levels of pesticides, residual solvents, bacterial levels, and heavy metals. L. Teach patients to purchase herbal medicines only from reputable manufacturers. Labels on herbal products need to contain the scientific name of the botanical, the name and address of the actual manufacturer, a batch or lot number, the date of manufacture, and the expiration date. M. Using natural products that have been verified by the U.S. Pharmacopeia (USP) is another way to ensure product safety, quality, and purity. N. Some herbs also contain toxic products that have been linked to cancer. O. As with any other medication, examine herbs for interaction and compatibility with other prescribed or over-the-counter substances that are being used simultaneously.

Nursing Process: Planning & Spiritual Health

A. A spiritual care plan includes realistic and individualized goals with relevant outcomes B. The patient identifies what is most important C. In a hospital setting, the pastoral care department is a valuable resource

Manipulative and Body-Based Methods (Involve movement of body with focus on body structures and systems)

A. Acupressure: Applying digital pressure in a specified way on designated points on the body to relieve pain, produce analgesia, or regulate a body function B. Chiropractic medicine: Manipulating the spinal column; includes physiotherapy and diet therapy C. Craniosacral therapy: Assessing the craniosacral motion for rate, amplitude, symmetry, and quality and attuning/aligning the spinal column, cerebrospinal fluid, and rhythmic processes, releasing restrictions or abnormal barriers to motion D. Massage therapy: Manipulating soft tissue through stroking, rubbing, or kneading to increase circulation, improve muscle tone, and provide relaxation E. Simple touch: Touching the patient in appropriate and gentle ways to make connection, display acceptance, and give appreciation

Energy Therapies (Use or manipulation of energy fields)

A. Acupuncture: Traditional Chinese method of producing analgesia or altering the function of a body system by inserting thin needles along a series of lines or channels, called meridians; direct needle manipulation of energetic meridians influences deeper internal organs by redirecting qi B. Healing touch: Biofield therapy; uses gentle touch directly on or close to body to influence and support the human energy system and bring balance to the whole body (physical, spiritual, emotional, and mental); a formal educational and certification system provides credentials for practitioners C. Reiki therapy: Biofield therapy derived from ancient Buddhist rituals; practitioner places hands on or above a body area and transfers "universal life energy," providing strength, harmony, and balance to treat a patient's health disturbances D. Therapeutic touch: Biofield therapy involving direction of a practitioner's balanced energies in an intentional manner toward those of a patient; practitioner's hands lay on or close to a patient's body E. Magnet therapy: Bioelectromagnetic therapy; devices (magnets) applied to the body surface, producing a measurable magnetic field; used primarily to alleviate pain associated with musculoskeletal injuries or disorders

Horticulture Therapy

A. Adjunct therapy to occupational and physical therapy B. Gardening, healing garden C. Stimulates five senses D. Provides leisure activities E. Improves motor function F. Provides sense of achievement G. Improves self-esteem

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.

Therapeutic Touch

A. Affects energy fields with conscious intent to help or heal B. Five phases: -Centering: To begin the practitioner centers physically and psychologically, becoming fully present in the moment and quieting outside distractions. -Assessing: Then the practitioner scans the body of the patient with the palms (roughly 2 to 6 inches [5 to 15 cm] from the body) from head to toe. -Unruffling: While assessing the energetic biofield of the patient, the practitioner focuses on the quality of the qi and areas of energy obstructions, redirecting the energy to harmonize and move. -Treating: Using long downward strokes over the energy fields of the body, the practitioner touches the body or maintains the hands in a position a few inches away from the body. -Evaluating: Ensuring that energy is flowing freely, and determining additional outcomes and responses to the treatment C. Therapeutic touch (TT) is a natural human potential that consists of placing the practitioner's hands on or close to the body of a person. A nurse developed this therapy. The practitioner attempts to redirect energy to bring the person back into an energy balance similar to that of the practitioner. D. Phases -Centering: To begin the practitioner centers physically and psychologically, becoming fully present in the moment and quieting outside distractions. -Assessing: Then the practitioner scans the body of the patient with the palms (roughly 2 to 6 inches [5 to 15 cm] from the body) from head to toe. -Unruffling: While assessing the energetic biofield of the patient, the practitioner focuses on the quality of the qi and areas of energy obstructions, redirecting the energy to harmonize and move. -Treating: Using long downward strokes over the energy fields of the body, the practitioner touches the body or maintains the hands in a position a few inches away from the body. -Evaluating: Ensuring that energy is flowing freely, and determining additional outcomes and responses to the treatment. E. Evidence supporting the effectiveness of TT is inconclusive, although it may be effective in treating pain in adults and children, dementia, trauma, and anxiety during acute and chronic illnesses. F. Although the use of TT causes very few complications or side effects, it is contraindicated in certain patient populations, especially those who are sensitive to human interaction and touch.

Standards for Patient Education

A. All state Nurse Practice Acts recognize that patient teaching falls within the scope of nursing practice. B. The Joint Commission sets standards for patient and family education. C. Successful accomplishment of standards requires collaboration among health care professionals.

Factors Influencing Self-Concept

A. Any real or perceived change that threatens identity, body image, or role performance can affect self-concept. B. Changes that occur in physical, spiritual, emotional, sexual, familial, and sociocultural health affect self-concept. -Change in health -Other crises •An individual's perception of the stressor is the most important factor in determining his or her response. •The ability to reestablish balance following a stressor is related to numerous factors, including the number of stressors, the duration of the stressors, and health status. •Being able to successfully adapt to stressors is likely to lead to a positive sense of self, whereas failure to adapt often leads to a negative self-concept. •Any change in health is a stressor that potentially affects self-concept. A physical change in the body sometimes leads to an altered body image, affecting identity and self-esteem. Chronic illnesses often alter role performance, which change an individual's identity and self-esteem. •The stressors created as a result of a crisis also affect a person's health. If the resulting identity confusion, disturbed body image, low self-esteem, or role conflict is not relieved, illness can result. •During self-concept crises, supportive and educative resources are valuable in helping a person learn new ways of coping with and responding to the stressful event or situation to maintain or enhance self-concept.

Mind-Body Interventions (Honor connections between thoughts and physiological functioning using emotion to influence health and well-being)

A. Art therapy: Use of art to reconcile emotional conflicts, foster self-awareness, and express patients' unspoken and frequently unconscious concerns about their disease B. Biofeedback: Process providing a person with visual or auditory information about autonomic physiological functions of the body such as muscle tension, skin temperature, and brain wave activity through the use of instruments C. Breathwork: Using a variety of breathing patterns to relax, invigorate, or open emotional channels D. Guided imagery: Concentrating on an image or series of images to treat pathological conditions E. Meditation: Self-directed practice for relaxing the body and calming the mind using focused rhythmic breathing F. Music therapy: Using music to address physical, psychological, cognitive, and social needs of individuals with disabilities and illnesses; improves physical movement and/or communication, develops emotional expression, evokes memories, and distracts people who are in pain G. Tai chi: Incorporating breath, movement, and meditation to cleanse, strengthen, and circulate vital life energy and blood; stimulate the immune system; and maintain external and internal balance H. Yoga: Focuses on body musculature, posture, breathing mechanisms, and consciousness; goal is attainment of physical and mental well-being through mastery of body achieved through exercise, holding of postures, proper breathing, and meditation

Nursing Process: Assessment & Spiritual Health

A. Assessment expresses a level of caring and support B. Taking a faith history reveals patient's beliefs about life, health, and a Supreme Being C. Through the patient's eyes D. Assessment tools -Listening -Ask direct questions -FICA (Faith, Importance, Community, Address) -Spiritual well-being (SWB) scale E. Faith/Belief -Ask about a religious source of guidance -Understand the patient's philosophy of life F. Life and self-responsibility: ask about a patient's understanding of illness limitations or threats and how the patient will adjust G. Connectedness: ask about the patient's ability to express a sense of relatedness to something greater than self H. Life satisfaction I. Culture: ask about faith and belief systems to understand culture and spirituality relationships J. Fellowship and community: ask about support networks K. Ritual and practice: ask about life practices used to assist in structure and support during difficult times L. Vocation: ask whether illness or hospitalization has altered spiritual expression

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

Whole Medical Systems (Complete systems of theory and practice that have evolved independently from or parallel to conventional biomedicine)

A. Ayurvedic medicine: One of the oldest systems of medicine, practiced in India since the first century AD. There are eight branches of Ayurvedic medicine, including internal medicine; surgery; treatment of head and neck disease; gynecology, obstetrics, and pediatrics; toxicology; psychiatry; elder care and rejuvenation; and sexual vitality. Treatments balance the doshas using a combination of dietary and lifestyle changes, herbal remedies and purgatives, massage, meditation, and exercise. B. Homeopathic medicine: Developed in Germany and practiced in the United States since the mid-1800s. It is a system of medical treatments based on the theory that certain diseases can be cured by giving small, highly diluted doses of substances that in a healthy person would produce symptoms like those of the disease. Prescribed substances called remedies are made from naturally occurring plant, animal, or mineral substances and are used to stimulate the vital force of the body so that it can heal itself. C. Latin American traditional healing: Curanderismo is a Latin American traditional healing system that includes a humoral model for classifying food, activity, drugs, and illnesses and a series of folk illnesses. The goal is to create a balance between the patient and his or her environment, thereby sustaining health. D. Native American traditional healing: Tribal traditions are individualistic, but similarities across traditions include the use of sweating and purging, herbal remedies, and ceremonies in which a shaman (a spiritual healer) makes contact with spirits to ask their direction in bringing healing to people to promote wholeness and healing. E. Naturopathic medicine: A system of therapeutics focused on treating the whole person and promoting health and well-being rather than an individual disease. Therapeutics include herbal medicine, nutritional supplementation, physical medicine, homeopathy, lifestyle counseling, and mind-body therapies with an orientation toward assisting the person's internal capacity for self-healing (vitalism). F. Traditional Chinese medicine (TCM): An ancient healing tradition identified in the first century AD focused on balancing yin/yang energies. It is a set of systematic techniques and methods, including acupuncture, herbal medicines, massage, acupressure, moxibustion (use of heat from burning herbs), qi gong (balancing energy flow through body movement), cupping, and massage. Fundamental concepts are from Taoism, Confucianism, and Buddhism.

Providing Presence

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

Training-Specific Therapies

A. Biofeedback B. Acupuncture C. Therapeutic touch D. Chiropractic therapy E. Traditional Chinese medicine F. Natural products and herbal therapies -Training-specific therapies are CAM treatments that nurses (or other health care providers) administer only after completing a specific course of study and training. -These therapies require postgraduate certificates or degrees indicating completion of additional education and training, national certification, or additional licensure beyond the registered nurse (RN) to practice and administer them. -Several training-specific therapies (e.g., biofeedback, acupuncture) are very effective and are often recommended by Western health care practitioners. However, others (e.g., homeopathy, naturopathy) have not been adequately studied, and their effectiveness in many conditions has been questioned. -Although many of these complementary therapies elicit positive effects, all therapies carry some risk, particularly when used in conjunction with conventional medical therapies. Therefore you need advanced knowledge to effectively talk about them with patients and to provide education about their safe use.

Nurse-Patient Relationship

A. Caring relationships are the foundation of clinical nursing practice. B. Therapeutic relationships promote a psychological climate that facilitates positive change and growth. -The goals of a therapeutic relationship focus on a patient achieving optimal personal growth related to personal identity, ability to form relationships, and ability to satisfy needs and achieve personal goals. -Patient's needs take priority over a nurse's needs. Your nonjudgmental acceptance of a patient is an important characteristic of the relationship. -Acceptance conveys a willingness to hear a message or acknowledge feelings. -A caring relationship between you and a patient does not just happen—you create it with skill and trust. 1. Preinteraction phase: occurs before meeting the patient 2. Orientation phase: when the nurse and the patient meet and get to know each other 3. Working phase: when the nurse and the patient work together to solve problems and accomplish goals 4. Termination phase: occurs at the end of a relationship -There is a natural progression of four goal-directed phases that characterize the nurse-patient relationship. -Socializing is an important initial component of interpersonal communication. It helps people get to know one another and relax. It is easy, superficial, and not deeply personal; whereas therapeutic interactions are often more intense, difficult, and uncomfortable. -In a therapeutic relationship it may be helpful to encourage patients to share personal stories. Sharing stories is called narrative interaction. Through listening to stories you begin to understand the context of others' lives and learn what is meaningful for them from their perspective. -As a nurse you can also tell stories to enhance patient education.

Types of Imagery

A. Cellular: Imagine events at cellular level -Imagine natural killer cells surrounding and attacking cancer cells B. End state: Imagine self in the situation wished for -See self as strong and healthy C. Energetic: Imagine free-flowing energy -Feel self pulling up energy from the earth through the soles of the feet D. Feeling State: Move from a feeling state of tension to one of peace -May imagine self at a beach or floating gently on the water E. Physiological: Involves entire body -Imagine all blood vessels relaxed and wider in order to lower blood pressure F. Psychological: Involves perception of self -Imagine a dialogue with a person with whom one is in conflict in an effort to find a new solution to the problem G. Spiritual: Make contact with God or the Divine -Imagine being held in the hands of God where you are perfectly safe

Critical Thinking in Nursing Practice

A. Clinical judgment is an essential skill that involves the interpretation of a patient's needs, concerns, or health problems and the decision to take action or not, to use or modify standard approaches, or to improvise new approaches on the basis of a patient's response. B. Nurses apply knowledge, clinical experiences, and professional standards when thinking critically and making decisions about patient care. C. As nurses develop professionally, it is important to acquire critical thinking skills that allow you to face each new patient care experience or problem with open-mindedness, creativity, confidence, and continual inquiry. D. Critical thinking is acquired through experience, commitment, and active curiosity. E. Critical thinking is not a simple step-by-step linear process that is learned in a short period of time.

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

Communication and Nursing Practice

A. Communication -A lifelong learning process -Essential for establishing nurse-patient relationships and delivering patient-centered care -Helps to reduce the risk of errors -Maintains effective relationships B. Therapeutic communication -Promotes personal growth -Helps patients reach their health-related goals

Complementary, Alternative, and Integrative Approaches to Health Part 1

A. Complementary and Alternative Medicine (CAM) an array of health care approaches with a history of use or origins outside of mainstream medicine B. Complementary therapies complement conventional treatments. Many of them, such as therapeutic touch, contain diagnostic and therapeutic methods that require special training. Others, such as guided imagery and breathwork, are easily learned and applied. Others include relaxation; exercise; massage; reflexology; prayer; biofeedback; hypnotherapy; creative therapies, including art, music, or dance therapy; meditation; chiropractic therapy; and herbs/supplements. C. Alternative therapies may include the same interventions as complementary therapies, but they become the primary treatment, replacing allopathic medical care. D. Alternative therapies are based on completely different philosophies and life systems than those used by allopathic medicine. The National Institutes of Health (NIH)/National Center for Complementary and Alternative Medicine (NCCAM) calls them whole medical systems such as traditional Chinese medicine (TCM), Ayurveda, and various forms of traditional or folk medicine. E. Because of the increased interest in complementary therapies, many health care programs, including medical and nursing schools, have integrated conventional "biomedical" education with programs that incorporate complementary and alternative therapy content. F. Integrative health care emphasizes the importance of the relationship between practitioner and patient; focuses on the whole person; is informed by evidence; and makes use of appropriate therapeutic approaches, health care professionals, and disciplines to achieve optimal health

Nursing Knowledge Base: Current Concepts in Spiritual Health

A. Concepts of spirituality -Self-transcendence -Connectedness -Faith -Hope B. Spiritual well-being -Transpersonally -Interpersonally -Faith -Religion -Hope

Critical Thinking Synthesis

A. Critical thinking and the nursing process go hand-in-hand in making quality decisions about patient care. -Critical thinking is a reasoning process by which you reflect on and analyze your thoughts, action, and knowledge. -As a beginning nurse it is important to learn the steps of the nursing process and incorporate the elements of critical thinking.

Critical Thinking Defined

A. Critical thinking is: -The ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process -A continuous process characterized by open-mindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant-Recognizing that an issue exists, analyzing information, evaluating information, and drawing conclusions B. A critical thinker considers what is important in each clinical situation, imagines and explores alternatives, considers ethical principles, and makes informed decisions about the care of patients. -The use of evidence-based knowledge, or knowledge based on research or clinical expertise, makes you an informed critical thinker. C. Critical thinking is a way of thinking about a situation that always asks "Why?", "What am I missing?", "What do I really know about this patient's situation?", and "What are my options?" -Critical thinking requires cognitive skills and the habit of asking questions, staying well informed, being honest in facing personal biases, and always being willing to reconsider and think clearly about issues. -Critical thinking is more than just problem solving. It is a continuous attempt to improve how to apply yourself when faced with problems in patient care. -Nurses who apply critical thinking in their work focus on options for solving problems and making decisions rather than rapidly and carelessly forming quick, simple solutions.

Patient Centered Care

A. Cultural competence vs. patient-centered care -Each emphasizes different aspects of quality -Patient-centeredness provides individualized care and restores an emphasis on personal relationships -Cultural competence aims to increase health equity and reduce disparities by concentrating on people of color and other disadvantaged populations B. Two landmark reports from the Institute of Medicine (IOM)—Crossing the Quality Chasm (IOM, 2001) and Unequal Treatment (Smedley et al., 2003)—highlight the importance of patient-centered care and cultural competence. C. Crossing the Quality Chasm identifies patient-centered care as one of six "aims" for high-quality health care. D. Unequal Treatment stresses the importance of developing cultural competence among health care providers to eliminate racial/ethnic health care disparities. E. Campinha-Bacote views cultural competency as an expansion of patient-centered care. More specifically, cultural competence can be seen as a necessary set of skills for nurses to attain in order to render effective patient-centered care. It is important for nurses to see themselves as becoming culturally competent. Your ability to exercise cultural competence by applying the components of Campinha-Bacote's model of cultural competency will allow you to deliver patient-centered care.

Movement Therapies (Eastern or Western approaches to promote well-being)

A. Dance therapy: Intimate and powerful medium because it is a direct expression of the mind and body; treats persons with social, emotional, cognitive, or physical problems B. Feldenkrais method: A complementary therapy based on establishment of good self-image through awareness and correction of body movements; integrates the understanding of the physics of body movement patterns with an awareness of the way people learn to move, behave, and interact C. Pilates: Method of body movement used to strengthen, lengthen, and improve the voluntary control of muscles and muscle groups, especially those used for posture and core strengthening; awareness of breathing and precise movements are integral components

Planning & Patient Education

A. Determine goals and expected outcomes that guide the choice of teaching strategies and approaches with a patient: -Set priorities. -Select timing to teach. -Organize the teaching materials. -Use teamwork and collaboration.

Ask a Clinical Question

A. Developing a PICOT question: -P = Patient population of interest -I = Intervention of interest -C = Comparison of interest -O = Outcome -T = Time B. The questions you ask eventually will lead you to the evidence for an answer. When you go to the scientific literature, you don't want to read 100 articles to find the handful that are most helpful—you want to read the best four to six articles that specifically address your question. Using the PICOT format can help. The more focused your question is, the easier it becomes to search for evidence in the scientific literature. •P = Patient population of interest. Identify patients by age, gender, ethnicity, and disease or health problem •I = Intervention of interest. Which intervention is worthwhile to use in practice (e.g., a treatment, diagnostic test, prognostic factor)? •C = Comparison of interest. What is the usual standard of care or the intervention used now in practice? •O = Outcome. What result do you wish to achieve or observe as a result of an intervention (e.g., change in patient behavior, physical finding, patient perception)? •T = Time. How much time is needed for an intervention to achieve an outcome (e.g., the amount of time needed to change quality of life or patient behavior)? C. Proper question formatting allows you to identify key words to use when conducting your literature search. D. Note that a well-designed PICOT question does not have to follow the sequence of P, I, C, O, and T. In addition, intervention (I), comparison (C), and time (T) are not appropriate to be used in every question. The aim is to ask a question that contains as many of the PICOT elements as possible.

Biologically Based Therapies (Natural products)

A. Dietary supplements: Defined by the Dietary Supplement Health and Education Act of 1994 and used to supplement dietary/nutritional intake by mouth; contain one or more dietary ingredients, including vitamins, minerals, herbs, or other botanical products B. Herbal medicines: Plant-based therapies used in whole systems of medicine or as individual preparations by allopathic providers and consumers for specific symptoms or issues C. Macrobiotic diet: Predominantly a vegan diet (no animal products except fish); initially used in the management of a variety of cancers; emphasis placed on whole cereal grains, vegetables, and unprocessed foods D. Mycotherapies: Fungi-based (mushroom) products E. Orthomolecular medicine (megavitamin): Increased intake of nutrients such as vitamin C and beta-carotene; treats cancer, schizophrenia, autism, and certain chronic diseases such as hypercholesterolemia and coronary artery disease F. Probiotics: Live microorganisms (in most cases, bacteria) that are similar to beneficial microorganisms found in the human gastrointestinal system; also called good bacteria G. The "Zone": Dietary program that requires eating protein, carbohydrate, and fat in a 30:40:30 ratio—30% of calories from protein, 40% from carbohydrate, and 30% from fat; used to balance insulin and other hormones for optimal health

Spiritual Health Critical Thinking

A. Each person has a unique spirituality. B. Personal experience in caring for patients in spiritual distress is valuable when helping patients select coping options.

Humor and Laughter

A. Establish relationships B. Relieve tension and anxiety C. Release anger and aggression D. Facilitate learning E. Cope with painful feelings F. Others do not always appreciate nursing humor

The Need for Evidence-Based Practice

A. Evidence-based care-Improves quality, safety, and patient outcomes-Increases nurse satisfaction-Reduces costs B. Evidence-based care improves quality, safety, patient outcomes, and nurse satisfaction while reducing costs. C. Implementing evidence-based practice (EBP) helps you make effective, timely, and appropriate clinical decisions in response to the broad political, professional, and societal forces present in today's health care environment. D. Nurses make important clinical decisions when caring for patients. It is important to translate best evidence into best practices at a patient's bedside. E. EBP is a problem-solving approach to clinical practice that integrates the conscientious use of best evidence in combination with a clinician's expertise and patient preferences and values in making decisions about patient care. F. Today EBP is an expectation of all health care institutions and professional nurses.

Nursing Knowledge Base & Self-Concept

A. Factors influencing the development of self-concept -Erikson's theory of development i. Each stage builds on the tasks of the previous stage ii. Successful mastery of each stage leads to a solid sense of self. iii. Self-esteem usually increases in early and middle childhood, adolescence, increases strongly in young adulthood, continues to increase in middle adulthood, and peaks between ages 60 and 70 years. iv. Self-esteem diminishes in old age; sharp drop in very old age

Family Effect on Self-Concept Development

A. Family plays key role -Children develop sense of self from family caregivers -Also gain accepted norms from family B. High parental support and parental monitoring are related to greater self-esteem and lower risk behaviors C. Positive communication and social support foster self-esteem and well-being in adolescence •Sometimes well-meaning parents cultivate negative self-concepts in children. Some literature suggests that parents are the most important influences on a child's development, yet variations in parenting approach depend on the culture. •Specifically a child's positive self-esteem and school achievement are fostered by parents who respond in a firm, consistent, and warm manner. •Parents who are harsh, inconsistent, or have low self-esteem themselves often behave in ways that foster negative self-concepts in their children. •Self-concept change demands an evidence-based practice approach supported by the entire health care team.

Types of Theory

A. Grand: Broad in scope, complex, more abstract -King - Goal Attainment B. Middle-range: Limited in scope and less abstract -Pender - Health Promotion -Benner - Skill Acquisition C. Practice: Narrow in scope and focus -Pain Management D. Theories have different purposes and are sometimes classified by levels of abstraction (grand versus middle-range versus practice theories) or the goals of the theory (descriptive or prescriptive).E. A grand theory does not provide guidelines for specific nursing interventions but provides the structural framework for broad and abstract ideas related to nursing. F. Middle-range theories address a specific phenomenon and reflect practices of administration, clinical interventions, or teaching. A middle-range theory tends to focus on a concept found in a specific field of nursing, such as uncertainty, incontinence, social support, quality of life, and caring, rather than reflect on a wide variety of nursing care situations, as the grand theories do. G. Practice theories, also known as situation-specific theories, bring theory to the bedside. Narrow in scope and focus, these theories guide the nursing care of a specific patient population at a specific time. H. Descriptive theories do not direct specific nursing activities or attempt to produce change but rather help to explain patient assessments. I. Nurses use prescriptive theories to anticipate the outcomes of nursing interventions

Nursing Process: Implementation & Spiritual Health

A. Health promotion -Establishing presence—involves giving attention, answering questions, having an encouraging attitude, and expressing a sense of trust; "being with" rather than "doing for" -Supportive healing relationship i. Mobilize hope. ii. Provide interpretation of suffering that is acceptable to patient. iii. Help patient use resources. B. Acute care -Support systems -Diet therapies -Supporting rituals C. Restorative and continuing care -Prayer-Meditation -Supporting grief work

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.

Theorists

A. Henderson - 14 Activities B. Neuman - Open Systems C. Abdellah - Patient-centered care D. King - Goal Attainment E. Roy - Adaptation F. Watson - Caring G. Rogers - Unitary Beings H. Parse - Human Becoming I. Benner - Skills Acquisition J. Pender - Health Promotion

Complementary, Alternative, and Integrative Approaches to Health Part 2

A. Holistic nursing regards and treats the mind-body-spirit of the patient: Uses holistic nursing interventions such as relaxation therapy, music therapy, touch therapies, and guided imagery B. The American Holistic Nurses Association maintains Standards of Holistic Nursing Practice C. Nurses have historically practiced in an integrative fashion; a review of nursing theory reveals the values of holism, relational care, and informed practice. D. Until recently, nursing identified its practice as holistic rather than integrated. E. Holistic nursing treats the mind-body-spirit of the patient, using interventions such as relaxation therapy, music therapy, touch therapies, and guided imagery. F. The American Holistic Nurses Association maintains Standards of Holistic Nursing Practice, which defines and establishes the scope of holistic practice and describes the level of care expected from a holistic nurse. G. Integrative nursing -Advances health and well-being through caring-healing relationships -Uses evidence to inform traditional and emerging interventions that support whole-person/whole-systems healing H. Weigh risks and benefits of each intervention when recommending complementary therapies I. Grounded in six principles, integrative nursing is defined as "a way of being-knowing-doing that advances the health and well-being of persons, families, and communities through caring-healing relationships. Integrative nurses use evidence to inform traditional and emerging interventions that support whole-person/whole-systems healing." J. Although the body of evidence about CAM is growing, limited data make it difficult to establish the specific benefits of complementary therapies. K. Weigh the risk and benefits of each intervention and consider the following when recommending complementary therapies: (1) the history of each therapy (many have been used by cultures for thousands of years to support health and reduce suffering); (2) nursing's history and experience with a particular therapy; (3) outcomes and safety data, including case study and qualitative research; and (4) the cultural influences and context for certain patient populations.Relaxation Therapy

Stressors Affecting Self-Concept

A. Identity stressors -Especially during adolescence B. Role performance stressors -Role conflict -Role ambiguity -Role strain -Role overload C. Body image stressors -Affect appearance, structure or function of a body part D. Self-esteem stressors -Vary by develop-mental stage •Identity stressors can occur at any time during the life span, but particularly during adolescence. •Compared to an adolescent, an adult generally has a more stable identity and thus a more firmly developed self-concept. •Identity confusion results when people do not maintain a clear, consistent, and continuous consciousness of personal identity. Inability to adapt to identity stressors can result in identity confusion regardless of stage of life. •Role performance stressors can occur in relationship to situational transitions that occur when parents, children, spouses, family members, or close friends die, or when people move, marry, divorce, or change jobs. They can also occur when one moves from a place of wellness to illness. •Role conflict results when a person has to assume two or more roles that are inconsistent, contradictory, or mutually exclusive. Negotiating a balance of time and energy between her children and parents creates role conflicts. •The sick role involves the expectations of others and society regarding how an individual behaves when sick. •Role ambiguity involves unclear role expectations, which makes people unsure about what to do or how to do it, creating stress and confusion. Common in adolescence. •Role strain combines role conflict and role ambiguity. •Role overload involves having roles or responsibilities that are unmanageable. This can occur when a person is ill. •Body image stressors include those that occur in appearance, structure, or function of a body part. •The response of society to physical changes in an individual often depends on the conditions surrounding the alteration. •Individuals with high self-esteem generally are more resilient and better able to cope with demands and stressors than those with low self-esteem. Low self-worth contributes to feeling unfulfilled and disconnected from others. •Decreased self-worth potentially can result in depression and unremitting uneasiness or anxiety. •Self-esteem stressors can vary within developmental stages.

Components and Interrelated Terms of Self-Concept

A. Identity-Internal sense of individuality, wholeness, and consistency of a person over time B. Body image-Involves attitudes related to physical appearance, structure, or function C. Role performance D. Self-esteem •Being "oneself" or living an authentic life is the basis of true identity .•An individual first identifies with parenting figures and later with other role models such as teachers or peers. Relationships with parents, teachers, and peers have unique and combined effects on young children's general, academic, and social self-concept. •The achievement of identity is necessary for intimate relationships because individuals express identity in relationships with others. •Cultural differences in identity exist. •Body image involves attitudes related to the body, including physical appearance, structure, or function. Feelings about body image include those related to sexuality, femininity and masculinity, youthfulness, health, and strength. •Be aware that most men and women experience some degree of dissatisfaction with their bodies, which affects body image and overall self-concept. •Cognitive growth and physical development also affect body image. Normal developmental changes such as puberty and aging have a more apparent effect on body image than on other aspects of self-concept. Hormonal changes during adolescence influence body image. •Cultural and societal attitudes and values influence body image. Culture and society dictate the accepted norms of body image and influence one's attitudes. •Body image is more favorable in cultures in which girls describe more reasonable views about physical appearance, report less social pressure for thinness, and have less tendency to base self-esteem on body image. •Body image issues are often associated with impaired self-concept and self-esteem. •Normal changes associated with maturation result in changes in role performance. Ideal societal role behaviors are often hard to achieve in real life. Individuals have multiple roles and personal needs that sometimes conflict. •Role performance is the way in which individuals perceive their ability to carry out significant roles. •Fulfillment of role expectations leads to an enhanced sense of self. Difficulty or failure to meet role expectations leads to deficits and often contributes to decreased self-esteem or altered self-concept. •Self-esteem is an individual's overall feeling of self-worth or the emotional appraisal of self-concept. It is the most fundamental self-evaluation because it represents the overall judgment of personal worth or value. Self-esteem is positive when one feels capable, worthwhile, and competent. •Considering the relationship between a person's actual self-concept and his or her ideal self enhances understanding of that person's self-esteem.

Vulnerable Populations

A. Immigrant populations B. Effects of poverty and homelessness C. Patients who are abused D. Patients with mental illness E. Older adults

Research Process

A. Institutional Review Board (IRB) B. Human Research Terminology-Informed consent means i. Participants receive full and complete information ii. They can understand the information iii. They have free choice to participate iv. They understand how their confidentiality will be kept -Confidentiality C. Before conducting any study with human subjects, the researcher obtains approvals from the agency's human subjects committee or institutional review board. An IRB includes scientists and laypersons who review all studies conducted at the institution to ensure that ethical principles, including the rights of human subjects, are followed. D. Confidentiality guarantees that any information a subject provides will not be reported in any manner that identifies the subject and will not be accessible to people outside the research team.

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

Critically Appraise the Evidence

A. Know the elements of an article and use a careful approach when reviewing each one. B. Evidence-based articles include the following elements: C. Abstract. An abstract is a brief summary that quickly tells you if the article is research or clinically based. An abstract summarizes the purpose of the article. It also includes the major themes or findings and the implications for nursing practice. D. Introduction. The introduction contains more information about the purpose of the article. There is usually brief supporting evidence as to why the topic is important. Together the abstract and introduction help you decide if you want to continue to read the entire article. E. Literature review or background. A good author offers a detailed background of the level of science or clinical information about the topic. The literature review offers an argument about what led the author to conduct a study or report on a clinical topic. This section of an article is very valuable. Even if the article itself does not address your PICOT question the way you desire, the literature review may lead you to other, more useful articles. F. Manuscript narrative. The "middle section" or narrative of an article differs according to the type of evidence-based article it is. A clinical article describes a clinical topic, which often includes a description of the patient population, the nature of a certain disease or health alteration, how patients are affected, and the appropriate nursing therapies. A research article contains several subsections within the narrative, including: G. Purpose statement: Explains the focus or intent of a study. It includes research questions or hypotheses—predictions made about the relationship or difference among study variables. An example of a research question is: Does music therapy reduce a patient's pain and anxiety? H. Methods or design: Explains how a research study was organized and conducted to answer the research question or test the hypothesis. This section explains the type of study that was conducted (e.g., RCT, case control study, or qualitative study) and the number of people who participated in the study. I. Results or conclusions: Both clinical and research articles have a summary section. In a clinical article, the author explains the clinical implications for the topic presented. In a research article, the author details the results of the study and explains whether a hypothesis is supported or how a research question is answered. This section includes a statistical analysis if it is a quantitative research study. A qualitative study summarizes the descriptive themes and ideas that arise from the researcher's analysis of data. J. Clinical implications: A research article includes a section that explains if the findings from the study have clinical implications. The researcher explains how to apply findings in a practice setting for the type of subjects studied.

Theories Used in Nursing Practice and Research

A. Kolcaba's theory of comfort: Enhanced comfort. The intervention of "quiet time" was studied for possible use with patients experiencing cardiac symptoms B. AACN Synergy Model: Nurse competencies, environmental factors, patient characteristics. Clinical judgment and duration of transport were found to influence patient safety during critical care transport C. Mishel's uncertainty in illness theory: Appraisal and management of uncertainty. Study results indicate that young adults with congenital heart disease are at risk for posttraumatic stress disorder (PTSD) and long-term stress due to chronic uncertainty D. Meleis et al.'s transitions theory: Nursing therapeutics (assessment of readiness, preparation for transition, role supplementation), mindfulness. A mindfulness-based transition program was applied to mothers with premature rupture of membranes to measure acceptance of pregnancy, readiness to give birth, maternal attachment, and competency in the role of motherhood

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

Implementation & Patient Education

A. Maintain learning attention and participation. B. Build on existing knowledge. C. Select teaching approach. D. Incorporate teaching with nursing care. E. Select appropriate instructional methods: -Group instruction -One-on-one discussion -Preparatory instruction -procedure -Demonstration -Analogy -Role playing -Simulation F. Illiteracy and other disabilities G. Cultural diversity H. Using different teaching tools I. Special needs of children and older adults

Meditation and Breathing

A. Meditation -Any activity that limits stimulus input by directing attention to a single unchanging or repetitive stimulus, person becomes more aware of self B. Clinical application -Lowers oxygen consumption, reduces respiratory and heart rates, and reduces anxiety, lowers BP C. Limitations -May become hypotensive -May enhance effects of certain drugs D. Meditation includes a wide range of practices that involve relaxing the body and stilling the mind. E. Four components of meditation are (1) a quiet space, (2) a comfortable position, (3) a receptive attitude, and (4) a focus of attention. F. Meditation differs from relaxation; the purpose of meditation is to become "mindful," increasing our ability to live freely and escape destructive patterns of negativity. G. Most meditation techniques involve slow, relaxed, deep abdominal breathing that evokes a restful state, lowers oxygen consumption, reduces respiratory and heart rates, and reduces anxiety. H. Meditation reduces overall systolic and diastolic blood pressures and significantly reduces hypertensive risk. It also successfully reduces relapses in alcohol treatment programs. Patients with cancer who use mindfulness-based cognitive therapies often experience less depression, anxiety, and distress, and report an improved quality of life. Patients suffering from posttraumatic stress disorder and chronic pain also benefit from mindfulness meditation. Meditation increases productivity, improves mood, increases sense of identity, and lowers irritability. I. Considerations for the appropriateness of meditation include the person's degree of self-discipline; meditation requires ongoing practice to achieve lasting results. Most meditation activities are easy to learn and do not require memorization or particular procedures. J. Meditation is contraindicated for some people. A person who has a strong fear of losing control will possibly perceive it as a form of mind control and thus will be resistant to learning the technique. Some individuals become hypotensive during meditation and require a much shorter session than the average 15- to 20-minute session. K. Meditation may enhance the effects of certain drugs. Therefore, monitor individuals learning meditation closely for physiological changes with respect to their medications. Prolonged practice of meditation techniques sometimes reduces the need for antihypertensive, thyroid-regulating, and psychotropic medications (e.g., antidepressants, antianxiety agents). In these cases, adjustment of the medication is necessary.

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

The Integrative Nursing Role

A. Need to encourage dialogue about the use of Complimentary and Alternative Medicine B. Responsibility to understand the benefits of therapies that encourage active patient participation C. Multiple practitioner approach: integrative D. Holistic in nature E. Follow Nurse Practice Act scope of practice. F. Work closely with patient -Most people using and seeking information about CAM are well educated and have a strong desire to actively participate in decision making about their health care. Allopathic physicians have increasing concerns that current conventional medicine is not meeting the needs of their patients. -Mainstream physicians who have increasing concerns that current conventional medicine is not meeting the needs of their patients. -All providers, including nurses, need to encourage open, honest dialogue about the use of CAM by patients and better understanding of the benefits of therapies that encourage active participation by patients in preventing or managing illness rather than relying solely on surgery or drugs. -Integrative health care involves interprofessional group practices in which a patient seeks care simultaneously from more than one type of practitioner. An interprofessional group practice represents a truly integrated system where all practitioners work side-by-side to improve the well-being of their patients. -This integrative approach is consistent with nursing's patient-centered legacy, focused on whole-person well-being and health. -Nurses should be essential participants in this type of health care delivery system as many already practice the use of touch, relaxation techniques, imagery, and breathwork using the principles of integrative nursing. -Know which patient is most likely to benefit from each therapy, which complications might occur, and which precautions are needed when using these therapies. -Familiarize yourself with the evidence in each modality that you incorporate into your practice. Know which patient is most likely to benefit from each therapy, when to employ the various therapies, which complications might occur, and which precautions are needed when using these therapies. -You need enough knowledge to discuss the full range of possible therapeutic options, both biomedical and complementary, so that you can help patients make informed health care decisions. -Always ask patients directly about their use of complementary therapies, including self-care activities such as yoga, meditation, or dietary supplements. -Be aware of the safety precautions for each complementary therapy and incorporate these in your teaching plans. Understand your state Nurse Practice Act with regard to complementary therapies and practice only within the scope of these laws.

Nursing Theories

A. Nightingale's Environmental Theory -Environment as the focus of nursing care -Grand theory B. Peplau's Interpersonal Theory -Focus on interpersonal relations between nurse, patient, and patient's family -Phases: preorientation, orientation, working, resolution -Middle-range theory C. Florence Nightingale is credited with developing the first nursing theory. The focus of Nightingale's grand theory is a patient's environment, which Nightingale believed nurses should manipulate (such as ventilation, light, decreased noise, hygiene, nutrition) so nature is able to restore a patient to health. Through observation and data collection, she linked the patient's health status with environmental factors and initiated improved hygiene and sanitary conditions during the Crimean War. F. Hildegard Peplau is considered to be the mother of psychiatric nursing; the focus of her middle-range theory includes interpersonal relations among a nurse, a patient, and a patient's family, and developing the nurse-patient relationship. According to Peplau, nurses help patients reduce anxiety by converting it into constructive actions. G. The phases of the nurse patient interpersonal relationship include: preorientation (data gathering), orientation (defining issue), working phase (therapeutic activity), and resolution (termination of relationship). In developing a nurse-patient relationship, the nurse serves as a resource person, counselor, and surrogate. H. As the nurse-patient relationship develops, the nurse and patient mutually define the problems and potential solutions. When the patient's original needs are resolved, new needs sometimes emerge. I. This middle-range theory is useful in establishing effective nurse-patient communication when obtaining a nursing history, providing patient education, or counseling patients and their families

Nurse's Effect on Patient's Self-Concept

A. Nurses need to remain aware of their own feelings, ideas, values, expectations, and judgments: -Use a positive and matter of fact approach. -Build a trusting relationship. -Be aware of facial and body expressions. B. Your acceptance of a patient with an altered self-concept can promote positive change. Often this simply involves sitting with a patient and forming a therapeutic relationship. C. You need to remain aware of your own feelings, ideas, values, expectations, and judgments. Self-awareness is critical in understanding and accepting others. D. Nurses derive their self-concepts and professional identity from their public image; work environment; education; and their professional, social, and cultural values. E. Nurses need to assess and clarify the following self-concept issues about themselves: -Thoughts and feelings about lifestyle, health, and illness -Awareness of how their own nonverbal communication affects patients and families -Personal values and expectations and how these affect patients -Ability to convey a nonjudgmental attitude toward patients and families-Preconceived attitudes toward cultural differences in self-concept and self-esteem F. Some patients with a change in body appearance or function are extremely sensitive to the verbal and nonverbal responses of the health care team. G. Nurses have a significant effect on patients by conveying genuine interest and acceptance. Including self-concept issues in the planning and delivery of care can influence patient outcomes positively. H. Your nursing care significantly affects a patient's body image. Patients closely watch the reactions of others to their wounds and scars, and it is very important to be aware of your responses toward the patient. Nonverbal behaviors convey the level of caring that exists for a patient and affect self-esteem. I. Learn to design specific self-concept interventions to fit a patient's profile of risk factors. It is essential to assess a patient's perception of a problem and work collaboratively to resolve self-concept issues.

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.

Patient Teaching Creative Visualization

A. Objective -The patient will demonstrate skills in creative visualization. B. Teaching Strategies -Set mutual goals the patient can meet. Success leads to confidence and increased self-esteem. -Create a clear image. Although it is sometimes difficult to develop a visual image, if the patient views the goals of the imagery with clear thoughts and in the present tense, the patient will be more successful in creating an effective image. -Have the patient frequently visualize the image. Have him or her perform this visualization during relaxing states and throughout the day but particularly before bedtime or on wakening, when his or her mind usually is more relaxed. -Have the patient repeat encouraging statements while focusing on the image. This alleviates any doubts about his or her ability to achieve established goals. C. Evaluation Use the principles of teach-back to evaluate patient/family caregiver learning: -Describe when you plan to use visualization. -I want to be sure I described this therapy well. Please explain to me the steps you are going to take to practice visualization.

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 Theories (cont.)

A. Orem's Self-Care Deficit Nursing Theory -Focuses on patient's self-care needs -Goal is for patient to manage his or her health problems.-Grand theory B. Leininger's Culture Care Theory -Theory of cultural care diversity and universality -Integrates patients' cultural traditions, values and beliefs into care plans -Middle-range theory C. Dorothea Orem's theory is commonly used in nursing practice. When applying this grand theory, a nurse continually assesses a patient's ability to perform self-care and intervenes as needed to ensure that the patients meets physical, psychological, sociological, and developmental needs. According to Orem, people who participate in self-care activities are more likely to improve their health outcomes. Nursing care becomes necessary when patients are unable to fulfill biological, psychological, developmental, or social needs. Nurses continually assess and determine why patients are unable to meet these needs, identify goals to help them, intervene to help them perform self-care, and evaluate how much self-care they are able to perform. D. Madeleine Leininger recognized the need to focus on culture in nursing, as she predicted that nursing and health care would become more global. She blended her background in anthropology with nursing to form her middle-range theory of cultural care diversity and universality. Human caring varies among cultures in its expressions, processes, and patterns. Social structure factors, such as a patient's politics, culture, and traditions, are significant forces affecting care and influencing the patient's health and illness patterns. E. The major concept of Leininger's theory is cultural diversity, and the goal of nursing care is to provide a patient with culturally specific nursing care. To provide care to patients of unique cultures, nurses safely integrate their cultural traditions, values, and beliefs into a plan of care. Leininger's theory recognizes the importance of culture and its influence on everything that involves a patient, including health beliefs, the role of family and community, and dietary practices.

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.

Care: Religious versus Spiritual

A. Patients benefit from both types of care: -Religious care: helping patients maintain faithfulness to their belief system and worship practices -Spiritual care: helping people identify meaning and purpose in life, look beyond the present, and maintain personal relations as well as a relationship with a higher being or life force

Phases of the Helping Relationship

A. Preinteraction Phase Before meeting a patient: • Review available data, including the medical and nursing history. • Talk to other caregivers who have information about the patient. • Anticipate health concerns or issues that arise.• Identify a location and setting that fosters comfortable, private interaction. • Plan enough time for the initial interaction. B. Orientation Phase When you and a and patient meet and get to know one another: • Set the tone for the relationship by adopting a warm, empathetic, caring manner. • Recognize that the initial relationship is often superficial, uncertain, and tentative. • Expect the patient to test your competence and commitment. • Closely observe the patient and expect to be closely observed by the patient. • Begin to make inferences and form judgments about patient messages and behaviors. • Assess the patient's health status. • Prioritize the patient's problems and identify his or her goals. • Clarify the patient's and your roles. • Form contracts with the patient that specify who will do what. • Let the patient know when to expect the relationship to be terminated. C. Working Phase When you and a patient work together to solve problems and accomplish goals: • Encourage and help the patient express feelings about his or her health. • Encourage and help the patient with self-exploration. • Provide information needed to understand and change behavior. • Encourage and help the patient set goals. • Take action to meet the goals set with the patient. • Use therapeutic communication skills to facilitate successful interactions. • Use appropriate self-disclosure and confrontation. D. Termination Phase During the ending of the relationship: • Remind the patient that termination is near. • Evaluate goal achievement with the patient. • Reminisce about the relationship with the patient. • Separate from the patient by relinquishing responsibility for his or her care. • Achieve a smooth transition for the patient to other caregivers as needed.

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

Touch

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

Acupuncture

A. Regulates or realigns vital energy (qi) CHē, which flows through channels in the form of a system of pathways called meridians B. Effective for pain C. Also used to treat other disorders with varying effectiveness D. As a key component of TCM, acupuncture is one of the oldest practices in the world. -When applied outside the whole system practice of TCM, acupuncture is viewed as a mind-body therapy and is called medical acupuncture. -In the United States, medical acupuncture is often provided as an individual treatment by conventionally trained health care providers. E. Acupuncture regulates or realigns the vital energy (qi), CHē which flows like a river through the body in channels that form a system of 20 pathways called meridians. An obstruction in these channels blocks energy flow in other parts of the body. Acupuncturists insert needles in specific areas along the channels called acupoints, through which the qi can be influenced and flow reestablished. F. Current evidence shows that acupuncture modifies the body's response to pain and how pain is processed by central neural pathways and cerebral function. G. Acupuncture is effective for a variety of health problems, such as low back pain, myofascial pain, hot flashes, simple and migraine headaches, osteoarthritis, plantar heel pain, and chronic shoulder pain. H. Acupuncture is a safe therapy when the practitioner has the appropriate training and uses sterilized needles. Although needle complications occur (e.g., infection, fainting), they are rare if the practitioner takes appropriate steps to ensure the safety of the equipment and the patient. I. In addition, you need to exercise caution when using acupuncture with pregnant patients and those who have a history of seizures, are carriers of hepatitis, or are immune compromised. Treatment is contraindicated in persons who have bleeding disorders and skin infections.

Relaxation Therapy

A. Relaxation Response B. Progressive relaxation C. Passive relaxation D. Limitations E. Some CAM therapies are general in nature and use natural processes to help patients with acute or chronic conditions. They are easily learned by health care professionals. F. The relaxation response is the state of generalized decreased cognitive, physiological, and/or behavioral arousal. G. The process of relaxation elongates the muscle fibers, reduces the neural impulses sent to the brain, and decreases the activity of the brain, as well as other body systems. Decreased heart and respiratory rates, blood pressure, and oxygen consumption and increased alpha brain activity and peripheral skin temperature characterize the relaxation response. H. Relaxation helps individuals develop cognitive skills to reduce the negative ways in which they respond to situations within their environment. Cognitive skills include the following: -Focusing (the ability to identify, differentiate, maintain attention on, and return attention to simple stimuli for an extended period). -Passivity (the ability to stop unnecessary goal-directed and analytic activity). -Receptivity (the ability to tolerate and accept experiences that are uncertain, unfamiliar, or paradoxical). I. Progressive relaxation training teaches an individual how to effectively rest and reduce tension in the body. The person learns to detect subtle localized muscle tension sequentially, one muscle group at a time. -One active progressive relaxation technique involves the use of slow, deep abdominal breathing while tightening and relaxing an ordered succession of muscle groups, focusing on the associated bodily sensations while letting go of extraneous thoughts. J. The goal of passive relaxation is to still the mind and body intentionally without the need to tighten and relax any particular body part. -One effective passive relaxation technique incorporates slow, abdominal breathing exercises while imagining warmth and relaxation flowing through specific body parts such as the lungs or hands. -Passive relaxation is useful for persons for whom the effort and energy expenditure of active muscle contracting leads to discomfort or exhaustion. K. Be aware that on occasion some relaxation techniques result in continued intensification of symptoms or the development of altogether new symptoms. L. An important consideration when choosing a relaxation technique is the physiological and psychological status of the individual. Progressive relaxation requires energy and is not recommended for weak patients.

Nursing and the Scientific Approach

A. Research allows you to study nursing questions and problems in greater depth within the context of nursing. -Quantitative •Experimental research •Nonexperimental research •Surveys •Evaluation research -Qualitative •Ethnography •Phenomenology •Grounded theory B. Nursing interventions must be tested through research to determine the measures that work best with specific patients. C. Approaches to research include both quantitative and qualitative methods. D. Quantitative approaches offer precise measurement and quantification. There are many quantitative methods, including: experimental, nonexperimental, survey, and evaluation research. E. Experimental research: One example of experimental research is the randomized controlled trial. An RCT is a true experimental study that tightly controls conditions to eliminate bias with the goal of generalizing the results of the study to similar groups of subjects. F. Because learning to understand how patients experience health problems cannot always be addressed through an RCT, nonexperimental descriptive studies are often used in nursing research. G. Nonexperimental descriptive studies describe, explain, or predict phenomena. Examples of nonexperimental descriptive studies include case control studies and correlational studies. A case control study is one in which researchers study one group of subjects with a certain condition (such as asthma) at the same time as another group of subjects who do not have the condition. A case control study determines if there is an association between one or more predictor variables and the condition. Correlational studies describe the relationship between two variables (such as the age of the adolescents and if the adolescents smoke). The researcher determines if the two variables are correlated or associated with one another and to what extent. H. Surveys obtain information regarding the frequency, distribution, and interrelation of variables among subjects in the study. I. Evaluation research is a form of quantitative research that determines how well a program, practice, procedure, or policy is working. J. Qualitative nursing research is the study of phenomena that are difficult to quantify or categorize, such as patients' perceptions of illness or quality of life. This research involves inductive reasoning to develop generalizations or theories from specific observations or interviews. There are a number of different qualitative research methods, including ethnography, phenomenology, and grounded theory. Each is based on a different philosophical or methodological view of how to collect, summarize, and analyze qualitative data.

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.

Evaluation & Patient Education

A. See through the patient's eyes. -Have the patient's learning needs been met? -Reinforces correct behavior, changing incorrect behavior, helps educator determine adequacy of teaching. B. Patient outcomes: -Legal responsibility -Documentation C. Teach back

Nursing Process: Assessment & Patient Education

A. See through the patient's eyes. -Teaching is patient-centered. B. Assess the patient's learning needs. -Information or skills needed to perform self-care and to understand the implications of a health problem. -Patient experiences that influence the need to learn. -Information that family caregivers need to support patient needs. C. Motivation to learn D. Readiness and ability to learn E. Teaching environment F. Resources for learning G. Health literacy

The Need for Evidence-Based Practice (cont.)

A. Sources of evidence -Textbooks -Articles from nursing and health care literature -Quality Improvement and risk management data -Standards of care -Infection control data -Benchmarking, retrospective, or concurrent chart reviews -Clinicians' expertise B. There are many sources of evidence. The challenge is to obtain the very best, most relevant, current, and accurate information at the right time, when you need it for patient care. C. A good textbook incorporates evidence into the information, practice guidelines, and procedures it includes. D. Articles from nursing and health care literature are available on almost any topic involving nursing practice in either journals or on the Internet. E. Another source of evidence comes from quality improvement and risk management data; international, national, and local standards of care; infection control data; benchmarking, retrospective, or concurrent chart reviews; and clinicians' expertise. F. The best information is evidence that comes from well-designed, systematically conducted research studies, mostly found in scientific journals. It is important to rely more on research evidence rather than solely on evidence that is not research based. G. When you face a clinical problem, always ask yourself where you can find the best evidence to help you find the best solution in caring for patients. Even when you use the best evidence available, application and outcomes will differ on the basis of your patient's values, preferences, concerns, and/or expectations. As a nurse you develop critical thinking skills to determine whether evidence is relevant and appropriate to your patients and to a clinical situation. H. For example, a single research article suggests that using medical clowns is an effective intervention for reducing fear and anxiety in children. However, if your patient is afraid of clowns, you will need to search for a better evidence-based therapy that your patient will accept. I. Using your clinical expertise and considering patient values and preferences ensures that you apply the evidence available in practice both safely and appropriately.

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.

Animal-Assisted Therapy

A. Specifically selected animals used as a treatment modality in health and human service settings B. Resident animals -Live at long-term health care facilities -Gravitate to most isolated or depressed clients

Factors Influencing Spirituality

A. Spiritual distress: -Impaired ability to experience and integrate meaning and purpose in life through connectedness with self, others, art, music, literature, nature, and/or a power greater than oneself -Acute illness -Chronic illness -Terminal illness -Near-death experience

Spiritual Health

A. Spiritual health represents a balance. B. Spiritual health matures with increasing awareness of meaning, purpose, and life values. C. Spiritual beliefs change as patients grow and develop.

Nurse Practice Acts (NPAs)

A. State and provincial nurse practice acts (NPAs) establish specific legal regulations for practice, and professional organizations establish standards of practice as criteria for nursing care. a. Overseen by State Boards of Nursing -In the United States, the State Boards of Nursing oversee NPAs. b. Regulate scope of nursing practice -NPAs regulate the scope of nursing practice and protect public health, safety, and welfare. c. Protect public health, safety, and welfare -This protection includes shielding the public from unqualified and unsafe nurses. Although each state defines for itself the scope of nursing practice, most have similar NPAs.

Collect the Best Evidence

A. The hierarchy of available evidence offers a guide to the types of literature or information that offer the best scientific evidence. B. This diagram of the hierarchy of evidence shows that stronger evidence is farther up the triangle. For instance, a well-designed randomized controlled trial (RCT) carries more weight than even the opinions of experts. C. At the top of the pyramid are systematic reviews or meta-analyses, which are state-of-the-art summaries from an individual researcher or panel of experts. Meta-analyses and systematic reviews are the perfect answers to PICOT questions because they rigorously summarize current evidence. D. In a meta-analysis, the researcher uses statistics to show the effect of an intervention on an outcome. E. In a systematic review, no statistics are used to draw conclusions about the evidence. F. RCTs are the most precise forms of experimental study and therefore are the gold standard for research. A single RCT is not as conclusive as a review of several RCTs on the same question. However, a single RCT that tests the intervention included in your question yields very useful evidence. G. If RCTs are not available, you can use results from other research studies such as descriptive or qualitative studies, to help answer your PICOT question. H. The use of clinical experts is at the bottom of the evidence pyramid, but do not consider clinical experts to be a poor source of evidence. Expert clinicians use evidence frequently as they build their own practice, and they are rich sources of information for clinical problems.

Implementation & Communication

A. Therapeutic communication techniques -Active listening i. Being attentive to what a patient is saying both verbally and nonverbally ii. SURETY Model -Sharing observations -Sharing empathy -Sharing hope -Sharing humor -Sharing feelings -Using touch -Using silence -Providing information -Clarifying -Focusing -Paraphrasing -Validation -Asking relevant questions -Summarizing -Self-disclosure -Confrontation B. Nontherapeutic communication techniques -Asking personal questions -Giving personal opinions -Changing the subject -Automatic responses -False reassurance -Sympathy -Asking for explanations -Approval or disapproval -Defensive responses -Passive or aggressive responses -Arguing C. Adapting communication techniques for the patient with special needs -Use thought and sensitivity -Adapt to unique circumstances, developmental level, or cognitive and sensory deficits

Nursing Process: Evaluation & Spiritual Health

A. Through the patient's eyes -Include the patient in your evaluation of care. -Outcomes established during the planning phase serve as the standards to evaluate the patient's progress.

Purposes of Patient Education

A. To help individuals, families, or communities achieve optimal levels of health B. Patient education includes: -Maintenance and promotion of health and illness prevention -Restoration of health -Coping with impaired functioning

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.

Focus on Older Adults The Importance of Touch

A. Touch is a primal need, as necessary as food, growth, or shelter. Touch is like a nutrient transmitted through the skin, and "skin hunger" is like a form of malnutrition that has reached epidemic proportions in the United States, especially among older adults. B. Older adults need touch as much as or more than any other age-group. However, older adults often experience "skin hunger." Older adults often have fewer family members or friends to touch them at a time when simple touch may enhance communication, especially when other senses are reduced. C. Simple touch helps older adults feel more connected to and accepted by those around them and more in tune with their environment. Touch enhances self-esteem and sense of worth. D. Nurses who react adversely to skin changes caused by aging often find it difficult to touch older adults. This reluctance communicates a negative message to the older adult. Therefore be aware of your own reactions to touch when caring for older adults to ensure a therapeutic approach to patient-centered care. E. Be mindful of a patient's own acceptance of touch. Ask permission to hold a hand or give a hug. Once you form a relationship with a patient, touch can usually be more spontaneous.

Culturally Congruent Care

A. Transcultural nursing -A comparative study of cultures to understand their similarities and differences B. Culturally congruent care -Care that fits a person's life patterns, values, and system of meaning C. Leininger defines transcultural nursing as a comparative study of cultures to understand their similarities (culture that is universal) and the differences among them (culture that is specific to particular groups). The goal of transcultural nursing is to provide culturally congruent care, or care that fits a person's life patterns, values, and system of meaning. Patterns and meaning are generated by people themselves rather than from predetermined criteria. D. Effective nursing care integrates the cultural values and beliefs of individuals, families, and communities with the perspectives of a multidisciplinary team of health care providers. E. When you provide culturally congruent care, you bridge cultural gaps to provide meaningful and supportive care for all patients. F. Do not assume that all members of a cultural group will feel the same way about a given situation. Instead, combine your knowledge about a cultural group with an attitude of helpfulness and flexibility to provide quality, patient-centered, culturally congruent care. G. Cultural competence or cultural respect H. Meaningful and useful care strategies based on knowledge of the cultural heritage, beliefs, attitudes, and behaviors of those to whom they render care -Acculturation -Assimilation

Self-Concept: Developmental Tasks

A. Trust versus Mistrust (Birth to 18 Months) -Develops trust following consistency in caregiving and nurturing interactions -Distinguishes self from environment B. Autonomy versus Shame and Doubt (18-24 Months to 3 Years) -Begins to communicate likes and dislikes -Increasingly independent in thoughts and actions -Appreciates body appearance and function (e.g., dressing, feeding, talking, and walking) C. Initiative versus Guilt (3 to 5 Years) -Identifies with a gender -Enhances self-awareness-Increases language skills, including identification of feelings D. Industry versus Inferiority (6 to 11 Years) -Incorporates feedback from peers and teachers -Increases self-esteem with new skill mastery (e.g., reading, mathematics, sports, music) -Aware of strengths and limitations E. Identity versus Role Confusion (12 to 18 Years) -Accepts body changes/maturation -Examines attitudes, values, and beliefs; establishes goals for the future -Feels positive about expanded sense of self F. Intimacy versus Isolation (Late Teens to Mid-40s) -Has stable, positive feelings about self-Experiences successful role transitions and increased responsibilities G. Generativity versus Self-Absorption (Mid-40s to Mid-60s) -Able to accept changes in appearance and physical endurance -Reassesses life goals-Shows contentment with aging H. Ego Integrity versus Despair (Mid-Late 60s to Death) -Feels positive about life and its meaning-Interested in providing a legacy for the next generation

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

Professional Roles of a Nurse

A. You are responsible for obtaining and maintaining specific knowledge and skills for a variety of professional roles and responsibilities. a. Autonomy and Accountability: Autonomy is an essential element of professional nursing that involves the initiation of independent nursing interventions without medical orders. Accountability means that you are responsible professionally and legally for the type and quality of nursing care provided. b. Caregiver: As a caregiver, you help patients maintain and regain health and find their maximum level of independent function through the healing process. A patient's health care needs include the patient's emotional, spiritual, and social well-being. c. Advocate: As a patient advocate you protect your patient's human and legal rights and help patients assert those rights when needed. d. Educator: As an educator, your teaching can be formal or informal. Always use teaching methods that match your patient's capabilities and needs, and incorporate other resources, such as the family, in teaching plans. e. Communicator: Your effectiveness as a communicator is central to the nurse—patient relationship. It allows you to know your patients, including their strengths, weaknesses, and needs. You will routinely communicate with patients and families, other nurses and health care professionals, resource people, and the community. f. Manager: As a manager, you will establish an environment for collaborative patient-centered care to provide safe, quality care with positive patient outcomes.

confidentiality

Act of keeping information private or secret; in health care the nurse shares information about a patient only with other nurses or health care providers who need to know private information about a patient to provide care for him or her; information can only be shared with the patient's consent.

discharge planning

Activities directed toward identifying future proposed therapy and the need for additional resources before and after returning home.

Benner's stages of nursing proficiency

Novice • Beginner with no experience • Taught general rules to help perform tasks • Rules are: context-free, independent of specific cases, and applied universally • Rule-governed behavior is limited and inflexible• Ex. "Tell me what I need to do and I'll do it." Advanced Beginner • Demonstrates acceptable performance • Has gained prior experience in actual situations to recognize recurring meaningful components • Principles, based on experiences, begin to be formulated to guide actions Competent • Typically a nurse with 2-3 years experience on the job in the same area or in similar day-to-day situations • More aware of long-term goals • Gains perspective from planning own actions based on conscious, abstract, and analytical thinking and helps to achieve greater efficiency and organization Proficient • Perceives and understands situations as whole parts • More holistic understanding improves decision-making • Learns from experiences what to expect in certain situations and how to modify plans Expert • No longer relies on principles, rules, or guidelines to connect situations and determine actions • Much more background of experience • Has intuitive grasp of clinical situations • Performance is now fluid, flexible, and highly-proficient

Developing a PICOT Question

P = Patient population of interest Identify patients by age, gender, ethnicity, and disease or health problem. I = Intervention or area of interest Which intervention is worthwhile to use in practice (e.g., a treatment, diagnostic test, prognostic factor)? What area of interest influences a desired outcome (e.g., complementary therapy, motivational interviewing). C = Comparison intervention or area of interest What is the usual standard of care or current intervention used now in practice? O = Outcome What result do you wish to achieve or observe as a result of an intervention (e.g., change in patient behavior, physical finding, or patient perception)? T = Time What amount of time is needed for an intervention to achieve an outcome (e.g., the amount of time needed to change quality of life or patient behavior)?

Nursing: Goal of Scope and Standards of Practice

To improve the health and well-being of all individuals, communities, and populations through the significant and visible contributions of registered nursing using standards-based practice

Nursing Process

assessment, diagnosis, outcome identification, planning, implementation, evaluation