Are freely chosen, enduring beliefs or attitudes about the worth of a person, object, idea, or action.

 Are important in influencing decisions, actions, including nurses ethical decision making. Not all values are moral values Example: People hold values about work, family, religion, politics, money, and relationships.

ESSENTIAL NURSING VALUES

ALTRUISM is a concern for the welfare and well being of others. In professional practice, altruism is reflected by the nurse s concern for the welfare of the patients, other nurses, and other health care providers. AUTONOMY the right to self determination. Professional practice reflects autonomy when the nurse respects patient s rights to make decisions about their health care.

HUMAN DIGNITY respect for the inherent worth and uniqueness of individuals and populations. In professional practice, human dignity is reflected when the nurse values and respects all patients and colleagues. INTEGRITY is acting in accordance with an appropriate code of ethics and accepted standards of practice. Reflected in professional practice when the nurse is honest and provides care based on an ethical framework that is accepted within the profession. SOCIAL JUSTICE is upholding moral, legal, and humanistic principles. This value is reflected in professional practice when the nurse works to ensure equal treatment under the law and equal access to quality care.

VALUES CLARIFICATION
A process by which people identify, examine, and develop their own individual values. CHOOSING (cognitive) beliefs are chosen Freely, without outside pressure From among alternatives After reflecting and considering consequences

PRIZING (affective) Chosen beliefs are prized and cherished. ACTING (behavioral) Chosen beliefs are Affirmed to others Incorporated into one s behavior Repeated consistently in one s life

 A method of inquiry that helps people to understand the morality of human behavior (i.e., it is the study of morality).  The practices or beliefs of a certain group (e.g., medical ethics, nursing ethics).
BIOETHICS ethics as applied to life. e.g., to decisions about abortion or euthanasia NURSING ETHICS refers to the ethical issues that occur in nursing practice

 Usually refers to private, personal standards of what is right and wrong in conduct, character, and attitude.

 The process of learning to tell the difference between right and wrong of learning what ought and ought not to be done.

 Are statements about broad, general, philosophic concepts such as autonomy and justice.  They provide the foundation of moral rules, which are specific prescriptions for actions. Example: the rule People should not lie is based on the moral principle of respect for persons (autonomy).

 Means that the nurse respects a client s right to make decisions even when those choices seem to the nurse not to be in the client s best interest. Also means treating others with consideration.  Respect for autonomy means that people should not be treated as an impersonal source of knowledge or training.

 Duty to do no harm.  Harm can mean intentionally causing harm, placing someone at risk of harm, and unintentionally causing harm. In nursing, intentional harm is never acceptable.  Unintentional harm occurs when the risk could not have been anticipated.

 Means doing good.  Nurses are obligated to do good, that is, to implement actions that benefit clients and their support persons. However, doing good can also pose a risk of doing harm. Example: a nurse may advise a client about a strenuous exercise program to improve general health, but should not do so if the client is at risk of a heart attack.

 Referred to as fairness.  Nurses face decisions in which a sense of justice should prevail. Example: a nurse making a home visits finds one client tearful and depressed, and knows she could help by staying for 30 more minutes to talk. However, that would take time from her next client, who is diabetic who needs a great deal of teaching and observation. The nurse will need to weigh the facts carefully in order to divide his/her time justly among her clients.

 Means to be faithful to agreements, commitments and promises.  Nurses commitments to clients include providing safe care and maintaining competence in nursing practice.

 It means telling the truth, which is essential to the integrity of the client-provider relationship.

 It is important to most people. A loss of privacy occurs if others inappropriately use their access to a person.  Nurses protect patient privacy by ensuring that the patient s body is appropriately covered, by not discussing medically irrelevant physical features and by not engaging in discussion of intimate details about the patient unless necessary for the provision of good care.

 The principle of confidentiality requires that information about a client be kept private.  What documented in the client s record is accessible only to those providing care to that client. No one else is entitled to that information unless the client had signed consent for Release of Information that identifies with whom information may be shared and for what purpose.

 Is a formal statement of a group s ideals and values.  It is a set of ethical principles that:
Is shared by members of the group Reflects their moral judgments over time Serves as a standard for their professional actions

Nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health and alleviate suffering. The need for nursing is universal. Inherent in nursing is respect for human rights, including the right to life, to dignity and to be treated with respect. Nursing care is unrestricted by considerations of age, color, creed, culture, disability or illness, gender, nationality, politics, race or social status. Nurses render health services to the individual, the family and the community and coordinate their services with those of related groups.

 The nurse is expected to provide safe and competent care so that harm (physical, psycho logic or material) to the recipient of the service is prevented

 Is the quality or state of being legally responsible for ones obligations and actions and to make financial restitution for wrongful acts.

 It is by which the nurse acts or fails to act are legally defined by nurse practice acts and by rule of reasonable and prudent professional with similar preparation and experience would do in similar circumstances.

 A nurse who is employed by a hospital work as an agent of the hospital and the nurses contract with the clients is an implied one.

 Independent nurse practitioner contractual relationship with the client is independent.  Nurse employed by a Hospital functions with employer employee relationship. The nurse represents and acts for the hospital and therefore must function within the policies of the agency.

(Also, respondent superior let the master answer) The nurse may also be held liable as an individual in case of inappropriate behavior. INAPPROPRIATE BEHAVIORS Hitting the client in any part of the body Assisting in criminal abortion. Taking drugs from the client s supply for personal use.

 The rights and responsibilities of the nurse in the role of a citizen are the same as those individual under the legal system.

 Is a process in which people affect one another through exchange of information, ideas and feelings.  As a member of the health team, nurses need to communicate information about clients accurately, timely, in an effective manner

VERBAL COMMUNICATION uses spoken or written words. NONVERBAL COMMUNICATION uses gestures, facial expression, posture/gait, body movements, physical appearance (also as body language), eye contact, tone of voice.

1. Simplicity includes use of commonly understood words, brevity and completeness. 2. Clarity Involves saying exactly what is meant. The nurse also needs to speak slowly and enunciate words well. Repeat the message as needed. Reduce distractions

3. Timing and Relevance require choice of appropriate time and consideration of the client s interests and concerns. Ask one question at a time. Wait for an answer before making another comment. 4. Adaptability involves adjustment on what the nurse says and how it is said depending on moods and behavior of the client. 5. Credibility means worthiness of belief. To become credible, the nurse requires an adequate knowledge about the topic being discussed. The nurse should be able to provide accurate information, to convey confidence and certainly in what she says. Most importantly, he/she should be a good role model for what she teaches.

 Communication is a basic component of relationships and nurse-client relationships.  Non-verbal communication is a more accurate expression of a person s thoughts and feelings than verbal communication.  When assessing nonverbal behaviors, consider cultural influences. Variety of feelings can be expressed by a single non-verbal expression. E.g. head nodding does not always mean agreement.  Effective communication is reciprocal interaction (two-way process) based on trust and aimed at identifying client needs and developing mutual goals.

 TRUST is the foundation of a positive nurse-client relationship. It develops gradually as the client perceives an attitude of acceptance, understanding and empathy from the nurse. The client initially may test the nurse s confidence such as sharing that he expects remain confidential.  Covert communication represents inner feelings that a person may be uncomfortable talking about. Such communication may be revealed through non-verbal modes. Validation is required for overt communication. It is an attempt to confirm to observer s perception through feedback, interpretation and classification.

 Therapeutic Communication is a fundamental component in all phases of the nursing process, and for establishing effective nurse client relationship.  Effective nurse client relationship is a helping relationship which is growth facilitating and provides support, comfort and hope.

 An intellectual and emotional bond between the nurse and the patient and is focused on the patient.  Respects the client as an individual-his ability to participate in his care, ethnic and cultural factors, family relationships and values.  Respects client s confidentiality.  Focuses on the client s well being.  Based on mutual trust, respect and acceptance.

DOCUMENTATION - serves as a permanent record of client information and care. REPORTING - takes place when two or more people share information about client care, either face to face or by telephone.

1. COMMUNICATION provides efficient and effective method of sharing information. It allows to convey meaningful data about the client. 2. LEGAL DOCUMENTATION it is admissible as evidence in a court of law. 3. STATISTICS provides statistical information that can be utilized for planning people s future needs.

4. EDUCATION serves as an educational tool for students in health discipline. 5. RESEARCH provides valuable health-related data for research. 6. AUDIT and QUALITY ASSURANCE monitors the quality of care received by the client and the competence of health care givers. 7. PLANNING CLIENT CARE provides data which the entire health team uses to plan care for the client. 8. REIMBURSEMENT provides the basis for decisions regarding care to be provided and subsequent reimbursement to agency, to cover health related expenses.

A.SOURCE RECORD record)

ORIENTED MEDICAL (Traditional client

B. PROBLEM ORIENTED MEDICAL RECORD (POMR or POR)

 Each person or department makes notations in a separate section/s of the client s chart.

1. 2. 3. 4. 5.

Admission sheet Physician s order sheet Medical history Nurse s notes Special records and reports (referrals, X-ray reports, laboratory findings, report of surgery, anesthesia record, flow sheets, vital signs, I&O, medications.

 Data about the client are recorded and arranged according to the source of the information. The record integrates all the data about the problem, gathered by the members of the health team.

1. DATABASE. Contains all the information about the client. 2. PROBLEM LIST. Contains all the aspects of the person s life requiring health care. 3. INITIAL LIST OF ORDERS or CARE PLANS. 4. PROGRESS NOTES: Nurse s or narrative notes (SOAPIE format)
     

S subjective data O objective data A assessment P planning I intervention P planning Flow sheets (data that are monitored) Discharge notes or referral summaries

 Provides a concise method of organizing and recording data about a client, making information readily accessible to all members of the health team. It is a series of flip cards usually kept in a portable file. It is a way to ensure continuity of care from one shift to another and one day to the next. It is a tool for change of shift report. But endorsement is not simply reciting content of the kardex. The health care needs of the client is still primary basis for endorsement.

 Kardex usually includes the following data:  Personal data (demographic data)  Basic needs  Allergies  Diagnostic tests  Daily nursing procedures  Medications and intravenous (IV) therapy, blood transfusions  Treatments like oxygen therapy, steam inhalation, suctioning, change of dressings, mechanical ventilation. Entries are usually in pencil so that they can be changed s client s condition changes. This implies the Kardex is for planning and communication purposes only.

 Entries are concise. Complete sentences are not required. Start each entry with a capital letter and end the entry is a single word or phrase.

Avoid left pen or pencil for permanence of data, because the client s chart can be used as an evidence in a legal court.

 Chart objective facts, not your interpretations or opinions. E.g.  Correct: ate 50% of the food served.  Incorrect: ate with poor appetite  Correct: Refused medications  Incorrect: uncooperative  Correct: Seen crying  Incorrect: depressed

 Place complaint of the client in quotation marks to indicate that it is his statement. E.g. complained of chest pain radiating down the left arm. Objective data are also to be charted. E.g. skin cold and clammy. Diaphoretic. Prefers to sit up. Vital signs taken as follows: Temp.=37.6 C, PR=110/min, RR=26/min, BP=146/90mmHg Describe behaviors rather than feelings to allow other health team members to determine the actual problems of the client. Refusal of medications and treatments must be documented.

 Only information that pertain to the client s health problems and care are recorded. Any other personal information that is conveyed to the nurse is inappropriate for the record.

 Notes should appear on each succeeding line. Continuous charting is done for each entry unless a time change occurs. No need for a new line for each new idea or entry. Date is entered in the date column on the first line of every page of nurse s notes and whenever the dates changes. Time is entered in the time column whenever a new time entry occurs.

 Avoid time changes in the text of the nurse s notes. Avoid double chart. If something appears on a particular sheet, it does not need to appear o the nurse s notes, unless there is an alteration from the normal, e.g. body temperature, blood pressure. Avoid squeezing information into a space because you forgot to chart it earlier. Add the information on the first available line. Write the time the event occurred, not the time you entered the information.

 Physician s visits. Times the patient leaves and returns to the unit, mode of the transportation and destination. Medications should be charted immediately after given. Treatments should be charted immediately after given.

 Use only those abbreviations and symbols approved by the institution; spell correctly; use proper grammar. Affix signature, place at the end of the charting, at the right hand margin of the nurse s notes. Sign each entry with your full name and status, e.g. SN for student nurse, RN for registered nurse. Script, not printing is used for the signature.

 Correct errors by drawing a single (horizontal) line through the error. Write the word error above the line, then sign your signature. No ink eradications, erasures or use of occlusive materials. E.g. ERROR JU Pulse 180/min 108 beats/min

 Only the health personnel who participate in the care of the client are allowed to read the chart. Chart only what you personally have done, observed, heard, smelled, or felt. Do not discard any part of the client record. Writing must be clear and easily read by the others. If writing is not legible, then print.

 For continuity of care It is based on health care needs of the client It is not mere reciting the content of the Kardex. Provide clear, accurate, and concise information. The nurse documents telephone report by including the following information:

a. When the call was made. b. Who made the call/report. c. Who was called. d. To whom information was given. e. What information was given. f. What information was received.

 Only RN s may receive telephone orders. The order needs to be verified by reporting it clearly and precisely. The order should be countersigned by the physician who made the order within prescribed period of time (within 24 hours). This is done when transferring a client from one unit to another.

ABBREVIATION Adb ABO ac ADL ad lib Adm AM amb amt approx BID BM BP BRP c

TERM Abdomen The main blood group system Before meals Activities of daily living As desired Admitted or admission Morning Ambulatory Amount Approximately Twice daily Bowel movement Blood pressure Bathroom privileges with

C CBC c/o DAT DC or D/C drsg Dx ECG (EKG) F fld Gl gtt h(hr) H2O HS or hs I&O IV

Celsius/centigrade Complete blood count Complains of Diet as tolerated Discontinue or discharge Dressing Diagnosis Electrocardiogram Fahrenheit Fluid Gastrointestinal Drop Hour Water At bedtime Intake and output intravenous

LMP (L) Meds ml/mL mod neg # NPO(NBM) NS (N/S) O2 OOB os OS pc PE(PX) Per/per PM

Last menstrual period Left Medications Milliliter moderate Negative Number of pounds Nothing by mouth Normal saline Oxygen Out of bed Mouth or opening Left eye After meals Physical Examination By or through Afternoon

OD po Postop/postop Preop/preop prep prn q qd Q2h, q3h,etc. qhs qid (R) s Stat/stat tid./TID TO TPR

Right eye or overdose By mouth Postoperatively Preoperatively Preaparation When necessary Every Everyday Every 2 hours, every 3 hours, etc. Everynight at bedtime Four times a day Right Without At once, immediately Three times a day Telephone order Temperature, pulse, respirations

Tr VO VS WNL wt

Tincture Verbal order Vital signs Within normal limits weight

 A change in human disposition or capability that persists over a period of time. Reflected by a change of behavior.

 BEHAVIORISM. The transfer of knowledge could occur if the new situation closely resembled the old situation. COGNITISM. Learning is a complex cognitive (intellectual) activity. (Lewin) Learning must be a individualized process. People do the best they can for themselves relative to their unique perceptions. HUMANISM. There is a natural tendency for people to learn and that learning flourishes in an encouraging environment. Involves providing options for the person and the resources and equipment for learning capacity for self determination and freedom to make choices. It involves respect for human dignity.