Fundamentals of Nursing

1. THEORETICAL FRAMEWORK of NURSING PRACTICE

1. NursingAs by the INTERNATIONAL COUNCIL OF NURSES (ICN, 1973) as written by Virginia Henderson: The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health. It’s recovery, or to a peaceful death that the client would perform unaided if he had the necessary strength, will or knowledge. Help the client gain independence as rapidly as possible.

1. CONCEPTUAL AND THEORETICAL MODELS OF NURSING PRACTICE Theorist Description

FLORENCE NIGHTINGALE

· Developed the first theory of nursing. · Focused on changing and manipulating the environment in order to put the patient in the best possible conditions for nature to act.

HILDEGARD PEPLAU

· Introduced the Interpersonal Model. · She defined nursing as a therapeutic, interpersonal process which strives to develop a nurse-patient relationship in which the nurse serves as a resource person, counselor and surrogate.

FAYE ABDELLAH· Defined nursing as having a problem-solving approach, with key nursing problems related to health needs of people; developed list 21 nursing problem areas

IDA JEAN ORLANDO

· Developed the three elements – client behavior, nurse reaction and nurse action – compose the nursing situation. She observed that the nurse provide direct assistance to meet an immediate need for help in order to avoid or to alleviate distress or helplessness.

MYRA LEVINE

· Described the Four Conservation Principles. 1. conservation of energy 2. conservation of structured integrity 3. conservation of personal integrity 4. conservation of social integrity

DOROTHY JOHNSON

· Developed the Behavioral System Model. 1. Patient’s behavior as a system that is a whole with

interacting parts 2. how the client adapts to illness 3. goal of nursing is to reduce so that the client can move

more easily through recovery.

MARTHA ROGERS

Conceptualized the Science of Unitary Human Beings. She asserted that human beings are more than different from the sum of their parts; the distinctive properties of the whole are significantly different from those of its parts.

DOROTHEA OREMEmphasizes the client’s self care needs; nursing care becomes necessary when client is unable to fulfill biological, psychological, developmental or social needs.

IMOGENE KINGNursing process is defined as dynamic interpersonal process between nurse, client and health care system.

BETTY NEUMANStress reduction is a goal of system model of nursing practice. Nursing actions are in primary, secondary or tertiary level of prevention

SISTER CALLISTA ROY

Presented the Adaptation Model. She viewed each person as a unified bio-psychosocial system in constant interaction with a changing environment. The goal of nursing is to help the person adapt to changes in physiological needs, self-concept,

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role function and interdependent relations during health and illness.

LYDIA HALLIntroduced the notion that nursing centers around three components: person(core), pathologic state and treatment(cure) and body(care).

JEAN WATSON

Conceptualized the Human Caring Model. She emphasized that nursing is the application of the art and human science through transpersonal caring transactions to help persons achieve mind-body-soul harmony, which generates self-knowledge, self-control, self-care and self-healing.

ROSEMARIE RIZZO PARSE

Introduced the Theory of Human Becoming. She emphasized free choice of personal meaning in relating to value priorities, co-creating of rhythmical patterns, in exchange with the environment and contranscending in many dimensions as possibilities unfold.

MADELEINE LENINGER

Developed the Transcultural Nursing Model. She advocated that nursing is a humanistic and scientific mode of helping a client through specific cultural caring processes (cultural values, beliefs and practices) to improve or maintain a health condition

2. ROLES AND FUNCTION OF A NURSE a. Caregiver – the caregiver role has traditionally included those activities that assist the client physically and psychologically while preserving the client’s dignity. Caregiving encompasses the physical, psychosocial, developmental, cultural and spiritual levels.b. Communicator – communication is an integral to all nursing roles. Nurses communicate with the client, support persons, other health professionals, and people in the community. In the role of communicator, nurses identify client problems and then communicate these verbally or in writing to other members of the health team. The quality of a nurse’s communication is an important factor in nursing care.c. Teacher – as a teacher, the nurse helps clients learn about their health and the health care procedures they need to perform to restore or maintain their health. The nurse assesses the client’s learning needs and readiness to learn, sets specific learning goals in conjunction with the client, enacts teaching strategies and measures learning. d. Client advocate – a client advocate acts to protect the client. In this role the nurse may represent the client’s needs and wishes to other health professionals, such as relaying the client’s wishes for information to the physician. They also assist clients in exercising their rights and help them speak up for themselves. e. Counselor – counseling is a process of helping a client to recognize and cope with stressful psychologic or social problems, to developed improved interpersonal relationships, and to promote personal growth. It involves providing emotional, intellectual, and psychologic support.f. Change agent – the nurse acts as a change agent when assisting others, that is, clients, to make modifications in their own behavior. Nurses also often act to make changes in a system such as clinical care, if it is not helping a client return to health. g. Leader – a leader influences others to work together to accomplish a specific goal. The leader role can be employed at different levels; individual client, family, groups of clients, colleagues, or the community. Effective leadership is a learned process requiring an understanding of the needs and goals that motivate people, the knowledge to apply the leadership skills, and the interpersonal skills to influence others. h. Manager – the nurse manages the nursing care of individuals, families, and communities. The nurse-manager also delegates nursing activities to ancillary workers and other nurses, and supervises and evaluates their performance. i. Case manager – nurse case managers work with the multidisciplinary health care team to measure the effectiveness of the case management plan and to monitor outcomes.j. Research consumer – nurses often use research to improve client care. In a clinical

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area nurses need to: · Have some awareness of the process and language of research · Be sensitive to issues related to protecting the rights of human subjects · Participate in identification of significant researchable problems · Be a discriminating consumer of research findings

2. Concepts of Health and IllnessI. Health – As defined by the World Health Organization (WHO): state of complete physical, mental and social well-being, not merely the absence of disease or infirmity.

a. Characteristics i. A concern for the individual as a total system ii. A view of health that identifies internal and external environment iii. An acknowledgment of the importance of an individual’s role in life A dynamic state in which the individual adapts to changes in internal and external environment to maintain a state of well being

b. Models of Health and Illness i. Health-Illness Continuum (Neuman ) – Degree of client wellness that exist at any point in time, ranging from an optimal wellness condition, with available energy at its maximum, to death which represents total energy depletion.

ii. High – Level Wellness Model (Halbert Dunn) – It is oriented toward maximizing the health potential of an individual. This model requires the individual to maintain a continuum of balance and purposeful direction within the environment.

iii. Agent – Host – environment Model (Leavell) – The level of health of an individual or group depends on the dynamic relationship of the agent, host and environment Ø Agent – any internal or external factor that disease or illness. Ø Host – the person or persons who may be susceptible to a particular illness or disease Ø Environment – consists of all factors outside of the host

iv. Health – Belief Model – Addresses the relationship between a person’s belief and behaviors. It provides a way of understanding and predicting how clients will behave in relation to their health and how they will comply with health care therapies.

Four Components Ø The individual is perception of susceptibility to an illness Ø The individual’s perception of the seriousness of the illness Ø The perceived threat of a disease Ø The perceived benefits of taking the necessary preventive measures

v. Evolutionary – Based Model – Illness and death serves as a evolutionary function. Evolutionary viability reflects the extent to which individual’s function to promote survival and well-being. The model interrelates the following elements: Ø Life events Ø Life style determinantsØ Evolutionary viability within the social context Ø Control perceptions Ø Viability emotions Ø Health outcomes

vi. Health Promotion Model – A “complimentary counterpart models of health protection”. Directed at increasing a client’s level of well being. Explain the reason for client’s participation health-promotion behaviors.

The model focuses on three functions:

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Ø It identifies factors (demographic and socially) enhance or decrease the participation in health promotion Ø It organizes cues into pattern to explain likelihood of a client’s participation health-promotion behaviors Ø It explains the reasons that individuals engage in health activities I

II. Illness – State in which a person’s physical, emotional, intellectual, social developmental or spiritual functioning is diminished or impaired. It is a condition characterized by a deviation from a normal, healthy state.

a. 3 Stages of Illness i. Stage of Denial – Refusal to acknowledge illness; anxiety, fear, irritability and aggressiveness. ii. Stage of Acceptance – Turns to professional help for assistance iii. Stage of Recovery (Rehabilitation or Convalescence) – The patient goes through of resolving loss or impairment of function

b. Rehabilitation i. A dynamic, health oriented process that assists individual who is ill or disabled to achieve his greatest possible level of physical, mental, spiritual, social and economical functioning. ii. Abilities not disabilities, are emphasized. iii. Begins during initial contact with the patient iv. Emphasis is on restoring the patient to independence or regain his pre-illness/predisability level of function as short a time as possible v. Patient must be an active participant in the rehabilitation goal setting an din rehabilitation process.

c. Focuses of Rehabilitation i. Coping pattern ii. Functional ability – focuses on self-care: activities of daily living (ADL); feeding, bathing/hygiene, dressing/grooming, toileting and mobilityiii. Mobility iv. Integrity of skin v. Control of bowel and bladder function

3. Concepts of StressI. Stress (Theory by Hans Selye) a. Non specific response of the body to nay demand made upon it b. Any situation in which a non specific demand requires an individual to respond or take action

II. Characteristics of Stress a. Stress is not nervous energy. Emotional reactions are common stressors b. Stress is not always the result of damage to the body c. Stress does not always result in feelings of distress (harmful or unpleasant stress) d. Stress is a necessary part of life and is essential for normal growth and development e. Stress involves the entire body acting as a whole and is an integrated manner f. Stress response is natural, productive and adaptive

III. Stressors – Factor or agent producing stress, maybe: physiological, psychological, social, environmental, developmental, spiritual or cultural and represent an unmet needs

a. Classification of Stressors i. Internal Stressors – originate from within the body. E.g. fever, pregnancy, menopause, emotion such as guilt ii. External Stressors – originate outside a person. E.g. change in family or social role,

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peer pressure, marked change in environmental temperature

b. Factors influencing response to stressorsi. Physiological functioning ii. Personality iii. Behavioral characteristicsiv. Nature of the stressor: integrity, scope, duration, number, and nature of other stressors

4. Homeostasis – Process of maintaining uniformity, stability and constancy with in the living organisms. (from Greek word homotos – like, and stasis – position)

5. Adaptation – Body’s adjustment to different circumstances and conditions. Process by the physiological or psychological dimensions change in response to stress; attempt to maintain optimal functioning

6. Adaptation to Stress-Physiological Response (Hans Selye)

I. Local Adaptation Syndrome (LAS) – Response of a body tissue, organ or part to the stress of trauma, illness or other physiological change

a. Characteristics i. The response is localized, it does not involve entire body systems ii. The response is adaptive, meaning that a stressor is necessary to stimulate it iii. The response is short term. It does not persist indefinitely iv. The response is restorative, meaning that the LAS assists in restoring homeostasis to the body region or part

b. Two Localized Responses i. Reflex Pain Response – is a localized response of the central nervous system to pain. It is an adaptive response and protects tissue from further damage. The response involves a sensory receptor, a sensory nerve from the spinal cord, and an effector muscle. An example would be the unconscious, reflex removal of the hand from a hot surface. ii. Inflammatory Response – is stimulated by trauma or infection. This response localizes the inflammation, thus revenging its spread and promotes healing. The inflammatory response may produce localized pain, swelling, heat, redness and changes in functioning.

c. Three Phases of Inflammatory Response i. First Phase – Narrowing of blood vessels occurs at the injury to control bleeding. Then histamine is released at the injury, increasing the number of white blood cells to combat infection.ii. Second Phase – It is characterized by release of exudates from the wound iii. Third Phase – The last phase is repair of tissue by regeneration or scar formation. Regeneration replaces damaged cells with identical or similar cells.

II. General Adaptation Syndrome (GAS) or Stress Syndrome – characterized by a chain or pattern of physiologic events. a. 3 Stages i. Alarm Reaction – initial reaction of the body which alerts the body’s defenses.

SELYE divided this stage into 2 parts: Ø The SHOCK PHASE Ø The COUNTERSHOCK PHASE

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ii. Stage of Resistance – occurs when the body’s adaptation takes place; the body attempts to adjust with the stressor and to limit the stressor to the smallest area of the body that can deal with it. iii. StressorEpinephrine Tachycardia ↑ Myocardial contractility ↑ Blood clotting ↑ Metabolism Norepinephrine ↓ Blood to kidney ↑ ReninCotisone Protein catablism GluconeogenesisStage of ResistanceAdaptationShock PhaseStage of Exhaustion ↓ ↓ Rest DeathStage of Exhaustion – the adaptation that the body made during the second stage cannot be maintained; the ways used to cope with the stressors have been exhausted

b. STRESSORS stimulate the sympathetic nervous system, which in turn stimulates the hypothalamus. The HYPOTHALAMUS releases corticotrophin releasing hormone (CRH). During times of stress, the ADRENAL MEDULLA secretes EPINEPHRINE & NOREPINEPHRINE in response to sympathetic stimulation.

Significant body responses to epinephrine include the following: i. Increased myocardial contractility, which increases cardiac output & blood flow to active muscles ii. Bronchial dilation, which allows increased oxygen intakeiii. Increased blood clotting iv. Increased cellular metabolism v. Increased fat mobilization to make energy available & to synthesize other compounds needed by the body.

7. Physiologic Indicators of Stressa. Pupils dilate to increase visual perception when serious threats to the body arise. b. Sweat production (diaphoresis) increases to control elevated body heat due to increased metabolism. c. The heart rate & cardiac output increase to transport nutrients and by-products of metabolism more efficiently. d. Skin is pallid because of constriction of peripheral vessels, an effect of norepinephrine. e. Sodium & water retention increase due to release of mineralocorticoids, which results in increased blood volume. f. The rate & depth of respirations increase because of dilation of the bronchioles, promoting hyperventilation. g. Urinary output may increase or decreases. h. The mouth may be dry. i. Peristalsis of the intestines decreases, resulting in possible constipation and flatus. j. For serious threats, mental alertness improves. k. Muscle tension increases to prepare for rapid motor activity or defense. l. Blood sugar increases because of release of glucocorticoids & gluconeogenesis.

8. Psychologic Indicators – psychologic manifestations of stress include anxiety, fear, anger, depression & unconscious ego defense mechanisms.

a. Anxiety – a common reaction to stress. It is a state of mental uneasiness, apprehension, dread, or foreboding or a feeling of helplessness related to an impending or anticipated unidentified threat to self or significant relationships. It can be experienced, subcutaneous or unconscious level. Can be manifested on 4 LEVELS: b. Fear – an emotion or feeling of apprehension aroused by impending or seeming danger, or other perceived threat. The object of fear may or may not be based in reality.

c. Anger – an emotional state consisting of a subjective feeling of animosity or strong

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displeasure. People may feel guilty when they feel anger because they have been taught that to feel angry is wrong. d. Depression – common reaction to events that seem overwhelming or negative. It is an extreme feeling of sadness, despair, dejection, lack of worth or emptiness.

Emotional symptoms can include: Feelings of tiredness, sadness, emptiness, or numbness Behavioral signs include: Irritability, inability to concentrate, difficulty making decisions, loss of sexual desire, crying, sleep disturbance and social withdrawal.

Physical signs include: Loss of appetite, weight loss, constipation, headache and dizziness

I. Cognitive Indicators – are thinking responses that include problem-solving, structuring, self-control or self-discipline, suppression and fantasya. Problem solving – involves thinking through the threatening situation, using a specific steps to arrive at a solution b. Structuring – arrangement or manipulation of a situation so that threatening events do not occur.c. Self-Control (discipline) – assuming a manner of facial expression that convey a sense of being in control or in change. d. Suppression – consciously and willfully putting a thought or feeling out of mind e. Fantasy – (daydreaming) – likened to make believe. Unfulfilled wishes & desires are imagined as fulfilled, or a threatening experience is reworked or replayed so that it ends differently from reality.

2. COPING STRATEGIES (COPING MECHANISMS) 3.

Coping – dealing with problems & situations or contending with them successfully. Coping Strategy – innate or acquired way of responding to a changing environment or specific problem or situation. According to Folkman and Lazarus, coping is “the cognitive & behavioral effort to manage specific external and/ or internal demands that are appraised as taxing or exceeding the resources of the person”.

1. Coping Strategies: 2 TypesI. Problem-focused coping – efforts to improve a situation by making changes or taking some action II. Emotion-focused coping – does not improve the situation, but the person often feels better.

Coping strategies are also viewed as: a. Long-term coping strategies – can be constructive & realistic b. Short-term coping strategies – can reduce stress to a tolerable limit temporarily but are in the end od ineffective ways to deal with reality.

Coping can be adaptive or maladaptive:

B. Adaptive Coping – helps the person to deal effectively with stressful events & minimizes distress associated with them. C. Maladaptive Coping – can result in unnecessary distress for the person & others associated with the person or stressful event.

*Effective coping results in adaptation; ineffective coping results in maladaptation. The effectiveness of an individual’s coping is influenced by a number of factors: · The number, duration & intensity of the stressors · Past experiences of the individual · Support systems available to the individual · Personal qualities of the person

*If the duration of the stressors is extended beyond the coping powers of the individual,

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that person becomes exhausted and may develop increased susceptibility to health problems. *Reaction to long term stress is seen in family members who undertake the care of a person in the home for a long period. This stress is called caregiver burden & produces responses such as chronic fatigue, sleeping difficulties & high BP. *Prolonged stress can also result in mental illness.

4. Relaxation Techniques – used to quiet the mind, release tension & counteract the fight or flight responses of General Adaptation Syndrome (GAS).

I. Breathing Exercises II. MassageIII. Progressive RelaxationIV. Imagery V. Biofeedback VI. Yoga VII. Meditation VIII. Therapeutic Touch IX. Music Therapy X. Humor & Laughter

3. PSYCHOLOGICAL RESPONSEExposure to a stressor results in psychological and physiological and physiological adaptive responses. As people are exposed a stressors, their ability to meet their basic needs is threatened. This threat whether actual or perceived, produces frustration, anxiety and tension. Psychological adaptive behaviors assist the person’s ability to cope with stressors. These behaviors are directed at stress management and are acquired through learning and experience as a person identifies acceptable and successful behaviors. Psychological adaptive behaviors are also related to as COPING MECHANISMS. It involves:

1. Task – Oriented Behaviors – Involve using cognitive abilities to reduce stress, solve problems, resolve conflicts and gratify needs. It enables a person to cope realistically with the demands of a stressor.

Three General Types I. Attack Behavior – Is acting to remove or overcome a stressor or to satisfy a need II. Withdrawal Behavior – Is removing the self physically or emotionally from the stressor

III. Compromise Behavior – Is changing the usual method of operating, substituting goals or omitting the satisfaction of needs to meet other needs or to avoid stress.

2. Defense Mechanisms – Unconscious behaviors that offer psychological protection from a stressful event. They are used by everyone and help protect against feelings of worthlessness and anxiety. Frequently activated by short-term stressors and usually do not result in psychiatric disorders.

4. TYPES OF NURSING DIAGNOSES

1. Formulating the Nursing Diagnosis I. Actual a. Clients demonstrates defining characteristics of a problem b. Nurse intervenes to resolve or help client cope with the problem

II. High-risk a. A problem is likely to develop based on assessment of risk factors b. Nurse intervenes to reduce risk factors or increase protective factors c. Example: encourage smoking cessation

III. Wellness

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a. Client is presently healthy but wishes to achieve a higher level of function b. Nurse intervenes to promote growth or maintenance of the healthy response

2. Collaborative Problems

I. Definition: a potential problem the nurse manages using both independent and interdependent interventionsII. Example: potential complication of head injury: loss of consciousness, epidural or subdural hematoma, seizures III. Usually occurs when a disease is present or a treatment is prescribed IV. Clients with similar disease or treatment will have the same potential for complications, which must be managed collaboratively; however, their responses to the condition will vary, so a broad range of nursing diagnoses will apply. a. Example: a client with asthma will always be at risk for lowered oxygen saturation; however, the client’s response to this condition will be unique based on his/her developmental level, past experiences and family configuration b. Refer to Table for examples of collaborative problemsExample: Disease/Situation Complication Related to EtiologyPotential complication of childbirth Potential complication of diuretic therapy

Hemorrhage Dysrhythmia

Related to Related to

1.Uterine atony 2. Retained placental fragment 3. Bladder distention Low serum potassium

5. METHODS USED for ASSESSMENT

1. Collaboration of Data: Objective & Subjective

I. Review of clinical record a. Client records contain information collected by many members of the healthcare team, such as demographics, past medical history, diagnostic test results and consultations b. Reviewing the client’s record before beginning an assessment prevents the nurse from repeating questions that the client has already been asked and identifies information that needs clarification.

II. Interview a. The purpose of an interview is to gather and provide information, identify problems of concerns, and provide teaching and support. b. The goals of an interview are to develop a rapport with the client and to collect data c. An interview has 3 major stages

i. Opening: purpose is to establish rapport by creating goodwill and trust; this is often achieved through a self – introduction, nonverbal gestures (a handshake), and small talk about the weather, local sports team, or recent current event; the purpose of the interview is also explained to the client at this time. ii. Body: during this phase, the client responds to open and closed-ended questions asked by the nurse. iii. Closing: either the client or the nurse may terminate the interview, it is important fro the nurse to try to maintain the rapport and trust that was developed thus far during the interview process. d. Types of questions

i. Closed questions used in directive interview Ø Re____ short factual answers; e.g. “Do you have pain?” Ø Answers usually reveal limited amounts of information

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Ø Useful with clients who are highly stressed and/or have difficulty communicating

ii. Open-ended questions used in nondirective interview Ø Encourage clients to express and clarify their thoughts and feelings; e.g. “How have you been sleeping lately?’ Ø Specify the broad area to be discussed and invite longer answers Ø Useful at the start of an interview or to change the subject

iii. Leading questions Ø Direct the client’s answer; e.g. “You don’t have any questions about your medications, do you?”Ø Suggests what answer is expected Ø Can result in client giving inaccurate data to please the nurse Ø Can limit client choice of topic for discussion

III. Nursing History a. Collection of information about the effect of the client’s illness on daily functioning and ability to cope with the stressor (the human response) b. Subjective data i. May be called “covert data” ii. Not measurable or observable iii. Obtained from client (primary source), significant others, or health professionals (secondary sources). iv. For example, the client states, “I have a headache” c. Objective data i. May be called “overt data”ii. Can be detected by someone other than the client iii. Includes measurable and observable client behavior iv. For example, a blood pressure reading of 190/110 mmHg.

IV. Physical assessment a. Systematic collection of information about the body systems through the use of observation, inspection, auscultation, palpation and percussion b. A body system format for physical assessment is found below: · General assessement · Integumentary system · Head, ears, eyes, nose, throat · Breast and axillae · Thorax and lungs · Cardiovascular system · Nervous system · Abdomen and gastrointestinal system · Anus and rectum · Genitourinary system · Reproductive system · Musculoskeletal systemV. Psychosocial assessment a. Helpful framework for organizing data

b. A suggested format for psychosocial assessment is found below: · Vocation/education/financial · Home and Family · Social, leisure, spiritual and cultural· Sexual· Activities of daily living · Health Habits · Psychological

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c. The developmental of Erickson, Freud, Havighurst, Kohlberg and Piaget may also be helpful for guiding data collection

VI. Consultation a. The nurse collects data from multiple sources: primary (client) and secondary (family members, support persons, healthcare professionals and records) b. Consultation with individuals who can contribute to the client’s database is helpful in achieving the most complete and accurate information about a client c. Supplemental information from secondary sources (any source other then the client) can help verify information, provide information for a client who cannot do so, and convey information about the client’s status prior to admission

VII. Review of literature a. A professional nurse engages in continued education to maintain knowledge of current information related to health care b. Reviewing professional journals and textbooks can help provide additional data to support or help analyze the client database

6. DOCUMENTING and REPORTING 1. Guidelines for Good Documentation and Reporting

I. Fact – information about clients and their care must be factual. A record should contain descriptive, objective information about what a nurse sees, hears, feels and smells

II. Accuracy – information must be accurate so that health team members have confidence in it

III. Completeness – the information within a record or a report should be complete, containing concise and thorough information about a client’s care. Concise data are easy to understand

IV. Currentness – ongoing decisions about care must be based on currently reported information. At the time of occurrence include the following: a. Vital signs b. Administration of medications and treatments c. Preparation of diagnostic tests or surgery d. Change in status e. Admission, transfer, discharge or death of a client f. Treatment fro a sudden change in status

V. Organization – the nurse communicate in a logical format or order

VI. Confidentiality – a confidential communication is information given by one person to another with trust and confidence that such information will not be disclosed

2. Documentation – anything written or printed that is relied on as a record of proof fro authorized persons.

Purposes of Records:I. Communication II. Planning Client Care III. Auditing Health Agencies IV. Research V. Education VI. Reimbursement VII. Legal Documentation

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VIII. Health Care Analysis

3. Documentation SystemsI. Source – Oriented Recorda. The traditional client record b. Each person or department makes notations in a separate section or sections of the client’s chart c. It is convenient because care providers from each discipline can easily locate the forms on which to record data and it is easy to trace the information d. Example: the admissions department has an admission sheet; the physician has a physician’s order sheet, a physician’s history sheet & progress notes e. NARRATIVE CHARTING is a traditional part of the source-oriented record

II. Problem – Oriented Medical Record (POMR) a. Established by Lawrence Weed b. The data are arranged according to the problems the client has rather than the source of the information.

The four (4) basic components: i. Database – consists of all information known about the client when the client first enters the health care agency. It includes the nursing assessment, the physician’s history, social & family data ii. Problem List – derived from the database. Usually kept at the front of the chart & serves as an index to the numbered entries in the progress notes. Problems are listed in the order in which they are identified & the list is continually updated as new problems are identified & others resolved iii. Plan of Care – care plans are generated by the person who lists the problems. Physician’s write physician’s orders or medical care plans; nurses write nursing orders or nursing care plansiv. Progress Notes – chart entry made by all health professionals involved in a client’s care; they all use the same type of sheet fro notes. Numbered to correspond to the problems on the problem list and may be lettered for the type of data

Example: SOAP Format Or SOAPIE and SOAPIER S – Subjective data O – Objective data A – Assessment P – Plan I – Intervention E – Evaluation R- Revision Advantages of POMR: § It encourages collaboration § Problem list in the front of the chart alerts caregivers to the client’s needs & makes it easier to track the status of each problem. Disadvantages of POMR: § Caregivers differ in their ability to use the required charting format

§ Takes constant vigilance to maintain an up-to-date problem list § Somewhat inefficient because assessments & interventions that apply to more than one problem must be repeated.

III. PIE (Problems, Interventions, and Evaluation) a. Groups information in to three (3) categories b. This system consists of a client care assessment floe sheet & progress notes c. FLOW SHEET – uses specific assessment criteria in a particular format, such as human needs or functional health patterns d. Eliminate the traditional care plan & incorporate an ongoing care plan into the progress notes

IV. Focus Charting a. Intended to make the client & client concerns & strengths the focus of care b. Three (3) columns fro recording are usually used: date & time, focus & progress notes

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V. Charting by Exception a. Documentation system in which only abnormal or significant findings or exceptions to norms are recorded b. Incorporates three (3) key elements:i. Flow sheets ii. Standards of nursing careiii. Bedside access to chart forms

VI. Computerized Documentation a. Developed as a way to manage the huge volume of information required in contemporary health care b. Nurses use computers to store the client’s database, add new data, create & revise care plans & document client progress.

VII. Case Management a. Emphasizes quality, cost-effective care delivered within an established length of stay b. Uses a multidisciplinary approach to planning & documenting client care, using critical pathways.

4. Nursing Care Plan (NCP)Two Types: I. Traditional Care Plan – written fro each client; it has 3 columns: nursing diagnoses, expected outcomes & nursing interventions.II. Standardized Care Plan – based on an institution’s standards of practice; thereby helping to provide a high quality of nursing care

5. KARDEX widely used, concise method of organizing & recording data about a client, making information quickly accessible to all health professionals. Consists of a series of cards kept in a portable index file or on computer generated forms. Information may be organized into sections:

I. Pertinent information about the clientII. List of medications III. List of IVF IV. List of daily treatments & proceduresV. List of Diagnostic procedures VI. Allergies VII. Specific data on how the client’s physical needs are to be met VIII. A problem list, stated goals & list of nursing approaches to meet the goals

6. Nursing Discharge / Referral Summaries – completed when the client is being discharged & transferred to another institution or to a home setting where a visit by a community health nurse is required. Regardless of format, it include some or all of the following:

I. Description of client’s physical, mental & emotional stateII. Resolved health problemsIII. Unresolved continuing health problems IV. Treatments that can be continued (e.g. wound care, oxygen therapy) V. Current medications VI. Restrictions that relate to activity, diet & bathingVII. Functional/self-care abilitiesVIII. Comfort level IX. Support networks X. Client education provided in relation to disease process XI. Discharge destination

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XII. Referral Services (e.g. social worker, home health nurse)

7. PHYSICAL EXAMINATION 8.

1. PurposesThe nurse uses physical assessment for the following reasons: I. To gather baseline data about the client’s healthII. To supplement, confirm or refute data obtained in the nursing historyIII. To confirm and identify nursing diagnosesIV. To make clinical judgments about a client’s changing health status and management

2. Preparation of ExaminationI. Environment – A physical examination requires privacy. An examination room that is well equipped for all necessary procedures is preferable II. Equipment – Hand washing is done before equipment preparation and the examination. Hand washing reduces the transmission of microorganisms III. Client a. Psychological Preparation – clients are easily embarrassed when forced to answer sensitive questions about bodily functions or when body parts are exposed and examined. The possibility that the examination will find something abnormal also creates anxiety so reduction of this anxiety may be the nurse’s highest priority before the examination b. Physical Preparation – the client’s physical comfort is vital to the success of the examination. Before starting, the nurse asks if the client needs to use the toilet. c. Positioning – during the examination, the nurse asks the clients to assume proper positions so that body parts are accessible and clients stay comfortable. Client’s abilities to assume positions will depend on their physical strength and degree of wellness.

3. Order of ExaminationI. General Survey – includes observation of general appearance and behavior, vital signs, height and weight measurementII. Review of systems III. Head to toe examination

4. Skills in Physical Examination

I. Inspection – to detect normal characteristics or significant physical signs. To inspect body parts accurately the nurse observes the following principles: a. Make sure good lighting is available b. Position and expose body parts so that all surface can be viewed c. Inspect each areas fro size, shape, color, symmetry, position and abnormalities d. If possible, compare each area inspected with the same area of the opposite side of the bodye. Use additional light (for example, a penlight) to inspect body cavities

II. Palpation – the hands can make delicate and sensitive measurements of specific physical signs, so palpation is used to examine all accessible parts of the body. The nurse uses different parts of the hand to detect characteristics such as texture, temperature and the perception of movement.

III. Percussion – examination by striking the body’s surface with a finger, vibration and sound are produced. This vibration is transmitted through the body tissues and the character of the sound depends on the density of the underlying tissue

IV. Auscultation – is listening to sound created in body organs to detect variations from normal. Some sounds can be heard with the unassisted ear, although most sounds can be heard only through a stethoscope.

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a. Bowel sounds b. Breath soundsi. Vesicularii. Bronchovesiculariii. Bronchial

5. Examples of Adventitious Breath SoundsI. Crackles (previously called rales) II. RhonchiIII. Wheeze IV. Friction rub

Therapeutic Communication Techniques 1. Using silence 2. Providing general leads 3. Being specific & tentative 4. Using open-ended questions 5. Using touch 6. Restating to paraphrasing 7. Seeking clarification 8. Perception checking or seeking consensual validation 9. Offering self 10. Giving information 11. Acknowledging 12. Clarifying time or sequence 13. Presenting reality 14. Focusing 15. Reflecting 16. Summarizing & planning

B. Barriers to Communication 1. Stereotyping 2. Agreeing & disagreeing 3. Being defensive 4. Challenging 5. Probing 6. Testing 7. Rejecting8. Changing topics & subjects 9. Unwarranted reassurance 10. Passing judgment 11. Giving common advice

Phases of the Helping Relationship

1. Pre-interaction Phase

2. Introductory Phase a. Opening the relationship b. Clarifying the problem c. Structuring & formulating the contract

3. Working Phase a. Exploring & understanding thoughts or feelings b. Facilitating & taking action

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4. Termination Phase

8. PRINCIPLES of ASEPSIS and INFECTION CONTROL

1. Chain of InfectionI. The chain of infection refers to those elements that must be present to cause an infection from a microorganismII. Basic to the principle of infection is to interrupt this chain so that an infection from a microorganism does not occur in clientsIII. Infectious agent; microorganisms capable of causing infections are referred to as an infectious agent or pathogen. IV. Modes of transmission: the microorganism must have a means of transmission to get from one location to another, called direct and indirect V. Susceptible host describes a host (human or animal) not possessing enough resistance against a particular pathogen to prevent disease or infection from occurring when exposed to the pathogen; in humans this may occur if the person’s resistance is low because of poor nutrition, lack of exercise of a coexisting illness that weakens the host. VI. Portal of entry: the means of a pathogen entering a host: the means of entry can be the same as one that is the portal of exit (gastrointestinal, respiratory, genitourinary tract). VII. Reservoir: the environment in which the microorganism lives to ensure survival; it can be a person, animal, arthropod, plant, oil or a combination of these things; reservoirs that support organism that are pathogenic to humans are inanimate objects food and water, and other humans. VIII. Portal of exit: the means in which the pathogen escapes from the reservoir and can cause disease; there is usually a common escape route for each type of microorganism; on humans, common escape routes are the gastrointestinal, respiratory and the genitourinary tract.

Modes of Transmission 1. Direct contact: describes the way in which microorganisms are transferred from person to person through biting, touching, kissing, or sexual intercourse; droplet spread is also a form of direct contact but can occur only if the source and the host are within 3 feet from each other; transmission by droplet can occur when a person coughs, sneezes, spits, or talks. 2. Indirect contact: can occur through fomites (inanimate objects or materials) or through vectors (animal or insect, flying or crawling); the fomites or vectors act as vehicle for transmission 3. Air: airborne transmission involves droplets or dust; droplet nuclei can remain in the air for long periods and dust particles containing infectious agents can become airborne infecting a susceptible host generally through the respiratory tract

2. Course of InfectionI. Incubation: the time between initial contact with an infectious agent until the first signs of symptoms - - > the incubation period varies from different pathogens; microorganisms are growing and multiplying during this stageII. Prodromal Stage: the time period from the onset of nonspecific symptoms to the appearance of specific symptoms related to the causative pathogen - - > symptoms range from being fatigued to having a low-grade fever with malaise; during this phase it is still possible to transmit the pathogen to another hostIII. Full Stage: manifestations of specific signs & symptoms of infectious agent; referred to as the acute stage; during this stage, it may be possible to transmit the infectious agent to another, depending on the virulence of the infectious agent IV. Convalescence : time period that the host takes to return to the pre-illness stage; also called the recovery period; - - >the host defense mechanisms have responded to the infectious agent and the signs and symptoms of the disease disappear; the host,

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however, is more vulnerable to other pathogens at this time; an appropriate nursing diagnostic label related to this process would be Risk for Infection

3. Inflammation – The protective response of the tissues of the body to injury or infection; the physiological reaction to injury or infection is the inflammatory response; it may be acute or chronic

Body’s responseI. The “inflammatory response” begins with vasoconstriction that is followed by a brief increase in vascular permeability; the blood vessels dilate allowing plasma to escape into the injured tissueII. WBCs (neutrophils, monocytes, and macrophages) migrate to the area of injury and attack and ingest the invaders (phagocytosis); this process is responsible for the signs of inflammation III. Redness occurs when blood accumulates in the dilated capillaries; warmth occurs as a result of the heat from the increased blood in the area, swelling occurs from fluid accumulation; the pain occurs from pressure or injury to the local nerves.

4. Immune ResponseI. The immune response involves specific reactions in the body to antigens or foreign material

II. This specific response is the body’s attempt to protect itself, the body protects itself by activating 2 types of lymphocytes, the T-lymphocytes and B-lymphocytes

III. Cell mediated immunity: T-lymphocytes are responsible for cellular immunity a. When fungi , protozoa, bacteria and some viruses activate T-lymphocytes, they enter the circulation from lymph tissue and seek out the antigen b. Once theantigen is found they produce proteins (lymphokines) that increase the migration of phagocytes to the area and keep them there to kill the antigen c. After the antigen is gone, the lymphokines disappear d. Some T-lymphocytes remain and keep a memory of the antigen and are reactivated if the antigen appears again.

IV. Humoral response: the ability of the body to develop a specific antibody to a specific antigen (antigen-antibody response)a. B-lymphocytes provide humoral immunity by producing antibodies that convey specific resistance to many bacterial and viral infections b. Active immunity is produced when the immune system is activated either naturally or artificially.i. Natural immunity involves acquisition of immunity through developing the disease ii. Active immunity can also be produced through vaccination by introducing into the body a weakened or killed antigen (artificially acquired immunity) iii. Passive immunity does not require a host to develop antibodies, rather it is transferred to the individual, passive immunity occurs when a mother passes antibodies to a newborn or when a person is given antibodies from an animal or person who has had the disease in the form of immune globulins; this type of immunity only offers temporary protection from the antigen.

5. Nosocomial InfectionI. Nosocomial Infections: are those that are acquired as a result of a healthcare delivery system II. Iatrogenic infection: these nosocomial infections are directly related to the client’s treatment or diagnostic procedures; an example of an iatrogenic infection would be a bacterial infection that results from an intravascular line or Pseudomonas aeruginosa pneumonia as a result of respiratory suctioningIII. Exogenous Infection: are a result of the healthcare facility environment or personnel; an example would be an upper respiratory infection resulting from contact with a caregiver who has an upper respiratory infection

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IV. Endogenous Infection: can occur from clients themselves or as a reactivation of a previous dormant organism such as tuberculosis; an example of endogenous infection would be a yeast infection arising in a woman receiving antibiotic therapy; the yeast organisms are always present in the vagina, but with the elimination of the normal bacterial flora, the yeast flourish.

6. Factors Increasing Susceptibility to Infection

I. Age: young infants & older adults are at greater risk of infection because of reduced defense mechanisms a. Young infants have reduced defenses related to immature immune systems b. In elderly people, physiological changes occur in the body that make them more susceptible to infectious disease; some of these changes are:i. Altered immune function (specifically, decreased phagocytosis by the neutrophils and by the macrophages) ii. Decreased bladder muscle tone resulting in urinary retention iii. Diminished cough reflex, loss of elastic recoil by the lungs leading to inability to evacuate normal secretionsiv. Gastrointestinal changes resulting in decreased swallowing ability and delayed gastric emptying.

II. Heredity: some people have a genetic predisposition or susceptibility to some infectious diseases

III. Cultural practices: healthcare beliefs and practices, as well as nutritional and hygiene practices, can influence a person’s susceptibility to infectious diseases

IV. Nutrition: inadequate nutrition can make a person more susceptible to infectious diseases; nutritional practices that do not supply the body with the basic components necessary to synthesized proteins affect the way the body’s immune system can respond to pathogens

V. Stress: stressors, both physical and emotional, affect the body’s ability to protect against invading pathogens; stressors affect the body by elevating blood cortisone levels; if elevation of serum cortisone is prolonged, it decreases the anti-inflammatory response and depletes energy stores, thus increasing the risk of infection

VI. Rest, exercise and personal health habits: altered rest and exercise patterns decrease the body’s protective, mechanisms and may cause physical stress to the body resulting in an increased risk of infection; personal health habits such as poor nutrition and unhealthy lifestyle habits increase the risk of infectious over time by altering the body’s response to pathogens

VII. Inadequate defenses: any physiological abnormality or lifestyle habit can influence normal defense mechanisms in the body, making the client more susceptible to infection; the immune system functions throughout the body and depends on the following: a. Intact skin and mucous membranes b. Adequate blood cell production and differentiation c. A functional lymphatic system and spleend. An ability to differentiate foreign tissue and pathogens from normal body tissue and flora; in autoimmune disease, the body has a problem with recognizing it’s own tissue and cells; people with autoimmune disease are at increased risk of infection related to their immune system deficiencies.

VIII. Environmental: an environment that exposes individuals to an increased number of toxins or pathogens also increases the risk of infection; pathogens grow well in warm

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moist areas with oxygen (aerobic) or without oxygen (anaerobic) depending on the microorganism, an environment that increases exposure to toxic substances also increases risk

IX. Immunization history: inadequately immunized people have an increased risk of infection specifically for those diseases for which vaccines have been developed.

X. Medications and medical therapies: examples of therapies and medications that increase clients risk for infection includes radiation treatment, anti-neo-plastic drugs, anti inflammatory drugs and surgery

7. Diagnostic Tests Used to Screen for InfectionI. Signs and symptoms related to infections are associated with the area infected; for instance, symptoms of a local infection on the skin or mucous membranes are localized swelling, redness, pain and warmth II. Symptoms related to systemic infections include fever, increased pulse & respirations, lethargy, anorexia, and enlarged lymph nodes III. Certain diagnostic tests are ordered to confirm the presence of an infection.

9. THEORIES OF PAIN 1. Specific Theory

I. Proposes that body’s neurons & pathways for pain transmission are specific, similar to other senses like tasteII. Free nerve endings in the skin act as pain receptors, accept input & transmit impulses along highly specific nerve fibersIII. Does not account for differences in pain perception or psychologic variables among individuals.

2. Pattern Theory I. Identifies 2 major types of pain fibers; rapidly & slowly conductingII. Stimulation of these fibers forms a pattern; impulses ascend to the brain to be interpreted as painfulIII. Does not account for differences in pain perception or psychologic variables among individuals.

3. Gate Control Theory I. Pain impulses can be modulated by a transmission blocking action within the CNS. II. Large-diameter cutaneous pain fibers can be stimulated (e.g. rubbing or scratching an area) and may inhibit smaller diameter fibers to prevent transmission of the impulse (“close the gate”).

4. Current Developments in Pain Theory – Indicate that pain mechanisms & responses are far more complex than believed to be in the past.

I. Pain may modulated at different points in the nervous system. a. First-order neurons at the tissue level b. Second-order neurons in the spinal cord that process nociceptor information c. Third-order tracts & pathways in the spinal cord & brain that relay/process this information

II. The role of the pain experience in the development of new nociceptors and/or reducing the threshold of current nociceptor is also being investigate

10.TYPES OF PAIN 1. Acute Pain

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I. Usually temporary, sudden in onset, localized, lasts for 6 months; results from tissue injury associated with trauma, surgery, or inflammation. Types of Acute Pain a. Somatic: arises from nerve receptors in the skin or close to body’s surface; may be sharp & well-localized or dull & diffuse; often accompanied by nausea & vomiting b. Visceral: arises from body’s organs; dull & poorly localized because of minimal noriceptors; accompanied by nausea & vomiting, hypotension & restlessness c. Referred pain: pain that is perceived in an area distant from the site of stimuli (e.g. pain in a shoulder following abdominal laparoscopic procedure).

II. Acute pain initiates the “fight-or-flight” response of the Autonomic Nervous System and is characterized by the following symptoms: a. Tachycardia b. Rapid, shallow respirations c. Increased BP d. Sweating e. Pallor f. Dilated pupils g. Fear & Anxiety

2. Chronic Pain I. Prolonged, lasting longer than 6 months, often not attributed to a definite cause, often unresponsive to medical treatment. Types of Chronic Pain a. Neuropathic: painfuil condition that results from damage to peripheral nerves caused by infection or disease; post-therapeutic neuralgia (shingles) is an example

b. Phantom: pain syndrome that occurs following surgical or traumatic amputation of a limb.i. The client is aware that the body part is missingii. Pain may result of stimulation of severed nerves at the site of amputationiii. Sensation may be experienced as an itching, pressure, or as stabbing or burning in nature iv. It can be triggered by stressors (fatigue, illness, emotions, weather) v. This experience is limited for most clients because the brain adapts to amputated limb; however, some clients experience abnormal sensation or pain over longer periods vi. This type of pain requires treatment just as any other type of pain does.

c. Psychogenic: pain that is experienced in the absence of a diagnosed physiologic cause or event; the client’s emotional needs may prompt pain sensation.

II. Depression is a common associated symptom for the client experiencing chronic pain; feelings of despair & hopelessness along with fatigue are expected findings.

11.PAIN ASSESSMENT

1. TOOLS/INTRUMENTS USEDI. A VERBAL REPORT using an intensity scale is a fast, easy & reliable method allowing the client to state pain intensity & in turn, promotes consisted communication among the nurse, client & other healthcare professionals about the client’s pain status; the 2 most common scales used are “0 to 5” or “0 to 10”. With 0 specifying no pain & the highest number specifying the worst pain

II. A VISUAL ANALOG SCALE is a horizontal pain-intensity scale with word modifiers at both ends of the scale, such as “no pain” at one end and “worst pain” at the other, clients are asked to point or mark along the line to convey the degree of pain being experienced

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III. A GRAPHIC RATING SCALE is similar to the visual analog scale but adds a numerical scale with the word modifiers, usually the numbers “0 to 10” are added to the scale.

IV. FACES PAIN SCALE children, clients who do not speak English & clients with communication impairments may have difficulty using a numerical pain intensity scale; the FACES pain scale may be used for children as young as 3 years old; this scale provides facial expressions (happy face reflects no pain, crying face represents worst pain)

V. PHYSIOLOGIC INDICATORS OF PAIN may be the only means a nurse can use to assess pain for a non-communicating client, facial & vocal expression may be the initial manifestations of pain; expressions may include rapid eye blinking, biting of the lip, moaning, crying, screaming, either closed or clenched eyes, or stiff unmoving body position

2. A B C D E method of pain assessmentI. This acronym was developed for cancer pain; however, it is very appropriate for clients with any type of pain, regardless of the underlying disease. II. A = Ask about pain

III. B = Believe the client & family reports pain IV. C = Choose pain control options appropriate for the client V. D = Deliver interventions in a timely, logical &coordinated fashion VI. E = Empower clients & families

3. P Q R S T assessment for pain receptionI. This method is especially helpful when approaching a new pain problemII. P = What precipitated the pain?III. Q = What are the quality & quantity of the pain?IV. R = What is the region of the pain? V. S = What is the severity of the pain? VI. T = What is the timing of the pain?

4. Pain HistoryI. Location – when clients report “pain all over”, this generally refers to total pain or existential distress (unless there is an underlying physiologic reason for pain all over the body, such as myalgias); assess the client’s emotional state for depression, fear, anxiety or hopelessness.

II. Intensity – It is important to quantify pain using a standard pain intensity scale. When clients cannot conceptualize pain using a number, simple word categorizes can be useful (e.g. no pain, mild, moderate, severe).

III. Quality a. Nociceptive pain are usually related to damage to bones, soft tissues, or internal organs; nociceptive pain includes somatic & visceral pains. i. Somatic pain is aching, throbbing pain; example arthritis ii. Visceral pain is squeezing, cramping pain; example: pain associated with ulcerative colitis

IV. Pattern – pain may be always present for a client; this is often termed baseline pain. Additional pain may occur intermittently that is of rapid onset & greater intensity than the baseline pain; known as breakthrough pain. People at end-of-life often have both types of pain. Cultural beliefs regarding the meaning of pain should be examined ADMINISTRATION OF MEDICATIONS

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12.DRUG NOMENCLATURE and FORMS 1. Names

I. Chemical Name – provides an exact description of the drug’s composition. An example of chemical name acetylsalicylic known common as Aspirin II. Generic Name – is given by the manufacturer who first develops the drug before it receives official approval. Protected by law, the generic name is given before a drug receives official publications.III. Official Name – is the name under which drug is listed in official publicationIV. Trade, Brand or Propriety Name – is the name under which a manufacturer markets.

2. Classification – Nurses categorized medications with similar characteristics by their class. Drug classification indicates the effects on a body system, the symptoms relieved or the desired effect. Each class contains drugs prescribed for similar types of health problems. The physical and chemical composition of drugs within a class is not necessarily the same. A drug may also belong to more than one class. For example, aspirin is an analgesic and antipyretic and an anti-inflammatory drug.

3. Forms – Drugs are available in a variety of forms preparations. The form of the drug determines its route o administration. For example, a capsule is taken orally and a solution may be given intravenously. The composition drug is designed to enhance its absorption and metabolism within the body. Many drugs are available in several forms such as tablets, capsules, elixirs and suppositories. When administering a medication, the nurse must be certain to give the metabolism in the proper form.

4. Principles in Administering Medications I. Observe the 7 RIGHTS of Drug Administration: a. Right Drug b. Right Dose c. Right Time d. Right Route e. Right Patient f. Right Recording g. Right Approach

II. Practice asepsis

III. Nurses who administer medications are responsible for their own actions. Question any order that you can consider incorrect.

IV. Be knowledgeable about medications that you administer

V. Keep narcotics & barbiturates in locked place

VI. Use only medications that are in clearly labeled containers

VII. Return liquid that are cloudy or have changed in color to the pharmacy

VIII. Before administering a medication, identify the client correctly

IX. Do not leave the medication at the bedside

X. If the client vomits after taking an oral medication, report this to the nurse in charge and/or physician

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XI. Preoperative medications are usually discontinued during the post operative period unless ordered to be continued

XII. When a medication is omitted for any reason, record the fact together with the reason

XIII. When a medication error is made, report immediately to the nurse in charge and/or physician

13.BASIC HUMAN NEEDS 1. Abraham Maslow – developed the five (5) levels of human needs:

I. Physiologic Needs – needs such as air, food, water, shelter, rest, sleep, activity and temperature maintenance are crucial for survival II. Safety and Security Needs – the need for safety has both physical and physiologic aspects III. Love and Belonging Needs – the third level of needs includes giving and receiving affection, attaining a place in a group and maintaining the feeling of belonging IV. Self-Esteem Needs – the individual needs both self-esteem and esteem from others V. Self-Actualization – when the need for self-esteem is satisfied, the individual strives for self-actualization, the innate need to develop one’s maximum potential and realize one’s abilities and qualities

2. Maslow’s Characteristics of a Self-Actualized PersonI. Is realistic, sees life clearly and is objective about his or her observationsII. Judges people correctlyIII. Has superior perception, is more decisive IV. Has a clear notion of right or wrong V. Is usually accurate in predicting future events VI. Understands art, music, politics and philosophy VII. Possesses humility, listens to others carefully VIII. Is dedicated to some work, task, duty or vocation IX. Is highly creative, flexible, spontaneous, courageous, and willing to make mistakes X. Is open to new ideas XI. Is self-confident and has self-respectXII. Has low degree of self-conflict; personality is integrated XIII. Respect self, does not need fame, possesses a feeling of self-controlXIV. Is highly independent, desires privacy XV. Can appear remote or detached XVI. is friendly, loving and governed more by inner directives than by society XVII. Can make decisions contrary to popular opinion XVIII. Is problem centered rather than self-centeredXIX. Accepts the world for what it is

14.MEETING OXYGENATION NEEDS 1. Oxygenation – a basic human need & is required to sustain life.2. Cardiovascular Physiology – the function of the cardiac system is to

deliver oxygen, nutrients, & other substances to the tissues and to remove the waste products of cellular metabolism

3. Structure and Function – the heart pumps blood through the pulmonary circulation by way of the right ventricle and to the systemic circulation by way of the left ventricle

I. Myocardial Pump – the “pumping action” of the heart is essential to maintain oxygen delivery II. Myocardial Blood Flow – to maintain adequate blood flow to the pulmonary and systemic circulations, myocardial blood flow must sufficiently supply oxygen and nutrients to the myocardium itself III. Coronary Artery Circulation – blood flow to the atria and ventricles does not supply

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oxygen and nutrients to the myocardium itself. It is the branch of the systemic circulation that supplies oxygen and nutrients and removal of waste from the myocardiumIV. Systemic Circulation – the arteries and veins of the systemic circulation deliver nutrients and oxygen and remove wastes from the tissues. Oxygenated blood flows from the left ventricle by way of of the aorta and into the large systemic arteries V. Regulation of Blood Flow – the amount of blood ejected from the left ventricle each minute is the cardiac output. The circulating volume of blood changes according to the oxygen and metabolic needs of the body. For example, during exercise, pregnancy and fever, the cardiac output increases but during sleep, the cardiac output decreases.

4. Steps in the Process of OxygenationI. Ventilation – process by which gases are moved into and out of the lungs. Adequate ventilation requires coordination of the muscular and elastic properties of the lung and thorax and intact innervation. The major inspiratory muscle is the “diaphragm” which is innervated by the “phrenic nerve”.II. Perfusion – the primary function of pulmonary circulation is to move blood to and from the alveolar-capillary membrane so that gas exchange can occur III. Exchange of Respiratory Gases – respiratory gases are exchanged in the alveoli of the lungs and the capillaries of the body tissues a. Diffusion – movement of molecules from an area of higher concentration to an area of lower concentration b. Oxygen Transport – delivery depends on the amount of oxygen entering the lungs (ventilation), blood flow to the lungs & tissues (perfusion), adequacy of diffusion & capacity of the blood to carry oxygen. c. Carbon Dioxide Transport – carbon dioxide diffuses into RBCs and I rapidly hydrated into carbonic acid because of the presence of carbonic hydrase

15.MEETING NUTRITIONAL NEEDS 1. Principles of Nutrition

I. Digestion – process by which food substances are changed into forms that can be absorbed through cell membranes II. Absorption – the taking in of substance by cells or membranesIII. Metabolism – sum of all physical and chemical processes by which a living organism is formed and maintained and by which energy is made available IV. Storage – some nutrients are stored when not used to provide energy; e.g. carbohydrates are stored either as glycogen or as fat V. Elimination – process of discarding unnecessary substances through evaporation, excretion

2. Nutrients

I. Carbohydrates – the primary sources are plant foods Types of Carbohydrates a. Simple (sugars) such as glucose, galactose, and fructose b. Complex such as starches (which are polysaccharides) and fibers (supplies bulk or roughage to the diet)

II. Proteins – organic substances made up of amino acids

III. Lipids – organic substances that are insoluble in water but soluble in alcohol and ether.a. Fatty acids – the basic structural units of all lipids and are either saturated (all the carbon atoms are filled with hydrogen) or unsaturated (could accommodate more hydrogen than it presently contains) b. Food sources of lipids are animal products (milk, egg yolks and meat) and plants and plant products (seeds, nuts, oils)

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IV. Vitamins – organic compounds not manufactured in the body and needed in small quantities to catalyze metabolic processes a. Water-soluble vitamins include C and B-complex vitamins b. Fat-soluble vitamins include A, D, E, and K and these can be stored in limited amounts in the body

V. Minerals – compounds that work with other nutrients in maintaining structure and function of the body a. Macronutrients – calcium, phosphate, sodium, potassium, chloride, magnesium and sulfur b. Micronutrients (trace elements) – iron, iodine, copper, zinc, manganese and fluoride The best sources are vegetables, legumes, milk and some meats

VI. Water – the body’s most basic nutrient need; it serves as a medium for metabolic reactions within cells and a transporter fro nutrients, waste products and other substances

16.MEETING URINARY ELIMINATION NEEDS 1. Normal Urinary Function

I. Normal urine output is 60mL/hr or 1500mL/day; should remain 30 mL/hr to ensure continued normal kidney function II. Urine normally consists of 96% water III. Solutes found in urine include: a. Organic solutes: urea, ammonia, uric acid and creatinine b. Inorganic solutes: sodium, potassium, chloride, sulfate, magnesium & phosphorus

2. Common Assessment FindingsI. Urgency – strong desire to void my be caused by inflammations or infections in the bladder or urethra II. Dysuria – painful or difficult voiding III. Frequency – voiding that occurs more than usual when compared with the person’s regular pattern or the generally accepted norm of voiding once every 3 to 6 hoursIV. Hesitancy – undue delay and difficulty in initiating voiding V. Polyuria – a large volume of urine or output voided at any given time VI. Oliguria – a small volume of urine or output between 100 to 500 mL/24 hr VII. Nocturia – excessive urination at night interrupting sleep VIII. Hematuria – RBCs in the urine

17.URINARY CATHETERIZATIONØ Is the introduction of a catheter through the urethra into the bladder for the purpose of withdrawing urine.

1. PurposesI. To relieve urinary retentionII. To obtain a sterile urine specimen from a woman III. To measure the amount of residual urine in the bladder IV. To obtain a urine specimen when a specimen cannot secure satisfactory by other means V. To empty bladder before and during surgery and before certain diagnostic examinations ***Several BASIC FACTS about the lower urinary tract system should be borne in mind when considering catheterization.

2. Necessary Equipment for CatheterizationØ Catheters are graded on the French scale according to the size of the lumen. For the female adult, No. 14 and No. 16 French catheters are usually used. Small catheters are generally not necessary and the size of the lumen is also so small that it increases the length of time necessary for emptying the bladder.Larger catheter distends the urethra and tends to increase the discomfort of the procedure. For male adult, No.18 and No. 20 French catheters usually used, but if this appears to

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be too large, smaller catheter should be used. No. 8 and No. 10 French catheters are commonly used for children.

3. Preparation of the PatientI. Adequate exploration II. Position – dorsal recumbent for the female and supine for the male using a firm mattress or treatment table, Sim’s or lateral position can be an alternate for the female patient III. Provision for privacy

4. Retention or Indwelling Catheter (Foley) – A catheter to remain in place for the following purposes:

I. The gradual decompression of an over distended bladder II. For intermittent bladder drainage III. For continuous bladder drainage An indwelling catheter has a balloon which is inflated after the catheter is inserted into the bladder. Because the inflated balloon is larger than the opening to the urethra, the catheter is retained in the bladder.

5. Procedure for InsertionI. Inflate the balloon with the prefilled syringe before inserting the catheter to check for balloon patency. Aspirate the fluid back into the syringe when it is determined that the balloon is patent. II. Hold the catheter with one hand and inflate the balloon according to the manufacturer’s instructions, as soon as the catheter is in the bladder and urine has begun to drain from the bladder. Usually 5 ml to 10 ml of sterile water is used III. If the patient complains of pain after the balloon is inflated, allow it to empty and replace the catheter with another one. The balloon is probably located in the urethra and is causing discomfort owing to distention of the urethra IV. Exert slight tension on the catheter after the balloon is inflated to assure its proper placement in the bladder V. Connect the catheter to the drainage tubing and drainage bag if not already connected VI. Tape the catheter along the interior aspect of the thigh fro a female patient. Be sure there is no tension on the catheter when it is taped to the patient VII. Hang the drainage bag on the frame of the bed below the level of the bladder

6. Caring for the Patient with an Indwelling CatheterI. Be sure to wash hands before and after caring for a patient with an indwelling catheter II. Clean the perineal area thoroughly, especially around the meatus, twice a day and after each bowel movement. This helps prevent organisms for entering the bladder III. Use soap or detergent and water to clean the perineal area and rinse the area well IV. Make sure that the patient maintains a generous fluid intake. This helps prevent infection and irrigates the catheter naturally by increasing urinary output V. Encourage the patient to be up and about as ordered VI. Record the patient’s intake and output VII. Note the volume and character of urine and record observations carefully VIII. Teach the patient the importance of personal hygiene, especially the importance of careful cleaning after having bowel movement and thorough washing of hands frequently IX. Report any signs of infection promptly. These include a burning sensation and irritation at the meatus, cloudy urine, a strong odor to the urine, an elevated temperature and chills X. Plan to change indwelling catheters only as necessary. The usual length of time between catheter changes varies and can be anywhere from 5 days to 2 weeks. The less often a catheter is changed, the less the likelihood than an infection will develop

7. Removing the Indwelling Catheter and Aftercare of the PatientI. Be sure the balloon is deflated before attempting to remove the catheter. This may be done by inserting a syringe into the balloon valve or by cutting the balloon valve II. Have the patient take several deep breaths to help him relax while gently removing the catheter. Wrap the catheter in a towel or disposable, waterproof drape III. Clean the area at the meatus thoroughly with antiseptic swabs after the catheter is removed IV. See to it that the patient’s fluid intake is generous and record the patient’s intake and output. Instruct the patient to void into the bedpan or urinal V. Observe the urine carefully for any signs of abnormality VI. Record and report any usual signs such as discomfort, a burning sensation when voiding, bleeding and changes in vital signs, especially the patient’s temperature. Be alert to any signs of infection and report them promptly

18.MEETING BOWEL ELIMINATION NEEDS 1. Factors that influence Bowel Elimination

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I. Age II. Diet III. Position IV. Pregnancy V. Fluid Intake VI. Activity VII. Psychological VIII. Personal Habits IX. Pain X. Medications XI. Surgery/Anesthesia

2. Characteristics of Normal StoolI. Color – varies from light to dark brown foods & medications may affect color II. Odor – aromatic, affected by ingested food and person’s bacterial flora III. Consistency – formed, soft, semi-solid; moist IV. Frequency – varies with diet (about 100 to 400 g/day) V. Constituents – small amount of undigested roughage, sloughed dead bacteria and epithelial cells, fat, protein, dried constituents of digestive juices (bile pigments); inorganic matter (calcium, phosphates)

3. Common Bowel Elimination ProblemsI. Constipation – abnormal frequency of defecation and abnormal hardening of stools II. Impaction – accumulated mass of dry feces that cannot be expelled III. Diarrhea – increased frequency of bowel movements (more than 3 times a day) as well as liquid consistency and increased amount; accompanied by urgency, discomfort and possibly incontinence IV. Incontinence – involuntary elimination of feces V. Flatulence – expulsion of gas from the rectum VI. Hemorrhoids – dilated portions of veins in the anal canal causing itching and pain and bright red bleeding upon defecation.

19.TYPES OF ENEMAS 1. Cleansing Enemas: Stimulate peristalsis through irrigation of colon and

rectum and by distentionI. Soap Suds: Mild soap solutions stimulate and irritate intestinal mucosa. Dilute 5 ml of castile soap in 1000 ml of waterII. Tap water: Give caution o infants or to adults with altered cardiac and renal reserveIII. Saline: For normal saline enemas, use smaller volume of solutionIV. Prepackaged disposable enema (Fleet): Approximately 125 cc, tip is pre-lubricate and does not require further preparation

2. Oil-Retention Enemas: Lubricates the rectum and colon; the feces absorb the oil and become softer and easier to pass

3. Carminative Enema: Provides relief from gaseous distention

4. Astringent Enema: Contracts tissue to control bleedingKey Points: Administering Enema I. Fill water container with 750 to 1000 cc of lukewarm solution, (500 cc or less for children, 250 cc or less fro an infant), 99 degrees F to 102 degrees F. Solutions that are too hot or too cold, or solutions that are instilled too quickly, can cause cramping and damage to rectal tissues II. Allow solution to run through the tubing so that air is removedIII. Place client on left side in Sim’s position IV. Lubricate the tip of the tubing with water-soluble lubricant V. Gently insert tubing into client’s rectum (3 to 4 inches for adult, 1 inch for infants, 2 to 3 inches for children), past the external and internal sphincters VI. Raise the water container no more than 12 to 18 inches above the client VII. Allow solution to flow slowly. If the flow is slow, the client will experience fewer cramps. The client will also be able to tolerate and retain a greater volume of solution VIII. After you have instilled the solution, instruct client to hold solution for about 10 to 15 minutesIX. Oil retention: enemas should be retained at least 1 hour. Cleansing enemas are retained 10 to 15 minutes.

20.NASOGASTRIC and INTESTINAL TUBES

1. Nasogastric TubesI. Levin Tube – single lumen a. Suctioning gastric contents b. Administering tube feedingsII. Salem Sump Tube – double lumen (smaller blue lumen vents the tube & prevents

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suction on the gastric mucosa, maintains intermittent suction regardless of suction source) a. Suctioning gastric contents b. Maintaining gastric decompression Key Points: a. Prior to insertion, position the client in High-Fowler’s position if possible. b. Use a water-soluble lubricant to facilitate insertion c. Measure the tube from the tip of the client’s nose to the earlobe and from the nose to the xiphoid process to determine the approximate amount of tube to insert to reach the stomach d. Flex the client’s head slightly forward; this will decrease the chance of entry into the trachea e. Insert the tube through the nose into the nasopharyngel area; ask the client to swallow, and as the swallow occurs, progress the tube past the area of the trachea and into the esophagus and stomach. Withdraw tube immediately if client experiences respiratory distress f. Secure the tube to the nose; do not allow the tube to exert pressure on the upper inner portion of the nares g. Validating placement of tube. · Aspirate gastric contents via a syringe to the end of the tube · Measure ph of aspirate fluid · Place the stethoscope over the gastric area and inject a small amount of air through the NGT. A characteristic sound of air entering the stomach from the tube should be heard h. Characteristics of nasogastric drainage: · Normally is greenish-yellowish, with strands of mucous · Coffee-ground drainage – old blood that has been broken down in the stomach · Bright red blood – bleeding from the esophagus, the stomach or swallowed from the lungs · Foul-smelling (fecal odor) – occurs with reverse peristalsis in bowel obstruction; increase in amount of drainage with obstruction

2. Intestinal Tubes – provide intestinal decompression proximal to a bowel obstruction. Prevent/decrease intestinal distention. Placement of a tube containing a mercury weight and allowing normal peristalsis to propel tube through the stomach into the intestine to the point of obstruction where decompression will occur

I. Types of Intestinal Tubes a. Cantor and Harris Tubes i. Approximately 6-10 feet longii. Single lumeniii. Mercury placed in rubber bag prior to tube insertion b. Miller-Abbot Tubes i. Approximately 10 feet long ii. Double lumen iii. One lumen utilized for aspiration of intestinal contents iv. Second lumen utilized to instill mercury into the rubber bag after the tube has been inserted into the stomach

II. Nursing Implications a. Maintain client on strict NPO b. Initial insertion usually done by physician and progression of the tube may be monitored via an X-ray c. After the tube has been placed in the stomach, position client on the right side to facilitae passage through the pyloric valve d. Advance the tube 2 to 4 inches at regular intervals as indicated by the physician e. Encourage activity, to facilitate movement of the tube through the intestine f. Evaluate the type of gastric secretions being aspirated g. Do not tape or secure the tube until it has reached the desired position h. Tubes may attached to suction and left in place for several daysi. Offer the client frequent oral hygiene, if possible offer hard candy or gum to reduce thirst j. Removal of the tube depends on the relief of the intestinal obstruction

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i. May be removed by gradual pulling back (4-6 inches per hour) and eventual removal via the nose or mouthii. May be allowed to progress through the intestines and expelled via the rectum.

21.LOSS AND GRIEFLoss – absence of an object, person, body part, emotion, idea or function that was valued I. Actual loss is identified and verified by others II. Perceived Loss cannot be verified by others III. Maturational Loss occurs in normal development IV. Situational Loss occurs without expectations V. Ultimate Loss (Death) results in a lost for a dying person as well as for those left behind, can be viewed as a time of growth for all who experienced it

2. Grieving Process (Theories of Grief, Dying and Mourning)I. 3 Phases of Grief a. Protest: lack of acceptance, concerning the loss, characterized by anger, ambivalence and cryingb. Despair: denial and acceptance occurs simultaneously causing disorganized behavior, characterized by crying and sadness c. Detachment: loss is realized; characterized by hopelessness, accurately defining the relationship with the lost individual and energy to move forward in life.

II. Kubler-5 Stages of Grieving a. Denial – characterized by shock and disbelief, serves as a buffer to mobilize defense mechanism b. Anger: resistance of the loss occurs, anger is typically directed toward others c. Bargaining = deals are sought with God or other higher power in an effort to postpone the loss d. Depression: loss is realized; may talk openly or withdraw. e. Acceptance: recognition of the loss occurs, disinterest may occur; future thinking may occur.

III. Worden’s 4 Tasks of Mourning a. Accept the reality of the loss, the loss is acceptedb. Experience the pain of grief, healthy behaviors are accomplished to assist in the grieving process. c. Adjust to the environment without the deceased, task are accomplished to reorient the environment,i.e. removing the clothes of the deceased from the closet. d. Emotionally relocate the deceased and move forward with life, correctly align the past, the present & look towards the future

3. Anticipatory Grief – expression of the symptoms of grief prior to the actual loss, grief period following the lost may be shortened and the intensity lessened because of the previous of grief; for example, a child told that a family move is expected may grieve about losing friends prior to actually living

4. Complications of BereavementI. Chronic Grief – symptoms of grief occur beyond the expected time frame and the severity of symptoms is greater; depression may result.II. Delayed Grief – when symptoms of grief are not expressed and are suppressed, a delayed reaction of grief occurs, the nurse should discuss the normal process of grieving with the client and give permission to express these symptoms

5. Symptoms of Normal Grief

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I. Feelings include sadness, exhaustion, numbness, helplessness, loneliness, and disorganization, preoccupation with the lost object or person, anxiety, depression. II. Thought patterns include fear, guilt, denial, ambivalence, anger III. Physical sensations include nausea, vomiting, anorexia, weight loss or gain, constipation or diarrhea, Diminished hearing or sight, chest pain, shortness of breath, tachycardia IV. Behaviors include crying, difficulty carrying out activities of daily living and insomia

6. Nursing Health Promotion (to facilitate mourning)1. Help client accept that the loss is real by providing sensitive, factual information concerning the loss 2. Encourage the expression of feelings to support people; this build relationships and enhances the grief process 3. Support efforts to live without the diseased person or in the face of disability; this promotes a client’s sense of control as well as a healthy vision of the future 4. Encourage establishment with new relationships to facilitate healing. 5. Allow time to grief, the work of grief may take longer for some; observe for a healthy progression of symptoms. 6. Interpret “normal” behavior by teaching thoughts, feelings, and behaviors that can be expected in the grief process 7. Provide continuing support in the form of the presence for therapeutic communication and resource information. 8. Be alert for signs of ineffective coping such as inability to carry out activities of daily living, signs of depression, or lack of expression of grief.

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Passive Aggressive Assertive

Self-denying Self-enhancing at the expense of others

Self-enhancing (self & others)

Inhibited Expressive Expressive

Puts down self;low self-worth and

confidencePuts down others Feels good about self

Allows others to choose Chooses for others Chooses for self

Does not achieve goalAchieves desired goal by

hurting others Achieves desired goal

LEADERSHIP, MANAGEMENT and RESEARCH

Overview:

Part I. LEADERSHIP AND MANAGEMENTI. Concepts of Nursing LeadershipII. Nursing ManagementII. Nursing Management ProcessIV. Code of Ethics for Nurses

Part II. RESEARCHI. Research in NursingII. Types of ResearchIII. Research Process

a. Phases of Nursing Researchb. Steps in Nursing Research

PART 1. LEADERSHIP AND MANAGEMENT

I. CONCEPTS OF NURSING LEADERSHIP

A. Behaviors of Leaders

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LEADERSHIP ROLES AND MANAGEMENT FUNCTION ASSOCIATED WITH DELEGATION

Leadership Roles Management Functions

1.        Responsible for delegation of task to subordinates.

1.        Generates job description /scope of practice statement for all personnel

2.        Acts as a role model, supporter and resource person

2.        Knows legal liabilities of supervision

3.        Influences subordinates to utilize delegation to facilitate team building and time management strategies

3.        Aware of capabilities and level of motivation of subordinates during task delegation

4.        Guides subordinates in determining appropriate situations for delegation

4.        Generates and implements a periodic review for each delegated task.

5. Ensures patient safety as minimum criteria in determining most appropriate person to accomplish the delegated task.

5.        Provides incentives and recognition to show appreciation for the delegated task completed.

B. LEADERSHIP ROLES AND MANAGEMENT FUNCTION ASSOCIATED WITH DELEGATION

C. LEADERSHIP ROLES AND FUNCTION RELATED TO PRELIMINARY STAFFING FUNCTION

LEADERSHIP ROLES AND FUNCTION RELATED TO PRELIMINARY STAFFING FUNCTION

Leadership Roles Management Functions

1. Plan activities for future staffing needs.

1. In charge of getting and maintaining adequate skilled work team to meet the goals of the organization.

2. Knowledgeable and aware of current and historical staffing events.

2.   Shares responsibility in terms of staff hiring

3. Capable of knowing and encouraging qualified and competent

3. In charge of planning and structuring needed interviews.

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individuals to join the organization

4. Serves as a role model 4. Uses techniques that would ensure a more valid and reliable interview process

5. Fully aware of possible personal biases during the time of pre-employment process or hiring.

5.   Knows the legal requirements needed in interview and selection of individuals to maintain firmness in the hiring practices.

1. Uses the interview process as a chance to promote and enhance the image of the organization.

1. Generates a selection criteria

2. Designates position to new personnel that can ensure success.

2. Uses information about organizational needs and employee’s strength to make wise decisions regarding placements.

3. Regularly reviews programs and holds orientations and meetings to ensure needs of the unit are being met.

3.   Uses expertise to guide new employees and lead a certain program

4. Ensures understanding of the organizational policies by new employees.

4. Always involved in conducting orientation for employees

EARLY LEADERSHIP THEORIES

A. Trait/ Individual Characteristic Theory

Some people have certain characteristics or personality traits that make them better leaders than others

B. Great Man Theory

Some people are born to lead, whereas others are born to be led.

C. Behavioral Theories

1. Autocratic

Self-centered leader A type of leadership wherein obedience to authority is strongly enforced Favors strict rules and established authority Well-defined group actions

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High productivity, low creativity, self-motivation and autonomy

2. Democratic

People-oriented leader (“We”) A type of leadership characterized by free and equal participation in decision-

making Promotes autonomy and growth Less efficient quantitatively than authoritative leadership

3. Laissez-faire

Permissive leader (“You”) A type of leadership that is permissive with little or no control and motivates

by support when requested by the group of people Frustrating due to over freedom Appropriate when problems are poorly defined Creativity and productivity will result if members are highly motivated and self-

directed

D. Situational and Contingency Theories

Requires the performance of both the leader and the followers Requirements of the leader differs according to varying situations A person may be a leader at one time and a follower in another

E. Contemporary Leadership Theories

1. Bureaucratic

Rule-centered (“They”) An institutional method for applying general rules to specific cases, making the

actions of management fair and predictable introduced by Max Weber.

2. Management Process by Henri Fayol’s

First identified the management functions of planning, organization, command, coordination, and control.

Introduced the following principles:

a. Principle of division of workb. Authority and responsibilityc. Unity of commandd. Remuneration of personnele. Establishment of tenuref. Communicationg. Centralizationh. Equity and Justicei. Esprit de corps

F. Theory X and Theory Y by Douglas McGregor

Theory X Assumptions:

1. The average individual has an inherent dislike for work and will avoid it whenever possible.

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2. The average individual prefers to be directed, hopes to avoid responsibility, and is more interested in financing incentives than in personal achievement.

3. Because people dislike work, they must be controlled, threatened and coerced to put forth sufficient effort to meet the organization’s objectives.

Theory Y Assumptions:

1. The expenditure of physical and mental effort is as natural as rest or play.2. Man will exercise self control and self direction in the service of objectives to which he is personally committed.3. The average person learns, under proper conditions, both to seek and to accept responsibility.4. The capacity to apply imagination and creativity to the solution of organizational problems is widely, rather than narrowly, distributed among workers.

Douglas McGregor’s Theory X & Theory Y and W. G. Ouchi’s Theory Z  

Theory X Employees Theory Y Employees Theory Z

Avoid work if possible Like and enjoy work Quality circles

€Dislike work Fitting employees to their

jobs

Must be directed Self-directed Consensus decision making

Have little ambition Imaginative and creative Guarantee of lifetime employment; Job security

Avoid responsibility

Need threats to be motivated

Seek responsibility Examining the long-term consequences of

management decision making

Need close supervision Have underutilized intellectual capacity

Slower promotions

Are motivated by rewards and punishments

Need only general supervision

Establishment of strong bonds of responsibility between superiors and subordinates

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Encouraged to participate in problem solving

A holistic concern for the workers

II. NURSING MANAGEMENT

SCIENTIFIC MANAGEMENT

A. Frederick Winslow Taylor Taylor’s System for Work Improvement Consisted of the following steps:

Controlled observation of the worker’s performance through time and motion study

Scientific selection of the best man to perform each job Training the selected worker to perform job tasks Paying the worker to according to a differential piece rate Appointing a foreman for each aspect of the work and making the production

worker responsible for reporting to a different functional foreman for each aspect of his job

B. Lillian Gilbreth - First Lady of Management

Benefits of job simplification and the establishment of work standards Effects of incentive wage plans and fatigue on work performance. Two of their children, frank and ernestine, wrote Cheaper by the Dozen

C. Henry Gantt

Development of task and bonus remuneration plan Emphasis on service rather than profit objects

CLASSIC ORGANIZATION

A. Henri Fayol - Father of the Management Process School

Developed the following management principles:

division of work and task specialization authority commensurate with the degree of his responsibility each employee should receive orders from only one supervisor A single person should direct the activities that are directed towards a single

objective The interest of the individual worker should be subordinated to the interest of

the whole group There should be an unbroken scalar chain of authority and communication All employees of the organization should be treated with equity and justice

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Efforts should be made to develop teamwork and esprit de corps among workers in the organization

B. Max Weber - (1864-1920), known as the Father of Modern Sociology / Father of Organizational Theory

He advocated that the ideal form of organization is bureaucracy. Emphasis is on rules.

Bureaucracies are founded on legal or rational authority which is based on law, procedures, rules, and so on. Positional authority of a superior over a subordinate stems from legal authority. Charismatic authority stems from the personal qualities of an individual.

Efficiency in bureaucracies comes from:

(1.) clearly defined and specialized functions; (2.) use of legal authority; (3.) hierarchical form; (4.) written rules and procedures; (5.) technically trained bureaucrats; (6.) appointment to positions based on technical expertise;(7.) promotions based on competence; (8.) clearly defined career paths.

C. James Mooney - he advocated that the management is the technique in directing people.

D. Lyndall Urwick - he advocated that the managerial process consists of planning, coordinating and controlling

HUMAN RELATION

A. Mary Parker Follett

Keypoints: a successful leadership was more of a result of training in leadership skills than

possession of specific personality traits suggested that a manager should not give orders to an employee, rather, the

two should together analyze the situation and then take orders from the situation

B. Elton Mayo - Hawthorne Experiments

concluded that much more than the physical environment affected worker productivity

other factors which influence productivity by modifying the worker’s social and psychological satisfactions

C. Kurt Lewin

Revived the study of group dynamics developed the field theory of human behavior proposed that a worker’s behavior is influenced by interactions between the

worker’s personality , the structure of the primary working group, and the socio-technical climate of the workplace.

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D. Jacob Moreno - developed sociometry, psychodrama, socio drama and role playing techniques

E. Chester Bernard - cooperation depends on non-financial inducements

BEHAVIORAL SCIENCE

A. Douglas McGregor - Theory X and Theory Y

B. Chris Argyris

during maturation, the individual moves to a condition of greater independence, increased productivity, more varied activity, longer time perspective and increased self control.

Proposed that the rigid structure and stringent rules of the typical bureaucracy block normal maturational changes

Flexibility within organization Employee participation in decision making

C. Frederick Herzberg - factors associated with dissatisfaction are different from the factors which cause satisfaction

D. Abraham Maslow

Hierarchy of Needs

OTHER MANAGEMENT THEORIES

A. Herbert Simon views business and service institutions as network of decision makers

B. ALVIN TOFFLER suggests that the only way that people will be able to maintain a sense of

equilibrium is for them to design personal and social change regulators.

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C. Henry Mintzberg

The manager’s job encompasses ten roles of which

3 are interpersonal figurehead leader liaison

3 are informational monitor disseminator spokesperson

The manager’s job encompasses ten roles of which

4 are decisional enterpreneur disturbance handler resource allocator negotiator

D. Rensis Likert

System 4 Superiors and subordinates demonstrate trust in each other Information is solicited in setting goals Decisions are made at all levels uses democratic process Training is provided

III.   THE NURSING MANAGEMENT PROCESS

A. PLANNING- a pre-determining course of action in order to arrive at a desired result.

CHARACTERISITICS OF A GOOD PLAN: Have clearly worded objectives, including desired results and methods for

evaluation Be guided by policies and or procedures affecting the planned action indicate priorities Develop actions that are flexible and realistic in terms of available personnel,

equipment, facilities and time. Develop logical sequence of activities Include the most practical methods for achieving each objective

ELEMENTS OF PLANNING:

1. Forecasting – estimating the future mission, vision, objectives2.       Establishing Objectives (SMART)

a.       Specificb.       Measurablec.       Attainabled.       Realistice.       Time-bound

3. Scheduling – setting a timeframe GANTT chart

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PERT diagram (Performance Eval Review Technique)

4.  Budget- numerical description of expected income and planned expenditures for an organization for a specific period of time.

a.       Approaches Centralized De-centralized

 b. Components of an Institutional Budget

Capital Expenditure Personnel Budget Operating Budget

Capital Expenditure

A large capital outlay for buildings or equipment that commits the institution to a particular path for sometime in the future

Includes physical changes such as replacement or expansion, major equipments and inventories.

Personnel Budget

Estimates the cost of direct labor necessary to meet the agency’s objectives. Determines recruitment, hiring, assignment, lay off and discharge of personnel.

Operating budget

Input-output analysis of expected revenues and expenses Includes personnel salaries, employees benefits and insurance, medical-surgical

supplies, office supplies, rent, heat, light, housekeeping, laundry service, drugs, pharmaceuticals, repairs, maintenance, in-service trainings, books etc

TYPES OF BUDGET:

A. Fixed-ceiling - Uppermost spending limit is fixed by the organization before subordinate managers are asked to develop budget proposals for their individual units.

B. Open-ended - operating manager presents a single cost estimate for what she considers the optimal activity level, without indicating how that plan should be scaled down if less funding is available.

C.  Flexible - can be adjusted or manipulated, consists of several financial plans, each for a different level of activity of different operating conditions

D. Sunset - designed to “self-destruct” within a prescribed period to ensure cessation of the funded program by a predetermined date.

E. Zero-based - expenses have to be justified to determine profit or loss, forces managers to set priorities and justify resources, based on previous year’s expenditure

F. Contingency - can be used in case of emergency; if not used, can be part of savings.

G. .Performance - based on functions, such as direct nursing care, supervision, in-service education, quality control, nursing audit, procedure revision and development, nursing research etc

H. Program - costs are computed for an entire program, as for ambulatory surgery program, both old and new, with every annual budget preparation.

DIRECT AND INDIRECT EXPENSES

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Direct: directly associated with patient care such as medical and surgical supplies, medicines, etc.

Indirect: for items like utilities- gas, electricity, communication facilities etc.

FIXED AND VARIABLE COSTS FIXED - expenses that are constant and are not related to productivity and

volume. Examples: building and equipment depreciation, utilities, fringe benefits, admin salaries

VARIABLE - fluctuates depending upon the volume or the census or the types of care required. Example: medical-surgical supplies, medicines, laundry and food costs.

5. Formulation of Policies, Procedures, Methods, and Courses of Action

Assignment Patterns for Delivery of Nursing Care    FUNCTIONAL NSG – emphasis is on getting the job done, assignments are divided among staff members according to job descriptions and how much work must be completed.

TOTAL CARE - or the case method of assignment, refers to giving of all direct care to the patient by an RN, maybe task-centered or patient-centered, the nurse provides all the care her patients need while she is on duty, work is not fragmented.

TEAM NURSING – devised to be used when teams would be composed of care providers who had diversity in education and abilities.

Based on: Every patient has the right to receive the best care possible with the available

staff and time Planning nursing care is basic in providing this care All nursing personnel have the right to receive help in doing their job A group of care providers with the leadership of a professional nurse can

provide better patient care than those same people working as individuals.

PRIMARY NURSING

RN is responsible and accountable for the care of the patient 24 hours a day. The responsibility includes assessing, planning, implementing, and evaluating

nursing care from the time the patient was admitted to the nursing unit until the patient is discharged from that unit.

Designed to return the RN to their original role of giving direct patient care, which would improve the quality of care given.

Ways to Address Patient Care Needs Direct nursing care Indirect Nursing Care NPI

Patient Care Classification System Level I – minimal care Level II – Intermediate or moderate care Level III – Intensive Care Level IV – Highly specialized Intensive Care (critically ill)

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TIME MANAGEMENT

3 Basic Steps in Time Management Time for planning & establishing priorities Completion of the task with the highest priority & ensuring that a task is finished

before beginning with another one. Reprioritization according to tasks left and new found information

Managing Time at Work Gather all equipment and supplies needed beforehand Group activities with similar locations. Use time wisely Record all nursing interventions immediately after each activity is finished Finish all work on the designated time.

B. ORGANIZING

The way a group is formed, including lines of communication, channeling of authority, span of control, & making decisions.

Formal structure of the organization which reflects official arrangement of positions & working relationships.

ORGANIZATIONAL PROCESSES

Delegation - creates an obligation to perform.

Basic concepts in Delegation: Authority is legitimized power. Power is the ability to influence others. Delegation is distribution of authority.

Delegation of authority is guided by several key principles and concepts:

a. Exception principle - Someone must be in charge. A person higher in the organization handles exceptions to the usual. The most exceptional, rare, or unusual decisions end up at the top management level because no one lower in the organization has the authority to handle them.

b. Scalar chain of command - The exception principle functions in concert with the concept of scalar chain of command - formal distribution of organizational authority is in a hierarchial fashion. The higher one is in an organization, the more authority one has.

c. Decentralization - Decisions are to be pushed down to the lowest feasible level in the organization. The organizational structure goal is to have working managers rather than managed workers.

d. Parity principle - Delegated authority must equal responsibility. With responsibility for a job must go the authority to accomplish the job.

e. Span of control - The span of control is the number of people a manager supervises. The organizational structure decision to be made is the number of subordinates a manager can effectively lead. The typical guideline is a span of control of no more than 5-6 people. However, a larger span of control is possible depending on the complexity, variety and proximity of jobs.

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f. Unity principle - Ideally, no one in an organization reports to more than one supervisor. Employees should not have to decide which of their supervisors to make unhappy because of the impossibility of following all the instructions given them.

Responsibility - is work assigned to a position.

Authority - gives the one delegated the right to command subordinates with the latter having the obligation to obey or perform the duties carried by his position.Accountability - is a moral responsibility. A manager may delegate responsibility but always remains accountable.

Communication - the transmission of information, opinion, and intention between and among individuals

MAJOR TYPES OF ORGANIZATION:

a.     formal organizationb.     informal organization

Line authority - is authority within an organization's or unit's chain of command. Staff authority - is advisory to line authority.

ACTIVITES OF ORGANIZING: a.   communicating with peopleb.   conducting meetingc.    coordinating activitiesd.    developing job descriptions

meaning of job description job description performance appraisal

ORGANIZATIONAL CHART: A graphic representation of the chain of authority from chief executive to each

member of the organization.

Uses: Outlines administrative control For policy making & planning Evaluates the weaknesses and strengths of the present structure Shows the relationships with other departments and agencies Orients new personnel

ADVANTAGES: Shows formal line of organization Helps identify roles and expectations Maps the lines of decision-making authority. Helps in understanding people’s

assignments

DISADVANTAGES: Only shows formal relationships Does not indicate level of authority Possible confusion of authority with status

TYPE OF ORGANIZATIONAL STRUCTURES

1.     Bureaucratic

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Commonly called line structures or staff organizations seen in large healthcare facilities

Advantage: Clearly defines authority and responsibilityDisadvantages:

Alienates workers Produces monotony Restricts upward communication

2. Ad hoc Used on a temporary basis to complete a particular project Usually disbanded after a project is completed

Advantage: Serves as a way for professionals to handle increasing amount of available informationDisadvantages: Decreases strength in the formal chain of command Decreases employees' loyalty to the parent organization

3. Matrix Focuses on both product and function, with emphasis on the required task and

the end-result of the function Focuses on both product and function, with emphasis on the required task and

the end-result of the function

Advantages: Centralizes expertise Less formal rules   Fewer levels of hierarchy

Disadvantage: Slow decision-making can produce confusion and frustration

C. STAFFING

Determine the type and number of personnel needed Starting With A Self-Assessment

The following guidelines can help a manager evaluate his or her recent staffing efforts and improve in the future:

Know yourself, Know your focus, and Know the strengths and weaknesses of employment.

The following eight-step process increases the chances of hiring success:

1. Determine the business' labor and management needs 2. Develop a current job description 3. Build a pool of applicants 4. Review applications and select those to be interviewed 5. Interview 6. Check references 7. Make a selection 8. Hire

STAFFING ACTIVITIES:

A. Interviewing

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A method for selecting employees Resumes and references are verified to determine the applicant’s qualifications.

 **The open-ended questions should be geared toward the following general areas: previous job accomplishments and achievement; non-job accomplishments and achievements; motivation and ambition; hobbies and use of leisure time; and "what if" Some examples are:

What has been your most important accomplishment in your current position? What are you looking for in an ideal job? When you are working on a project, how do you know you are doing a good job?

  Do’s for the Interviewer:

1. Make sure the applicant does most of the talking. 2. Make the interview fun.3. Listen!!! 4. Be attentive. 5. Concentrate on the interview and what the applicant is saying 6. Show enthusiasm throughout the interview. 7. "Read" nonverbal messages. 8. Show appreciation for the person being interested in the position. 9. Show pride in the Profession10. Stay in control of the interview.

B. Recruitment Uses ads, career days, and literature Managers share the responsibility for recruitment with nurse recruiters.

 C. Selection

Based on job requirements Notification of the results is given

  D. Placement

Confirmation of the applicant’s acceptance in writing E. Indoctrination

Consists of induction, orientation and socialization of employees Needs complete employee handbook

JOB DESCRIPTION Specification of duties, conditions, and requirements of a particular job prepared

through job analysis Purposes:

For recruitment, placement or transfer For guidance, direction, evaluation and performance Helps reduce conflict, frustrations and overlapping duties To determine working relationships Basis for salary range

D.      DIRECTING

Delegation - transferring of responsibility from higher to lower authority Policy utilization, revision, & updating Supervision - guides, directs motivates, teaches, and facilitates

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Frequent Mistakes in Delegating: Under delegation Over delegation Improper delegation

E. CONTROLLING

Performance appraisals, fiscal accountability, quality control, legal and ethical control, and professional and collegial control.

1. Performance Appraisala. Individual performance (70%)b. Personal traits (30%)

Types of Rating ScalesA. Trait Rating ScaleB. Job Dimension ScaleC. Behaviorally-anchored Rating ScaleD. ChecklistE. Peer ReviewF. Self-Appraisal

2.       Accreditation Evaluation of the quality of nursing education provided

 3.       Development of Standards

Predetermined level of excellence that serves as a guide to practice 4.       Audit

measurement tools used to provide quality care 5.       Goal-Setting

consider the availability of resources

Principles Of Management

A. Command Responsibility

B. Chain of Command (hierarchical level)

3 Levels of Management Top level management - ADMINISTRATOR Middle management - SUPERVISORS 1st line management – HEAD NURSES, SENIOR NURSES Operational Level – STAFF NURSES, NURSING ATTENDANT

IV. CODE OF ETHICS FOR PHILIPPINE NURSES

The Philippine Nurses Association Special Committee, under the chairmanship of Dean Emeritus Julita V. Sotejo, developed a Code of Ethics for Filipino nurses (1982)

The Code of Ethics promulgated by the Philippine Nurses Association (PNA) was approved by the Professional Regulation Commission and through Board Resolution No. 1955 was recommended for use (1989) and approved by the General Assembly of the PNA last October 25, 1990.

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Amended Code of Ethics for Nurses

Pursuant of Section 3 of R.A. 877 (Philippine Nursing Law, Section 6 of P.D. No. 223)

Recommended and endorsed by the PNA Adopted to govern the practice of nursing

A. Nurses and People Values, customs, and spiritual beliefs held by individuals are to be respected. Nurses hold in strict confidence personal information acquired in the process of

giving care.

B. Nurses and Practice Nurses maintain or modify standards of practice within the reality of any given

situation. Nurses are aware that their actions have professional, ethical, moral, and legal

dimensions.

C. Nurses and Co-workers Nurses maintain collaborative working relationship with their co-workers and

other members of the health team D. Nurses and Society

Nurses are contributing members of the society. They assume responsibilities inherent in being members and citizens of the community in which they work.

E. Nurses and the Profession Nurses are expected to be members of professional organization of nurses. Nurses help to determine and implement desirable standards of nursing practice

and nursing education.

SANCTION A nurse found, after due process, to have violated any provision of this Code of

Ethics, shall be guilty of unprofessional and unethical conduct and shall suffer the sanction of censure or reprimand, suspension and revocation of her/his certificate of registration.

I. STANDARDS OF NURSING PRACTICE

A. Qualification of Nursing Practice Must be a graduate of Bachelor of Science in Nursing Must have a license to practice nursing in the country Must be physically and mentally fit to work

B. Personal Qualities & Professional Proficiencies

Should be interested and willing to work and learn with individuals /groups in a variety of settings

Should have a warm personality and concern for people Must be resourceful and creative Must have a capacity and ability to work cooperatively with others Must take the initiative to improve self and service Must be competent in performing work through the use of nursing process Should have a skill in decision-making, communicating, and relating with others Must be active in participating in issue confronting nurses and nursing

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C. Duties and Responsibilities

Utilization of nursing process, assessment, planning, implementation and evaluation of care.

Establishment of linkage with community resources and coordination of services with other members of the health team

Motivation of individuals, families, and communities to accept primary responsibility for their own health care; the utilization of indigenous resources and appropriate technology in bringing about improvement in the quality of their lives.

Participation in teaching, guidance, and supervision of the students in nursing education programs; administration of nursing services in varied settings.

Undertaking nursing and health manpower development, training and research and soliciting finances

D. Problems Encountered in the Practice

Negligence – acting or non-acting causing injury or harm to another person or to property

Malpractice – improper or unskillful care of a patient by a nurseIncompetence

lack of ability, legal qualifications or fitness to discharge the required duty One of the grounds for revocation or suspension of certificate of registration

Liability of Nurses for the Work of Nursing Aides – delegation of duties to nursing aides

Liability of the Work of Nursing Students - students should not perform professional nursing duties

PART II. R E S E A R C H

Why do research?“There must be a better way…”

Purpose of Research to answer questions, whether they arise from a simple need or curiosity.

1.  Professionalism2.  Accountability3.  Social relevance of Nursing4.  Research and Decision making in Nursing

Why do research?

The value and usefulness of the scientific approach for making real world decision about nursing practice are clearer if you realize that:

A. Science doesn’t have to be dogmatic an mechanisticB. Science involves a process of discovery as well as process of proofC. Science requires an interpretation of acts and these interpretation can

changeD. Most of the principles and topics for nursing research exist in the practice

of clinical nursing.

Alternative Ways of knowing:

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Use of trials and error combined with common sense Use of authority and tradition Use of inspiration and intuition Use of logical reasoning

Basic Assumptions that Underpin the Scientific Approach:

It is better to be knowledgeable of the world than to be ignorant of it Observes of the world are able to relate observation conceptually and make

meaning out of them.

SCIENTIFIC INQUIRY

A process in which observable, verifiable data are systematically collected from the world through our senses to describe, explain and predicts events.

Characteristics of Scientific Inquiry that other ways of knowing don’t have:

SELF CORRECTION OR OBJECTIVITY THE USE OF SENSORY, EMPIRICAL (based on observation and experience)

EVIDENCE

Basic Aims of Scientific Inquiry: DEVELOP EXPLANATIONS OF THE WORLD [THEORIES] FIND SOLUTIONS TO PROBLEMS

I. RESEARCH IN NURSING

Nursing research, according to the ANA Commission on Nursing Research, is research that develops knowledge about the following:

Health and promotion of health over the full life span Care of persons with health problems and disabilities Nursing actions to enhance people’s ability to respond effectively to actual or

potential health problems

Nursing research includes investigation into:

Health promotion and health restoration of individuals, families, groups, and communities

  Issues related to nursing education, administration, and the profession’s role in health policy formation

The ANA’s Standards of Clinical Nursing Practice states that all nurses should select nursing interventions that are substantiated by research and, further, that all nurses may participate in research activities based on their level of education, their position, and their practice setting. The nurse is expected to:

Have some awareness of the process and language of research Be sensitive to issues related to protecting the rights of human subjects Participate in identifying significant researchable problems Be a discriminating consumer of research findings

Nurses who participate in research or who practice in settings where research is conducted with human subjects play an important role in safeguarding the following rights:

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A. Right not to be harmed subjects should be free from exposure to the possibility of injury going beyond

everyday situationsB. Right to full disclosure

subjects should be given complete information about their participation in the study

C. Right of self-determination subjects should feel free from constraints, coercion, or any undue influence to

participate in a studyD. Right to privacy and confidentiality

subjects should be able to participate in a study without worrying about later embarrassment

II. RESEARCH

systematic, controlled and empirical investigation that aims to develop general knowledge about natural phenomena

Systematic: progresses through a series of steps according to a pre-specified plan of action

Controlled: involves imposing conditions on the situation so that errors are minimized and validity is maximized

Empirical: evidence is on hand to support the study findings and is used as the basis for generating knowledge

General Purposes:

Description Explanation Exploration Prediction and Control

Steps in the Research Process:

1. Identification of a problem 2. Review of related literature 3. Development of a study framework 4. Formulation of hypothesis5. Selection of the study design 6. Selection of population, sample and setting 7. Data collection 8. Analysis and interpretation of data

What is a research question?

Explicit query about a problem, or issue that can be challenged, examined, and analyzed, and that will yield useful or new information.

A reflection of the opinions and ideas of the researcher

Where to look for research topics?

Thoughts Personal experiences Experiences Observations

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Previous researches Literature sources Existing theories

What are the basic requirements for selection?

a. Knowledge on the topicb. Being interested in it

What is a researchable question?

One that yields hard facts to help solve a problem, produce new research, add to theory, or improve nursing practice.

One that provides answers that explain describes, identify, substantiate, predict or qualify.

Nursing research must be:

Usable Now questions Clear

Two basic components to every question:

a. Stem b. TopicHow to ask research questions?

Start with a simple question Ask an active question

LEVELS OF QUESTIONS:

Level I: There is little to no literature on either the topic or the population Purpose: to describe what is found as it exists naturally

Level II: There is knowledge about the topic and about the population but the intent of the

researcher is to do a statistical description of the relationships among variables

Level III: There is a great deal of knowledge or theory about the topic, to test the theory

through direct manipulation of variables. All level 3 questions lead to experimental designs

Finding the level of knowledge according to topic:

Level I: questions have one variable in one population Level II: questions have two or more variables in one population Level III: questions have cause and effect

Elements of a research problem:1. Review of related literature2. The rationale for developing the question3. The theoretical or conceptual framework

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VARIABLES Independent: “cause”, the variable which is thought to influence the dependent

variable.Dependent: “effect” or the variable that is influenced by the researcher’s manipulation

(control) of the independent variable.

OTHER TYPES:

Attribute- preexisting characteristics of the study participants, which the researcher simply observes or measures

Continuous- a variable that can take on an infinite range of values along a specified continuum (ex. Height)

TYPES OF NURSING RESEARCH

1. BASIC, OR PURE RESEARCH Directed to develop theories that can increase the state of knowledge

2. APPLIED RESEARCH Directed to solve problems or make decisions for what are considered

practical purposes. Also directed at clinical trials aimed at developing and valuating new

program, program, product, method or procedure.

According to Diers: All nursing research are applied research There are 3 distinguish characteristics of a nursing problem:

1. MUST INVOLVE A “DIFFERENCE THAT MATTERS” IN TERMS OF ITS CONSEQUENCES IN IMPROVING PATIENT CARE

2. MUST HAVE A RELATIONSHIP TO MORE CONCEPTUAL ISSUES AND THEREFORE HAS THE POTENTIAL FOR CONTRIBUTING TO THEORY DEVELOPMENT AND OUR BODY OF SCIENTIFIC NURSING KNOWLEDGE

3. NURSES MUST HAVE ACCESS TO OR CONTROL OVER THE PHENOMENON BEING STUDIED

3. PURE / APPLIED RESEARCH Classifying types of nursing studies based on how relevant

- the subjects - the content - the conditions

are to the real world nursing problems and decisions

Stage I. Not Directly RelevantExample:

studying the mechanism of wound healing using guinea pigs not directly relevant to the practice of nursing, uses animals in testing.

Stage II. Relevant Topics or SubjectsExample:

a researcher interested in the concept of hunger conducted his study by making college students drink through a tube from behind screen with no visual cues about what they are taking in.

it is being conducted with people instead of animals but the topics of hunger and satiation are not specifically related to nursing activity

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Stage III. Relevant Topics and Subjects Example

study to determine whether infants placed in different body positions consumed different amounts of energy

it involves people as subjects and compares different positioning choices have direct concern to nursing practice

Stage IV. Relevant Topics, Subjects and Trial ConditionsExample:

This is an example of research in nursing intervention under a special condition.Stage V. Normal Field of ConditionsStage VI. Advocacy and Adoption

Research that demonstrate the applicability of primary nursing – in which one nurse is totally responsible for a case load of patients.

Types of Nursing Research according to purpose or design:

RESEARCH DESIGN Provides a plan, or blueprint, for answering the research question Specifies control mechanisms to be used in the study The more knowledge there is about the topic and the higher the control of

variables, the stronger the design.

The following are to be considered in selecting the research design:

The setting for the study a)  Laboratory study – designed to be more highly controlled in relation to both

the research environment and the extraneous variables b)  Field study – done in natural settings (e.g.: wards, communities, homes) or

somewhere other than in a controlled laboratory setting Timing of data collection

a)      Looking into the past Historical – descriptive studies that ask people to recall events or people

from the past, or refer to written historical documents and artifacts to reconstruct the past

Retrospective – a phenomenon that occurs in the present is linked to a phenomenon in the past

Ex Post Facto – essentially the same as retrospective studies (Note: In some books, ex post facto studies, considered to be the same as correlational studies, are classified into retrospective and prospective studies)

Gauging the present Cross-Sectional – designed to obtain a “cross-section” of the

population at a given point in time

Predicting the future Prospective – a phenomenon existing in the present is linked to a

phenomenon predicted to happen in the future Longitudinal – designed to follow the subjects for a period of time,

obtaining repeated measurements and establishing changes in the variables over time

Types of Nursing Research according to purpose or design:

a. Exploratory To obtain a richer familiarity with a phenomenon and clarify concepts as a basis

for further research.

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Methods: INTERVIEWING, PARTICIPANT OBSERVATION, DOCUMENT ANALYSIS, EXPLORATORY

b. Exploratory collects in-depth data on a single concept or variable

Examples:1. What are the reactions of patients to being cared for by student nurses?2. What are the administrative characteristics of nurses?

c. Descriptive to obtain complete and accurate information about the phenomenon studies known variables that have not been studied in a particular population

METHODS: INTERVIEWS, QUESTIONNAIRES, DIRECT OBSERVATION, ANALYSIS OF RECORDS

d. Explanatory TO PROVIDE CONCEPTUAL ANALYSES GROUNDED IN OBSERVATION OF

HUMAN BEHAVIORMETHODS: INETRVIEWS, PARTICIPANT OBSERVATIONS CONSTANT COMPARATIVE ANALYSIS

e. Correlational – studies the relationship of two or more variables

f. Experimental and quasi experimental To test hypothesis about relationship studies the effect of a manipulated variable on another variable

METHODS: EXPERIMENTS, QUASI-EXPERIMENTS

1. True experiment Manipulation of independent variable Imposing control on at least one group (meaning, there should be at least two

groups)  Randomization of subjects to assigned groups

2. Quasi-experiment Manipulation of independent variable May have a non-equivalent control (comparison) group No random assignment

GENERAL STEPS IN THE RESEARCH PROCESS

5 Phases:1. Conceptual Phase2. Design & Planning Phase3. Empirical Phase4. Analytic Phase5. The Dessimination Phase

Steps in Research Process1. Formulating & Delimiting the problem2. Review of Related Literature3. Defining the Theoretical Framework4. Formulating Hypothesis and Defining variables5. Selecting Research Design6. Identifying the Population to be Studied7. Specifying Methods to Measure the Research Variables

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8. Designing the Sampling Plan9. Finalizing and Reviewing the Research Plan10.Conducting the Pilot Study and Making Revisions11.Collecting Data12.Preparing Data for Analysis13.Analyzing Data14. Interpreting Results15.Communicating the findings16.Utilizing the findings

Phase I: THE CONCEPTUAL PHASE Includes thinking, reading, conceptualizing, reconceptualizing, theorizing, and

reviewing ideas with colleagues or advisers. The researcher calls on such skills as creativity, deductive reasoning, insight,

and firm grounding on previous research on the topic of interest.

Step 1: Formulating and Delimiting the Problem In developing a research question, nurse researchers must consider the

following:

a. Substantive dimensions (e.g. Is this research question of theoretical or clinical significance?)

b. Methodological dimensions (e.g. How can this question be best studied?)

c. Practical dimensions (e.g. Are adequate resources available to conduct a study?)

d. Ethical dimensions (e.g. Can this question be studied in a manner consistent with guidelines for the protection of subjects?)

How to state a research problem stated in the form of a question an explicit query of about a problem or issue that can be challenged,

examined, analyzed and will yield useful new information. Defining the purpose of research

The researcher’s statement on why the question is important and what use the answer will serve

Step 2: Reviewing Related Literature Provides the researcher with ideas for defining concepts and instruments Provides full awareness of the facts, issues, prior findings, theories and

instruments, that may be related to the study question. Provides a foundation upon which to base new knowledge and generally is

conducted well before any data are collected in a quantitative study Familiarization with previous studies can be useful in suggesting research topics

or in identifying aspects of a problem.

Step 3: Defining the Theoretical Framework Previous theory is used as a basis for generating predictions that can be tested

through empirical research

Step 4: Formulating Hypothesis and Defining Variables A statement of the researcher's expectations about relationships between the

variables under investigation A prediction of expected outcomes States the relationships that the researcher expects to find as a result of the

study

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Hypotheses are statements of the relationship between two or more variables or concepts.

Variables should be operationally defined

Phase II: THE DESIGN AND PLANNING PHASES The investigator decides on the method to be used to address research

questions and plans for the actual collection of data.Step 5: Selecting the Research Design

Research design is a well-thought-out, systematic and even controlled plan for finding answers to study questions.

Experimental Research - Researcher actively introduces some form of interventionNon-experimental Research - Researcher collects data without trying to make any

changes or introduce any treatment.

Step 6: Identifying the Population to be studied

Population - group to be studiedSample - those elements of a population from whom data will be actually collected and

from whom generalizations from the population will be made.Selecting the population and sample:

Arises from the need to specify the group to which the results of a study can be applied

Population refers to the aggregate or totality of all the objects, subjects, or members that conform to a set of specifications.

Sample selection: a)   Randomness – the distribution of distinguishing characteristics in the sample should approximate that in the population as closely as possible

b)   Accessibility – refers to whether the researcher can reasonably expect to find enough elements or units of the population

c) Generalizability d) Representative

Types of data to be collected: 1. Qualitative study – data collected have names or labels 2. Quantitative data – data collected reflects the measurement (numerical) of

variables or attributes

Issues of control:

a. Internal validity – the extent to which the results of the study can actually be attributed to the action of the independent variable and not to any other; the degree to which unwanted influences* are controlled

a.1 Extraneous variables – interferes with the action of the variables being studied a.2 Bias – influencing the outcome of a study in any way, even unconsciously a.3 Hawthorne effect – the subjects’ awareness of being studied affects their

responses

b. External validity – the degree to which the findings of the study are generalizable to the population; depends on the degree to which the sample represents the population

Step 7: Specifying Methods to Measure the Research Variables

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Research variables are first identified to clarify exactly the meaning of each before selecting an appropriate method of collecting the data.

Data Collection Approaches:

1. Biophysiologic Measure 1.a Self-reports: Subjects are asked about their feelings, behaviors, attitudes, and

personal traits. 1.b Observation: Researcher collects data by noting people's behavior as well as the

relevant aspects of it.

Step 8: Designing the Sampling Plan A sample refers to the small fraction of the population. It is more practical to use a sample in order to minimize cost rather than

collecting data from a population. Selected sample may not adequately reflect the behaviors, traits, symptoms, or

beliefs of the population.

Types of sampling method:

a. Probability sampling – use of random selection process to select elements of a population

b. Simple random sampling – is a type of probability sampling that ensures that each element of the population has an equal and an independent chance of being chosen. (use table of numbers or assign numbers)

c. Stratified random sampling – divide population into strata (age, gender, educational background), determine the number of cases desired in each stratum, random sample the groups.

d. Cluster random sampling – groups, rather than people are selected from the population. Successive steps of selection are done (state, country, city) then samples are randomly selected from clusters.

e. Systematic random sampling – involves selecting the kth element in the population. Uses sampling interval.

Types of Nonprobability sampling:

a. Convenience sampling – accidental, incidental sampling; choosing readily available subjects/ respondents for study

b. Snowball sampling- involves the assistance of the study subjects to get other subjects.

C. Quota sampling – divides the group into strata then use convenience sampling to select respondents/ subjectsd. Purposive sampling- handpicking of subjects who are representatives of the whole

population.

SAMPLE SIZE – between 30 – 500, statistically accepted accdg to Roscoe (1975).

Step 9: Finalizing and Reviewing the Research Plan To generate support for financial resource To ensure that the plan does not violate ethical principles

Step 10: Conducting the Pilot Study and Making Revisions

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Provides the strengths and weaknesses of your larger project’s intended design, sample size and data collection instrument.

Done to assess the adequacy of the data collection plan Carried out as much as the major study so that any detected weakness will be

truly representative of inadequacies inherent in the major study. Pilot subjects should be chosen from the same population as subjects for the

major study. Revisions and refinements are done after the pilot study to reduce or eliminate

problems encountered. Second trial is advisable if extensive revisions are required.

Phase III: THE EMPIRICAL PHASE Involves the collection of research data and the preparation of those data for

analysis

Step 11: Collecting the Data

Data sources: people, documents, laboratory materials.Data collection instruments: interviews, questionnaires, physiological test, and psychological tests

Enough materials should be available to complete the study. Participants should be informed on the schedule of the activities. Research personnel, e.g. interviewers, should be conscientious in keeping their

appointments. Suitable system of maintaining confidentiality of information should be

implemented.

Analyzing the data: Taking the data that have been collected apart and reorganizing them so that the

researcher can make some sense of them in relation to the study question, research objectives or study hypothesis.

Step 12: Preparing the Data for Analysis Questionnaires should be checked for the completeness of answers.  Coding should be done. It is the process of translating verbal data into

categories or numeric form.    Research information should be transferred from written documents to the

computer files for analysis.

Phase IV: THE ANALYTIC PHASE

Step 13: Analyzing the Data Data are processed and analyzed in an orderly, coherent fashion to determine

the relationship among the variables. Quantitative information is generally analyzed through statistical procedures.

Classification of statistics:

a. Descriptive – allows researcher to examine the characteristics, behaviors, and experiences of study participants

b. Inferential – helps the researcher determine the likelihood that the sample that is chosen is actually a representative of the population

Statistical Techniques:

1. Measure to condense data

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Frequency distribution - all values are listed and the number of times each one appears is recorded, values may be listed from highest to lowest

2. Measures of central tendency

Mode – value that occurs most often in a set of data under considerationMedian – middle score or value in the data.Mean – average sum of values divided by the total number of values

3. Measures of variability Describe how values are spread out in a given set of values

Range – the distance between the highest and the lowest value in a group of values.Percentile – datum point below which lies a certain percentage of the values in

frequency distributionStandard Deviation – measurement that indicates the average deviation or deviation of

all values in a set of values from the mean of value of those data.

- Used in testing the hypothesis

t-Test Used to analyze difference between two means

Chi-square Test (X2) Used to assess whether a relationship exists between two nominal-level

variablesAnalysis of Variance (ANOVA)

Tests mean differences among 3 or more groups by comparing the variability within groups

Analysis of Covariance (ANCOVA) Tests mean differences among groups on a dependent variable, while controlling

for one or more extraneous variable (covariates)Spearman Rank-Order Correlation Coefficient

Tests an association between two ranked variables

Step 14: Interpreting the Results Interpretation is the process of making sense of the results and examining the

implications of the findings within the broader context.   It provides the answer to the questions posed in the first phase of the project. Begins with an attempt to explain the findings, within the context of the

theoretical framework, prior knowledge in the area, and the limitations of the study.

Phase V: THE DESIMINATION PHASE

Step 15: Communicating the Findings Research report in the form of term papers, dissertations, journal articles, papers

for presentation at professional conferences, books, etc. is prepared to present the results to others.

Step 16: Utilizing the Findings Recommendations as to how the results of the study can be incorporated into the

practice of nursing Disseminating findings to practicing nurses.

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PROFESSIONAL ADJUSTMENTI. Definition of terms:

Nursing jurisprudence

Comprises all the legal rules and principles affecting the nursing profession

Legislation Act or process of making laws

Nursing Legislation Making of laws affecting the nursing profession

Rights Innate capacity to control actions of others with the approval and sanction of the State. Ex Bill of rights

Legal rights Claim which can be enforced by law against a person or community whose duty is to respect it.

Court Forum where disputes are settled

Jurisdiction Authority to hear and decide legal controversies

Venue Venue where suit can be heard

Legal remedy Means employed to enforce a right or redress a wrong

Ordinary remedy Ordinary action or suit in a court of law

Extra ordinary remedy

Afforded by law other than the ordinary remedy

Writ Mandatory rule of action1. Certiorari - review; acted w/o or in excess of

jurisdiction; grave abuse of discretion & there is no appeal nor any plain, speedy & adequate remedy in the ordinary course of law.

2. Prohibition - stop prosecuting a case3. Mandamus - perform a specific act w/c pertains to

his/her duty4. Quo warranto - recover an office or franchise

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Provisional remedy Provided for present need, temporary protection while an action is pending

1. Injunction - refrain from doing an act2. Preliminary injunction - granted at any stage of the action3. Final injunction - granted when rights of the parties are determined

Process Means to compel defendant to appear in court1. Warrant - directs a person to do an act, addressed

to an officer, affording him protection from damages when he does the act.

2. Search warrant - to search for material / personal property & bring them to court

3. Subpoena ad testificandum - witness to testify4. Subpoena duces tecum – witness & documents5. Summon - defendant to testify

Plaintiff Complaining party

Defendant Person charged of a crime

Accuser Private offended party represented by the state (People of the Phil.)

Witness A person who has knowledge of the fact pertaining to the case; testify to the genuineness of the makers’ signature in an instrument.

Expert witness One who is qualified to testify based on special knowledge, skills, experience and training..

Damage Loss or injury

Damages Sum of money for compensation to injury/damage done

Nursing The diagnosis or treatment of human responses to actual or potential health problem (ANA)

Profession Acceptance of the service (motive) – not to make money but promote health or knowledge or good laws

Nursing profession Performance for a fee, salary or other reward, compensation, of professional nursing services to individual, family, and community in various stages of development towards the promotion of health, prevention of illness, restoration of health and alleviation of suffering thru:

utilization of the nursing process establishment of connection with community

resources and coordination with the health team motivation of the individual, family, & community

and coordination with the health team

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participation in teaching, guidance and supervision of students in nursing education program

undertaking nursing & health manpower development training and research

II. Law

A. Law - rule of civil conduct prescribed by the supreme power in a state commanding what is right and prohibiting what is wrong. ( “ Law is the effort of humanity to create principles. It is difficult to find law that applies to every situation. Focus on principles not cases. That’s what you need to look for one more time”.)

Place of law in the profession:– contribute to the orderly progress & gen. welfare of the society– to minimize violations of laws

Aspects of the profession under the provision of law: All are governed by specific provisions of law for the purpose of attaining the

normal procedure in the practice of the profession which include: exam and registration of applicants professional conduct of the registered professional maintenance of ethical and technical standards of the

profession illegal practice of unregistered person the exercise of the power and duties of the BON

B. Classification1. Divine law2. Human law

2. A. Public – applies to people of the state - Criminal law – crime & its penalty

- International law - law & relationship of nations - Political law- organization & administration of govt.2. B. Private - Civil law – organizing family & regulating property - Commercial law – rights of property & relations of persons

engaged in commerce - Remedial law - prescribe methods of enforcing rts. & obtaining

redress of their invasion

A. Morality - behavior in accordance with the gen. ethical principles of health care

B. Principles of morality

1. The golden rule2. Two-fold effect3. Principle of totality4. Epikia5. One who acts under an agent is himself responsible6. No one is obliged to betray himself7. The end does not justify the means8. Defects of nature may be corrected9. The greatest good for the greater number

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10.Nno one is held to the impossible11.The morality of cooperation12.Principle relating to the origin and destruction of human life13.The good Samaritan law (“Love article” – if one does not act, you

will be responsible for moral negligence. Courage is doing exactly what one believes in.”)

14.A litlle more or less does not change the substance of an act15. If one is willing to cooperate in an act, no injustice is done to him

C. Ethics

1. Ethics - deals with one’s responsibilities (duties/obligations) as defined by logical arguments

– Serve the purpose of governing conduct to ensure the protection of individual’s rights.

2. Importance: makes clear why one act is better than another keep an orderly social life by having agreements, understanding,

principles or rules of procedure moral conduct and ethical system must be intelligently appraised

and criticized Seeks to point out to men the true value of life and attempts to

stimulate the moral sense, discover the true values of life and inspire men to gain in for quest of these values.

D. Bioethics1. Bioethics - synonymous term with healthcare ethics and encompass not only questions of quality of life, life-sustaining and a life-altering techniques and bio-science in general (Catalano)2. Human acts – voluntary, full knowledge, will to do it3. Acts of man - involuntary actions of man

E. Nursing ethics - formal study of ethical issues that arise in the practice of nursing and of the analysis used in the judgment of the practice.

F. Theories1. Utilitarian or teleological – the end justifies the means2. Deontological - the end DOES NOT justify the means; the act is the criterion for the determination of good and not the consequence.3. Intuitionism - people inherently knows what is right and what is wrong

G. Principles of nursing ethics1. Autonomy

o consento informed consento patient’s bill of rightso false imprisonment/ illegal detentiono arbitrary detentiono restraints

death and the dying

a. right of informed refusal

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b. DNR orderc. death certificated. care of the bodye. organ transplantf. organ donationg. autopsy h. assisted suicide

unauthorized patient discharge

2. Paternalism – giving care like a good father/mother of a family3. Non-maleficence – do no harm; remove harm; prevent harm

o medication rightso doctor’s ordero telephone ordero imprudence - deficiency of action; lack of skillo negligence – lack of foresight; deficiency of perceptiono assaulto battery

4. Beneficence – to do goodo client advocate

5. Justice - equality6. Veracity - telling the truth

o fraud – deliberate deception intended to produce unlawful gain

o defamation – character assassination verbal or writteno libel - writteno slander – verbal/oralo medical record

7. Fidelity – loyalty/ faithfulness and keeping promises8. Confidentiality – observing the seal of secrecy

o privileged communication o invasion of privacyo hearsay evidenceo dying declaration or ante mortem statemento nurses as witness

a. when prohibition appliesb. duration of the seal of secrecy

III. Nursing Code of Ethics

1. four-fold responsibility of a nurseo promotion of healtho prevention of illnesso alleviation of sufferingo restoration of healtho spiritual health – holistic care; self-transcendence – going

beyond self to help other to reach self-actualization

2. Elements of the code of ethics– nurses and patient– nurses and practice

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– nurses and co-workers– nurses and society– nurses and physician– nurses and profession

IV. Nurses and Contracts

a. Contracts• Meeting of the minds between two persons whereby one binds

himself, with respect to the other, to give something or to render some services ( Art.1305, CC)

• Characteristics1. obligatory – has force of law between parties2. autonomy - may establish agreement not contrary to law,

morals good order, public order, public policy3. mutuality - binding on both parties4. relativity - takes effect between parties, their assigns &

heirs

• Stages1. negotiation – from indicate interest to time contract is

concluded2. perfection - birth; meeting of the mind on object and cause3. consummation - death; performance of respective

commitments

• Kinds1. express - formal agreement whether written or verbal2. implied - presumed or inferred from acts

• duo ut des - I give that you give• duo ut facias - I give, you do• Facio ut des - I do, you give• Facio formal ut facias - I do. You do

3. Formal- required to be in writing by some special laws 4. informal - is not required to be in writing; intention is based on written document, correspondence or oral/written agreement 5. Void or inexistent

• Object or purpose is contrary to law…..• simulated or fictitious• object did not exist• object beyond commerce of man• performance of an impossible service• object cannot be determined with certainty• expressly prohibited or declared by law as void,

invalid, ineffective• direct result of n illegal contract

6. Voidable - can be annulled or voided• One party is incapable of giving consent• Consent is vitiated by mistake, violence, intimidation,

undue influence, fraud

b. Elements of validity1. Consent

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o Legal ageo Sound mindo Not under the influence of intoxicating drugso Not suffering from mental disability

2. Object or subject mattero Not outside commerce of man including future thingso Rights which are not intransmissibleo Future inheritance in cases expressly specified by lawo All services which are not contrary to law…..

3. Cause - consideration, material, cause, reason, motive, price or impelling influence

c. Breach of contract - failure to perform an agreement whether express or implied

1. prevention of performance2. failure because of inconvenience or difficulty3. failure of cooperation4. abandonment of duty5. substitution of performance6. failure to use due care

Legal excuses:1. Discovery of material representation2. Where performance is illegal3. Illness or force majeure4. Death of patient or nurse5. Insufficient contract

V. Nurses and WillsA. Succession – mode of acquisition of rights, property & obligation

transmitted thru will or by operation of law upon the death of the testator.

B. Decedent - person whose property is transmitted thru succession; testator

C. Estate - interest in hand or property to be transmitted

D. Testamentary capacity - capacity to comprehend the nature of transaction he is engaging that time, recollect the property to be disposed; the persons who would have claims to the property, comprehend the manner in which the instrument will distribute the property

E. Wills – act whereby a person is permitted with the formalities prescribed by law to control to a certain degree the disposition of his property to take effect upon his death.

Who may make a will;

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o All persons who are not expressly prohibited by law (minors, mentally incapacitated; mental capacity to be determined at the time of its execution

o Married woman w/o the consent of the husband & w/o authority of the court ( separate property, share of the conjugal property or absolute community of property)

Forms/Kinds:o Notarial ( 3 or more credible witnesses, attestation

clause, acknowledgement)o Holographic – written, dated and signed by the

testator himself o Joint or Mutual will – not allowed as a matter of

public policy

Witnesses to wills :o Legal ageo Not blind, deaf or blindo Able to read and writeo Domiciled in the Philippineso Is not convicted of falsification of document or false

testimony

Living willo Health care proxy form provided by hospitalso Forms part of hospital recordso Designates health care representative –

physical/mental incapacityo Includes to accept or refuse treatment, services,

procedures, provide, withhold or withdraw life-sustaining devices; organ donation or acceptance

o Doctors should be informedo Signed by patient and two other personso It has the force of law

Advanced Directive / Durable power of attorney Document made by a competent individual to establish desired health care for

the future or give someone else the right to make health care decision if the individual becomes incompetent.

Made part of the medical record Physician must be notified of its presence so that orders will be consistent with

client’ wishes

A. Felonies – act or omission punishable by law1. Omission – inaction; failure to perform a (+) duty; there should be a law

requiring to perform the act.2. Intent – purpose to use a particular means to affect a result (deliberate intent

– freedom and intelligence)3. Motive – moving power which impels one to act for a definite result

B. Persons criminally liable1. Principal

– by direct participation– by inducement– by indispensable cooperation

2. Accomplice – accessory before the fact3. Accessory – accessory after the fact

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-profiting themselves or assisting others to profit-concealing, destroying body of the crime, effects, instruments to prevent its discovery-harboring concealing, assisting the escape of the principal

C. Stages of execution1. Cconsummated 2. Frustrated3. Attempted

– conspiracy – two or more person agreed and committed the felony; a means by which another person is held liable for the commission of a crime; each criminal is responsible for the acts of his associates provided such act is a result of a common plan.

– proposal - a person who decided to commit a felony proposes its execution to another

D. Circumstances affecting criminal liability1. Justifying – free from criminal and civil liability

– self – defense» unlawful aggression» reasonable necessity of the means employed to

prevent /repel it» lack of sufficient provocation on the person defending

himselfo defense of relatives – up to 4th degree by consanguinityo defense of a stranger – defending not induced by resentment, revenge or

other evil motiveo who acts in fulfillment of a duty or in a lawful exercise of a right or officeo who acts in obedience to an order by a superior for some lawful purpose

2. Exempting – no criminal liability only civil liability mistake of fact – ( ignorantia facti excusat) must be committed in good

faith or under an honest beliefoan act or omission which is a result of a misapprehension of facts

that is voluntary but not intentional; o the actor performed an act which would be lawful had It been true as

he believed it to beoEx. stabbing of a victim w/c the accused believed to be an intruder

showed mistake in identity due to good faithoBUT if there is negligence, the said mistake of fact is not exempting,

actor is liable by means of culpa (w/o intent) An insane or imbecile unless acted during lucid interval Under 9 years of age Over 9 under 15, unless acted with discernment While performing a lawful act w/ due care causes an injury by mere

accident without fault or intention of doing it Who acted under the compulsion of an irresistible force from a third

person. Ex. a person is struck with butts of the gun of those who killed another to compel him to bury the victim – not liable as an accessory; actor acts against his will.

Impulse of uncontrollable fear o actor acts without a will; completely deprived of freedomo it is an impulse coming from within the person of the actorocompulsion must be of such character as to leave no opportunity for

the actor to escape

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oEx. one is compelled under the fear of death to join the rebels, he is not liable for rebellion

Insuperable or lawful causeo applies to felonies committed by omission

o the law imposes a duty to perform the act, if he fails he violates the law; if it is due to lawful or insuperable cause, he is criminally exempt

Instigation o when a peace officer induces a person to commit a crime, w/o

inducement the crime will not be committed. If it is a private person he is principal by inducement

o Ex. A policeman induced a nurse to bring to him a prohibited drug w/c he made him believe he would buy and when the drug was delivered he made an arrest

3. Mitigating• Under 18 or over 70• No intention to commit so grave a wrong• Sufficient provocation or threat on the part of the offended party

immediately preceded the act• Voluntary surrender• Deaf, dumb or blind or suffering from physical defect• Such illness that would diminish the exercise of his will power

4. Aggravating• Advantage of public position• In contempt or insult to public authorities• Abuse of confidence or obvious ungratefulness• Committed on occasion of epidemic, conflagration, shipwreck or

other calamity or misfortune• In consideration of a price or reward or promise• Committed by means of fire, explosion, stranding of a vessel• with evident premeditation• craft, fraud or disguise

5. Alternating ( either mitigating or aggravating)• relationship, intoxication, degree of education)

VII. Nurses and Crimes

1. parricide – ascendants, descendants (legitimate of illegitimate), spouse2. murder – with intent to kill3. homicide – without intent to kill4. infanticide - less than 3 days of age5. abortion – termination of pregnancy before fetus is viable ( 3-6 mos)6. child abuse - any form of cruelty to a child’s moral or metal well being or

any form of sexual attack w/c may or may not amount to rape.7. abused/neglected child – suffering from serious physical or emotional

injuries inflicted on them including malnutrition

– Under Philippine Law , Child Abuse refers to the maltreatment, whether habitual or not, of the child, and such maltreatment includes any of the following:

a. psychological and physical abuse, neglect, cruelty, sexual abuse and emotional

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maltreatment;b. any act, by deeds or words, which debases , degrades, or demeans the

intrinsic worth and dignity of a child as a human being;c. unreasonable deprivation of the child’s basic needs for survival, such as

food, shelter, ord. failure to immediately give medical treatment to an injured child, resulting

in serious impairment of his growth and development or in his permanent incapacity or death.

8. sexual harassment – words, gestures actions w/c tend to annoy and verbally abuse another person

9. simulation of birth – crime against status by substitution of one child with another; concealing or abandoning any legitimate child with intent to lose civil status

10. misdemeanor – use to express every offense inferior to felony and punishable by indictment or by particular prescribed proceedings.

Example:a. a person who practices nursing without certificate of registrationb. any person assuming or using title r advertising as registered nurse

without being conferred such titlec. any person advertising any title tending to convey the impression that

she is a nurse (e.g. using nurse’s uniform and cap)

11.Malpractice - the neglect of a physician or a nurse to apply that degree of skill and learning in the treatment of a patient, which is customarily applied in treating and caring for the sick or wounded similarly suffering in the same community.

For nurses, malpractice refers to the failure to follow a reasonable professional standard of care, thereby resulting in injury to a patient.

VII. Nurses and Narcotics

o Dangerous Drug Board - was created by RA 6425 (Dangerous Drug Act of 1972)

o Narcotic drugs – any drug which produces insensibility, stupor, melancholy or dullness of mind with delusions and which may be habit forming. Ex. opium, opium derivatives and synthetic opiates

o Dangerous drugs - refers to prohibited or regulated drugso Prohibited drugs – include opium, and its active components and

derivatives (heroin, morphine, LSD)o Regulated drugs - include self-inducing sedatives (Phenobarbital,

amphetamines) RA 953 – Narcotics Drug Law

Nurse in relation to Narcotics : The nurse must remember that the dispensing, administering, distribution

or giving away of narcotics to a patient by a registered physician, veterinary surgeon or other practitioner registered under the narcotics drug law should be in THE COURSE OF HIS PROFESSIONAL PRACTICE only and for legitimate medical purposes. Nurse can handle narcotics in the course of their professional practice only as agents for practitioners of institutions under whose direction or supervision their duties are performed.

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Medical Orders, Drugs and Medications: RA 6675 states that only registered Medical, Dental & Veterinary

practitioners whether in private, public or corporation are only authorized to prescribe drugs.

RA 5921 or Pharmacy Act – all prescription must contain the following:

– Name of prescriber– PRC #– Office or address– Patient’s name, age sex, & data of prescription– Drug must be written with its generic name

• Dependent and coordinated function of the nurse and authorized personnel and only when the order is in writing and bears the doctor’s signature does the nurse have the legal right to follow them.

• Intravenous Therapy and Legal Implications :• Nurses now participates in complex intravenous therapy

procedures that was once were performed by doctors.• Legal rights to give IV injections is based on the Phil. Nursing Act of

1991, sec. 27 Art. V• Board of Nursing resolution No. 8 series of 1994

• Scope of duties and responsibilities of IVTN:– interpret orders

• perform venipuncture except cutdown• prepare, monitor, additives, push• administer blood, blood products as ordered• recognize incompatibilities• maintain, replace in accordance with the procedure• establish flow rate of fluids and blood• proficient technical ability in the use, care and evaluation• Documentation

IX. Legal Responsibilities of Nurses– Supervision of Patients:

1. Application of principles based upon the biological, physical and social sciences as well as execution of nursing procedures

2. being responsible for the performance of every nursing procedure and technique for the recovery of the patient

3. being careful and conscientious in the discharge of duties to avoid liabilities for damages.

– Operation of Patients: 1. The nurse attends to the matter of securing the patient’s signature on

the form for giving consent to surgery2. A form is called “operating permit” is usually provided by the hospital for

the purpose.

– Unauthorized discharge of Patients - when a patient insists on leaving the hospital against the advice of the doctor, the nurse should require him to sign a statement whereby he assumes full responsibility for leaving the hospital and releases the hospital personnel from any responsibility.

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- Concept of Accountability:1. The accountability of the nurse to the patient, physician or to the public has a reference to the quality of nursing care she renders.2. A contractual obligation which a nurse assumed exposes her to a

certain degree of accountability; the term accountability carries the idea of sanction or penalty

X. PROFESSIONAL NEGLIGENCE:

a. Negligence - the doing of that thing which a reasonably prudent person would not have done or the failure to do that thing which a reasonably prudent person should have done.

b. The essential conditions:1. The existence of a duty on the part of the person charged, to protect the

complaining party from the injury received.2. Failure to meet standard care3. Foreseability of harm resulting from failure to meet standard4. An injury resulting from such failure

c. Proof of liability1. Duty – at the time of injury, a duty existed between nurse and patient2. Breach of duty3. Proximate cause – breach was the legal cause of injury4. Damage or injury

d. Doctrine of res ipsa loquitor – let the thing speaks for itselfe. Doctrine of respondeat superior – let the master answer for the acts of his

slavesf. Doctrine of force majeure – act of God g. Captain of the ship doctrine – the leader of a team is responsible for the act

of his membersh. Doctrine of corporate liability – the liability of the hospital in cases of

defective equipment/ facilities w/c caused harm/ injury to a patient

XI. The Philippine Nursing Law

a. History February 5,1915 – RA 2493 Practice of nursing was under

Medical and Surgical Law

Classifications of nurses: Class A:

1. Graduate of 2 ½ years in Nursing2. Clinical experience must be done in a 30 bed

capacity hospital in pediatrics, OB, Medicine, Surgery, EENT

3. Good moral character and good physical health 20 yrs. of age

4. Registration is with the Director of Health Class B: 2nd class nurses; nurse attendant; unregistered

nurses1. Graduate of intermediate grade2. Good moral character and good physical health3. Registration is with the district health officer

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4. They were allowed to wear cap or uniform of class A nurses

on or after January 1, 1919 it is unlawful to practice nursing if not registered

March 1, 1919 – RA 2808 – (First True Nursing Law) – The Act Regulating the Practice of Nursing Profession in the Philippines

creation of the Board of Examiners ( 1 doctor as chair; 2 nurses as members) appointed by Secretary of Interior

Chair: Dr. Juan Cabarus Members: Anastacia Giron-Tupas

Belen Del Rosario

Functions of BOEo issuance of certificate of registrationo revoke certificate of registrationo administer examination (practical & writteno examines the condition affecting practice of nursing

March 8, 1922 - RA 3025 – Registration of Red Cross Aids & Welfare Workers

o assist people during calamities war, disaster, epidemics and waro examination dates – 2nd Monday of April and October instead of

2nd Monday of June and Decembero grant privilege of practicing nursing without examination to nurses

registered under the laws of any state or territory of the U. S. or any foreign country

December 5, 1932 - RA 4007 – Reorganization Act of 1932 BOE was put under the custody of Bureau of Civil Service

1950 – Congress passed two laws o RA 465 - Standardization of Examination & Examination Feeso RA 546 - BOE is under the direct supervision of Pres. of the Phil.

1953 – Birth of Filipino Nurses Association (Formal recognition)

Legislative Committee Chair: Mrs. Obdulia KabigtingMembers: Ms. Annie Sand

Ms. Conchita RuizMs. Jovita Sotejo – 1st FNA Pres.

June 19, 1953 – Philippine Nursing Law sponsored by former Senator Geronima T. Pecson

November 21, 1991 - RA 7164 – Philippine Nursing Law of 1991 - sponsored by Sen. Edgardo Angara & Sen. Heherson Alvarez

October 21, 2002 - RA 9173 – Philippine Nursing Act of 2002 - sponsored Sen. Juan Flavier

RA 9173

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• An act providing for a more responsive nursing profession, repealing for the purpose RA 7164 known as the “Phil. Nursing Act of 1991 and for other purposes. This act shall be known as the “Phil. Nursing Act of 2002”

• Declaration of Policy - it is hereby declared the policy of the State to assumes responsibility for the protection and improvement of the nursing profession by instituting measures that will result in:

• relevant nursing education, • humane working conditions, • better career prospect • and a dignified existence of our nurses.• The State hereby guarantees the delivery of quality basic health care

services through an adequate nursing personnel system throughout the country.

• Creation and Composition of the Board • A chairperson and six members, appointed by the President of the Republic of

the Philippines• 2 nominees per vacancy of the PRC chosen and ranked from a list of 3 nominees

per vacancy of the accredited professional organization of nurses who has the ff. qualifications at the time of their appointment:

• natural born citizen• member of good standing of the accredited professional organization for nurses• RN, MAN, MA Education or other allied profession from university duly

recognized by the Government; provide that majority are MAN; Chairman is MAN holder

• 10 years continuous practice; last 5 years in the Phil.• not convicted of any offense involving moral turpitude• membership to the board shall hold 3 areas namely, nursing education, nursing

service and community service• Requirement upon qualification:

• immediately resign from teaching from any school, college or university offering nursing education, review program for the local nursing board or in any office or employment in the government or in any government owned corporations

• She/he shall not have pecuniary interest or administrative supervision over any institution offering nursing education.

• Term of Office • 3 years ; can be reappointed for another 3 years• any vacancy in the Board occurring shall be filled for the unexpired portion of the

term only (HOLD OVER DOCTRINE)• the Board shall be under the supervision of PRC

• Powers and Duties of the Board – shall supervise and regulate the practice of nursing and shall have the following powers:

• Quasi – Judicial Powers – conducts hearings and investigations to resolve complaints against nurse

practitioners for unethical and unprofessional conduct; issues subpoena ad testificandum & subpoena duces tecum to secure appearance of respondents & production of documents and punish with contempt for non-compliance, impeding & or otherwise interfering with the conduct of the proceedings.

• Quasi – Legislative Powers– promulgate Code of Ethics– recognize nursing specialty organization with the accredited professional

organization

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– prescribe, adopt, issue, promulgate guidelines, regulations, measures and decisions as may be necessary for the improvement of the nursing practice, advancement of the nursing profession and for the proper and full enforcement of this Act

• POLICE POWERS:– conduct licensure exam for nurses– issue suspend or revoke certificate of registration– Monitor and enforce quality standards of nursing

practice ; exercise powers necessary to ensure the maintenance of efficient, ethical, technical and moral professional standards in the practice of nursing taking into account

the health needs of the nation.

– Ensure quality nursing education by:– examining prescribed facilities of nursing schools– ensure standards of nursing education are properly complied and

maintained

• Removal or Suspension of Board Members – continued neglect of duty– commission or toleration of irregularities in the licensure examination– unprofessional, immoral or dishonorable conduct

• Quasi – Legislative Powers – conducts hearings and investigations to resolve complaints against nurse

practitioners for unethical and unprofessional conduct; issues subpoena ad testificandum & subpoena duces tecum to secure appearance of respondents & production of documents and punish with contempt for non-compliance, impeding & or otherwise interfering with the conduct of the proceedings.

• Quasi – Judicial Powers: – promulgate Code of Ethics– recognize nursing specialty organization with the accredited professional

organization

• Quasi – Judicial Powers: – promulgate Code of Ethics– recognize nursing specialty organization with the accredited professional

organization– prescribe, adopt, issue, promulgate guidelines, regulations, measures and

decisions as may be necessary for the improvement of the nursing practice, advancement of the nursing profession and for the proper and full enforcement of this Act

• Removal or Suspension of Board Members– continued neglect of duty– commission or toleration of irregularities in the licensure examination– unprofessional, immoral or dishonorable conduct

Qualifications for Admission to the Licensure Examination:

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• Citizen of the Phil or subject of a country which permits Filipino nurses to practice within its territorial limits on the same basis as the subject or citizen of such country, PROVIDED, the requirements for the registration or licensing of nurse in said country are substantially the same as those prescribed in this Act.

• Good moral character• BSN degree holder from a college or university

Ratings• General weighted average of 75% with no grade lower than 60 % in any subject• An examiner who gets an average of 75% or higher but gets a rating of below

60% percent in any subject, takes the examination only on the subject he/she failed but should obtain a rating of at least 75% in the subject/s repeated

• Certificate of registration shall be issued after the oath taking ceremony, which is renewable every three years

Registration by Reciprocity• A certificate of registration/ professional license may be issued without

examination to nurses registered under the laws of a foreign country or state provided that the requirements for registration or licensing of nurses in said country are substantially the same as those prescribed under this Act, provided further that the laws of such State grant the same privileges to registered nurses of the Phil., on the same basis as the subject or citizens of such foreign country or State.

Practice Through Special/Temporary Permit• Licensed nurses from foreign country/state whose services are either for a fee or

free if they are internationally known specialists, or outstanding experts in any branch or specialty of nursing

• On medical mission whose service shall be free in a particular hospital, center or clinic

• Exchange professors in any branch of specialty nursing• The special permit shall be effective only for the duration of the project, medical

mission or employment contract.

Revocation/Suspension of Cert. of Registration/ Prof. License & Cancellation of Special/Temporary Permit

• Persons convicted by final judgment of any criminal offense involving moral turpitude

• Person guilty of immoral or dishonorable conduct• Any person declared by court to be of unsound mind• Unprofessional and unethical standard• Gross incompetence or serious ignorance• Malpractice or negligence in the practice of nursing• Uses fraud deceit, or false statements in obtaining certificate of registration/

professional license or special/temporary permit • Violation of the Code of Ethics or conditions for the issuance of temporary/special

permit• Practicing his/her profession during his/her suspension from such practice• PROVIDED however that such suspension of the cert. of registration/prof. license

shall be for a period not to exceed 4 years

Inactive nurses returning to practice (for more than 5 years) are required to undergo 1 month didactic training & 3 months practicum in accredited hospitals.

• Qualifications of the Faculty 1. RN

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2.0ne year experience of clinical practice in a filed of specialization3. Member of good standing of accredited professional nursing org.4. MAN, MA Education or other allied medical sciences conferred by a

college or university duly recognized by the government5. Dean - MAN and must have at least 5 years experience in nursing

• Scope of Nursing Practice • A person shall be deemed to be practicing nursing within the meaning of

this Act when he/she singly or in collaboration with another, initiates and performs nursing services to individuals, families and communities in any health care setting.

1. It includes but not limited to: nursing care during conception, labor, delivery, infancy, childhood, toddler, pre-school, school age, adolescence, adulthood and old age.

2. As independent practitioners, nurses are primarily responsible for the promotion of health & prevention of illness.

3. As members of the health team, nurses shall collaborate with other health care providers for the curative, preventive, and rehabilitative aspects of care, restoration of health, alleviation of suffering and when recovery is not possible, towards a peaceful death.

4. Provide nursing through the utilization of the nursing process. Nursing care includes but not limited to:– traditional and innovative approaches– therapeutic use of self– executing health care techniques and procedures, essential primary

health care, comfort measures, & health teachings– administration of written prescriptions for treatment therapies, oral,

parenteral medications, – internal examinations during labor in the absence of antenatal

bleeding – delivery– in case of suturing of perineal laceration, special training shall be

provided according to protocol established

5. Establish linkages with community resources and coordination with the health team6. Provide health education to include families and communities

• each, guide and supervise students in nursing education programs including administration of services in varied settings such as hospitals, and clinics and undertake consultation services; engage in such activities that require the utilization of knowledge and decision making skills as registered nurses

• undertake nursing and health human resources development training, which shall include but not limited to the development of advance nursing practice

• Qualifications of Nursing Service Administrators– RN– At least 2 yrs. experience in gen. nursing service administration– BSN degree holder with at least 9 units in management and administration

courses at the graduate level– Member of good standing of the accredited professional organization for nurses– For chief nurse/ director of nursing service – 5 yrs. experience in supervisory

or managerial position & MAN holder

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– For military chief nurses – MAN plus completion of the General Staff Course (GSC)

• Prohibitions in the Practice of Nursing ( Penalty: fine of Ps50,000.00 but not more than Ps100,000.00 or imprisonment of not less than 1 year but not more than 6 years or both)

- Any person who practices nursing1. without certificate of registration/ professional license ; temporary permit2. Who uses as his/her own certificate of registration/ license/permit of another3. Who uses an invalid, suspended, revoked, expired, cancelled certificate,

license or permit4. Who gives any false evidence to the Board in order to obtain a cert. of

registration/ license/ or permit5. Who appends BSN/ RN or any similar appendages to his/her name without

having been conferred said degree or registration6. Who falsely advertises as registered/licensed nurse or uses any other means

that tend to convey the impression that he/she is a registered/licensed nurse7. Who as a registered/licensed nurse, abets or assists the illegal practice of a

person who is not lawfully qualified to practice nursing

– any person or the CEO of a juridical entity who undertakes in-service educational programs or who conducts review classes for both local & foreign examination without permit/clearance from the BON & PRC

– any person or employer of nurses who violates the minimum base pay of nurses and the incentives & benefits that should be accorded as specified in RA 6758 “Compensation and classification Act of 1989”

– Any person or the CEO of a juridical entity violating any provision of this Act and its rules and its rules and regulations

• BON RESOLUTION NO. 20 SERIES OF 1994 1. Stages of development shall include conception, labor, delivery, newborn,

neonatal, infancy, toddler, pre-school, school age, adolescence, adulthood, aged and death.

2. Nursing care of individual includes:– Supervision and care of women during pregnancy and labor– Performing internal examination and delivery of babies– Suturing lacerations in the absence of a physician– Providing first aid and emergency care– Recommending herbal and symptomatic medicines

3. Intravenous injections shall include:– Intravenous administration of drugs, fluids and electrolytes, blood and

blood products– Insertion of needle butterfly in IV infusion

• LAWS AND REGULATIONS AFFECTING NURSING/MIDWIFERY PRACTICE IN THE PHILIPPINES

Republic Acts:RA 1136 - TB law, reorganizing division of TB control in the DOHRA 3573 - Reporting of Communicable DiseasesRA 3753 - Civil Registry Law-RA 4073 - Treatment of Leprosy in a government skin clinic, rural health unit or

by duly licensed physicianRA 4226 - Hospital Licensure ActRA 5181 - Permanent residence & reciprocity qualifications for

examination/registration

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RA 5901 - Working hours & compensation of hospital & clinic personnelRA 6136 - Expressly authorizes the giving of IV & other injections by the nurse

only under the direction & supervision of a physicianRA 6675 - Generics Act of 1988RA 6725 - Strengthening Prohibition on Discrimination against WomenRA 7170 - Organ DonationRA 7305 - Magna Carta of Public Health WorkersRA 7392 - Midwifery LawRA 7600 - Rooming –in and Breastfeeding Act of 1992RA 7610 - Child Abuse & ExploitationRA 7624 - Drug EducationRA 7877 - Sexual Harassment LawRA 8172 - Asin Law of the PhilippinesRA 8187 - Paternity LeaveRA 8353 - Anti-Rape LawRA8423 - Traditional & Alternative Medicine Act of 1997RA 8749 - Clean Air ActRA 8980 - Early Childhood Care & Development Act of the PhilippinesRA 8981 - Comprehensive Drug Act of 2002RA 9165 - PRC Modernization Act of 2002RA 9288 - Newborn Screening Act

Presidential Decrees:• PD 48 - Four (4) children with paid maternity leave privileges• PD 69 - Four (4) children for tax exemption• PD 223 - Creation of PRC• PD 442 - New Labor Code• PD 603 - Child and Youth Welfare Code• PD 651 - Birth Registration• PD 825 - Garbage Disposal • PD 856 - Sanitation Code

PD 965 - Family Planning & Responsible Parenthood Instructions prior to issuance of marriage license

• PD 996 - Compulsory Immunization for children below eight (8) years old

Executive Orders:EO 51 - Milk Code

EO 80 - Collective Bargaining Rights of government workersEO 296- Accredited professional organization of nurses must create a

nomination committee composed of its past presidents who will screen nominees or applicants to the BON

EO 857 - Compulsory Dollar Remittance

PRC and Board Resolutions:# 187 s. 1991 - Issuance and Renewal of Professional License# 217 s. 1992 - Delisting of delinquent professionals# 633 s. 1984 - ICN Code of Ethics# 1955 s. 1989 - PNA Code of Ethics# 8 s. 1994 - Special Training on IV Therapy

Proclamations , Pronouncements, Letters of Instructions & House Bills:

Proc. # 6 - United Nations’ goal on Universal Child Immunization by 1990Proc. # 539 - Nurses’ Week (every 3rd week of October)LOI # 949 - Legal basis of Primary Health Care

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HB 4110 - REPRODUCTIVE Health Care Agenda Act of 2001HB 3744 - Empowerment of Women in Vulnerable Situation ActHB 3773 - Responsible Parenthood and Population Movement Act of 2005

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