NURSING 3125 WEEK FIVE OCT 4, 2019

ETHICAL RESPONSIBILITIES AND LEGAL OBLIGATIONS IN NURSING PRACTICE

 Ethics: an expression of values/beliefs that guide practice
 Relational ethics: a developing ethical theory with core elements of mutual respect, engagement,
embodied knowledge, interdependent environment, and uncertainty
 Deontology: central core concepts of reason and duty: obligation to act in accordance with rules
 Bioethics: clinical situations
o Autonomy: respect rights of others to make their own decisions
 Ex. patients right to refuse medication
o Nonmaleficence: minimize harm and do no wrong
 Ex. maintain expertise in nursing skill through nursing education
o Beneficence: promote good
 Ex. spending extra time to calm an extremely anxious patient
o Justice: distribute resources or care equally regardless of personal attributes
 Ex. intensive care nurse devotes equal attention to someone who has attempted suicide
as to someone who suffered brain aneurism
o Principle of impossibility: a right or obligation cannot be met within the current situation is no
longer an obligation
 Ex. a person doesn’t have right to receive MRI if MRI is unavailable
 Ex. a person doesn’t have right to be cured of schizophrenia when currently no cures
o Fidelity: maintain loyalty and commitment to patient to perform duty in best manner
 Ex. patient requires dressing change its our duty
Patients’ Rights:
 Legal rights:
o Right to, refusal of, and, authorization of treatment
 Consent: presence of psychotic thinking still enables person to consent, competency:
capacity to understand the consequences of one’s decisions, Adv. Directives: decision
maker when not able to, invol. admission criteria: 3 points, community treatment orders
 Nurses role: responsible for explaining the legal policies of the institution to both the
patient and family and can help them understand adv. directives
 Confidentiality: the right to privacy of information
o duty to warn, protect and report abuse: risk of violence assessment
 child abuse
 protection for persons in care act (PPIC)
 confidentiality for communicable disease: duty to report
 confidentiality after death: confidentiality still protected as reputation can still be hurt
 protection of patients: precautions to protect patient must be taken
Legal Responsibilities and Duties
 Tort Law
o Tort: a civil wrong for which money damages may be collected by injured party from the
responsible
o Intentional tort: willful or intentional acts that violate another person’s rights or property
 Assault: reasonable belief that a person means to cause one harm
 Battery: offensive or harmful touching; intentional physical contact
 False imprisonment: detention of a patient with no legal or agency policies to support it
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 Other: invasion of privacy, hurt financial status, photographing, defamation of
character (slander: verbal, libel: printing)
o Unintentional tort: unintended acts that produce injury or harm to another person.
 Negligence: carelessness: ex. no shovel snow someone falls and break hip
 Health care providers who fail to act in accordance with professional standards
(malpractice: act or omission to act that breaches the duty of due care and
results in or is responsible for a person injuries)
 Five elements to prove negligence: 1. Duty 2. Breach of duty: abandonment 3.
Cause in fact 4. Proximate cause 5. Damages (likelihood of harm also evaluated)
o Supervisor liability
Documentation
 Timely and accurate
 Derived from laws, regulations, professional standards or practice, policy and case law
 Purpose: to communicate among team members
o Includes assessments, treatment plans, interventions, and client responses to care
 The best defense is a good defense; if it’s not documented it’s not done...!
 Factual charting is best way to defend yourself in court
 Cannot say patient is being…. You have to state the behaviours objectively and describe behaviours
How to chart:
- Stick to facts
- Avoid labelling
- Be specific
- Use neutral language
- Eliminate bias
- Keep record intact
What to chart
- Significant situations
- Complete assessment data, esp. baseline data on admission
- Discharge instructions

Schizophrenia Spectrum and Other Disorders

 Psychosis: onset: males 18-25 females 25-35
 Key features: delusions, hallucinations, disorganized thinking, abnormal motor behaviour, negative
symptoms
 Etiology: biological factors (genetics), neurobiological factors (dopamine theory/other), brain structure
(head injury), psychological and environmental factors (prenatal, psychological, environmental
stressors)
 Co-morbities: substance abuse disorders, nicotine dependence, depression, anxiety, and polydipsia
(water intoxication), suicide, physical illnesses
Prognosis:
- Most detoriation occurs in first 2-5 years after onset; slower onset is a more ominous sign as opposed
to faster onset
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Assessments: observing behaviour and other outward manifestations of disorder, establish trust, early
engagement between nurse and client is important in predicting recovery;
 General assessment: symptom groups
- During prepsychotic phase: detection and treatment of symptoms that may warn of onset lesson
risk of developing disorder or decrease severity of disorder; monitor those for high risk for
symptoms such as abnormal social development and cognitive dysfunction
 Mental status assessment
 AIMS (abnormal involuntary movement scale)
 PANSS (Positive and negative syndrome scale)
 BPRS (Brief psychiatric rating scale)
Phases of Illness
- Phase I: Acute: onset or exacerbation of florid, disruptive symptoms (ex. hallucinations, delusions,
apathy, withdrawal) with resultant loss of functional abilities; increased care or hospitalization may be
required
- Phase II: Stabilization: Symptoms are diminishing and there is movement toward one’s pervious level
of functioning (baseline); day hospitalization or care in a residential crisis center or a supervised group
home may be needed
- Phase III: Maintenance: the person is at your nearing baseline (or premorbid) functioning; symptoms
are absent or diminished; Level of functioning allows person to live in community; ideally recovery with
a few or no residual symptoms; most live in own residences; treatment interventions
Symptom groups: ***know def of symptom terms
- Positive: the presence of something that isn’t normal present
o Usually appear early in the illness and their dramatic nature capture our attention and often
precipitates hospitalization
o Normal CT findings; normal neuropsychological test results; favorable response to antipsychotic
medication
o Alternations In thinking: “why are all these lights trying to slow me down, they must be against me”
but some can catch themselves with reality testing; but some believe what they think is real is real;
delusions may present (anxiety)
 Concrete thinking: the apple and orange are round vs the apple and orange are both fruits
(abstract)
o Alternation in speech: associations tie one thought logically to another; associative looseness:
these threads are interrupted or illogically connected
 Circumstantiality: refers to inclusion of unnesccary and often tedious details in ones’
conversation (e.g. describe your breakfast when asked how your day is going)
 Tangentiality: a departure from main topic; go on tangents to less important topics
 Neologisms: made up words; meaning for person but different for others/not real
“maneroligies”
 Echolalia: pathological repeating of another’s words and if often seen in catatonia
- Come get your medication repeats it;
- Clang association: chose words based on sound “click, clack, clutch, close”
 Word salad: jumble of words that is meaningless to listener—and perhaps speakers as well
o Alteration in perception: error of one’s view of reality
 Depersonalization: a nonspecific feeling that a person has lost his or her identity
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 Derealization: false perception that the environment has changed ex. everything big
 Boundary impairment: impaired ability to sense where one’s self ends and other’s selves begin
ex. a person might drink another’s drink
 Hallucinations- priority is to ask what the voice is telling you: in case its harm related
o Alterations in behaviour: bizarre and agitated behaviours ex. eccentric dress, grooming, rituals
 Catatonia: increase/decrease movement- moves little or not at all (stiporous); nurse
raises arm and arm stays like statue- Waxy flexibility
 Slowing of movements; stereotyped behaviours: repeated motor behaviours that do not
presently serve a logical purpose
 Robot like obedience; impaired impulse control;
 Echopraxia: the mimicking of movements of another; also seen in catatonia
- Negative: the absence of something; develop slowly; interfere most with adjustment and coping
o ex. no longer initiates or maintain relationships, or hygiene maintenance
o affect flat, blunt, inappropriate, bizarre/odd
- Cognitive: abnormalities in how a person thinks
o Difficulty with attention, memory, info processing, cognitive flexibility
- Affective: involving emotions and their expression
o Assessment for depression is crucial: increases suicide risk
- Many people with schizophrenia experience anosognosia, an inability to recognize they are ill, caused
by illness itself

Pharmacology Interventions:
• Typical Antipsychotics (1st generation): block dopamine
o positive symptoms
o dopamine (D2 receptor) antagonists (postsynaptic)
o antagonists for acetylcholine, norepinephrine, and histamine receptors
o movement-related and anticholinergic side effects
• Atypical Antipsychotics (2nd generation): block serotonin and dopamine
o positive and negative symptoms
o dopamine (postsynaptic) and serotonin (presynaptic) antagonists
o metabolic-related side effects

Complications:
• Anticholinergic toxicity
• Neuroleptic malignant syndrome (NMS)
o **know s/s
• Agranulocytosis: check blood work!!!!!
o particularly with clozapine; last line of def.
• Extrapyramidal Symptoms (EPS)
o Tardive dyskinesia:
o Dystonia:
o Pseudo-Parkinsonism:
o Akathisia: restlessness
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Types of Therapies
• Individual and Group Therapies:
o Psychoeducation, Family therapy, Cognitive remediation, Milieu therapy, Social skills
training
• Integrative Therapies:
o Yoga, Nutrition therapy

Nursing interventions:
 Establish open, trusting relationship
 Assist with management of symptoms
o Do not challenge; provide reality
 Provide reassurance of safety
 Identify safety risk to self or others
 Assist to identify new adaptive coping strategies
 Promote physical health, well-being, relaxation response

Case study:
Legal implications: assault and battery; right to refuse medication unless control purposes; documentation
room visible to nursing station, take someone with you for care
NURSING 3125 WEEK FIVE OCT 4, 2019
Nursing interventions: ensure safety; trust establishment; rapport; present reality-validate their fear still;
reassure their safety.