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principles of right and wrong


standards of right and wrong


independence to make decisions


to be spared from harm


care given is in the best interest of the patient


give each his or her due: act fairly


to keep a promise to a patient about care promised


ability to provide care

Compassionate caring

ability to care for your patient


not breaching confidentiality


to have a good understanding of


knowledge: knowing, not guessing

Practical wisdom

having an understanding each patient is different


to have the inner strength to stand up for your patient


to do the right thing

Institutional ethic committee functions

1. education
2. policy making
3. case review
4. consultation
5. research

Professional values

to encourage healthcare professionals to respect the individuality of patients. be neutral and non-judgmental


an advocate for your patient

Human dignity

respect for the inherent worth and uniqueness of individuals and populations.


acting in accordance with an appropriate code of ethics and accepted standards of practice.

Social justice

upholding moral, legal, and humanistic principles.

Code of ethics

to adhere to the moral norms of of the professional nurse and to embrace them as part of what it means to be a nurse.

Nurse practice act

most important laws pertaining to a nurse. laws in each state to protect the public; define the scope of practice.


a standard or rule of conduct established and enforced by the government; that which is fixed: designed to protect the public

Types of law

1. civil
2. contract
3. criminal

Civil law

-deal with rights of individuals
-remedies: money or compensation

Contract law

-involves agreements between parties or individuals

Criminal law

-guidance and protection to those injures by offenses against society

Nursing practice rules made by

1. federal legislation:
health insurance
2. state legislation:
scope of practice, education requirements
3. board of nursing:
delegation, licensing, discipline
4. healthcare institution:
policy and procedure


a wrongful act that is committed by someone or an entity that causes injury to another person or property

Intentional torts

assault, battery, invasion of privacy, intentional infliction of emotional distress

Standards of care

the degree of care that a reasonably prudent nurse should exercise under the same or similar circumstances. Degree of skill, care and judgement used by an ordinary health care provider in similar circumstances.

Standards of care components

1. nurse practice act
2. ANA standards
3. JCAHO standards
4. agency policies and procedures
5. patients bill of rights

Elements of negligence

1. duty
2. breach of duty
3. proximate cause
4. damages

Burden of proof

case proved with a preponderance of evidence

Nursing process

-a problem solving framework for planning/delivering care to patients and their families
-an approach that enables a nurse to organize and deliver nursing care while utilizing critical thinking skills, decision making, and judgement based on knowledge and experience

Critical thinking

thinking, learning, knowledge, and experience will influence how we critically think. Active, organized, cognitive process used to carefully to examine ones thinking and the thinking of others.

Critical thinking skills

1. interpretation
2. analysis
3. evaluation
4. inference
5. explanation
6. self-regulation


be systematic in data collection. look for patterns, clarify any data that you are uncertain about


be open minded. do not make careless assumptions


look at situations objectively. reflect on your own behavior


look for meaning and significance. do the data about the client help you in seeing that a problem may exist.


support your findings and conclusions


reflect on your own experiences. identify in what way you can improve your own performance.

Nursing process steps

1. assessing
2. diagnosing
3. planning
4. implementing interventions
5. evaluating

Assessing 1st step

collect information about patient through interviewing patient and family.
-physical assessment
-collaborate planning and care

Assessing 2nd step

interview/ planned communication
-medical records
-working phase/ gather info
-termination phase
-is there anything you need to tell me?

Assessment 3rd step

-nursing health history (past and current)
-physical exam
-objective data
-subjective data

Objective data

what you observe

Subjective data

what the patient states

Sources of data collection

1. patient
2. records
3. family
4. significant other
5. data collection
-attempt to prevent omission of data or collection of inaccurate data
-data should be organized and analyzed. problems potential problems, and strengths are identified and labeled (diagnosis)

Methods of data collection

1. interview
2. nursing history
3. biographical information
4. reason for seeking healthcare
5. patients expectations
6. present illness
7. past health history

Review of systems

-physical exam
-begin with vitals and examine all body systems
-observe for abnormalities
-progressive head to toe assessment
-inspection, auscultation, palpation, and percussion


the matching or agreement between two or more things. the subjective and objective data should coincide.

Medical record

-baseline for prior vitals, lab values or other diagnostic problems.
-data about the patients medical history and doctors treatment plan
-allows the nurse to view consistency and congruency of personal observations
-analysis of data
-data clustering
-recognize patterns
-compare findings to normal and healthy standards
-*problem identificaiton

Diagnostic and lab data

the collection and verification through diagnostic testing (xrays and lab values) to identify or verify alterations in health.

Gordon's functional health

1. health perception-health management
2. nutritional- metabolic pattern
3. elimination pattern
4. activity- excercise pattern
5. sleep-rest pattern
6. cognitive- perceptual pattern
7. self- perception- self- concept pattern
8. role- relationship pattern
9. sexuality- reproductive pattern
10. coping- stress tolerance pattern
11. value- belief pattern

Health perception- health management

describes the patients perceived pattern of health and well-being and how health is managed

Nutritional- metabolic pattern

describes the patients pattern of food and fluid consumption relative to metabolic need and pattern indicators of local nutrient supply

Elimination pattern

describes patterns of excretory function (bowel, bladder, and skin)

Activity- exercise pattern

describes patterns of exercise, activity, leisure, and recreation

Sleep- rest pattern

describes patterns of sleep, rest and relaxation

Cognitive- perceptual pattern

describes sensory- perceptual and cognitive patterns

Self- perception- self- concept pattern

describes the patients self- concept pattern and perceptions of self (body image and feeling state)

Role- relationship pattern

describes the patients pattern of role engagements and relationships

Sexuality- reproductive pattern

describes the patients patterns of satisfaction and dissatisfaction with sexuality pattern, describes reproductive pattern

Coping- stress tolerance pattern

describes the patients general coping pattern and the effectiveness of the pattern in terms of stress tolerance

Value- belief pattern

describes patterns of values, beliefs, (including spiritual) and goals that guide the clients choices or decisions


clinical judgement about individual, family, or community response to actual and potential health problems or life processes. the nursing diagnosis guides you in selecting nursing interventions to achieve desired outcomes.


north american nursing diagnosis association
responsible for diagnosis (activity intolerance, risk for falls)


etiology- the cause (r/t)
signs and symptoms


deliberate decision- making and problem- solving skills to design individualized nursing care for each patient. client centered goals are established.
-done through communication and collaboration with family members, consulting with members of the health care team, review of patient literature, modify care, and record relevant info about the patients health care needs and clinical management.

Maslow's hierarchy of needs

1st level of needs- physiological
2nd level of needs- security and safety
3rd level of needs- love/belonging
4th level of needs- self-esteem
5th level of needs- self actualization
-theory of human needs: must meet the needs of one level before being able to move on to the next level


specific, measurable behavior or response that reflects the patients highest possible level of wellness and independence in function
1. short term goal
2. long term goal

Short term goal

objective behavior or response that is to be expected to be met in a short time, less than a week

Long term goal

objective behavior or response that is to be expected to be met over a longer period, weeks or months

Nursing care plan

nursing diagnostic statement, goals, expected outcomes, and specific nursing activities and interventions.
coordinates nursing care, promotes continuity of care, and lists outcome criteria to be used in the evaluation of nursing care.


-includes nurse initiated, doctor initiated and collaborative interventions.
-S and S of nursing diagnosis


a determination as to why the goals have or have not been met.
patients response to nursing care each time you have contact with your patient.
-done through frequent re-assessment of the patient
-*this allows us to collect ongoing data and determine if nursing interventions were effective in minimizing or resolving the patients problems
-the primary source of data for evaluation come from the patient

Care plan revision

-when goals are met, that section of the care plan is considered "resolved"
-expected outcomes and interventions are established
-*your close monitoring is the patients first line of defense


process of data collection, data analysis, which leads to develop a nursing diagnosis

Nursing history

an interview in which the patients perception of his or her current health status is the focus


a scientific explanation for a nursing explanation

Nursing diagnosis

an actual or potential problem

Medical diagnosis

a doctors statement of a disease process or pathophysiological patient problem


an activity the nurse plans and implements to help the patient achieve a goal

Effective documentation

-consistent with professional and agency standards
-organized and timely
-legally prudent

Emergency verbal orders

1. record in patients medical record
2. read back order to verify
3. date and note the times orders were issued in an emergency
4. record verbal order, name of the doctor, followed by the nurses name and initials

Verbal orders

1. review order for accuracy
2. sign order with name, title and pager number
3. date and note orders signed

Purpose of patient records

-communication with other healthcare professionals
-record of diagnostic and therapeutic orders
-care planning
-quality of care reviewing
-decision analysis
-legal and historical

Purpose of recording data

-facilitate patient care
-serve as a financial and legal record
-help in clinical research
-support decision analysis

Methods of documentation

1. source oriented records: different sections in chart
2. problem oriented medical records: problem list
3. PIE charting: Problem, Intervention, Evaluation
-doesn't develop a separate plan of care, it incorporates the plan of care into the progress notes
4. focus charting: works around patient problem or DARP
5. charting by exception
6. computerized records


D- data
A- action
R- response
P- plan

Formats for documentation

-initial nursing assessment
-kardex and patient care summary
-critical collaborative pathways
-progress notes
-flow sheets
-discharge and transfer summary
-home healthcare documentation
-long term care documentation

Types of flow sheets

1. graphic record
2. 24- hr fluid balance report
3. medication record
4. 24- hr patient care records

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