Lecture 1A

Patient Care Concepts; Cultural Concepts

Introduction

• Medical Surgical Nursing• Care of adults during illness• Goals

– Promote and maintain health

– Alleviate suffering• “Clients” • Nurses

– Focus on the clients response to actual or potential disruption in health

5 core competencies

1. Provide client-centered care

2. Working in interdisciplinary teams

3. Using evidence-based practices

4. Applying quality improvement principles

5. Using information technology

Provide Client-Centered Care

• Unique• Specific• Listen & respect• Relieve pain

Working in interdisciplinary teams

• All members of the health care team work together– Communicate– Cooperate– Collaborate

Using evidence-based practices

• Nursing knowledge must be established through– Clinical research

Applying quality improvement principles

• Identify• Reduce• Quality Assurance

Using information technology

• Computers

• Describe the application of the nursing process to basic medical-surgical nursing.

Introduction: Nursing Process• is a systematic method of

providing care to clients• Allows nurses to

communicate plans and activities to – Clients– Health care providers– Families

• Encourages orderly thought, analysis, planning

Holistic Health

• Treat the Whole person– Mental– Emotional– Spiritual– Physical– Social

Overview of the Nursing Process• Purpose is to provide client care that is:

– Individualized– Holistic– Effective– Efficient

Overview of the Nursing Process

• Consists of 5 steps• Build on each other• Not linear

Dynamic Nursing Process

• Used throughout the life span

• in any care setting

Small group questions:

1. Describe the steps of the nursing process?2. What is the purpose of the nursing process?3. In what clinical setting is the nursing process

used?

Assessment

• Step #1• Involves

– Collecting data– Validating the data– Organizing the data– Interpreting the data– Documenting the data

Assessment

• Purpose of assessment:– Data collection

• Types of assessment:– Comprehensive– Focused– Ongoing

Assessment

• Comprehensive assessment– Baseline– Physical & psychosocial

Assessment

• Focused Assessment– Limited in scope– Screening for a specific

problem– Short stay

• Ongoing assessment– Follow-up– Monitoring and

observing changes related to specific problems

Assessment• Types of data

– Subjective• Data from the client’s point

of view– Interview

– Objective• Observable & measurable

– Physical assessment– Lab – Dx testing

Assessment

• Validating the Data• Organizing the Data• Interpreting the Data

– Relevant vs. irrelevant– Gaps?– Identify patterns

• Document the Data

iClicker

1. Baby Jane a 2 month infant goes into the doctor for her initial immunization and well baby check-up. What type of assessment should the nurse perform?A. ComprehensiveB. Focused C. Ongoing

Which one of the following is objective data?

A. NauseaB. PainC. DizzinessD. Unsteady gaitE. Anxiety

Which one of the following is subjective data?

A. VomitingB. Warm, moist skinC. Head acheD. Bruise on the right armE. Temperature 99.3 o F

Diagnosis

• Step 2 in the nursing process

• Nursing diagnosis:– “A clinical judgment about individual, family or

community responses to actual or potential heal problems / life processes.

– A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.”

Medical vs. Nursing diagnosis

Medical diagnosis Nursing diagnosis

Identifies conditions the MD is licensed & qualified to treat

Identifies situations the nurse is licensed & qualified to treat

Focuses on illness, injury or disease processes

Focuses on the clients responses to actual or potential health / life problems

Medical vs. Nursing diagnosis

Medical diagnosis Nursing diagnosis

Remains constant until a cure is effected

Changes as the clients response and/or the health problem changes

i.e. Breast cancer i.e. Knowledge deficitPowerlessnessGrieving, anticipatoryBody image disturbanceIndividual coping, ineffective

DiangosisNursing diagnosis Medical diagnosis

Breathing patterns, ineffective

Chronic obstructive pulmonary disease

Activity intolerance Cerebrovascular accident

Pain Appendectomy

Body image disturbance Amputation

Body temperature, risk for altered

Strep throat

Planning & Outcome identification

• Step 3– Types of planning

• Initial• Ongoing• Discharge

Planning & Outcome identification

• Identifying outcomes– Goals

• An aim, intent or end.

– Short term goals• Hours to days (less

than a week)– Long term goals

• Weeks to months

Planning & Outcome identification

• Developing specific nursing interventions– Independent nursing interventions

• No order needed– Elevate edematous legs

– Interdependent nursing interventions• With interdisciplinary team member

– Assist client with physical therapy exercises

– Dependent nursing interventions• Require an order

– Administering of medications

The nursing care plan includes “administer digoxin per MD order”. What type of

intervention is this?A. DependentB. InterdependentC. Independent

Prioritizing Nrs Dx

• Maslow’s hierarchy of needs

Maslow’s Hierarchy of Needs• Physiological:

– Breathing, food, water, sex (gender) sleep, homeostasis, excretion– ABC’s

• Safety– Security of body, employment, resources, morality, family, health or

property• Love/Belonging

– Friendship, family, sexual intimacy• Esteem

– Self esteem, confidence, achievement, respect of others, respect by others• Self-Actualization

– Morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts

Implementation

• 4th step:– Execution of the nursing

care plan

–DO IT–DO IT RIGHT–DO IT RIGHT

NOW!

• Direct• Assist• Supervise• Delegate• Teach• Monitor

Evaluation

• 5th step– Have the clients goals

have been met, partially met or not met.

Role of the LVN• Use the nursing process• Contribute to diagnosis &

nursing care plan• The RN has ultimate

responsibility• RN’s can independently• LVN’s work in conjunction

with RN’s• Provide info• Implement

Multiple Roles: Caregiver

• Provide personal, individual assistance– Caring is the means by

which the nurse is connected with and concerned for the client

Multiple Roles: Manager

• Leader• Coordinate care • Manage time, resources

and environment• Prioritizing

Multiple Roles: Advocate

• “One who speaks for another”

• Protects the clients right

• Communication• Educate• Supports• Resources / Referrals

Multiple Roles: Teacher

• Who?– Family & Patient

• What?– Health promotion– Illness prevention

• Why?– Continuity of care

• How?– Interpersonal skills

Critical Thinking & the Nursing Process

• Critical thinking definition– “A goal-directed thinking

in which a person attempts to use cognitive knowledge and skills to determine the best overall result or choose the best action, given the particular circumstances.”

• Thinking like a nurse – How a nurse thinks!

Characteristics of a Critical Thinker• Thinking Independently• Use analytic process• Use intuition• Having intellectual

courage• Having empathy• Being fair-minded• Being disciplined• Being creative • Being confident in self

• (See Box 1-2, pg 8 of Med-Surg text book)

Nurse-Patient Relationship

• Professional Boundaries– “The limits maintained

between a person who is vulnerable (the client) and the person with power (the nurse)”

Zone of Helpfulness

Under-involved

Over-involved

• Is it consistent with the Code of Ethics

• Is it consistent with Nursing Practice Standards

• Is it consistent with your duty to act in the best interest of your client?

• Does it promote client autonomy and self-determination?

• Is this a behavior or interaction you would want other people to know you had engaged in with a client?

If the Answer is

NO to any

question , stop and

report

Communication• Convey Respect

competence, caring, honest– Do not overwhelm the client – Matter-of-fact questions– Don't make promises you

can't keep– Be dependable– Treat each client as an

individual• Listen• Empathy

– Respect the client

Communication

• Establishing the Setting– Comfortable

environment– Relaxed, unhurried– Sit down– Face the speaker – Maintain eye contact– Provide for privacy– Avoid interruptions

Communication

– Let the client talk– Keep questions brief and

simple– Use understandable language– Ask one question at a time– Give the client time to

answer

– Clarify client responses– Avoid leading questions. – Avoid how or why

questions– Avoid the use of cliché

statements– Open ended questions– Avoid interrupting the

client

Communication• Interviewing Techniques

– Reflection– Restating – Open-ended questions – Silence– Clarification

Health-illness continuum

• What is health?– The individual's state of

health is one of continual change

Culture / Race / Ethnic group / Prejudice

• Culture: – “Is the learned behavior, values,

beliefs, norms, and practices shared by a particular group of people that guide their thinking, decisions and actions”

• Race: – “To identify differences in physical

characteristics, such as skin color, eye shape and bone structure.”

• Ethnic group: – “A group of people who share and are

unified by experiences and background based on such factors as socioeconomic status, religion, education and residence.”

• Prejudice– “The act or state of

holding unreasonable preconceived judgments or convictions.”

• Ethnocentrism: – “Belief that their own

cultural group’s beliefs and values are the only acceptable ones”

• “People of every culture have the right to have their cultural values known, respected, and addressed appropriately”

• The nurse must be …– Sensitive– Aware– Respectful

6 cultural characteristic• Communication

– Listening– Verbal / Non-verbal– Touch

• Space– Personal space– Eye contact

• Social orientation– Definition of family– Religious beliefs– Diet

• Time– Social time– Future oriented vs.

present oriented• Environmental control

– Can you control your environment or does it control you?

• Biological variations

Religious Care Consideration

• Islam: – Prayers – washing,

privacy– Caregiver of the same

gender– Food: Do not eat pork or

alcohol– Fasting: Ramadan

Religious Care Consideration

• Judaism– Sabbath (Friday night –

Saturday night) avoid activities

– Food: Kosher (not milk + meat); NO PORK

Religious Care Consideration

• Hinduism– Vegetarian– No BEEF – (Cows are

sacred)

Religious Care Consideration

• Catholic:– No meat on Friday– Religious icons (rosary,

medals etc) don’t lose them

– Anointment for healing, and when death imminent

Religious Care Consideration

• The Church of Jesus Christ of LDS/Mormon– No tea, coffee, alcohol– Wear special

underclothing

• Methodist– On request clergy anoint

with oil

• Lutheran – On request clergy anoint

with oil

Religious Care Consideration

• Assemblies of God– May seek divine healing

thought prayer and laying on of hands

Religious Care Consideration

• Jehovah’s Witness– No blood transfusions– Do not observe

national / religious holidays

Religious Care Consideration

• 7th day Adventist– No caffeine, pork,

lobster, crab,– Many vegetarian– Sabbath is on Saturday

Religious Care Consideration

• Christian Science – Gen. do not seek

traditional medical treatment

– Avoid immunizations on religious grounds

Cultural influences

• Technological factors• Religious & philosophical

factors• Kinship and social factors• Cultural values and life-

ways• Political and legal factors• Economic factors• Educational Factors