Fundamentals of Nursing Module 3 Fundamentals of Nursing

Nursing as a Profession Criteria of a profession Extended education Body of knowledge Provides a specific service Autonomy in decision-making and practice Code of ethics Professional organization and publication Disciplinary course of action

Definition of a Profession Discussion How do you define the term profession? What does the term professional mean to you? What behaviors would you expect? How would you define nursing?

Definitions Profession Professional Nursing Type of occupation that meets certain criteria that raise it above the level of an occupation Professional A person who belongs to and practices a profession Nursing The diagnosis and treatment of human responses to actual or potential health problems (ANA, 1980)

Nursing Education Requirements Associate degree Diploma Baccalaureate degree Master’s degree Doctoral Degree

Role of the Professional Nurse Provider of care Assists the patient physically and psychologically Communicator Communicates verbally and in writing to patients, significant others, health professionals and the community

Role of the Professional Nurse (continued) Teacher Assists patients to learn and perform at a level necessary to restore, improve and maintain health status Client Advocate Represents the patient’s needs/wishes to others; acts to protect the patients by assisting them to exercise their rights

Role of the Professional Nurse (continued) Counselor Assists patients to recognize and cope with stressful problems, develop improved interpersonal relationships and promote personal growth Change Agent Assists patients to make modifications in their own behavior

Role of the Professional Nurse (continued) Leader Influences others to work together to accomplish specific goals Manager of Care Manages the care of individuals, families and communities

Role of the Professional Nurse (continued) Member of the Discipline of Nursing Models and values nursing, commits to professional growth, abides by the standards of practice and legal/ethical principles, conducts research, and strives to advance the profession of nursing.

Legal Basis for Nursing Practice Nurse Practice Act Provides laws that control the practice of nursing in each state Mandates that, under the law, only licensed professionals can practice nursing All states now have mandatory nurse practice acts

Legal Basis for Nursing Practice (continued) Standards of Practice Identify the minimal knowledge and conduct expected from a professional practitioner based on education and experience Nursing practice is guided by legal restrictions and responsibilities regulated by state nurse practice acts General standards have been developed by the American Nurses’ Association (ANA) Practice is also guided by professional obligations

Types of Law Statutory Regulatory Common – created by legislators at state and federal level Regulatory – created by administrative groups (ex: Board of Registered Nursing) Common – used to resolve disputes between 2 persons based on principles of justice, reason and common good

Types of Law (continued) Criminal law Public law that deals with the safety and welfare of the public 2 types include misdemeanors or felonies

Types of Law (continued) Civil Law Protects the rights of individuals in situations which generally involve harm to an individual or property Negligence is failure to use care that a reasonable person would use under similar circumstances Malpractice is professional negligence, misconduct, or unreasonable lack of skill resulting in injury or loss

Types of Law (continued) Good Samaritan Act Protects health practitioners against malpractice claims for care provided in emergency situations Nurse is required to perform in a “reasonable and prudent manner” and within accepted standards

Legal Infractions Terms Assault Unjustifiable threat or attempt to touch or injure Battery Any intentional touching or injury without consent

Legal Issues Related to Nursing Practice Review and discuss Legal Responsibilities of the Nurse on Study Guide 3 Review and discuss the Patient’s Bill of Rights

Legal Issues Related to Nursing Practice Informed Consent Agreement to the performance of a procedure/treatment based on knowledge of facts, risks, alternatives

Informed Consent continued Person giving consent must: Be of sound mind and physically competent and legally an adult Consent must be voluntary Consent must be thoroughly understood Must be witnessed by an authorized person such as the physician or a nurse

Informed Consent (continued) The physician is responsible for obtaining the consent. The nurse may witness the signing of the consent.

Consent of Minors Consent of Minors Emancipated minor Minors 14 years of age and older must consent to treatment along with their parent or guardian Emancipated minor Is a person age 14 or older, who has been granted the status of adulthood by a court order or other formal arrangement They can consent for treatment themselves

Potential Liability for Nurses See Study Guide 5 “Areas of Potential Liability for Nurses” Choose several to discuss as a class

Restraints Restraints A device used to immobilize a patient or extremity and restrain the level of activity

Restraints 2 justifications for using restraints To protect patients from injuring themselves To protect others from the patient

Alternatives to Using Restraints Before restraining a patient, alternatives must be used and documentation must state that these were tried and failed Try to determine the cause(s) of the patient’s behavior Eg: medication

Alternatives to Using Restraints (continued) Physiological alternatives Reposition the patient Adjust medications to relieve pain Cover IV tubes to “hide” the tube Psychological alternatives Provide appropriate visual/auditory stimuli Increase visits from friends and family

Alternatives to Using Restraints (continued) Environmental alternatives Put items within easy reach Place patient near the nurses’ station Hire private duty nurse to stay with patient

Documentation of Restraint Use Follow facility policies which protect you and them from legal actions Document the patient evaluation process Why restraint was needed List behaviors Alternatives tried

Documentation of Restraints (continued) Document the requirement for an order or protocol authorizing the restraints Physician’s order must be time limited Verbal orders must be signed within time specified in facility policy A PRN (as needed) order is never allowed

Documentation of Restraints (continued) Document your on-going assessment and care of the patient Nutrition Hydration Elimination Special nursing services (ex: private duty nurse) Follow policy regarding frequency/documentation of on-going assessment

Applying Restraints Follow the manufacturer’s instructions Apply to provide for as much movement as possible Be careful that vest restraints are not put on backwards Adjust the restraint so it is not so tight to reduce circulation or cause pressure ulcers

Applying Restraints (continued) Tie the restraint to the bed frame, not the bed rail Use a knot that will not tighten when pulled (ex: clove hitch) Pad bony prominences when needed

Monitoring the Patient in Restraints Follow facility protocol Assess every 30 minutes Remove the restraint for 10 minutes at least every 2 hours; assess for skin and neurological impairment; perform range of motion Document restraint assessment on appropriate restraint assessment tool provided by the facility

Types of Restraints Mitt restraint Belt restraint Jacket restraint Wrist or ankle restraint

Using Restraints in Behavioral Health Strict time limits Adults: 4 hour limit Children age 9-17: 2 hour limit Children under age 8: 1 hour limit

Unusual Occurrence Incidents Also known as incident reports An incident is “any event that is not consistent with the routine operation of a healthcare unit or routine care of a patient” (Perry and Potter 2005)

Unusual Occurrence Incidents (continued) Examples: Accidental needle stick Medication error Patient or visitor fall A physician’s order not being carried out by the nurse Equipment malfunction

Unusual Occurrence Incidents (continued) The report is a confidential record between the observer of the incident and the agency Risk Manager that documents the facts of the incident It is an objective account of the occurrence and does not include opinions, judgments or blame

Unusual Occurrence Incidents (continued) Complete a report even if there is no injury Never document in the nurses’ notes that an incident report was completed.

Unusual Occurrence Incidents Class Discussion: Give some examples of incidents in which you would complete a report.

Ethical Terms (continued) Code of Ethics – a written list of professional values and standards of conduct which provide a framework for decision-making There are several codes of ethics that may be adopted; in the U.S. the ANA Code of Ethics is generally accepted (see study guide)

Ethical Issues in Nursing Practice Making ethical decisions is a common part of every day nursing care Ethical decision-making is a skill that can be learned

Ethical Terms Ethics – systematic study of what “ought” to be done, the justification of what is right or good Ethical Dilemma – situation that required a choice between two equally favorable alternatives

Ethical Concepts That Apply to Nursing Practice Define and discuss the following concepts from the study guide Morals Values Autonomy Beneficence

Ethical Decision-Making Process 1. Clearly identify the problem 2. Consider the causative factors, variables, precipitating events 3. Explore various options for action Select the most appropriate plan for dealing with the ethical dilemma Implement decided course of action Evaluate results/consequences

Ethical Decision-Making Activity Choose an ethical dilemma from the study guide (Common Ethical Issues Involving Nurses) Discuss your chosen dilemma using the 4 steps for solving an ethical dilemma on the previous slide.

Confidentiality Nurses are legally and ethically obligated to keep information about patients confidential. The tort invasion of privacy protects the patient’s right to be free from intrusion into their private affairs. The ANA Code of Ethics also provides for a patient’s privacy.

Confidentiality - HIPAA The American Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996 and was required to be instituted in April 2003 Requires that patient health information be available only to those with the right and need to have this information

Confidentiality Nurses role in maintaining confidentiality Don’t discuss information where others might overhear Protect computer screen from being viewed by visitors Protect patient charts from being viewed Do not share your computer ID or password Access/transmission of patient information via internet requires strict scrutiny

The Joint Commission’s National Patient Safety Goals Introduced in 2003; updated annually Written by a group of experts who review all of the sentinel events (unexpected occurrences involving death or serious physical or psychological injury) Experts define problem areas and advise The Joint Commission on how to remedy these problems

National Patient Safety Goals for Hospitals In 2007, there are 8 goals that hospitals must follow Goal # 1: Improve the accuracy of patient identification Use at least 2 patient identifiers Includes assigned ID number, social security number, name, date of birth as options Follow organizational policy

National Patient Safety Goals (continued) Goal #2 Improve the effectiveness of caregiver communications Includes guidelines for verbal orders Hospitals must develop a list of abbreviations, symbols, and dose designations that are not to be used Must develop guidelines regarding abnormal test results and time for reporting Must create a standardized, consistent approach to “hand-off” communication

National Patient Safety Goals (continued) Goal # 3 Improve safety of using medications Standardize and limit the number of drug concentrations Identify and review look-alike/sound-alike drugs Create list of high-risk medications and have them labeled Patient identification must be on all medication containers

National Patient Safety Goals (continued) Goal # 7 Reduce the risk of healthcare-associated infections Proper handwashing Review infections leading to death or major permanent loss of function while a patient

National Patient Safety Goals (continued) Goal # 8 Accurately and completely reconcile medications across the continuum of care Compare current medications with those ordered when admitted Communicate complete list of meds to next provider of service

National Patient Safety Goals (continued) Goal # 9 Reduce the risk of patient harm resulting from falls Implement a fall reduction program Implement evaluation of the effectiveness of the program

National Patient Safety Goals (continued) Goal # 13 Encourage patients’ active involvement in their own care Encourage patients and their families to report concerns about safety Teach about preventing infection by washing hands Encourage self-care

National Patient Safety Goals (continued) Goal # 15 Identify safety risks inherent in your patient population Hospital should review all of its own sentinel events and assess trouble spots in the care environment Complete assessment and follow-up on every patient admitted for behavioral/emotional problems. *According to The Joint Commission, suicide has been the most frequently reported sentinel event in staffed, round-the-clock facilities since The Joint Commission began its reporting policy in 1996.

Patient Falls Falls are the leading cause of accidents among older adults Electronic devices are available to detect patients attempting to get out of bed

Fall Risk Assessment Identify clients at risk on admission and throughout hospital stay Fall Risk Assessment Tools identify the risk level based on the following: Physical condition Mental status Medications Age History of previous fall Ambulatory devices used

Nursing Interventions to Prevent Falls Identify clients at risk Implement fall prevention precautions Place items within easy reach of client Assist with ambulation; use ambulatory aids Teach client and family members of precautions used in the hospital Non-skid footwear Use of handrails

Body Mechanics Safe and efficient body movements depend upon balance and the interrelationship of the center of gravity

Body Mechanics Review Summary of Guidelines and Principles Related to Body Mechanics in the study guide

Body Mechanics When Moving Patients Assess the situation; get help if needed Ensure patient safety by engaging locks and brakes Bring the patient close to your center of gravity Face in the direction of movement to prevent spinal twisting

Body Mechanics When Moving Patients Establish a broad base of support Lower your center of gravity by bending your knees Tighten gluteal, abdominal, leg and arm muscles

Applications of Cold and Heat Cold applications Cause vasoconstriction Reduce blood supply Remove oxygen, metabolites, and waste Slow bacterial growth Decreases inflammation

Cold Applications (continued) Dry cold: cold pack, ice bag, ice collar Moist cold: compress or sponge bath

Applications of Cold and Heat Heat applications Cause vasodilation Increase blood supply Brings oxygen, nutrients, antibodies and leukocytes Increases inflammation Helps rid body of waste (via polymorphonculear levkacytes)

Heat Applications (continued) Dry heat: aqua pad, disposable heat pack, electric pad (K-Pad) Moist heat: compress, soak, sitz bath

Nursing Care Cold and Heat Applications Re-assess every 15 minutes after starting treatment Evaluation: examine area to which cold or heat was applied and document client response on the medical record

Medical vs. Surgical Asepsis Asepsis is the absence of pathogenic microorganisms Medical asepsis - maintaining a patient and the environment as free from pathogens as possible Surgical asepsis - eliminating all microorganisms, non-pathogenic and pathogenic

Surgical Asepsis Principles Use a sterile field for sterile materials Keep hands in front of you and above your waist Edges of sterile containers are not sterile once opened A dry field is necessary to maintain sterility of the field

Nosocomial Infections An infection acquired while a patient Caused by bacteria, viruses, fungi or parasites Patients are at high risk Multiple illnesses Elderly Lowered resistance

Iatrogenic Infection An iatrogenic infection is a type of nosocomial infection resulting from a diagnostic or therapeutic procedure Example: a urinary tract infection (UTI) that develops after a catheter insertion

Chain of Infection 6 links in the chain of infection Infectious agent Reservoir Portal of exit Mode of transmission Portal of entry Susceptible host

Nurses Role in Preventing Infection Infection does not occur or spread when one of the links is broken Discuss ways in which health care practitioners can break each link

Medical Asepsis Principles Also known as clean technique Includes Handwashing Standard precautions Isolation technique Cleaning/disinfecting of equipment

Infection Control Standard precautions are the primary strategies for prevention of infection transmission Handwashing Gloves Mask, eye protection Gown

Change in a Patient’s Condition The Nurse Practice Act requires that the nurse observe and appropriately report a change in a patient’s condition. Reporting should include assessment data including vital signs, behaviors of the patient nursing interventions pertinent background information other related information (lab work, x-ray, etc.)

Change in Patient’s Condition (continued) Changes might include: Sudden respiratory depression or difficulty Change in cardiac status Sudden unexpected pain Sudden confusion Critical change in vital signs Anything out of the “expected behavior” of a patient

Therapeutic Communication Types of communication include Verbal Non verbal Active listening

Variables That Influence Communication Perception Values/beliefs Culture Gender Age Developmental level Environmental factors

Characteristics of Therapeutic Relationships Mutually determined goals Goal-directed toward meeting patient’s needs Provision of environment to maximize patient’s potential for growth Patient learning new coping skills Predictable phases of the relationship

Essential Conditions for Therapeutic Communication Rapport Trust Respect Empathy Genuineness

Cultural Considerations for Therapeutic Communication It is important to review the characteristics associated with a specific culture These include Personal space Eye contact Use of touch Silence

Therapeutic Communication Techniques Review the techniques listed in the study guide. Practice using several of these with a classmate. Review Blocks to Therapeutic Communication in the study guide. Practice using these with a classmate.

Assessment and Interventions for Safe Fluid Therapy Measuring intake and output (I & O) is an independent nursing function Patients on intravenous (IV) therapy or who have a urinary catheter are automatically on I & O I & O is used to determine the fluid and electrolyte status

Intake and Output Intake includes All fluids taken my mouth All fluids taken by nasogastric and jejunostomy tubes All parenteral fluids (intravenous, blood)

Intake and Output Output includes Urine Emesis (vomit) Diarrhea Gastric suction T-tube drainage Drainage from surgical wounds/other drainage tubes

Nursing Diagnoses for Fluid Volume Fluid Volume Deficit Dehydration Hypovolemia Fluid Volume Excess Hypervolemia

Nutrition 5 food groups Breads, cereals, rice, pasta Vegetables Fruits Milk, yogurt and cheese Meat, poultry, fish, dried beans and peas, eggs, nuts

Culture and Nutrition Visit the web site listed in the patient study guide to view and discuss food pyramids from a variety of cultures

Common Therapeutic Diets Discuss foods that are and are not allowed on the following diets Regular Soft Mechanical soft Clear liquid vs. full liquid No added salt (NAS) High fiber American Diabetes Association diets

Nutritional Assessment Gather baseline data Include client’s weight Identify specific nutritional deficits Establish nutritional needs Identify physical and psychosocial factors that may influence nutritional needs

Nursing Diagnoses for Nutrition Body image disturbance Altered nutrition: less than body requirements Altered nutrition: more than body requirements Self-care deficit: feeding

Nursing Interventions to Promote Nutritional Well-Being Assist with food choices Refer to dietician if needed Provide comfortable environment Free of odors, noise Promote appealing food presentation Hot/cold food Offer to open containers Assist with feeding as needed

Enteral Tube Feedings Enteral feeding involves the delivery of formula via a tube into the stomach or jejunum Includes Nasogastric tube (NG tube) Gastric tube (G-tube) Jejunal tube (J-tube)

Nursing Care with Enteral Tubes Check for placement according to hospital policy An x-ray is the only positive method for placement Assess bowel sounds Assess skin around insertion site Keep the head of the bed elevated for continuous feedings and during intermittent feedings to prevent aspiration

Nursing Care With Enteral Tubes (continued) When delivering medications through a NG or G tube: Dissolve the tablet in water Flush the tube before and after delivering the medication Blood glucose monitoring is often done during enteral feedings as the solutions can be high in glucose

Total Parenteral Nutrition (TPN) A form of nutritional support in which nutrients are given intravenously The patient must have a central venous access system in place

TPN Complications Complications can be reduced by meticulous care of the venous access device Prevent infection Prevent metabolic, electrolyte, fluid balance complications Maintain parenteral system

Nursing Care of the Client on TPN Change tubing every 24 hours using strict aseptic technique Assess for signs of infection Monitor blood glucose Daily weight Intake and output

Health Care of the Older Adult Older adults are 65-years-old and older 65-74 young old 75-84 middle old 85-99 old-old (fastest growing subgroup) 100 + elite old

Health Care of the Older Adult (continued) 50% of hospitalized clients on med-surg units are older than 65 8% of elderly have 1 or more chronic illnesses 50% have 2 or more chronic illnesses 5% live in institutional settings

Assessment Guidelines for Older Adults Adjust to physiologic changes Be familiar with sensory changes, changes in each body system Adapt assessment techniques to diminishing energy and ability Allow for frequent breaks if a lengthy assessment is needed

Assessment Guidelines (continued) In addition to physical assessment, the older adult may need assessment of: Ability to perform ADL’s (Activities of Daily Living - functional assessment) Network of support (family and friends) Health beliefs in nutrition, exercise, etc. Sleep patterns Living arrangements Financial assessment Self-esteem View of life and acceptance of death

Reminiscence/Life Review An adaptive function that allows them to recall the past and assign meaning to these experiences Can be a nursing intervention to encourage self-esteem, increase communication skills, and increase social interaction

Pain and the Older Adult May not report pain as feels it is a part of aging 85% of patients in nursing homes have pain Pain response: have similar pain tolerance as young adults

Pain Assessment Use methods as with adults (pain scale) Don’t assume that if patient is busy or sleeping, they don’t have pain; need to ask them If cognitive impairment is present, watch for non-verbal cues Agitation Aggression Wandering Change in vital signs Grimacing

Pain Management Ask what they usually use for pain and is it working If acute pain, can use narcotics but may need a decreased dose

Medications and the Older Adult 25% of all prescriptions are written for people older than 65 Physiologic changes caused by aging affect the activity and response of drugs Absorption, distribution, metabolism, excretion

Polypharmacy Many older adults are using multiple medications, use multiple pharmacies, have multiple physicians Multiple drugs may lead to adverse reactions

Polypharmacy Most common adverse reaction in the elderly is confusion Confusion in the absence of disease is not normal!!

Nursing Interventions for Polypharmacy Assess medications they are taking Encourage client to use one pharmacy for all medications Encourage client to review with primary caregiver all medications they are taking

Medication Noncompliance in the Older Adult May be non-compliant due to: Not understanding how to take medication Forgetful Don’t like the side effects Don’t have the money to purchase medications

Nutrition and the Older Adult Risk of nutritional problems increases with age Energy needs decrease but nutrient needs remain the same

Causes of Malnutrition in the Older Adult Loss of teeth Digestive system changes Loss/decrease of appetite Lactose intolerance Fixed income Lack of socialization during meals

Nursing Interventions to Improve Nutrition Small, frequent meals Assist with food choices Identify causes of decreased appetite Refer to dentist for teeth issues Refer to social services for financial problems Discuss ways to improve socialization during meal time

Goals for Older Adults Follow therapeutic plan of care Ensure transportation to MD visits Ensure primary physician is aware of all medications currently taking Maximize independence in self-care activities Educate about resources to assist them with care if needed

Goals (continued) Maintenance of ability to communicate Educate about assistive devises such as hearing aids Assist with financial counseling to help pay for these aids if needed

Goals (continued) Maintenance of positive self-image Assist the patient to participate in appropriate social activities to enhance the feeling of worth Encourage open expression of concerns such as feelings of hopelessness

Goals (continued) Remain free of injury Perform fall risk assessment In the hospitalized patient Perform fall risk assessment Orient to surroundings and re-orient as needed Provide assistance with ADL’s

Goals (continued) Maintain bowel and bladder elimination patterns Discuss nutrition to promote elimination Discuss use of medications if prescribed Urinary incontinence (loss of bladder control) is a symptom, not a disease.

Goals (continued) Maintain adequate nutritional status When hospitalized Intake and output Daily weight Dietary referral for preferences Socialization Assist with feeding Liquid supplements as needed

Goals (continued) Maintain adequate fluid and electrolyte status Place water within easy reach of the client Offer fluids every 1-2 hours Monitor electrolytes Intake and output Administer and monitor IV fluids if needed

End-of-Life Issues Death and Dying Nurses must recognize influences on the dying process Legal Ethical Religious Spiritual Biological Provide sensitive, skilled and supportive care

End-of-Life Issues (continued) Both the patient who is dying and the family members grieve as they recognize the loss Nursing Diagnosis of Anticipatory Grieving includes: Denial worthlessness Anger concentrate Feelings of guilt Inability to concentrate

End-of-Life Legal Issues Medical Directive to Physician (Living Will) Addresses only the withholding or withdrawal of medical treatment that would artificially prolong life Becomes effective when the primary physician and one other doctor say in writing that an individual is in a terminal or irreversible condition and that death will occur if life-sustaining medical care is not given Some states allow for personal instructions to be added to this document

End-of-Life Legal Issues (continued) Advanced Health Care Directive Used to be called Durable Power of Attorney An Advance Directive that allows an individual to appoint representatives to make health care decisions if they become incapacitated This document affects only health care and should not be confused with granting power of attorney for other matters Becomes effective when the person becomes terminally ill or incapacitated.

Nursing Responsibility for Advance Directives Each state varies; nurses need to be aware of requirements for their state Be prepared to answer questions from the patient about these directives Ask if your patient has these and make sure copies are placed in their charts Advance Directives must be honored

End-of-Life Issues (continued) Artificial Nutrition and Hydration is another important ethical and legal issue Feelings about withholding food and fluids are emotionally charged and often have religious connotations. U.S. Supreme Court has upheld the right of patients to accept or reject the administration of artificial nutrition and hydration.

End-of-Life Issues (continued) Hospice Care Focuses on support and care of the dying person and family Goal: to facilitate a peaceful and dignified death Based on holistic concepts Improve quality of life rather than cure Support patient and family

Hospice Care (continued) Principles of hospice care can be carried out in a variety of settings Home and hospital are the most common settings Palliative care: differs from hospice in that the client is not necessarily believed to be dying

Nursing Care of the Dying Patient Provide personal hygiene measures Relieve pain Essential for patient to maintain some quality in their life Assist with movement, nutrition, hydration, elimination

Nursing Care (continued) Provide spiritual support Arrange access to individuals who can provide spiritual care Facilitate prayer, meditation and discussion with appropriate clergy or spiritual advisor

Nursing Care (continued) Support patient’s family Use therapeutic communication to facilitate their feelings Display empathy and caring Educate family on what is happening and what the family can expect Encourage family members to participate in the physical care of the patient

Do Not Resuscitate Also called DNR, No Code Must be written Must be reviewed regularly as per policy May have specific requests Example: may okay vasopressors and fluids but no chest compressions or intubation

Photo Acknowledgement: Unless noted otherwise, all photos and clip art contained in this module were obtained from the 2003 Microsoft Office Clip Art Gallery.