Nursing Regulations and Malpractice: A Comprehensive Guide, Exams of Nursing

Download Nursing Regulations and Malpractice: A Comprehensive Guide and more Exams Nursing in PDF only on Docsity! 1 | P a g e NUR 205/NUR 205 EXAMS 2024 WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED RATIONALES ANSWERS 2024(NEWEST) ALREADY GRADED A+ A1C test Diabetic diagnosis test checking sugar on red blood cells to get an average glucose level over several months (90 days) A1C Normal range Optimal level is lower than 7 DM type 2 education HYDRATION Increase exercise Proper Vit D intake Low carb Increased Fiber intake Check BS before meals DM type 1 CANNOT/have Oral glycemic Diuretics Fasting When blood sugar level is low, you first need to try Try fast acting carbs *orange/apple juices, crackers & pB, honey Fluid in each of the body compartments contains? Electrolytes To have normal body function ____________ the bodies cells must have fluids and electroytles in the right compartment intracellular fluid Fluid inside cells; majority of fluids are inside cell 2 | P a g e extracellular fluid body fluids located outside of cells Third-spacing the accumulation and sequestration of trapped extracellular fluid in an actual or potential body space as a result of disease or injury Edema Abnormal accumulation of fluid in interstitial spaces of tissues. Occurs as a result of conditions such as cardiac, renal or liver disease Body Fluids Transport nutrients to the cell and then carry waste products from the cells isotonic Solution A solution whose solute concentration is EQUAL to the solute concentration inside a cell Hypotonic solution Solute concentration is less than that inside the cell; cell gains water (SWELLS) Hypertonic Solution Solute concentration is greater than that inside the cell; cell loses water (SHRINKS) Insensible water loss the loss of water not noticeable by a person, such as through evaporation from the skin and exhalation from the lungs during breathing 5 | P a g e -Renal disease/failure -Liver disease/failure -CHF -Pulmonary edema -excess fluid intake (oral/intravenous) -increased ADH or SIADH -too much Na+ -high cortico steroid levels caused by stress or pain -stopped diuretics Treatments for FVE -Fluid restriction -Sodium restriction -strict I&O -diuretics -daily weights -O2 may be needed -elevate HOB -slow IV infusion or stop -treat underlying cause Normal Calcium 8.5-10 Metabolic Acidosis Low pH (lower than 7.35) Low HCO3 (lower than 22) Causes: diarrhea, alcohol, DKA, excessive laxatives, kussmal breathing Metablolic Acidosis Treatments/Interventions Monitor K+ values Seizure precautions Strict I&O monitoring Monitor LOC Sodium bicarb Rehydrate patient Metabolic Alkalosis High pH (7.45 or higher) High HCO3 (26 or higher) Causes: vomiting, gastric suctioning, dehydrations, overuse of antacids Results in hypokalemia 6 | P a g e Metabolic Alkalosis Treatment/Interventions Monitor signs for resp distress Monitor K+ and Ca+ levels K+ replacement Medications to flush out the excessive bicarb Iv/Oral fluids Administer antiemetic medications Nutrition replacement Seizure precautions Respiratory Acidosis Low pH (7.35or lower) High Pc02 (45 or higher) Causes: COPD, hypoventilation, asthma, pneumonia, pulmonary edema, sedation Respiratory Acidosis Treatment/Interventions Administer 02 as prescribed sit HOB or orthopenic position Encourage fluids to thin secretions Administer respiratory therapies May need suction kit at the bedside Monitor electrolytes Administer respiratory infection antibiotics or steroids Bronchodilators ** Respiratory Alkalosis High pH (7.45 or higher) Low Pc02 (35 or lower) Causes: Hyperventilation, anxiety, obesity, fever Respiratory Alkalosis Treatment/Interventions Breathing techniques into a paper bag Anti anxiety meds Relaxation techniques monitor electrolytes Provide emotional support Hypokalemia K+ lower than 3.5 Causes: ** Vomiting/Diarrhea 7 | P a g e DKA Excessive diuretics or corticosteroids Increased secretion of aldosterone Wound drainage Prolonged gastric suctioning Excessive diaphoresis Kidney disease/failure Hypokalemia S/S Muscle cramps Constipation Lethargy Weakness Low respirations Confusion Low or absent DTR Dysrhythmias Hypokalemia Treatments/Interventions Place pt on cardiac monitor monitor vital signs monitor electrolytes administer K+ supplements increase K+ rich foods Hyperkalemia Higher than 5 Causes: Burns, acute kidney failure, excessive use of K+ supps and intake of K+ foods, intestinal obstruction, cell damage Hyperkalemia S/S muscle weakness hypotension diarrhea hyperactive bowel sounds flat P waves Prolonged PR interval Depressed ST Hyperkalemia Treatment/Interventions Place pt on cardiac monitor monitor I&O monitor vital signs 10 | P a g e Onset: 30 minutes Peak: 2 hours Duration: 8 hours Intermediate-Acting Insulin NPH (Humulin N, Novolin N) Intermediate-Acting Insulin Onset? Peak? Duration? Onset: 2 hours Peak: 8 hours Duration: 16 hours Long-Acting Insulin glargine (Lantus) detemir (Levemir) Long-Acting Insulin Onset? Peak? Duration? -Onset: 1-2 hrs -Peak: None -Duration: 24 hrs -DO NOT MIX! Hypoglycemic 15/15 Rule Low BS Give 15 grams of glucose/simple carb Recheck BS in 15 minutes (if less than 70 repeat) When educating a type 1 DM, what is a large priority? the risk of hypoglycemia 6 rights of drug administration Right patient, right drug, right dose, right route, right time, right documentation 3 medication checks 11 | P a g e Check MAR/order Check when you pull the medication Check at the patient bedside How to know if your patient can swallow pills whole? -ask if they can -check gag reflex -when given report ask if they can take pills whole Intramuscular (IM) injection into a muscle No more than 3 ml At a 90 degree angle Where are the IM injection sites? Deltoid Gluteus Maximus (not recommended) Vastus lateralis *** Recurs femoris Subcutaneous injections Injection of a small amount of a medication under the skin into fatty or connective tissue 45-90 degree angle 1 ml fluid maximum Transdermal injection diffuse through the epidermis at a known rate into the dermis 5-15 degree angle Bevel up Pull skin back Make a "wheel" Endocrine system Glands secrete hormones that regulate processes such as growth, reproduction, and nutrient use (metabolism) by body cells. Insulin Hormone Necessary for carb regulation and glucose control Hormones Chemical messengers, mostly those manufactured by the endocrine glands, that are produce metabolic change Normal BS 12 | P a g e 70-120 Fasting BS 70-100 Pre-diabetic BS over 140 Mild Hypoglycemia Symptoms Hunger Nervousness Palpitations Sweating Tachycardia Tremor Moderate Hypoglycemia Symptoms Confusion Double Vision Drowsiness Emotional Changes Headache Impaired Coordination Inability to concentrate Irrational or combative behavior Lightheadedness Numbness of the lips and tongue Slurred speech Severe Hypoglycemia Symptoms Difficulty arousing Disoriented behavior Loss of consciousness Seizures Hyperglycemic Symptoms Polydipsia (increased thirst) Polyphasia (Increase hunger) Polyuria (increased urination) Warm, flushed skin Blurred vision Poor wound healing Diabetic Keto acidosis (DKA) 15 | P a g e Examples of oral hypoglycemics -Metformin -Glypiside Do not give oral hypoglycemics to who? Type 1 diabetics Metabolic Syndrome A cluster of conditions like high BS, high BP, excessive wasting, body fat, abnormally high lipids acting together that increase the risk of heart disease, stroke, and diabetes. Type 1 DM Glycogen Found in the pancreas; stores glucose (stored sugar for energy source) Euglycemia The term used to describe normal BS levels 70—120 he nurse is applying compression stockings and administeringan anticoagulant to a patient. Why is the nurse performing theseinterventions? Reduction of thrombus formation A 74-year-old patient who has returned to the nursing home after surgical removal of bilateral cataracts reports feeling a little uncertain about walking alone. Which approach would the nurse use to assist the patient with ambulation? Have the patient grasp your arm just above the elbow and walk at a comfortable pace. Which strategy does the nurse use when communicating with a hearing-impaired patient? Select all that apply. Avoid eating or chewing while speaking. Use a normal tone of voice and normal inflections of speech. Use written information to enhance the spoken word. A nurse is caring for a patient in the intensive care unit (ICU) and finds that the patient is restless, anxious, and inattentive. The nurse understands that the patient is experiencing sensory overload. Which measure would the nurse take to make the patient comfortable? Provide constant reorientation. Control excessive stimuli. While assessing a patient with impaired mobility, the nurse prioritizes which type of related complication? Respiratory 16 | P a g e The nurse is caring for a patient who has been immobile for a month because of quadriplegia. Which risk would the nurse be prepared for? Select all that apply. Risk of developing atelectasis. Risk of developing hypostatic pneumonia. Risk of ineffective coughing. Which patient is at greatest risk of developing multiple adverse effects of immobility? 80-year-old woman with a stroke A patient is undergoing treatment in a long-term care facility. Which type of immobility complication is likely to develop in the immobilized patient? pressure ulcers Which term is used to explain the relationship of one body part to another along a horizontal or vertical line? Body alignment Which measure would the nurse adopt to reposition a patient in bed? For patients with stage Ill or IV pressure ulcers, care should be taken to avoid shearing force. Which patient's crutch movement is similar to the arm motion of normal walking? Patient C: condition- Arthritis of the knees type of crutches- Two-point crutch gait Arrange the steps in order for applying a patients nasal cannula. #1: Attach the nasal cannula to a humidified oxygen source. #2: Insert the nasal prongs slightly into the patient's nostrils. #3: Adjust the lanyard so that the cannula fits snugly but not too tight. #4: Monitor the patients response with SpOz. #5: Observe the patient's external ears and nares for evidence of medical device-related pressure injury (MDRPI). Which oxygen delivery system would the nurse select to administer oxygen at 4 L/min to a patient needing a low-flow delivery device? nasal cannula Which function does the pictured type of airway serve? Prevents obstruction of the trachea by displacement of the tongue into the oropharynx Which nursing intervention helps to ensure that a patient receives 35% oxygen via Venturi mask as prescribed? 17 | P a g e Adjust the barrel on the mask to the correct oxygen level Which statement made by a patient's caregiver indicates successful teaching about safety measures related to home oxygen therapy? "I should check the oxygen level of the portable tank before transporting the patient." What is a nasal cannula most often used for / characteristic related to this type of oxygen delivery system? Is useful for short periods, such as during patient transportation Which delivery device is used for short-term oxygen therapy and delivers oxygen concentrations from 6 to 12 L/min? simple face mask Which guideline would the nurse follow to determine when a humidification device is needed for home oxygen therapy? When oxygen is being delivered at greater than 4 L/min Which factor can affect the oxygen-carrying capacity of the blood? Anemia, Toxin inhalation, & blood loss. Which phrase defines hypoxia? Inadequate tissue oxygenation at the cellular level Which condition would the nurse suspect in a patient receiving intravenous (IV) fluids who develops tenderness, warmth, erythema, and pain at the site? Plebitis A health care provider prescribes 2 L of intravenous fluid over 6 hours using gravity-flow tubing and a macrodrip with a drop factor of 10 for a patient who has been vomiting. Calculate the minute flow rate of the infusion in gtt/min. 56 gtt/min. Which electrolyte imbalance will the nurse suspect in the patient with chronic diarrhea who demonstrates a positive Chostek's sign? Hypocalcemia, & Hypomagnesemia. 20 | P a g e Simple oxygen face mask are single pt use and are low-flow mask which entrain the air from the atmosphere. What type of pts use a simple face mask? Used for short-term oxygen therapy and is useful when transporting a patient How much oxygen is delivered into a simple face mask? Oxygen flow rates between 5 and 10 L/min and can deliver oxygen concentrations from 40% to 60%. What is some important info about simple mask? - Used when the patient needs a moderate amount of oxygen - Assess for skin breakdown under the mask and behind the ears - Must be removed for the patient to eat. The patient is placed on a nasal cannula when eating, and the mask is replaced after eating - Hard to use on a patient who is anxious or claustrophobi What is a Venturi mask? A Venturi face mask is A fixed performance device that delivers a constant concentration of oxygen despite the patient's respiratory pattern. What type of pt uses a Venturi face mask? Used on pts with chronic lung disorder How much oxygen is delivered in a Venturi mask? Venturi mask deliver 24% to 60% by using different adapters and by adjusting the oxygen flow from 2 to 15 L/min. How much oxygen is delivered into the Venturi mask? Venturi mask deliver 24% to 60% by using different adapters and by adjusting the oxygen flow from 2 to 15 L/min. 21 | P a g e Which complication from potassium chloride will the nurse monitor for when administering the medication ordered by the health care provider to a patient who has had 10 episodes of vomiting in 2 days? Cardiac dysrhythmia Which drugs would be appropriate for a patient who develops a febrile nonhemolytic transfusion reaction after a blood transfusion? Antipyretics What is some important info about Venturi mask? - Most commonly used for high-flow delivery - Delivers most accurate oxygen concentration (concentrates it) - The mask is fitted to the face (pinch the nose piece to secure and place the strap around their head) - An adaptor is attached to the bottom of mask - Some masks that have an adapter with a dial to determine the oxygen concentration to be delivered to the patient. - Remove mask and check skin every 2-3 hours What is a non-rebreather mask? Two-one way valves between bag and mask that prevents exhaled air from entering the bag. What type of pts use a non-rebreather mask? Can be used in emergency situations with patients who need a lot of oxygen at once (trauma injury or smoke inhalation). Hard to use on patients who are anxious or claustrophobic, use nasal cannula instead. How much oxygen is delivered into a non-rebreather mask? Can provide up to 100% oxygen, minimum flow 10mL/min What is some important info to know about the non-rebreather masks? - One-way valves on both sides of the mask to prevent room air from entering mask on inhalation - Reservoir bag must be kept inflated at one-third to one-half full on inspiration so the patient receives the optimal amount of oxygen - Forms a seal around nose and mouth, check for skin irritation - Can only breathe while mask is hooked up to an oxygen tank 22 | P a g e What is a partial rebreather? A partial rebreather is a mask that will provide very high concentrations of oxygen to patients without the risk of suffocation. Partial rebreathers allow some air to be recycled instead of completely preventing patients from rebreathing air. Parital rebreathers use a two-way valve instead of a one-way to promote oxygen recycling. What's type of pts use a partial rebreather? This mask is best suited for patients who are in need of high concentration oxygen but do not need help breathing. They are often used in emergency situations such as traumatic injuries, after smoke inhalation, and in carbon monoxide poisoning cases. How much oxygen is delivered into a partial rebreather? Partial rebreather masks typically administer between 50% and 70% oxygen to the patient. It requires around 10-15 L/min. What is some important info to know about partial rebreathers? To apply the mask, first attach the end of the tube to the oxygen source and turn up the oxygen to at least 10 L. Close the valve with your fingers to ensure the bag will inflate with oxygen properly. Then place the mask on top of the patient's nose and mouth area and secure it around their head with the strap and adjust to fit. This mask covers the nose and mouth but not with a tight seal. Monitor patient for skin irritation from the mask. What is a C-PAP? continuous positive airway pressure What does a CPAP do? Provides the patient with a preset of continuous positive pressure throughout the respiratory cycle with each breath; constant pressure keep the alveoli open during inspiration and exhalation. What is the range for a CPAP? The usual range for C-PAP is 5-15 cm H2O 25 | P a g e A nurse is asking a client who had a stroke assessment questions. The client is struggling to answer the questions. What is the client experiencing? Expressive aphasia A client reports needing to stop walking every 50 feet to rest. What is the client experiencing? Activity intolerance American Nurses Association definition of nursing practice (P,P,O) Protection, promotion, and optimization of health and abilities,through diagnosis and treatment. International Council of Nurses definition of nursing practice collaboration and autonomous care of individuals, families, groups and communities, sick or well in all settings. Nurses responsibilities of professional nurse care giver Change agent Delegator educator Manager advocate Researcher leader Collaborator Development of nursing profession through the ages 1.Nightingale founder of nursing (Notes on Nursing journal) 2. Journal was lost then found an started to gain importance 3.Military saw potential and started educating people to be nurses 4.American Red Cross was founded during civil war 5.advancement of nursing during WW2 brought about the need more educated nurses ANA standard of practice and performance ensure quality of care and serve as legal criteria for adequate patient care 1. Nursing process (direct patient care nurses will always follow these standards) 2.Professional Performance (Cont. education are key factor in enhancing performance) What is a Metaparadigm? multiple concepts that I.D. and describe the central basis of something (nurses focus in concepts of, person,enviro., health, and nursing) 26 | P a g e what is a conceptual model? interrelated concepts that provide direction for practice, research, and education What is Nightingales Philosophy? patients enviro. plays key role in healing and recovery process. (clean air,water, dressings, housing, etc. and low noise and light setting etc.) Benners model: Socialization into nursing 5. Novice= no experience 4.Advanced beginner= limited experience 3.Competent= working 2-3 years learn from these people* 2.Proficient= uses experiences to make decisions 1.Expert= no longer abides by the rules/ guidlines LPN (Lowest) Licensed Practical Nurse:12-18 month training, Can only take data and can not diagnose, perform assessment, or initiate patient care RN Registered Nurse: 2-4 yr degree program OR 3 yr diploma program (3 types) Associate degree nurse ;ADN Diploma program Bachelor of science in nursing; BSN MSN Masters of science nursing: focus in specific area of advanced practice 1.Certified nurse midwife(CNP) 2. Nurse Practitioner (NP) 3.Certified registered nurse anesthetist(CRNA) 4.Clinical nurse leader (CNL) Doctor of Philosophy & Doctor of Nursing Practice Leadership role in research, teaching, administration DNP=focus on clinical aspect which include NP, CNS, CNM, CRNA What are future trends that will influence nursing practice? 27 | P a g e 1.Nursing shortage (retiring nurses) 2.Quality and Safety education (cont. edu.) 3.Independent Nursing Practice (renewing license) Formation of of personal beliefs and values 1.First-order belief: basic belief in something (hard to change) 2.Higher-order belief:forming stereotypes,generalization, & prejudice What is Values Conflict? Doing something you know you shouldn't be doing! when a persons behaviors are inconsistent with their values ie)treating a murderer, you might feel troubled about that What is Values Clarification? a process that is used to reflect, clarify, and prioritize personal values to increase self-awareness and decision making. (used with end-of-life care patients) How would you use Values Clarification to solve a Values Conflict? ie)someone cont. to smoke even when they have lung cancer 1. inform the patient with facts kindly yet "matter-of-factly" 2.this informs the patient of consequences of his/her actions and they have a full understanding of their decisions Autonomy making independent decisions for oneself Accountability accepting responsibilities for ones own actions Advocacy promoting interests of others/ cause greater than ourselves Beneficence doing good Confidentiality ethical concept that limits sharing private info. Fidelity keeping promises/ agreements made with others Justice acting fairly and equitably 30 | P a g e Negative self-talk= internal talk that damages potential of oneself Meditation= prayer, and mindful reflection What is Inter-personal Communication? conversation occurring b/w 2+ people (Formal & informal) a) inter-professional= collaborating comm. b/w diff. medical fields What is the goal of Small Group Communication? meeting established goals or needs of group participants What are the components of Professional Communication? 5parts RAACD RAACD 1)Respect 2)Advocacy 3)Assertiveness 4)Collaboration 5)Delegation What are the components of Holistic Communication? CLEAR C=center (center yourself) L= Listen (wholeheartedly) E= Empathetic (feeling for the person and their emotions) A=Attentiveness (being attentive to someone) R=Respect (respect the whole person) What are the 5 parts of small group dynamics? (ALL THE 'INGs) Forming= forming what it is that needs to be accomplished Storming= working out any problems w/in the group Norming= problems w/in the group have been overcome and ppl start working together Performing= problem solving and creation of answer emerged Adjourning= group dismisses What is the QSEN definition of Teamwork &Collaboration? "Allows the team to function effectively by maintaining open communication,mutual respect, and shared decision-making." What are characteristics of teamwork? 1.Competence & Accountability 2.Common Purpose 3.Effective communication & competence 4.Trust & Respect 5. Valuing diverse knowledge and skills 6. Humor 31 | P a g e Nurses Boundary Violations a)self-disclosure of personal info. b)keeping secrets w/ patients from Dr.'s, family, etc. c)spending excessive amount of time w/ 1 patient d) acting as if the patient as close personal relationship e)inappropriate sexual involvement w/ a nurse What are the responsibilities of a Student Nurse? "Promote the highest level of moral & ethical principles" 1.Students must be committed to excellence, compassion, and integrity 2.Disciplined in their studies and clinical practices renaissance and reformation referred to as the dark ages of nursing characterized by: - major advancements in pharmacology, chemistry, and medical knowledge -nursing care was done by common women, prisoners, thieves, etc. -nursing was an undesirable job with poor pay and long hours social conditions of renaissance famine, plague, filth, and crime ravaged europe - nursing orders were established out of concern for social welfare sisters of charity nursing order established during the renaissance and reformation period - recruited young women for nurse training, developed educational programs, and cared for abandoned children St. Vincent de paul nursing order established during the renaissance and reformation period - established the hospital for the foundling to care for orphaned and abandoned children colonial america period health care was deficient in this time period- life expectancy was low, plagues (yellow fever and small pox) were a constant threat - physicians were hardly trained and used cruel techniques (bleeding and purgatives) Pennsylvania Hospital first hospital built in the US in 1751 - was completed through the efforts of ben franklin Florence Nightingale (early on) 32 | P a g e family did not want her to be a nurse at first - in 1851 she went to a 3 month training program at the institute of deaconesses at Kaiserwerth Germany Kaiserwerth A German institute for training of nannies, governesses, and nurses - Florence Nightingale took 2 visits to observe and learn nursing practices, organization of hospitals - Institution provided religious instruction as well as learning healthcare practices Sydney Herbert invites Florence Nightingale to apply for a post of superintendent in a healthcare establishment Post of superintendent (FN) FN held this job for 14 months and did a lot of important stuff while she was there - decided that there would be no religious means test to get into the hospital as a patient this way they could provide better care - understood the importance of environment in healthcare Crimean War - 1853-1856 • War between Turkey and Russia over the Bosphorus waterway and trade routes. • Turkey supported by Great Britain and France • Most of war fought in the Crimea FN Crimean War 1854- accepted an assignment to lead 38 nurses who were sisters/nuns from various religious order to work at the Barracks Hospital in Scutari - their assistance was initially refused by the army physicians but eventually they were desperate enough to ask for help - purchased med supplies, food, and linens- set up a kitchen and laundry service major accomplishments of FN - founder of professional nursing - demonstrated the value of aseptic techniques and infection control procedures - honored for her contributions to nursing research - demonstrated the value of political activism to affect health care reform - established the first nursing school in england -honored as the founder of professional nursing services, initiated social services, spent up to 20 hrs a day providing care - introduced principles of asepsis and infection control, a system for transcribing physician's orders, and a system to maintain patient records - kept careful stats: saw a drop from 42% death rate drop to 2% as a result of sanitary conditions Mary Seacole 35 | P a g e - 3 year program (27-36 months) - based on FNs conception of nursing edu - had an apprenticeship format that filled nursing vaccines at the hospital - this was the way that most nurses in the US were education unto the 90s - did not offer academic credt - currently no diploma programs in MI nursing edu- BSN 4-5 year program that offers a BSN degree - about 550 nationally, 16 programs in Michigan - offers maximum flexibility, job opportunity, job security, access to higher edu, facilitates improved outcomes and generates improved understanding of care outside of the hospital University of Minnesota First university to implement a BSN program - established in 1909 Yale First Ivy league school to have a BSN nursing program - established in 1924 nursing edu- ADN began in 1952, developed by Mildred Montag - based in community colleges - 2 year technical education - about 900 national programs, 36 programs in MI - currently account for the largest number of nurses who graduate with a basic education degree in nursing Lilan Wald the founder of public health nursing-> she developed a viable practice for public health nursing (the henry street settlement) located in the lower east side of NYC - the purpose was to provide well baby care, health education, disease prevention, and treatment of minor illnesses - nursing practice here formed the basis for public health nursing in the US Metropolitan Life Insurance Company first nursing service for occupational health - the idea was that the prevention of disease in workers promoted productivity - had sliding scale fees WW1 nursing saw great advancements in medical and public health - improved hospital care and surgical techniques 36 | P a g e - discoveries in pharmacology (insulin and precursor to penicillin) - environmental condtions improved nursing advances WW1 - nurses served honorably during WWI - nurse anesthetists made their first appearance as part of the front line surgical team - US public health services sought the assistance of a nurse to establish nursing services at military outposts - american red cross became more active Mary Breckinridge Established the Frontier Nursing Service in 1925 in rural kentucky to assist disadvantaged women and children - she documented the impact of nursing services on improving the health communities - well known for midwifery services Sheppard-Towner Act first legislation to assist special populations and provide public health nurses with resources to promote the health and well-being of women, infants, and children New Deal was enacted to rescue the country and provide for medical care and other services for the large number of indigent people during the great depression Social Security Act of 1935 affected health care and provided avenues for public health nurses main purposes of this legislation: - national old-age insurance system - federal grants to states for maternal and child welfare services -vocational rehabilitation services for the handicapped -medical care for crippled children and blind people to strengthen public health services - a federal-state unemployment system WW2 nursing programs were enacted to expand nursing education and increase the number of nurses in all military branches advancements of this time period: - nursing became an essential part of the miltary advance - nurses recognized as an integral part of the military and attained officer rank in the army nurse corps post WW2 nursing 37 | P a g e there was a push for women to return to childbearing ad marriage rather than continue to work outside of the house advances in this time period: - the value of nurses in the armed services was demonstrated during the Korean war - nursing emerged as a true profession with minimum national standards for nursing education - by 1950, all states had adopted the state board test pool - the number of BSN programs grew - associate degree programs developed in community and junior colleges Nursing Training Act of 1943 the first instance of federal funding being used to support nurse training Hill-Burton Act provided funding to construct hospitals; created a hospital construction boom that increased the demand for professional nurses 1960s before this time African American nurses were barred from membership in the American Nurses Association because of segregation laws, by during this decade all barriers were dropped False- they have to pass a licensing exam T/F: when nurse completes a diploma, associate degree, or baccalaureate programs they become a licensed practical nurse Columbian Exposition an exposition held in Chicago in 1893 to showcase America's social, cultural, and scientific advances and its growing cultural parity with western Europe which led to transformation in American nursing through the congress on Hospitals, nursing, and dispensaries (was originally a celebration the 400th anniversary of columbus in the new world) - first major exposition in which women played a prominent role - FN provided a major paper, Sick-Nursing and Health-Nursing, that was read at the congress, but she was unable to attend the event likely due to her age (73) - FNs paper focused on curricular development, proposing a regularized curriculum as well as evidence based cto measure effectiveness through statistics - the world fair congress of hospitals, dispensaries, and nursing outlined the global future for nursing for the next 50 years - themes discovered: caring as a process, ideological conflict b/t religious and secularly based nursing care and education, and the emerging professionalization of nursing MSU Mission To enhance the health of community by providing excellence in nursing education, nursing research and nursing practice. We will advance the profession of nursing and serve as an advocate for optimal healthcare for all people. 40 | P a g e nursing role - caregiver - therapeutic communicator, teacher/educator - counselor: be someone to talk to - leader - researcher: stay up to date with research - advocate - critical thinker - manager - rehabilitator graduate education in nursing there are many master programs, and 2 terminal degrees (PhD, DnP) -> DnP is more clinical/practice focused -> PhD is more scholarship/research - there are lots of different programs for NPs continuing education Classes required for license renewal - have to submit a certain number (25) continuing education credits every few years to keep your license Nurse Practice Acts laws established in each state in the US to regulate the practice of nursing- they differ from state to state, but all have certain elements in common: - they define the legal scope of nursing practice - they establish criteria for education and licensure of nurses - they ID violations that can result in disciplinary actions against the nurse - exclude untrained or unlicensed people from practicing nursing - create a state board of nursing - make and enforce rules and regulations - define important terms and activities in nursing - provide legal requirements and titles for RNs and LPNs this info for Michigan is found in the MI public health code ANA Standards of Practice - defines the activities of nurses that are specific and unique to nursing - allows nurses to carry out professional roles, serving as protection for the nurse, the patient, and the healthcare institution Each nurse is accountable for their own quality of practice and is responsible for the use of these standards to ensure knowledge, safe, and comprehensive nursing care 41 | P a g e If these standards are breached, you may end up with a malpractice lawsuit - malpractice is a civil case Accreditation mandatory and voluntary - msu is accredited by association of colleges of nursing (AACN) and the commission on collegiate nursing education (CCNE) licensure national council licensure examination (NCLEX) for entry level competence - if you move to another state, you do not have to retake the NCLEX (call the state board of nursing to let them know you are moving) Certification validates specialty knowledge, experience, and clinical judgement - can be required that you attend formal program EX: - American Nurses Association, formal practice: APRN, BC (advance practice RN, board certified) - American Association of Critical care nursing: CCRN ( not formal practice- can apply to be certified if you have worked in critical care for a few years) -American College of Nurse Midwives: CNM -American Association of Nurse Anesthetists: CRNA -National Association of school nurses: CSN Laws affecting nursing practice - occupational safety and health acts (OSHA) - controlled substance acts - health care quality improvement act: laws that ID incompetent care providers - Americans with disabilities act - good samaritan laws: protects you in emergency situations while practicing w/in scope - civil rights act - reporting obligations (CDC) - requirements for wills, durable power of attorney - health insurance portability and accountability act (HIPPA) crime a wrong against a person or his/her property - consider to be against the public as well, punishable by the state - > misdemeanor, felony tort 42 | P a g e a wrong committed by a person against another person or his/her property - subject to action in a civil court - can be intentional or unintentional intentional tort you know better - fraud: ex- misrepresentation (pretending to be a doctor) - defamation: derogatory remarks that ruin the reputation - assault and battery: assault is the threat, battery is following thru with the threat - false imprisonment - invasion of privacy unintentional tort - negligence: occurs when harm or injury is caused by an act of either omission or commission by a layperson - malpractice: an act of negligence by a professional person as compared to the actions of another professional person in a similar circumstance Elements to prove malpractice 1. duty: what a prudent nurse does 2. breech of duty: failure to meet standards of care 3. causation: what resulted due to the breech of duty 4. damages: actual harm or injury ex: - duty: patient has a call light - breech of duty: forgot to give them the call light after moving them - cause: did patient fall trying to reach the call button - damages: injury because of the breech Areas of liability for nurses - failure to monitor and assess - failure to ensure safety -medication errors -improper implementation of skills or procedures - documentation errors Ethical Principles 1. autonomy 2. nonmaleficence 3. beneficence 4. justice 5. fidelity 45 | P a g e this is a professional relationship - does not occur spontaneously - dynamic: both people are active participants - characterized by an unequal sharing of info - > patient focused to achieve goals - separate from a friendship - purposeful - time-limited - person providing assistance is accountable for the outcomes of the relationship and the means used to attain them interprofessional communication if done poorly, the patient loses because the healthcare team could not talk effectively to make an appropriate plan of care interprofessionality a process by which professionals reflect on and develop ways of practicing that provides an integrated and cohesive answer to the needs of the client/family/population -it involves continuous interaction and knowledge sharing between professionals, organized to solve or explore a variety of education and care issues all while seeking to optimize the patient's participation 98,000 number of deaths annually due to medical errors 220-440,000 number of patients that suffer harm due to medical mistakes 1-7 number of patients that will suffer a poor outcome due to medical errors while hospitalized medical errors 3rd leading cause of death 5 Parts of Communication Process (Berlo) 1. the stimulus or referent- something to communicate 2. the sender or source of the message (encoder) 3. the message itself 4. the medium of channel of communication (auditory, visual, kinesthetic) 5. the receiver (decoder) feedback provides confirmation of the message (evidence that the receiver understands the intended message) - need this loop to make sure that everyone is on the same page 46 | P a g e noise factors that distort the quality of a message and interfere with the communication process (distractors) verbal communication an exchange of words, written or stated - used extensively in healthcare - must be aware of the words you use and how they may be interpreted by someone else - must be aware of what the patient says and if their nonverbals match their verbals when writing make sure it is accurate, concise, and logical SBAR consistent, clear, structured, and easy-to-use method of communication between health care personnel; it organizes communication by the categories of: Situation, Background, Assessment, and Recommendations. nonverbal communication body language - 93% of a message - the way you listen, look, and react are important and can be very useful tools - make sure body language conveys what you wanted to communicate - ex: touch, eye contact, facial expressions, body posture, gait, gestures, physical appearance, dress/grooming, sounds, silence MORE RELIABLE INDICATION OF THE TRUE MESSAGE personal space nonverbal that relies on social cues - take social cues, arms length away is a typical standard in america but can be different in other cultures - if you sit down and someone moves back from you, move your chair back a little bit - if you sit down and someone moves in closer, move your chair in closer can't assume everyone wants to be arm length apart touch nonverbal to use with caution - before you touch someone, ALWAYS ask it is ok and touch with a purpose of showing professional empathy eye contact nonverbal that suggests respect and willingness to listen and to keep communication open (shows engagement) silence 47 | P a g e nonverbal that can be a bit uncomfortable - used when you just do not know what to say or when you need to compose yourself - " I am just going to sit here with you for a minute or two and we can take some deep breaths" Levels of Communication 1. Intrapersonal 2. Interpersonal 3. Small group 4. organizational intrapersonal communication communication with oneself, self talk - ex: reassuring yourself before speaking infront of a big group of people interpersonal communication communication between two people Small Group/Organizational Communication communicating to/with a large number of people - ex: conference room or auditorium self serving interaction a person who dominates a group to promote their own agenda factors influencing effective communicating - developmental level: regulation of development correlates with intellectual (cognitive) development - gender - sociocultural differences - roles and responsibilities - space and territorial - physical, mental, and emotional state - values - environment (comfort zone) phases of therapeutic relationship - orientation phase - working phase - termination phase orientation phase of therapeutic relationship - establish tone and guidelines for the relationship - identify each other by name (Mr., Mrs., Ms, Dr.) - clarify roles of both people 50 | P a g e - obtain accurate and thorough information (gather data) - utilize therapeutic communication overview of the interview purpose: to obtain accurate and thorough info - data collection (health history) - interviewing techniques and utilized to obtain info - therapeutic communication - the interview occurs in orientation phase of the helping relationship external factors affecting the interview physical setting - privacy - interruptions - environment dress - client should remain in street clothes during the interview - nurse should meet the standards for the setting for professional appearence documentation - note taking: take caution - tape recording and picture taking is not allowed phases of the interveiw - introduction - working phase - closing orientation phase of interview the phase of the therapeutic relationship that the interview happens introduction phase of interview set the stage - welcome that patient and use their name - intro yourself and explain your note - indicate how long interview will take and if there will be a subsequent physical exam - remove internal/external potential factors that could be barriers to communication - ensure comfort and put client at ease - describe the purpose and expectations of the interview - describe confidentiality - do not use diminutives (honey, sweetie) working phase of interview 51 | P a g e open ended questions to allow the patient a wide range of possible responses (encourages free verbalization) - beginning - to introduce a new section of questions - whenever the person introduces a new topic - ex: tell me how I can help you, what brings you here today, tell more about it closed ended questions - limited answers - use for specific info only - fill in any details the client left out - ex: what meds have you been taking, when did symptoms start, etc validating questions - nurse restates what they heard or observed clarifying questions - allows the nurse to gain an understanding of patients comment reflective question - repeating what the patient said or describing person's feelings sequencing questions - place events in chronological order directing questions - used to obtain more info about a topic or to intro a new aspect of a current topic NOTE any of the patients nonverbals closing phase of interview should end gracefully - summarize what you have learned about the patient's health history during the interview - THANK the client for their time and cooperation Relating to Patients from Different Cultures - what are your personal beliefs surrounding people from different cultures - be aware of verbal and nonverbal feedback - speak slowly and distinctly- obtain a translator if needed (do not use family members) - keep messages simple Assessment 52 | P a g e the process of gathering information about a client's health status - data is the information gathered - > subjective: what they tell us -> objective: what we gather should be done any time that you interact with a client purpose of assesment -establish a database -ID actual and potential problems -focus on specific problems -determine immediate needs and prioritize -determine the etiology of a problem -determine related or contributing factors - ID strengths as a basis for changing behavior -ID the risks or complications (any comorbidities) -recognize complications subjective data information provided by the client that you cannot observe directly - what the patient says - this is the type of data collected in the health history objective data characteristics about the client that you can observe directly - what you see - this is the type of data collected during the physical assesment sources of data client: usually the best source (with exceptions) significant others: good source, maintain confidentiality colleagues: other health professionals (share on a need to know basis) types of databases - initial assessment/complete database - focused/problem centered -ongoing/follow up database - emergency database initial assessment/complete database complete health history and full physical exam - asks all the questions focused/problem centered database 55 | P a g e - past pertinent medical history: dates, serious or chronic illnesses (how long, when were you diagnosed) - past injuries: dates, accidents, fractures, penetrating wounds, head injuries, burns, how the patient recovered (any chronic problems) - immunizations and dates - geographical exposures: w/in or outside of the US (were there any immunizations required for travel) - allergies/ reactions: note how they react and how the reaction is managed family profile genogram/pedigree - show at least 3 generations- 2 previous, 1 current, and second generation if applicable (include brothers and sisters for current and immediate past generation) - must have a key - most document: denies family history of diabetes, cancer, etc. - never use the names on the genogram relationships and environment - quality of relationships: how do they get along with family (ask about violence/abuse as an adult) - who is their support system - home, neighborhood, usual environment: where do they live (type of home and neighborhood) and with who (give ages and relationships- including pets) - > do they have access to transportations - > involvement in community - >safety (do they feel safe, do they have smoke detector, carbon monoxide detector, high crime rates) -> adequate heating/cooling/ utilities teaching/learning/education profile -education: highest degree completed. Give degree and year -developmental status: can use erikson/levinsons/havighurst (must give evidence as to why the client is in a that stage -desire to learn: specific info the client is asking about -current knowledge about conditions: what do they know about condition/risk factors/family history of chronic disease -info you taught client, including references -barriers to teaching CAGE questions -c: have you ever thought you should cut down on your drinking -a: have you ever been annoyed by criticism of your drinking 56 | P a g e -g: have you ever felt guilty about your drinking -e: do you drink in the morning (eye-opener) one yes indicates hazardous drinking two or more yes answers indicates ETOH abuse and dependence (more info must be obtained) socialization/leisure patterns -hobbies/interests: what the client likes to do alone or with others -social patterns: ->social obligations ->considers self an introvert or extrovert. ->is time alone pleasurable or isolating -> use of alcohol, tobacco, drugs, and caffeine (amount, type, frequency, has use affected work or family) -participation in formal activities: church, clubs, sports teams, professional organizations - activity/exercise: type/amount/method of warm-up -typical day: time they get up/eat breakfast/leave for work or school/eat lunch/return home/eat dinner/evening activities/go to bed current health status - reason for seeking care (chief complaint) -> present health or history of present illness (HPOI) - collect 8 critical characteristics - knowledge/understanding of health problems (self evaluation) - clients perception of current health/quality of life -> how do you define health? ->how do you view your situation now? -> what are your concerns? ->what do you think will happen in the future? - limitation of function (bathing, grocery shopping, cooking, etc.) and management of limitation (equipment, resources, people) -health/life goals: -> what are your health goals? -> what do you want to do with your life? ->where do you see yourself in 5-10 years? (for elderly, what do you want to do most of all with the rest 57 | P a g e of your life) - health promotion activities: last physical exam, pap, pelvic, dental, eye, hearing test, colonoscopy, mammogram, prostate, do you wear sunblock, wear a seatbelt, helmet, etc. psychological profile self concept - perception of personal strengths - areas they would like to improve - how do they think others would describe them current stress factors: describe greatest current stress - have there been any changes in lifestyle recently and how does this make you feel coping mechanisms: steps taken to relieve stress (label if they are adaptive or maladaptive) maladaptive anything that does not allow a person to function within or adapt to the stresses and everyday demands of life adaptive reasonable mechanism for coping with the stresses and demands of daily life spiritual profile/value system specific beliefs/practices - participation in rituals (prayer, communion, sabbath, confession) - how do beliefs affect concept of health/illness -does seeking health care interfere with their belief system how do you get through difficult times: use of prayer, seeking out advice from family or clergy source of strength and hope: belief in higher power, prayer, mediation, value system, feelings about illness/death/afterlife meaning and purpose in life: why are you here on earth? what is important about life? - use FICA questions MORE THAN JUST RELIGION FICA F: do you consider yourself spiritual or religious I: how important are spiritual things to you? what influence does it have on how you take care of 60 | P a g e table without difficulty - mood and affect: mood and affect appropriate to the situation and topic of conversation affect outward appearance of mood - this should match how the patient feels cognitive functioning (mental assessment) - orientation: person, place, and time -attention span: focuses on conversation without difficulty - memory: immediate (intact AEB ability to recall 4 words), recent (intact AEB ability to recall 24 hr diet), and remote (intact AEB ability to recall historical events/past health) - new learning: able to recall 4 unrelated words without difficulty after 5, 10, and 30 minutes medications -include over the counter (OTC), vitamins, minerals, herbs, suppositories, enemas -note how long they have been taking the medication and note dose, frequency and route - ask what it is for or why they are taking it - think about possible interactions with alcohol/ other drugs or recreational drugs thought process/perception (mental assessment) - thought process/thought content: is content consistent and logical - perceptions: is client aware of reality (illusions/hallucinations) - screen for anxiety and depression - screen for suicidal thoughts and if they have a plan - mental health history: denies history of or if treated give dates/length of counseling and or medications 8 critical characteristics 1. Location: tell me where it hurts, point to it 2. Character: does it feel like it burns, stabbing, dull 3. Quantity or Severity: scale from 0-10 4. Timing: time of day it flares up 5. Setting: setting that it flares up in 6. Aggravating or Relieving Factors: what makes it worse and what makes it better 7. Associated Factors: anything that accompanies it (nausea, fatigue, etc.) 8. Patient's Perception: what do you think is going on? what worries you about this? review of systems - evaluate past and present health state of each body system - to double check in case any significant data was omitted - to evaluate health promotion practices ex: 61 | P a g e - respiratory: denies history of lung diseases (asthma, emphysema, bronchitis, pneumonia, tuberculosis), chest pain with breathing, wheezing or noisy breathing, cough, sputum, hemoptysis, toxin or pollution exposure - health promo: give date of last chest x-ray or note never had a chest x-ray and date of last TB skin test therapeutic communication an interpersonal interaction between the nurse and the client during which the nurse focuses on the client's specific needs to promote an effective exchange of information Goals of this technique - establish a relationship - ID the most important client concern at the moment - assess the client's perception of the problem - facilitate the clients expression of emotion - teach the client and the family necessary self-care skills - recognize the client's needs - implement interventions designed to address the clients needs - guide the client toward IDing the plan of action to as satisfying and socially acceptable solution using concrete messages the nurse should use words that are as clear as possible when speaking to the client so that the client can understand the message - the words are explicit and need no interpretation, the speaker uses nouns and questions are clear, direct, and easy to understand interpreting signals to understand what a client means, the nurse watches and listens carefully for cues - cues are verbal and nonverbal that signal keywords or issues for the client - cue words can help the nurse to know what to ask next or how to respond to the client accepting indicates reception - therapeutic communication technique that indicates the nurse has heard and followed the train of thought EX: "yes", "I understand", or nodding broad openings Allows the client to take the initiative in introducing the topic - therapeutic communication technique that makes explicit that the client has the lead in the interaction EX: "is there something you would like to talk about", "where would you like to begin" consensual validation 62 | P a g e searching for mutual understanding, for accord in the meaning of the words - therapeutic communication technique that ensures the words being said have the same meaning for both participants EX: "tell me whether my understanding of it agrees with yours" encouraging comparison asking that similarities and differences be noted - therapeutic communication that compares ideas, experiences, or relationships to bring out recurrent themes EX: "was it something like...?", "have you had similar experiences" encouraging the description of perceptions asking the client to verbalize what he or she perceives - therapeutic communication technique that emphasizes the need for the nurse to see things from a clients perspective to understand them EX: "tell me when you feel anxious" "do tell me what is happening" "what does the voice seem to be saying" encouraging expression asking the client to appraise the quality of his or her experiences - therapeutic communication technique where the nurse asks the client to consider people and events in light of his or her own values EX: "what are your feelings in regard to..." "does this contribute to your distress" exploring delving further into a subject or idea - therapeutic communication technique that is used when clients deal with topics superficially. Exploring can help them examine the issue more fully. EX: " tell me more about that" " would you describe it more fully" focusing concentrating on a single point - therapeutic communication technique where the nurse encourages the client to concentrate his or her 65 | P a g e seeking to make clear that which is not meaningful or that which is vague - therapeutic communication technique where the nurse should seek clarification through interactions with the client EX: "I am not sure that I follow, could you tell me more?" silence absence of verbal communication, which provides time for the client to put thoughts or feelings into words, to regain composure, or to continue talking - therapeutic communication technique that often encourages the client to verbalize, provided that it is interested Nurse says nothing, but continues to make eye contact suggesting collaboration offering to share, to strive, to work with the client for his or her benefit - therapeutic communication technique used when the nurse seeks to offer a relationship in which the client can ID problems in living with others, grow emotionally, and improve the ability to form satisfactory relationships EX: "perhaps you and I can discuss and discover the triggers for your anxiety" summarizing organizing and summing up that which has gone before - therapeutic communication technique that seeks to bring out the important points of the discussion and to increase the awareness and understanding of both participants EX: "so in summary..." " Have I got this straight?" translating into feelings seeking to verbalize client's feelings that he or she expresses only indirectly - therapeutic communication technique used because often what the client says, when taken literally, seems meaningless or far removed from reality EX: client: "I am dead" nurse: "are you suggesting that you feel lifeless" verbalizing the implied voicing what the client has hinted at or suggested - therapeutic communication technique that puts into words what the client as said indirectly to make sure the discussion is less obscure 66 | P a g e EX: client: "I cannot talk to you or anyone, it is a waste of time" nurse: "do you feel that no one understands" voicing doubt expressing uncertainty as to the reality of client's perception - therapeutic communication technique that is used because another means of responding to distortions of reality is to express doubt EX: "Isn't that unusual" "really?" open-ended comments unfinished questions that prompt the client to continue- questions that cannot be answered with a 1 word answer - therapeutic communication technique that allows the client to decide what content is relevant EX: "tell me more about your pain" "tell me about your family" Clarifying makes the meaning of client's message clear - therapeutic communication technique that prevents the nurse from making assumptions about a client's message EX: client: whenever I talk to my doctor, I feel so upset nurse: tell me what is making you upset? confronting nurses verbal response to incongruence between client's words and actions - therapeutic communication that encourages the client to recognize potential areas for change EX: client: I am so angry at her (while smiling) nurse: you said you are angry, yet you are smiling? setting limits stating expectations for appropriate behavior - therapeutic communication technique used to establish behavioral parameters 67 | P a g e EX: nurse: It seems that you are feeling unsure of how to behave right now client: what do you mean nurse: well you are asking me a lot of personal questions. The reason you are here is because you have some health issues and problems. Tell me more clearly what brought you here to the clinic so I can help you. reassuring nontherapeutic communication technique that indicates there is no cause of anxiety EX: I would not worry about that giving approval nontherapeutic communication technique that offers unnecessary approval and implies that the behavior that is being praised is the only acceptable one EX: That is good! rejecting nontherapeutic communication technique that refuses to consider or shows contempt for the client's ideas or behavior EX: "Let's not discuss about that" disapproving nontherapeutic communication technique that denounces the client's idea or behavior EX: "that is bad!" agreeing nontherapeutic communication technique that indicates accord with the client EX: "that is right", "I agree" disagreeing nontherapeutic communication that shows opposition to the client's idea EX: "I definitely disagree with what you are saying" "I do not believe that" advising nontherapeutic communication that tells the client what to do 70 | P a g e - establishing a national focus - identifying and learning from errors (reporting) - raising performance standards and expectations - implementing safety systems in health care organizations quality and safety preventable medical errors persist as the number 3 killer in the us- third only to heart disease and cancer- claiming the lives of some 400,000 people each year stats to promote quality of care pay for performance: better performance = better pay penalties for excess readmission: - started with medicare and Medicaid focusing on CHF patients and has expanded - we have to make sure that when a patient goes home they have the support they need before they are discharged affordable care act (obama care) expand coverage, control heath care costs, and improve health care delivery system - cant charge a person for pre-existing conditions, can't charge women extra, and kids covered under their parents insurance until 26 yo - health care costs is sometimes a reason that people file bankruptcy provide Medicaid or subsidized coverage to qualifying people with incomes up to 400% of poverty, beginning in 2014 (help those in poverty) - not everyone has health care in the US and may only seek care when things get really bad provide a new way to get health insurance (health insurance market place) - designed to help people more easily find health insurance that fits their budget the US health care dollar - for every dollar spent on healthcare we are still focused on hospital care (very expensive) - > pushing to expand health care from the hospital and into the community - physicians and clinical services and pharmaceutical drugs have the biggest dollar input next to hospitals health care delivery systems and care coordination - physicians and hospitals - multispecialty group practices (big specialty hospitals like mayo, MI medicine) - community health centers - prepaid group practice (insurance- HMO, PPO) - accountable care organizations (designated ACO if they meet certain criteria based on what they provide and their outcomes) - medical homes to medical neighborhoods (these are medical systems, not nursing homes) 71 | P a g e HMO Health maintenance organization - prepaid group practice/health insurance plan in which patients receive health care from assigned providers PPO preferred provider organizations - prepaid group practice/health insurance plan in which patients get a list of health care providers to pick from Agency for Healthcare Research and Quality (AHRQ) mission is to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work within the US department of health and human services and with other partners to make sure that the evidence is understood and used AHRQ Definition of the Patient-Centered Medical Home (PCMH) criteria for PCMH - comprehensive care - patient centered/coordinated care - accessible services - quality and safety PCMH is a designation, not a nursing home! False T/F: the number of physicians practicing primary care is INCREASING levels of health care - primary health care: common health problems (cold) - secondary health care: acute care, hospitalization, surgery - tertiary health care: rare and complex issues paying for health care out of pocket payment: done without insurance individual private insurance (BCBS): you pay for this (look at the insurance market place for this) employer-based private insurance government financing - medicare: diagnostic related groups (65+) - medicaid (poverty) 72 | P a g e - children's health insurance program (CHIP) - veteran's health administration (VHA) health care settings - Hospitals - Primary care centers - Ambulatory care centers and clinics - Home health care (seeing more move to the home) - Hospital at home (if you have the right support at home) - Extended care - Specialized care centers and settings (day care centers with a specific demographic like dementia patients) - Health care services for the seriously ill and dying - Health care agencies magnet designation this type of hospital has been recognized for quality patient care and nursing excellence and innovations in professional nursing practice - this designation is for nurses - not a once and done, have to be constantly meet criteria and a big piece of this criteria is having BSNs at the bedside Role of Nurses in Hospitals - direct care providers - manager of other members of the health care team - administrator - clinical nurse specialist - patient educator - in service educator (people educate staff on new technology) - research role of nurse in primary care centers advanced practice registered nurses (APRNS - nurse practitioners - midwives - nurse anesthetists - clinical nurse specialists work independently or collaboratively with physicians to make assessments and care for patients who require health maintenance of health promotion activities depending on state regulations, APRNs may have their own offices and clinics to provide primary care and treatment to patients and refer only complex health problems to a physician - there is a push for independence 75 | P a g e - different facilities in the US charge different rates comparative effectiveness analysis - best outcomes, what they need to improve one increasing patient cost sharing strategies to reduce health care costs/changes in care delivery utilizing quality improvement tools to reduce waste and improve safety - if something is not working, what can we do instead improving transitions across settings - acute to long term/going home (smooth as possible) making the delivery of medical services more efficient and less costly - takes months to see specialist and it costs a lot eliminating unnecessary costs such as fraud and abuse improving population health - health promotion Nurses role in health care reform - changes taking place in health care give nurses the opportunity to help shape health care for the future - nurses re becoming a stronger voice in addressing health-related problems in our nation and proposing solutions - nurses in greater numbers are increasing their education and becoming APRNs - the focus of nursing care provided by all nurses is holistic care essential to promoting health and preventing illness nurses have to be at the table when decisions are made False T/F: medical diagnoses represent situations that are the primary responsibility of nurses nursing process 1. assessment - health history and physical assessment - sources of data include: patient, family/significant others, patient records, other health care professionals, and nursing/healthcare literature 2. diagnosis 3. outcome identification and planning (plans may change!) 76 | P a g e 4. implementing (the interventions) 5. evaluation North American Nursing Diagnosis Association (NANDA) nursing diagnosis is a clinical judgement about individual, family, or community responses to actual or potential health problems/life processes that provides the basis for definitive therapy toward achievement of outcomes for which a nurse is accountable Steps leading to diagnosis assessment - collecting data - identifying cues and making inferences - validating data - organizing (clustering) data - identifying patterns/testing first impressions - reporting and recording data (EHR) interpreting data - analysis and synthesis of data - this takes time! diagnosis - creating a list of suspected problems/diagnosis (236 total diagnosis) - ruling out similar problems/diagnoses - naming actual and potential problems/diagnoses and clarifying what is causing or contributing to them (what are patients at risk for) - determining risk factors that must be managed - identifying resources, strengths, and areas for health promotion. discuss nursing diagnosis with client (patient centered care) purpose of the diagnosing step - identifying how an individual, group, or community responds to actual or potential health and life processes - identify factors that contribute to, or cause, health problems (etiologies) - identify resources of strengths upon which the individual, group or community can draw on to prevent or resolve problems diagnosing -interpret and analyze patient data -identify patient strengths and health problems -formulate and validate nursing diagnoses 77 | P a g e -develop a prioritized list of nursing diagnoses -detect and refer signs and symptoms that may indicate a problem beyond the nurse's experience components of a nursing diagnosis - a label - definition - set of defining characteristics - related factors label (component of diagnosis) NANDA made, cannot be made up - may include a qualifier (impaired, altered, decreased, ineffective, acute, or chronic) - ex: altered skin, ineffective coping definition (component of diagnosis) a precise description - NOT documented in chart - should match with patients presentation defining characteristics (component of diagnosis) descriptors of a client's behavior that determine whether a nursing diagnosis is present - these show up in the physical or health history assessments - they are directly or indirectly observable clinical cues (S/S) - can be objective or subjective (ex: altered skin integrity vs. patient complaint of pain) related factors (component of nursing diagnosis) states what is causing or contributing to the nursing diagnosis - what the nurse can treat actual nursing diagnoses describes human responses to health conditions/life processes that exist in an individual, family or community - ex: impaired skin integrity, ineffective airway clearance, pain, fluid volume deficit risk for nursing diagnosis describes human responses that MAY develop in a vulnerable person, family, or community - this plan is aimed at preventing the problem - ex: risk for infection, risk for falls, risk for fluid volume deficit wellness nursing diagnosis decribes human responses to levels of wellness in an individual, family, or community that have the potential for growth and/or the potential for enhancement to a higher state of wellbeing - must have an effective present status or function 80 | P a g e 1. physiological 2. safety 3. love/belonging 4. esteem 5. self-actualization expected outcome the desirable end result of nursing care - includes subject, verb, performance criteria, target time (possibly a condition) - must be realistic or achievable - should be measurable, timed, and can be directly observed - expected results should be acceptable to the client and be agreed upon (patient centered) - time frame: short term (1hr-1 week), long term (weeks to months) types of outcomes - cognitive: increases patient knowledge - psychomotor: new skills - affective: change in beliefs/attitudes - physiological: physical change in patient psychomotor goal by 03/06/16 patient will walk the length of the hallway with a walker cognitive goal by 03/06/16 patient will list 5 low fat snacks to replace high fat foods affective goal by 03/06/16 patient will value her health sufficiently to stop smoking variables influencing outcome achievement patient variables - developmental stage - psychosocial background nurse variables - resources - current standard of care - research findings (current evidence based practice) - ethical and legal guides to practice reasons for failed outcomes - failure to involve the patient - insufficient data - Dx developed from insufficient data 81 | P a g e - outcomes stated to broad - failure to write nursing orders clearly - inaccurate nursing orders - failure to evaluate and update plan (have to constantly evaluate) writing outcomes (ex) need to be specific and measurable - client will gain 5 pounds by October 31 - client will rate pain as less than 3 on a 0-10 scale by 10/31 - client will be able to feed self by the end of the week implementing - carry out the plan (organize resources) - continue data collection and modify the plan of care as needed (anticipate unexpected outcomes/situations) - promote self-care: teaching, counseling, advocacy - document care planning identify using interventions: any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient outcomes nurse-initiated intervention independent of the physician (i.e. assist with activities like coughing and deep breathing, reduce risk of injury or infection through sterile dressing changes, reposition patient, etc.) physician-initiated intervention within the scope of the nursing practice, but requires a physicians order for the nurse to implement collaborative interventions treatments initiated by other providers (PT, OT, pharmacist) and carried out by a nurse interventions - monitoring the client's status (keep assessing) - assisting the client who is partially or fully unable to care for himself - supporting clients who lack willpower, resilience, or the motivation to care for herself - protecting - sustaining life and physical function elements of intervention - need to make very specific so other nurses can follow - involves writing who, what, where, when, why, how 1. who: person providing care 82 | P a g e 2. what: care that will most effectively meet the clients needs 3. where: home, clinic, hospital 4. when: refers to the time that the care is delivered or the sequence of events required 5. why: provides the rationale for care and includes evidence that the care will meet the clients needs 6. how: defines the methods of interventions Nursing Interventions Classification (NIC) very detailed recipe - a system that is a standardized method of identifying nursing interventions - developed at the university of Iowa - used a standardized language appropriate for computerized client information systems to describe the component of client care that is nursing practice evaluation determine the clients progress toward the attainment of expected outcomes - reassess the client - compare your findings to the expected outcomes - determine the clients status - measure how well he patient has achieved desired outcome - identify factors contributing to the patients success or failure - modify the plan of care if indicated determine the effectiveness of nursing care - assessment was it accurate and thorough - diagnosis: was the dx derived from data and did it accurately identify the problem - planning: were expected outcomes measurable and realistic - intervention: were they appropriate and implemented correctly ANA Standards of Clinical Nursing Practice consists of standards of care and standards of professional performance - standards of care describe competent practice of nursing process - standards of performance depict competent professional behavior held liable for this! ANA standards of practice (2015) standard 1: assessment - the nurse collects comprehensive data pertinent to the patients health or the situation standard 2: nursing dx - the nurse analyzes the assessment data to determine the dx or issues 85 | P a g e - case management model (Critical pathways or variance charting) - computerized documentation (electronic medical records: EMRs, EHRs) change of shift report basic identifying information about each patient current appraisal of each patient's health - changes in medical condition and patient response to therapy - where patient stands in relation to identified diagnoses and goals current orders - nurse and physician summary of each newly admitted patient report on patient transferred or discharged Incident or Adverse Occurrence Reports document situations that have caused harm or have the potential to cause harm to clients, employees, or visitors (i.e. med errors, client falls, accidental needle sticks) this report is not part of the clients medical record and should not be referenced in the clients record - this is a specific form separate from charting - can be subpoenaed if taken to court over the EHR with mention of an incident report Historical foundations of the nurse educator role - health education has long been considered a standard care-giving role of the nurse - patient teaching is recognized as an independent nursing function - nursing practice has expanded to include education in broad concepts of health and illness organizations and agencies promulgating standards and mandates 1. national league for nursing - first observed health teaching as an important function within the scope of the nursing practice - responsible for identifying course content for curriculum on principles of teaching and learning 2. ANA - responsible for establishing standards and qualifications for practice, including patient teaching 3. ICN (international council of nurses) - endorses health education as an essential component of nursing care delivery 4. state nurse practice acts - universally includes teaching within the scope of nursing practice 86 | P a g e 5. Joint commission - accreditation mandates require evidence (EHR) of patient education to improve outcomes - lets us know when the are coming to evaluate 6. American hospital association - patients bill of rights ensures that clients receive complete and current information 7. Pew health professions commission - puts forth a set of health profession competencies for the 21st century - over 1/2 of recommendations pertain to importance of patient and staff education - this is a charitable trust Aims of teaching and counseling patient education is the process of influencing the patients behavior to effect changes in knowledge, attitudes, and skills needed to: - maintain and promote health - prevent illness - restore health - facilitate coping trends affecting health care social, economic, and political forces that affect a nurses role in teaching - growth of accountable care organizations and the patient centered medical home (need to show evidence of patient edu) - increased attention to health and well being of everyone in society (shift to PHC focus) - cost containment measures to control healthcare expenses - expanding scope and depth of nurses practice responsibilities - consumers demanding more knowledge and skills for self-care - demographic trends influencing type and amount of health care needed (rural vs urban needs) - recognition of lifestyle related disease which are largely preventable - health literacy increasingly required (need literacy before health literacy) - advocacy for self help groups Nurses as educators promote - high level wellness and related self-care practices - disease prevention or early detection - enhance recovery time from trauma or illness with a reduction in complication rates - enhance ability to adjust to developmental life changes and acute, chronic, and terminal illness - family acceptance of lifestyle necessitated by illness or disability benefits of patient education - increases patient satisfaction - improves quality of life - ensures continuity of care 87 | P a g e - decreases anxiety and maximizes independence - costs savings patient education the process of helping patients learn health-related behaviors to achieve the goal of optimal health and independence in self-care teaching planned method (intervention) that involves sharing information and experiences to meet the intended learner outcome learning process by which a person acquires or increases knowledge or changes behavior in a measurable way as a result of the experience roles of the nurse as a educator nurses function in the role of educator as: - the giver of information - the assessor of needs - the evaluator of learning - the reviser of the teaching/learning method the partnership philosophy stresses the participatory nature of the teaching and learning process teaching acronym T - Tune into the patient. E - Edit patient information. A - Act on every teaching moment. C - Clarify often. H - Honor the patient as partner in the education process. barriers to patient education the nurse - makes assumptions - teaches before knowing who he/she is teaching - talks without letting the patient chime in - lectures - does not let the learner interrupt - listens in a hurry - ignores or makes light of the learners concerns - teaches when the problem is not lack of info 3 learning domains 90 | P a g e teaching patients with low literacy - show pictures - engage in discussion - role paly - demo - provide hands on practice - emphasize key points in simple terms and provide examples - limit the amount of info in a single teaching session - reinforce info through repetition - TEACH BACK - avoid handouts with lots of pages - always be respectful- acknowledge that everyone has something they are not good at learning strengths - what is the patients best learning style (Reading, demo and re-demo, etc.) - are they motivated/ do they want to learn - do they have a strong network of support - successful learning in the past what to teach - orientation to the hospital and patient room - basic anatomy, physiology, pathophysiology (course of symptoms) - medications, side effects, when to take - diagnostic procedure, the what, when, why, how/meaning of their results - goals of treatment plan - steps to avoid or overcome complications - length of stay (LOS) questions - home care, community resources, and needed follow up teaching process nursing Dx - deficient knowledge r/t - ineffective health maintenance r/t - ineffective health management r/t - readiness for enhanced knowledge r/t teaching process etiology (r/t) - cognitive limitation - information misinterpretation's - lack of interest in learning - unready to learn - lack of desire at this time - lack of recall - limited exposure to information (specify) 91 | P a g e - unfamiliarity with information resources - limited practice skill teaching nursing dx example deficient knowledge r/t unfamiliarity with resources and info AEB did not know how to use call light components of learning objectives 1. performance 2. conditions 3. ID outcome/goal - these make the objective clear and measurable bad vs good learning outcome - mrs. avery will understand about DM before discharge from the health care facility - on the day before discharge (february 13, 2015) mrs. avery will develop a breakfast, lunch, and dinner menu by selecting foods from an ADA food list that meets the recommended nutritional servings for her prescribed diet teaching strategies - lecture - discussion - panel discussion - demonstration - discovery - role playing - audiovisual materials - printed materials - programmed instruction - web based instruction considerations for successful patient teaching - forming contractual agreements (formal and informal) - consider time constraints (nice to know vs need to know) - scheduling (short and many vs long and few) - group vs individual teaching - manipulating the physical environment - promoting compliance - effective communication promote adherence 92 | P a g e - be certain that instructions are understandable and support patient goals - include the patient and family as partners in process - utilize interactive teaching strategies develop interpersonal relationships with patients and their families teach back closed-loop communication technique that assesses patient retention of the information imparted during a teaching session - you teach them something and ask them to explain what they learned back to you - before you go ask them if they have any questions counseling the interpersonal process of assisting patients to make decisions that promote their overall wellbeing nurse as counselor - make everyone feel comfortable in the situation and surroundings - counseling may be formal or informal - use interpersonal skills of warmth, friendliness, openness, and empathy - caring is fundamental in the counseling role types: -short term - long term motivational interviewing Evidence based counseling approach that health care providers can use to help patients adhere to treatment recommendations - emphasizes using a directive patient centered style of interaction to promote behavioral change by helping patients explore and resolve ambivalence - current evidence supports the effectiveness of this technique for chronic-disease management, medication adherence, smoking cessation, weight loss, and more - this technique is philosophically congruent with nursing practice as it is a patient-centered, non- judgmental, non-confrontational and non-adversarial approach to the care of people - builds upon therapeutic communication techniques and provides specific approaches and principles that enable collaboration with people on treatment decisions with a focus on offering choices rather than prescriptions core principles - express empathy - develop a discrepancy - roll with resistance - support self efficacy communication skills required 95 | P a g e - error work - pricing updates - quality measures updates - clinical decision support tools evaluate (SDLC) measures if the new technology is meeting meaningful use objectives for the financial incentive as well as higher quality care than just paper and pencil - is out EHR helping us realize our organizational goals - is it reducing medication errors - is it eliminating duplicate ordering of testes - is it allowing more time for our providers to spend with patients - is it improving overall health of our patients nursing informatics what it is and isnt • Is: - Bridges professional practices with informational sciences - Pursuit of making people better at what they do - $$$ • Isn't: - Tinkering with computers - Managing information or analyzing large datasets - Functioning in a circumscribed IT role (this is its own thing, IT services) informatics applications - Diagnosis - Therapy - Decision-making - Professional Education - Intra and Interprofessional Care - Networking - Dissemination of Information informatics at work - Electronic Health Records - Telehealth - Mobile Devices - Clinical of Biomedical Devices - Research general computer literacy requirement with regards to accreditation and NCLEX assessment that grads of BSN are generally computer literate 96 | P a g e hardware - functions - central processing unit a. ROM b. RAM - binary code - storage - software ROM read only memory - retains memory RAM Random Access Memory - erases when the computer is turned off (temporary memory) binary code language in which a computer is programmed for and how it communicates with software programs, consists of 1 ad 0 and each sequence of 8 is a bite - similar to morse code software task specific progreams developed in binary code ex: - word processing - spreadsheets - database management - presentation - communication - web browsers data - A collection of numbers, characters or facts - Often collected during admission process - Data has little meaning by itself (ex: temp, if temp is 102 and its by itself, we don't know what is going on with the patient) information - Data that has been interpreted - Accumulated as nurses perform and record ongoing assessments 97 | P a g e - > temp of 102 is recorded and we take multiple temps over a period of time getting bits of data and this gives us the info that they have fever) accessing quality info - It is important that as health care providers that we access quality info ourselves AND that we are responsible for guiding patients to quality info themselves as well Characteristics of Quality Information: - Accurate - Quantifiable: evidence that qualities its quality - Verifiable - Available: has to be available for us to use it - Free from bias or modification (ex: Wikipedia) - Comprehensive: thorough - Appropriate - Current: info turns over about every 18 months (be weary of info older than 3 years old) browsers tools that we use to access info ex: - internet explorer - chrome - firefox - safari search engines programs that are used to search the web - google - bing - yahoo URL Uniform Resource Locator - the specific location of a certain piece of info or site - similar to an address search engine unifiers Metasearch Site-shorten search time by searching search engines at one time, filters for duplicates and presents results (consolidates multiple search engines at the same time giving us 1 list of results) Boolean Operators