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Lippincott Manual of Nursing Practice, 9th Edition - Free ebook download as PDF File .pdf), Text File .txt) or read book online for free. It's about nursing practice. Request PDF on ResearchGate | On Jan 1, , Christine Garvey and others published lippincott manual of nursing practice 9th edition. The Washington Manual of Pediatrics (Lippincott Manual Series) Nursing Theories and Nursing Practice, Third Edition Resource Manual for Nursing Research: Generating and Assessing Evidence for Nursing Practice, 9th Edition.
STAFF The clinical treatments described and recommended in this publica- tion are based on research and consultation with nursing, medical, Executive Publisher and legal authorities. To the best of our knowledge, these procedures Judith A. Nevertheless, they cant be con- Editorial Director sidered absolute and universal recommendations. For individual H. Nancy Holmes applications, all recommendations must be considered in light of the patients clinical condition and, before administration of new or Clinical Director infrequently used drugs, in light of the latest package insert informa- Joan M. The authors and publisher disclaim any responsibility for any Art Director adverse effects resulting from the suggested procedures, from any Elaine Kasmer undetected errors, or from the readers misunderstanding of the text.
Not Specified Please provide a valid price range. downloading Format see all. All Listings 2,, Accepts Offers , Auction 10, download It Now 2,, Item Location see all. US Only. North America. Delivery Options see all. Free International Shipping. Show only see all. Free Returns. Returns Accepted. Authorized Seller. Subjective data obtained by interviewing the patient, iors, and skills to help the nurse provide care effectively in family members, or significant other and reviewing cross-cultural situations.
Many print and online resources are past medical records. Provides the opportunity to convey interest, support, traditions of various cultures. However, the nurse must always and understanding to the patient and to establish a use caution and avoid generalizing and stereotyping patients. Culturally competent care begins with an individualized 2. The physical examination patient assessment, including the patients own definition of a. Objective data obtained to determine the patients health and expectations for care.
Based on this assessment, the physical status, limitations, and assets. Should be done in a private, comfortable environment Leininger offers guidelines for providing care to with efficiency and respect. Consider cultural care preser- vation, which allows patients to continue cultural practices Nursing Diagnosis that do not cause harm or interfere with treatment.
In cultural 1. Organize, analyze, synthesize, and summarize the assess- care negotiation, the patient and health care staff negotiate the ment data. If the patient is 2. Identify the patients health problem, its particular char- engaging in harmful practices, the nurse can help the patient acteristics, and etiology.
Nursing diagnoses con- tinue to be developed and refined. It involves assessment data collection , nursing diagnosis, plan- Planning ning, implementation, and evaluation, with subsequent modifi- See Nursing Care Plan , page 8. Assign priorities to the nursing diagnoses.
Highest pri- of the nursing diagnoses. The process as a whole is cyclical, with ority is given to problems that are the most urgent and the steps being interrelated, interdependent, and recurrent. Assessmentsystematic collection of data to determine the a. Specify short-term, intermediate, and long-term goals patients health status and to identify any actual or poten- as established by nurse and patient together. Analysis of data is included as part of b. Goals should be specific, measurable, and patient- the assessment.
For those who wish to emphasize its impor- focused and should include a time frame. Alcoholism Nausea Dysfunctional ventilatory weaning response Noncompliance specify Effective breast-feeding Overflow urinary incontinence Effective therapeutic regimen management Parental role conflict Energy field disturbance Perceived constipation Excess fluid volume Post-trauma syndrome Fatigue Powerlessness Fear Rape-trauma syndrome Feeding self-care deficit Rape-trauma syndrome: Compound reaction Functional urinary incontinence Rape-trauma syndrome: Silent reaction Grieving Readiness for enhanced self-care Health-seeking behaviors specify Readiness for enhanced comfort Hopelessness Readiness for enhanced communication Hyperthermia Readiness for enhanced community coping Hypothermia Readiness for enhanced coping Imbalanced nutrition: Less than body requirements Readiness for enhanced decision making Imbalanced nutrition: Definitions and Classifications Reprinted with permission.
Identify nursing interventions as appropriate for goal coding, and reimbursement for nursing care in the attainment. Include independent nursing actions as well as med- 4. Formulate the nursing care plan. The nursing care plan ical orders.
Should be detailed to provide continuity of care. Include nursing diagnoses, expected outcomes, inter- dardized language describing treatments performed by ventions, and a space for evaluation. More than b. May use a standardized care plancheck off appro- NIC interventions have been developed through the priate data and fill in target dates for expected out- University of Iowa College of Nursing.
NIC is organ- comes and frequency and other specifics of interven- ized into 30 classifications and 7 domains and includes tions. May use a protocol that gives specific sequential interventions for illness prevention and treatment. John Preston, a year-old businessman, was admitted stopped smoking. Physical examination revealed that Mr.
He had expe- Prestons vital signs were within normal limits. He stated that rienced substernal chest pain and weakness in his arms after he had feared he was having a heart attack until his pain having lunch with a business associate.
The pain had subsided and until he was told that his electrocardiogram lessened by the time he arrived at the hospital. The nursing was normal. He verbalized that he wanted to find out how he history revealed that he had been hospitalized 5 months pre- could prevent the attacks of pain in the future. The physicians viously with the same complaints and had been told by his orders on admission included activity as tolerated, low-choles- physician to go to the emergency department if the pain ever terol diet, and nitroglycerin 0.
He had been placed on a low-fat diet and had as needed. GOAL Short-term: Relief of pain Intermediate: Inclusion of healthy lifestyle measures that decrease myocardial ischemia Long-term: Compliance with therapeutic regimen. Will tolerate dietary regimen. Encourage food and fluid 24 h Denies chest pain after meals; no Will not experience chest pain intake that promotes healthy constipation or diarrhea; fluid intake after meals.
Will maintain normal bowel elimination and that does elimination. Will identify foods low in cho- Request consultation with die- 48 h Dietitian reviewed diet restrictions lesterol and those foods that are titian. Reinforce diet teach- with patient and wife; wife to be avoided. Patient Will select well-balanced diet selects and eats a balanced diet con- within prescribed restrictions.
Will identify activities and exer- Encourage alterations in 48 h Patient and wife have identified cises that could precipitate chest activities and exercise that activities and situations that should pain: Will describe action, use, and Teach about nitroglycerin 24 h Patient has accurately stated action, correct administration of nitro- regimen.
The role is more allowed by DRG, expected outcomes, and key events independent and the basic concepts of home health are differ- that must occur for the patient to be discharged by ent from hospital or outpatient nursing.
Key events are not as specific as nursing interventions, but are categorized by day of stay and Roles and Duties of the Home Care Nurse who is responsible nurse, physician, other health 1. The home care nurse maintains a comprehensive knowl- team member, patient, family.
May also use a computerized care plan that is based on 2. The home care nurse performs an extensive evaluation of assessment data and allows for the selection of nursing the patients medical history, physical condition, psychoso- interventions and establishment of expected outcomes. The home care nurse functions independently, recom- Implementation mending to the primary or specialty health care provider 1.
Coordinate activities of patient, family, significant oth- what services are needed in the home. The home care nurse coordinates the services of other members.
Delegate specific nursing interventions to other members apy, nutrition, and social work. The home care nurse oversees the entire treatment plan a. Consider the capabilities and limitations of the mem- and keeps the health care provider apprised of the bers of the nursing team.
Supervise the performance of the nursing interventions. The home care nurse acts as a liaison between patient, 3. Record the patients responses to the nursing interven- family, caregivers, and the primary health care provider tions precisely and concisely. The home care nurse may function as supervisor of home Evaluation health aides who provide direct daily care for the patient.
Determines the success of nursing care and the need to alter 8. The home care nurse must honor the same patient rights the care plan.
Collect assessment data. Compare patients actual outcomes to expected outcomes Skills for Home Care Nursing to determine to what extent goals have been achieved.
Good rapport buildingto engage the patient, family, and a. Clear communicationto provide effective teaching to ate the effects of nursing interventions. More than family and caregivers, to relate assessment information outcomes are organized into 29 classifications and 7 about the patient to the health care provider, and to share domains. Disciplines other than nursing have found information with the home care team. NOC useful in evaluating the effectiveness of their 3. Cultural competenceknowledge and appreciation of the interventions.
Cultural 3. Include the patient, family, or significant other; nursing practices may affect family structure, communication, team members; and other health team members in the and decision making in the home; health beliefs, nutri- evaluation. Identify alterations that need to be made in the goals and religious beliefs. Accurate documentationrecord keeping in home care is used for reimbursement of nursing services, accreditation Continuation of the Nursing Process and regulatory review, and communication among the 1.
Continue all steps of the nursing process: Continuous evaluation provides the means for maintain- Reimbursement Issues ing the viability of the entire nursing process and for 1. Home health care services are reimbursed by Medicare, demonstrating accountability for the quality of nursing Medicaid, and a variety of commercial insurances and care rendered. Some patients are willing to pay out of pocket for addi- Patient Teaching tional services not covered by insurance because of the 1.
Patient teaching is directed toward the patient, family, well-established value of home care services com- caregivers, and involved significant others. Patient teaching is usually considered skilled and is there- services. Topics may include: Services are reimbursed by Medicare if they meet the fol- a. Disease process, pathophysiology, and signs and symp- lowing criteria: Services are ordered by a physician current law does b. Administration of injectable medication or complex not recognize nurse practitioners.
Services are intermittent or needed on a part-time basis. Diabetic management for a patient newly diagnosed c.
The patient is homebound. The services required are skilled need to be provided d. Wound or ostomy care. Gastrostomy and enteral feedings. Management of peripheral or central I. Use of adaptive devices for carrying out activities of e. The services requested are reasonable and medically daily living and ambulation.
Transfer techniques and body alignment. The home health nurse must evaluate the case and ensure j. Preparation and maintenance of therapeutic diet.
This information must be docu- 3. Barriers to learning should be evaluated and removed or mented so reimbursement wont be denied. The nursing process is carried out in home care as it is in other b. Personal barriers, such as sensory deficits, poor reading nursing settings. Patient interactions are structured differently skills, and drowsiness. The teaching plan should include the three domains of patient for a limited time.
Many procedures and nursing inter- learning: Cognitivesharing of facts and information. Major concerns of b. Affectiveaddressing the patients feelings about the the home care nurse are patient teaching, infection control, disease and treatment. Psychomotordiscussing performance of desired behavior or steps in a procedure. The Home Care Visit 5. Documentation of patient teaching should be specific and 1. The initial home care visit should be preceded by infor- include the degree of patient competence of the proce- mation gathering and an introductory phone call to the dure.
Patient teaching plans may take several sessions to imple- 2. Extensive assessment is carried out at the first visit, ment successfully. Nosocomial infection rates are much lower in home care, review of current treatment plan. Once assessment gathered from multiple sources is immune systems and the variability of a clean or sterile complete, nursing diagnoses are formed. Outcome planning goal setting is done with the 2.
The nurse should assess and maintain a clean environment. Make sure that clean or sterile supplies are readily 5. The plan is implemented over a prescribed time period available when needed. Interventions may be: Make sure that contaminated supplies are disposed of a.
Cognitiveinvolves patient teaching. Psychosocialreinforces coping mechanisms, supports i. Needles should be disposed of in a safe and secure caregivers, reduces stress. Technicalentails procedures, such as wound care and which can be disposed of through the home catheter insertion. Evaluation is ongoing at every visit and by follow-up ii. Supplies, such as dressings, gloves, and catheters, phone calls to adjust and refine the care plan and fre- should be securely bagged and disposed of in small quency of service.
Recertification for continued service, discharge, or trans- the patients home. However, biohazardous waste fer to a hospital or nursing home ultimately occurs. The nurse should be aware of all methods of transmission American Nurses Association.
Position statement: Risk and of infection and implement and teach preventive prac- responsibility in providing nursing care. Silver Spring, Md.: ANA Publishing. American Nurses Credentialing Center. Andrew, M.
Transcultural concepts in nurs- 4. The nurse must perform ongoing assessment for signs and ing care 5th ed. Nursing interventions classifica- caregivers what to look for.
The nurse should be aware of community-acquired infec- Carpenito-Moyet, L. Handbook of nursing diagnosis 12th tions that may be prevalent in certain populations, such ed. Nursing diagnosis: Applications to hepatitis, and sexually transmitted diseases. Teach preventive practices. Canadian Nurses Association. Promot- b. Encourage and institute screening programs. Report infections according to the local public health cna-nurses. Encourage and provide vaccination for the patient and Catalano, K. Proposed household contacts for influenza, pneumococcal pneumo- Regulations for Enforcement of the Patient Safety and Quality nia, hepatitis B, and others as appropriate.
Improvement Act of Plastic Surgical Nursing, 28 2 , Ensuring Safety Griffiths, B. Nursing Perspective: Gastroenterology Nursing, 30 6 , Hunt, R. Introduction to community based nursing.
Assess for environmental safety issuescluttered spaces, Philadelphia: Institute of Medicine. Preventing medication errors. Washing- 3. Assess for the patients personal safety issuessensory ton, D. The Joint Commission. National patient safety goals. Assess safety in the bathroomhandrails, bath mat, [Online]. Assess safety in the kitchenproper refrigeration of food, Kenneley, I.
Infection control and prevention in home ability to shop for and cook meals, oven safety. Prevention activities are the key to desired patient 6. Be alert for abuse and neglect, especially of children, outcomes. Home Healthcare Nurse, 25 7 , Leininger, M. Transcultural nursing: Concepts, theories, research, and practice.
New York: McEwan, M. Theoretical basis for nursing. Be continually cognizant of your own safetyget direc- 2nd ed. Nursing outcomes classification enter suspicious areas without an escort, be alert to your NOC 4th ed.
Muller-Staub, et al. Improved quality of nursing documenta- tion: Results of a nursing diagnoses, interventions, and outcomes implementation study. American Association of Colleges of Nursing. NANDA nursing diagnoses: Definitions of the Schools. American Nurses Association. ANA handle with care campaign.
Office of Minority Health. Culturally compe- [Online]. A cornerstone of caring. Nursings social policy state- https: Publication 03NSPS.
Along 1. Respect for the individuals autonomy incorporates princi- with this privilege, nurses carry equal duties of responsibility and ples of freedom of choice, self-determination, and privacy. The professional nurses duty is to view and treat each integral to the profession. Greater efforts must be made from individual as an autonomous, self-determining person within the profession to apply evidence-based research data to with the freedom to act in accordance with self-chosen, daily practice systematically and deliberately, thereby increasing informed goals, as long as the action does not interfere or patient safety, improving outcomes, and reducing risk and infringe on the autonomous action of another.
Transformation of the professional culture within 3. See the National League of Nursing Statement on the health care system itself would give nurses at the bedside the Patients Rights see Box The Joint Commission has established National Patient health care. Additional measures might include protocol imple- Safety Goals based on such settings as ambulatory care, mentation, preceptor performance review, peer review, continu- assisted living, and the facility. See www. Although the vast majority of claims may be with- aspiration and duty to help promote the well-being of others out merit, many professional nurses will have to deal with the and, often, is the primary motivating factor for those who unfamiliar legal system.
A system of ethical principles and stan- choose a career in the health care profession. Health care dards of care will be beneficial in such situations.
Therefore, it is professionals aspire to help people achieve a better life preferable for the nursing profession to incorporate certain ethi- through an improved state of health. In the health care profession, this principle is actualized Clinical ethics literature identifies four principles and values only with the complementary principle of beneficence that are integral to the professional nurses practice: As the health care dollar becomes increasingly more National League of Nursing scarce, justice seeks to allocate resources fairly and treat BOX Statement on Patients Rights patients equally.
Dilemmas arise when resources are scarce and insufficient Nurses have a responsibility to uphold the following rights of to meet the needs of everyone. How do we decide fairly patients: To health care that is accessible and that meets profes- 4.
One might consider whether it is just or fair for many sional standards, regardless of the setting. Along with respect for people and their autonomy, the com- payment, or ethical or political beliefs. To information about their diagnosis, prognosis, and plex principle of justice is a culturally comfortable principle treatmentincluding alternatives to care and risks in countries such as the United States.
Nonetheless, the involvedin terms they and their families can readily application of justice is complex and often challenging. To informed participation in all decisions concerning their health care.
Ethical dilemmas arise when two or more ethical princi- their care. To privacy during interview, examination, and treatment. To privacy in communicating and visiting with people of 2. Such dilemmas can best be addressed by applying princi- their choice. Clinicians should network with their colleagues and con- being taken against them.
To appropriate instruction or education from health care personnel so that they can achieve an optimal level of Ethics Committees wellness and an understanding of their basic health needs.
Ethics committees identify, examine, and promote resolu- To confidentiality of all records except as otherwise pro- tion of ethical issues and dilemmas by: Protecting the patients rights. Protecting the staff and the organization. To access to all health records pertaining to them, to c. Reviewing decisions regarding clinical practice and challenge and correct their records for accuracy, and to standards of practice.
Improving the quality of care and services. To information on the charges for services, including the e. Serving as educational resources to staff. Building a consensus on ethical issues with other pro- To be fully informed as to all their rights in all health fessional organizations. Addressing and resolving ethical dilemmas is usually a challenging decision shared with the clinical staff.
A pattern of unsafe nurse-to-patient ratio can be caused justified by the benefits of the procedures or treatments. It is best to seek to promote a balance of potential risk- 2. A series of actions to best resolve the problem includes: Address this unsafe situation verbally and in writing to being to strive to maximize expected benefits and mini- the unit charge nurse with copies to the nursing super- mize possible harms. Therefore, nonmaleficence should visor and director of nursing.
This will likely prompt action by the facility, such as creating an as-needed pool of nurses to call for such JUSTICE situations, hiring more staff or, in the interim, securing 1. Justice, or fairness, relates to the distribution of services contracts with outside nursing agencies and utilizing and resources.
Tolerance by staff nurses employed under such circum- fall-induced injury versus the restriction of the patients stances will preclude appropriate resolution and will leave freedom of movement about the room. Document ongoing assessments of potential problems, needs, potentially increasing the risk of liability. Although the employer is liable for the acts of the members.
Apply restraints according to the policy of the rehabilita- nurse will not be exonerated should a patients care be tion unit until an order is secured from the physician. Consult facility policy on restraint use. Secure an order from the physician for restraints to be used as needed, including specific criteria outlined in Nonresponse by Physician step 1d.
A patient arrives to the rehabilitation unit at 9 PM with 6. Reassess the patients need for diuretic and sleep aid or numerous positive criteria for falling, including poor sedative use. Discuss discontinuation of any unnecessary short-term memory, daily use of a diuretic, daily use of a medications that increase the patients degree of confu- sleep aid, a history of a fall within the preceding 2 sion or risk for falling if possible. Patient is oriented to time, place, and person, his new Inappropriate Orders room, facility bed, and call light use.
A year-old patient with a diagnosis of uncontrolled b. The nurse instructs patient to summon her if he needs heart failure is presently in the intensive care unit for to void or otherwise get out of bed, at least until he treatment and hemodynamic monitoring. He is becom- becomes familiar with his new environment. Upon returning to patients room 10 minutes later, signs are stable and respiratory distress is absent. A the nurse finds patient out of bed, arranging his house officer is summoned to evaluate this change in clothes in his closet, standing in a pool of urine on the clinical status.
The house officer, unfamiliar with the patient, spends d. The nurse weighs the risks and benefits of restraint use 2 minutes reviewing the chart, examines the patient and determines whether alternatives are available. The nurse intends to b. You tell the house officer that you heard decreased ask the physician for an order with clear specification breath sounds in the left, lower lung and ask him to of the least restrictive method of restraint, the dura- order some diagnostic tests, such as a chest X-ray and tion, circumstances, frequency of monitoring, and arterial blood gas analysis, and share your concern that reevaluation if it differs from facility policy.
However, administering a sedative to the patient may mask the the physician does not return her calls. The nurse doc- underlying cause of the anxiety, lead to respiratory com- uments her initial assessment of the patient, her nurs- promise, and delay diagnosis and treatment of the under- ing diagnoses, the orientation to room and equipment lying clinical problem.
Nevertheless, he leaves the unit. You decide not to give the sedative ordered by the she found the patient out of bed, and her repeated house officer. Although you cannot automatically follow an order you telephone call. Again, a series of actions may resolve the problem or at either. Address this situation a. Document the scenario described above in the with intermediate measures while waiting for the physi- patients chart, contact the resident on call, and notify cians return call: Raise side rails on patients bed.
If assessment by the resident on call agrees with the b. Move patient to a room close to the nurses station. Place a sign on patients room door and above the bed concerns with him, obtain appropriate stat orders, and identifying him as being at risk for falling.
Place a sign above the bed instructing personnel to raise physicians orders and the actions you took. Notify all involved medical and nursing personnel of e.
Check on the patient frequently during the first 24 the patients status. Document clearly, succinctly, and in a timely fashion. Your actions reflect concern about the best interest of the 3. Call the patients family, advising them of your concern patient and, although they may yield negative behaviors about the patients safety and discuss the issue of restraints by the house officer or resident, it is more important to with them.
Discuss the risk for falling and prevention of prevent potential injury to the patient. Address concerns or special requests for information not to be disclosed. Integral to the practice of any profession is the inherent standards. The law places limits on preexisting condition need to be responsible for actions taken and for omissions.
The professional nurse must be proactive and take all credit for prior coverage, makes it illegal to use health sta- appropriate measures to ensure that her own practice is tus as a reason for denying coverage, guarantees group cov- not lacking, remiss, or deficient in any area or way.
Useful proactive measures include: The law a. Maintaining familiarity of relevant, current facility included provisions designed to save money for health policies, procedures, and regulations as they apply to care businesses by encouraging electronic transactions and the nurses practice and specialty area. Providing for self-audit. The law gave Congress until c. Providing for peer review to assess reasonableness of August 21, , to pass comprehensive health privacy care in a particular setting for a particular problem.
However, Congress did not enact such legisla- d. Working with local nursing organizations to make cer- tion and the law required that after 3 years, the Depart- tain that local standards of practice are met.
Examining the quality accuracy and completeness of protections by regulation. Establishing open working relationships with col- ually identifiable health information. The rule: Limits the use and disclosure of certain individually comed for the greater goal of quality patient care. Local standards of practice normally coordinate with b. Gives patients the right to access their medical records.
Restricts most disclosure of health information to the minimum needed for the intended purpose. Establishes safeguards and restrictions regarding the use The professional nurse has the duty to: Promote what is best for the patient. Ensure that the patients needs are met. Provides for criminal or civil sanctions for improper 3. Protect the patients rights. The patients privacy is consistent with the Hippocratic mation outweighs the principle of confidentiality.
How- Oath and with the law as part of the constitutional right ever, legal counsel should be consulted because these to privacy. Although the professional nurse should assure the patient eralizations cannot be assumed. It may be appropriate to breach confidentiality on a lim- and discussed with the patient at the earliest opportunity. It is imperative to clearly understand the process of a.
If a patient reveals intent to harm himself or another informed consent and the legal standard for disclosure of individual, it is imperative to protect the patient and confidential patient information to others. The Medical Record Confidentiality Act of , a fed- b. A clinician employed by a company, school, military eral statute, is the primary federal law governing the use unit, or court has split allegiances, and the patient of health treatment and payment records. Several practi- should be so advised at the appropriate time.
Court orders, subpoenas, and summonses in some states a. Respecting the individuals right to privacy when may require the clinician to release records for review or requesting or responding to a request for a patients testify in court. However, legal counsel should be con- medical records. Most insurance companies, health maintenance tion to protect and respect patient-provider privilege organizations, and governmental payers require partic- statutes. When a patient places his medical condition at issue, NURSING ALERT With the increasing cultural diversity of our such as in personal injury cases, workmans compensa- patient population, it is prudent to obtain an interpreter for the tion, or in various other cases of patients claiming patient if there is a reasonable chance that the patient will not under- injuries for which they are seeking compensation from stand explanations in the English language.
The professional nurses scope of practice is defined and out- g. Criminal codes in many states require reporting gun- lined by the State Board of Nursing that governs practice. Licensure is granted by an agency of state government spouse, or elder abuse if they have reasonable cause to and permits individuals accountable for the practice of suspect abuse.
Certification is provided by a nongovernmental association 1. Environmental Health and Nursing Practice. Competencies for Advanced Nursing Practice. Advancing Practice in Rehabilitation Nursing. Cancer Nursing: Principles and Practice. Nursing Practice, Policy and Change. Clinical Genetics in Nursing Practice. Advanced Nursing Practice 2nd Edition. Intravenous Therapy in Nursing Practice. Essentials of Nursing Research: Recommend Documents.