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NursingConceptsUnit1-CH1,15,24,25,37
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- 2. Historical Perspective Highlights •Nurses: • • • • Respond to needs of patients Actively participate in policy Respond and adapt to challenges Make clinical judgments and decisions about patients’ health care needs based on knowledge, experience, and standards of care • Nursing: • Care is provided according to standards of practice and a code of ethics.
- 3. Florence Nightingale • Firstpracticing epidemiologist • a person who specializes in disease that can affect a community or population of people. • Organized first school of nursing • Improved sanitation in battlefield hospitals • Her practices remain a basic part of nursing today.
- 4. Civil War tothe Beginning of the Twentieth Century • The growth of nursing in the United States: • Clara Barton founded the American Red Cross. • Dorothea Lynde Dix • Mother Bickerdyke • Harriet Tubman • Mary Mahoney • Isabel Hampton Robb • Lillian Wald and Mary Brewster: Henry Street Settlement
- 5. The Twentieth Century •Movement toward scientific, research-based practice and defined body of knowledge • 1901: Army Nurse Corps established • 1906: Mary Adelaide Nutting, first professor of nursing at Columbia University • 1908: Navy Nurse Corps established • 1920-1923: Study of nursing education • 1940s and 1950s: Associations emerged • 1970: Emergency Room Nurses Organization
- 6. The Twenty-First Century •Nursing code of ethics • Changes in curriculum • Nursing in multiple care settings • Advances in technology and informatics • End-of-life care
- 7. Influences on Nursing •Changes in society lead to changes in nursing: • Health care reform • Demographic changes • Medically underserved • Threat of bioterrorism • Rising health care costs • Nursing shortage
- 8. Nursing as aProfession • A profession has characteristics: • Requires an extended education • Requires a body of knowledge • Provides a specific service • Has autonomy • Incorporates a code of ethics
- 9. Scope and Standardsof Practice • Nursing: Scope and Standards of Practice • 1960: Documentation began • Standards of Practice • Standards of Professional Performance • Goal • To improve the health and well-being of all individuals, communities, and populations through the significant and visible contributions of registered nursing using standards-based practice
- 10. Standards of Practice •Nursing standards provide the guidelines for implementing and evaluating nursing care. • Six standards of practice: • Assessment • Diagnosis • Outcomes identification • Planning • Implementation • Evaluation
- 11. Standards of ProfessionalPerformance Ethics Quality of Practice Professional Practice Evaluation Education Communication Resources EvidenceBased Practice and Research Leadership Environment al Health Collaboration
- 12. Code of Ethics •A code of ethics is the philosophical ideals of right and wrong that define principles used to provide care. • It is important for you to incorporate your own values and ethics into your practice. • Ask yourself: How do your ethics, values, and practice compare with established standards?
- 13. Quick Quiz! 1. Nursingis defined as a profession because nurses A. Perform specific skills. B. Practice autonomy. C. Utilize knowledge from the medical discipline. D. Charge a fee for services rendered. Answer: B. Practice Autonomy
- 14. Autonomy in Nursing •BACKGROUND: • Professional autonomy means having the authority to make decisions and the freedom to act in accordance with one's professional knowledge base. An understanding of autonomy is needed to clarify and develop the nursing profession in rapidly changing health care environments and internationally there is a concern about how the core elements of nursing are taken care of when focusing on expansion and extension of specialist nursing roles. • RESULTS: • The nurses' descriptions of their experiences of autonomy in work situations emerged as four themes: 'to have a holistic view', 'to know the patient', 'to know that you know' and 'to dare'. To be knowledgeable and confident was found to be the coherent meaning of autonomy in nursing practice. • CONCLUSIONS: • Authority of total patient care, the power to make decisions in a relationship with the patient and next of kin and the freedom to make clinical judgements, choices and actions seem to be connected to the meaning of autonomy in nursing practice. • RELEVANCE TO CLINICAL PRACTICE: • To gain autonomous practice, nurses must be competent and have the courage to take charge in situations where they are responsible. This study shows the challenges in handling this autonomous practice. 14
- 15. Nursing Education • Professionalregistered nurse education • 2-year associate’s degree • 4-year baccalaureate degree • Graduate education • Master’s degree, advanced practice RN • Doctoral degrees • Continuing and in-service education
- 16. Case Study • Minggraduated with an associate’s degree in nursing last year and currently works in a longterm care facility. Although Ming enjoys his work and has been promoted to shift supervisor on his unit, he finds that he’d like to pursue a nursing career that offers a regular schedule and more autonomy than he currently experiences at the long-term care facility. • Ming considers returning to school for an advanced degree.
- 17. Case Study (cont’d) •Ming is particularly drawn to the idea of becoming an advanced practice registered nurse (APRN). • Ming’s career options for becoming an APRN include which of the following? (Select all that apply.) A. Physician assistant (PA) B. Clinical nurse specialist (CNS) C. Certified nurse midwife (CNM) D. Certified RN anesthetist (CRNA)
- 18. Case Study (cont’d) •If Ming decides to pursue a career as an APRN, which patient populations may he serve? (Select all that apply.) A. Adult-gerontology B. Prison inmates C. Neonatology D. Psychiatric mental health
- 19. Case Study (cont’d) •If Ming decides to choose a career as a critical care CNS, then his specialty is identified by which means? A. Population B. Setting C. Disease specialty D. Type of care E. Type of problem
- 20. Nursing Practice • Nursespractice in a variety of settings. • Nurses: • Protect, promote, and optimize our patients’ health • Prevent illness and injury • Alleviate suffering through the diagnosis and treatment of human responses • Advocate for the care of our patients
- 21. Nursing Practice • NursePractice Acts • Licensure and certification • Science and art of nursing practice • Benner’s stages of nursing proficiency: • Novice • Advanced beginner • Competent • Proficient • Expert
- 22. Professional Responsibilities • Nursesare responsible for obtaining and maintaining specific knowledge and skills. • In the past: • To provide care and comfort • Now: • To provide care and comfort and to emphasize health promotion and illness prevention
- 23. Professional Roles Autonomy andAccountability • Caregiver • Advocate • Educator • Communicator • Manager
- 24. Career Development • Nursingprovides an opportunity for you to commit to lifelong learning and career development.
- 25. Professional Nursing Organizations •National League for Nursing (NLN) • American Nurses Association (ANA) • International Council of Nursing (ICN) • National Student Nurses Association (NSNA) or Canadian Student Nurses Association (CSNA) • Other professional organizations focus on specific areas.
- 26. Quick Quiz! The NLNand the ANA are professional organizations that deal with: A. Nursing issues of concern. B. Political and professional issues affecting health care. C. Financial issues affecting health care. D. All of the above issues.
- 27. Quality and SafetyEducation for Nurses (QSEN) Competency: Patient-Centered Care Teamwork and Collaboration Evidence-Based Practice Quality Improvement Safety Informatics
- 28. Additional Nursing Trends •Genomics •Publicperception of nursing •Impact of nursing on politics and health policy •Future trends
- 29. Chapter 15 Critical Thinkingin Nursing Practice
- 30. Critical Thinking Defined •Critical thinking is: • A continuous process characterized by openmindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant • Recognizing that an issue exists, analyzing information, evaluating information, and making conclusions
- 31. Clinical Decisions inNursing Practice • Clinical decision making requires critical thinking. • Clinical decision-making skills separate professional nurses from technical and ancillary staff. • Patients often have problems for which no textbook answers exist. • Nurses need to seek knowledge, act quickly, and make sound clinical decisions.
- 32. Critical Thinking Skills Interpretation Analysis Inference Evaluation Anexample of inference is a scientist guessing at the result of an experiment using things he's already learned. A “Gut Feeling” a diagnosis or diagnostic study of a physical or mental condition Self-regulation Explanation Self-regulation means that the government has granted a professional group, such as registered nurses, the privilege and responsibility to regulate themselves.
- 33. Thinking and Learning •Learning is a lifelong process. • Intellectual and emotional growth involves learning new knowledge, as well as refining the ability to think, solve problems, and make judgments. • The science of nursing continues to grow. Nurses need to be flexible and open to new information.
- 34. Concepts for aCritical Thinker • Truth seeking • Open-mindedness • Analytic approach • Systematic approach • Self-confidence • Inquisitiveness • Maturity
- 35. Critical Thinking Competencies Scientificmethod Problem solving Decision making Diagnostic reasoning and inference Clinical decision making Nursing process as a competency
- 37. Five Components ofCritical Thinking Knowledge base Experience Nursing process competencies Attitudes Standards
- 38. Nursing Process • Thenursing process is a five-step clinical decision-making approach: “ADPIE” Assessment Diagnosis Planning Implementation Evaluation
- 39. Attitudes a NurseNeeds Confidence Perseverance Independence Creativity Fairness Curiosity Responsibility Integrity Risk taking Discipline Humility
- 40. Developing Critical ThinkingSkills Reflective Journaling: A tool used to clarify concepts through reflection by thinking back or recalling situations Concept Mapping: A visual representation of patient problems and interventions that illustrates an interrelationship
- 41. Critical Thinking andDelegation • Effective communication is needed between registered nurses (RNs) and nursing assistive personnel (NAP) for giving feedback and clarifying tasks and patient status. • When patients’ clinical conditions change, warranting attention by RNs, clear directions are necessary to avoid missed care. • Applying critical thinking can help an RN make the decision about when to appropriately delegate care.
- 42. Reflective Journaling The Circleof Meaning model adapted to nursing encourages concept clarification and a search for meaning in nursing practice. The Circle of Meaning model uses a series of questions to help you through a clinical experience and to find meaning.
- 43. Caring for Groupsof Patients • Identify the nursing diagnoses and collaborative problems of each patient. • Decide which are most urgent. • Consider the time it will take to care for those patients. • Consider the resources that you have to manage each problem. • Consider how to involve the patients as participants in care. • Decide how to combine activities. • Decide which nursing care procedures to delegate. • Discuss complex cases with the health care team.
- 44. Meeting With Colleagues •When nurses have a formal means to discuss their experiences such as a staff meeting or a unit practice council, the dialogue allows for questions, differing viewpoints, and sharing of experiences. • When nurses are able to discuss their practices, the process validates good practice and offers challenges and constructive criticism.
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- 46. Components of CriticalThinking in Nursing • I. Specific knowledge base in nursing • II. Experience • III. Critical thinking competencies • IV. Attitudes for critical thinking • V. Standards for critical thinking • A. Intellectual standards • B. Professional standards
- 47. Synthesis of CriticalThinking With the Nursing Process Competency
- 48. Critical Thinking Synthesis Areasoning process used to reflect on and analyze thoughts, actions, and knowledge Requires a desire to grow intellectually Requires the use of nursing process to make nursing care decisions
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- 50. Communication and NursingPractice • A lifelong learning process for nurses • An essential attribute of professional nursing practice • Builds relationships with patients, families, and multidisciplinary team members
- 51. Communication and Interpersonal Relationships Communicationis the means to establish helpingtrust relationships. The ability to relate to others is important for interpersonal communication. Developing communication skills requires an understanding both of the communication process and of ones own communication experience.
- 52. Communication and Interpersonal Relationships(cont’d) • Therapeutic communication occurs within a healing relationship between a nurse and a patient. • The nurse’s communication can result in both harm and good. • Skilled communication empowers others and enables people to know themselves and to make their own choices.
- 53. Developing Communication Skills Criticalthinking Perseverance and creativity Self-confidence Fairness and integrity Humility
- 54. Developing Communication Skills (cont’d) •Thinking is influenced by perception • Five senses • Culture • Education • Perceptual bias
- 55. Quick Quiz! 1. Matchthe levels of communication. 1. Intrapersonal A. One-to-one interaction between two people 2. Interpersonal B. Occurs within an individual 3. Transpersonal C. Interaction with an audience 4. Small group D. Interaction within a person’s spiritual domain 5. Public E. Interactions with a small number of people Copyright line.
- 56. Levels of Communication Answerto matching quiz: 1. Intrapersonal 2. Interpersonal 3. Transpersonal 4. Small group 5. Public B. Occurs within an individual A. One-to-one interaction between two people D. Interaction within a person’s spiritual domain E. Interactions with a small number of people C. Interaction with an audience
- 57. Basic Elements ofthe Communication Process
- 58. Quick Quiz! 3. Matchthe basic elements of communication. 1. Referent A. One who encodes and one who decodes the message 2. Sender and receiver B. The setting for sender-receiver interactions 3. Message C. Message the receiver returns 4. Channels D. Motivates one to communicate with another 5. Feedback E. Means of conveying and receiving messages 6. Interpersonal variables F. Factors that influence communication 7. Environment G. Content of the message
- 59. Basic Elements ofthe Communication Process 1. Referent D. Motivates one to communicate with another 2. Sender and receiver A. One who encodes and one who decodes the message 3. Message G. Content of the message 4. Channels E. Means of conveying and receiving messages 5. Feedback C. Message the receiver returns 6. Interpersonal variables F. Factors that influence communication 7. Environment B. The setting for sender-receiver interactions
- 60. Forms of Communication •Verbal aspects of communication: Vocabulary Intonation Denotative and Clarity and connotative brevity meaning Pacing Timing and relevance
- 61. Forms of Communication (cont’d) •Nonverbal • Personal appearance • Posture and gait • Facial expressions • Eye contact • Gestures • Sounds • Territoriality and personal space
- 62. Forms of Communication (cont’d) •Symbolic • The verbal and nonverbal symbolism used by others to convey meaning • Metacommunication • A broad term that refers to all factors that influence communication
- 63. Nurse-Patient Relationship 1. Preinteractionphase: occurs before meeting the patient 2. Orientation phase: when the nurse and the patient meet and get to know each other 3. Working phase: when the nurse and the patient work together to solve problems and accomplish goals 4. Termination phase: occurs at the end of a relationship
- 64. Professional Nursing Relationships Nurse-patienthelping relationships Nurse-family relationships Nurse-health team relationships Nurse-community relationships
- 65. Elements of ProfessionalCommunication Appearance, demeanor, and behavior Courtesy Use of names Trustworthiness Autonomy and responsibility Assertiveness
- 66. Nursing Process: Assessment •Through the patient’s eyes • Gather information, synthesize, apply critical thinking • Physical and emotional factors • Developmental factors • Sociocultural factors • Gender
- 67. Nursing Process: Diagnosis •Nursing diagnosis for communication • Many patients experience difficulty with communication: • Lacking skills in attending, listening, responding, or self-expression • Inability to articulate, inappropriate verbalization • Difficulty forming words • Difficulty with comprehension
- 68. Nursing Process: Planning •Goals and outcomes • Specific and measurable • Setting of priorities • Teamwork and collaboration
- 69. Case Study (cont’d) •During her visit, Roberto tells Suzanne, “I really want to go visit my uncles in New York, but I’m not sure I’m up for the trip.” • Suzanne is understanding: “It sounds like you miss your family. Let’s talk about your options for maintaining contact.” • As they talk, Suzanne helps Roberto to identify two methods of communicating with his family in New York.
- 70. Nursing Process: Implementation •Therapeutic communication techniques • are specific responses that encourage the expression of feelings and ideas and convey acceptance and respect. • Active listening • means being attentive to what a patient is saying both verbally and nonverbally. • Use “SOLER”: Sit facing the patient; Observe an open posture, Lean toward the patient, Establish and maintain intermittent eye contact; Relax
- 71. Nursing Process: Implementation (cont’d) •Therapeutic communication techniques • Nontherapeutic communication techniques • Adapting communication techniques
- 72. Adapting Communication Techniques •Patients who cannot speak clearly • Cognitive impairment • Hearing impairment • Visual impairment • Unresponsive • Patients who do not speak English (or your language)
- 73. Nursing Process: Evaluation •Through the patient’s eyes • Patient outcomes • Nurses and patients need to determine whether the plan of care has been successful. • Nursing interventions are evaluated to determine which strategies or interventions were effective. • If expected outcomes are not met, the plan of care needs to be modified.
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- 75. Standards for PatientEducation • The Joint Commission (TJC) sets standards for patient and family education. • Successful accomplishment of standards requires collaboration among health care professionals. • All state Nurse Practice Acts recognize that patient teaching falls within the scope of nursing practice.
- 76. Purposes of PatientEducation • To help individuals, families, or communities achieve optimal levels of health • Patient education includes: • Maintenance and promotion of health and illness prevention • Restoration of health • Coping with impaired functioning
- 77. Teaching and Learning •Teaching • An interactive process that promotes learning • Learning • The purposeful acquisition of knowledge, skills, behaviors, and attitudes
- 78. Role of theNurse in Teaching and Learning Teach information that the patient and the family need to make informed decisions regarding their care. • Determine what patients need to know. • Identify when patients are ready to learn.
- 79. TJC’s Speak UpTips • Speak up if you have questions or concerns. • Pay attention to the care you get. • Educate yourself about your illness. • Ask a trusted family member or friend to be your advocate. • Know which medicines you take and why. • Use a health care organization that has been carefully evaluated. • Participate in all decisions about your treatment.
- 80. Teaching as Communication •Closely parallels the communication process • Depends partly on effective interpersonal communication • The learning objective describes what the learner will be able to accomplish after instruction is given.
- 81. Domains of Learning Cognitive Includesall intellectual behaviors and requires thinking Affective Deals with expression of feelings and acceptance of attitudes, opinions, or values Psychomotor Involves acquiring skills that require integration of mental and muscular activity Copyright line.
- 82. Domains of Learning •Different teaching methods are appropriate for each domain of learning. • Cognitive: discussion (one-on-one or group), lecture, question-and-answer session, role play, discovery, independent project, field experience • Affective: role play, discussion (one-on-one or group) • Psychomotor: demonstration, practice, return demonstration, independent projects, games
- 83. Basic Learning Principles Motivationto learn Addresses the patient’s desire or willingness to learn Ability to learn Depends on physical and cognitive abilities, developmental level, physical wellness, thought processes Learning environment Allows a person to attend to instruction Copyright line. Slide 83
- 84. Motivation to Learn • • Attentionalset: the mental state that allows the learner to focus on and comprehend a learning activity Motivation: a force that acts on or within a person (e.g., idea, emotion, physical need) to cause the person to behave in a particular way
- 85. Motivation to Learn(cont’d) Use of theory to enhance motivation and learning Self-efficacy: refers to a person’s perceived ability to successfully complete a task.
- 86. Motivation to Learn(cont’d) • Psychosocial adaptation to illness • Difficult for patients to accept • Need to grieve • Learning occurs in the acceptance stage. • Active participation • Learning occurs when the patient is actively involved in the educational session.
- 87. Ability to Learn •Developmental capability • Cognitive development • Prior knowledge • Learning in children • Developmental stage
- 88. Ability to Learn(cont’d) • Adult learning • Self-directed • Patient-centered • Physical capability • Level of personal development • Physical health • Fatigue
- 89. Learning Environment Well lit Goodventilation Appropriate furniture Comfortable temperature Quiet Private
- 90. Integrating the Nursing andTeaching Processes • The nursing process and the teaching process are not the same. • The nursing process focuses on the patient’s total health care needs. • The teaching process focuses on the patient’s learning needs and ability to learn. • When education becomes part of the care plan, the teaching process begins.
- 91. Nursing Process: Assessment •See through the patient’s eyes. • Teaching is patient-centered. • Assess the patient’s learning needs. • Ask questions to identify motivation to learn. • Determine the patient’s physical and cognitive ability to learn. • Provide an appropriate teaching environment. • Assess the readiness and ability of a family caregiver or other learning resource. • Assess health literacy/learning disabilities.
- 92. Nursing Process: Assessment(cont’d) • Health literacy: the cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health. • Health literacy includes patients’ reading and mathematics skills, comprehension, and decision-making and functioning skills with regard to health care.
- 93. Nursing Process: NursingDiagnosis • Nursing diagnoses for patient education • Deficient knowledge (affective, cognitive, psychomotor) • Ineffective health maintenance • Impaired home maintenance • Ineffective family therapeutic regimen management • Ineffective self-health management • Noncompliance (with medications)
- 94. Nursing Process: Planning •Determine goals and expected outcomes that guide the choice of teaching strategies and approaches with a patient: • Set priorities. • Select timing to teach. • Organize the teaching materials. • Use teamwork and collaboration.
- 95. Nursing Process: Implementation • Maintainlearning attention and participation. • Build on existing knowledge. • Select teaching approach. • Incorporate teaching with nursing care.
- 96. Nursing Process: Implementation (cont’d) •Select appropriate instructional methods: • Group instruction • One-on-one discussion • Preparatory instruction • Demonstration • Analogy • Role playing • Simulation
- 97. Nursing Process: Implementation (cont’d) •Illiteracy and other disabilities • Cultural diversity • Using different teaching tools • Special needs of children and older adults
- 98. Nursing Process: Evaluation •See through the patient’s eyes. • Have the patient’s learning needs been met? • Evaluate a patient’s learning by observing performance of expected learning behaviors under desired conditions. • Discontinue, adjust, or amend the plan. • Patient outcomes: • Legal responsibility • Documentation
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- 100. Scientific Knowledge Base •Fight-or-flight response • Neurophysiological responses: • Medulla oblongata • Reticular formation • Pituitary gland
- 101. General Adaptation Syndrome(GAS) • An immediate physiological response of the whole body to stress; involves several body systems, especially the autonomic nervous and endocrine systems, and includes immunological changes • A three-stage reaction to stress: • Alarm reaction • Resistance stage • Exhaustion stage
- 102. Quick Quiz! You area nurse working in the college student health center. You receive a call that an athlete has just fallen and has been injured. You know that according to the general adaptation syndrome, the athlete will be exhibiting: A. An increased appetite. B. An increased heart rate. C. A decrease in perspiration. D. A decrease in respiratory rate.
- 103. General Adaptation Syndrome •Psychological stress • Primary appraisal • Secondary appraisal • Coping • Personal characteristics that influence response to a stressor: • Level of personal control • Presence of a social support system • Feelings of competence
- 104. General Adaptation Syndrome(cont’d) • Primary appraisal: evaluating an event for its personal meaning • Secondary appraisal: focuses on possible coping strategies • Coping: the person’s effort to manage psychological stress • Ego-defense mechanisms: regulate emotional distress and give a person protection from anxiety and stress
- 105. Types of Stress •Chronic • Chronic stress occurs in stable conditions and results from stressful roles. • Acute • Time-limited events that threaten a person for a relatively brief period provoke acute stress.
- 106. Types of Stress •Posttraumatic stress disorder: • An acute stress disorder that begins when a person experiences, witnesses, or is confronted with a traumatic event • May include flashbacks = Recurrent and intrusive recollections of the event
- 107. Types of Crises •Developmental • Developmental crises occur as a person moves through the stages of life. • Situational • External sources such as a job change, motor vehicle crash, death, or severe illness provoke situational crises. • Adventitious • A major natural or man-made disaster or a crime of violence can create an adventitious crisis.
- 108. Quick Quiz! 2. Apatient comes into the emergency department complaining of chest pain. When discussing possible reasons why the chest pain has occurred, the nurse learns that the patient is depressed because of the loss of a job. This type of crisis can be classified as: A. Maturational. B. Situational. C. Sociocultural. D. Posttraumatic. 31 - 108
- 109. Nursing Knowledge Base: NursingTheory and Role of Stress • Neuman systems model: • Based on the concepts of stress and reaction to stress • Nurses develop interventions to prevent or reduce stress on patients or to help them cope.
- 110. Nursing Knowledge Base:Nursing Theory and Role of Stress (cont’d) • Neuman systems model • Primary prevention promotes patient wellness by stress prevention and reduction of risk factors. • Secondary prevention occurs after symptoms appear. • Tertiary prevention begins when the patient’s system becomes more stable and recovers.
- 111. Nursing Knowledge Base: FactorsInfluencing Stress and Coping • Situational factors • Arise from job changes, illness, caregiver stress • Maturational factors • Vary with life stages • Sociocultural factors • Environmental, social, and cultural stressors perceived by children, adolescents, and adults
- 112. Critical Thinking • Keepin mind the neurophysiological changes the patient may be experiencing. • Use clear communication principles. • Be confident. • Utilize the Standards of Care for Psychiatric Mental Health Nursing Practice (ANA).
- 113. Nursing Process (ADPIE) •Assessment • Nursing diagnosis • Planning • Implementation • Evaluation
- 114. Nursing Process: Assessment •See through the patient’s eyes: • Gather information (including patient’s perception). • Synthesize the information. • Apply critical thinking. • Subjective findings • Objective findings
- 115. Nursing Process: NursingDiagnosis • Nursing diagnoses for stress: • Coping • Ineffective coping • Multiple diagnoses
- 116. Nursing Process: Planning •Goals and outcomes • Desirable outcomes frequently include • Effective coping, family coping, caregiver emotional health, and psychosocial adjustment: life change • Setting priorities • Teamwork and collaboration
- 117. Nursing Process: Implementation •Health promotion • Regular exercise • Support systems • Time management • Guided imagery and visualization • Progressive muscle relaxation • Assertiveness training • Journal writing • Stress management in the workplace
- 118. Nursing Process: Implementation(cont’d) • Crisis: When stress overwhelms a person’s usual coping mechanisms and demands mobilization of all available resources, the situation becomes a crisis. • Acute care • Crisis intervention • Restorative and continuing care
- 119. Nursing Process: Evaluation •Through the patient’s eyes: • Has stress been reduced?
- 120. Nursing Process: Evaluation •Patient outcomes: • Measure outcomes for each diagnosis. • Maintain communication. • Continually assess needs for additional support.
Editor's Notes
- #4 Florence Nightingale believed that the role of nurses was to help the body recover, and then remain free, from disease. Nightingale was the first practicing epidemiologist. She used her keen mind and statistical analysis to show the connection between poor sanitation and diseases like cholera and dysentery. In 1860, Florence organized the first school of nursing, the Nightingale Training School for Nurses, at St. Thomas’ Hospital in London.Known as the Lady with the Lamp, Nightingale crossed the battlefields of the Crimean War with her lantern. By improving sanitation in battlefield hospitals, she showed how effective fresh air, hygiene, and nutrition were in the treatment of wounded soldiers.The practices she advocated remain a basic part of nursing care in the twenty-first century.
- #7 The American Nurses Association established the Center for Ethics and Human Rights in the 1990s. This center helps nurses at large address complex ethical and human rights issues. In 2001, the code of ethics was revised to reflect current ethical issues that affect nursing practice. (See also Chapter 22, Ethics and Values.)The nursing curriculum has continued to change to meet changing societal needs. Issues such as bioterrorism, emerging infections, disaster management, and technology advances were not included in the curriculum as late as 10 years ago. Today, nurses work in multiple settings. Nurses also work in non–patient care environments to support the needs of nursing, nursing education, and patient care. [Ask students in what other areas nurses can work and still support nursing, nursing education, and the patient? Answer: politics, lobbying groups, not-for-profit agencies]The End-of-Life Nursing Education Consortium (ELNEC), offered collaboratively by the American Association of Colleges of Nursing (AACN) and the City of Hope Medical Center, has brought end-of-life care and practices into nursing curricula and professional continuing education programs for practicing nurses.
- #12 The ANA has identified 10 Standards of Professional Performance. [Refer students to Box 1-2 (on p. 5 of the text).]These standards serve as objective guidelines for nurses to follow. They help nurses be accountable for their actions, their patients, and their peers.
- #14 Answer: B
- #17 [Ask the class: What are some options open to Ming?]Ming’s research indicates that accelerated RN to MSN programs are available,where he may obtain a master’s degree.
- #18 [Discuss areas of specialization for the APRN. Answers: B, C, D]Rationale: The four core roles for APRNs include clinical nurse specialist (CNS), certified nurse midwife (CNM), certified RN anesthetist (CRNA), and certified nurse practitioner (CNP). Physician assistant (PA) is not a nursing role.
- #19 Answers: A, C, DRationale: APRNs serve six patient populations: adult-gerontology, pediatrics, neonatology, women’s health/gender related, family, and psychiatric mental health. Although APRNs may care for prison inmates, this group is not a separate patient population, but rather falls into the other six categories based on age, gender, and medical condition.
- #20 Answer: BRationale: The CNS specialty may be identified by a population (e.g., geriatrics), a setting (e.g., critical care), a disease specialty (e.g., diabetes), a type of care (e.g., rehabilitation), or a type of problem (e.g., pain).
- #24 Autonomy is an essential element of professional nursing that involves the initiation of independent nursing interventions without medical orders. Caregiver: Nurses help their patients regain health and find their maximum level of independent function through the healing process. Healing involves the body, mind, and spirit. [See Chapter 35 for more information on spiritual health.]Advocate: Nurses protect the human and legal rights of their patients and help patients assert those rights when needed. [See Chapter 9 for more information on cultural and ethnic issues.]Educator: Your teaching can be formal or informal and will involve the patient, family, significant other, or other support systems. [Chapter 25 reviews Patient Education.]Communicator: [See Chapter 24.] You know that communication is central to the nurse-patient relationship. Again, it is important to develop a communication style for use with patients and members of their support system, as well as a style for communicating with other members of the health care team.Manager: As a manager, you will collaborate with others to help your patients meet their established outcomes and will evaluate the manner in which care is administered. As a manager of care, you will evaluate staff nurses to determine whether they meet professional and health care facility standards.
- #25 Ask students to discuss career opportunities available to them. Some answers may include: •Staff nurse in med-surg, OR, PACU, ED, Short Stay unit, ICU, CCU, TCU, OB, PEDS, or L&D, or in an outpatient setting.•Advanced practice nurse: Requires additional education and experience.APNs can be nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, or nurse midwives.•Nurse educator: Requires additional education and experience.•Nurse administrator: Requires additional education and experience.•Nurse researcher[Photois on p. 8 of the text.]
- #27 Answer: D
- #28 One trend in nursing, QSEN, addresses the challenge to prepare nurses with the competencies needed to continuously improve the quality of care in their work environments. See Table 1-1, Quality and Safety Education for Nurses (on p. 9 of the text), for examples of each QSEN competency. Definitions follow:Patient-Centered Care: Recognize the patient or designee as the source of control and a full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs. Teamwork and Collaboration: Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care.Evidence-Based Practice: Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care. [See also Box 1-4, Evidence-Based Practice: Safety Competencies and Patient-Centered Care, on p. 10 of the text.]Quality Improvement: Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems. Safety: Minimize risk of harm to patients and providers through both system effectiveness and individual performance. Informatics: Use information and technology to communicate, manage knowledge, mitigate error, and support decision making.
- #29 The nursing profession will continue to evolve and grow, and so must individual nurses. How has genomics affected nursing? [Discuss the impact of gene research on nursing practice.]Today great emphasis is placed on nurses and nursing. We are highlighted, as in TV ads by the Johnson and Johnson Foundation campaign to draw individuals into the profession. [Ask students: How will this publicity affect your role?]Nurses are becoming more politically sophisticated and, as a result, are able to increase the influence of nursing on health care policy and practice. What other trends do you anticipate? [Discuss.]
- #33 •Table 15-1 (on text p. 193) presents the critical thinking skills that you will employ in your nursing career.•These skills are: •Interpretation:Be orderly in data collection. Look for patterns to categorize data (e.g., nursing diagnoses [see Chapter 17]). Clarify any data you are uncertain about. •Analysis:Be open-minded as you look at information about a patient. Do not make careless assumptions. Do the data reveal what you believe is true, or are there other options? •Inference:Look at the meaning and significance of findings. Are there relationships between findings? Do the data about the patient help you see that a problem exists? •Evaluation: Look at all situations objectively. Use criteria (e.g., expected outcomes, pain characteristics, learning objectives) to determine results of nursing actions. Reflect on your own behavior. •Explanation: Support your findings and conclusions. Use knowledge and experience to choose strategies to use in the care of patients. •Self-regulation: Reflect on your experiences. Identify ways that you can improve your own performance. What will make you believe that you have been successful?
- #35 [See Table 15-2 on text p. 194.]•Truth seeking: Seek the true meaning of a situation. Be courageous, honest, and objective about asking questions.•Open-mindedness: Be tolerant of different views; be sensitive to the possibility of your own prejudices; respect the right of others to have different opinions.•Analytic approach: Analyze potentially problematic situations; anticipate possible results or consequences; value reason; use evidence-based knowledge.•Systematic approach: Be organized and focused; work hard in any inquiry.•Self-confidence: Trust in your own reasoning processes.•Inquisitiveness: Be eager to acquire knowledge and learn explanations, even when applications of knowledge are not immediately clear. Value learning for learning’s sake.•Maturity: Multiple solutions are acceptable. Reflect on your own judgments; have cognitive maturity.
- #37 •Let’s look at a critical thinking model for nursing judgment. [This is Fig. 15-1 from text p. 194. The model’s levels of critical thinking in the pyramid at the top of the model are discussed on this slide. The components of critical thinking, at the bottom of the model, are discussed on the next slide.]•This model presents three levels of critical thinking: •Level 1 is Basic: At the basic level, nurses think concretely on the basis of a set of rules or principles, following a step-by-step process without deviation from the plan. Following a procedure step by step without adjusting to a patient’s unique needs is an example of basic critical thinking. •Level 2 is Complex: Complex critical thinking analyzes and examines choices independently. Nurses learn to think beyond and synthesize knowledge. In complex critical thinking, a nurse learns that alternative and perhaps conflicting solutions exist. •Level 3 is Commitment: Commitment is the third level of critical thinking. Nurses anticipate needs and make choices without assistance from others.
- #39 •Nursing process is a scientific method with five specific steps.•Nursing process is essentially the process of applying the scientific method to caring for a patient. The scientific method has five steps: 1. Identifying the problem 2. Collecting data 3. Formulating a question or hypothesis 4. Testing the question or hypothesis 5. Evaluating results of the test or study[Discuss with students how the five steps of nursing process relate to the five steps of the scientific method.]
- #40 •Critical thinking attitudes help you to know when more information is necessary and when it is misleading and to recognize your own knowledge limits.•A nurse needs 11 attitudes when thinking critically. [The 11 attitudes a nurse needs are presented in Table 15-3 on text p. 200.] These attitudes include confidence, independence, fairness, responsibility, risk taking, discipline, perseverance, creativity, curiosity, integrity, and humility. Let’s discuss the first six attitudes. [The remaining five are covered in the next slide.]•To acquire and show confidence, learn how to introduce yourself to a patient; speak with conviction when you begin a treatment or procedure. Do not lead a patient to think that you are unable to perform care safely. Always be well prepared before performing a nursing activity. Encourage a patient to ask questions.•To develop independence, read the nursing literature, especially when different views on the same subject are presented. Talk with other nurses and share ideas about nursing interventions.•To practice and extend fairness, listen to both sides in any discussion. If a patient or a family member complains about a coworker, listen to the story and then speak with the coworker. If a staff member labels a patient as uncooperative, assume the care of that patient with openness and a desire to meet that patient’s needs.•To take on responsibility and authority, ask for help if you are uncertain about how to perform a nursing skill. Refer to a policy and procedure manual to review steps of a skill. Report any problems immediately. Follow standards of practice in your care.•To become comfortable with risk taking , if your knowledge causes you to question a health care provider’s order, do so. Be willing to recommend alternative approaches to nursing care when colleagues are having little success with patients.•To develop discipline, be thorough in whatever you do. Use known scientific and practice-based criteria for activities such as assessment and evaluation. Take the time to be thorough and manage your time effectively.
- #42 [This slide covers the content of Box 15-1 on text p. 197: Critical Thinking and Delegation, which is drawn from the results of two separate studies in which nurses were asked to describe the process of delegation in their clinical practice.] •Nurses synthesize large amounts of information and think through complex and often emergent clinical situations to make decisions about patient care, including delegation. •An important delegation issue is the right circumstances. Registered nurses (RNs) are responsible for making clinical decisions when patients’ conditions change, including determining what and when to delegate.•When an RN makes the clinical decision to delegate care, it is expected that nursing assistive personnel (NAP) must report significant findings, and that the RN must follow up on tasks that have been delegated. •Delegation is ineffective if RNs fail to carry out proper supervision and evaluation of care. When delegation is ineffective, often activities such as ambulation, feedings, and turning are missed by NAP. •Successful delegation depends on good communication, developing a trusting and respectful relationship, and showing initiative.
- #43 [The Circle of Meaning model adapted to nursing encourages concept clarification and a search for meaning in nursing practice (Bilinski, 2002).]•The series of questions that the Circle of Meaning Model uses are as follows:1. Which experience, situation, or information in your clinical experience seems confusing, difficult, or interesting?2. What is the meaning of the experience? What feelings did you have? What feelings did your patient have? What influenced the experience? Which guesses or questions developed with the first connection in question 1? Give examples.3. Do the feelings, guesses, or questions remind you of any experience from the past or present or something that you think is a desirable future experience? How does it relate? What are the implications/significance?4. What are the connections between what is being described and what you have learned about nursing science, research, and theory? What are some possible solutions? Which approach or solution would you choose and why? How is this approach effective?
- #44 •Box 15-2 (on text p. 197) covers the important issues of clinical decision making for groups of patients.•Identify the nursing diagnoses and collaborative problems of each patient (see Chapter 17).•Analyze patients’ diagnoses/problems and decide which are most urgent on the basis of basic needs, the patients’ changing or unstable status, and problem complexity (see Chapter 18).•Consider the time it will take to care for patients whose problems are of high priority (e.g., do you have the time to restart a critical intravenous [IV] line when medication is due for a different patient?).•Consider the resources you have to manage each problem, nursing assistive personnel assigned with you, other health care providers, and patients’ family members.•Consider how to involve the patients as decision makers and participants in care.•Decide how to combine activities to resolve more than one patient problem at a time.•Decide which, if any, nursing care procedures to delegate to assistive personnel so you are able to spend your time on activities requiring professional nursing knowledge.•Discuss complex cases with other members of the health care team to ensure a smooth transition in care requirements.
- #45 •Meeting with colleagues gives you the chance todiscuss and examine work experiences.•Discussinganticipated and unanticipated outcomes in any clinical situation allows you to continually learn and develop your expertise and knowledge (Cirocco, 2007). •Much can be learned by drawing from others’ experiences and perspectives to promote reflective critical thinking.
- #46 [Fig. 15-2 from text p. 198 is a model of the five-step nursing process.]•This model of the five-step nursing process illustrates that the critical thinking and clinical decision making that you will engage in as nurses are not part of a simple, linear process. •Each step of the process is affected by the step before and will affect the steps that follow.•The purpose of the nursing process is to diagnose and treat human responses to actual or potential health problems (American Nurses Association, 2010). •Human responses include patient symptoms and physiological reactions to treatment, the need for knowledge when health care providers make a new diagnosis or treatment plan, and a patient’s ability to cope with loss. •Use of the process allows nurses to help patients meet agreed-on outcomes for better health.•The nursing process requires a nurse to use the general and specific critical thinking competencies that we have reviewed to focus on a particular patient’s unique needs.•Within each step of the nursing process, you apply critical thinking to provide the very best professional care to your patients.
- #47 [Review Box 15-3 on text p. 199: Components of Critical Thinking in Nursing.]I. Specific knowledge base in nursingII. ExperienceIII. Critical thinking competencies A. General critical thinking B. Specific critical thinking C. Specific critical thinking in nursing: nursing processIV. Attitudes for critical thinking Confidence, Independence, Fairness, Responsibility, Risk taking, Discipline, Perseverance, Creativity, Curiosity, Integrity, HumilityV. Standards for critical thinking A. Intellectual standards Clear, Precise, Specific, Accurate, Relevant, Plausible, Consistent, Logical, Deep, Broad, Complete, Significant, Adequate (for purpose), Fair B. Professional standards 1. Ethical criteria for nursing judgment 2. Criteria for evaluation 3. Professional responsibility
- #48 [This is Fig. 15-3 from text p. 203, a synthesis of critical thinking with the nursing process competency, or the five steps of the nursing process.]•As a beginning nurse, it is important to learn the steps of the nursing process and incorporate the elements of critical thinking.•Critical thinking is a reasoning process by which you reflect on and analyze your own thoughts, actions, and knowledge. •To be a good critical thinker requires dedication and a desire to grow intellectually. •The two processes, dedication and the desire to grow intellectually, go hand in hand in making quality decisions about patient care.[Discuss the QSEN Box on text p. XXX: Building Competency in Quality Improvement.]
- #53 •Every nuance of posture, every small expression and gesture, every word chosen, every attitude held—all have the potential to hurt or heal.•Respect the potential power of communication, and do not carelessly misuse communication to hurt, manipulate, or coerce others.[Ask the class: What are some ways that nurses with expertise in communication express caring? Then discuss.]•Nurses with expertise in communication express caring by:Becoming sensitive to self and othersPromoting and accepting the expression of positive and negative feelingsDeveloping helping-trust relationshipsInstilling faith and hopePromoting interpersonal teaching and learningProviding a supportive environmentAssisting with gratification of human needsAllowing for spiritual expression
- #54 •Nurses who develop critical thinking skills make the best communicators. They draw on theoretical knowledge about communication and integrate this knowledge with knowledge previously learned through personal experience. Critical thinking skills can be used to interpret messages received from others, analyze their content, make inferences about their meaning, evaluate their effects, explain rationale for communication techniques used, and self-examine personal communication skills.•Perseverance and creativity are also helpful because they motivate a nurse to identify innovative solutions. •Patients respond more readily to a self-confident attitude.[How could self-confidence help you in making suggestions about nursing interventions to your colleagues?]•Colleagues sometimes question suggested nursing interventions; having confidence in yourself will help you speak up and offer new ideas.•An attitude of fairness goes a long way in the ability to listen to both sides in any discussion; integrity allows nurses to recognize when their opinions conflict with those of their patients, review positions, and decide how to communicate to reach mutually beneficial decisions. •You won’t know everything. Having an attitude of humility is necessary to recognize and communicate the need for more information before making a decision.
- #55 Communication is most effective when the receiver and the sender accurately perceive the meaning of one another’s messages.It is challenging to understand human communication within interpersonal relationships.•Each person bases understanding of a situation through the filter of her senses (sight, hearing, taste, touch, and smell) and her life experiences (culture, education, past events).•Perceptual biases are human tendencies that interfere with accurately perceiving and interpreting messages from others.•People often assume that others think, feel, act, react, and behave as they would in similar circumstances. They tend to distort or ignore information that goes against their expectations, preconceptions, or stereotypes.•You can overcome perceptual bias by thinking critically, which will help you control these tendencies and communicate effectively.
- #58 •This simple linear model represents a very complex process with its essential components.•The sender’s and the receiver’s physical and developmental status, perceptions, values, emotions, knowledge, sociocultural background, roles, and environment all influence message transmission.[Image is Figure 24-1 from text p. 312 Communication as an active process between sender and receiver.]
- #64 •The nurse-patient relationship has four phases.[See Box 24-4on text p. 315Phases of the Helping Relationship for further discussion.]
- #70 [Suzanne identifies two outcomes from her conversation with Roberto. What are the outcomes that Suzanne identifies?]•Outcomes for Roberto include the following:Patient identifies two methods to maintain communication with family in New York.Patient verbalizes his concerns regarding his declining health.
- #71 •Communication techniques need to be used to prevent barriers when rendering care to patients. •Effective communication techniques are facilitative and tend to encourage the other person to openly express ideas, feelings, or concerns.•Active listening mnemonic means: S—This posture (sitting) conveys the message that you are there to listen and are interested in what the patient is saying. O—Observe an open posture (i.e., keep arms and legs uncrossed). This posture suggests that the you are “open” to what the patient says. A “closed” position conveys a defensive attitude, possibly provoking a similar response in the patient. L—Lean toward the patient. This posture conveys that you are involved and interested in the interaction. E—Establish and maintain intermittent eye contact. This behavior conveys your involvement in and willingness to listen to what the patient is saying. Absence of eye contact or shifting the eyes gives the message that you are not interested in what the patient is saying. R—Relax. It is important to communicate a sense of being relaxed and comfortable with the patient. Restlessness communicates to the patient lack of interest and a feeling of discomfort.[Ask the class for other therapeutic techniques in addition to active listening. Discuss the following: active listening, sharing observations, sharing empathy, sharing hope, sharing humor, sharing feelings, using touch, using silence, providing information, clarifying, focusing, paraphrasing, asking relevant questions, summarizing, self-disclosure, and confrontation.]
- #73 Older adults with sensory, motor, or cognitive impairments require adaptation of communication techniques to compensate for their loss of function and special needs.[Ask the students to consider how they would adapt communication techniques for patients with each of the situations listed. Discuss.] Patients with impaired verbal communication require special consideration and alterations in communication techniques to facilitate sending, receiving, and interpreting messages.
- #80 The assumption is that patients who ask questions and are aware of their rights have a greater chance of getting the care they need when they need it.[Ask the class: With which tips can you help your patient? Discuss.]
- #83 [See Box 25-2 on text p. 331 Appropriate Teaching Methods Based on Domains of Learning for further discussion.]
- #85 •Physical discomfort, anxiety, and environmental distractions influence the patient’s ability to focus on learning.•Motivation sometimes results from a social, task mastery, or physical motive.
- #86 •It is important to use learning theory in health education; it is difficult to change attitudes and values simply by teaching facts.•Using a theory that matches the patient’s needs in practice will provide more effective patient education.•Self-efficacy is a concept included in many health promotion theories because it is often a strong predictor of healthy behaviors, and because many interventions improve self-efficacy, resulting in improved lifestyle choices.
- #87 •A temporary or permanent loss of health is often difficult for patients to accept. They need to grieve, and the process of grieving gives them time to adapt psychologically to the emotional and physical implications of illness.•Readiness to learn is related to the stage of grieving.When the patient enters the stage of acceptance, the stage compatible with learning, introduce a teaching plan. Continuous assessment of the patient’s behaviors determines the stage of grieving. [See Table 25-1 on text p. 333 Relationship Between Psychosocial Adaptation to Illness, Grief, and Learning for further discussion.]•Teaching continues as long as the patient remains in a stage conducive to learning.
- #88 •Cognitive development influences the patient’s ability to learn. You need to know the patient’s level of knowledge and intellectual skills before beginning a teaching plan. •Learning occurs more readily when new information complements existing knowledge. (For example, measuring liquid or solid food portions requires the ability to perform some mathematical calculations.)•The developmental stage of a child determines the capability and types of behaviors that children are able to learn. [See Box 25-3 on text p. 334 Teaching Methods Based on Patient’s Developmental Capacity for further discussion.][Image is Figure 25-1 on text p. 333 The nurse uses developmentally appropriate food models to teach healthy eating behaviors to the school-age child.]
- #89 •Teaching adults differs from teaching children. Adults are able to critically reflect on their current situation and sometimes need help to see their problems and change their perspectives. Adults tend to be self-directed learners, but they often become dependent in new learning situations.•Make education patient-centered by developing educational topics and goals in collaboration with the adult patient.•The ability to learn often depends on the patient’s level of physical development and overall physical health. To learn psychomotor skills, a patient needs to possess a certain level of strength, coordination, and sensory acuity. (For example, it is useless to teach a patient to transfer from a bed to a wheelchair if he or she has insufficient upper body strength.)•The ability to attend to the learning process depends on physical comfort and anxiety levels and the presence of environmental distraction.•Postpone teaching when an illness becomes aggravated by complications such as high fever or respiratory difficulty.•Schedule teaching for a time when the patient will be fresh and not fatigued.
- #90 •The ideal setting helps the patient focus on the learning task.•When teaching in a group, arrange the group so that participants can see one another. As learners observe each other’s verbal and nonverbal interaction, they will communicate more effectively. •Time teaching so it occurs when a patient is ready to learn.
- #93 •The elderly, minorities, immigrants, persons of low income, and people with chronic mental and/or physical health conditions are at greatest risk for low health literacy.•Approximately half of Medicare/Medicaid recipients are functionally illiterate. Functional illiteracy is the inability to read above a fifth grade level.[Can you think of reasons why it is important to assess health literacy in your patients?]•The reading level of health care materials ranges from elementary school level to college level.•Patients with low health literacy may not be able to understand a basic patient education pamphlet, or to determine interactions on a medication label. •Patients with low math skills will have difficulty calculating medication dosages and frequencies.
- #97 [Discuss each instructional method.]•Preparatory instruction consists of providing information about procedures before they occur. It often decreases anxiety because patients have a better idea of what to expect during the procedure.•Demonstrations are most effective when learners first observe the teacher and then, during areturn demonstration, have the chance to practice the skill.•Analogies supplement verbal instruction with familiar images that make complex information more real and understandable.
- #103 Answer: B
- #104 The GAS is activated indirectly for psychological threats, which are different for each person. The intensity, duration, and number of other stressors that occur at the same time affect a person’s response.It is often more difficult to cope with an unexpected stressor.
- #105 A person experiences stress only if the event or circumstance is personally significant. Coping means making an effort to manage psychological stress.Coping is a process that constantly changes to manage demands on a person’s resources. Coping behaviors constantly change as individuals perceive new information.Coping mechanisms include psychological adaptive behaviors, which are often task oriented, involving the use of direct problem-solving techniques to cope with threats. [What are some examples of ego-defense mechanisms?] [See Box 37-1 on text p. 734 Examples of Ego-Defense Mechanisms for further discussion.]
- #107 Posttraumatic stress begins when a person experiences, witnesses, or is confronted with a traumatic event and responds with intense fear or helplessness. Examples of traumatic events that lead to posttraumatic stress disorder (PTSD) include motor vehicle crashes, natural disasters, violent personal assault, and military combat.
- #108 A crisis implies that a person is facing a turning point in life. A patient whose stress is so severe that he or she is unable to cope using any of the means that have worked before is experiencing a crisis.This means that previous ways of coping are not effective, and the person must change.A new developmental stage such as marriage, birth of a child, or retirement requires new coping styles.A person may advance or regress as the result of a crisis, depending on how he or she manages the crisis.Generally, a crisis is resolved in some way within approximately 6 weeks. Crisis intervention aims to return the person to a precrisis level of functioning and to promote growth.
- #111 Neuman’s model stresses the importance of accuracy in assessment, as well as the importance of interventions that promote optimal wellness utilizing primary, secondary, or tertiary prevention. In secondary prevention, the nurse determines the meaning of the patient’s illness and stress, and determines the patient’s resulting needs and available resources for accommodating those needs.At the tertiary level of prevention, the nurse supports rehabilitation processes involved in healing and moving the patient back to wellness, as well as the primary level of disease prevention.
- #115 Establish a trusting nurse-patient relationship. Gather information: Ask questions and make observations of nonverbal behavior. [See Box 37-5 on text p. 737 for examples of nursing assessment questions. Look for clues in the patient’s environment.] Once a stressor has been identified, assess the patient’s perception of the event and his or her coping strategy. Determine whether the patient is suicidal or homicidal by asking directly.Synthesize the information and adopt a critical thinking attitude while observing and analyzing patient behavior. [See Figure 37-3 on text p. 736 The critical thinking model for stress and coping assessment.]Take time to understand a patient’s understanding of the precipitating event and the ways in which stress is affecting his or her life. By inquiring about patient expectations and priorities, you are better able to ensure that you address all of the patient’s needs in some way.Subjective findings include information that you receive by talking with the patient.Objective findings include information that you observe about the patient’s grooming and hygiene, gait, actions, quality of speech, eye contact, and attitude.[What are some examples of objective findings that could indicate a high level of stress in your patient?]
- #116 A review of assessment data leads the nurse to cluster data that indicate a potential or actual stressor and the patient’s response. Clustering of data, along with application of the nurse’s knowledge and experiences with patients in stress, leads to individualized nursing diagnoses. [See Box 37-6 on p. 737 for further discussion.]•Nursing diagnoses for people experiencing stress generally focus on coping.•Major defining characteristics of Ineffective coping include verbalization of an inability to cope and an inability to ask for help.•Stress often results in multiple nursing diagnoses. •Examples of these diagnoses include but are not limited to Anxiety, Caregiver role strain, Ineffective coping, Fear, Risk for posttrauma syndrome, Insomnia, Situational low self-esteem, and Stress overload.
- #117 The nurse often selects interventions for stress and improved coping such as coping enhancement and crisis intervention, in addition to individualized interventions, after considering the nursing diagnosis, the resources available to the patient, and the goals identified by the patient and the nurse.[See Figure 37-4 on text p. 738 Critical thinking model for stress and coping planning for further discussion.]When setting priorities for care, consider the patient’s perspective and responses to assessment questions. The patient’s clinical condition and perception of stress determine which nursing diagnosis has the greatest priority. As in all areas of nursing, safety of the patient and others in his or her environment is the first priority.Recognize the need for collaboration and consultation; inform the patient about potential resources; and make arrangements for interventions such as consultations, group sessions, or therapy as needed.[An example of a concept map is shown in Figure 37-5 on text p. 740.]
- #118 Three primary modes of intervention for stress are to decrease stress-producing situations, increase resistance to stress, and learn skills that reduce the physiological response to stress. Educate patients and families about the importance of health promotion.A variety of techniques, including regular exercise, utilization of a support group, breaking tasks into manageable pieces through time management, relaxation techniques, assertiveness training, and journal writing, can help patients cope with stress.Stressors such as rapid changes in health care technology, diversity in the workforce, organizational restructuring, and changing work systems place stress on employees. Burnoutoccurs as a result of chronic stress.[What are some strategies for coping with workplace burnout?] [See text p. 741 for further discussion.][Image is Figure 37-6 from text p. 741.]
- #119 The precipitating event usually occurs approximately 1 to 2 weeks before the individual seeks help, but sometimes it has occurred within the past 24 hours. Crisis intervention aims to return the person to a precrisis level of functioning and to promote growth. [See Figure 37-7 on text p. 742 Crisis intervention model for further discussion.]When using a crisis intervention approach, you help the patient make the mental connection between the stressful event and his or her reaction to it. You can assist the patient in seeing the situation realistically, being aware of the emotions the event has triggered, and seeking support, and you can help the patient explore effective coping mechanisms.A person who has experienced a crisis has changed, and the effects often last for years or for the rest of the person’s life. The final stage of adapting to a crisis is acknowledgment of the long-term implications of the crisis. If a person has successfully coped with a crisis and its consequences, he or she becomes more mature and healthy.
- #120 A patient recovering from acute stress often spontaneously reports feeling better when the stressor is gone. Recovery from chronic stress occurs more gradually as the patient emerges from the strain. In either situation, reassess the patient for the presence of new or recurring stress-related symptoms. [See Figure 37-8 on text p. 743 Critical thinking model for stress and coping evaluation for further discussion.]
- #121 Remember that coping with stress takes time. Maintain ongoing communication with patients regarding their coping. Engaging the patient as a partner in health care sets the stage for open communication. If contact with a patient ends before you have achieved the resolution of goals, it is important to refer him or her to appropriate resources so progress is not delayed or interrupted.An essential part of the evaluation process is collaborating with patients to determine whether their own expectations from nursing have been met. Any revision in the plan of care includes steps to address patient expectations.