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Institutional ethic committee functions
2. policy making
3. case review
to encourage healthcare professionals to respect the individuality of patients. be neutral and non-judgmental
acting in accordance with an appropriate code of ethics and accepted standards of practice.
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
Nursing practice rules made by
1. federal legislation:
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
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
-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
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
be systematic in data collection. look for patterns, clarify any data that you are uncertain about
look for meaning and significance. do the data about the client help you in seeing that a problem may exist.
reflect on your own experiences. identify in what way you can improve your own performance.
Nursing process steps
4. implementing interventions
Assessing 1st step
collect information about patient through interviewing patient and family.
-collaborate planning and care
Assessing 2nd step
interview/ planned communication
-working phase/ gather info
-is there anything you need to tell me?
Assessment 3rd step
-nursing health history (past and current)
Sources of data collection
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
2. nursing history
3. biographical information
4. reason for seeking healthcare
5. patients expectations
6. present illness
7. past health history
Review of systems
-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.
-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
-compare findings to normal and healthy standards
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
Self- perception- self- concept pattern
describes the patients self- concept pattern and perceptions of self (body image and feeling state)
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)
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
an interview in which the patients perception of his or her current health status is the focus
-consistent with professional and agency standards
-organized and timely
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
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
-quality of care reviewing
-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
Formats for documentation
-initial nursing assessment
-kardex and patient care summary
-critical collaborative pathways
-discharge and transfer summary
-home healthcare documentation
-long term care documentation
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