Chapter 1: Nursing Practice Today

Nursing involves the (1) protection, promotion, and optimization of health and abilities; (2) prevention of illness and injury; (3) alleviation of suffering through the diagnosis and treatment of human response; and (4) advocacy in the care of individuals, families, communities, and populations. Nurses offer skilled care to those recuperating from illness or injury, advocate for patients’ rights, teach patients so that they can make informed decisions, support patients at critical times, and help them navigate the increasingly complex health care system. Certification in nursing specialties (e.g., ambulatory care, critical care, gerontologic, pediatric, psychiatric and mental health, and community health nursing) is offered through a variety of nursing organizations. • Entry-level nurses with an associate or baccalaureate degree in nursing are prepared to function as generalists. With additional preparation, nurses can assume roles such as clinical nurse specialist and nurse practitioner. • The exact roles (i.e., independent, dependent, collaborative) of the nurse are often determined by state and agency policies. In most cases, the nurse’s role is one of “interdependence and co-participation” with the patient and other health team members.

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Delegation of nursing interventions to licensed practical nurses/licensed vocational nurses (LPNs/LVNs) and unlicensed assistive personnel (UAP) is an important function of the professional nurse. Healthy People 2010 is a broad-based program that involves government, private, public, and nonprofit organizations in preventing disease and promoting health. Evidence-based practice (EBP) is the conscientious use of the best evidence (e.g., findings from research) in combination with clinician expertise and patient preferences and values in clinical decision-making. Nursing informatics is a specialty that integrates nursing science, computer science, and information science in identifying, collecting, processing, and managing data and information to support nursing practice, administration, education, and research. • The five elements of the nursing process are assessment, diagnosis, planning, implementation, and evaluation. Once begun, the nursing process is not only continuous but it is also cyclic in nature.

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Standardized nursing terminologies can promote continuity of patient care and provide data that can support the credibility of the profession. Nursing diagnoses describe health states that nurses can legally diagnose and treat. A threepart nursing diagnosis statement includes the problem, etiology, and signs and symptoms.

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Collaborative problems are potential or actual complications of disease or treatment that nurses treat with other health care providers, most frequently physicians. The Nursing Outcomes Classification (NOC) is a research-based, standardized language for nursing outcomes. It is used to evaluate the effects of nursing interventions. NOC is a list of measures that describes patient outcomes influenced by nursing interventions. The Nursing Interventions Classification (NIC) includes independent and collaborative interventions that nurses carry out, or direct others to carry out, on behalf of patients. A nursing intervention is any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes. • The setting of specific outcomes with outcome indicators is necessary for systematic measurement of the patient’s progress. • Outcomes may be developed by writing specific outcome statements or choosing outcomes from the Nursing Outcomes Classification (NOC). • The Nursing Interventions Classification (NIC) includes treatments (both physiologic and psychosocial) that nurses perform in all settings and specialties. • NIC and NOC provide a common language for communication among nurses and facilitate computer collection of standardized nursing data. • During the evaluation phase, the nurse determines whether the patient outcomes and nursing interventions were realistic, measurable, and achievable.

Assessment, diagnosis, outcomes, interventions, and evaluation of the patient’s response to care are a critical part of the patient’s record. • When nursing terminologies are used in information systems for documentation of nursing practice, nurses can track and report on the benefits of nursing care.

***Chapter 2: Health Disparities
• • • • Determinants of health are those factors that influence the health of individuals. Health disparities refer to differences in measures in the health status among groups of people in a community, a state, or the entire nation. Racial, ethnic, and cultural differences exist in the health screening behaviors, treatments provided, and access to health care providers. Factors such as stereotyping and prejudice can affect health care seeking behavior in minority populations.

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Discrimination and bias occur when negative treatment occurs based on race, ethnicity, gender, aging, and sexual orientation. Use of standardized evidence-based guidelines can reduce health disparities in diagnosis and treatment. Interpersonal skills such as active listening, relationship building, and effective communication are basic to the delivery of high quality and equitable health care.

***Chapter 4: Health History and Physical Examination
• • The nurse and physician both obtain a patient history and perform a physical examination, but they use different formats and analyze the data differently. The nursing assessment includes both subjective and objective data. o Subjective data are what the patient tells the nurse about himself or herself. o Objective data are obtained using inspection, palpation, percussion, and auscultation during the physical examination. A comprehensive database includes information about the patient’s health status, health maintenance behaviors, individual coping patterns, support systems, current development tasks, and any risk factors or lifestyle changes. When a patient is unable to provide data (e.g., the person is aphasic or unconscious), the person assuming responsibility for the patient’s welfare can be asked about the patient. Patients should be informed that federal legislation affects the exchange, privacy, and security of an individual’s health information. Assessment data should be obtained and organized systematically so that they can be analyzed to make judgments about the patient’s health status and health problems. One framework for obtaining data uses the functional health patterns developed by Gordon. Subjective data include past health history, medications, surgery, or other treatments. The two types of physical examinations are as follows: o Screening o Focused (problem-centered)

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***Chapter 5: Patient and Family Teaching
• Specific goals for patient education include health promotion, prevention of disease, management

of illness, and appropriate selection and use of treatment options. • A teaching plan includes assessment of the patient’s ability, need, and readiness to learn as well as identification of problems that can be resolved with teaching. • Learning occurs when there is an internal mental change characterized by rearrangement of neural pathways. • Teaching is a process of deliberately arranging external conditions to promote the internal transformation that results in a change in behavior. • When teaching adults, it is important to identify what is valued by the person to enhance motivation. • Reinforcement is a strong motivational factor for maintaining behavior. Positive reinforcement involves rewarding a desired behavior with a positive stimulus to increase its occurrence. • Required skills for the nurse as a teacher include knowledge of the subject matter, communication skills, and empathy. • Because of shortened hospital stays and clinic visits, the nurse and the patient need to set priorities of the patient’s learning needs so that teaching can occur during any contact with the patient or family. • Education of family members is important because family members can promote the patient’s self-care and prevent complications. • The teaching process involves development of a plan that includes assessment, diagnosis, setting patient outcomes or objectives, intervention, and evaluation. • • • The patient’s experiences, rate of learning, and ability to retain information are affected by age. Pain, fatigue, and certain medications influence the patient’s ability to learn. Anxiety and depression can negatively affect the patient’s motivation and readiness to learn.

• An individual’s belief in his or her capability to produce and regulate events in life affects motivation, thought patterns, behavior, and emotions. • Health literacy is defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. • Each person has a distinct style of learning. The three learning styles are as follows: (1) Visual (reading) (2) Auditory (listening) (3) Physical (doing things)

• Learning objectives are written statements that define exactly how patients demonstrate their mastery of the content. • Learning objectives contain the following four elements:

(1) (2) (3) (4)

Who will perform the activity or acquire the desired behavior The actual behavior that the learner will exhibit to demonstrate mastery of the objective The conditions under which the behavior is to be demonstrated The specific criteria that will be used to measure the patient’s success

• Selecting a particular strategy is determined by at least three factors: (1) Patient characteristics (e.g., age, educational background, nature of illness, culture) (2) Subject matter (3) Available resources • Because of extent of health illiteracy, it is now recommended that all patient education materials be written at the 5th- to 6th-grade reading level. • Evaluation strategies for teaching include observing the patient directly, observation of verbal and nonverbal cues, discussion with the patient or family member, using a standardized measurement tool, and the patient’s self-evaluation of progress.

***Chapter 6: Older Adults
• • • • • • Ageism (negative attitude based on another’s age) can lead to discrimination and disparities in health care provided to older adults. Aging affects every body system. Biologic aging is a balance of positive (e.g., healthy diet, exercise, coping, resources) and negative factors (e.g., smoking, obesity). Biologic theories can be divided into stochastic and non-stochastic theories. Older women are especially at risk for chronic health problems, including arthritis, hypertension, strokes, and diabetes. The frail elderly are individuals who are more vulnerable because of declining physical health and limited resources. Activities of daily living (ADL), including bathing, dressing, eating, toileting, and transferring, are important for the nurse to assess in the older patient living with chronic illness. For the hospitalized older adult, there are special concerns related to high surgical risk, acute confusional state, nosocomial infection, and premature discharge with an unstable condition. The intensity and complexity of caregiving place the caregiver at risk for high levels of stress. This may lead to emotional problems, including depression, anger, and resentment. Family members are perpetrators in approximately 9 out of 10 cases of domestic elder abuse and neglect. Continuing care retirement communities, congregate housing, and assisted living facilities are housing options for the older adult.

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Home health care services require physician recommendation and skilled nursing care for Medicare reimbursement. Ethical issues surrounding care of the older adult include using restraints, evaluating the patient’s ability to make decisions, initiating resuscitation, treating infections, providing nutrition and hydration, and advocating for an institutional ethics committee. Reducing disability through geriatric rehabilitation is important to the quality of life of the older adult. Age-related changes in pharmacodynamics and pharmacokinetics of drugs, as well as polypharmacy, put the older adult at risk for adverse drug reactions. Depression is the most common mood disorder in older adults. The comprehensive nursing geriatric assessment includes a thorough history using a functional health pattern format, physical assessment, mood assessment, mental status evaluation, ADL and instrumental ADL (IADL) evaluation, and social-environmental assessment.

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***Chapter 7: Community-Based Nursing and Home Care
• • • The focus of community-based nursing is the illness-oriented care of individuals and families throughout the lifespan. Many factors are changing the health care system, including socioeconomic status, demographics, prevalence and type of illness, technology, and increased consumerism. The goals of case management are to provide quality care along a continuum, decrease fragmentation of care across many settings, enhance the patient’s qualify of life, and contain cost. The use of Diagnosis Related Groups (DRGs) has had a dramatic impact on health care. Health care is constrained by third-party payer cost containment. Community-based settings where nursing care is delivered include ambulatory care, transitional care, and long-term care (skilled nursing, intermediate care, and residential care facilities). Community-oriented nursing involves the engagement of nursing in promoting and protecting the health of populations. Home health care may include health maintenance, education, illness prevention, diagnosis and treatment of disease, palliative care, and rehabilitation. Skilled nursing care may include observation, assessment, management evaluation, teaching, training, administration of medications, wound care, tube feeding, catheter care,

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and behavioral health interventions. • • In home care situations, it is common for caregivers to become physically, emotionally, and economically overwhelmed with responsibilities and demands of caregiving. The home health care team may include the patient, family, nurses, physician, social worker, physical therapist, occupational therapist, speech therapist, home health aide, pharmacist, respiratory therapist, and dietitian.

***Chapter 8: Complementary and Alternative Therapies
• Complementary and alternative therapies include a broad domain of resources, including health systems, modalities, and practices other than those intrinsic to the dominant health system of a particular society or culture. This definition highlights that what might be considered “complementary and alternative” in one country or at one period of history might be considered “conventional” in another place or time. Individuals often “self-select” these therapies, using them without professional supervision. Nearly half of the users of these therapies do not consult an alternative and complementary practitioner or disclose such use to their traditional health care provider. Patients should be advised that complementary therapies do not replace conventional therapies, but can often be used in combination with conventional therapies. Traditional Chinese Medicine (TCM) is a complete system of medicine with an individualized form of diagnosis and treatment, as well as having its focus on prevention. TCM includes acupuncture, Chinese herbal medicine, and other modalities. Mind-body interventions are a variety of techniques designed to facilitate the mind’s capacity to affect body function, including behavioral, psychologic, social, and spiritual approaches to health such as imagery, biofeedback, prayer, and meditation. Over the past 30 years, a resurgence of interest in herbal therapy has occurred in countries whose health care is dominated by the biomedical model. Medicinal plants work in much the same way as drugs; both are absorbed and trigger biologic effects that can be therapeutic. Many have more than one physiologic effect and thus have more than one condition for which they can be used. Patients should be advised that if they take herbal therapies, they should adhere to the suggested dosage. Herbal preparations taken in large doses can be toxic. Manipulative and body-based methods include interventions and approaches to health care based on manipulation or movement of the body. Examples include chiropractic therapy, yoga, massage, and acupressure.

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Massage is a form of touch and also a form of caring, communication, and comfort. Nurses can use specific massage techniques as part of nursing care, when indicated by the nursing diagnosis or patient assessment. Energy therapies are those that involve the manipulation of energy fields such as Therapeutic Touch, Healing Touch, and Reiki. Therapeutic Touch (TT) is a method of detecting and balancing human energy that was developed jointly by a nurse and a traditional healer. It is important for the nurse to collect data on the patient’s use of complementary and alternative therapies.

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