أساسيات التمريض PDF

Evolution of Nursing and Health Care HISTORICAL OVERVIEW By learning from historical role models: Nurses can enhance their abilities to create positive change in the present and set a course for the future. Nursing history offers learning where the profession has been and its advancements. Learning from the past is the major reason for studying history. Ignoring nursing’s history can be detrimental to the future of the profession. By applying the lessons gained from a historical review, nurses will be a vital force in the new millennium. Evolution of Nursing Nursing has evolved with the development early civilizations to the present era of advanced nursing practice and health care reform. 1. Early Civilizations Evolution of nursing dates back to 4000 BC, mother-nurses worked with priests. In 2000 BC, use of wet nurses is recorded in Babylonia and Assyria. 2. Ancient Greece The nursing that was done by women was performed in the home. 3. Roman Empire Western hospitals were religious & charitable institutions in monasteries and convents. No formal training in therapeutic modalities and volunteered to nurse the sick. 4. Middle Ages Hospitals in large Byzantine cities were staffed by paid male assistants and male nurses. Hospitals were established as almshouses, care of sick secondary. The dominant caregivers in the Byzantine setting were men In rural parts of these societies, nursing was viewed as a natural nurturing job for women. 5. Renaissance Universities were established, but no formal nursing schools were founded. Women continued to fulfill the traditional role of nurturer/caregiver in the home. 6. Enlightenment and Industrial Revolution 1 Medical schools were founded, including the Royal College of Surgeons in London in 1800. At the end of the 18th century, no standards for nurses who worked in hospitals. Early to mid-1800s, nursing was considered unseemly for women. Most nursing care was still performed in the home by female relatives of ill. Religious Influences The development of nursing started in India (800–600 BC) and flourished in Greece and Ireland in 3 BC with male nurse-priests. In 1836, Theodor Fleidner revived the Church Order of Deaconesses to care for those in a hospital he had founded that these deaconesses of Kaiserwerth became formally trained in nursing. Florence Nightingale received her nurse’s training at the Kaiserwerth Institute. The Nursing Sisters of the Holy Cross was founded in LeMans, France by Father Bassil Moreau in 1841. In 1855, Saint Mary’s College became influential on the emerging role of women. Florence Nightingale Florence Nightingale is considered the founder of modern nursing. She became a nurse over the objections of society and her family. After completing the 3-month course of study at Kaiserwerth Institute Nightingale forged the future of nursing education She established Nightingale Training School of Nurses at St. Thomas’ Hospital in London. This was the first school for nurses that provided both theory-based knowledge and clinical skill building. She revolutionalized public’s perception of nursing & method for educating nurses. Some of Nightingale’s novel beliefs about nursing education were: o A holistic framework inclusive of illness and health o The need for a theoretical basis for nursing practice o A liberal education as a foundation for nursing practice o The importance of creating an environment that promotes healing o The need for a body of nursing knowledge that was distinct from medical knowledge Nightingale introduced many concepts that still used today that are: 1) Having a systematic method of assessing clients; 2) Individualizing care on the basis of the client’s needs and preferences; 2 3) Maintaining confidentiality. 4) Recognized the influence of environmental factors on health. 5) Provide clean surroundings with fresh air and light to improve the quality of care. 6) Nurses should be formally educated and function as client advocates. Nursing and the Civil War America’s need for nurses increased dramatically during the Civil War (1861– 1865). 12 sisters started caring for wounded soldiers, by end of the war, reached 80 sisters Dorothea Dix appointed 1st nursing administrative position by federal government. As a result of her efforts, more than 2000 women cared for the sick in the Union Army. Clara Barton in 1881, organized the Red Cross in the United States. Barton lobbied presidents and senators to allow nurses to form an organization to provide war relief. The Women’s Movement In 1848, Women were not considered equal to men, society did not value education for women, and women did not have the right to vote. With suffrage, not only were the rights of women advocated but also the nursing profession itself advanced. By the mid-1900s, more women were being accepted into colleges and universities, even though university-based nursing programs were available. Nursing Pioneers The establishment of public health nursing, provision of rural health care services, & advancement of nursing education occurred as a result of nurse pioneers works Lillian Wald In 1893, the first community health nurse, she founded public health nursing. Improved housing conditions in tenement districts Supported education for the mentally challenged Advocated passage of more lenient immigration regulations Initiated change of child labor laws Wald also established a school of nursing. 3 Isabel Hampton Robb Responsible for founding several nursing organizations, namely the Superintendents’ Society in 1893 and the Nurses’ Associated Alumnae of the United States and Canada in 1896. She recognized the necessity of nurses’ participating in professional organizations to establish unity throughout nursing on positions and issues. She was instrumental in establishing both the American Nurses Association and the National League of Nursing Education. Early supporter of the rights of nursing students. She called for shorter working hours and emphasized the role of the nursing student as learner instead of employee. Jane Delano created a division among nursing leaders Delano was opposed to the aide education plan (Physicians, not nurses, would train the aides in caring for the sick) because it violated the educational standards already established by nursing. Annie Goodrich Goodrich pushed for the establishment of an Army training school for nurses advocate of college-based educational nursing programs, Goodrich became the first dean of Yale University School of Nursing. Adelaide Nutting 1910 She actively campaigned for nurses being educated in university settings and Was the first nurse to be appointed to a university professorship Appointed to direct department established to prepare nurses for teaching and supervision in nurse training schools, for administration in hospitals, and for work in preventive and social aspects of nursing. Lavinia Dock 1914 She wrote one of the first nursing textbooks, Materia Medica for Nurses. Dock wrote many other books & was the first editor of American Journal of Nursing She encouraged nurses to unite when physicians objected to reforming labor laws to include nursing students. Mary Breckinridge 1925 She introduced a system for delivering health care to rural America. She created a decentralized system for primary nursing care services 4 Martha Franklin Martha Franklin was one of the first people to advocate racial equality in nursing. In 1908, Franklin organized the National Association of Colored Graduate Nurses (NACGN) Linda Richards 1873 She introduced the practice of keeping nurses’ notes and physicians’ orders as part of medical records. Also, Richards began the practice of nurses wearing uniforms. Margaret Sanger 1912 She coined the phrase “birth control” Adah Belle Thoms Thoms was one of the first to recognize public health as a field of nursing. NURSING IN THE 20TH CENTURY Flexner Report In 1910 Abraham Flexner visited the 155 medical schools in the United States and Canada. The Flexner report was based on these findings, and its goal was to increase accountability in medical education. The results of the study brought about the following changes: Closure of inadequate medical schools, Consolidation of schools with limited resources, Creation of nonprofit status for remaining schools, and Establishment of medical education in university settings based on standards and strong economic resources. Early Insurance Plans The concepts of third-party payments and prepaid health insurance were instituted Lillian Wald suggested the establishment of a national health insurance plan Landmark Reports in Nursing Education Goldmark Report 1923 Goldmark identified the major weakness of the hospital- based training programs as that of putting the needs of the institution (service delivery) before the needs of the student (education). 5 Some major inadequacies identified in nursing education by the study were limited resources, low admission standards, lack of supervision, poorly trained instructors, and failure to correlate clinical practice with theory. The report concluded that for nursing to be on equal footing with other disciplines, nursing education should occur in the university setting. Brown Report Several recommendations were put forth in this study, including the need for nurses to demonstrate greater professional competence by moving nursing education from the hospital to the university setting. Education and Practice: Contemporary Reports 1980s National Commission on Nursing The commission’s conclusions addressed the need for: Adequate clinical education for students Baccalaureate education and educational mobility Involvement of nurses in collaborative institutional and clinical decision making Improved working conditions, specifically, salaries, flexible scheduling, and differentiated practice As a result of the commission’s study, attention was given to the need for physicians and nurses to enter into collaborative practice. Secretary’s Commission on Nursing 1988 Made the following recommendations related to nursing practice: Nurse compensation Health care financing Nurse decision making Development, use, and maintenance of nursing resources SOCIAL FORCES AFFECTING NURSING From 4000 BC through the Christian era, women perform nurse role only in home. Church caused nursing to be viewed as a “service,” not a profession as medicine. The Crimean and Civil Wars focusing on women as nurse providers and on the need for nurse training. 6 During the 20th century, the evolution of medical education as an established profession had advanced that of nursing. Nursing almost exclusively a female profession had little power and, therefore, did not exert much influence on the social forces at play. The 1960s technologic advances increased the scope of practice The 1970s nursing theories were developed and nursing education in university setting. Nurses were becoming more politically astute in that they were working through professional organizations to affect health care legislation. During the 1980s, nursing became more specialized and autonomous. Expanded roles of nurses in response to greater demands for nursing services. During the 1990s, nurses were actively assuming more responsibilities for the delivery of health care. Nurses were involved in shaping policies for health care reform. Healthy People Initiatives Healthy People 2010 goals and objectives Major goals 1. Increase quality and years of healthy life. 2. Eliminate health disparities. Enabling goals 1. Promote healthy behaviors. 2. Promote healthy and safe communities. 3. Improve systems for personal and public health. 4. Prevent and reduce diseases and disorders. THE FUTURE OF NURSING Pressing issues for nursing include developing evidence-based practice adopted in diverse nursing care settings; monitoring safe practice in a restructured health care environment; and designing systems that will enhance collaborative planning, and implement actions and policies to address the changes occurring in the nursing labor market. Nurses and nursing students need to stay abreast of current issues and be active with local nursing leaders to communicate nursing’s position(s) on health care reform and alternative health care delivery models. Nurses are being recognized as autonomous professionals and are involved in administrative and clinical decision making. 7 Only when nurses are empowered are they truly autonomous. Summary Nursing is an art and a science in which people are assisted in learning to care for themselves whenever possible and cared for when they are unable to meet their own needs. Nurses will understand such issues as autonomy, unity within the profession, supply and demand, salary, education, and current practice and the empowerment of the profession by studying nursing’s history. Nursing’s early history was heavily influenced by religious organizations and the need for nurses to care for soldiers during wartime. Florence Nightingale forged the future of nursing practice & education as a result of her experiences in training nurses to care for soldiers. Nursing’s early American leaders, professional organizations, and landmark reports have influenced the infrastructure of current nursing practice. Influential nursing leaders, such as Lillian Wald, Jane Delano, Isabel Hampton Robb, Annie Goodrich, Adelaide Nutting, and Lavinia Dock, were instrumental in the advancement of nursing education and practice. Other nursing pioneers, such as Amelia Greenwald, Mary Breckenridge, Mamie Hale, Mary Mahoney, Linda Richards, and Margaret Sanger, made important contributions to both nursing education and the fields of rural, public health, maternity, and multicultural nursing. In 1923, the Goldmark report concluded that, for nursing to be on equal footing with other disciplines, nursing education should occur in the university setting. The Brown report (1948) addressed the need for nurses to demonstrate greater professional competence by moving nursing education to the university setting. The Health Maintenance Organization Act of 1973 provided an alternative to the private health insurance industry. Contemporary reports issued by the National Commission on Nursing, the Institute of Medicine, and the Secretary’s Commission on Nursing focused on the areas of nursing education, practice, and nursing’srole in health care financing policies. Developments such as alternative methods of health care delivery, evidence- based practice, and the efforts devoted to health care reform have led to diversified nursing roles. As the nursing profession continues to evolve and respond to the challenges within the health care system, nurses will remain responsive to societal needs. 8 Theoretical Foundations of Nursing Nursing theory provides a perspective from which to define the what of nursing, to describe the who of nursing (who is the client) and when nursing is needed, and to identify the boundaries and goals of nursing’s therapeutic activities. Theory is fundamental to effective nursing practice and research. The professionalization of nursing has been and is being brought about through the development and use of nursing theory. Components of the Theoretical Foundation The basic elements that structure a nursing theory are concepts and propositions. 1. Concept A concept is the basic building block of a theory. A concept is a vehicle of thought. The term concept refers to a “complex mental formulation of. 2. Proposition A proposition is a statement that proposes a relationship between concepts. What Is a Theory? A theory is a set of concepts and propositions that provide an orderly way to view phenomena. USE OF THEORIES FROM OTHER DISCIPLINES Non-nursing theories are often incorporated into nursing practice together with specific nursing theories. Non-nursing theories are transformed by the unique approach of the nursing perspective. Theories from biological, physical and behavioral sciences are commonly used in the practice of nursing. For example, Maslow’s Hierarchy of Basic Human Needs, Erikson’s Theory of Human Development Selye’s General Adaptation Syndrome IMPORTANCE OF NURSING THEORIES Why do we have nursing theories? In the early part of nursing’s history, Knowledge was extremely limited and almost entirely task oriented. From the very beginnings of nursing education, there was a need to categorize knowledge and to analyze client care situations to communicate in coherent and meaningful ways. 9 Nursing theories provide a framework for thought in which to examine situations. Greater professional autonomy and control of certain aspects of practice are achieved. Theory is necessary for continued development and evolution of the nursing discipline. Knowledge for nursing practice is developed through nursing research that, in turn, is used to either test existing theories or generate new theories. Exploring a variety of nursing theories ought to provide nurses with new insights into patient care, opening nursing options, and stimulating innovative interventions. Theoretical thinking enhances & strengthens nurse’s role & helps one to actually think nursing. Nursing theory is a tool for effective nursing practice. SCOPE OF THEORIES Essentially, three different categories relate to the scope of theories: grand theories, middle-range theories, and micro-range theories. 1. Grand Theory A grand theory is composed of concepts representing global and extremely complex phenomena. An example of a grand theory is Orem’s Self-Care Deficit Theory of Nursing. 2. Middle-Range Theory A theory that addresses more concrete and more narrowly defined phenomena. An example of a middle-range theory is Peplau’s Theory of Interpersonal Relations. 3. Micro-Range Theory A micro-range theory explains a specific phenomenon of concern to the discipline (Fawcett, 1993), such as the effect of social supports on grieving and would establish nursing care guidelines to address the problem. SELECTED NURSING THEORIES 1) Early nursing theorists were attempting to answer questions related to the “what” and “how” of nursing.( Florence Nightingale (1859) 2) The theories developed by Levine, Orem, and Roy are useful in guiding nursing practice. 3) A new worldview of nursing is emerging in the work of such theorists as Watson, Rogers, and Parse. 10 Summary Concepts are vehicles of thought and are the building blocks of theory. Propositions are relational statements that link concepts together. Theories help to show how things fit together. The function of theory is to provide a framework for explaining, predicting, and sometimes controlling situations. Nursing uses theories from other disciplines in conjunction with nursing theory. The development, use, and testing of nursing theory are necessary for the professionalization of the discipline of nursing. The relationship between nursing theory, practice, and research is an interdependent one. As a practice-oriented discipline, nursing theory and research inform and transform nursing practice. Theories range in scope from grand theories to middle- range to micro-range theories. The metaparadigm names the phenomena of concern to a discipline and distinguishes one discipline from another. The currently accepted metaparadigm concepts in nursing are person, environment, health, and nursing. The metaparadigm may be composed of more than one paradigm. Parse purports that there are two paradigms in nursing: the Totality Paradigm and the Simultaneity Paradigm. 11 NURSING THEORIES AND APPLICATIONS THEORIST: Florence Nightingale (1820–1910) Environmental Theory EXPLANATION Man An individual whose natural defenses are influenced by a healthy or unhealthy environment Health A state in which the environment is optimal for the natural body processes to achieve reparative outcomes Environment All the external conditions capable of preventing, suppressing, or contributing to disease or death Nursing Putting the client in the best condition for nature to act Synopsis of Theory External conditions such as ventilation, light, odor, and cleanliness can prevent, suppress, or contribute to disease or death. Application to Nurses modify unhealthy aspects of the environment to put the client in the best Nursing Practice condition for nature to act. THEORIST: Virginia Henderson (1897–1996) Basic Needs Theory EXPLANATION Man An individual with human needs that have unique meaning and value Health The ability to independently satisfy human needs composed of 14 basic physical, psychological, and social elements Environment The setting in which a person learns unique patterns for living Nursing Temporarily assisting a person who lacks the necessary strength, will, and knowledge to satisfy one or more of 14 basic needs People have basic needs that are components of health. Synopsis of Theory The significance and value of these needs are unique to each person. Application to Nurses assist in performing those activities that the client would perform if he or she had Nursing Practice strength, will, and knowledge. THEORIST: Dorothea Orem ( 1914–) Self-Care Theory EXPLANATION Man An individual who uses self-care to sustain life and health, recover from disease or injury, or cope with its effects Health The result of practices that people have learned to carry out on their own behalf to maintain life and well-being Environment External elements with which man interacts in the struggle to maintain self-care Nursing A human service that assists people to progressively maximize their selfcare potential Synopsis of Theory People learn behaviors that they perform on their own behalf to maintain life, health, and well-being. Application to Nurses assist clients with self-care to improve or to maintain health. Nursing Practice THEORIST: Sister Callista Roy (1939– ): Adaptation Theory EXPLANATION Man A social, mental, spiritual, and physical being affected by stimuli in the internal and external environments Health A person’s ability to adapt to changes in the environment Environment Internal and external forces in a continuous state of change Nursing A humanitarian art and expanding science that manipulates and modifies stimuli to promote and to facilitate man’s ability to adapt Synopsis of Theory Man is a biopsychosocial being. A change in one component results in adaptive changes in the others. Application to Nurses assess biologic, psychological, and social factors interfering with health; alter the 12 Nursing Practice stimuli causing the Maladaptation; and evaluate the effectiveness of the action taken. LEVELS OF RESPONSIBILITIES FOR THE NURSING PROCESS* PRACTICAL/VOCATIONAL ASSOCIATE DEGREE BACCALAUREATE NURSE NURSE NURSE Assessing Gathers data by interviewing, Collects data from people with Identifies the information observing, and performing a basic complex health problems with needed from individuals or physical examination of people unpredictable outcomes, their groups to provide an with common health problems with family, medical records, and appropriate nursing database predictable outcomes other health team members Diagnosing Contributes to the development of Uses a classification list to Conducts clinical testing of nursing diagnoses by reporting write a Nursing diagnostic approved nursing diagnoses abnormal assessment data statement, including the Proposes new diagnostic problem, its etiology, and signs categories for consideration & and symptoms Identifies approval problems that require collaboration with the physician Planning Assists in setting realistic and Sets realistic, measurable goals Develops written standards for measurable goals Suggests nursing Develops a written nursing practice actions that can prevent, reduce, or individualized plan of care Plans care for healthy or sick eliminate health problems with with specific nursing orders individuals or groups in predictable outcomes that reflects the standards for structured health care agencies Assists in developing a written plan nursing practice or the community of care Implementing Performs basic nursing care under Identifies priorities Directs Applies nursing theory to the the direction of a registered nurse others to carry out nursing approaches used for resolving orders actual and potential health problems of individuals or groups Evaluating Shares observations on the progress Evaluates the outcomes of Conducts research on nursing of the client in reaching established nursing care routinely activities that may be goals Revises the plan of care improved with further study Contributes to the revision of the plan of care 13 Definitions of Nursing Early Definitions of Nursing A nurse is a person who nourishes, fosters, and protects—a person who is prepared to care for the sick, injured, and aged. Florence N., in her Notes on Nursing: What It Is and What It Is Not, described the nurse’s role as one that would “put the patient in the best condition for nature to act upon him”. The Effect of Technology on the Definition of Nursing Technologic advances have significantly affected the definition of nursing and the role of the nurse; the methods by which care is delivered have been reshaped significantly. Definitions of Nursing Theorists Many would expect that any definition of nursing must indicate that it is both an art and a science. It is an art in the sense that it is composed of skills that require expertise, adeptness, and proficiency for their competent execution. It is a science in the sense that it requires systematized knowledge derived from observation, critical thinking, study, and research. The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge, and to do this in such a way as to help him gain independence as rapidly as possible. (Henderson, 1966, p. 15). Nursing as Defined by Organizations American Nurses Association Definitions Of Nursing ANA in 1980, stated: “Nursing is the diagnosis and treatment of human responses to actual or potential health problems” (ANA, 1980, p. 9). Nursing As Defined By The National Council Of State Boards Of Nursing “The ‘Practice of Nursing’ means assisting individuals or groups to maintain or attain optimal health, implementing a strategy of care to accomplish defined goals, and evaluating responses to care and treatment” (NCSBN, 1994). Legal Definitions of Nursing The NCSBN has given the following definition: “the ‘practice of nursing’ means assisting individuals or groups to maintain or attain optimal health, implementing a strategy of care to accomplish defined goals, and evaluating responses to care and treatment. This practice includes, but is not limited to, initiating and maintaining comfort measures, promoting and supporting human functions and responses, establishing an environment conducive to wellbeing, providing health counseling and teaching, and collaborating on certain aspects of the health regimen. 14 Practice Settings Nursing Practice Settings are expanding as a result of changes in the health care delivery system. A. Hospitals and Restorative settings: Hospitals may be acute, long-term, or rehabilitation care facilities. Nurses employed in the acute care setting care for clients with sever multi-system illness and complex medical, psychological, and social problems. It has become more specialized and complex. Nursing services in the hospital operate 24 hours a day, 7 days a week. Long-term care is provided in institutions as chronic disease hospitals, psychiatric hospitals, and nursing homes. Restorative care facilities employ many types of health care professionals. The goal of these institutions is to teach disabled clients to achieve a maximal level of function and to teach families to help them reach that level. B. Community-Based Practice settings: Nursing in Community-Based Practice settings is focused on health promotion and maintenance, education and management, and coordination and continuity of restorative care within the client's community. The nurse assesses the health needs of individuals, families, and communities. 1. Schools: Nursing services include health education in disease prevention, health promotion, and sex education. Provide care for students with non emergent acute illnesses. Make referrals for students and their families when additional, more specializes health care is needed. 2. Occupational health settings: The nurse develops programs aimed at increasing health and safety in work places by reducing the number of occupational accidents, the risk of occupational diseases, or the transmission of a contagious disease among the workers. Provide programs for health promotion, disease prevention, and health education. The nurse may take a more active role in risk factor identification for heart disease, provide education for breast self-examination, and assist employee with health promotion and maintenance plans. In emergency situations, gives emergency care and arranges transportation to a hospital. She refers employees to additional health resources when necessary. 3. Home health care agencies: Nurses in these agencies provide home-based nursing care to clients discharged from that particular institution. (Retirement Home) 4. Other agencies include: The visiting nurse association, public health nursing agencies, hospices, and private home care agencies. The nurse must be skilled at teaching. C. Other Settings: Physician's office, managed care organization, or health care consultation service. N.B:The nursing field is booming and there is a huge need for nurses. 15 Factors affecting nursing practice To understand nursing as it is practiced today and as it will be practiced tomorrow requires not only a historical perspective of nursing evolution but also this an understanding of some of the social forces currently influencing profession. These forces usually affect the entire health care system, and nursing. These include: 1- Economics: Greater financial support provided through public and private health insurance programs has increased the demand for nursing care. Health services as emergency care, mental health counseling, and preventive physical examinations are increasingly being used by people who could not afford them in the past. These changes present challenges to nurses. Currently the health care is shifting its emphasis from inpatients to outpatients with preadmission testing, post hospitalization rehabilitation, home health care, health maintenance, and physical fitness. 2- Increasing longevity of people and changes in patient needs: The growing tendency to discharge clients from the hospital earlier has created now needs for nursing client education is an important aspect of care. Therefore teaching patient and their families how to care for the client after discharge is very important. Another aspect of changes in patient needs is the fastest growing age group is that of people 85 years and older. Because the heaviest users of health services are the elderly, more emphasis is being placed on their needs; the need for services has increased, and gerontology has become a significant branch of medicine and nursing. 3- Technological advances: Advances made in technology have drastically changed health care and nursing practice. Computers, implants, genetics are emerging technology of the first twenty century that demand the most highly skilled nurse. Problems created by technological advances present new challenges to nurses, so this required that nurses become highly specialized education to deal with advanced equipment and devices to monitor and treat patients safely. Moreover the nurse must continually update her knowledge and skills to use the technology to provide safe and effective care for the patient. 4- Demographic changes: Demographic changes that have influenced health care in recent decades include the population shift from rural areas to urban centers, the increasing life span, the higher incidence of chronic, long-term illness; and the increased incidence of diseases such as alcoholism and lung cancer. Nursing as a profession respond to such changes by exploring new methods for providing care, by changing educational emphasis, and by establishing practice standards in new areas. 5-Consumer demands: Consumers of nursing services (the public) have become an increasingly effective force in changing nursing practice. These demands include public's expectation that it will have a voice in determining the type, quality and cost of health care. Consumers are better informed today than ever before and are asserting their rights in the area of health care delivery. 16 6-Health promotion and wellness: Health promotion, maintenance, and illness prevention are beginning to receive as much emphasis as the diagnosis and treatment of disease. 7-Nursing shortage: Most of hospitals report referred to an acute shortage of registered nurses, particularly in areas such as intensive care, emergency, and operating rooms. This shortage is thought to be the result of many factors, e.g.; a decline in student enrollment and an increase in the number of nurses leaving nursing. Also nurses' salaries and benefits do not reflect their levels of education, experience, or performance. In addition, weekend and shift work appears unattractive to many prospective students. Another factor considered to affect this shortage is nursing's public image. 8- legislation: Legislation about nursing practice and health matters affects both the public and nursing. Changes in legislation relating to health also affect nursing. E.g.; relaxation of laws governing abortions has been associated with reduced maternal morbidity from self-induced abortions. On the other hand legislation regarding the Medicare Payment System has had an enormous influence on nursing practice in hospitals and communities. Many clients leave hospitals sooner than they did in the past. As a result, more clients in hospitals are seriously ill, and more clients at home require more complex nursing care than in the past. 9- Women's movement: This movement has greatly influenced society. Female clients have assumed more responsibility for their own care. Also, women's health issues are receiving more attention and more research than even a decade ago. The movement has also influenced nursing by inspiring nurses to pursue more autonomy and accountability in their clients care. 10- Human Rights movements: This movement is changing the way views the rights of all of its members. Many groups have special health care needs, and nursing has responded by respecting all clients as individuals with a right to good care and with basic human rights. 11- Cultural Diversity: As the people of the world move about, nurses are confronted with many cultures different from their own. So nurse must now have an awareness of how different cultures view health and illness. 17 Nursing Profession Outline 1- Definition:- Profession, Professional, Professionalism 2- Characteristics of Professional Nursing Practice A. Characteristics of Professional possesses B. Process of professionalization C. Nursing position on the occupation-profession continuum D. Nursing progress toward professionalism 3- Accreditation in nursing education Profession Profession is a prestigious occupation with a high degree of identification among the member that requires a lengthy and a rigorous education in an intellectually demanding and theoretically based course of study; that engages in rigorous self-regulation and control; that hold authority over clients; and that puts service to society above simple self-interest. Professional Professional is the degree to which characteristics of a profession are present. (Noun) Professional is someone who is a member of an established learned profession. (Adjective) Professional is a person or activity that characterizes or conforms to the technical and ethical standards of a profession. Professionalism Professionalism refers to the conduct, goals, or qualities that characterize or mark a profession or a professional person. Nursing is not simply a collection of specific skills, and the nurse is not simply a person trained to perform specific tasks. Nursing is a profession. When we say person acts "professionally" we imply that the person is conscientious in actions, knowledgeable in the subject and responsible to self and others. Characteristic of professional nursing practice: 1. A profession requires an extended education. 2. A profession has a theoretical body of knowledge leading to defined skills, abilities and norms. 3. A profession provides a specific service 4. Members of a profession have autonomy in decision making and practice. 5. The profession as a whole has code of ethics for practice. (A) Education: As a profession, nursing requires that its members possess a significant amount of education. Most nurses agree that nursing education is important to practice and that must respond to changes in health care created by scientific and technological advances. (B) Theory: The practice of professional nursing and nursing knowledge has been developed through nursing theory. Theoretical models serve as frameworks for nursing clinical practice. Nursing theories also lead to further research that increases the scientific basis of nursing practice. (C) Service: 18 Nursing has always been a service profession, although in the past the service was usually viewed as a charitable one. Today, nursing is a vital and important component of the health care delivery system. Nurses today and in the future need a more consumer - focused and service - based practice. (D) Autonomy & Empowerment: Autonomy is an essential element to professional nursing. Autonomy means that a person is reasonably independent and self - governing in decision-making and practice. Nurses attain increased autonomy through higher levels of education. (E) Code of Ethics: Nursing has a code of ethics that defines the principles by which nurses' function. In addition, nurses incorporate their own values and ethics into practice. The code for nurses with interpretive statements provides a guide for carrying out nursing responsibilities that provide quality-nursing care and provides for the ethical obligations of the profession. Abraham Flexner in 1915 argued that Characteristics of a profession were: 1. Activities must be intellectual, carrying with it high responsibility. 2. Learned in nature and is refreshed and refined through research, because it based on a body of knowledge. 3. Practical in addition to being theoretical. 4. Taught through a process of highly specialized professional education. 5. Has internal organization of members & well developed group consciousness. 6. Has a practitioner who is motivated by altruism (the desire to help others) and who are responsive to public interest. Process of professionalization It is generally described as a series of stages characterized by specific events or changes in the structure of the occupation as it strives to achieve professional status. Wilensky observed that a series of events occur as occupations move toward professionalism: People begin doing the work full-time and stake out a jurisdiction Early masters of the technique or adherence of the movement become concerned about the standards of training and practice and setup a training school which lodged in Universities. Teachers achieve success in promoting more effective organization local and national. Legal protection appears. A formal code of ethics is adopted The process of professionalization Profession Became full- 1st 1st 1st national 1st state Formal time training university professional license code of occupation school school association low ethics Low 17 century 1784 1817 1878 1732 1908 Medicine 1700 1765 1779 1847 Before 1912 1780 School teaching 17 century 1823 1879 1857 1781 1929 Librarianship 1732 1887 1897 1876 Before 1938 1919 Nursing 17 century 1861 1909 1897 1903 1950 Social work 1898 1898 1904 1874 1940 1948 19 Position of nursing on the occupation-profession model Profession Nursing Occupation Dimension 1- Theory Absent Present(limited) Present 2- Relevance to social No relevant Relevant Relevant value 3- Training period Short, not Varied in length; some Long and specialized specialization specialized 4- Motivation Self interest Service Service 5- Autonomy Absent Incomplete Complete 6- Commitment Short-term Varies; relatively short Long term 7- Sense of community Low Minimal High 8- Code of ethics undeveloped Highly developed Highly developed Nursing position on the occupation-profession continuum Compared with professions in general, nursing scores very well in relevance to social values, service motivation and a code of ethics. However: 1. Nursing theory is still in the process of being developed and refined. 2. Its education is not standardized with university preparation as a minimum requirement. 3. Control over its practice is limited. 4. Many of its members are not wholly committed with their work. 5. A sense of community and cohesion has yet to be fully realized. Because some nursing professional characteristics are not as highly developed as those of established professions, nursing continues to rank just slightly above the midpoint of Pavalko continuum- thus; it is classified as a semiprofessional. Accreditation in nursing education Accreditation is a process whereby educational institutions or programs are surveyed and evaluated. To be accredited, nursing programs must meet criteria established by the National League for Nursing Accrediting Commission (NLNAC1999). The purposes of the education programs in nursing are to: 1. Uphold agreed upon standards for educational quality and public accountability. 2. Assure the public of accurate information regarding nursing in education programs at any levels. 3. Foster continues developing and improvement in the quality of the education programs in nursing. 4. Evaluate nursing programs in relation both to their stated purpose and the agreed upon standards and criteria for accreditation. 5. Involve institutional administrators and the faculty, staff and students of nursing programs in the process of contentious self- examination. 6. Bring together practitioner, administrators, faculty staff and students in improving nursing quality and the preparation of the students for their responsibilities to society. 20 21 Changing Role in Nursing Education Introduction The future of nursing looks bright and exciting. With technologic advances, changes in health care settings, increased demand for the services of RN, and the shift back to the acute care – setting, nurses now have increased opportunities to chart their own abilities. Nurses who have career plans and career goals will see the future trends in health care as a challenge and an opportunity for career growth in areas such as case manger, independent consultant, nurse practitioner, policy maker, or entrepreneur. In contrast, nurses without career goals may find themselves displaced or obsolete. There has never been a more exciting time to be entering the profession of nursing than right now. Opportunities in nursing are wide open to those with the sensitivity and the creativity to embrace the future Nursing Evolution For years care has been provided to patients in hospitals and long-term care facilities by individuals we have called nursing aids or assistants. In the past, these care givers were hired without formal preparation for their responsibilities and were provided ' on the job training ' the use of the nursing aide likely started during world war I and was certainly reinforced during world war II when approximately 150.000 trained volunteer nursing aids served in wartime hospitals and army hospitals. Training programs were started in 1897 (kalisch, 1995). The first programs were initiated through the Ballard school around 1892 and the course of study lasted approximately 3 months, and the students called 'attendants ' were trained to care for invalids ,the elderly ,and children in a home settings. Other early educational nursing programs were offered by Thompson school. In 1907, The American Red Cross began in 1908, household nursing Association school of Attendant Nursing begun in Boston in 1918. Although only 11 schools were in existence by 1930 the number of program expanded rapidly during the 1940. The educational preparation nurse takes place in a great variety of settings programs may be offered by high schools, trade or technical schools, hospitals junior or community colleges, Universities or independent agencies. By October 1990, all pea pole working as nursing assistants in nursing homes would be required to complete a competency evaluation programs or approved course of study (Heger, 1995; Sorrentio, 1994). These regulations require that the nurse complete a minimum of 75 hours of theory and practice and both a theory and practice examination in order to be certified.(Certified Nursing Assistant, CAN). 22 Types of educational programs: Nursing student can choose their educational route according to their goals. A-Entry –level education: 1-practical nursing program: Preparation: 1 year program to perform technical skills under the supervision of RN. The main responsibilities are: Personal hygiene and grooming, Assisting patients with nutritional & elimination needs Assisting mobility Sit for licensure examination to become a Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN). 2-Diploma nursing program: It is the 1st type of educational preparation for RNs. It requires 3 years hospital based programs Deliver direct patient care in a variety of environments. Take the state or provincial board of nursing examination for registered nurse licensure. The graduates work as beginning practitioners in acute, intermediate, long –term and ambulatory health care facilities. Also they must demonstrate competency in the assessment, planning, implementation and evaluation of nursing process. Many diploma schools closed after 1965, when the American Nurses Association (ANA) published a position paper stating that all nursing education should take place in institution of higher learning. The organization also recommended two levels of nursing practice; professional and technical. The professional nurse would have an associated degree The technical nurse would work under the direct supervision of the professional nurse. 3-Associated degree Nursing Program (AND) Are offered at junior & community colleges (2 years in length). Prepared to function as quality practitioner under supervision of professional nurse. Take the state or provincial board of nursing examination for registered licensure. Canada doesn't have an AND. 4-Baccalaureate Degree Nursing Program: Four academic years located in colleges and universities? The course of study combines the theory and practice of nursing with general education in the humanities and behavioral, biological, and physical science. It emphasizes community health, research, leadership, and management. Students successfully completing program take state or provincial board of nursing examination for registered licensure. In Canada, a bachelor of science in nursing (BScN) is equal to a bachelor of science in nursing in the USA and it will be equal to this in Egypt after accreditation was accomplished. 23 B-Advanced Nursing Education Opportunities (Non Traditional): 1-Master's Degree Nursing: It began in the last quarter of the 19th century in response to the need for better educated faculty and supervisor staff. The catholic university of America in Washington offered one of the early graduated programs for nurses. It began in nursing education 1935. Until the 1960, the master's degree in nursing was viewed as a terminal degree. Nurses interested in training advanced education in specialties may complete graduate programs in their specific area of interest. It takes about 2 years to be completed. 2-Doctoral degree program: It is usually obtained after completing master's program. Produce nurse philosophers, ethicists, theorists, and researchers. 3-Other Available Options: 1- Continuing Education (CE): It is designed to assist nurses in gaining & maintaining knowledge & skills in practice. It is offered in forms as workshops, short courses, conferences, evening courses & supplements in professional nursing journal. 2- Online universities (computer-based courses): The University of Kansas in 1998- three years after its first online nursing course –phased out its traditional RN to BSN program because of low enrollment and offers it exclusively online Computer-based courses typically in value simulated cases, gaming, slide presentations, discussions- real time and asynchronous-and exercises. California state university is exploring the internet as away of expanding its nursing programs internationally it provides baccalaureate and master degrees. 3- Articulated programs: Provide direct articulation b/w lower–level & higher–level programs. It provides a wide articulation plans for registered nurse to transfer to BSN programs or even to master's pathways. 24 Nursing Organizations As the nursing profession has developed and advanced, organizations that have become integral to the profession have increased. The number of associations continues to grow at local, state, and national levels. Nursing organizations may be related to a specialty, or they may encompass all areas of nursing. The Organizations that involve most nurses or student nurses are the A N A, the CAN, the NLN, the CCNE, the national student nurses Association (NSNA), and the Canadian university nursing student Association 1- American Nurses Association (ANA) It was established in 1890, but the name ANA was adopted in the US in 1911. The ANA is the professional organization for nurses in the United States. Only registered nurses are admitted to its membership. It is important because it makes decisions about the functions, activities, and goals of the nursing profession. It is the voice for nurses. Its major purposes are To promote high standards of nursing care To improve the quality and availability of heath care To foster the professional development of nurses and advance their economic and general welfare. Also publishes the American journal of nursing 2-Canadian nurses Association (CAN) It promotes high standards of practice and professional development for Canadian nurses. Its functions are as ANA. 3-National League for Nursing (NLN): It was established in 1952. Its membership includes nurses, persons form other health professions, and agencies concerned with nursing education and service. One major function of the NLN is the accreditation of educational programs in nursing. It also offers testing and consultation services. Also it ensures that the public need for nursing is met. 4-International Council of Nursing: It is the oldest world wide organization established as a federation of national nursing organizations the ANA represents the United States in this council this nonpolitical group brings together people from many countries who have a common interest in nursing and a common purpose of developing nursing throughout the world 5. Commission on Collegiate Nursing Education (CCNE): It is an autonomous agency that contributes to the development of public heath by ensuring quality and integrity of baccalaureate and graduate education. 6. National Student Nurses Association (NSNA) It was established in 1953. It is national organization for nursing students in the US. Its goals are to nursing education to provide for highest quality health care, provide programs representative of fundamental and current professional interests and concerns.also it aids in the developmental of the whole person, his or her professional role, and his or her responsibility for the health care of people in all walks of life. It serves as the voice of nursing students. 25 In addition to the above organizations, a variety of professional groups focus on particular nursing specialties. The American Association of Critical –care Nurses (AACN) is such an organization. The American Academy of Nurses (AAN), whose purpose is to recognize nurses who have made major contributions to the nursing profession. Present roles and functions of nurses In the past, the principal role of nurses was to provide care and comfort as they carried out specific nursing functions. However, changes in nursing have expanded the role to include emphasis on health promotion and illness prevention, as well as concern for the client as a whole. (1) Caregiver: As providers of care, nurses assume responsibility for helping clients promote, restore, and maintain health and wellness. Nurses view each client as unique and consider the "whole" person in the caring process. Also they not only concern about physiologic needs but also emotional, social, and spiritual needs. They must set priorities for care and assist clients in meeting all needs in the most timely and cost-effective manner. (2) Clinical Decision Maker: Nurses must use critical thinking skills in choosing the best approaches to client care, help clients to participate in this decision making, and use safe and effective judgments when providing care. They are also responsible for involving other members of the healthcare team and the families of clients in decision making to ensure that sound choices are made. (3) Protector and client Advocate: As a protector nurse helps to maintain a safe environment for the client and takes steps to prevent injury and protect the client from possible adverse effects of diagnostic or treatment measures As an advocate the nurse protects the clients' human and legal rights and helping clients in asserting these rights (4) Manager and Coordinator: The goal of nurses' role as manager and coordinator is to complete client care effectively, efficiently, and in a manner that benefits the client. Promoting, restoring, and maintaining health involve coordinating the service that a variety of heath care professionals offer. (5) Rehabilitator: Rehabilitation is the process by which individuals return to maximal levels of functioning after illness, accidents, or other disabling events. Frequently clients experience physical or emotional impairments that change their lives, and the nurse helps them adapt as fully as possible. (6) Comforter: The role of comforter, caring for the client as a person, is a traditional and historical one in nursing and has continued to be important as nurses have assumed new roles. Because 26 nursing care must be directed to the whole person, rather than simply the body, comfort and emotional support often help to give the client strength to recover. (7) Communicator: Because nurses usually are the health care professionals who spend the most time with clients, they have the best opportunity for observing, communicating, and identifying problems, or improvement in the plan of care. They are responsible forms. Nurses must be knowledgeable, articulate and capable of effective written and verbal expression. (8) Teacher / Educator: Educating clients about diseases and its prevention, nutrition, and healthy behaviors is essential. Nurses must explain treatments and procedures, for which they are responsible, answer any question clients have, and evaluate the progress of clients toward health. (9) Researcher: Responsibilities of the nurse researcher vary according to the level of research expertise and level of education. However, nurses must critically evaluated research studies for their quality and relevance to nursing and apply the findings to clinical practice. (10) Case manager: The case manager is responsible for assessment, coordination, integration and evaluation of effectiveness and efficiency of health services using clinical pathways as tools to designate what care should be provided for a given health problem within a specific time frame. (11) Consultant: As nurses developed specialized area of expertise, they are often called on to serve as consultants. A consultant is one who draws from personal expertise to advice others, validate current practices provide specialized knowledge. Career development and expanded nursing roles Many additional opportunities for career development and advancement are available in nursing. These opportunities, some of which require advanced education, lead to new and varied roles and exciting challenges. Some expanded nursing roles include: (1) Advanced practice nurse (APN): APN is generally the most independent functioning nurse. She has a master's degree in nursing, advanced education in pharmacology and physical assessment, and certification and expertise in a specialized area of practice. The term advanced practice nurse is an umbrella term for an advanced clinical nurse that includes nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and nurse-midwives. (A) Nurse practitioner: A nurse practitioner has advanced education, at least a master's degree in nursing, and is a graduate of a nurse practitioner program. Nurse practitioners function with more independence and autonomy than other nurses and are highly skilled at doing ……. nursing assessments, performing physical examinations, counseling, teaching, and 27 treating minor health problem. Nurse practitioners have a specialty, as obstetrics, pediatrics, or family care. (B) Clinical nurse specialist: She has a master's degree in nursing and may have advanced experience and expertise in a specialized area of practice (e.g. gerontology, pediatrics, critical care, oncology, endocrinology, cardiovascular or pulmonary disease). Their roles include clinician, educator, manager, consultant, and researcher. (C) Certified registered nurse anesthetist(CRNA): Is a RN who has received advanced training in an accredited program in anesthesiology. Nurse anesthetists provide surgical anesthesia under the guidance and supervision of an anesthesiologist, who is a physician with advanced knowledge of surgical anesthesia. (D) Certified nurse - midwife (CNM): Is an RN who is also educated in midwifery and is certified by the American College of Nurse - Midwives? The practice of nurse - midwifery involves providing independent care for women during normal pregnancy, labor, and delivery, as well as care for the newborn. (2) Nurse administrator: The nurse administrators manage and control client care. They are responsible for specific nursing units and serve as liaisons between staff members and directors of nursing. Educational preparation for nurse administrators requires at least a baccalaureate degree in nursing and, in some cases, a master's or doctoral degree. (3) Nurse Educator: A Nurse educator works primarily in schools of nursing, staff development departments of health care agencies, and client education departments. Advanced education in nursing is required, usually a master's degree. Teaching at the baccalaureate, master's, or doctoral level in nursing usually requires a doctoral degree. People in this career role must continue to maintain expertise in the practice setting, develop expert knowledge of theory, perfect classroom presentation style, and have in-depth knowledge of curriculum development and higher education. 28 CRITICAL THINKING AND THE NURSING PROCESS Critical Thinking and Safe Care Outline: A. Critical Thinking Attitudes 1. Intellectual Humility 2. Intellectual Courage 3. Intellectual Empathy 4. Intellectual Integrity 5. Intellectual Perseverance 6. Faith in Reason 7. Intellectual Sense of Justice B. Knowledge Base Concern for Patient Safety C. Critical Thinking Skills Problem Solving Other Critical Thinking Skills Introduction Think critically; means the use of knowledge and skills to make the best decisions possible in patient care situations. “Critical thinking is the use of those cognitive [knowledge] skills or strategies that increase the probability of a desirable outcome.” Critical thinking is sometimes called directed thinking because it focuses on a goal. Other terms used include reasoning, common sense, analysis, and inquiry. Good thinking requires: 9 Critical thinking attitudes and skills 9 Good knowledge base Critical Thinking Attitudes 1- Intellectual Humility People with intellectual humility have the ability to say, “I am not sure about that…. I need more information.” Certainly, we want our patients to think we are smart and know what we are doing, but patients also respect nurses who can say, “I do not know; let me find out.” It is unsafe to care for patients when you are not sure of what you need to do. 2- Intellectual Courage Intellectual courage allows you to look at other points of view even when you do not agree with them at first. Maybe you really believe that 8-hour shifts are best for nurses, and have a lot of good reasons for your belief. But if you have intellectual courage, you will be willing to really listen to the arguments for changing to 12-hour shifts. Maybe you will even be convinced. Sometimes you have to have the courage to say, “Okay, I see you were right after all.” 3- Intellectual Empathy Consider the patient who snaps as you enter her room, “I’ve been waiting all morning for my bath. If you do not help me with it right now I am going to call your supervisor.” The first response that comes into your head is, “I have five other patients; you are lucky I am here now!” But, if you have intellectual empathy, you will be able to think, “If I were this patient, who is in chronic pain and is tired of being in the hospital, how would I feel?” It might change how you respond. 4- Intellectual Integrity Your patient seems to ask a hundred questions when you bring her a medication that has been newly prescribed for her high blood pressure. But later you notice she is taking an herbal 29 remedy from her purse. Someone with intellectual integrity would want the same kind of proof that both types of medications are safe and effective before using them. 5- Intellectual Perseverance Do not give up. Consider this scenario. You have concerns about some side effects you have noticed when you administer a new drug to your patients. You mentioned it to the physician and he said not to worry about it, but you are still concerned. If you have intellectual perseverance, you might do some research on the web, then go to your supervisor or the pharmacist to discuss your concerns. 6- Faith in Reason If you have faith in reason, you believe in your heart that good thinking, and reason, will indeed result in the best outcomes for your patients. And if you really believe, you will be more likely to attend a seminar or read an article on critical thinking skills. 7- Intellectual Sense of Justice One of your co-workers wants to change the medication administration schedule on your unit. She says it is because it will be better for the patients, but you think it might be because it fits her break schedule better. If you have an intellectual sense of justice, you will be sure that your thinking is not biased by something that you just want for yourself, like your co-worker seems to be doing. You should examine your own motives as well as those of others when you are making decisions. So, what does this all mean to you as a nursing student? Knowledge Base Nurses must have a good knowledge base in order to safely care for their patients. The best knowledge upon which to base your practice comes from research. Nurse researchers try new methods for taking care of patients and compare them with traditional methods to determine what works best. When nursing care is based on good, well-designed research studies, it is called evidence based practice. As nurses, we need to use as many interventions as we can that have been researched. Other interventions, until they are validated by research, have to be based on our best critical thinking skills. Some expert organizations are beginning to “bundle” best practice strategies together to increase their use. Bundles are groups of interventions that, when used together, have been shown to improve patient outcomes. To find more information on bundles, go to http://www.ihi.org/ihi and type “bundles” in the search window. Concern for Patient Safety 9 Health-care providers are being held accountable for safe care by society. 9 As a result, guidelines to reduce errors in health care and improve patient outcomes have been developed. 9 The Joint Commission on Accreditation of Hospitals and Organizations 2006 patient safety goals can be found at http://www.jcipatientsafety.org. These goals are throughout the book to increase awareness and understanding of them. They address important areas of concern such as: 9 Using medications safely 9 Correctly identifying patients 9 Identifying operative sites correctly 9 Improving communication 9 Reducing fall injuries 9 Reducing risk for infections Critical Thinking Skills Problem Solving Problem solving is one type of critical thinking skill. Nurses solve problems on a daily basis. However, a problem can be handled in a way that may or may not help the patient. For instance, consider Mr. Frank, who is in pain and requests pain medication. An alternative approach is to use a standard problem-solving method: 30 1. Gather data. Decide to use a pain-rating scale on which the patient rates pain on a scale of 0 (no pain) to 10 (the greatest pain possible). You check his history and find he has compression fractures of his spine. You next go to the medication record and find that he has no alternative pain medications ordered. 2. Identify the problem. Here you use your knowledge base to draw the conclusion that Mr. Frank is in acute pain, and the current medication orders are not sufficient to provide pain relief. 3. Decide what outcome (sometimes called a goal) is desirable. The outcome should be determined by you (the nurse) and the patient working together. In this case you talk to Mr. Frank and determine that he needs pain relief now; he cannot wait until the next scheduled dose of medication. He states that he is able to tolerate a pain rating of 3 or less on a 10-point scale. 4. Plan what to do. Formulate and evaluate some alternative solutions. For example, tell Mr. Frank that he has to wait 40 minutes; giving the medication early might relieve his pain, you could decide to try some non–drug pain-control methods, such as relaxation, distraction, or imagery. Another alternative is to report to the physician that Mr. Frank’s pain is not controlled with the current pain-control regimen. Once you have several alternative courses of action, decide which will best help the patient. Then you can discuss those options with the registered nurse (RN) and together decide the best thing to do; in this case, you might decide to have the RN contact the physician while you work with the patient on relaxation exercises. You might decide to ask Mr. Frank if he would like to listen to some of the music his wife brought in for him. You can also tell Mr. Frank that the physician is being contacted. 5. Implement the plan of care. The RN enters the room and informs you and the patient that the physician has changed the analgesic orders. You obtain and administer the first dose of the new analgesic, being sure to explain its effects and side effects to Mr. Frank. The RN also informs Mr. Frank that the physician has ordered a consultation with the pain clinic. 6. Evaluate the plan of care. Did the plan work? As you reassess Mr. Frank 30 minutes later, he rates his pain level at 2. You think back to the desired outcome, compare it with the current data collected, and determine that your interventions were successful. Other Critical Thinking Skills Problem solving is just one critical thinking skill. There are many others that are beyond the scope of this book. Following are a few questions to ask yourself as you continue to develop your critical thinking. There are many more questions you might ask. These are not in any order, nor would they all be asked for a given situation. They are just some ideas to get you started. Have I thought this through? What information do I need? How do I know? Is someone influencing my thinking in ways I am not aware of? What conclusions can I draw from the information I have? Am I basing this decision on assumptions that may or may not be true? Am I thinking creatively about this, or am I in a rut? Is there an expert I can consult that can help me think through this? Is there any research or evidence that this is true? Am I too stressed or tired to think carefully about this right now? 31 NURSING PROCESS 1) Assessment 1. Conduct the health history. 2. Perform the physical assessment. 3. Interview the patient’s family or significant others. 4. Study the health record. 5. Organize, analyze, synthesize, and summarize the collected data. Elements of the Assessment Process Data collection Data verification Data organization Data interpretation Data documentation Purpose of Assessment The purpose of assessment is to establish a database concerning a client’s physical, psychosocial, and emotional health in order to identify health promoting behaviors as well as actual and/or potential health problems. TYPES OF ASSESSMENT There are three types of assessment: Comprehensive, Focused & Ongoing assessment A. Comprehensive Assessment 1. Completed upon admission 2. Includes a complete health history 3. Provides a baseline data 4. Should include: Assessment of physical and psychosocial aspects of the client’s health, The client’s perception of health He presence of health risk factors The client’s coping patterns B. Focused Assessment 1. Limited in scope 2. Focus on a particular need or health problem or potential risks. 3. Often used in health care agencies with short stays (e.g., outpatient surgery centers and emergency departments, labor & delivery & in mental health settings). C. Ongoing Assessment 1. Systematic follow-up is required when problems are identified during a comprehensive or focused assessment. 2. Includes systematic monitoring and observation related to specific problems 32 3. Allows to broaden or to confirm the validity of the initial assessment data 4. Important when problems have been identified and a plan of care has been implemented to address these problems 5. Allow to determine the response to nursing interventions 6. Allow to identify any emerging problems. DATA COLLECTION The nurse must possess strong cognitive, interpersonal, and technical skills in order to elicit appropriate information and make relevant observations during the data collection process. Types of Data Subjective data are data from the client’s point of view and include feelings, perceptions, and concerns. The data (symptoms) are obtained through interviews. Objective data are observable and measurable (quantitative) data, obtained through observation, assessment techniques performed during the physical examination, and laboratory and diagnostic testing. The data (signs) can be seen, heard, or felt by someone other than the patient. Comprehensive and accurate assessments include both subjective & objective data. Sources of Data 1. Client 2. Family/significant other 3. Other health care professionals 4. Medical records 5. Interdisciplinary conferences, rounds, and consultations 6. Results of diagnostic tests 7. Relevant literature Methods of Data Collection 1. Observation 2. Interview 3. Health history 4. Symptom analysis 5. Physical examination 6. Laboratory and diagnostic data 1) Observation Observations include factors as client mood, interactions with others, physical and emotional responses, and any safety considerations. By observation, nurse can detect nonverbal cues that indicate a variety of feelings as presence of pain, anxiety, and anger. 33 2) Interview Interview is a therapeutic interaction used to collect information about client’s health history and current client’s health needs. Observation of nonverbal behavior is also essential to effective data collection. Phases of Interview: interview has three phases: Introduction, Working and Closure. 1. Introduction Establishes the goals for the interaction Collection of data about the client Allow adequate time and privacy for the client Inform client about approximate interview duration. Nurse should sit, establish eye contact with the client, and listen attentively Note nonverbal messages that can indicate that the client is uncomfortable, tired, or preoccupied with other matters 2. Working y Focuses on the details of data collection y depends on the type of assessment to be conducted y Interview may be structured and formal or unstructured and informal y Interview begins with questions about biographical data. y Client’s reason for seeking health care y Information is gathered from the general to the specific y Use of Nursing Checklist provides guidelines for interview. y A comprehensive interview is facilitated by open-ended questions, while focused interview will be facilitated by direct, closed questions. 3. Closure y The nurse should indicate Interview Closure by stating that almost all information needed has been obtained or interview time is almost over. y During closure phase, the nurse summarizes what was covered or accomplished during interview and requests validation of perceptions with the client. Preparing the Interview Environment Assure adequate lighting. Maintain a comfortable room temperature. Select an environment that is as free of noise and distractions as possible. Maintain client privacy. Make sure that the interview is timed appropriately. Promote client comfort. 3) Health History 1. Demographic information 7. Allergies 2. Reason for seeking health care 8. Current medications 34 3. Perception of health status 9. Developmental level 4. Previous illnesses 10. Psychosocial history 5. Client/family medical history 11. Socio-cultural history 6. Immunizations/exposure to 12. Activities of daily living communicable disease 13. Review of systems 4) Physical Examination The purpose of the physical examination is to make direct observations of any deviations from normal and to validate subjective data gathered through the interview. Baseline measurements are obtained, and physical examination techniques are used to gather objective data. y Baseline Data Is the systematic organization of observations obtained during physical examination that forms the basis for comparison and evaluation of a client at a given time. Measurement of height, weight, and vital signs (temperature, pulse, respirations, and blood pressure) is important for comparison with future measurements in order to judge the significance of any changes (progress or regression) over time. Assessment Techniques Physical examination incorporates the use of visual, auditory, tactile, and olfactory senses & systematic assessment techniques. The four assessment techniques used in physical examination are: Inspection, Palpation, Percussion and Auscultation. 1. Inspection y Inspection involves careful visual observation. y The client is observed first from a general point of view and then with specific attention to detail. y Effective inspection requires adequate lighting and exposure of the body parts being observed. y Nurses must also be sensitive to the client’s feelings of embarrassment with the use of inspection and respond to this situation by discussing the technique with the client and using measures such as draping in order to increase client’s comfort. 2. Palpation y Palpation uses the sense of touch to assess texture, temperature, moisture, organ location and size, vibrations and pulsations, swelling, masses, and tenderness. Palpation requires a calm, gentle approach and is used systematically, with light palpation preceding deep palpation and palpation of tender areas performed last. y The palpation technique uses the hands and fingers in different ways for assessment of: Temperature: Best detected using the dorsal (back) surface of the hand Texture, pulses, and swelling: Best detected using fingertips Vibration: Best detected with the base of the fingers Shape and consistency of organs or masses: Best detected by grasping organ or mass between fingertips 35 3. Percussion y Percussion uses short, tapping strokes on the surface of the skin to create vibrations of underlying organs. y It is used for assessing the structures density or determining location & the size of organs. y Structures with more air (as the lungs) produce louder, deeper, and longer sounds with percussion than more dense, solid structures (as the liver), which produce softer, higher, and shorter sounds. 4. Auscultation y Auscultation involves listening to sounds in the body that are created by movement of air or fluid. Areas most often auscultator include the lungs, heart, abdomen, and blood vessels. Although direct auscultation is sometimes possible, a stethoscope is usually employed in order to channel the sound. 5) Laboratory and Diagnostic Data y Results of laboratory and diagnostic tests can be useful objective data as these values often serve as defining characteristics for various altered health states; these can also be helpful in ruling out certain suspected problems. y For example, diabetic clients who are poorly controlled on diet and/or medication will usually have an elevated blood glucose level. The pattern of these types of variations is useful in determining a plan of care. In addition, the effectiveness of nursing and medical interventions and progress toward health restoration are often monitored through laboratory and diagnostic test data. DATA VERIFICATION It is the process through which data are validated as being complete and accurate. When initial data collection is completed, data are reviewed for inconsistencies or omissions. Data verification is done by examining the congruence between subjective and objective data. Findings should also be compared with norms. Any grossly abnormal findings should be rechecked and confirmed. DATA ORGANIZATION After data collection is completed and information is validated, the nurse organizes, or clusters, the information together in order to identify areas of strengths and weaknesses. This process is known as data clustering. DATA INTERPRETATION Data clustering facilitates recognition of patterns & determine further data needed. Data interpretation is necessary for identification of nursing diagnoses. DATA DOCUMENTATION Accurate and complete recording of assessment data are essential for communicating information to other health care team members. 36 In addition, documentation is the basis for determining quality of care and should include appropriate data to support identified problems. Types of Assessment Formats a) Open-Ended Formats Allows the nurse to write a narrative description of observations. It is more time-consuming for nurse and allows flexibility in recording findings. b) Checklist Formats Facilitate documentation by summarizing findings in an abbreviated form. Provide more consistency in information recording & reduce likelihood of omitting relevant information. c) Combination Formats Allow the convenience of a checklist together with space to document a complete narrative description of any significant or abnormal findings. d) Specialty Formats Specialty areas such as outpatient surgery, labor and delivery, and psychiatric facilities may use abbreviated formats focused directly on assessment needs for particular service provided. Documentation of assessment data is essential as a means of communication among health care team members to assure accurate problem identification, determination of appropriate client outcomes, and continuity of care. 2) Nursing diagnosis Statement that describes the human response (health state or actual/potential altered interaction pattern) of an individual or group which the nurse can order the definitive interventions to maintain the health state or to reduce, eliminate, or prevent alterations”. PURPOSES OF NURSING DIAGNOSIS Nursing diagnosis allows for: Empowerment of the profession of nursing Facilitates effective communication Provides a means to individualize nursing care Essential to clinical practice & education and pivotal for theory development and research COMPONENTS OF A NURSING DIAGNOSIS The Two-Part Statement y First component is a problem statement or diagnostic label. y Second component is the etiology linked by term related to (RT). Examples: Disturbed Body Image RT loss of left lower extremity y Activity Intolerance RT decreased oxygen-carrying capacity of cells. 37 y Descriptive words (qualifiers) include: Acute, Chronic, Decreased, Deficient, Depleted, Disturbed, Dysfunctional, Enhanced, Excessive, Impaired, Increased, Ineffective, Intermittent, Potential for, Risk. These terms are placed (used) before the problem statement. The Three-Part Statement y First component is diagnostic label. y Second component is etiology linked by related to. y Third component is the defining characteristics (signs & symptoms, subjective and objective data, or clinical manifestations). y Third part is joined to the first two components with phrase “as evidenced by” y Defining characteristics may assist the nurse in identifying client goals, measurable client outcome criteria, and relevant nursing interventions. Comparison of 1- 2 & 3 Part Nursing Diagnosis Statements One-Part Statement Two-Part Statement Three-Part Statement Part 1: Wellness Part 1: Problem Related to Part 1: Problem Related to condition/state to be Part 2: Etiology (no Part 2: Etiology enhanced (no Related to, no defining characteristics) Part 3: Defining etiology, and no defining characteristics characteristics) CATEGORIES OF NURSING DIAGNOSES Actual diagnoses: are those problems that are already in existence. Example: y Excess Fluid Volume related to (RT) IV infusion therapy overload y Anxiety RT unknown results of breast biopsy. Risk diagnoses situations in which problems might occur but are not currently exist. Examples: Risk for Poisoning RT increased mobility of infant and failure to have house childproofed y Risk for Deficient Fluid Volume RT excessive number of stools. y Wellness diagnoses identify the individual or state that may be enhanced by health promoting activities. y Consist of a one-part statement (no “related to”) that uses label “Potential for Enhanced” followed by state nurse desires to enhance. y Examples: Readiness for Enhanced Community Coping and Readiness for Enhanced Spiritual Well-Being. TAXONOMY OF NURSING DIAGNOSIS y It is the type of classification under which diagnostic label is grouped based on which human response client is demonstrating to the actual or perceived stressor. y NANDA taxonomy is composed of 9 patterns of human response: 1. Exchanging 3. Perceiving 2. Valuing 4. Communicating 38 5. Choosing 8. Moving 6. Knowing 9. Feeling 7. Relating DEVELOPING A NURSING DIAGNOSIS Assessing Database y Collects data cues from the client. y Examples of cues: poor skin turgor, parched lips, dry skin, decreased urine output, and complaint of thirst. y Processes these cues and determines a nursing diagnosis, plans client outcomes, and implements therapeutic nursing interventions. Validating Cues y After reviewing data cues, validates that information and examines it carefully. y Example: determines if information is accurate and complete. Interpreting Cues y Through interpretation of data cues and use of critical-thinking strategies, the nurse assigns a meaning to the data cues. Clustering Cues y Once the cues have been collected, validated, and interpreted, the data are then grouped into clusters. y Related pieces of information about client are grouped together. y Conclusions are drawn from the data cues. Example: data cues that can be clustered include: Subjective: “I always seem to be hungry and I eat five or six times a day” and “I’ve gained 12 pounds in the past year.” Objective: weight 204 pounds, protruding abdomen, double chin, fleshy loose upper arms, and dimpling of buttocks. STEPS IN DEVELOPING A NURSING DIAGNOSIS 1. Data cues are collected from the assessment phase. 2. Data cues are validated and examined. 3. Data cues are interpreted & assigned a meaning through the use of critical thinking. 4. Data are grouped into clusters. 5. The NANDA list is consulted. 6. The first part of nursing diagnosis statement is written. 7. Related to (RT) factors are identified. 8. Phrases from steps 6 and 7 are combined to form a two-part nursing diagnosis. Writing the Nursing Diagnosis Statement y Nursing diagnosis from NANDA list becomes the diagnostic label, first part of diagnosis statement. y Etiologies are also identified from NANDA list. 39 y Appropriate etiology is selected and joined to the first part of the statement with the “related to” phrase. y In a two-part statement, would be Imbalanced Nutrition: More Than Body Requirements RT excessive food intake. y The three part statement would be Imbalanced Nutrition: More Than Body Requirements AEB weight gain, increased appetite, excess adipose tissue, and increased abdominal girth. y EX Mr. Lowder is a 62-year-old male who was admitted last night through the emergency room because of difficulty breathing. He was also experiencing some difficulty voiding. His lower extremities are very swollen. History reveals he smokes one pack of cigarettes a day and has done this for the past 45 years. His vital signs are P 112; R 30; BP 172/96; T 101.1°F. He has an eighth-grade education, attends church every week, is estranged from his daughter, and says, “I hate hospitals because my mother died in one.” 1. From the data cues in this case study, group data into clusters. 2. Look at the NANDA list of diagnoses and see which diagnoses “fit” best with your data clusters. 3. Write the first part of the NANDA diagnosis for each cluster. 4. Attempt to identify etiological (related to) factors for the list you started in step 3. 5. Write two-part nursing diagnosis statements by combining steps 3 and 4. 6. Identify whether the nursing diagnoses on your list are actual, possible, risk, or wellness oriented nursing diagnosis statements. 7. Prioritize the nursing diagnoses. 3) Outcome Identification & Planning The four critical elements of planning include: Establishing priorities Setting goals and developing expected outcomes Planning nursing interventions (with collaboration and consultation) Documenting Purposes of Outcome Identification and Planning Maintain or improve health at an optimal level Framework on which to base scientific nursing practice. Provide adequate direction to ensure quality nursing care for individual clients Present a vehicle to improve staff communication, and to provide continuity in the delivery of individualized, quality nursing care to all clients. Process of Outcome Identification And Planning Establishing Priorities Establishing Goals and Expected Outcomes Writing Goals 40 1- Establishing Priorities Examines client’s nursing diagnoses and ranks them in order of physiological or psychological importance. Nursing diagnoses is ranked by nurse, client or family. Priorities of physiological needs (respiration, nutrition, hydration, elimination) The next (safe environment, stable living condition) Determine its level of need, and rank the need in order of priority. Consider the client preferences. Involve client in establishing priorities Anticipation of future diagnoses. Prioritizing Nursing Diagnoses with Accompanying Nursing Implications Priority Diagnosis Nursing Implications High Ineffective Breathing Assess breath sounds. Pattern Auscultate lungs. Monitor vital signs. Reposition client. Moderate Risk for Impaired Skin Perform comprehensive skin assessment. Integrity Keep skin clean and dry. Provide turning schedule. Low Ineffective Coping Assist to identify problem. Encourage keeping daily journal. Teach expressing feelings strategies. Establishing Goals and Expected Outcomes After assessing the client, formulating nursing diagnoses, and establishing priorities, the nurse sets goals & identifies and establishes expected outcomes for each nursing diagnosis. The purposes are to provide guidelines for individualized nursing interventions and to establish evaluation criteria to measure the effectiveness of care plan. A goal is a broad statement describing the intended or desired change in the client’s behavior, response, or outcome. An expected outcome is a detailed, specific statement that describes the methods through which the goal will be achieved. Writing Goals y Goals establish appropriate evaluation criteria to measure the effectiveness of planned nursing interventions y Goals

أساسيات التمريض PDF

Document Details

Tags

Related

Summary

Full Transcript

Upgrade to continue