Nursing Legal and Ethical Responsibilities PDF

LEGAL AND ETHICAL RESPONSIBILITIES The word law is derived from an Anglo-Saxon term meaning that which is “laid down or fixed.” Two types of law 1. Public law - deals with an individual’s relationship to the state. 2. Civil law - deals with relations between individuals. LEGAL LIABILITY IN NU...

LEGAL AND ETHICAL RESPONSIBILITIES The word law is derived from an Anglo-Saxon term meaning that which is “laid down or fixed.” Two types of law 1. Public law - deals with an individual’s relationship to the state. 2. Civil law - deals with relations between individuals. LEGAL LIABILITY IN NURSING When the nurse fails to meet the legal expectations of care, the client can initiate action if harm or injury is incurred by the client. Negligence and Malpractice Liability is an obligation one has incurred or might incur through any act or failure to act. Malpractice - refers to a professional person’s wrongful conduct, improper discharge of professional duties, or failure to meet the standards of acceptable care that results in harm to another person. (Zerwekh & Claborn, 2008). Negligence (breach of duty) - is the failure of an individual to provide care that a reasonable person would ordinarily use in a similar circumstance. In other words, action that is contrary to the conduct of a reasonable person and results in harm is considered to be negligent behavior. Proof of liability depends on four elements: 1. Duty is an obligation created either by law or contract or by any voluntary action. It is the first element that must be proved for malpractice. 2. Breach of duty occurs when a nurse fails to act in accord with the standard of care. An act of commission or omission of the nurse may constitute a breach of the standard of care. 3. Injury (physical, financial, or emotional harm) must be demonstrated by the person making the claim to prove negligence. 4. Causation is the breach of duty that must be proved to have legally caused the injury. A cause-and-effect relationship must be clearly established. INFORMED CONSENT Laws regarding informed con sent protect the client’s right to self-determination. A client is able to make an informed decision about consenting to or refusing a treatment regime only if adequate information has been presented. The law requires that clients, or their representatives, be given sufficient information regarding various treatment modalities so that the consent is an informed process. A consent is a voluntary act by which a person agrees to allow someone else to do something. Informed consent means that the client understands the reason for the proposed intervention, and its benefits and risks, and agrees to the treatment by signing a consent form. The client must be mentally competent to give consent for medical procedures. Obtaining the informed consent requires client teaching by the health care provider since clients must understand procedures and consequences of treatment and nontreatment. The health care provider may not coerce the client to sign the consent. The client has the right to refuse the information, waive the informed consent, and undergo treatment. The client’s refusal must be documented in the client’s medical record. The signing of an informed consent can also be waived for urgent medical and surgical intervention as long as institutional policy so indicates. Obtaining the client’s informed consent is the responsibility of the health care provider who is to perform the therapeutic activity. Safety First display. When nurses sign a consent form as a witness, in actuality they are validating that they have seen the client sign the consent form. Parental or guardian consent should be obtained before treatment is initiated on a minor. There are three exceptions 1. An emergency; situations where the consent of the minor is sufficient, such as treatment of a sexually transmitted disease. 2. Situations where a court order or other legal authorization has been obtained. If a client is a minor and the parents or legal guardian deny the lifesaving treatment, the court may overrule the decision. 3. Under the laws of most states and Canadian provinces, an emancipated minor (one who is married, pregnant, a parent, or financially independent) can give a valid consent to treatment. ASSAULT AND BATTERY Assault - is an intent to touch a person in an offensive, insulting, or physically intimidating manner. Battery - is the touching of another person without the person’s consent. The legal issues arising from assault and battery are usually based on whether the client consented to the touching that occurred. Because assault and battery both deal with acts of touching, the client’s cultural values, beliefs, and practices must be respected by the nurse. If the nurse fails to recognize cultural differences, undesired outcomes may occur in the nurse client relationship. False Imprisonment - occurs when clients are led to believe they cannot leave a place. The most common example of this tort is telling a client not to leave the hospital until the bill is paid (Zerwekh & Claborn, 2008). RESTRAINTS AND SECLUSION The Omnibus Budget Reconciliation Act (OBRA) of 1987 outlines the rights of the client and the responsibilities of health care providers regarding the use of both physical and chemical restraints. The nurse is to use safety measures, such as keeping the client’s bed in a low position and frequently assessing the client, in an effort to avoid the use of restraints. Chemical restraints, primarily psychotropic medications (e.g., sedatives, hypnotics, antianxiety agents, and neuroleptics), are used to control hyperactive behavior of agitated clients. If a competent client refuses to follow orders and the nurse uses restraints, the nurse can be charged with false imprisonment, assault and battery, or both. In an emergency situation when a client becomes violent and is in imminent danger of harming himself or herself or others, the nurse may apply restraints and then immediately obtain an order from the prescribing practitioner. The law mandates that the use of restraints or seclusion must have a prescribing practitioner order. The nurse is legally accountable for the client in restraints or seclusion. Care of clients in restraints requires documentation according to specific agency policies. PRIVACY AND CONFIDENTIALITY An essential component of nursing practice is protecting the client’s confidentiality and privacy. The American Nurses Association (ANA) Guide to the Code of Ethics for Nurses (2008a) identifies privacy and confidentiality as key elements in maintaining the integrity of the nursing profession. Nurses are accountable for respecting the client’s right to privacy. State laws that respect privilege doctrine guarantee that no one will reveal confidential information without the client’s permission. Nurses must obtain the client’s permission before disclosing any information regarding the client, going through the client’s personal belongings, performing procedures, and photographing the client. The Canadian Nurses Association (CNA) has developed its own code of ethics. The CNA’s Code of Ethics for Nursing (2008) has involved nurses in all provinces and territories in Canada. Within the CNA’s Code of Ethics, the value that applies to confidentiality states that the nurse is responsible to hold confidential all information about a client learned in health care settings. The nurse-client relationship is based on trust. Any violation of the client’s privacy or breach of confidentiality may interfere with trust. Nurses must ensure that clients understand their privacy rights, including withholding information, such as their diagnoses, from the family. For example, clients with sexually transmitted diseases or who are positive for the human immunodeficiency virus (HIV) may choose to withhold this information from their family. Privacy involves more than protecting confidential communication. Nursing care should be delivered with a caring attitude that provides for privacy, such as keeping the door to the client’s room closed, knocking before entering the client’s room, closing the curtains around the bed before exposing the client, and draping the client appropriately for procedures. A rapidly increasing problem that threatens privacy and confidentiality is access to electronic data. The technological proliferation of cellular phones, facsimile machines, and electronic health records (EHRs) may jeopardize the privacy of information. In 2004, a presidential executive order called for the adoption of EHRs by 2014 (Westra, Delaney, Konicek, & Kennan, 2008). As the use of EHRs expands, there will be more issues about protecting the privacy of shared health information. In 1996, Congress enacted the Health Insurance Portability and Accountability Act (HIPAA) to ensure the privacy of individual health care information. HIPAA rules require written confirmation that clients have been informed about their privacy rights (U.S. Department of Health and Human Services, 2002). As a result of the HIPAA, the following changes have been implemented in health care settings: Posting a client’s name near the room door is prohibited. Charts containing clients’ names cannot be within public view. Calling out clients’ names (e.g., in clinic waiting rooms) is prohibited. Medical records must be stored in secure areas. Clients’ health care information must be discussed in private areas. DEFAMATION Defamation - occurs when information is communicated to a third party that causes damage to someone else’s reputation either in writing (libel) or verbally (slander). The most common examples of this tort are giving out inaccurate or inappropriate information from the medical record; discussing clients, families, or visitors in public areas; and speaking negatively about coworkers (Zerwekh & Claborn, 2008). FRAUD Fraud results from a deliberate deception intended to produce unlawful gain. Fraudulent billing practices include overcharging for services and billing for services that were not provided. Other examples of fraud in health care include obtaining and using false credentials and falsifying medical records. Nursing activities to deter fraud include the following: Documenting facts accurately Reporting illegal activities Educating peers and the public as to what constitutes fraud UNPROFESSIONAL CONDUCT Conduct of a health care provider that could adversely affect the health and welfare of the public constitutes unprofessional conduct. The following actions or omissions constitute unprofessional conduct: Breach in client confidentiality Failure to use sufficient knowledge, skills, or nursing judgment when practicing nursing Physically or verbally abusing a client Assuming duties without sufficient preparation Knowingly delegating nursing tasks to unlicensed personnel that places the client at risk for injury Failure to accurately maintain a record for each client or falsifying a client’s record Leaving a nursing assignment without properly notifying appropriate personnel USE OF CONTROLLED SUBSTANCES The improper use of controlled substances may lead to criminal penalties under laws governing the distribution and use of controlled substances (narcotics, depressants, stimulants, and hallucinogens). Agencies that distribute controlled substances must follow federal and state regulations regarding the security and access to these drugs. Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970 (Controlled Substances Act) requires accurate documentation of narcotic administration. THE IMPAIRED NURSE If a nurse suspects a coworker is abusing chemicals, the nurse has a duty to report the individual to nursing administration in a confidential manner with the goal of treatment being the priority issue. Nursing administration should then notify the board of nursing regarding the nurse’s behavior. Nurses must safeguard the client and the public by reporting the incompetent, unethical, or illegal practice of any person. Some boards of nursing will discipline a nurse for failing to report a fellow nurse who is abusing drugs. Impaired nurse - is habitually intemperate or is addicted to the use of alcohol or habit-forming drugs. Some indicators of substance abuse in nurses are: Social isolation (e.g., requesting to work the night shift) Changes in personal appearance and mood Excessive work-related tardiness, absences, and accidents Excuses for being unavailable while on duty Resistance to change Defensive when questioned about client complaints and discrepancies in the narcotic control sheet Failure to meet schedules and deadlines Inaccurate and sloppy documentation SAFETY The promotion of physical safety is one of the most important responsibilities of the nurse. There are four areas regarding client safety in which nurses are at legal risk: 1. Failure to monitor client status 2. Medication errors 3. Falls 4. Use of restraints LEGAL ISSUES RELATED TO DEATH AND DYING 1. Do Not Resuscitate Orders Cardiac arrest requires the initiation of cardiopulmonary resuscitation (CPR) by competent persons. In health care settings, caregivers (often nurses) perform CPR and other lifesaving measures according to agency policy unless the primary prescribing practitioner has written a do not resuscitate (DNR) order in the client’s medical record. The prescribing practitioner’s DNR order provides an exception to the universal standing order to resuscitate. Health care agencies are required to have policies in place that provide a mechanism for reaching a DNR decision as well as for resolving conflicts in decision making. The principles of informed consent must be respected by the prescribing practitioner who writes a DNR order. When the client is either comatose or near death, there should be knowledgeable concurrence by the prescribing practitioner and the client’s family or guardian about actions to prolong the client’s life. It is the responsibility of the nurse to know and follow the client’s wishes relative to resuscitation and the application of life-support systems. This information must be documented in the client’s medical record. 2. Wills The United States and Canada have laws regarding the legal requirements for written and oral wills. Nurses are usually required to notify the prescribing practitioner and nurse supervisor before acting as a witness and signing a will. Nurses should refrain from assisting the client with the wording of the will, as this should be done with legal advice from an attorney. When serving as a witness, a nurse is verifying that it is indeed the client who is actually signing the documents. 3. Pronouncement of Death Medicine has yet to agree on one acceptable definition of death. The various definitions are as follows: the absence of awareness of external stimuli, lack of movement or spontaneous breathing, absent reflexes, a flat brain wave repeated twice in 24 hours, and the Uniform Definition of Brain Death, which requires irreversible cessation of all functioning of the brain. State regulatory boards have initiated laws to protect the public when dealing with issues of death. It is usually within the scope of practice of medicine to pronounce a client dead. However, some boards of nursing allow the nurse, in certain circumstances and with thorough documentation, to make a determination and pronouncement of death. 4. Care of the Deceased When a client dies, the nurse is obligated to treat the deceased with respect and dignity. The nurse should prepare the body for removal to the morgue in accordance with agency policies. The nurse is responsible for properly identifying the body. Wrongful identification of the body could result in severe distress for the family of the deceased as well as negative legal ramifications for both the health care agency and the nurse.  5. Autopsies An autopsy is performed to determine the cause of death. Autopsy results are used in cases of suspicious death or the presence of communicable disease. The cause of death also has implications regarding payment from insurance policies and workers’ compensation. Some states require consent for an autopsy in writing, whereas other states accept telegrams or documented telephone conversations. Regardless of how consent is obtained, the prescribing practitioner must document that consent was obtained and identify in the client’s record who authorized the autopsy. In some states, consent for an autopsy is not required in unwitnessed deaths because this situation requires a mandatory autopsy. The nurse is responsible for ensuring that all documentation is in place before releasing a body for autopsy. 6. Organ Donation All 50 states have adopted the Uniform Anatomical Gift Act for cadaver organ donation. In the United States and Canada, any person aged 18 or older may become an organ donor by written consent. In the absence of appropriate documentation, a family member or legal guardian may authorize donation of the organs. Nurses and other caregivers are expected to approach families for organ donation in the absence of documentation of the client’s wishes. Consent for an organ donation requires the collaborative efforts of the nurse with prescribing practitioners, social workers, and clergy to ensure timely removal of the organs. CONCEPT OF ETHICS Ethics - is the branch of philosophy that examines the differences between right and wrong. Ethics looks at human behavior—what people do under what type of circumstances. But ethics is not merely a philosophical discussion; ethical persons put their beliefs into action. Morality is behavior in accordance with custom or tradition and usually reflects personal or religious beliefs. example of a moral belief: is a person’s desire to maintain his or her right to die. Bioethics - the application of general ethical principles to health care. Ethics is the free, rational, and publicly stated assessment of alternative actions in relation to theories, principles, and rules. Ethics is rooted in the legal system and reflects the political values of our society. An example of an ethical belief is the practice of parents’ teaching their children the importance of telling the truth. Relationship between Legal and Ethical Concepts There is a connection between acts that are legal and acts that are ethical. Sometimes, it is difficult to separate legalities from ethics. Some legal acts are considered to be unethical and vice versa. According to Burkhardt and Nathaniel (2007), the following contribute to the occasional discrepancies between law and ethics: Ethical opinions reflect individual differences. Human behavior and motivation are too complex to be accurately reflected in law. The legal system judges action rather than intention. Laws change according to social and political influences. Professional nursing actions are both legal and ethical. ETHICAL PRINCIPLES Ethical principles - are tenets that direct or govern actions. They are widely accepted and generally are based on the humane aspects of society. Ethical decisions are principled; that is, they reflect what is best for the client and society. By applying ethical principles, nurses become more systematic in solving ethical conflicts. Ethical principles can be used as guidelines in analyzing dilemmas; they can also serve as a justification (rationale) for the resolution of ethical problems. Remember that these principles are not absolute; there can be exceptions to each principle in any given situation.  Ethical Principle Description 1. Autonomy ▪ Respect for an individual’s right to self-determination; respect for individual liberty. ▪ Freedom of choice 2. Nonmaleficence ▪ Obligation to do or cause no harm to another. ▪ Do no harm 3. Beneficence ▪ Duty to do good to others and to maintain a balance between benefits and harms ▪ To do good 4. Justice ▪ Equitable distribution of potential benefits and risks ▪ Fairness to all 5. Veracity Obligation to tell the truth 6. Fidelity Duty to do what one has promised. “word of honor” 7. Stewardship Conscientiously taking care of ones self. 8. Double Effect An act has both good and bad effect, Paternalism, an occurrence in which health care providers decide what is ‘‘best’’ for clients and then attempt to coerce (or ‘‘encourage’’) them to act against their own choices. Paternalistic health care providers treat competent adults as if they are children who need protection. Paternalism is usually not considered an ethical approach. However, in some situations paternalism may be advisable. For example, when prevention of harm overrides the loss of individual freedom and when an individual’s ability to choose is limited by incompetency, paternalism may be justified. The principle of inviolability of life states that it is not ethical to violate or destroy human life from the moment of conception and through the subsequent stages. Humble Position is a type of nursing approach that often decrease the client’s defense and makes the client more willing to listen without feeling embarrassed. ETHICAL CODES One hallmark of a profession is the determination of ethical behavior for its members. Several nursing organizations have developed codes as guidelines for ethical conduct. The International Council of Nurses (ICN) first developed its ethical code in 1953 and revised it in 2006. The ICN Code for Nurses (ICN, 2006) emphasizes nursing’s respect for human rights, including the right to life, the right to dignity, and the right to be treated with respect. The ICN code promotes an environment that respects the values, customs, and spiritual beliefs of the individual. The CNA developed a code of ethics in 1980 and revised it in 2008 (CNA, 2008). The CNA code serves as a guide for professional nurses to assist in working through ethical dilemmas encountered in all practice settings. The Filipino Client's Bill of Rights 1. The client the right to considerate and respectful care, irrespective of his/her socio-economic status. 2. The client the right to obtain from his/her physician complete current information concerning his/her diagnosis, treatment and prognosis in a terminology that the client can reasonably be expected to understand. When it is not medially advisable to give such information to the client, the information should be made available to an appropriate person on his/her behalf- He/she has the right to know by name or in person, the medical team responsible for coordinating his/her care. 3. The client has the right to receive from his/her physician information necessary to give informed consent prior to the start of any procedure and/or treatment. Except in emergencies, such information for informed consent should include, but not necessarily be limited to, the specific procedure and/or treatment, the medically significant risks involved, and the probable duration of incapacitation- When medically significant, alternatives for care or treatment exist, or when the client requests information concerning medical alternatives, the client has the right to such information. The client also has the right to know the name of the person responsible for the procedure and/or treatment. 4. The client has the right to refuse treatment/life - giving measures, to the extent permitted by law, and to be informed of the medical consequences of his/her action. 5. The client has the right to every consideration of his/her privacy concerning his/her own medical care t program. Case discussion. consultation, examination treatment are confidential and should be conducted discretely. Those not directly involved in his/her care must have the permission of the client to be present. 6. The client has the right to expect that all communications and records pertaining to his/her care should be treated as confidential. 7. The client has the right to request for services that within its capacity, a hospital must respond to. The hospital must provide evaluation, service and/or referral as indicated by the urgency of care. When Medically permissible, a client may be transferred to another facility only after he/she has received complete information concerning the needs and alternatives for such transfer. The institution to which the client is to be transferred must first have accepted the client for transfer. 8. The client has the right to obtain information regarding any relationship of the hospital to another health care and educational institutions in so far as his/her care is concerned. The client has the right to obtain information regarding the existence of any professional relationship among individuals, by name, who are treating him/her. 9. The client has the right to be advised if the hospital proposes to engage in or perform human experimentation affecting his/her care or treatment. The client has the right to refuse or participate in such research projects. 10. The client has the right to expect reasonable continuity of care. He/she has the right to know in advance the schedule of appointment with the physicians and where to see them. The client has the right to expect that the hospital will provide a mechanism whereby he/she is informed by his/her physician it or a delegate of the physician of the clients continuing health care requirements following discharge, 11. The client has the right to examine and receive an explanation or his/her bill regardless of the source of payment. 12. The client has the right to know what hospital rules and regulation apply to his/her conduct as a client. ETHICAL DILEMMAS Ethical dilemma - occurs when there is a conflict between two or more ethical principles. Ethical dilemmas are situations of conflicting requirements for which there is no right or wrong option. The most beneficial decision depends on the circumstances. Ethical analysis is not an exact science. When an ethical dilemma occurs, the nurse must make a choice between two alternatives that are equally unsatisfactory. In some cases, even after a dilemma seems to have been resolved, questions remain. This ambiguity makes it emotionally painful for the persons involved. The emotional discomfort is often a result of the nurse’s trying to second guess the decision and may lead to such self-messages as ‘‘If only I had done this’’ or ‘‘Maybe I should have.… Euthanasia Most people hope to experience a peaceful gentle death when their ‘‘time comes.’’ The word euthanasia comes from the Greek word euthanatos, which literally means ‘‘good, or gentle, death.’’ In current times, euthanasia refers to mercy killing (deliberate ending of life as a humane action). Active euthanasia refers to taking deliberate action that will hasten the client’s death. Passive euthanasia means cooperating with the client’s dying process. Passive euthanasia is the omission of an action that would prolong life. Assisted suicide is a form of active euthanasia in which health care professionals provide clients with the means to end their own lives. Recently, physician–assisted suicide has been the topic of much controversy. In 1997, the U.S. Supreme Court decided that there was no constitutionally protected right to physician–assisted suicide for clients who are terminally ill. Nurses have differing opinions regarding assisted suicide. Some view it as a violation of the ethical principles upon which the practice of nursing is based: autonomy, nonmaleficence, beneficence, justice, veracity, and fidelity. Other nurses view assisted suicide as a humane act. Regardless of a nurse’s personal viewpoint, assisted suicide is still illegal except in Oregon, the only state that has designated assisted suicide as a legal action. Other nurses may see assisted suicide as an ethical dilemma; they agree that it violates some ethical principles but question whether it violates others. KEY POINTS Standards are necessary to demonstrate to the public, government and other stakeholders that nurses are to maintaining public trust. Informed consent requires a full understanding of the and risks of a procedure. It protects the client, the nurse, The physician and the hospital. Advance directive is a document by a competent individual to establish the desired health care for the future or give someone else the right to make health care decisions if the individual becomes incompetent. Types: o Living will/Instructive directive: - Specifies the treatments that a client wants or does not want, if he/she become unable to make decisions for himself/herself. o Proxy or durable power of attorney: - The client appoints a particular person or surrogate to make medical decisions for him/her if he/she becomes unable to do so. The physician involved in the process must obtain the consent. The assigned primary nurse can serve as a witness to the client's signature. A Telephone orders should be accepted by the nurse only in extreme emergency. If a nurse receives a telephone order, the following should done: ✓ read back the order to ensure the order has been correctly received ✓ write the physician's name and one's name and signature. ✓ note the time ✓ make sure that the ordering physician signs his name as he/ she arrives, within 24, hours How to be Protected from Malpractice Suits ✓ Practice in accordance with standards ✓ Nursing law (and other relevant laws) ✓ Established clinical practices/procedures ✓ Agency and policies and procedures ✓ Legal concepts and principles ✓ Be careful not to encroach on medical practice ✓ Follow established practices protocols ✓ Observe agency policies and procedures. ✓ Always put client's and welfare first. ✓ Upgrade technical/clinical skills ✓ Document properly. ROLES OF THE NURSE On the client’s admission to the ward On the client’s discharge from the ward 1.Room preparation 1. Discuss the client's home care needs with the family. 2.Greet the client and family 2. Review the physician's orders on medications 3.Escort them to the assigned room treatment and follow-up 4.In non-private room, introduce to roommates 3. Provide discharge instruction to the client and family 5.Assess the general appearance of the client 4. Check that accounts have been settled 6.Check the physician admitting orders 5.Transport the client to the transportation service. 7.Assess the client's vital signs 6. Document the client's status and discharge on the 8. Obtain a nursing history discharge summary form 9. Perform physical assessment 7.Notify the appropriate department of the time of the 10.Provide instruction on scheduled treatments and client's discharge procedures 11. Notify the physician of the client admission 12.Clarify policies and procedures the client's family CATEGORIES OF NURSING INTERVENTION Categories Definition Examples 1. Dependent Intervention Performed based on instruction or Administer 2mg of haloperidol TID written directives given by other members of the health team 2. Independent Intervention Aspects of nursing care which are Assist the client to do deep identified in the nursing law that breathing and coughing exercises does not require directives from others. 3. Interdependent Intervention Nursing care which the nurse Administration of total parenteral carries out in collaboration with nutrition other members of the health team. TOP 10 BIGGEST BRAIN DAMAGING HABITS BY W.H.O 1. No breakfast 6. Sleep deprivation 2. Overeating 7. Head covered while sleeping 3. Smoking 8. Working your brain during illness 4. High sugar consumption 9. Lack in stimulating thoughts 5. Air pollution 10. Talking rarely BREAST SELF-EXAMINATION (BSE) is a screening method used in attempt to detect early breast cancer. The method involves the woman herself looking and feeling each breast for possible lumps, distortions or swelling. BSE was once promoted heavily as a means of finding cancer at a more curable stage, but large randomized controlled studies found that it was not effective in preventing death and actually caused harm through needless biopsies and surgery. “How to Performa Breast Self-Examination” There arę many good reasons for doing a Breast Self-Examination (BSE) every month. It's easy to do, and the more you do it, the better you get at it. suspicious breast lumps are found by women performing these self-exams, When you know how your breast normally feels you will be able to feel any changes. The best time to examine your breasts is right after your period. When they are not tender or swollen. If you do not have regular periods or sometimes skip a month, do it on the same day of every month. In six easy steps, here's how to do a BSE: 1. Lie down and put a pillow under your right shoulder. Place your right arm behind your head. 2. Use the finger pads three on your middle fingers on your left hand to feel for lumps or thickening in your right breast. Your "finger pads are the top thirds of each finger. 3. Press firmly enough to know how your breast feels. if you're not sure how hard to press, ask your health care provider. Or try to copy the way your health provider uses the finger pads during a breast exam- Learn what your breast feels like most of the time. A firm ridge in the curve of each breast is normal. 4. Move around the breast in a set way. You can choose either the circle (A), the up and down (B),or the wedge (C), Do it the same way month. It you belp to make sure that you've gone over the entire breast area, and to remember how your breast feels. 5. Now examine your left breast using the right hand finger nads 6. Repeat the examination of both breasts while standing, with one arm behind your head. The upright position to check the upper and outer parts of the breasts (toward your armpit). You may want to do the standing part of the BSE while you are in shower. Some breast changes can be felt more easily when your skin is wet and soapy. ▪ For added safety, you can also check your breast for any dimpling of the skin, changes in the nipple, redness, or standing in front of a miror right after your BSE each month. ▪ It is important for women to remember that BSE is not the only test for early detection of breast cancer. Mammography and clinical breast examination by a health professional are more than sensitive than BSE for finding small cancers. That is why the ACS recommends a of mammography, clinical* breast exam (CBE), and breast self-exam as outlined below: o Women 40 and older should have an annual mammogram, annual CBE by a health professional, and should perform monthly BSE. The CBE should be done close to the scheduled mammogram. o Women 20 to 39 should have a CBE every three years and should perform monthly BSE. Non -cancerous lump have the following characteristics: 1. They are smooth to the touch. 2. They are usually round in shape. 3. They are almost always painful. 4. They move easily when you touch them 5. A slight enlargement of the breast usually accompanies their presence. 6. Some non-cancerous limp also disappear one or two days after menstruation. Cancerous lumps, on the other hand, have the following traits: 1. They are usually painless (although here are a few that cause pain) 2: They feel hard and solid. 3., They do not disappear when you get out period. 4. They usually feel rigid and immobile. STRESS Is the state produced by a change in environment that is perceived as challenging, threatening or damaging to the person’s dynamic balance of equilibrium. Elements that causes Stress: 1. Causative factor 2. Individual personality or genetic make up 3. Reaction of the Individual Types of Stress: 1. Physical stressor 2. Psychological stressor 3. Familial stressor 4. Financial stressor 5. Social stressor 6. Spiritual stressor 7. Academic stressor 8. Clinical stressor Signs and Symptoms of Stress: Symptoms or reaction to stress can be divided into several categories: physical, cognitive, emotional, behavioral. Examples of sign and symptoms of stress and the categories under which they fall include. Physical Cognitive Emotional Behavioral Headaches Difficulty Concentrating Anger Increased alcohol use Backaches Forgetfulness Anxiety Cigarette smoking Chest Tightness Worrying thoughts of death Depression Increased caffeine use Fatigue Poor attention to details Poor self esteem Drug use Perfectionist Stomach Cramps Moodiness Overreacting Tendencies Difficulty Breathing Incisiveness Suspiciousness Violence Diarrhea Feeling Hopeless Guilt Weight gain or loss Loss Of Sexual Interest Catastrophizing Weeping Relationship conflict Insomnia Blowing things out of proportion Loss of motivation Decreased activity Coping with stress: 1. Coping Strategies 2. Social Support 3. Biofeedback 4. Aerobic exercise LOSS Loss is any situation (either actual, potential, or perceived) in which a valued object is changed or is no longer accessible to the individual. Because change is a major constant in life, everyone experiences losses. Loss can be actual (e.g., a spouse is lost through divorce) or anticipated (a person is diagnosed with a terminal illness and has only a short time to live). A loss can be tangible or intangible. For example, when a person is fired from a job, the tangible loss is income, whereas the loss of self-esteem is intangible. Losses occur as a result of moving from one developmental stage to another. An example of such a maturational loss is the adolescent who loses the younger child’s freedom from responsibility. A situational loss occurs in response to external events, usually beyond the individual’s control (such as the death of a significant other). LOSS AS CRISIS Loss precipitates anxiety and a feeling of vulnerability— which may lead to crisis. When a significant other dies, one’s sense of safety and security is disrupted. Grieving is a mechanism for crisis resolution. When an individual feels overwhelmed by stress and the usual coping mechanisms are no longer effective, crisis occurs. TYPES OF LOSS Loss occurs when a valued object is changed or is no longer available. Not everyone responds to loss in the same way because the significance of the lost object or person is determined by individual perceptions. Actual loss: Death of a loved one, theft of one’s property Perceived loss: Occurs when a sense of loss is felt by an individual but is not tangible to others Physical loss: Loss of an extremity in an accident, scarring from burns, permanent injury Psychological loss: Such as a woman feeling inadequate after menopause and resultant infertility Four major categories of loss: 1. Loss of external objects 2. Loss of familiar environment 3. Loss of aspects of self 4. Loss of significant other GRIEF Grief is a series of intense physical and psychological responses that occur following a loss. It is a normal, natural, necessary, and adaptive response to a loss. Loss leads to the adaptive process of mourning, the period of time during which the grief is expressed and resolution and integration of the loss occur. Bereavement is the period of grief following the death of a loved one. Types of grief: 1. Uncomplicated Grief a grief reaction that normally follows a significant loss. Uncomplicated grief runs a fairly predictable course that ends with the relinquishing of the lost object and resumption of the previous life. Even though the bereaved person’s life is changed forever, the person is able to regain the ability to function. 2. Dysfunctional Grief do not progress through the stages of overwhelming emotions associated with grief, or they may fail to demonstrate any behaviors commonly associated with grief. The person experiencing pathologic grief continues to have strong emotional reactions, does not return to a normal sleep pattern or work routine, usually remains isolated, and has altered eating habits. The bereaved may have the need to endlessly tell and retell the story of loss but without subsequent healing. Visits to the grave site or mausoleum may be made often or not at all. Dysfunctional grief is a demonstration of a persistent pattern of intense grief that does not result in reconciliation of feelings. 3. Anticipatory Grief is the occurrence of grief work before an expected loss. Anticipatory grief may be experienced by the terminally ill person as well as family. This phenomenon promotes adaptive grieving by freeing up the mourner’s emotional energy. Although anticipatory grieving may be helpful in adjusting to the loss, it may also result in some disadvantages. For example, for the dying client, anticipatory grieving may lead to family members’ distancing themselves and not being available to provide support. Also, if the family members have separated themselves emotionally from the dying client, they may seem cold and distant and thus may not meet society’s expectations of mourning behavior. Cause of Death The intensity of the grief response changes according to the cause of death, be it unexpected, traumatic, or a suicide. 1. Unexpected Death The loss occurring with an unexpected death poses particular difficulty for the bereaved in achieving closure. Unanticipated death, such as a death resulting from a natural disaster or other tragedy (e.g., airplane crash), leaves survivors shocked and bereaved. Often, the inability to say goodbye compounds the trauma of the death and may be a factor contributing to altered grieving. 2. Traumatic Death Complicated grief is associated with traumatic death such as death by homicide or suicide. Although traumatic death does not necessarily predispose the survivor to complications in mourning, survivors suffer emotions of greater intensity than those associated with normal grief. When loved ones die violently, the grievers may suffer from traumatic imagery, that is, reliving the terror of the incident or imagining the feelings of horror felt by the victim. Traumatic imagery is a common occurrence with traumatic death. Such thoughts, coupled with intense grief, can lead to posttraumatic stress disorder (PTSD). Nurses must be aware of the possibility of PTSD and be alert for the presence of symptoms, which may include: Sleep disturbances, such as recurrent, terror-filled nightmares Psychological distress Chronic anxiety Unless complicated grief is recognized and the survivors are encouraged to express the intense feelings, they will not be able to progress through the normal, adaptive grieving process. 3. Suicide The loss of a loved one to suicide is frequently compounded by feelings of blame in the survivors. They feel guilty for failing to recognize clues that may have enabled the victim to receive help. These feelings of guilt and self-blame can be transformed into anger at the victim for inflicting such pain, at themselves, and at caregivers. Feelings of shame for having a suicide in the family may also be present. DEATH In today’s social climate, death is viewed as something to be avoided at all costs; medicine, with its technological advances, pursues immortality. ‘‘People in our country deny death, believing that medical science can cure any patient. Death is often seen as a failure of the health care system rather than a natural aspect of life’’ (American Association of Colleges of Nursing [AACN], 2008, p. 1). Scientific advances do not change the fact that death is a part of every human existence. STAGES OF DEATH AND DYING In her classic works, Elizabeth Ku¨bler-Ross (1969, 1974) 1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance