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 Are freely chosen, enduring beliefs or attitudes about the worth of a person, object, idea, or action.  Are important in influencing decisions, actions, including nurses ethical decision making. ‡ Not all values are moral values Example: People hold values about work, family, religion, politics, money, and relationships.

ALTRUISM is a concern for the welfare and well being of others. In professional practice, altruism is reflected by the nurse s concern for the welfare of the patients, other nurses, and other health care providers. AUTONOMY the right to self determination. Professional practice reflects autonomy when the nurse respects patient s rights to make decisions about their health care.

legal.HUMAN DIGNITY respect for the inherent worth and uniqueness of individuals and populations. human dignity is reflected when the nurse values and respects all patients and colleagues. Reflected in professional practice when the nurse is honest and provides care based on an ethical framework that is accepted within the profession. SOCIAL JUSTICE is upholding moral. INTEGRITY is acting in accordance with an appropriate code of ethics and accepted standards of practice. and humanistic principles. This value is reflected in professional practice when the nurse works to ensure equal treatment under the law and equal access to quality care. . In professional practice.

VALUES CLARIFICATION A process by which people identify. and develop their own individual values. examine. without outside pressure ‡ From among alternatives ‡ After reflecting and considering consequences . CHOOSING (cognitive) beliefs are chosen ‡ Freely.

ACTING (behavioral) Chosen beliefs are ‡ Affirmed to others ‡ Incorporated into one s behavior ‡ Repeated consistently in one s life .PRIZING (affective) Chosen beliefs are prized and cherished.


to decisions about abortion or euthanasia NURSING ETHICS refers to the ethical issues that occur in nursing practice . it is the study of morality). medical ethics. nursing ethics). e.g. A method of inquiry that helps people to understand the morality of human behavior (i.. BIOETHICS ethics as applied to life.g...  The practices or beliefs of a certain group (e.e.

personal standards of what is right and wrong in conduct.  The process of learning to tell the difference between right and wrong of learning what ought and ought not to be done. and attitude. character. Usually refers to private. .

which are specific prescriptions for actions.  They provide the foundation of moral rules. general. philosophic concepts such as autonomy and justice. Example: the rule People should not lie is based on the moral principle of respect for persons (autonomy). Are statements about broad. .


 Means that the nurse respects a client s right to make decisions even when those choices seem to the nurse not to be in the client s best interest.  Respect for autonomy means that people should not be treated as an impersonal source of knowledge or training. Also means treating others with consideration. .

and unintentionally causing harm.  Harm can mean intentionally causing harm.  Unintentional harm occurs when the risk could not have been anticipated. placing someone at risk of harm. Duty to do no harm. intentional harm is never acceptable. In nursing. .

that is. Means doing good.  Nurses are obligated to do good. Example: a nurse may advise a client about a strenuous exercise program to improve general health. to implement actions that benefit clients and their support persons. However. . doing good can also pose a risk of doing harm. but should not do so if the client is at risk of a heart attack.

. that would take time from her next client. Referred to as fairness. who is diabetic who needs a great deal of teaching and observation. However. The nurse will need to weigh the facts carefully in order to divide his/her time justly among her clients. and knows she could help by staying for 30 more minutes to talk.  Nurses face decisions in which a sense of justice should prevail. Example: a nurse making a home visits finds one client tearful and depressed.

which is essential to the integrity of the client-provider relationship. commitments and promises. Means to be faithful to agreements. .  Nurses commitments to clients include providing safe care and maintaining competence in nursing practice.  It means telling the truth.

. It is important to most people. by not discussing medically irrelevant physical features and by not engaging in discussion of intimate details about the patient unless necessary for the provision of good care.  Nurses protect patient privacy by ensuring that the patient s body is appropriately covered. A loss of privacy occurs if others inappropriately use their access to a person.

. The principle of confidentiality requires that information about a client be kept private.  What documented in the client s record is accessible only to those providing care to that client. No one else is entitled to that information unless the client had signed consent for Release of Information that identifies with whom information may be shared and for what purpose.

 It is a set of ethical principles that: ‡ Is shared by members of the group ‡ Reflects their moral judgments over time ‡ Serves as a standard for their professional actions . Is a formal statement of a group s ideals and values.

race or social status.Nurses have four fundamental responsibilities: to promote health. . nationality. including the right to life. to prevent illness. Nursing care is unrestricted by considerations of age. culture. creed. to dignity and to be treated with respect. The need for nursing is universal. gender. Nurses render health services to the individual. disability or illness. Inherent in nursing is respect for human rights. politics. the family and the community and coordinate their services with those of related groups. color. to restore health and alleviate suffering.


psycho logic or material) to the recipient of the service is prevented . The nurse is expected to provide safe and competent care so that harm (physical.

 Is the quality or state of being legally responsible for one·s obligations and actions and to make financial restitution for wrongful acts. .

. It is by which the nurse acts or fails to act are legally defined by nurse practice acts and by rule of reasonable and prudent professional with similar preparation and experience would do in similar circumstances.

 A nurse who is employed by a hospital work as an agent of the hospital and the nurse·s contract with the clients is an implied one. .

The nurse represents and acts for the hospital and therefore must function within the policies of the agency.  Nurse employed by a Hospital ² functions with employer ² employee relationship. . Independent nurse practitioner ² contractual relationship with the client is independent.

INAPPROPRIATE BEHAVIORS ‡ Hitting the client in any part of the body ‡ Assisting in criminal abortion. ‡ Taking drugs from the client s supply for personal use. respondent superior let the master answer) The nurse may also be held liable as an individual in case of inappropriate behavior.(Also. .

. The rights and responsibilities of the nurse in the role of a citizen are the same as those individual under the legal system.


 As a member of the health team. in an effective manner . nurses need to communicate information about clients accurately. timely. ideas and feelings. Is a process in which people affect one another through exchange of information.

posture/gait. body movements. eye contact. NONVERBAL COMMUNICATION uses gestures. tone of voice. facial expression. . physical appearance (also as body language).VERBAL COMMUNICATION uses spoken or written words.

Clarity Involves saying exactly what is meant. Reduce distractions . brevity and completeness. Repeat the message as needed.1. The nurse also needs to speak slowly and enunciate words well. 2. Simplicity includes use of commonly understood words.

. Most importantly. to convey confidence and certainly in what she says. Ask one question at a time. 4.3. The nurse should be able to provide accurate information. Adaptability involves adjustment on what the nurse says and how it is said depending on moods and behavior of the client. Wait for an answer before making another comment. 5. he/she should be a good role model for what she teaches. To become credible. Credibility means worthiness of belief. the nurse requires an adequate knowledge about the topic being discussed. Timing and Relevance require choice of appropriate time and consideration of the client s interests and concerns.


g.  When assessing nonverbal behaviors. Communication is a basic component of relationships and nurse-client relationships. E. consider cultural influences. head nodding does not always mean agreement.  Effective communication is reciprocal interaction (two-way process) based on trust and aimed at identifying client needs and developing mutual goals. . Variety of feelings can be expressed by a single non-verbal expression.  Non-verbal communication is a more accurate expression of a person s thoughts and feelings than verbal communication.

interpretation and classification. It is an attempt to confirm to observer s perception through feedback.  Covert communication represents inner feelings that a person may be uncomfortable talking about. It develops gradually as the client perceives an attitude of acceptance. The client initially may test the nurse s confidence such as sharing that he expects remain confidential. Such communication may be revealed through non-verbal modes. . understanding and empathy from the nurse. Validation is required for overt communication. TRUST is the foundation of a positive nurse-client relationship.

 Therapeutic Communication is a fundamental component in all phases of the nursing process, and for establishing effective nurse client relationship.  Effective nurse client relationship is a helping relationship which is growth facilitating and provides support, comfort and hope.

 An intellectual and emotional bond between the nurse and the patient and is focused on the patient.  Respects the client as an individual-his ability to participate in his care, ethnic and cultural factors, family relationships and values.  Respects client s confidentiality.  Focuses on the client s well being.  Based on mutual trust, respect and acceptance.

DOCUMENTATION - serves as a permanent record of client information and care. REPORTING - takes place when two or more people share information about client care, either face to face or by telephone.

It allows to convey meaningful data about the client. STATISTICS provides statistical information that can be utilized for planning people s future needs. . LEGAL DOCUMENTATION it is admissible as evidence in a court of law. 3. 2. COMMUNICATION provides efficient and effective method of sharing information.1.

REIMBURSEMENT provides the basis for decisions regarding care to be provided and subsequent reimbursement to agency. EDUCATION serves as an educational tool for students in health discipline. 8. 5. PLANNING CLIENT CARE provides data which the entire health team uses to plan care for the client. RESEARCH provides valuable health-related data for research.4. 7. to cover health related expenses. 6. . AUDIT and QUALITY ASSURANCE monitors the quality of care received by the client and the competence of health care givers.


2. 5. flow sheets. anesthesia record. laboratory findings.‡ Each person or department makes notations in a separate section/s of the client s chart. 1. report of surgery. . I&O. medications. Admission sheet Physician s order sheet Medical history Nurse s notes Special records and reports (referrals. 3. vital signs. X-ray reports. 4.

‡ The record integrates all the data about the problem.‡ Data about the client are recorded and arranged according to the source of the information. gathered by the members of the health team. .

1. 2. Contains all the information about the client. DATABASE. PROGRESS NOTES: Nurse s or narrative notes (SOAPIE format) ‡       ‡ ‡ S subjective data O objective data A assessment P planning I intervention P planning Flow sheets (data that are monitored) Discharge notes or referral summaries . INITIAL LIST OF ORDERS or CARE PLANS. Contains all the aspects of the person s life requiring health care. 3. PROBLEM LIST. 4.

. making information readily accessible to all members of the health team.‡ Provides a concise method of organizing and recording data about a client. ‡ It is a series of flip cards usually kept in a portable file. But endorsement is not simply reciting content of the kardex. The health care needs of the client is still primary basis for endorsement. ‡ It is a way to ensure continuity of care from one shift to another and one day to the next. ‡ It is a tool for change of shift report.

This implies the Kardex is for planning and communication purposes only. blood transfusions  Treatments like oxygen therapy. ‡ Entries are usually in pencil so that they can be changed s client s condition changes. change of dressings. steam inhalation.‡ Kardex usually includes the following data:  Personal data (demographic data)  Basic needs  Allergies  Diagnostic tests  Daily nursing procedures  Medications and intravenous (IV) therapy. . suctioning. mechanical ventilation.


because the client s chart can be used as an evidence in a legal court.‡ Entries are concise. ‡ Complete sentences are not required. ‡ Start each entry with a capital letter and end the entry is a single word or phrase. . ‡ Avoid left pen or pencil for permanence of data.

 Correct: ate 50% of the food served.  Incorrect: ate with poor appetite  Correct: Refused medications  Incorrect: uncooperative  Correct: Seen crying  Incorrect: depressed .‡ Chart objective facts. not your interpretations or opinions. E.g.

complained of chest pain radiating down the left arm.‡ Place complaint of the client in quotation marks to indicate that it is his statement. Diaphoretic. BP=146/90mmHg ‡ Describe behaviors rather than feelings to allow other health team members to determine the actual problems of the client.g. RR=26/min. ‡ E.6 C. ‡ Refusal of medications and treatments must be documented. .=37. skin cold and clammy. Vital signs taken as follows: Temp. ‡ Objective data are also to be charted. Prefers to sit up. PR=110/min.g. ‡ E.

.‡ Only information that pertain to the client s health problems and care are recorded. ‡ Any other personal information that is conveyed to the nurse is inappropriate for the record.

‡ Date is entered in the date column on the first line of every page of nurse s notes and whenever the dates changes.‡ Notes should appear on each succeeding line. ‡ Continuous charting is done for each entry unless a time change occurs. . No need for a new line for each new idea or entry. ‡ Time is entered in the time column whenever a new time entry occurs.

If something appears on a particular sheet.g. it does not need to appear o the nurse s notes. e. blood pressure. ‡ Avoid squeezing information into a space because you forgot to chart it earlier. Add the information on the first available line. unless there is an alteration from the normal. body temperature. Write the time the event occurred.‡ Avoid time changes in the text of the nurse s notes. . not the time you entered the information. ‡ Avoid double chart.

‡ Treatments should be charted immediately after given.‡ Physician s visits. mode of the transportation and destination. ‡ Times the patient leaves and returns to the unit. ‡ Medications should be charted immediately after given. .

not printing is used for the signature. e. ‡ Sign each entry with your full name and status. ‡ Script. ‡ Affix signature. at the right hand margin of the nurse s notes.‡ Use only those abbreviations and symbols approved by the institution. SN for student nurse. place at the end of the charting. .g. use proper grammar. spell correctly. RN for registered nurse.

E. ERROR JU Pulse 180/min 108 beats/min . ‡ Write the word error above the line. then sign your signature.g.‡ Correct errors by drawing a single (horizontal) line through the error. erasures or use of occlusive materials. ‡ No ink eradications.

heard. smelled. observed. . ‡ If writing is not legible. or felt. ‡ Do not discard any part of the client record.‡ Only the health personnel who participate in the care of the client are allowed to read the chart. then print. ‡ Chart only what you personally have done. ‡ Writing must be clear and easily read by the others.



‡ For continuity of care ‡ It is based on health care needs of the client ‡ It is not mere reciting the content of the Kardex. and concise information. ‡ Provide clear. ‡ The nurse documents telephone report by including the following information: . accurate.

To whom information was given. What information was received. When the call was made. What information was given. Who made the call/report. e. . f. b. d. Who was called. c.a.

‡ The order needs to be verified by reporting it clearly and precisely.‡ Only RN s may receive telephone orders. ‡ The order should be countersigned by the physician who made the order within prescribed period of time (within 24 hours). . ‡ This is done when transferring a client from one unit to another.

ABBREVIATION Adb ABO ac ADL ad lib Adm AM amb amt approx BID BM BP BRP c TERM Abdomen The main blood group system Before meals Activities of daily living As desired Admitted or admission Morning Ambulatory Amount Approximately Twice daily Bowel movement Blood pressure Bathroom privileges with .

C CBC c/o DAT DC or D/C drsg Dx ECG (EKG) F fld Gl gtt h(hr) H2O HS or hs I&O IV Celsius/centigrade Complete blood count Complains of Diet as tolerated Discontinue or discharge Dressing Diagnosis Electrocardiogram Fahrenheit Fluid Gastrointestinal Drop Hour Water At bedtime Intake and output intravenous .

LMP (L) Meds ml/mL mod neg # NPO(NBM) NS (N/S) O2 OOB os OS pc PE(PX) Per/per PM Last menstrual period Left Medications Milliliter moderate Negative Number of pounds Nothing by mouth Normal saline Oxygen Out of bed Mouth or opening Left eye After meals Physical Examination By or through Afternoon .

etc. immediately Three times a day Telephone order Temperature. qhs qid (R) s Stat/stat tid.OD po Postop/postop Preop/preop prep prn q qd Q2h. respirations . pulse. Everynight at bedtime Four times a day Right Without At once./TID TO TPR Right eye or overdose By mouth Postoperatively Preoperatively Preaparation When necessary Every Everyday Every 2 hours. etc. q3h. every 3 hours.

Tr VO VS WNL wt Tincture Verbal order Vital signs Within normal limits weight .

.‡ A change in human disposition or capability that persists over a period of time. ‡ Reflected by a change of behavior.

There is a natural tendency for people to learn and that learning flourishes in an encouraging environment. The transfer of knowledge could occur if the new situation closely resembled the old situation. It involves respect for human dignity.‡ BEHAVIORISM. Involves providing options for the person and the resources and equipment for learning capacity for self determination and freedom to make choices. ‡ COGNITISM. ‡ HUMANISM. People do the best they can for themselves relative to their unique perceptions. . (Lewin) Learning must be a individualized process. Learning is a complex cognitive (intellectual) activity.