NCM 103 Finals - Fundamentals of Nursing Practice PDF

NCM 103 FINAL Term Fundamentals of Nursing Practice a. Provide nursing care through the u;liza;on of the nursing process. UNIT 1 ETHICO-MORAL AND LEGAL CONSIDERATIONS IN THE PRACTICE OF NURSING...

NCM 103 FINAL Term Fundamentals of Nursing Practice a. Provide nursing care through the u;liza;on of the nursing process. UNIT 1 ETHICO-MORAL AND LEGAL CONSIDERATIONS IN THE PRACTICE OF NURSING - Nursing care includes, but not limited to, tradi0onal and innova0ve approaches, therapeu0c use of self, LEGAL CONSIDERATIONS IN NURSING PRACTICE execu0ng health care techniques and procedures, - ethical and legal responsibilities that nurses must essen0al primary health care, comfort measures, adhere to while providing patient care. health teachings, and administra0on of wriOen - Ensures patient safety prescrip0on for treatment, therapies, oral, topical - Maintain professional standards and parenteral medica0ons, internal examina0on - Uphold legal obligations during labor in the absence of antenatal bleeding and delivery. ELEMENTS OF LEGAL CONSIDERATIONS IN NURSING PRACTICE In case of suturing of perineal lacera0on, special training shall - Licensing and Cer;fica;on: possess valid licenses and be provided according to protocol established; meet cer0fica0on requirements to prac0ce nursing legally in their jurisdic0on. b. Establish linkages with community resources and - Scope of Prac;ce: prac0ce within the defined scope coordina;on with the health team; of nursing prac0ce established by their state or country. c. Provide health educa;on to individuals, families and - Pa;ent Consent and Confiden;ality: Obtain communi;es; informed consent from pa0ents before providing treatment or procedures. They are also obligated to d. Teach, guide and supervise students in nursing educa;on maintain pa0ent confiden0ality as per health privacy programs including the administra;on of nursing services in laws. varied seZngs such as hospitals and clinics; undertake - Documenta;on: Accurate and 0mely documenta0on consulta;on services; engage in such ac;vi;es that require the of pa0ent assessments, interven0ons, and outcomes. u;liza;on of knowledge and decision-making skills of a - Repor;ng Obliga;ons: mandated reporters of certain registered nurse; and condi0ons, such as suspected abuse, neglect, or communicable diseases e. Undertake nursing and health human resource - Medica;on Administra;on: Adhere to strict development training and research, which shall include, but not guidelines for medica0on administra0on limited to, the development of advance nursing prac;ce; - Professional Liability: Nurses can be held legally accountable for negligence or malprac0ce if their - Provided, that this sec0on shall not apply to nursing ac0ons result in harm to a pa0ent. students who perform nursing func0ons under the direct supervision of a qualified faculty: LESSON 1: RA 9173 PHILIPPINE NURSING ACT OF 2002 - Provided, further, that in the prac0ce of nursing in all RA 9173: Philippine Nursing Act of 2002 seRngs, the nurse is duty-bound to observe the Code - enacted in 2002 (Amendment to RA 1764: Philippine of Ethics for Nurses and uphold the standards of safe Nursing Act of 1991) -provide for protec0on and nursing prac0ce. improvement of nursing profession -ins0tute reforms - ins0tu0ng measures that shall result in relevant - The nurse is required to maintain competence by nursing educa0on, humane working condi0ons, con0nual learning through con0nuing professional beOer career prospects and dignified existence for educa0on to be provided by the accredited nurses. professional organiza0on or any recognized RA 9173 Ar;cle 6 Sec.28 : Scope of nursing prac;ce professional nursing organiza0on: Scope of nursing ARTICLE VI, SEC. 28. Scope of Nursing - Provided, finally, that the program and ac0vity for the - A person shall be deemed to be prac0cing nursing con0nuing professional educa0on shall be submiOed within the meaning of this Act when he/she singly or to and approved by the Board. in collabora0on with another, ini0ates and performs nursing services to individuals, families and communi0es in any health care seRng. Lesson 2: NATIONAL NURSING CORE COMPETENCY STANDARDS (NNCCS) It includes, but not limited to, nursing care during concep0on, - Heightened by the escala0ng complexity of labor, delivery, infancy, childhood, toddler, pre-school, school globaliza0on, dynamics of informa0on, technology, age, adolescence, adulthood and old age. demographic changes, health care reforms and increasing demands for quality nursing care from - As independent prac00oners, nurses are primarily consumers, expecta0ons for contemporary nursing responsible for the promo0on of health and prac0ce competencies emerged. Thus, in 2005, as an preven0on of illness. output of a key project, Board of Nursing (BON) Resolu0on No. 112, Series of 2005, adopted and As members of the health team, nurses shall collaborate with promulgated the Core Competency Standards of other health care providers for the cura;ve, preven;ve, and Nursing Prac0ce in the Philippines. rehabilita;ve aspects of care, restora;on of health, allevia;on of suffering, and when recovery is not possible, towards a - As mandated, the BON ensured, through a peaceful death. It shall be the duty of the nurse to: monitoring and evalua0on scheme, that the core competency standards are implemented and u0lized effec0vely in nursing educa0on, in the development BAI JUNIE  of test ques0ons for the Nurse Licensure Examina0on Responsibility 5: Demonstrates ability to lead and supervise (NLE), and in nursing service as a basis for orienta0on, nursing support staff. training and performance appraisal. - applies supervision skills; assess supervisory needs of the support staff; monitor and evaluate performance NATIONAL NURSING CORE COMPETENCY STANDARDS Amend Board Resolu;on No. 112, Series of 2005 Responsibility 6: U0lizes appropriate mechanisms for networking, linkage building and referrals Three Roles of the Entry Level Nurse: - collaborate with Non-government organiza0ons; 1. 1.Beginning Nurse’s Role on Client Care referral system 2. 2.Beginning Nurse’s Role on Leadership and Management 3. BEGINNING NURSE’S ROLE ON RESEARCH: 3. 3. Beginning Nurse’s Role on Research Responsibility 1: Engage in nursing or health related research 1. BEGINNING NURSE’S ROLE ON CLIENT CARE: with or under the supervision of an experienced researcher. Responsibility 2: Evaluates research study/report u0lizing Responsibility 1: Prac0ces in accordance with legal principles guidelines in the conduct of a wriOen research cri0que. and the code of ethics in making personal and professional Responsibility 3: Applies the research process in improving client judgment. care in partnership with a quality improvement/qual ity - Advocate pa0ent’s bill of rights; scope of nursing assurance/nursing audit team. prac0ce; clarifies unclear doctor’s order.; maintaining pa0ent’s privacy; confiden0ality of records etc.; LESSON 3: CODE OF ETHICS OF NURSE’S IN THE PHILIPPINES informed consent; updated license Accdg to Webster: Ethics is the “study of the standards of Responsibility 2: U0lizes the nursing process in the conduct and moral judgment.” interdisciplinary care of clients that empowers the clients and - -It teaches nurses to judge accurately the moral promotes safe quality care. goodness of any human ac0on.” - -establish rapport w/pa0ent; support system; promo0ng client independency The Code of Ethics for Filipino Nurses was made ager a consulta0on on October 23, 2003 at Iloilo City ager accredited Responsibility 3: Maintains complete and up to date recording professional organiza0ons decided to adopt a new Code of Ethics and repor0ng system. under the RA 9173. This contained the following as taken from - -conform to documenta0on standard; document data the Professional Regula0on Commission: clearly, correctly and in 0mely manner; maintaining confiden0ality; system and tools in records keeping CODE OF ETHICS FOR FILIPINO NURSES 6 Ar0cles Responsibility 4: Establishes collabora0ve rela0onship with Ar0cle 1- PREAMBLE colleagues and other members of the team to enhance nursing Ar0cle 2- Registered Nurses and People and other health care services Ar0cle 3-Registered Nurses and Prac0ce - maintain good interpersonal rela0onship intra Ar0cle 4- Registered Nurses and Co-worker agency.; collabora0on of work; communica0on Ar0cle 5- Registered Nurses, Society and Environment Ar0cle 6-Registered Nurses and Profession Responsibility 5: Promotes professional and personal growth and development. ARTICLE 1: PREAMBLE - Earning master’s/Phd degree; trainings. - Health is a fundamental right of every individual. The Filipino registered nurse, believing in the worth and 2. BEGINNING NURSE’S ROLE ON MANAGEMENT AND dignity of each human being, recognizes the primary LEADERSHIP: responsibility to preserve health at all cost. This responsibility encompasses promo0on of health, Responsibility 1: Demonstrates management and leadership preven0on of illness, allevia0on of suffering, and skills to provide safe and quality care. restora0on of health. However, when the foregoing - Coordinate care ; delegates task according to staff are not possible, assistance towards a peaceful death competencies shall be his/her obliga0on. Responsibility 2: Demonstrates accountability for safe nursing - To assume this responsibility, registered nurses have prac0ce to gain knowledge and understanding of man’s - accomplish assigned work within specified 0me; cultural, social, spiritual, physiological, psychological, organize workload and ecological aspects of illness, u0lizing the therapeu0c process. Cultural diversity and poli0cal Responsibility 3: Demonstrates management and leadership and socio-economic status are inherent factors to skills to deliver health programs and services effec0vely to effec0ve nursing care. specific client groups in the community seRngs - uses strategies to implement community health - The desire for the respect and confidence of clientele, programs; colleagues, co- workers, and the members of the community provides the incen0ve to aOain and Responsibility 4: Manages a community/village based health maintain the highest possible degree of ethical facility/component of health program or nursing service. conduct. - coordinate task and func0ons of BHW, midwife; mobilizes resources for effec0ve program implementa0on BAI JUNIE ARTICLE II: REGISTERED NURSES AND PEOPLE ETHICAL PRINCIPLES GUIDELINES TO BE OBSERVED: REGISTERED NURSES MUST - Values, customs, and spiritual beliefs held by - perform their professional du0es in conformity with individuals shall be respected. exis0ng laws, rules regula0ons, measures, and - Individual freedom to make ra0onal and generally accepted principles of moral conduct and unconstrained decisions shall be respected. proper decorum. - Personal informa0on acquired in the process of giving nursing care shall be held in strict confidence. - not allow themselves to be used in adver0sement that should demean the image of the profession (i.e. GUIDELINES TO BE OBSERVED: REGISTERED NURSES MUST indecent exposure, viola0on of dress code, seduc0ve - consider the individuality and totality of pa0ents behavior, etc.). when they administer care. - decline any gig, favor or hospitality which might be - respect the spiritual beliefs and prac0ces of pa0ents interpreted as capitalizing on pa0ents. regarding diet and treatment. - uphold the rights of individuals. - not demand and receive any commission, fee or - take into considera0on the culture and values of emolument for recommending or referring a pa0ent pa0ents in providing nursing care. However, in the to a physician, a co-nurse or another health care event of conflicts, their welfare and safety must take worker; not to pay any commission, fee or other precedence. compensa0ons to the one referring or recommending a pa0ent to them for nursing care. ARTICLE 3:REGISTERED NURSES AND PRACTICE ETHICAL - avoid any abuse of the privileged rela0onship which PRINCIPLES exists with pa0ents and of the privilege access - Human life is inviolable. allowed to their property, residence or workplace. - Quality and excellence in the care of the pa0ents are REGISTERED NURSES AND CO-WORKERS ETHICAL PRINCIPLES: the goals of nursing prac0ce. - The Registered Nurse is in solidarity with other - Accurate documenta0on of ac0ons and outcomes of members of the healthcare team in working for the delivered care is the hallmark of nursing pa0ent’s best interest. accountability. - The Registered Nurse maintains collegial and GUIDELINES TO BE OBSERVED: REGISTERED NURSES MUST collabora0ve working rela0onship with colleagues and other health care providers. - know the defini0on and scope of nursing prac0ce which are in the provisions of R. A. No. 9173, known GUIDELINES TO BE OBSERVED: REGISTERED NURSES MUST as the “Philippine Nursing Act of 2002” and Board Res. No. 425, Series of 2003, the “Rules and - maintain their professional role/iden0ty while Regula0ons Implemen0ng the Philippine Nursing Act. working with other members of the health team. of 2002”, (the IRR). - conform with group ac0vi0es as those of a health - be aware of their du0es and responsibili0es in the team should be based on acceptable, ethico-legal prac0ce of their profession as defined in the standards. “Philippine Nursing Act of 2002” and the IRR. - contribute to the professional growth and - acquire and develop the necessary competence in development of other members of the health team. knowledge, skills, and aRtudes to effec0vely render - ac0vely par0cipate in professional organiza0ons. appropriate nursing services through varied learning - not act in any manner prejudicial to other situa0ons. professions. - if they are administrators, be responsible in providing - honor and safeguard the reputa0on and dignity of the favorable environment for the growth and members of nursing and other professions; refrain development of Registered Nurses in their charge. from making unfair and unwarranted comments or - be cognizant that professional programs for specialty cri0cisms on their competence, conduct, and cer0fica0on by the BON are accredited through the procedures; or not do anything that will bring Nursing Specialty Cer0fica0on Council (NSCC) discredit to a colleague and to any member of other - see to it that quality nursing care and prac0ce meet professions. the op0mum standard of safe nursing prac0ce. - respect the rights of their co-workers. - insure that modifica0on of prac0ce shall consider the principles of safe nursing prac0ce. REGISTERED NURSES, SOCIETY, AND ENVIRONMENT ETHICAL - if in posi0on of authority in a work environment, be PRINCIPLES normally and legally responsible for devising a system - The preserva0on of life, respect for human rights, and of minimizing occurrences of ineffec0ve and unlawful promo0on of healthy environment shall be a nursing prac0ce. commitment of a Registered Nurse. - ensure that pa0ents’ records shall be available only if - The establishment of linkages with the public in they are to be issued to those who are professionally promo0ng local, na0onal, and interna0onal efforts to and directly involved in their care and when they are meet health and social needs of the people as a required by law. contribu0ng member of society is a noble concern of a Registered Nurse. ETHICAL PRINCIPLE: 4. Registered Nurses are the advocates of the pa0ents: they shall GUIDELINES TO BE OBSERVED: REGISTERED NURSES MUST take appropriate steps to safeguard their rights and privileges. - be conscious of their obliga0ons as ci0zens and, as such, be involved in community concerns. 5. Registered Nurses are aware that their ac0ons have - be equipped with knowledge of health resources professional, ethical, moral, and legal dimensions. They strive to within the community, and take roles in primary perform their work in the best interest of all concerned. health care. BAI JUNIE  - The workshop focused on gathering the group and - ac0vely par0cipate in programs, projects, and contemplate on the vision, mission, and the core ac0vi0es that respond to the problems of society. values of the Nursing Profession. - lead their lives in conformity with the principles of - This then paved the way to construc0on of the right conduct and proper decorum. Philippine Professional Nursing Roadmap - project an image that will uplig the nursing profession at all 0mes. PHILIPPINE PROFESSIONAL NURSING ROADMAP 2030: - A Program of Good Governance of the Nursing REGISTERED NURSES AND THE PROFESSION ETHICAL Profession PRINCIPLES: - Maintenance of loyalty to the nursing profession and VISION 2030 preserva0on of its integrity are ideal. - Philippine Professional Nursing Care: the BEST for the - Compliance with the by-laws of the accredited Filipinos and the CHOICE of the World by 2030 professional organiza0on (PNA), and other professional organiza0ons of which the Registered MISSION Nurse is a member is a logy duty. - We, the Filipino nurses, responding to the needs of - Commitment to con0nual learning and ac0ve society, are engaged in providing humane and par0cipa0on in the development and growth of the globally competent nursing care. profession are commendable obliga0ons. - Contribu0on to the improvement of the socio- CORE VALUES economic condi0ons and general welfare of nurses Love of God through appropriate legisla0on is a prac0ce and a Caring visionary mission. Integrity Excellence GUIDELINES TO BE OBSERVED: REGISTERED NURSES MUST Na0onalism - be members of the Accredited Professional Organiza0on (PNA). GOALS AND OBJECTIVES - strictly adhere to the nursing standards. - Develop dynamic leaders and provide opportuni0es for innova0ve management in educa0on, training and - strive to secure equitable socio-economic and work research condi0ons in nursing through appropriate legisla0on and other means. - Ensure adherence to professional, ethical and legal standards for the health and safety of the public - assert for the implementa0on of labor and work standards. - Prac0ce good governance to sustain par0cipa0ve efforts among nurses and nursing organiza0ons - Maintain linkages with domes0c and interna0onal stakeholders Lesson 4: PHILIPPINE PROFESSIONAL NURSING ROADMAP 2030 - Sustain growth and produc0vity that improve the quality of life of nurses, the Filipino and the people of the world THE FILIPINO NURSE Objec;ves: - -To live the core values and to manifest the desired quali0es of a Filipino Nurse - -Foster sense of accountability among all nurses COLLABORATIVE PARTNERSHIPS - To advocate collegiality and mutual respect that cut across all health disciplines - To engage stakeholders and make them co-owners of nursing issues and concerns - To ac0vely par0cipate socio-economic and poli0cal arena of the country SERVICE EXCELLENCE - -To put into commiOed prac0ce the quality standards in educa0on and nursing service - -To ins0tu0onalize sustainable organiza0onal support for nursing posi0ons COMPETENCY ENHANCEMENT - To promote func0onal integra0on between educa0on and service - Last June 5, 2008, a seminar workshop was headed by - To ins0tu0onalize a sustainable and effec0ve the BON co-sponsored by the Associa0on of Deans of con0nuing professional educa0on and development Philippine College of Nursing (ADPCN) held in for individual nurses and ins0tu0ons University of Sto. Tomas hall. BAI JUNIE  LINKAGES/NETWORKING - To ins0tu0onalize best prac0ce resource genera0on D. Trustworthiness - To adopt local and global best prac0ces in the - Communicate warmth and demonstrate consistency, management of resources reliability, honesty, competence and respect - To forge linkages to generate funds from - -Avoid dishonesty at all cost governments and NGOs - -Avoid sharing personal informa0on or gossiping about others SOCIAL IMPACT - Empowered clients to maintain the highest level of E. Autonomy and Responsibility - wellness and well-being - Make choices and accept responsibility for the - Nursing Profession as a recognized leader in primary outcomes of their ac0on health care - Take ini0a0ve in problem solving - To ensure “posi0ve prac0ce environment” for nurses F. Asser;veness - All of those should lead to us having Culture of - An asser0ve nurse communicates self-assurance, Excellence and Dynamic Leaders communicates feelings, take responsibility for choices and respecpul of other’s feelings, ideas and choices. UNIT 2: THERAPEUTIC COMMUNICATION NURSE-PATIENT RELATIONSHIP - Interpersonal, therapeu0c or helping rela0onship A. Elements of Professional Communica0on - serve as the founda0on of clinical nursing prac0ce B. Nurse-Pa0ent Rela0onship -Characteris0cs and helps promote a psychological climate that -Goals facilitates posi0ve change and growth. -Phases - it may develop within minutes or weeks. -progresses C. Therapeu0c Techniques through stages in succession. NURSE-PATIENT COMMUNICATION CHARACTERISTICS OF A NURSE – PATIENT RELATIONSHIP IS: THERAPEUTIC COMMUNICATION - the face-to-face process of interac0ng that focuses - An intellectual and emo0onal bond between the on advancing the physical and emo0onal well- nurse and the client and is focused on the client. being of a pa0ent. - Respect for the client as an individual - used by the nurse to provide support and - Respect for client’s confiden0ality informa0on to the pa0ent - Focuses on the client’s well-being - an interac0on that is helpful and healing for one or - Based on mutual trust, respect and more of the par0cipants; the client benefits from - acceptance knowing that someone cares and understands GOALS ELEMENTS OF PROFESSIONAL COMMUNICATION - to establish trust and rapport with pa0ents A. Professional appearance, demeanor and behavior - iden0fy most client concern at that moment A professional should: - Assess client’s percep0on of the problem as it unfold - Be clean, neat, well-groomed, conserva0vely dressed and odor free PHASES: 1. Pre-interac0on - Reflect warmth, friendliness, confidence and 2. Introductory competence -Speak in a clear, well-modulated voice 3. Working - Use good grammar 4. Termina0on - Listen to others and communicate effec0vely - Be on 0me, organized, well prepared and equipped PRE-INTERACTION PHASE for his / her responsibili0es - Planning stage before an interview - The nurse reviews per0nent knowledge, considers B. Courtesy poten0al areas of concern, and - Say hello and goodbye to pa0ents - develops plan for interac0on. - Knock on doors before entering - Say hello and goodbye to pa0ents -Knock on doors INTRODUCTORY PHASE/ORIENTATION/PRE-HELPING before entering -State your purpose, address people by name Sets the tone for the rest of the rela;onship Consists of: - Say “please” and “thank you” to team members A. OPENING THE RELATIONSHIP 1. Client and nurse iden0fy each other by name. C. Use of names 2. When ini0ated by the nurse, the nurse must explain - Introduce yourself and status (i.e. student nurse, to the client to give him / her an idea of what to registered nurse or licensed prac0cal nurse) expect - Address people by their names (usually by their 3. When ini0ated by the client, the nurse needs to help - last names) the client express concerns and reasons for seeking - Avoid terms of endearment help. - Avoid referring to pa0ents by diagnosis, room number or other aOribute BAI JUNIE  Tenta;ve statement: “You seem uncomfortable about your B. CLARIFYING THE PROBLEM illness.” C. STRUCTURING AND FORMULATING THE CONTRACT Using open-ended ques;ons 1. Nurse and client develop a degree of trust and - Done by specifying only the topic and invi0ng the verbally agree on: client to give answers that are longer than one or two - Loca0on, frequency and length of mee0ngs -Overall words. purpose of the rela0onship Using touch - How confiden0al materials will be handled -Tasks to - Conveys affec0on, compassion, empathy, emo0onal be accomplished support, encouragement, tenderness and personal - Dura0on and indica0ons for termina0on of the aOen0on rela0onship - Nurses must be sensi0ve to the client’s reac0on to By the end of this phase according to Berman, et.al., (2015), the touch and use it wisely client should begin to: - Touch should be as gentle or as firm as needed and a. Develop trust in the nurse delivered in a comfor0ng, non-threatening manner - b. View the nurse as a competent professional capable PuRng arm over the client’s shoulder, placing your of helping hand over the client’s hand c. View the nurse as honest, open and concerned about their welfare Special zones of touch: d. Believe that the nurse will respect client a. Social zone confiden0ality - Permission not needed. Hands, arms, shoulder, back e. Feel comfortable talking with the nurse about feelings b. Consent zone and other sensi0ve issues - Permission needed. Mouth, wrists, feet f. Understand the purpose of the rela0onships and the c. Vulnerable zone roles - Special care needed. Face, neck, front of body g. Feel that they are ac0ve par0cipants in developing a d. In0mate zone mutually agreeable plan of care - Great sensi0vity needed. Genitalia, rectum WORKING PHASE Resta;ng or paraphrasing - Phase where the client and the nurse begin to view - Ac0vely listening to the client’s statement and then each other as unique individuals repea0ng those thoughts or feelings in a similar - Nurse and client accomplish the tasks outlined in the manner introductory phase, enhance trust and support and Example: develop caring Client: “I couldn’t manage to eat any dinner last night – not even Stages: the dessert.” A. Exploring and understanding thoughts and feelings Nurse: “You had difficulty ea0ng yesterday?” -Nurse must possess empathe0c listening, respect, genuineness, concreteness and confronta0on Seeking clarifica;on (Berman, et.al, 2015) - A method of making the client’s broad overall B. Facilita;ng and taking ac;on meaning of the message more understandable. -Nurse plans programs within the client’s capabili0es Ogen done when paraphrasing is difficult. and considers long and short term goals. - The nurse can restate the message or confess TERMINATION PHASE confusion and ask the client to repeat or restate the message. - Ogen expected to be difficult and filled with ambivalence PERCEPTION CHECKING OR SEEKING CONSENSUAL VALIDATION - Nurse and client accept feelings of loss; client accepts Similar to clarifying, however, only verifies the meaning of a the end of the rela0onship without feelings of anxiety specific word. or dependence (Berman, et.al, 2015) 1. Example: a. Client: “My husband never gives me any THERAPEUTIC COMMUNICATION TECHNIQUES presents.” b. Nurse: “You mean he has never given you Silence a present for your birthday or Christmas?” - accep0ng pauses or moments of silence that may c. Client: “Well – not never. He does get me take several seconds or minutes, without interjec0ng something for my birthday and Christmas any verbal responses. but he never thinks of giving me anything at any other 0me.” Providing general leads - Use of statements or ques0ons that: -encourage the Offering self client to verbalize -choose a topic of conversa0on - - Sugges0ng one’s presence, interest or wish to facilitate con0nued verbaliza0on understand the client without making any demands or aOaching condi0ons that the client must comply Being specific and tenta;ve with to receive the nurse’s aOen0on. “I’ll stay with - Make use of statements that are specific rather than you un0l your daughter arrives.”, “We can sit here for general, and tenta0ve rather than absolute a while, we don’t need to talk unless you would like Specific statement: “Rate your pain on a scale of 1- 10.” to.” General statement: “Are you in pain?” Absolute statement: “You don’t care about your illness and you never will.” BAI JUNIE  Giving informa;on - Nurses may not discuss a client's examination, - Providing in a simple and direct manner, specific observation, conversation, or treatment with other factual informa0on the client may or may not clients or staff not involved in the client's care. request. - Nurses are responsible for protecting records from all unauthorized readers. Acknowledging - Only staff directly involved in a specific client's care - Giving recogni0on, in a nonjudgmental way, of a has legitimate access to the record. change in behavior, an effort a client has made or a - 7. Clients frequently request copies of their medical contribu0on to a communica0on. record, and they have the right to read those records. - Example: “I no0ce you were squin0ng your eyes. Do - When nurses and other health care professionals you have difficulty seeing? have a legitimate reason to use records for data gathering research, or continuing education, Clarifying ;me or sequence appropriate authorization must obtain according to - Helping the client clarify an event, situa0on or agency policy. happening in rela0on to 0me. - Sharing personal information or gossiping about - Example: others violates nursing ethical codes and practice - Client: “I vomited this morning.” Nurse: “Was that standards. It sends the message that the nurse ager breakfast?” cannot be trusted and damages the interpersonal relationships. Presen;ng reality - Helping the client differen0ate between the real and Purposes of Client Records. unreal. a. Communication - This serves as the vehicle by which different health Focusing professionals who interact with a client communicate - Helping the client expand or develop a topic of with each other. importance - This also prevents fragmentation, repetition, and delays in client care Reflec;ng b. Planning client care - Direc0ng feelings, ideas, ques0ons or content back to - Data from the client's record can be used as a basis in the client to enable him / her to explore his / her own planning care for the patient ideas and feelings about a situa0on. c. Auditing health agencies - This allows accrediting agencies to determine if a Summarizing particular health agency is meeting its stated - Sta0ng the main points of a discussion to clarify the standards. relevant points discussed. d. Research - Information from the client's record can be used as a source of data for research. e. Education DOCUMENTING AND REPORTING - his can be used as educational tool by students. 1. Documenting f. Reimbursement - The process of making an entry on a client record Also - Client's record makes it possible for facilities to called as charting or recording obtain payment from Medicare or insurance - This should be accurate, comprehensive, and flexible companies. enough to retrieve critical data, maintain continuity g. Legal documentation of care, track client outcomes, and reflects current - This is a legal document and is usually admissible in standards of nursing practice court as evidence. - Data recorded, reported, or communicated to other h. Health care analysis health care professionals are CONFIDENTIAL and - his may assist in identifying agency needs, such as must be protected. underutilized or overutilized hospital services. 2. Documentation - Is anything written or printed that is relied on as Documentation Systems record or proof for authorized person a. Source-oriented record / traditional client record - Effective documentation ensures continuity of care - Each person or department makes notations in separate saves time and minimizes the risk of error. sections of the client's chart. 3. Report b. Problem Oriented Medical Record (POMR) - an oral, written or computer-based communication - Arranged according to the client's problem rather than the intended to convey information to others. source of information (Berman, et.al, 2015). 4. Record - This encourages collaboration and the problem list in front of - a written or computer-based report the chart alerts caregivers to the client's needs and 5. Maintaining Confidentiality makes it easier to track the status of each problem. - Maintaining confidentiality is an important aspect of professional behavior. Components: 1. Database – consists of all information known about - Nurses are legally and ethically obligated to keep the client upon the client's first entry into the agency; information about clients confidential contains nursing assessment, physician's history, - It is essential that the nurse safeguard the client' right social and family data, and the results of the physical to privacy by carefully protecting information of a examination and baseline diagnostic tests (Berman, sensitive, private nature. et.al, 2015). BAI JUNIE  2. Problem List – derived from the database and is kept 2. Nursing Care Plans at the front of the chart 2 types: 3. Plan of care – initial list of orders or plan of care with reference to the problem list a. Traditional care plans – written for each client; most 4. Progress notes – a chart entry made by all health forms have three columns containing the nursing professionals involved in a client's care. diagnoses, expected outcomes and nursing interventions (Berman, et.al. 2015) b. Standardized care plans – developed to save documentation time; may be based on an Ex.: institution's standards of practice SOAPIE format S-subjective data O-objective data c. Kardexes A-Assessment - A widely used, concise method of organizing and recording data about a The interpretation or conclusion drawn about the subjective client Consists of a series of cards kept in and objective data. a portable index file or on computer- generated forms P-Plan - May be a temporary sheet written in I-Interventions pencil for ease in recording frequent E-Evaluation changes in the details of client's care R- Revision (Berman, et.al. 2015) 4. Flow Sheets c. PIE - enable nurses to record nursing data quickly and - Acronym for problem, intervention, and evaluation of concisely and provide an easy-to-read record of the nursing care client's condition over time - This system consists of a client care assessment flow - Ex. Graphic record, intake and output record, sheet and progress notes medication administration record, skin assessment d. Focus charting record - Intended to make the client and his concerns and strengths the focus of care 5. Progress Notes - Focus may be a condition, a nursing diagnosis, a - Made by nurses to provide information about the behavior, a sign or symptom, an acute change in the progress a client is making towards achieving desired client's condition or the client strength the progress outcomes (Berman, et.al, 2015). notes is organized into: 6. Nursing Discharge D - data - refers to a record of the client's condition after A – action admission and include instructions for the client upon R - response discharge - Provides a holistic perspective of the client and his 7. Referral Summaries needs - Given to a patient for transfer to another institution; e. Charting by Exception (CBE) this includes the patient's history, diagnosis, - Documentation system in which only abnormal or laboratory test result, medications, etc. of the significant findings or exceptions to norms are patient. recorded f. Computerized Documentation General Guidelines for Recording - Developed to help manage the huge volume of 1. Date and Time information required in contemporary health care; - Record time in a conventional manner or according makes use of computers to store the client's to military time. database, add new data, create, and revise care plans 2. Timing and document client's progress - Follow agency's protocol about the frequency of (Berman, et.al, 2015)g. documentation. g. Case Management - Adjust frequency as the client's condition indicates. - Emphasize quality, cost-effective care delivered 3. Legibility within an established length of stay; uses - This should be easy to read to prevent multidisciplinary approach to planning and misinterpretation. documenting client care, using critical pathways 4. Permanence (Berman, et.al, 2015) - Use dark ink so that the record is permanent. Follow agency's policy about the type of pen and ink used for Documenting Nursing Activities recording 5.Accepted terminology 1. Admission Nursing Assessment - Use only commonly accepted abbreviations, symbols and terms specified by the agency. - Also referred to as an initial database, nursing history - If in doubt, write the term in full. or nursing assessment - - Can be organized according to health patterns, body 6. Correct spelling systems, functional abilities, health problems and risks, nursing model or type of health care setting. - This is essential for accuracy recording - If unsure of the spelling, look it up in a dictionary or other resource books 7. Signature BAI JUNIE  - Include name and title. - Chart for someone else. - Sign only entries you made. - Use "patient" or "client", as it is their chart. Leave a - Some agencies may have signature sheets, after blank for colleagues to chart later. signing this signature sheet, nurses can use their - Alter a record even if requested by a superior or initials. physician. - In computerized charting, each nurse has his/her own - Record assumptions or words reflecting bias. code. Reporting 8. Accuracy - Are oral, written, or audiotape exchanges of - Client's name and identifying information should be information between caregivers. written on each page of the record - Purpose: to communicate a specific information to a - Before making an entry, check that it is the correct person or a group of people. chart - Identify charts by name and not by room number Types of Report: - Special care is needed when caring for clients with 1. Change of Shift Report the same last name. - Given to all nurses on the next shift - Quote exact words of patient. - Done to provide continuity of care for clients by - Avoid general words such as large, good, well, or providing the new caregivers a quick summary of normal. client needs and details of care to be given - When a recording mistake is made, draw a line - also termed as ORAL REPORT ENDORSEMENT and through it and write the words mistaken entry above HANDOFF COMMUNICATION or next to the original entry, with your initials or ENDORSEMENT name so that original entry remains visible. The outgoing nurses give endorsements to the - Avoid writing ERROR when a recording mistake has incoming nurses. been made. This can lead to an assumption that a Key elements: clinical error has caused an injury. a. Follow a particular order (e.g. room numbers) - Write on every line, not in between the lines. If a b. Provide identifying information for each client. blank space appears in a notation, draw a line c. For new clients, provide the reason for admission or through the blank so that no additional information medical diagnosis, surgery, diagnostic tests, and can be recorded at any other time and by any other therapies in the past 24 hours. person. d. Include significant changes in the clients' condition 9. Sequence and present information in order (ADPIE) - Document events in the order in which they occur. e. Provide exact information. - Update or delete problems as needed. f. Report client's need for special emotional support. 10. Appropriateness g. Include current nurse-prescribed orders. - Record only information that pertains to the client's h. Provide a summary of newly admitted clients, health problem and care. transferred, and discharged from the unit. 11. Completeness i. Clearly state priorities of care that is due after the - Record all assessments, nursing interventions, client shift begins. problems, comments and responses to interventions j. Be concise. Do not elaborate on background data or and tests, progress towards goals and routine care. Do not report coming and going of communication with other members of the health visitors. team. 2. Telephone Report 12. Conciseness When receiving: - Recording needs to brief and complete - Document the date and time, the name of the 13. Legal prudence person giving the information and the subject of the - Accurate, complete documentation gives legal information received, then sign the notation. protection to the nurse DO: - Repeat the message back to the sender to ensure accuracy. DOS AND DON'TS IN RECORDING - When giving: use SBAR Tool DO: - S=ituation - Chart a change in the client's condition and show - -State your name, unit, client name. that follow up actions were taken. - -Briefly state the problem - Read the nurses' notes prior to care to determine if - B=ackground there has been a change in the client's condition. - medical diagnosis; date of admission; pertinent - Record all nursing actions on time. If in case medical history; brief summary of treatment to date. recording was not done immediately, bear in mind - A=ssessment that a late entry is better than no entry. - vital signs change ; pain scale, - Use objective, specific, and factual prescriptions. - R=ecommendation - Correct charting errors - Chart all teaching. Have the client’s chart ready to give primary care - Record the client's actual words by putting quotes provider any further information. around the statement. Chart the client's response to After reporting, document date, time and content of interventions. the call - Review notes whether they are clear and reflect what you want to say. DON'T: - Chart in advance of the event. - Use vague terms. BAI JUNIE Telephone orders B=ackground - Write the complete order down and read it back to - medical diagnosis; date of admission; pertinent the primary care provider to ensure accuracy. medical history; brief summary of treatment to date. - Question about any order that is ambiguous, unusual, A=ssessment or contraindicated to the client's condition. R=ecommendation - Transcribe the order onto the physician's order sheet, - Have the client’s chart ready to give primary care indicating it as a verbal order (VO) or telephone order provider any further information. (TO) - After reporting, document date, time, and content of - The order must be countersigned by the primary care the call. provider within a time period described by agency R=eadback policy. 3. Nursing rounds INCIDENT REPORT (IR) Purposes: - (also called an EVENT REPORT or OCCURRENCE - Obtain information that will help plan nursing care. REPORT) - Provide clients the opportunity to discuss their care. - is a formal report written by practitioners, nurses, or - Evaluate the nursing care client has received. other staff member. - done most in healthcare facilities to report such as Guidelines of Quality Documentation and Reporting occurrence of injuries, patient complaints, → Factual medication errors, equipment failure, adverse - A record must contain descriptive, objective reactions to drugs or treatments, or errors in patient information about what a nurse sees, hears, feels, care must be reported. and smells. - The use of vague terms, such as appears, seems, and The person who identifies that the incident occurred should apparently, is not acceptable because these words complete the incident report. This may not be the same person suggest that the nurse is stating an opinion. actually involved with the incident. Example: "The client seems anxious" (the phrase seems anxious is a conclusion without supporting facts.) When filling out an incident report, include the following information: → Accurate 1. the exact time and date. 2. the names of persons involved and any witnesses. - The exact use of measurements establishes accuracy. 3. factual information about what happened; and Example: “Intake of 350 mL of water” is more 4. other relevant facts, including your actions (such as accurate than “the client drank an adequate amount notifying the health care provider) and any corrective of fluid” actions taken. - Documentation of concise data is clear and easy to understand. The report should be completed as soon as possible and filed - It is essential to avoid the use of unnecessary words according to agency policy, usually within 24 hours. and irrelevant details → Complete The person who identifies that the incident occurred - The information within a recorded entry or a report should complete the incident report. needs to be complete, containing appropriate and This may not be the same person actually involved essential information. Example: The client verbalizes with the incident. sharp, throbbing pain localized along lateral side of right ankle, beginning approximately 15 minutes ago REFERRAL SYSTEM after twisting his foot on the stair. Client rates pain as - is defined as the process in which the primary health 8 on a scale of 0-10. care physician who has lesser facilities to manage → Current clinical condition seeks the assistance of specialist - Timely entries are essential in the client's ongoing partner with resources to guide in managing clinical care. To increase accuracy and decrease unnecessary episode. duplication, many healthcare agencies use records - Referral does not mean transferring responsibility but kept near the client's bedside, which facilitate it is sharing responsibility in pa0ent care. immediate documentation of information as it is collected from a client Factors affecting referrals: → Organized 1. Availability of qualified consultants - The nurse communicates information in a logical 2. Physician specialty order. Example: An organized note describes the 3. Length of training client's pain, nurse's assessment, nurse's 4. Unexplained findings interventions, and the client’s response. 5. Uncertainty of diagnosis 6. Patient characteristics (e.g. attitude of wanting the best SUPPLEMENTAL possible care) Telephone Report Referral Letter Outline: When giving: 1. Patient details (name, age, sex, and location) SBAR Tool SBAR (or ISBAR or ISBARR) 2. Details of family physician (name of physician making request - is a structured method for communicating critical and name of physician being information that requires immediate attention and Consulted action. 3. Reasons for referral I=dentify 4. Degree of urgency for appointment S=ituation 5. Clinical problem - State Nurse’s name, unit, client name. 6. Important previous history - Briefly state the problem 7. Findings on physical examination BAI JUNIE 8. Findings on investigation (photocopies of results should be Other major resources for information on EBP included) are: 9. Medication and drug sensitivities a. Health links search engine at the 10. Expected outcome and desirable follow up University of Washington Academic Types of Referral Center for Evidence-based Nursing at the 1. ROUTINE University of Texas Health Science Center - Seeking expert opinion for diagnosis and prognosis at San Antonio. 2. EMERGENCY b. National Guideline Clearinghouse To reach the expert on time before occurrence of (www.guideline.gov), a public resource deterioration with providing all expected information for evidence-based clinical practice in referral letter. Usually, the pa0ent is accompanied guidelines. by a physician and a nurse in an ambulance ager thorough physical examina0on and that pa0ent’s ANAs Standards of Professional Performance condi0on can tolerate the travel. Pertaining to Research STANDARD 13: RESEARCH HEALTH CARE ELECTRONIC DATABASES Measurement Criteria - are systems into which healthcare providers routinely The registered nurse: Utilizes best available evidence, including enter clinical and laboratory data. research findings, to guide practice decisions DATABASE - is any collection of data organized for storage, Actively participates in research activities at various levels accessibility, and retrieval. appropriate to the nurse’s level of education and HEALTHCARE DATABASE position. Such activities may include: 1. Identifying clinical problems specific to nursing - serves to replace the paper documents, file folders, research (patient care and nursing practice) and filing cabinets. 2. Participating in data collection (surveys, pilot ELECTRONIC HEALTH RECORDS projects and formal studies - one of the most commonly used forms of healthcare 3. Participating in a formal committee or program databases 4. Sharing research activities and/or findings with Usually, the pa0ent is accompanied by a physician and a nurse in peers and others an ambulance ager thorough physical examina0on and that 5. Conducting research pa0ent’s condi0on can tolerate the travel. 6. Critically analyzing and interpreting research for application to practice 7. Using research findings in the development of TOPICS: EVIDENCE BASED PRACTICE IN NURSING policies, procedures, and standards of practice in RESEARCH-RELATED ROLES AND RESPONSIBILITIES patient care 8. Incorporating research as a basis for learning Evidence-based Practice (EBP) - is the process of collecting, processing, and implementing research findings to improve clinical practice, the work environment, or patient outcomes. (Jolinda, C. et al 2014). In EBP, the nurse integrates research findings with clinical experience, the client’s preferences, and available resources in RESEARCH in general, is a systema0c inquiry that uses disciplined planning and implemen0ng care. methods to answer ques0ons or solve problems (Polit& Beck, 2011). The ul0mate goal of research is to develop, refine and Cochrane Database of Systematic Reviews expand a body of knowledge. – a significant source of EBP data Cochrane Collaboration ROLES OF NURSES IN RESEARCH –is an international not-for-profit organization dedicated to 1. As Principal Investigator making up-to-date, accurate information about the 2. As Member of a Research Team effects of health care readily available worldwide. 3. As Evaluator of Research Findings 4. As Consumers of Research Findings EBP started back in 1970s with Archie Cochrane who was an 5. As Client Advocates in a Research Study epidemiologist in United Kingdom. U0lizing the EBP approach to 6. As Subjects of Research nursing prac0ce helps us provide the highest quality and most cost-efficient pa0ent care As Principal Inves;gators- Nurses need special research prepara0on and training to conduct a scien0fic study. As When you incorporate up-to-date information from new EBP principal inves0gators, they need to thoroughly read the research, you’ll be able to question current practices. You may literature on the chosen topic or problem. ask questions such as: As nurses, we see our pa0ents and we are done with “Are my current nursing interventions the most effective or them. When we conduct research, we become a part of making safest for my patients?” or cancer history, for example. We get to be a part of development process and this could be very rewarding. “ Could we utilize this new EBP interventions in my work area?” As Member of a Research Team - A nurse may be the collector to conduct an experimental investigation which is all considered as part of one’s normal workload. Sometimes, it is better to be part of a team to help lighten the load of BAI JUNIE  researching but definitely the responsibility attached as a researcher is never diminished. RIGHT TO FULL DISCLOSURE - FULL DISCLOSURE, the act of making clear the As Evaluator of Research Findings client’s role in a research situation, is a basic right. This means that deception, by either withholding – A nurse must determine the usefulness of research information about a client’s participation in a study findings in the prac0ce of nursing and con0nuously relate or giving the client false or misleading information these findings to actual situa0on which in turn may lead about what participating in the study involve, must to another inves0ga0on. not occur. – To become an evaluator requires the conduct of research through one’s own efforts. This ensures that the RIGHT TO SELF-DETERMINATION evaluator knows what to look out for. The evaluator may - Many clients feel pressured to participate in be a referee of a research paper or a panelist in a forum studies. They believe that they must please the where a research is presented for cri0quing. physicians and nurses who are responsible for their treatment and care. Careful planning is important so that the sources - The RIGHT TO SELF-DETERMINATION means that identified stand the best chance of being RELEVANT. participants should feel free from constraints, coercion, or any undue influence to participate in a The most comprehensive electronic database for study. nurses is CINAHL (Cumulative Index of Nursing and RIGHT TO PRIVACY Allied Health Literature). - Privacy enables a client to participate without worrying about later embarrassment. The As consumers of Research Findings anonymity of a study participant must be ensured even if the investigator cannot link a specific person Nurses are research users and beneficiaries and are apt to put to the information reported. these findings into use in their prac0ce. However, this must be CONFIDENTIALITY judiciously done to prove reliability of research findings. The - means that any information a participant relates will nurse must be voracious consumer of research findings for an not be made public or available to others without enlightened prac0ce. the participant’s consent. We all want to learn and we should be willing to learn. When - Measures may include the use of pseudonyms or there are new nursing interven0ons, new treatments, we should code numbers or reporting only aggregate or group not be afraid to ask ques0ons before we apply those data in published research. As Subjects of Research As Client Advocates in a Research Study Nurses may also be study respondents who will provide data for Nurses must explain thoroughly to clients who are involved in the the research, intended to change and or improve nursing study the nature of the research and answer their ques0ons prac0ce. They themselves can become subjects of a research sa0sfactorily. The welfare of the clients must be a priority in the too. As nurses, they can provide insights about the profession conduct of the research. The ethics of research must always and its educa0on in general. prevail. Melnyk and Finecout-Overholt(2004) advocate asking clinical The research nurse should understand the study that they ques;ons in the PICOT format. are assigned to so that they can verify if a pa0ent is eligible for a certain study. One strategy for stating the problem you wish to explore is to use the PICOT format: The nurse should con0nuously assess the pa0ent if there are side effects, like in clinical trials and update the physician P – Patient, population, or problem of interest immediately. I - Intervention of therapy to consider for the subject of interest PROTECTING THE RIGHTS OF STUDY PARTICIPANTS C – Comparison of interventions, such as no treatment O – Outcome of the intervention - All nurses who practice in settings where research is being conducted with human subjects or who Example: participate in such research play an important role in safeguarding the following rights: - A 55 year old female has just come into the 1.RIGHT NOT TO BE HARMED hospital. She has been diagnosed with high blood 2.RIGHT TO FULL DISCLOSURE pressure. She exercises and eats right. You need to 3.RIGHT TO SELF-DETERMINATION decide with your team whether she needs to be on 4.RIGHT TO PRIVACY beta-blocker or an ACE-inhibitor. RIGHT NOT TO BE HARMED P- 55 year old female with high blood pressure I- beta blocker - The RISK OF HARM to a research subject is exposure C- ACE-inhibitor to the possibility of injury going beyond everyday O- symptom relief, blood pressure control situations. The risk can be immediate or delayed and Research Question after PICO can be physical, emotional, legal, financial, or social in nature. Risks can also involve psychological factors - In 55 year old women with hypertension, are beta- such as exposure to stress or anxiety, or social blockers more effective than ACE-inhibitors in factors, such as loss of confidentiality or loss of controlling high blood pressure? privacy. Potential risks of participating in a study need to be detailed in informed consent documents. BAI JUNIE  Let us all apply evidence-based prac0ce in the clinical area to improve pa0ent outcomes. CONCEPT OF LEADERSHIP AND MANAGEMENT A. Role of the Nurse as Leader/Manager - Linked to each other (managers must have leadership abilities, and leaders often manage). - these two roles are different from each other LEADER - influences others to work together to accomplish a LEADERSHIP STYLES ACCDG. TO THE BEHAVIORISTS specific goal. 1. AUTOCRATIC LEADER – makes decisions for the group - Leaders are often visionary; they are informed, – determines policies, giving orders and articulate, confident, and self-aware. directions to the group. - Leaders also usually have outstanding interpersonal – Members are often dissatisfied with this skills and are excellent listeners and communicators. leadership style; however, at times an MANAGER autocratic style is the most effective. - is an employee of an organization who is given EXAMPLE authority, power, and responsibility for planning, When urgent decisions are necessary (e.g. a cardiac arrest, a unit organizing, fire, or a terrorist attack), one person must - coordinating, and directing the work of others, and assume the responsibility for making decisions without being for establishing and evaluating standards. challenged by other team members. - The nurse manager is involved in myriad daily tasks and details related to patient care planning, quality 2. DEMOCRATIC LEADER improvement, goal setting, and budgeting. - encourages group discussion and decision making. - Nurse managers also oversee staff schedules and - acts as a catalyst or facilitator, actively guiding the assignments, performance, professional growth, and group toward achieving the group goals. the ongoing provision of educational and career - Providing constructive feedback, offering opportunities. information, making suggestions, and asking - Managers understand organizational structure and questions to become the focus of the participative culture. leader. - They control human, financial, and material - This style allows more self-motivation and more resources. creativity among group members. - Nurses are responsible for managing client care. - It also calls for a great deal of cooperation and - Some nurses assume a position within the coordination among group members. organization as unit manager, supervisor, or - This leadership style can be extremely effective in the executive. health care setting. As a manager, the nurse is responsible for: 3. LAISSEZ-FAIRE LEADER a. Efficiently accomplishing the goals of the organization, - recognizes the group’s need for autonomy and self- b. Efficiently using the organization’s resources, regulation. c. Ensuring effective client care, and - assumes a “hands-off” approach. d. Ensuring compliance with institutional, professional, - A laissez-faire style is most effective for groups whose regulatory, and governmental standards. members have both personal and professional maturity, so that once the group has decided, the COMPARISON OF LEADER AND MANAGER members become committed to it and have the ROLES required expertise to implement it. The leader acts as a resource person. 4. BUREAUCRATIC LEADER - does not trust self or others to make decisions and instead relies on the organization’s rules, policies, and procedures to direct the group’s work efforts. - Group members are usually dissatisfied with the leader’s inflexibility and impersonal relations with them. B. POSITIVE PRACTICE ENVIRONMENT 1. ELEMENTS