OB Chapter 3 (COMPLETE W/EVOLVE)

In applying ethical principles, the nurse should always show respect to the client, provide privacy, and ensure the client has the information needed to make decisions. This is called:

Autonomy.

In applying ethical principles, the nurse should treat all clients equally, regardless of disease or social or economic status. This is termed:

Justice.

Belief That Abortion Is Taking a Life

Many people believe that legalized abortion condones taking a life and feel morally bound to protect the lives of fetuses.

Elective Pregnancy Termination

-Abortion, or elective termination of pregnancy, was a volatile legal, social, and political issue even before the Roe v. Wade decision by the US Supreme Court in 1973. -The supreme court stated that abortion was legal and laws prohibiting abortion were unconstitutional because they interfered with the mother's constitutional right to privacy. -Decision stipulated that 1) a woman could obtain an abortion at any time during the first trimester, 2) the state could regulate abortions during the second trimester only to protect the woman's health, and 3) the state could regulate or prohibit abortion during the third trimester, except when the mother's life might be jeopardized by continuing the pregnancy.

Prenatal Care in the US (Continued)

-About 25% of teens who give birth will have their second baby within 2 years of the first. -Teen mothers are less likely to complete their education and more likely to be poor compared with adult mothers. -Teen mothers may be repeating the path that their mothers took. -These woman may not understand the importance of the care or may deny they are pregnant. -Others want to hide substance use or other habits from disapproving healthcare workers. -Language and cultural differences also play a part in whether a woman seeks prenatal care.

Fetal Therapy

-Becoming more common -Fetal surgery is still relatively uncommon -The risks and benefits of surgery for major fetal anomalies must be considered in every case. Even when surgery is successful, the fetus may not survive. -The mother may require weeks of bed rest and a cesarean birth. Yet, despite the risks, successful fetal surgery may result in birth of an infant who could not otherwise have survived. -As with any situation involving informed consent, women need adequate information before making a decision. They should understand if procedures are still experimental, the known chances of a procedure's success, and if any alternative treatments are available and their chances of success.

Late Preterm Infants

-Birth rates are rising for late preterm infants, also called near term infants. Born between 34-46 completed weeks of pregnancy. -Late preterm newborns have more complications, including respiratory distress that often requires ventilatory apnea, bradycardia, jaundice, and sepsis before hospital discharge. -Neonatal mortality rates at 34 to 35 weeks are significantly higher than mortality rates in babies born at 37 or ore weeks of gestation.

Agency Policies

-Each health care agency sets specific policies, procedures, and protocols that govern nursing care -In the event of a malpractice claim, the applicable policy, procedure, or protocol is likely to be used as evidence. Accountability: -A recurrent issue that pertains to nursing accountability is inadequate staffing. -A nurse has the duty to communicate concerns immediately though established channels. However, a nurse will not be excuse from responsibility for errors such as late medication administration or patient injury related to inadequate supervision that leads to a fail. -Accountability also involves competency.

Ethics and Bioethics

-Ethics involves determining the best course of action in a certain situation. Ethical reasoning is the analysis of what is morally right and reasonable. -Bioethics is the application of ethics to health care. -Ethical issues have become more complex as technology has created more option in health care. -Controversial because agreement over what is right or best does not exist. Ethical Dilemmas: -An ethical dilemma is a situation in which no solution is completely satisfactory. -Opposing courses of action may seem equally desirable, or all possible solutions may seem undesirable. -Most difficult situations -Nurses must apply ethical theories, principles and determine the burdens and benefits of any course of action.

Homelessness

-Homeless families are often composed of single women and domestic violence is often part of their history. -Homeless people may wait till health problems are severe because of shame. -Ongoing care for diabetes, HIV/AIDS, or addiction is often missed. Mental illness susch as depression, bipolar disorder, or schizophrenia is more common among the homeless and may be left untreated. -The pregnant homeless woman, often a teen, is less likely to seek prenatal care that might catch complications such as maternal hypertension and diabetes, or she may be a user of alcohol or drugs. Inadequate maternal weight gain adds to the risk for prematurity and low birth weight. -Prostitution to earn money may result in pregnancy and add to its problems with such factors as infections, violence, and inadequate health care. -Homeless teens are more likely to have poor eating habits, to smoke, to have greater risks for preterm labor, anemia, and hypertension during pregnancy, and to deliver a low birth weight infant.

Fetal Injury

-If a mother's actions cause injury to her fetus, the question of whether she should be retrained or prosecuted has legal and ethical implications. -In cases, women have been forced to undergo cesarean births against their will when physicians have testified that such a procedure was necessary to prevent injury to the fetus. -Supreme Court has ruled that a child has the right to begin life with sound mind and body. many state laws require that evidence of prenatal drug exposure be reported. -However, forcing a woman to behave in a certain way because she is pregnant violates the principles of autonomy, self determination of competent adults, bodily integrity, and personal freedom.

Ethical and Legal Reproductive Issues

-Many issues cross the boundary between ethics and legality. -Apply to many fields of care, including reproduction and women's health.

Belief That Abortion Is a Private Choice

-Many women who support this view sate that they would not choose abortion for themselves. Still, they support the right of each woman to make her own decision and view government action as interference in a very private part of women's lives.

Documentation

-Meet the standard of care, or the level of care expected of a professional as determined by laws, professional organizations, and health care agencies. -Documentation is the bet evidence. -Fetal monitoring strips, electronic data, etc. -Recorded electronically or paper or both. -Unfortunately, the lack of accurate and thorough documentation of care is the most common area found lacking in malpractice cases. Documenting Fetal Monitoring: -Fetal monitor paper strips are important sources of information about the other and fetus during labor and birth. -Risks increase the importance of nurses recording summaries about the fetal condition. Documenting Discharge Teaching: -Discharge teaching is important to ensure that patients know how to take care of themselves and their infants after they leave. -Nurses must document the teaching they perform.

Malpractice: Limiting Loss

-Negligence is the failure to perform as a reasonable, prudent person of similar background would act in a similar situation. -May consist of doing something that should not be dope or failing to do something that should be done. -Malpractice is negligence by professionals. -Nurses may be accused of malpractice if they don not perform according to established standards. -More health care workers practice defensively and accumulate evidence that their actions are in the patient's best interests. -Nurses are responsible and accountable for their own actions. -Prevention of claims is sometimes referred to as risk management or quality assurance. -Nurses can prevent malpractice judgments by following guidelines for informed consent, refusal or care, and documentation.

Nurse Practice Acts

-Nurse practice act that determines the scope of practice of registered nurses in that state. -Define what the nurse is allowed to do when caring for patients. -Laws relating to nursing practice also delineate methods, called standard procedures or protocols, by which nurses may assume certain duties. -Specify the nursing qualifications required for practicing the procedures. -Allow the role of the nurse to change to meet the needs of the community and expanding knowledge. -Had a mutual recognition model for nursing licensure, or a multistate nurse licensure compact

Solving Dilemmas in Daily Practice

-Nurses are often involved in supporting parents when tragedy strikes during a birth. Must be knowledgeable.

Professional Obligations

-Nurses have no obligation to support a position with which they disagree. -As always, nurses must respect the decisions of women wo look to nurses for care.

Implications for Nurses

-Nurses have several responsibilities. -First, they must be informed about the complexity of the abortion issue from legal and ethical standpoints and know the regulations and laws in their state. -Second, they must realize that for many people, abortion is an ethical dilemma, which results in confusion, ambivalence, and personal distress. -Must also recognize that for many others, the issue is not a dilemma but a fundamental violation of the personal or religious views.

Care versus Care

-One problem to be addressed is whether the focus of healthcare should be on preventive and caring measures or cures for diseases. -Prevention avoids suffering and is less expensive than treating diseases after diagnosis. -Low birth weight (LBWs) infants constitute a small percentage of all newborns, they require a large percentage of total hospital expenditures. -Expenses of one preterm infant for a single day in an intensive care nursery are more than enough to pay for care of the mother throughout her pregnancy and birth. -If the mother had received prenatal care early, infant might have avoided intensive care.

Informed Consent

-Patients have the right to decide whether to accept or reject treatment options. Competence: -The patient must be competent, or able to think through a situation and make rational decisions. -A Patient who has received drugs that impair the ability to think is temporarily incompetent. -The age of majority is 18 -Adolescents can consent independently to some treatments. -An emancipated minor is younger than the age of majority, usually 18 years, and considered medically competent to make some medical decisions independent of parent or guardian. -Treatment may proceed if evidence that the patient does not want the treatment is lacking. Emergency may be specifically defined by state law and is usually restricted to unforeseen conditions. Full Disclosure: -Second requirement is full disclosure of information, including details of what the treatment entails, expected results, meaning of those results.

Social Issues: Poverty

-Poverty remains an underlying factor in problems such as homelessness and inadequate access to health care. -Because of adverse living conditions, poor health care, and poor nutrition, infants born to woman in low income groups are more likely to begin life with problems such as low birth weight. -Poverty often breeds Poverty. -Children may leave educational system early, less likely to learn skills necessary to obtain good jobs. -Childbearing at an early age is common -The working poor have little opportunity to save for emergencies such as serious illness. -People without insurance seek care only when absolutely necessary. -Some women receive no health care during pregnancy until they arrive at the hospital for birth. -Temporary Assistance to Needy Families (TANF) which provides money for basic living costs of indigent children and their families.

Prenatal Care in the US

-Prenatal care is widely accepted as an important element in a good pregnancy outcome. -Early prenatal care for all races during the first trimester was 70.7% and late (third trimester) or no prenatal care was 7%. -Because preterm infants are the largest category of those needing intensive care, millions of dollars could be saved each year by ensuring adequate prenatal care and good maternal nutrition. Even a small improvement in birth weight or gestational age reduces complications and hospital time. -Minority women are more likely to be indigent, less likely to seek prenatal care, and more likely to die in childbirth when compared with white woman.

Mandated Contraception

-Requiring contraception has been used as a condition of probation, allowing women accused of child abuse to avoid jail terms. -Some people believe that mandated contraception is a reasonable way to prevent additional births in the case of women who are considered unsuitable parents and to reduce government expenses for dependent children. -Access to free or lowcost information on family planning would be more appropriate and ethical.

Ethical Principles

-Rules are also important for solving ethical dilemmas. Four of the most important principles are beneficence, non-maleficence, respect for autonomy, and justice. -Treatments designed to do good may also cause harm.

Personal Values

-Some nurses have no objection to participation in performing abortions. Others do not assist with abortions but may care for women after the procedure. Some nurses will assist with a first-trimester abortion but may object to alter abortions. -A nurse may or may not oppose abortion if pregnancy endangers the woman's health.

Standards of Care

-Standards of care are set by professional associations and describe the level of care that can be expected from practitioners.

Maintaining expertise

-The nurse can also reduce malpractice liability by maintaining expertise -States require proof of continuing education for renewal of nursing licenses. -expertise is a concern when nurses are "floated", or required to work with patients who needs differ from those of the nurses usual patience. -in the situations, nurses need cross training, which includes orientation and education to perform care safely in new areas.

Safeguards for Health Care

-Three categories of safeguards determine the law's view of nursing practice: 1) nurse practice acts, 2) standards of care set by professional organizations, and 3) rules and policies set by the institution employing the nurse.

Ethical Theories

-Three models guide ethical decision making: deontologic, utilitarian, and human rights. Deontologic Model: -The deotological model determines what is right by applying ethical principles and moral rules. It does not vary, "Life must be maintained at all costs and in all circumstancds." -Would not consider the quality of life Utilitarian Model: -The utilitarian model approaches ethical dilemmas by analyzing the benefits and burdens of any course of action to find one that will result in the greatest amount of good. Actions may vary. -Concerned more with the consequences of actions than the actions themselves. -"The end justifies the means." Human Rights Model: -The belief that each person has human rights is the basis for the human rights model to making ethical decisions.

Documenting incidents

-another form of documentation use in risk management is the incident report, sometimes called a quality assurance report or variance report. -The nurse complete a report when something occurs that might result in legal action. -incident reports are not a part of the patient's chart and should not be referred to on the chart. -late entries must be accurate in objective rather than defensive especially if the outcome was negative in the entry

Delegation to unlicensed assistive personnel

-delegation of care to an unlicensed person may allow the nurse to focus on grader needs within the group of patients. -nurses must be aware that they remain legally responsible for patient assessments and must make the critical judgment is necessary to ensure patient safety when delegating task to UAP.

The nurse as a patient advocate

-nurses are ethically and legally bound to act as the patient advocate. -nurses must document their efforts to seek help for patients.

Early discharge

-regardless of the patient's diagnosis, teatime for my mission to discharge is a short as possible to keep cost and check and to reduce the chances for a hospital acquired infection.

Select the tasks for which the nurse is responsible when delegating tasks to unlicensed assistive personnel. (Select all that apply). A. Client assessment B. Critical judgments to ensure client safety C. Capabilities of each unlicensed person D. Supervision of the unlicensed person

A,B,C

Select the elements listed that are necessary to prove negligence. (Select all that apply) A. Duty B. Breach of duty C. Damage D. Proximate cause E. Breaking the standard of care

A,B,C,D

Select which of the following statements are stipulated in the Roe v. Wade decision. (Select all that apply). A. A woman can obtain an abortion at any time during the first trimester. B. A woman can obtain an abortion at any time during the pregnancy when both mother and father sign releases. C. The state can regulate abortions during the second trimester only to protect the woman's health. D. The state can regulate or prohibit abortion during the third trimester, except when the mother's life might be jeopardized by continuing the pregnancy. E. Late-term abortions are banned.

A,C,D

Which of the following statements are true concerning poverty in the United States? (Select all that apply). A. The poverty rate has decreased since the 1990s. B. In poverty-ranked families, the children have increased motivation to finish their education. C. The working poor usually do not have health care insurance. D. Malnutrition is one major problem among the homeless. E. Teenage pregnancy contributes to homelessness.

A,C,D,E

Concerns about early discharge

Although advantages of early discharge include reduced risk for hospital acquired infection and prompt ambulation, concerns also exist for newly delivered women. Women may be exhausted from a long labor or complicated birth and unable to absorb all the information nurses attempt to teach before discharge. -nurses may detect early signs of maternal infant complications that may not be evident to parents while in the healthcare facility. -similar problems make her in the older woman who must care for herself after an inpatient or outpatient procedure.

EVOLVE: A client is severely injured in an accident. The physician states that the client will be in a vegetative state for the rest of her life. The decision was made to maintain the client's life, regardless of cost. The theory used to decide this ethical dilemma was:

Deontologic

A nurse is hired as relief staff in an abortion clinic. The first night on duty, the new nurse informs the charge nurse that abortion is against her religious beliefs and she will not assist in the procedure. The charge nurse should be aware that this is a(n):

Ethical issue. The new nurse should have informed the hiring committee of her beliefs prior to being hired.

Issues in Infertility

Infertility Treatment: -Many techniques are more successful, but ethical concerns include the high cost and overall low success of some infertility treatments. -Techniques may benefit only a small percentage of infertile couples. -Many couples never give birth -Successful treatment may lead to multiple gestations, usually twins -Other ethical concerns focus on the fate of unused embryos. -In multiple pregnancies with more fetuses thatn can be expected to sruvive intact, reduction surgery may be used. -The ethical and long-term psychological implications of this procedure are also controversial. -What are the ethical implications of conceiving and giving birth to children whose mother is several decades older than their friends mothers and is more likely to die when the children are relatively young? Surrogate Parenting: -In surrogate parenting, a woman agrees to bear an infant for another woman. -These embryos are then implanted into the surrogate mother. -Cases in which the surrogate mother has wanted to keep the child have created controversy. No standard regulations govern thee cases, which are decided individually. -Screening of parents and surrogates is necessary to determine whether they are suited for their roles. -An issue closely related to surrogate parenting is the use of donor gametes or unused embryos from another infertile couple.

Government Programs for Health Care

Medicaid: -Medicaid provides health care for indigent persons, older adults, and persons with disabilities. -Pregnant women and young children are especially targeted. -All women who's income is below 133% of the current federal poverty level are eligible for perinatal care. -Women who do not have private insurance or Medicaid may receive prenatal care at public clinics. Shelters and Health Care for the Homeless: -Federal funding has assisted homeless people with shelter and health care. -Have additional difficulties in obtaining health care because of lack of transportation, inconvenient hours, and poor continuity of care. -Quality and quantity of care in clinics may be poor because of inadequate funding. -Clinics headed by nurse practitioners are often opened in underserved rural and inner city areas. -Nursing students often find that some of their clinical practice occurs in clinics such as these rather than in an acute care hospital. Innovative Programs: -Innovative programs to ensure that all women receive good prenatal care are necessary to improve pregnancy outcomes. -Bilingual health care workers and bilingual educational classes are part of some programs. -The number of such neighborhood programs is insufficient to make adequate health care for women and childern a reality.

Before signing a permission slip for treatment, the client states to the nurse, "I know the doctor wants me to do this, but I am not real sure about going through the pain." The next appropriate action by the nurse should be to:

Notify the physician prior to the client signing the permission form.

The client has signed permission to have a bilateral tubal ligation. Before surgery, the client states to the nurse, "I think this is the best thing for me. Anyway, I can always take a pill later if I want more children." The next appropriate action by the nurse should be to

Notify the physician that the client has misinformation concerning the surgery.

A nurse in Virginia is allowed to administer intravenous medications to a client. This procedure is allowed according to the:

Nurse practice act.

The Health Insurance Portability and Accountability Act not only aids in the reduction of fraud in the insurance industry but also:

Protects personal medical privacy.

The best evidence that a standard of care has been maintained is ________________________.

documentation

The nursing committee is discussing ways to decrease pregnancy rates among the mentally handicapped clients in their mental health clinic. Which of the following suggestions is the most ethical in this situation?

To individualize a family planning teaching plan for each client to ensure understanding and compliance

Informed Consent (Continued)

Understanding of Information: -Third requirement is that the person must comprehend information. -Patient confidentially is compromised when nonprofessional interpreters are used for sensitive information. Voluntary Consent: -Fourth requirement is that patients must be allwed to make choices voluntarily. Refusal of Care -Patients refuse treatment when they believe that the benefits of treatment are insufficient to balance the burdens of the treatment. -First, the physician or nurse should establish that the patient understand the treatment and consequences of refusal. -Patients may be asked to sign forms indicating that they understand the possible results of treatment refusal. -In cases of an ethical dilemma a referral may be made to the hospital ethics committee. -Coercion is illegal and unethical in obtaining consent. -Nurses must be sure that personal feelings do not adversely affect the quality of their care.

One major ethical concern in infertility treatment is the fate of unused _______________.

embryos

Rules or principles that govern right conduct, specifically those that relate to health care are termed ______________.

bioethics

Before signing an informed consent, the client must by able to think through a situation and make rational decisions. This is termed _________________________.

competence

A situation faced by a nurse in which no solution seems completely satisfactory can be termed a(n) _______________ _____________.

ethical dilemma

Negligence by a professional person is termed __________.

malpractice

A woman who agrees to bear an infant for another woman is termed a ___________________ parent

surrogate