Nursing 2101
Student Care Plans
Because student care plans are a learning activity as well as a plan of care, they may be more lengthy and detailed than care plans used by working nurses. Educators may also modify the three-, four-, or five- column plan by adding a column for "Rationale" after the nursing interventions column. A rationale is the scientific principle given as the reason for selecting a particular nursing intervention. Students may also be required to cite supporting literature for their stated rationale.
Impact of Illness on the Client
Behavioral and emotional changes Loss of autonomy Self-concept and body image changes Lifestyle changes
Internal Variables
Biologic dimension (genetic makeup, gender, age, and developmental level) Psychologic dimension (mind-body interactions and self-concept) Cognitive dimension (intellectual factors include lifestyle choices and spiritual and religious beliefs)
Horticultural Therapy
Botanical (plant) healings are used by 80% of the world's population. These include herbs, aromatherapy, homeopathy, and naturopathy
Components of the Evaluation Process
Collecting data related to the desired outcomes (NOC indicators) Comparing the data with outcomes Relating nursing activities to outcomes Drawing conclusions about problem status Continuing, modifying, or terminating the nursing care plan The nurse determines the client's progress toward goal achievement and the effectiveness of the nursing care plan. The plan may be continued, modified, or terminated. Goal met? Goal not met? Goal partially met? Reason behind the exlpanation
Computerized care plans:
Computers are increasingly being used to create and store nursing care plans. The computer can generate both standardized and individualized care plans.
Concept maps (student care plan):
Concept maps- visual tool in which ideas or data are enclosed in circles or boxes of some shape and relationships between these are indicated by connecting lines or arrows. Often used to complex relationships among ideas, processes, actions. Pathophysiology flow sheets or concept maps are used to depict linkages between disease processes, laboratory data, medications, signs and symptoms, risk factors, and other relevant data.
Health Beliefs
Concepts about health that an individual believes are true. Such beliefs may or may not be founded on fact. Some of these are influenced by culture.
Goals/Desired Outcomes:
Describe what the nurse wants to achieve by implementing the nursing interventions. Purposes: Provides direction for planning nursing interventions Serves as criteria for evaluating client progress Enables determination of problem resolution Helps motivate by providing a sense of achievement Goals are derived from the client's nursing diagnoses—primarily from the diagnostic label. For every nursing diagnosis, the nurse must write the desired outcome or outcomes that, when achieved, directly demonstrate resolution of the problem.
Guidelines for Writing Nursing Care Plans
Date and sign the plan Use category headings Use standardized/approved medical or English symbols and key words Be specific Refer to procedure book or other sources rather than including all steps on written plan Tailor the plan to the client Incorporate prevention and health maintenance Include interventions for ongoing assessment Include collaborative and coordination activities Include discharge plans and home care
Nursing diagnoses:
Describes human responses to disease processes/health problems Oriented to the client Nurse responsible for diagnosing, treatment orders, actions May change frequently Classification system in development
Problem (diagnostic label) and definition:
Describes the client's health problem or response for which nursing therapy is given. It describes the client's health status clearly and concisely in a few words. The purpose of the diagnostic label is to direct the formation of client goals and desired outcomes. It may also suggest some nursing interventions.
Discharge Planning:
Discharge planning, the process of anticipating and planning for needs after discharge, is a crucial part of comprehensive health care and should be addressed in each client's care plan. EFFECTIVE DISCHARGE PLANNING BEINGS AT FIRST CLIENT CONTACT and involves comprehensive and ongoing assessment to obtain information about the client's ongoing needs.
Manual Healing Methods
Manual healing methods include chiropractic, massage, and other modalities. The three most prominent therapies using the hands to alter the biofield, or energy field, are therapeutic touch (TT), healing touch (HT), and Reiki. All three approaches could be simply defined as the use of the hands on or near the body with the intention to help or to heal. The goals are to accelerate the person's own healing process and to facilitate healing at all levels of body, mind, emotions, and spirit.
The action stage:
Occurs when the person actively implements behavioral and cognitive strategies of the action plan to interrupt previous health risk behaviors and adopt new ones. This stage requires the greatest commitment of time and energy.
The preparation stage:
Occurs when the person intends to take action in the immediate future (e.g., within the next month). Some people in this stage may have already started making small behavioral changes, such as buying a self-help book. At this stage, the person makes the final specific plans to accomplish the change.
Ongoing Planning:
Ongoing planning is done by all nurses who work with the client. As nurses obtain new information and evaluate the client's responses to care, they can individualize the initial care plan further. Ongoing planning also occurs at the beginning of a shift as the nurse plans the care to be given that day.
Quality Assurance
Ongoing, systematic process Evaluate and promote excellence in provision of health care May evaluate the level of care provided May be evaluation of performance of one nurse or an agency or country
Stages of Health Behavior Change
PRECONTEMPLATION CONTEMPLATION PREPARATION ACTION MAINTENANCE TERMINATION
Nuclear Family
Parents and their children who live together
The top 10 reasons to improve thinking include:
Patients are sicker, with multiple problems. There is more consumer involvement (patients and families). Nurses must be able to move from one setting to another. Rapid change and information explosion requires us to develop new learning and workplace skills. Consumers and payers demand to see evidence of benefits, efficiency, and results. Today's progress often creates new problems that can't be solved by old ways of thinking. Redesigning care delivery and nursing curricula is useless if students and nurses don't have the thinking skills required to deal with today's world. It can be done—it doesn't have to be that difficult. Your ability to focus your thinking to get the results you need can make the difference between whether you succeed or fail in this fast-paced world.
The seven components of wellness are:
Physical Occupational Emotional Spiritual Intellectual Environmental Social
External Variables
Physical environment Standards of living Family and cultural beliefs Social support networks
Initial planning:
Based on the admission assessment Results in the initial comprehensive plan of care
Herbal Medicine
Be aware that some herbal supplements can be a problem when interacting with prescribed medications. There are no regulations to controlling dosage, purity, safety of these supplements. Many are costly and have no proven efficacy. ALWAYS ask patients being admitted to the hospital if they take herbals, what kind and how much.
Health is:
Presence or absence of disease Complete physical, mental, social well-being Ability to maintain normal roles Process of adaptation to physical and social environment Striving toward optimal wellness Individual definitions Dynamic state of being - developmental and behavioral potential realized to the fullness Health is not something achieved at a specific time, it is an ongoing process, a way of life, through which a person develops and encourages every aspect of the body, mind, and feelings to interrelate harmoniously as much as possible.
Collaborative Problems:
Present when disease/situation present No classification system
Basic Two-Part Statement
Problem Etiology
Basic Three-Part Statement
Problem Etiology (related to) Evidenced by
Clinical Model
Provides the narrowest interpretation of health People viewed as physiologic systems Health identified by the absence of signs and symptoms of disease or injury State of not being "sick" Opposite of health is disease or injury
Health Status
State of health of an individual at a given time. A report of health status may include anxiety, depression, or acute illness and thus describe the individual's problem in general. Health status can also describe such specifics as pulse rate or body temperature.
Formats for Nursing Care Plans:
Student care plans Concept maps Computerized care plans Multidisciplinary (collaborative) care plans, also called critical pathway
Components of Goal/Desired Outcome Statements
Subject. The subject, a noun, is the client, any part of the client, or some attribute of the client. Verb. The verb specifies an action the client is to perform. Verbs that denote directly observable behaviors, such as administer, show, or walk, must be used. Conditions or modifiers. Conditions or modifiers may be added to the verb to explain the circumstances under which the behavior is to be performed. They explain what, where, when, or how. Criterion of desired performance. The criterion indicates the standard by which a performance is evaluated or the level at which the client will perform the specified behavior. These criteria may specify time or speed, accuracy, distance, and quality.
Cues are:
Subjective and objective data that can be directly observed by the nurse.
Examining:
Systematic data-collection method: Cephalocaudal or head to toe. Uses observation and inspection, auscultation, palpation, and percussion: Blood pressure Pulses Heart and lungs sounds Skin temperature and moisture Muscle strength
Nursing Outcomes Classification (NOC)
Taxonomy for describing client outcomes that respond to nursing interventions NOC outcome similar to a goal in traditional language Outcomes broadly stated and conceptual Made more specific by identifying indicators that apply to client Includes a five-point scale (a measure) used to rate the client's status
Nursing Interventions Classification (NIC)
Taxonomy of nursing interventions Developed by the Iowa Intervention Project First published in 1992 Updated every 4 years More than 514 interventions developed Each intervention includes: A label (name) A definition A list of activities that outline key actions Linked to NANDA diagnostic labels Select appropriate intervention and customize
Occupational
The ability to achieve a balance between work and leisure time. A person's beliefs about education, employment, and home influence personal satisfaction and relationships with others.
Physical
The ability to carry out daily tasks, achieve fitness, maintain adequate nutrition and proper body fat, avoid abusing drugs and alcohol or using tobacco products, and generally practice positive lifestyle habits.
Social
The ability to interact successfully with people and within the environment of which each person is a part, to develop and maintain intimacy with significant others, and to develop respect and tolerance for those with different opinions and beliefs.
Intellectual
The ability to learn and use information effectively for personal, family, and career development. Intellectual wellness involves striving for continued growth and learning to deal with new challenges effectively.
Emotional
The ability to manage stress and express emotions appropriately. Emotional wellness involves the ability to recognize, accept, and express feelings and to accept one's limitations.
Environmental
The ability to promote health measures that improve the standard of living and quality of life in the community. This includes influences such as food, water, and air.
Validation is:
The act of double checking or verifying data to confirm that it is accurate and factual. Helps the nurse ensure that assessment information is complete and data agrees.
Health Behaviors
The actions people take to understand their health state, maintain an optimal state of health, prevent illness and injury, and reach their maximum physical and mental potential.
Spiritual
The belief in some force (nature, science, religion, or a higher power) that serves to unite human beings and provide meaning and purpose to life. It includes a person's own morals, values, and ethics.
Planning:
The third phase of the nursing process: Prioritizing problems/diagnoses Formulating client goals/desired outcomes Selecting nursing interventions Writing individualized nursing interventions In planning, the nurse refers to the client's assessment data and diagnostic statements for direction in formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client's health problems
What are the benefits of collaboration between the nurse and the patient?
Their relationship contributes to growth and development of both nurse and patient.
Nursing intervention:
is any treatment based upon clinical judgement and knowledge that a nurse performs to enhance patient outcomes. The end product of the planning phase is the patient care plan.
The termination stage:
is the ultimate goal where the individual has complete confidence that the problem is no longer a temptation or threat.
A medical diagnosis is:
made by a physician and refers to a condition that only a physician can treat. Medical diagnoses refer to disease processes—specific pathophysiologic responses that are fairly uniform from one client to another. Does not consider humans responses. Diagnosis remains as long as disease present. Well-developed and accepted classification.
Protocols are:
pre-printed to indicate the actions commonly required for a particular group of clients. Protocols may include both the physician's orders and nursing interventions.
Priority setting is
the process of establishing a preferential sequence for addressing nursing diagnoses and interventions. The nurse and client begin planning by ranking nursing diagnoses in the order to be addressed. Instead of rank-ordering diagnoses, nurses can group them as having high, medium, or low priority. Life-threatening problems are designated as high priority. Health-threatening problems are assigned medium priority because they may result in delayed development or cause destructive physical or emotional changes. A low-priority problem is one that arises from normal developmental needs or that requires only minimal nursing support.
Assessing is:
the systematic and continuous collection, organization, validation, and documentation of data (information). In effect, assessing is a continuous process carried out during all phases of the nursing process. All phases of the nursing process depend on the accurate and complete collection of data.
Health Risk Factors
Age, sex, racial group General health, lifestyle behaviors, demographic data Occupational risks Genetics
Massage
Aids the ability of the body to heal itself Aimed at achieving or increasing health and well-being
A nursing diagnosis has three components:
(1) the problem and its definition, (2) the etiology, and (3) the defining characteristics.
Defining characteristics:
Are the cluster of signs and symptoms that indicate the presence of a particular diagnostic label. For actual nursing diagnoses, the defining characteristics are the client's signs and symptoms. For risk nursing diagnoses, no subjective and objective signs are present. Thus, the factors that cause the client to be more vulnerable to the problem form the etiology of a risk nursing diagnosis.
Socratic Questioning
A technique one can use to look beneath the surface, recognize and examine assumptions, search for inconsistencies, examine multiple points of view, and differentiate what one knows from what one merely believes.
Healthy People 2020
A SOCIETY IN WHICH ALL PEOPLE LIVE LONG, HEALTHY LIVES. Identify nationwide health improvement priorities. Increase public awareness and understanding of the determinants of health, disease, and disability and the opportunities for progress. Provide measurable objectives and goals that are applicable at the national, State, and local levels. Engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge. Identify critical research, evaluation, and data collection needs. Attain high quality, longer lives free of preventable disease, disability, injury, and premature death. Achieve health equity, eliminate disparities, and improve the health of all groups. Create social and physical environments that promote good health for all. Promote quality of life, healthy development and healthy behaviors across all life stages.
Interviewing:
A planned communication or conversation with a purpose, such as to get or give information, identify problems of mutual concern, evaluate change, teach, provide support, or provide counseling or therapy. Interviewing can be directive or nondirective.
Collaborative interventions
Actions nurse carries out in collaboration with other health team members Reflect overlapping responsibilities of health care team
Nursing Interventions and Activities
Actions nurse performs to achieve goals/desired outcomes Focus on eliminating or reducing etiology of nursing diagnosis Treat signs and symptoms and defining characteristics When it is not possible to change the etiologic factors, the nurse chooses interventions to treat the signs and symptoms or the defining characteristics in NANDA terminology. Interventions for risk nursing diagnoses should focus on measures to reduce the client's risk factors, which are also found in the second clause.
Dependent interventions
Activities carried out under physician's orders or supervision, or according to specified routines
Richard Kalish
Adapted Maslow's hierarchy of needs into six levels rather than five. He suggests an additional category between the physiologic needs and the safety and security needs. This category, referred to as stimulation needs, includes sex, activity, exploration, manipulation, and novelty
Health Care Adherence
Adherence - the extent to which individual's behavior coincides with medical or health advice Nonadherence : 1) Establish why client is not following regimen 2) Demonstrate caring 3) Encourage healthy behaviors through positive reinforcement 4) Use aids to reinforce teaching 5) Establish therapeutic relationship of freedom, mutual understanding, mutual responsibility with client and support persons To enhance adherence, nurses need to ensure that the client is able to perform the prescribed therapy, understands the necessary instructions, is a willing participant in establishing goals of therapy, and values the planned outcomes of behavior changes.
Disease
Alteration in body function A reduction of capacities or a shortening of the normal life span Causation of disease - etiology
Health Care Professionals
Alternative (Complementary Care Providers) Dentists Nurses Nutritionists Occupational Therapists Paramedics/EMTs Pharmacists Physical therapists Physicians Physician assistants Podiatrists Respiratory therapists Social workers Spiritual support personnel Unlicensed assistive personnel (UAPs
Nursing Care Plan:
Although formats differ from agency to agency, the care plan is often organized into four columns or categories: (a) nursing diagnoses, (b) goals/desired outcomes, (c) nursing interventions, and (d) evaluation. Some agencies use a three-column plan in which evaluation is done in the goals column or in the nurses' notes; others have a five- column plan that adds a column for assessment data preceding the nursing diagnosis column.
Steps in Diagnostic Process:
Analyzing Data: 1) Compare data against standards 2) Cluster cues 3) Identify gaps and inconsistencies Identifying health problems, risks, and strengths Formulating diagnostic statements
Reviewing and Modifying the Care Plan (Evaluation Process)
Assessing. An incomplete or incorrect database influences all subsequent steps of the nursing process and care plan. If data are incomplete, the nurse needs to reassess the client and record the new data. Diagnosing. If the database was incomplete, new diagnostic statements may be required. If the database was complete, the nurse needs to analyze whether the problems were identified correctly and whether the nursing diagnoses were relevant to that database. After making judgments about problem status, the nurse revises or adds new diagnoses as needed to reflect the most recent client data. Planning desired outcomes. If a nursing diagnosis was inaccurate, obviously the goal statement will need revision. If the nursing diagnosis was appropriate, the nurse then checks if the goals were realistic and attainable. The nurse should also determine whether priorities have changed and whether the client still agrees with the priorities. Interventions. The nurse investigates whether the nursing interventions were related to goal achievement and whether the best nursing interventions were selected. Even when diagnoses and goals were appropriate, the nursing interventions selected may not have been the best ones to achieve the goal. New nursing interventions may reflect changes in the amount of nursing care the client needs, scheduling changes, or rearrangement of nursing activities to group similar activities or to permit longer rest or activity periods for the client. If new nursing diagnoses have been written, then new nursing interventions will also be necessary. Implementing. Even if all sections of the care plan appear to be satisfactory, the manner in which the plan was implemented may have interfered with goal achievement. Before selecting new interventions, the nurse should check whether they were carried out. Other personnel may not have carried them out, either because the interventions were unclear or because they were unreasonable in terms of external constraints such as money, staff, time, and equipment.
Open-ended questions:
Associated with the nondirective interview, invite clients to discover and explore, elaborate, clarify, or illustrate their thoughts or feelings. An open-ended question specifies only the broad topic to be discussed, and invites answers longer than one or two words. Such questions give clients the freedom to divulge only the information that they are ready to disclose. The open-ended question is useful at the beginning of an interview or to change topics and to elicit attitudes. Open-ended questions may begin with "what" or "how."
Critical Thinking Attitudes
Certain attitudes are crucial to critical thinking. These attitudes are based on the assumption that a rational person is motivated to develop, learn, and grow. A critical thinker works to develop the following attitudes or traits: independence, fair-mindedness, insight, intellectual humility, intellectual courage, integrity, perseverance, confidence, and curiosity. Critical thinking requires that individuals think for themselves. Critical thinkers are fair-minded, assessing all viewpoints with the same standards and not basing their judgments on personal or group bias or prejudice. Critical thinkers are open to the possibility that their personal biases or social pressures and customs could unduly affect their thinking. With an attitude of courage, one is willing to consider and examine fairly one's own ideas or views, especially those to which one may have a strongly negative reaction. Intellectual integrity requires that individuals apply the same rigorous standards of proof to their own knowledge and beliefs as they apply to the knowledge and beliefs of others. Nurses who are critical thinkers show perseverance in finding effective solutions to client and nursing problems. This determination enables them to clarify concepts and sort out related issues, in spite of difficulties and frustrations. Critical thinkers believe that well-reasoned thinking will lead to trustworthy conclusions. The mind of a critical thinker is filled with questions: Why do we believe this? What causes that? Does it have to be this way? Could something else work? What would happen if we did it another way? Who says that is so? The curious nurse may value tradition but is not afraid to examine traditions to be sure they are still valid.
Acute Illness
Characterized by severe symptoms of relatively short duration Symptoms often appear abruptly, subside quickly May or may not require intervention by health care professionals Most people return to normal level of wellness
Standards of Critical Thinking
Clarity Accuracy Relevance Logicalness Breadth Precision Significance Completeness Fairness Depth
Factors Influencing Adherence
Client motivation to become well. Degree of lifestyle change necessary. Perceived severity of the health care problem. Value placed on reducing the threat of illness. Difficulty in understanding performing specific behaviors. Degree of inconvenience of the illness itself or of the regimens. Beliefs that the prescribed therapy or regimen will or will not help. Complexity, side effects, and duration of the proposed therapy. Overall cost of prescribed therapy.
The nurse must consider a variety of factors when assigning priorities
Client's health values and beliefs Client's priorities Resources available to the nurse and client Urgency of the health problem Medical treatment plan
Models of health have been developed to explain health and its relationship to illness or injury.
Clinical Model Role Performance Model Adaptive Model Agent-Host-Environment Model Health-Illness Continuum
Critical Thinking Skills
Critical analysis Inductive and deductive reasoning Making valid inferences Differentiating facts from opinions Evaluating the credibility of information sources Clarifying concepts Recognizing assumptions
Critical Thinking Skills:
Critical analysis Socratic questioning Inductive reasoning Deductive reasoning
Critical Analysis:
Critical analysis is the application of a set of questions to a particular situation or idea to determine essential information and ideas and discard superfluous information and ideas. The questions are not sequential steps; rather, they are a set of criteria for judging an idea.
Keys to Clinical Success
Critical thinking and clinical reasoning Awareness of safe practice Professional behavior Responsibility and accountability for practice Good communication
Critical Thinking is:
Critical thinking is essential to safe, competent, skillful nursing practice. Decisions that nurses must make about client care and about the distribution of limited resources force them to think and act in areas where there are neither clear answers nor standard procedures, and where conflicting forces turn decision making into a complex process. Nurses therefore need to embrace the attitudes that promote critical thinking and master critical-thinking skills in order to process and evaluate both previously learned and new information. Nurses use knowledge from other subjects and fields. Because nurses deal holistically with human responses, they must draw meaningful information from other subject areas in order to understand the meaning of client data and to plan effective interventions. Nurses deal with change in stressful environments. Nurses work in rapidly changing situations. Treatments, medications, and technology change constantly, and a client's condition may change from minute to minute. Routine actions may therefore not be adequate to deal with the situation at hand. Nurses make important decisions. During the course of a workday, nurses make vital decisions of many kinds. These decisions often determine the well-being of clients and even their very survival, so it is important that the decisions be sound. Nurses use critical thinking to collect and interpret the information needed to make decisions. Nurses work as part of a team. In a team there are differing opinions, beliefs, and biases presented regarding clinical decisions. The nurse must be able to accept the information gathered from team members and sort through it using critical thinking in order to make sound decisions regarding client care and nursing practice.
Reviewing and Modifying the Care Plan (Evaluation Process)
Critique each phase of the nursing process Check whether the interventions were Carried out Unclear or unreasonable Make necessary modifications Implement the modified plan Begin nursing process again
Be sure your data consists of ___ and not___.
Cues; Inferences.
Characteristics of the nursing process:
Cyclic and dynamic nature Client centeredness Focus on problem-solving and decision-making Interpersonal and collaborative style Universal applicability Use of critical thinking
Why validate data during the assessment?
Double checking data for accuracy and completeness. Avoid making assumptions or erroneous conclusions.
Non-Directive Approach to Interviewing
During a nondirective interview, or rapport-building interview, the nurse allows the client to control the purpose, subject matter, and pacing. A combination of directive and nondirective approaches is usually appropriate during the information-gathering interview.
Concept of Individuality
Each individual is a unique being Focus on total care and individualized care context Total care context considers all the principles that apply when taking care of any client Individualized care context means using the total care principles that apply to the person at this time
The goal is assessing is:
Establish a database about the client's response to health concerns or illness.
Bioelectromagnetics
Every animal, plant, and mineral has an electromagnetic field Enables organic and inorganic objects to communicate and interact Penetrate the body affecting the functioning of cells, tissues, organs, and systems Contraindications : pregnancy, pacemakers, implanted defibrillators, aneurysm clips in the brain, cochlear implants. Any electrical device. Should not be used by people on anticoagulants, with an open wound, or freshly torn muscle.
Implementing Nursing Interventions
Evidence-based practice Clearly understand interventions Adapt activities to the individual client Implement safe care Provide teaching, support, and comfort Be holistic Respect the dignity of the client and enhance self esteem Encourage active client participation
Documenting data during the assessment:
Factual Non-judgmental
Health Risks Experienced by Infants
Failure to thrive Infant colic Child abuse Sudden Infant Death Syndrome (SIDS)
Families
Families consist of persons (structure) and their responsibilities within the family (roles). A family structure of parents and their offspring is known as the nuclear family. The relatives of nuclear families, such as grandparents or aunts and uncles, compose the extended family. The different types of families in today's society include the traditional family, the two-career family, the single-parent family, the adolescent family, the foster family, the blended family, the intragenerational family, the cohabiting family, the gay and lesbian family, and single adults living alone. The traditional family is viewed as an autonomous unit in which both parents reside in the home with their children. The mother often assumes the nurturing role and the father provides the necessary economic resources. In the two-career family, both spouses are employed. They may or may not have children. Finding good-quality, affordable child care is one of the greatest stresses faced by working parents. The single-parent family is a family headed by a single parent. There are many reasons for single parenthood, including death of a spouse, separation, divorce, birth of a child to an unmarried woman, or adoption of a child by a single man or woman. The stresses of single parenthood are many: child care concerns, financial concerns, role overload and fatigue in managing daily tasks, and social isolation. In the adolescent family, an adolescent is the parent. These young parents are often developmentally, physically, emotionally, and financially ill-prepared to undertake the responsibility of parenthood. Their children are often at greater risk for health and social problems and have few role models to assist in breaking out of the cycle of poverty. A foster family agrees to temporarily care for children who can no longer live with their birth parents. The legal agreement between the foster family and court to care for the child includes the expectations of the foster parents and the financial compensation they will receive. It is hoped that the fostered child can return to the birth parent at some point or be legally and permanently adopted by other parents. A blended family is formed when existing family units join together. Family integration requires time and effort. When blended families with children form following the divorce or death of a parent, adjustment can be particularly challenged by the normal processes of grief and loss. An intragenerational family is formed when more than two generations live together. A cohabiting family (communal) consists of unrelated individuals or families who live under one roof. Reasons for cohabiting may be a need for companionship, a desire to achieve a sense of family, testing a relationship or commitment, or sharing expenses and household management. Gay and lesbian families are based on the same goals of caring and commitment seen in heterosexual relationships. The structure is as diverse as that of heterosexual families. Children raised in these family units develop sex role orientation and behaviors similar to children in the general population. Legal issues for same-sex couples are significant and constantly changing. Single adults living alone represent a significant portion of today's society. Singles include young, self-supporting adults who have recently left the nuclear family as well as older adults living alone. Young adults typically move in and out of living situations and may fall into different categories of family types at various times. Older adults may find themselves single through divorce, separation, or the death of a spouse, but they generally live alone for the remainder of their lives.
Secondary source of data:
Family members or other support persons, other health professionals, records and reports, laboratory and diagnostic analyses, and relevant literature are secondary or indirect sources. All data from secondary sources should be validated if possible
Family Health Risk Factors
Family violence Maturity of individual members: Stress and coping Heredity: Health problems Gender or race Sociologic-income, financial threats Lifestyle
Quality Improvement
Focus on process Uses a systematic approach to improve the quality of care Often focus on identifying and correcting a system's problems Continuous quality improvement (CQI) Total quality management (TQM) Performance improvement (PI) Persistent quality improvement (PQI)
Medicare
For adults over 65 Part A provides hospitalization, home care, hospice Part B provides partial outpatient and physician services (voluntary) Part D prescription plan (voluntary) Does not cover dental, eyeglasses, hearing aids, etc
Prayer
Form of communication and fellowship with the Deity or Creator Self-care strategy Provides comfort, increases hope, and promotes healing and psychological well-being
Impact of Illness on Patients and Their Families
Functions of the family include securing economic resources, which is usually done by the adult members; protecting physical health by providing adequate nutrition and health care services; providing an environment conducive to physical growth and health; and influencing the cognitive and psychosocial growth of its members. In families where members are physically and emotionally nurtured, individuals are challenged to achieve their potential in the family unit. As individual needs are met, family members are able to reach out to others in the family and the community, and to society. Each family has values and beliefs that are unique to culture of origin and shape the family's structure, methods of interaction, health care practices, and coping mechanisms.
Asking questions:
Fundamental to nursing assessment Helps build your relationship with the patient and family Remember: listen to what is said and left unspoken
Observing:
Gathering data using the senses. Used to obtain following types of data: Skin color (vision) Body or breath odors (smell) Lung or heart sounds (hearing) Skin temperature (touch)
Frameworks for Nursing Assessment:
Gordon's functional health pattern framework Orem's self-care model Roy's adaptation model Jean Watson - caring- healing model
Concept Mapping
Linear and nonlinear relationships Represent critical thinking Also known as Mind mapping Used to develop analytical skills
Tactical Errors in Asking Questions:
Long-winded build-up: KISS principle - keep it short and simple Multiple choice mix-up: Don't barrage pt with multiple questions Incomprehensible and cryptic codes: Don't talk doctor Offensive use of "why" Misuse of open and closed questions
The purpose of the nursing process is to:
Identify a client's health status and actual or potential health care problems or needs, to establish plans to meet the identified needs, and to deliver specific nurising interventions to meet those needs.
Decision-Making Process
Identify purpose Set and weigh criteria Seek and examine alternatives Project, implement, and evaluate outcome
Comparing Data with Outcomes (Evaluation Process)
If the first two parts of the evaluation process have been carried out effectively, it is relatively simple to determine whether a desired outcome has been met. Both the nurse and client play an active role in comparing the client's actual responses with the desired outcomes. When determining whether a goal has been achieved, the nurse can draw one of three possible conclusions: The goal was met; that is, the client response is the same as the desired outcome. The goal was partially met; that is, either a short-term goal was achieved but the long-term goal was not, or the desired outcome was only partially attained. The goal was not met. The fourth aspect of the evaluating process is determining whether the nursing activities had any relation to the outcomes. The nurse uses judgments about goal achievement to determine whether the care plan was effective in resolving, reducing, or preventing client problems. After drawing conclusions about the status of the client's problems, the nurse modifies the care plan as indicated. Depending on the agency, modifications may be made by drawing a line through portions of the care plan, or marking portions using a highlighting pen, or writing "Discontinued" (dc'd), "goal met," or "problem resolved" and the date.
Health Protection/Illness Prevention
Illness or injury specific Motivated by avoidance of illness Seeks to thwart the occurrence of insults to health and well-being
Problem-Solving Process
In problem solving, the nurse obtains information that clarifies the nature of the problem and suggests possible solutions. The nurse then carefully evaluates the possible solutions and chooses the best one to implement. Trial and error- a number of approaches are tried until a solution is found. Not the best method for patient care problems Intuition- understanding or learning of things without conscious use of reasoning. "Gut feeling" Inner voice Research process, scientific method- formalized, logical, systematic approaches to solving problems.
Hand-Mediated Biofield Therapies
Includes Therapeutic Touch (TT), Healing Touch (HT), and Reiki Use of hands on or near with intention to heal Goal of care is to accelerate person's own healing process Facilitate healing of body, mind, emotions, and spirit
Data Source: The Client Record.
Includes documentation from other health professionals Medical records Past and present health and illness patterns Coping behaviors, health practices, allergies Therapy reports Laboratory reports
Infrared Photoenergy Therapy
Increase energy inside cells Improve circulation Improve sensory impairment
Factors that Affect Health Care Delivery
Increasing number of elderly Advances in technology Economics Women's health issues Uneven distribution of services Access to health insurance Homeless and the poor HIPAA Demographic changes
Role of the Nurse During a Family Crisis
Information and support: Patient and family education Resource identification: Internal family resources, External community resources Emotional support and counseling: Loss, Grieving
Types of planning:
Initial Planning Ongoing Planning Discharge Planning
Directive Approach to Interviewing:
Is highly structured and elicits specific information. The nurse establishes the purpose of the interview and controls the interview, at least at the outset. Used to gather and give information when time is limited, e.g., in an emergency.
Clinical Reasoning:
Is logical, reflective, concurrent, and creative thinking about clients and client care Begins with clinical judgments Making interpretations or conclusions about a client's needs, concerns, or health problems and deciding upon a course of action Drawn from patient data
Deductive reasoning:
Is reasoning from the general premise to the specific conclusion. Not always valid.
Etiology:
Is the component of a nursing diagnosis that identifies one or more probable causes of the health problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client's care. Differentiating among possible causes in the nursing diagnosis is essential because each may require different nursing interventions.
Chronic Illness
Lasts for an extended period Usually has a slow onset Often have periods of remissions and exacerbations Care includes promoting independence, sense of control, and wellness Learn how to live with physical limitations and discomfort
Independent nursing interventions for a collaborative problem focus mainly on:
Monitoring the client's condition and preventing development of the potential complication. Definitive treatment of the condition requires both medical and nursing interventions. Nursing diagnoses, by contrast, involve human responses, which vary greatly from one person to the next. Therefore, the same set of nursing diagnoses cannot be expected to occur with all persons who have a particular disease or condition; moreover, a single nursing diagnosis may occur as a response to any number of diseases. Thus, the nurse uses nursing diagnoses rather than collaborative problems whenever possible, since nursing diagnoses are more individualized to a specific client and emphasize human responses to which the nurse can independently take action.
Standardized Approaches to Care Planning:
Most health care agencies have devised a variety of pre-printed, standardized plans for providing essential nursing care to specified groups of clients who have certain needs in common. Standards of care, standardized care plans, protocols, policies, and procedures are developed are accepted by the nursing staff in order to (a) ensure that minimally acceptable standards are met and (b) promote efficient use of nurses' time by removing the need to author common activities that are done over and over for many of the clients on a nursing unit.
Miscellaneous Therapies
Music therapy Humor and laughter Bioelectromagnetics Infrared photoenergy therapy Detoxifying therapies Animal-assisted therapy Horticultural therapy
Individualization of Standardized Care Plans
Must include unique needs of each client Usually consists of both preprinted and nurse-created sections Standardized care plans for predictable, commonly occurring problems Individual plan for unusual problems or problems needing special attention
Health Promotion
Not disease oriented Motivated by personal, positive approach to wellness Seeks to expand positive potential for health
Extended family
Nuclear family plus the relatives of the family (aunts, uncles, grandparents)
Reasoning Patterns Used by Nurses
Nurses use a variety of reasoning patterns depending on the nurse's initial grasp of the situation, the demands of the situation, and the goals of the nurse's practice. The three interrelated patterns of reasoning used by experienced nurses include analytic processes, intuition, and narrative thinking. Analytic processes are used to breakdown a situation into its elements in order to generate alternative actions and the systematic and rational weighing of these alternatives against clinical data or the likelihood of achieving outcomes. Intuition is often based on an indefinable feeling as the result of previous experience in a similar situation. Narrative thinking uses talking about the events as a method interpreting and decision making.
Diagnosing: The pivotal second phase of the nursing process.
Nurses use critical-thinking skills to interpret assessment data and identify client strengths and problems.
Nurses need to clarify their understanding of health wellness and illness for theses reasons:
Nurses' definitions of health largely determine the scope and nature of nursing practice and people's health beliefs influence their health practices.
Types of Nursing Interventions
Nursing interventions are identified and written during the planning step of the nursing process; however, they are actually performed during the implementation stage. Nursing interventions include both direct and indirect care, as well as nurse-initiated, physician-initiated, and other provider-initiated treatments. Direct care is an intervention performed through interaction with the client. Indirect care is an intervention performed away from but on behalf of the client such as interdisciplinary collaboration or management of the care environment.
Methods of Data Collection
Observing Interviewing Examining
The Nursing Process - Implementing
Reassessing the client Determining the nurse's need for assistance Implementing nursing interventions Supervising delegated care Documenting nursing activities
Chiropractic
Reduce or eliminate pain Correct spinal dysfunction Muscles and ligaments strengthened by spinal rehabilitative exercises Preventive maintenance to ensure the problem does not recur
Requirements for Effective Clinical Reasoning
Requirements for effective clinical reasoning and decision making include cognitive ability, creativity, curiosity, interpersonal skills, cultural competence, psychomotor skills, and technological skills. Used every day in almost every nursing situation. Cognitive skills - ongoing education to stay current in one's area of practice. If you do not participate in continuing education you become an unsafe care provider. Life long education is the name of the game!
Creativity
Results in development of new ideas and products Generate many ideas rapidly Able to change viewpoints or directions in thinking Create original solutions to problems Independent and self-confident, even under pressure Demonstrate individuality
Ways of Demonstrating Critical Thinking
Rigorous personal assessment Reflection Analysis of thinking processes and attitudes Cultivation of critical thinking abilities Attendance at conferences Awareness of own thinking-while thinking Create environments that support critical thinking
Impact of Illness: Family Changes
Role changes Task reassignments Increased demands on time Anxiety about outcomes Conflict about unaccustomed responsibilities Financial problems Loneliness as a result of separation and pending loss Change in social customs
Acupuncture, Acupressure, Reflexology
Rooted in concept of life energy (qi) Pressure points act as gateway to moderate flow of qi Applying pressure or stimulating points Use of finger pressure, needles Acupressure on feet, hands or ears- reflexology
Criteria for Choosing Appropriate Interventions
Safe and appropriate for the individual's age, health, and condition Achievable with the resources available Congruent with the client's values, beliefs, and culture Congruent with other therapies Based on nursing knowledge and experience or knowledge from relevant sciences (i.e., based on a rationale) Within established standards of care as determined by state laws, professional associations, and the policies of the institution
Developing Critical-Thinking Attitudes and Skills
Self-assessment: Self-reflection Tolerating dissonance and ambiguity: Suspending judgment Seeking situations where good thinking is practiced Creating environments that support critical thinking: Avoiding "group think"
The Planning Process consists of:
Setting priorities Establishing client goals/desired outcomes Selecting nursing interventions Writing individualized nursing interventions on care plans
Suchman (1979) described five stages of illness:
Stage 1—Symptom experience: The person comes to believe something is wrong. Stage 2—Assumption of the sick role: The person accepts the sick role and seeks confirmation from family and friends. Stage 3—Medical care contact: The person seeks advice of a health professional either on his or her own initiative or at the urging of significant others. Stage 4—Dependent client role: After accepting the illness and seeking treatment, the client becomes dependent on the professional for help. Stage 5—Recovery or rehabilitation: The client is expected to relinquish the dependent role and resume former roles and responsibilities.
Successful Implementation
The cognitive skills (intellectual skills) include problem solving, decision making, critical thinking, and creativity. They are crucial to safe, intelligent nursing care. Interpersonal skills are all of the activities, verbal and nonverbal, people use when interacting directly with one another. The effectiveness of a nursing action often depends largely on the nurse's ability to communicate with others. The nurse uses therapeutic communication to understand the client and in turn be understood. A nurse also needs to work effectively with others as a member of the health care team. Technical skills are purposeful "hands-on" skills such as manipulating equipment, giving injections, bandaging, moving, lifting, and repositioning clients. These skills are also called tasks, procedures, or psychomotor skills. The term psychomotor refers to physical actions that are controlled by the mind, not reflexive. Technical skills require knowledge and manual dexterity. The number of technical skills expected of a nurse has greatly increased in recent years because of the pervasive use of technology, especially in acute care hospitals.
Maslow's Hierarchy of Needs
The five levels in ascending order are as follows: 5) Physiologic needs. Needs such as air, food, water, shelter, rest, sleep, activity, and temperature maintenance are crucial for survival. 4) Safety and security needs. The need for safety has both physical and psychologic aspects. The person needs to feel safe, both in the physical environment and in relationships. 3) Love and belonging needs. The third level of needs includes giving and receiving affection, attaining a place in a group, and maintaining the feeling of belonging. 2) Self-esteem needs. The individual needs both self-esteem and esteem from others. 1) Self-actualization. When the need for self-esteem is satisfied, the individual strives for self-actualization, the innate need to develop one's maximum potential and realize one's abilities and qualities. Unfulfilled needs puts one at risk for development of illness.
The Nursing Process and Critical Thinking
The higher order skills of critical thinking are put into play as soon as the nurse begins to use the nursing process to provide client care, which involves highly individualized people who do not all respond to a situation in the same way. The nursing process serves as a method of solving problems, guiding the critical-thinking process through rational steps to improve clinical reasoning and clinical decision making
During the maintenance stage:
The person strives to prevent relapse by integrating newly adopted behaviors into his or her lifestyle. This stage lasts until the person no longer experiences temptation to return to previous unhealthy behaviors. Without a strong commitment to maintenance, there will be a relapse, usually to the precontemplation or contemplation stage.
Family Health Risk Factors
The incidence of family violence has increased in recent years. Statistics are not accurate, because many cases remain unreported. Family violence includes abuse between intimate partners, child abuse, and elder abuse, and may include physical, mental, and verbal abuse, as well as neglect. Early symptoms are evident in burns, cuts, fractures, and even death. Other manifestations often seen are depression, alcohol and substance abuse, and suicide attempts. Nurses should be alert to the symptoms of family violence and take appropriate measures to report it and obtain resources for the family. Common risk factors regarding family health include maturity factors, heredity factors, gender or race, sociologic factors, and lifestyle factors. Families with members at both ends of the age continuum are at risk of developing health problems. Families entering childbearing and child-rearing phases experience changes in roles, responsibilities, and expectations. Adolescent mothers, due to their developmental level and lack of knowledge about parenting, and single-parent families, due to role overload, are more likely to develop health problems. Many elderly persons feel a lack of purpose and decreased self-esteem which in turn reduce their motivation to engage in health-promoting behaviors. Persons born into families with a history of certain diseases are at greater risk of developing these conditions. Gender or race may predispose individuals to specific health risks. For example, men are at greater risk of having cardiovascular disease at an earlier age than women. Women are at risk of developing osteoporosis, particularly after menopause. Sickle-cell anemia is a hereditary disease limited to people of African descent, for example. Poverty is a major sociologic problem that affects not only the family but also the community and society. Poverty is a real concern among the rising number of single-parent families. As the number of these families increases, poverty will affect a large number of growing children. When ill, the poor are likely to put off seeking services until the illness reaches an advanced state and requires longer or more complex treatment. Many diseases are preventable, the effects can be minimized, or the onset of disease can be delayed through lifestyle modifications. Other important lifestyle considerations are exercise, stress management, and rest.
Impact of Illness on the Family
The kind of effect and its extent depend chiefly on three factors: (a) the member of the family who is ill, (b) the seriousness and length of the illness, and (c) the cultural and social customs the family follows.
Writing Nurse Diagnoses
The last step is formulating the diagnostic statement. Most nursing diagnoses are written as two-part or three-part statements, but there are variations of these. The basic two-part statement includes the following: (1) problem, which is the statement of the client's response (NANDA label) and (2) etiology, which are the factors contributing to or probable causes of the responses. The two parts are joined by the words related to rather than due to. The basic three-part nursing diagnosis statement is called the PES format: P is for problem, E is for etiology, and S is for signs and symptoms manifested by the client. Actual nursing diagnoses can be documented by using the three-part statement (see Box 7-6) because the signs and symptoms have been identified.
Factors determining the impact of Illness on a Family
The nature of the illness. The duration of the illness. The residual effects of the illness (permanent disability). The meaning of the illness to the family. The financial impact of the illness. The effect of the illness on future family functioning.
In order to analyze data:
The nurse compares data against standards looking for significant cues, clusters cues in order to generate a tentative hypothesis, and identifies gaps and inconsistencies in data. For experienced nurses, these activities occur continuously rather than sequentially.
Inferences are:
The nurse's interpretation or conclusions made based on cues.
Stages of the Interview:
The opening: Establish rapport, Orient client to purpose The body: Data collection The closing: Signal the end of the interview, Answer questions, Maintain rapport
Primary source of data:
The patient/client.
During the contemplation stage:
The person acknowledges having a problem, seriously considers changing a specific behavior, actively gathers information, and verbalizes plans to change the behavior in the near future (e.g., next six months). The person, however, may not be ready to commit to action.
In the precontemplation stage:
The person does not think about changing his or her behavior in the next 6 months. The person may be uninformed or underinformed about the consequences of the risk behavior(s). The person who has tried changing previously and was unsuccessful may now see the behavior as his or her "fate" or believe that change is hopeless.
Independent interventions
Those activities nurses are licensed to initiate (i.e., physical care, ongoing assessment)
The interview setting:
Time: Client free of pain; Limited interruptions Place: Private, Comfortable environment, Limited distractions Seating Arrangement: Hospital, Office or clinic, Group Distance: Comfortable Language: Use easily-understood terminology, Interpreter or translator
Healthy People 2010
To increase quality and years of healthy life To eliminate health disparities Organized around 28 focus areas to improve health Establishes a set of leading health indicators reflecting public health concerns Indicators will help develop action plans to improve the health of both individuals and communities Individual health closely linked to community health and reverse Vision is "healthy people in healthy communities"
Main reason for asking questions:
To secure data that is essential to providing care to your patients.
Planning begins:
With first client contact. Continues until nurse-client relationship ends (discharge). Multidisciplinary The nurse who performs the admission assessment usually develops the initial comprehensive plan of care. This nurse has the benefit of the client's body language as well as some intuitive kinds of information that are not available solely from the written database.
Sentinel Event
Unexpected occurrence Death or serious injury Called sentinel because they signal need for immediate investigation and response Assess cause, plan for intervention, evaluate result of plan Root cause analysis Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
Closed questions:
Used in the directive interview, are restrictive and generally require only short answers. Closed questions often begin with "when," "where," "who," "what," "do (did, does)," or "is (are, was)." A highly stressed person and someone who has difficulty communicating will find closed questions easier to answer than open-ended questions.
Agent-Host-Environment Model
Used primarily to predict illness Identifies risk factors Each factor constantly interacts with the others, health an ever changing state Three interactive elements: 1) Agent -factor that leads to illness 2) Host - person at risk 3) Environment- factors external to host When in balance, health is maintained When not in balance, disease occurs
Avoiding Errors in Diagnostic Reasoning When Writing a Nursing Diagnosis
Verify: Talk with client and family Knowledge base and clinical experience Knowledge of normal standards Use resources Base diagnosis on patterns Improve critical thinking skills
Wellness is:
Wellness is a state of well-being. Basic aspects of wellness include self-responsibility; an ultimate goal; a dynamic, growing process; daily decision making in the areas of nutrition, stress management, physical fitness, preventive health care, and emotional health; and, most importantly, the whole being of the individual.
One-Part Statement
Wellness or Syndrome diagnoses Consist of a NANDA label only.
The following guidelines can help nurses write useful goals and desired outcomes:
Write goals and outcomes in terms of client responses, not nurse activities. Beginning each goal statement with the client will may help focus the goal on client behaviours and responses. Avoid statements that start with enable, facilitate, allow, let, permit, or similar verbs followed by the word client. These verbs indicate what the nurse hopes to accomplish, not what the client will do. Be sure that desired outcomes are realistic for the client's capabilities, limitations, and designated time span, if it is indicated. Limitations refers to finances, equipment, family support, social services, physical and mental condition, and time. Ensure that the goals and desired outcomes are compatible with the therapies of other professionals. Make sure that each goal is derived from only one nursing diagnosis. Keeping the goal statement related to only one diagnosis facilitates evaluation of care by ensuring that planned nursing interventions are clearly related to the diagnosis. Use observable, measurable terms for outcomes. Avoid words that are vague and require interpretation or judgment by the observer. If used in outcomes, these phrases can lead to disagreements about whether the outcome was met. These phrases may be suitable for a broad client goal but are not sufficiently clear and specific to guide the nurse when evaluating client responses. Make sure the client considers the goals/desired outcomes important and values them.
Mind-Body Therapies
Yoga Meditation Hypnotherapy Guided imagery Qigong T'ai chi
A nursing diagnosis is:
a statement of nursing judgment and refers to a condition that nurses, by virtue of their education, experience, and expertise, are licensed to treat. In contrast, nursing diagnoses describe the human response, a client's physical, sociocultural, psychologic, and spiritual responses to an illness or a health problem
A collaborative problem is:
a type of potential problem that nurses manage using both independent and physician-prescribed interventions.
A standing order is:
a written document about policies, rules, regulations, or orders regarding client care. Standing orders give nurses the authority to carry out specific actions under certain circumstances, often when a physician is not immediately available.
Objective data:
also referred to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination. For example, a discoloration of the skin or a blood pressure reading is objective data. During the physical examination, the nurse obtains objective data to validate subjective data and to complete the assessment phase of the nursing process.
Subjective data:
also referred to as symptoms or covert data, are apparent only to the person affected and can be described or verified only by that person. Itching, pain, and feelings of worry are examples of subjective data. Subjective data include the client's sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situation.
Standardized care plans
are pre-printed guides for the nursing care of a client who has a need that arises frequently in the agency. They are written from the perspective of what care the client can expect.
Standards of care:
describe nursing actions for clients with similar medical conditions rather than individuals, and they describe achievable rather than ideal nursing care. They define the interventions for which nurses are held accountable; they do not contain medical interventions.
Policies and procedures are:
developed to govern the handling of frequently occurring situations. Some policies and procedures are similar to protocols and specify what is to be done in a given situation.
In inductive reasoning:
generalizations are formed from a set of facts or observations. When viewed together, certain bits of information suggest a particular interpretation. Inductive reasoning moves from specific examples (premises) to a generalized conclusion—for example, after touching several hot flames (premise), we conclude that all flames are hot.
