Chapter 1 Historical and Contemporary Nursing • American Civil War

Practice
– Harriet Tubman-the moses of her people
Women's Roles • Traditional female roles of
– Sojourner Truth-womens advocate
wife, mother, daughter, and sister have always
included the care and nurturing of other family – Dorothea Dix-union superintendent of female
members. From the beginning of time, women nurse
have cared for infants and children; thus,
nursing could be said to have its roots in the • World War I
home. – Harsh environments and new injuries
Men's Roles World War I
• Men have worked as nurses as far back as – Progress in the field of surgery
before the Crusades.
• World War II

Religion (1 of 2) – Acute shortage of caregivers

• Christian parable of the Good Samaritan – Cadet Nurse Corps

• Roman Empire • Vietnam War

– Conversion to Christianity – Youngest group of medical personnel to serve

in wartime
– Houses of care and healing
• Afghanistan and Iraq (2001–2015)
▪ Fabiola-wealthy matrons of the roman empire
– Nurses 55% male
• Crusades
– 6,326 nurses
– Knights Hospitalers
Nightingale (1820–1910)
– Knights of Saint Lazarus
– Improved standards of care for war casualties
– It provides nursing care to their sick and
injured comrades. – Nursing's first scientist-theorist, nurse
researcher
• Medieval
– Notes on Nursing: What It Is, and What It Is
– Alexian Brothers- black plague Not
– Deaconess groups suppressed – Nightingale Training School for Nurses
• 1800s • Barton (1821–1912)
– Order of Deaconesses reinstituted 1836 – Volunteer nurse in American Civil War
Crimean War – Establishment of American Red Cross
– Florence Nightingale • Richards (1841–1930)
– Inadequacy of care given to soldiers led to – America's first trained nurse
public outcry
– Initiated practice of wearing uniforms • Grant (1958–)

• Mahoney (1845–1926) – First male president of ANA and first African

American VP of ANA
– First African American professional nurse
Nursing Education (2 of 2)
– Worked for acceptance and equal opportunity
• NCLEX-RN exam, verified completion of
• Wald (1867–1940)
prescribed course of study
– Founder of public health nursing
– Accredited programs
– Trained services to poor in NYC slums
• Licensure
– Henry Street Settlement
• Mutual recognition, multistate licensure
• Dock (1858–1956)
• In PH: NLE * PRC * RA 9173 “Philippine
– Protest movements for women's rights nursing act of 1991”

– Legislation to allow nurses control their own The Metaparadigm for Nursing
profession
– Metaparadigm
▪ Precursor to National League of Nursing
▪ Concepts that can be superimposed on any
• Sanger (1879–1966) work in the profession

– Considered founder of Planned Parenthood – Four concepts

• Breckinridge (1881–1965) ▪ Individuals or clients are the recipients of

nursing care.
– Established Frontier Nursing Service (FNS) in
rural U.S. ▪ Environment is the internal and external
surroundings affecting the client.
– Started one of the first midwifery training
schools in U.S. ▪ Health is the degree of wellness/well-being
the client experiences.
• Breckinridge (1881–1965)
▪ Nursing is the attributes, characteristics, and
– Established Frontier Nursing Service (FNS) in actions of the nurse providing
rural U.S.
care on behalf of, or in conjunction with, the
– Started one of the first midwifery training client
schools in U.S.
Recipients of Nursing
• Christ man (1915–2011)
• Consumer
– A founder of American Assembly for Men in
Nursing (AAMN) • Patient

– First man nominated for ANA president and – Person waiting for, undergoing medical
inducted into Hall of Fame treatment and care

– First man elected to American Academy of • Client

Nursing (AAN)
– Person who engages in advice, services of Teacher • Help clients learn about health and
another who is qualified to provide healthcare procedures to restore or maintain
health
service
Client Advocate • Represent, protect the client's
– Increasingly used over patient
needs and wishes
Scope of nursing
Counselor • Help client to recognize and cope
• Promoting Health and Wellness with stressful psychological or social problems,
develop improved relationships, and promote
– Individual and community activities to personal growth
enhance health lifestyles
Change Agent • Assist clients to make
• Preventing Illness modifications in behavior
– Immunizations Leader • Influence others to work together to
– Prenatal and infant care accomplish specific goals

– Prevention of STIs Manager • Manage care of individuals, families,

and communities • Delegate nursing activities
• Restoring Health
Case Manager • Work with or act as primary
– Direct care to ill person nurse to oversee care of specific caseload
– Diagnostic and assessment procedures Research Consumer • Use research to improve
– Consulting other healthcare professionals client care
• Care for the Dying • Profession – Occupation that requires
– Comforting people of all ages extensive education – Special knowledge, skill,
and preparation
– In homes, hospitals, extended care facilities,
and hospices Specialized Education • Hospital diploma,
associate degree, baccalaureate degree,
• ANA master's degree, and doctoral degree
– Standards of Practice Code of ethics
– Standards of Professional Performance • Integrity – Member expected to do what is
considered right regardless of personal cost •
Caregiver
Self-regulating • Setting standards for members
• Assist client physically and psychologically • Independence at work, responsibility,
while preserving client's dignity accountability for one's actions

Communicator • Governance – Establishment and maintenance

of social, political, and economic arrangements
• Identify client problems and communicate
by which practitioners control practice, self-
them to other members of the healthcare
discipline, working conditions, and professional
Team affairs.
• Professional identity – "Matters of obligation on what ought to be
done"
– "Sense of oneself influenced by
characteristics, norms, and values of the nursing – Beyond observing code of ethics

discipline, resulting in individual thinking, 4. Aesthetic knowing: the art of nursing

acting, and feeling like a nurse"
– Expressed by individual nurse's creativity and
• Benner's stages of nursing expertise style in meeting needs of clients

– Stage I: Novice – Care that is effective and satisfying

– Stage II: Advanced beginner Theory of Human Care (Jean Watson)

– Stage III: Competent • Basis for nursing's role in society

– Stage IV: Proficient • Commitment to care of the whole person as

well as individuals
– Stage V: Expert
and groups
• Internet's influence on healthcare •
Telehealth – Medical information exchanged via Transpersonal human caring: Transpersonal
electronic communications to improve patient's caring
health status
“conveys a concern for the inner life world of
• Telenursing – Provide nursing practice at a another seeking to
distance
connect with and embrace the soul of the other
• No state boundaries – Licensure issues through the processes of caring and

healing and being in authentic relation, in the

• Caring – Sharing deep and genuine moment.
concern about the welfare of another person Metaphysical
• Milton Mayerhoff(1990) – Caring is helping • Each person seeks harmony within mind,
growth and actualization of another. – Caring body, and soul, actualizing real self
process develops over time. – Supports client's
potential and need to grow Factors Influencing the Communication

1. Empirical knowing: the science of nursing Process (1 of 5)

– From factual, observable phenomena to • Development

theoretical analysis – Knowledge of client's stage
2. Personal knowing: the therapeutic use of self – Varies across life span
– Promotes wholeness, integrity in personal • Gender
encounter
– Girls seek confirmation, minimize differences,
– Achieves engagement and establish intimacy.
3. Ethical knowing: the moral component
– Boys establish independence and negotiate • Boundaries
status within group.
– Limits crucial to nurse–client relationship
• Values and Perceptions
Therapeutic Communication
– Standards that influence behavior
• Promotes understanding
– Personal view of an event
• Establishes constructive relationships
• Personal Space
• Pre-interaction Phase
– Intimate (0 to 1-1/2 feet)
– Obtain information before first face-to-face
– Personal (1-1/2 to 4 feet) meeting

– Social (4 to 12 feet) ▪ Name, address, age, medical history, and/or

social history
– Public (12 to 15 feet)
– Anxious feelings in nurse addressed by
• Territoriality
identifying specific information to be
– Space, things that individual considers as
discussed
belonging to self
– Positive outcomes can evolve
• Roles and Relationships
Introductory Phase
– Between sender and receiver
– Orientation phase
• Environment
▪ Sets tone for rest of the
– Most effective communication in comfortable
environment relationship

– Privacy – Develop trust and security

• Congruence – Getting to know each other

– Verbal and nonverbal aspects of message – Resistive behaviors may be

match
displayed.
• Interpersonal Attitudes
• Working Phase
– Caring and warmth
– View each other as unique individuals
– Respect
– Once caring develops, empathy increases.
• Interpersonal Attitudes
– Exploring and understanding thoughts and
– Elderspeak feelings

▪ Similar to baby talk – Facilitating and taking action

▪ Patronizing to older adults Empathy

– Acceptance • Ability to experience,

in the present, a ▪ Can be blaming and delivered

situation as another in a rushed manner

person did at some

time in the past Teaching-

• Resolution Phase
Teaching
– Nurse and client accept feelings of loss.
– Major aspect of nursing practice
– Client accepts the end of the relationship
Learning need
without feelings of anxiety or
– Desire to know
Dependence
• Compliance
Communication Styles
– Desire to act on learning
– Nurses are taught to be descriptive
• Adherence
both verbally and in writing.
– Commitment to regimen
– Physicians are taught to be brief, to
• Andragogy
the point, and focused.
– Art and science of teaching adults
▪ Impatience may result.
• Pedagogy
– SBAR approach describes:
– Art and science of teaching children
▪ Situation
• Geragogy
▪ Background
– Art and science of teaching older adults
▪ Assessment
• Bloom's domains of learning
▪ Recommendations
– Cognitive (thinking) level
Assertive Communication
▪ Six intellectual abilities, thinking processes
– Promotes client safety by minimizing
miscommunication with colleagues – Affective (feeling) level

– Honest, direct, and appropriate; open to ideas ▪ Personal issues

– Respects rights of others – Psychomotor (physical skill) level

Passive Communication ▪ Fine and gross motor abilities

▪ Allowing one's own rights to Behaviorism

be violated by others – Thorndike, Pavlov, Skinner, Bandura

Aggressive communication – Learning based on learner's behavior

– Response ▪ Learning self-motivated, self-initiated, self-
evaluated
▪ Act that is traced to the effects of a stimulus
▪ Individual is a unique composite of biological,
– Conditioning used to change behaviors
psychological, social, cultural,
– Positive reinforcement (Skinner and Pavlov).
and spiritual factors.
– Bandura
▪ Learning focuses on self-development and
▪ Observational learning and instruction through achieving full potential
imitation and modeling
Telemedicine
▪ D. Albert Bandura's social learning theory (SLT)
– Health information,
suggests that we learn
services, and products
social behavior by observing and imitating the
behavior of others provided via Internet

• Cognitivism – Often interchangeable

– Piaget, Lewin, Bloom with "telehealth"

▪ Learning • Modalities

–Complex cognitive – Real-time

activity – Store-and-forward

▪ Learner structures and – Remote client

processes information Monitoring

▪ Perception chosen by Health Literacy

Individual – Capacity to obtain, process, and understand

the basic health information and
Cognitivism
services needed to make appropriate health
Jean William Fritz Piaget: “Cognitive
decisions
development of the Children “

– Lewin, Bloom Chapter 10

▪ Personal characteristics affect perceptions. Assessing
▪ Context important • Nursing process

–Social, emotional, physical – Systematic, rational method of planning and

providing individualized nursing care
• Humanism
– Purposes
– Maslow, Rogers
▪ Identify client's health status and actual or
potential healthcare problems of
needs Client Records

▪ Establish plans to meet needs – Medical records

▪ Deliver specific interventions – Records of therapies

• 4 types of assessment – Laboratory records

– Initial nursing assessment • Healthcare Professionals

– Problem-focused assessment – Important to ensure continuity of care when

clients transferred to and from home
– Emergency assessment
and healthcare agencies
– Time-lapsed reassessment
• Literature
Subjective data
– Standards or norms against which to compare
– Symptoms or covert data
findings
– Apparent only to person affected
– Current methodologies and research findings
– Can be described only by person affected
Observing
– Includes sensations, feelings, values, beliefs,
– Gathering data using the senses
attitudes, and perception of
– Used to obtain following types of data:
personal health status and life situation
▪ Skin color (vision)
Objective data
▪ Body or breath odors (smell)
– Signs or overt data
▪ Lung or heart sounds (hearing)
– Detectable by an observer
▪ Skin temperature (touch
– Can be measured or tested against an
accepted standard Data Collection Methods (1 of 13)

– Can be seen, heard, felt, or smelled • Observing

– Obtained through observation or physical – Gathering data using the senses

examination
– Used to obtain following types of data:
Client
▪ Skin color (vision)
– Best source unless too ill, young, or confused
▪ Body or breath odors (smell)
to communicate clearly
▪ Lung or heart sounds (hearing)
Support People
▪ Skin temperature (touch)
– Family members, friends, caregivers
Interviewing

– Interview
▪ Planned communication or a conversation – Vital signs, height and weight
with a purpose
– Cephalocaudal approach
▪ Focused interview
▪ Head-to-toe progression
–Nurse asks the client specific questions to
– Screening examination
collect information related to
▪ Review of systems
the client's problem
• Validation
– Directive interview
– The act of "double-checking," verifying data to
▪ Nurse establishes purpose
confirm it is accurate and factual
– Nondirective interview
• Wellness Models
▪ Rapport
– Assist clients to identify and explore lifestyle
–Understanding between two or more people habits and health behaviors, beliefs,

▪ Client controls the purpose, subject matter, values, and attitudes

and pacing
• Nonnursing Models
Types of interview questions
– Body systems model
▪ Closed questions
▪ Integumentary, respiratory, cardiovascular,
–Restrictive nervous, musculoskeletal,

• Yes/no gastrointestinal, genitourinary, reproductive,

and immune systems
• Factual
Chapter 11
–Less effort and information from client
Diagnosing
–"What medications did you take?"
Diagnosis
–"Are you having pain now?"
– A statement or conclusion regarding the
– Types of interview questions
nature of a phenomenon
▪ Open-ended questions
• Diagnostic labels
–Specify broad topic to discuss
– Standardized NANDA names for diagnoses
–Invite longer answers
• Etiology
–Get more information from client
– Causal relationship between ad problem and
• Examining its related factors

– Systematic data-collection method • Nursing diagnosis

– Uses observation and inspection, auscultation, – Problem statement consisting of diagnostic

palpation, and percussion label plus etiology
Actual nursing diagnosis • Medical diagnosis

– Problem presents at the time of assessment. – Made by a physician

Health promotion diagnosis – Refers to a disease process

– Preparedness to implement behaviors to The Diagnostic Process

improve their health condition
• Critical thinking
– Example: Readiness for Enhanced Nutrition
– Reviewing data and considering explanations
Risk nursing diagnosis before forming opinions

– Problem does not exist. • Analysis

– Presence of risk factors – Separation into components (deductive

reasoning)
Syndrome diagnosis
• Synthesis
– Cluster of nursing diagnoses that have similar
interventions – Putting together of parts into whole (inductive
reasoning
Components of a Nursing Diagnosis (1 of
Basic Two-Part Statements
3)
– Problem (P)
• Problem (Diagnostic Label) and Definition
– Etiology (E)
– Describes the client's health problem or
response – Joined by the words "related to"

– May require specification – Add words if NANDA label contains the word
Specify
• Etiology (Related Factors and Risk Factors)
Basic Three-Part Statements
– Identifies one or more probable causes of the
health problem – PES format

– Gives direction to the required nursing ▪ Problem (P)

therapy
▪ Etiology (E)
• Defining Characteristics
▪ Signs and symptoms (S)
– Cluster of existing signs and symptoms
– Recommended for beginning diagnosticians
indicates actual diagnosis
– List signs and symptoms grouped by
▪ Clients have signs and symptoms.
subjective and objective data
Nursing diagnosis

– A statement of nursing judgment based on

education, experience, expertise and

license to treat
Chapter 12 – Tailored to meet the unique needs of a
specific client
Planning
• Standardized care plans
Planning – Kept with client's individualized care plan,
– Deliberate, systematic, problem-solving phase then permanent medical record
of nursing process – Provide detailed interventions
• Nursing interventions – Written in the nursing process format
– Treatment that a nurse performs to enhance • Protocols
patient/client outcomes
– Indicate actions commonly required for a
particular groups of clients
Initial Planning
– May include both primary care provider's
• Develops initial comprehensive plan of care orders and nursing interventions
• Begun after initial assessment • Policies and procedures
Ongoing Planning (1 of 2) – Developed to govern handling of frequently
• Done by all nurses who work with the client occurring situations

• Individualization of initial care plan Standing order

Discharge Planning – Written document

• Process of anticipating and planning for needs ▪ Policies

after discharge ▪ Rules
• Addressed in each client's care plan ▪ Regulations

▪ Orders regarding patient care

Developing Nursing Care Plans (1 of 2)
Individualization of standardized care plans
• Informal nursing care plan
– Fit the unique needs of each client
– A strategy for action that exists in nurse's
mind – Usually both preauthored and nurse-created
sections
• Formal nursing care plan
Formats for Nursing Care Plans (1 of 2)
– Written or computerized guide
• Student Care Plans
• Standardized care plan
– Rationale
– A formal plan that specifies actions for a
group of clients with common needs ▪ Evidence-based principle given as the reason
for selecting a particular
• Individualized care plan
nursing intervention
– Concept maps Implementing

▪ Visual tool in which ideas or data are enclosed • Doing and documenting the activities that are
in circles or boxes with the specific nursing actions needed to

relationships indicated by lines or arrows carry out interventions

Computerized Care Plans Cognitive (intellectual) skills

– Create and store nursing care plans – Problem solving

– Can be accessed at a centrally located – Decision making

terminal at nurses' station or in clients'
– Critical thinking
Rooms
– Creativity
Multidisciplinary (Collaborative) Care
• Interpersonal skills
Plans
– Verbal and nonverbal
• Also known as collaborative care plans or
– Effectiveness depends largely on ability to
critical pathways
communicate.
Guidelines for Writing Nursing Care
– Therapeutic communication necessary for
Plans (1 of 3) caring, comforting, advocating,

1. Date and sign the plan referring, counseling, and supporting

2. Use category headings • Technical skills

3. Use standardized/approved medical or – Purposeful "hands-on" skills

English symbols and key words rather than
– Often called tasks, procedures, or
complete sentences to communicate your ideas psychomotor skills
unless agency policy dictates
– Psychomotor
otherwise
▪ Physical actions that are controlled by the
4. Be specific mind, not by reflexes

Chapter 13 – Require knowledge and often require manual

dexterity
Implementing and
Process of Implementing (1 of 7)
Evaluating
Reassessing the Client
Nursing process
– Reassess to make sure the intervention is still
– Action oriented
needed
– Client centered
– Client's condition may have changed.
– Outcome directed
• Determining the Nurse's Need for Assistance
– Inability to implement the nursing activity ▪ Structure evaluation
safely
–Focuses on setting
• Implementing the Nursing Interventions
▪ Process evaluation
– Base actions on scientific knowledge
–Focuses on care given
• Supervising Delegated Care
▪ Outcome evaluation
– Nurse still responsible for client's overall care
–Focuses on demonstrable changes in client's
Documenting Nursing Activities health status as result of

– Record nursing interventions and client nursing care

responses
• Quality Improvement
– Do not record in advance
– The Joint Commission Mission
Process of Evaluating Client Responses
▪ "To continuously improve the safety and
(1 of 9) quality of care provided to the

• Collecting Data public the provision of healthcare accreditation

and related services that
– Some may require interpretation.
support performance improvement in
• Comparing Data with Desired Outcomes
healthcare organizations"
– Conclusions
Great emphasis on sentinel event
▪ Goal was met.
▪ Unexpected occurrence involving death or
▪ Goal was partially met. serious physical or psychological

▪ Goal was not met injury or the risk thereof

Evaluating the Quality of Nursing Care (1 – Sentinel event

of 10) ▪ Unexpected occurrence involving death or

serious physical or psychological
• Quality Assurance
injury, or risk thereof
– Ongoing, systematic process
– Root cause analysis
– Evaluates and promotes excellence in
provision of healthcare ▪ Process for identifying the factors that bring
about deviations in practices
– May evaluate level of care provided
that lead to the event
– May evaluate performance of a nurse or
agency or country – National Quality Forum

• Quality Assurance ▪ 12 nursing-sensitive care measures to evaluate

quality of nursing care
– Three components:
▪ Serious reportable events (SREs) or "never Ethical and Legal Considerations (2 of 4)
events"
• Ensuring Confidentiality of Computer Records
–Facility may not be paid for care if SRE has
– Personal password that is not to be shared
occurred.
– Never leave a computer terminal unattended
Nursing-Sensitive Indicators
after logging on
– National Quality Forum (NQF)
– Can be written or computer based
▪ Serious reportable events (SRE) also known as
"never events"
• Ensuring Confidentiality of Computer Records
Nursing Audit
– Shred all unneeded computer-generated
– Examination or review of records worksheets

– Retrospective audit
Purposes of Client Records (1 of 3)
▪ Evaluation of a client's record after discharge
from an agency • Communication

– Concurrent audit – Prevents fragmentation, repetition, and

delays in care
▪ Evaluation of a client's healthcare while client
still receiving care from the • Planning Client Care

Agency – Nurses use baseline and ongoing data to

evaluate effectiveness of the care plan.
Chapter 14
• Auditing Health Agencies
Documenting and
– Review client records for quality assurance
Reporting
purposes
• Discussion
• Research
– Informal oral consideration of a subject by
– Treatment plans for a number of clients with
two or more healthcare personnel
the same health problems can yield
• Report
information helpful in treating other clients
– Oral, written, or computer-based
• Education
communication intended to convey information
• Reimbursement
to others
– From the federal government
• Record
– Must contain correct DRGs
– Also called chart or client record
• Legal Documentation
– Formal, legal document that provides
evidence of a client's care – Admissible in court as evidence unless client
objects because information client
gives to primary care provider is confidential • Progress notes organized into DAR format

• Healthcare Analysis – Data

– Identify agency needs such as over utilized ▪ Assessment phase

and underutilized hospital services
– Action
Documentation Systems
▪ Planning and implementing phase
Source-Oriented Record
– Response
• Traditional client record
▪ Evaluation phase
Problem-Oriented Medical Record (1 of 4)
Holistic perspective of client needs
• Data arranged according to client problem
• Nursing process framework for progress notes
• Database
• DAR progress notes
– All information known about the client when
– Data
the client first enters the healthcare
– Action
agency
– Response
• Problem List
Charting by Exception (2 of 2)
– Listed in order in which they are identified and
others resolved • Documentation according to standards
involves a check mark.
Plan of Care
Computerized Documentation (1 of 2)
– Made with reference to active problems
• Developed to manage volume of information
– Generated by individual who lists the
problems • Used by nurses to:
• Progress Notes – Store client's database, new data
– Made by all health professionals involved in a – Create and revise care plans
client's care
– Document client's progress
– Uses SOAP, SOAPIE, SOAPIER documentation
Case Management
PIE
• Quality, cost-effective care delivered within
• Groups information into three categories established length of stay
– Problems • Uses multidisciplinary approach, critical
pathways, CBE
– Interventions
Documenting Nursing Activities
– Evaluation
• Describe client's ongoing status in record
• Focus on client concerns and strengths
Admission Nursing Assessment

• Comprehensive admission assessment when

client first admitted to nursing unit

Nursing Care Plans (2 of 2)

• Traditional care plans

– Written for each client

• Standardized care plans

– Based on institutions standards of practice

Kardexes (1 of 2)

• Concise method of organizing and recording

data

• Series of cards kept in a portable index file or

on computer-generated form

• Information quickly accessible

Flow Sheets (1 of 2)

• Graphic Record

– Body temperature, pulse, respiratory rate,

blood pressure, weight, other

significant clinical data

• Intake and Output Record

– All routes measured and recorded

• Medication Administration Record

– Date of order, expiration date, name and

dose, frequency and route of

administration, nurse's signature

• Skin Assessment Record

– Such as the Braden Assessment

Progress Notes

• Provide information about progress client is

making toward achieving desired

outcomes