chapter 2
Nursing Concepts, the Nursing Process, and Trends in Nursing
After studying this chapter, the student should be able to:
1 Recognize the psychological, social, and environmental factors that shape patient individuality.
2 Discuss factors contributing to health and illness.
3 Use critical thinking skills to solve patient problems.
4 Demonstrate correct techniques for performing various nursing skills.
5 Discuss the importance of the history of the nursing profession to today’s nurses.
6 Verbalize the ethical and legal aspects of rendering nursing care.
http://evolve.elsevier.com/Mosby/comprehensivePN
HEALTH AND ILLNESS
HEALTH DEFINED
A According to the World Health Organization (WHO), health is “a state of complete physical, mental, and social well-being and not merely an absence of disease or infirmity.”
B According to Abraham H. Maslow, health exists when all human needs are satisfied.
C According to Hans Selye, health exists when an individual is in a relative state of adaptation to his or her environment.
D In 1990, Healthy People 2000: National Health Promotion and Disease Prevention Objectives was published in an effort to reduce preventable diseases, disabilities, and deaths. In 2000 these objectives were reevaluated, and Healthy People 2010 was formulated with two main goals: to increase life expectancy for people of all ages while improving their quality of life and reducing health disparities.
E Healthy People 2020 has four overarching goals: to attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; to achieve health equity, eliminate disparities, and improve the health of people in all groups; to create social and physical environments that promote good health for all; and to promote quality of life, healthy development, and healthy behaviors across all life stages.
ILLNESS DEFINED
A No single definition exists.
B Illness exists when disease is present, when an individual believes that he or she is ill (subjective symptoms), or when objective signs of illness are detected by the individual or the professional.
C Illness exists when all basic human needs are not satisfied.
D Illness is a state of disturbance in the homeostasis of the body, either of body structure and function or of emotional or sociologic functioning.
HEALTH-ILLNESS CONTINUUM
A An individual is rarely totally healthy or totally ill.
B The individual’s position is constantly changing in the balance between health and illness.
C The individual’s position on the continuum is determined by need satisfaction, the stage of disease progression, and his or her perception of relative health or illness.
VARIABLES INFLUENCING HEALTH BELIEFS AND PRACTICES
A Many variables influence a person’s perception of health and illness.
B Internal variables include the patient’s developmental stage, knowledge level, perception of functioning, emotional factors, and religious or spiritual views.
C External variables include the patient’s family practices, socioeconomic status, and cultural practices.
TRENDS IN NURSING
PRACTICAL/VOCATIONAL NURSING IN THE UNITED STATES
History
A Practical/vocational nursing evolved to provide better use of nursing personnel and ease the shortage of nurses.
B The first school to train practical/vocational nurses was the Ballard School in New York City, founded in 1893. This 3-month program taught care of chronic invalids, older persons, and children. Graduates of this program were referred to as Attendant Nurses.
C In 1907 the Thompson School was founded in Brattleboro, Vermont. The Household Nursing Association School of Attendant Nursing was founded in Boston in 1918.
D In the 1940s approximately 50 approved programs were in existence; during the 1950s the number of schools of practical/vocational nursing grew. Most programs were extended to 12 months, placing emphasis on integrating class instruction with clinical experience.
E In 1956 Public Law 911 appropriated millions of dollars for improving and expanding practical/vocational nurse training. The U.S. Office of Education established a practical nurse education service.
F Today more than 1200 practical/vocational nursing schools are located in hospitals, colleges, and vocational-technical schools, providing instruction to more than 50,000 students each year.
G Approximately 500,000 practical/vocational nurses are licensed in the United States and five U.S. territories (American Samoa, Guam, Northern Mariana Islands, Puerto Rico, and the Virgin Islands).
Education
A Practical/vocational nursing programs must meet requirements and be approved by the state board of nursing.
B Practical/vocational nursing schools of high standards may voluntarily apply for national accreditation by the National League for Nursing Accrediting Commission (NLNAC).
C Admission requirements of practical/vocational nursing programs vary, but, in general, applicants must:
1. Be at least 17 years of age
2. Have a high school diploma or equivalent
3. Have good physical and mental health
D The curriculum incorporates content and concepts from the biological and physical sciences, behavioral sciences, and principles and practices of nursing.
E The curriculum includes nursing theory and clinical practice, which provide the students with learning opportunities to meet physical and psychosocial needs of mothers and infants, children, medical-surgical patients, older adults, and patients with long-term illnesses.
F Graduates receive a diploma or certificate and are eligible to take the National Council Licensure Examination for Practical Nurses licensing examination (the NCLEX-PN examination).
G Practical/vocational nursing is the entry level into the practice of nursing.
Role Responsibilities
A The licensed practical nurse/licensed vocational nurse (LPN/LVN) has a vital and effective role as a member of the health care team.
B The LPN/LVN provides direct nursing care to patients whose conditions are stable under the supervision and direction of a registered nurse (RN) or physician.
C The LPN/LVN assists the RN with the care of patients whose conditions are unstable or complex.
D The LPN/LVN, adhering to the nursing process, observes, assesses, records, reports, and performs basic therapeutic, preventive, and rehabilitative procedures.
E LPN/LVNs work in acute- and long-term care hospitals, nursing homes, physicians’ offices, ambulatory care facilities, home health agencies, community agencies, schools, and industries.
F The need for LPN/LVNs has increased in long-term care and decreased in acute-care hospitals.
G To identify the abilities of the beginning practitioner in practical/vocational nursing, see Box 2-1 and Appendix A.
Continuing Education
A Each LPN/LVN is responsible for maintaining competency and increasing his or her level of knowledge.
B The rapid growth of nursing and medical knowledge and advances in technology require nurses to keep up-to-date.
C The LPN/LVN must take advantage of learning opportunities through in-service programs where employed; attending seminars and workshops available through institutions and school, official, or voluntary organizations; and reading professional journals.
D Membership in nursing organizations provides continuing education opportunities, usually at a lower cost to members.
E Some states now require continuing education credits for LPNs/LVNs.
Health Care Team
A Members of the health care team vary, depending on the patient’s needs and goals.
B Constant team members are as follows:
C Other team members include certified nursing assistants (CNAs), unlicensed assistive personnel (UAPs), physical therapists, social workers, speech therapists, occupational therapists, respiratory therapists, dietitians, and clergy.
D Successful nursing care depends on the interaction and cooperation of all members of the team.
LPN/LVN ROLE IN LEADERSHIP
A Leadership has been defined as the use of one’s individual skills to influence others to work or perform to the best of their ability.
B The number of LPN/LVN positions in extended-care facilities is increasing. LPN/LVNs are being placed in the role of charge nurse, responsible for assigning CNA and UAP job tasks.
C Assigning is within the scope of practice of the LPN/LVN and involves allotting tasks that are in the job description of CNAs and UAPs.
D The LPN/LVN must know agency policy and job descriptions of CNAs and UAPs before assigning tasks.
E Tasks assigned may include assistance with activities of daily living (ADLs) and uncomplicated tasks. See the Critical Thinking Challenge box for an exercise dealing with the issue of task assignment.
Critical Thinking Challenge
Task Assignment
A nurse has the following set of tasks to complete during the next 8 hours:
Complete assessments of four patients, and electronically chart the assessments
Obtain vital signs of four patients
Administer narcotics to a postoperative patient
F The LPN/LVN provides clear, concise descriptions of what tasks are to be accomplished; a time frame; and feedback and praise for staff members’ efforts.
G The LPN/LVN is legally liable for improperly assigning tasks.
Delegation
A Many states are debating the issue of delegation as it pertains to the LPN/LVN scope of practice.
B Bernhard and Walsh (1995) define delegation as the process of assigning part of one person’s responsibility to another qualified person, with the person’s consent. Delegation is a transfer of responsibility and authority while maintaining accountability.
C LPN/LVNs must ensure that the nurse practice act of their state permits delegation. The nurse practice act should authorize specific tasks to be delegated.
D The LPN/LVN must ensure that the delegate has demonstrated the appropriate level of competency to perform the delegated task.
Conflict Resolution
A Conflict results when one person’s expectations or rights cross those of another person.
B LPN/LVNs in leadership roles need to become accustomed to resolving conflicts.
C The steps in conflict resolution include recognition, clarification, negotiation (compromise), and decision making.
D In addition to conflict resolution, LPN/LVNs must address common individual problems. See Box 2-2 for examples of some of those employee problem areas.
E LPN/LVNs have an ethical and legal responsibility to report substance abuse among peers. See the Critical Thinking Challenge box for an exercise involving peer substance abuse. Drug addiction among nurses tends to be greater than among the general population, although exact figures are difficult to determine.
Critical Thinking ChallengeF Most states have impaired professional rehabilitation programs to help rehabilitate health care personnel addicted to drugs and/or alcohol.
LEGISLATION RELATED TO PRACTICE OF LICENSED PRACTICAL/VOCATIONAL NURSING
Nurse Practice Act
A Nursing is subject to laws passed by the state legislature.
B Laws pertaining to nursing are in the state nurse practice act.
C The nurse practice act varies from state to state. Some states define the practice of nursing, whereas others describe what a nurse may or may not do in the practice of nursing.
D The nurse practice act also provides for some type of nursing board to regulate nursing practice and procedures regarding the following:
E The LPN/LVN must practice nursing within the legally defined scope of his or her state nurse practice act.
State Boards of Nursing
A State boards of nursing administer the state nurse practice act.
B Membership on the board varies from state to state, usually consisting of RNs, LPN/LVNs, and consumers appointed by the governor.
C In most states both professional and practical/vocational nursing practices are under the same board; some states have two boards, one for each.
D Functions of the state board of nursing
1. Enforces established educational requirements of schools of nursing
a. Surveys program to determine if preestablished standards are being met
b. Approves new programs that meet standards
c. Withholds or withdraws approval from programs that do not meet standards
a. Grants license to applicants who have passed the National Council of State Boards of Nursing (NCSBN) licensing examination
3. Conducts investigations and hearings relating to charges of unsafe nursing practice
4. Interprets the nurse practice act based on past practice, standard of care, and information from other states
Licensure
A Licensure protects the public from unqualified practitioners.
B A license is mandatory to practice nursing.
C Licensure permits use of the title licensed practical nurse (LPN) or licensed vocational nurse (LVN).
D Qualifications vary from state to state, but most states require the following for licensure:
E License must be renewed for a small fee at regular intervals.
F Many states require LPN/LVNs to submit proof of continuing education before license is renewed.
G The license may be revoked or suspended for acts of misconduct or incompetence, such as those associated with drug addiction, or conviction of a felony.
H Licensure by endorsement occurs when a state board of nursing reviews the credentials of a nurse licensed in another state and determines that the nurse meets the qualifications of the state.
Examination
A As of 1994 the NCSBN examination is given to all qualified applicants via computerized adaptive testing (CAT). This test, the NCLEX-PN examination, is used to determine whether the LPN/LVN candidate is prepared to practice nursing safely. The examination tests knowledge of nursing care and ability to apply that knowledge in a clinical situation with beginning competence.
B Testing takes place in more than 1200 computer testing sites throughout the United States. Candidates schedule a test date after graduation. Testing occurs throughout the year, 6 days per week, 15 hours per day. Each examinee sits at an individual computer terminal and answers questions on the screen. The candidate’s answer to each question determines the next question to be presented. No two persons receive the same test.
C The test stops when the candidate’s ability level has been estimated at a predetermined degree of accuracy. The minimum number of test items that must be answered is 85; the maximum number of items is 205. The maximum time allotment for the test is 5 hours; most candidates complete the test in less than 5 hours.
LEGAL IMPLICATIONS FOR THE LICENSED PRACTICAL NURSE/LICENSED VOCATIONAL NURSE
Responsibilities
A To function within the scope of the state nurse practice act
B To maintain standards of care
C To function according to employer or agency policy
D To apply the skills and knowledge that a prudent LPN/LVN with comparable training would apply in a similar situation
E To maintain complete and accurate patient records
Delivery of Nursing Care
A Functional method: each nursing team member is assigned specific tasks (e.g., obtaining and recording all vital signs, administering all medications).
B Team nursing: a group of patients is cared for by a team consisting of professional nurses, practical/vocational nurses, nurses’ aides, and at times student nurses.
Illegal Actions
1. An act or wrong committed by one person against another that results in injury or damage
2. Can be either the commission or omission of an act
3. Acts of negligence include:
b. Incorrect performance of care
(1) Administration of wrong medication.
(2) Administration of medication or treatment to wrong patient.
(3) Failure to ensure safety through use of side rails or restraints as ordered by the physician.
(4) Failure to prevent injury while applying heat.
(5) Gross negligence: Patient’s life is endangered or lost—often results in criminal action.
1. Legal liability exists even if no damage occurs to the other person
2. May not be covered by malpractice insurance
(1) Definition: threat or attempt to make bodily contact with another person without that person’s consent, with intent to injure
(2) Example: threatening to restrain or physically punish patient if he or she does not cooperate
a. Definition: unwarranted restriction of another person by force or threat of force.
b. Examples: detaining patient in hospital against his or her will; unwarranted use of restraints.
c. Patient who wishes to leave hospital against advice of the physician may be asked to sign a release; patient cannot be detained if he or she refuses to sign.
Other Legal Aspects
1. These laws give certain persons legal protection when giving aid at the scene of an accident; not all states cover nurses.
2. Their purpose is to encourage people to give assistance at the scene of an emergency.
3. These laws do not make it legally necessary for a nurse to assist.
4. When nurses do assist, they are expected to use good judgment in deciding whether an emergency exists.
5. The LPN/LVN is expected to exercise a standard of care that a reasonable LPN/LVN with comparable training would exercise in similar circumstances.
1. All states have laws that require reporting of known or suspected cases of child abuse.
2. The laws grant immunity from civil suits to individuals who are required to report child abuse.
1. The Controlled Substances Act of 1970 is a federal law that regulates the manufacture, sale, prescription, and dispensing of narcotics and other harmful drugs.
2. Violation of the law by a nurse is a felony and will result in revocation of the LPN/LVN license.
1. A will is a legal declaration of how a person (testator) wishes to dispose of his or her property after death.
2. For a will to be valid, the testator must be of sound mind and acting without force.
3. No legal reason exists for the nurse not to witness a will; the witness is witnessing only the person’s signature, not the contents of the will.
E Advance directives: documents in which an individual can specify his or her wishes regarding end-of-life care
1. Durable power of attorney for health care—the individual appoints someone to make health care decisions if the patient himself or herself is unable to do so; may be the patient’s lawyer or an impartial friend. The power of attorney for health care should not be the patient’s physician or a family member who benefits from the will.
2. Living will—a document that specifies the patient’s wishes regarding health care decisions. The document usually states that the patient’s wishes should be followed when “no reasonable chance for recovery” exists.
3. The Patient Self-Determination Act ensures that all individuals are aware of their rights with regard to advance directives when they are admitted to any acute-care hospital that receives federal funding.
1. Professional liability policies cover liability arising out of the rendering of or failure to render professional service.
2. The policy is a safeguard against suits for damages; proving innocence can be expensive.
3. The policy can be purchased from nursing organizations, bargaining organizations, and private insurance companies.
4. Malpractice insurance provides monetary award of damages within specified limits of the policy and legal fees, court costs, and payment of bond.
5. Employer’s insurance protects the employee only while he or she is on duty.
PATIENTS’ RIGHTS
Bill of Rights
A Patients have the right to courteous, individual care given without discrimination as to race, color, religion, gender, marital status, national origin, or ability to pay.
B A patient’s bill of rights, also known as a “patient care partnership,” is a statement of what the patient can expect from the institution.
C The following is paraphrased from the Patient’s Bill of Rights adopted by the American Hospital Association. The patient should:
1. Be given considerate and respectful care.
2. Obtain from the physician complete current information concerning diagnosis, treatment, and prognosis in terms that the patient can be reasonably expected to understand.
3. Receive from the physician information necessary to give informed consent before the start of any procedure or treatment.
4. Be allowed to refuse treatment to the extent permitted by law and be informed of the medical consequences of that action.
5. Be given every consideration of privacy concerning his or her medical care program.
6. Expect that all communications and records pertaining to his or her care be treated as confidential.
7. Expect that, within its capacity, a hospital must respond reasonably to the request of a patient for services.
8. Obtain information concerning any relationships of the patient’s hospital to other health care and educational institutions insofar as his or her care is concerned.
9. Be advised if the hospital proposes to engage in or perform human experimentation affecting the patient’s care or treatment.
10. Expect reasonable continuity of care.
11. Examine and receive an explanation of the bill, regardless of the source of payment.
12. Know what hospital rules and regulations apply to the patient’s conduct.
Standard of Care
A Patients are entitled to a safe, competent standard of nursing care, no matter who administers it (RN, LPN/LVN, student).
B The LPN/LVN is accountable for his or her own actions and must ensure that the patient receives qualified care.
C If the LPN/LVN thinks that the patient assignment is beyond his or her ability, he or she must discuss the matter with the RN before carrying out the assigned tasks.
D Standard of care is established by:
Patient Advocate
A An advocate acts on behalf of another person and stands up or speaks up on behalf of that person.
B The patient has the right to information needed to make informed decisions freely and without pressure.
C The responsibility of the LPN/LVN is to:
2. Support patients in the decisions they make.
3. Inform physician when the patient apparently does not understand what is going to happen to him or her.
4. Observe and speak out regarding instances of incompetent, unethical, or illegal practice by any member of the health care team.
5. Know hospital policy regarding the procedure to follow when patients’ rights are being violated.
D Many hospitals employ a patient representative who serves as a liaison between the patient and the institution and who has the power to act to resolve patients’ problems.
Informed Consent
A Before any invasive procedure can be performed, the patient must give written consent, except in extreme emergency when failure to treat may be considered negligence.
B The patient must be fully informed of the extent of the proposed procedure, risks and benefits, alternatives, and their consequences.
C Consent must be obtained by the physician, whose duty it is to advise the patient.
D This consent must be obtained while the patient is of sound mind; it should be signed before administration of any preoperative narcotic medications.
E Consent may be withdrawn by the patient before the procedure.
Patient Medical Records: The Chart
A The chart is a legal document, in either paper or electronic form.
B The chart provides an account of the patient’s hospitalization.
C The chart may be used as evidence in courts of law and records only information related to the patient’s health problem.
D The Health Insurance Portability and Accountability Act of 1996 (HIPPA) has four objectives:
1. Ensures health insurance portability when workers change jobs
2. Reduces health care fraud and abuse
3. Enforces standards for health information
4. Guarantees security and privacy of health care (information contained in records must be held in confidence)
E Only authorized persons should have access to patient records.
F Most states consider medical records the property of the hospital, and the contents the property of the patient.
NURSING ORGANIZATIONS
1. The LPN/LVN has the responsibility to join a professional organization and support practical/vocational nursing by becoming an active member.
B National Association for Practical Nurse Education and Service (NAPNES) (www.napnes.org)
1. NAPNES was organized in 1941 to promote the development of sound practical/vocational nursing education and to promote advancement and recognition of the LPN/LVN as a member of the health team.
a. Regular members: LPN/LVNs, practical nursing educators, other RNs, general educators, physicians, hospital and nursing home administrators, practical/vocational nursing students, and interested laypersons.
b. Student members: students in state-approved schools of practical/vocational nursing.
c. Agency members: hospitals, nursing homes, schools of practical/vocational nursing, alumni groups, civic organizations, and other institutions or groups in harmony with NAPNES objectives.
3. Functions and activities listed by NAPNES
a. Serves as clearinghouse for information about practical/vocational nursing, including information about functions and roles of LPN/LVNs
b. Publishes Journal of Practical Nursing quarterly
c. Prepares publications useful to faculties in schools of practical/vocational nursing
d. Sponsors workshops and seminars for LPN/LVNs and practical nursing educators in conjunction with state LPN/LVN associations, universities, and national organizations
e. Engages in activities aimed at protecting and strengthening position of LPN/LVNs and cooperates with state LPN/LVN associations in activities of this kind
f. Provides consultation to state LPN/LVN constituencies on matters relating to their organization and programs
g. Sponsors “national certification” in pharmacology and long-term care for LPN/LVNs
C National Federation of Licensed Practical Nurses (NFLPN) (www.nflpn.org)
1. NFLPN was organized in 1949 to foster high standards in practical nursing and promote practical nursing.
2. Membership is limited to LPN/LVNs and student practical/vocational nurses.
3. Affiliate membership is available to individuals who are not LPN/LVNs or students but are interested in the work of NFLPN.
4. Many state associations exist.
a. Provides leadership for LPN/LVNs employed in the United States
b. Fosters high standards of practical/vocational nursing education and practice
c. Encourages every LPN/LVN to make continuing education a priority
d. Achieves recognition for LPN/LVNs and advocates the effectiveness of LPN/LVNs in every type of health care facility
e. Interprets the role and function of the LPN/LVN for the public
f. Represents practical/vocational nursing through relationships with other national nursing, medical, and allied health organizations; legislators; government officials; health agencies; educators; and other professional groups
g. Serves as the central source of information on the new and changing aspects of practical/vocational nursing education and practice
D National League for Nursing (NLN) (www.nln.org)
1. The NLN was organized in 1952 by the combination of the National League for Nursing Education and six other national nursing organizations.
a. Individual membership: anyone interested in nursing: RNs, LPN/LVNs, student nurses, consumers.
b. Agency membership: hospitals, nursing homes, public health agencies, schools of nursing.
a. Defining and furthering good standards for all nursing service
b. Defining and promoting good standards for institutions giving nursing education on all levels
c. Helping to extend facilities to meet these services when necessary
d. Helping in proper distribution of nursing education and nursing service
e. Working to improve organized nursing services in hospitals, public health agencies, nursing homes, and other agencies; accrediting community public health nursing services; and developing criteria and other self-evaluation tools
f. Working to improve nursing education programs; NLNAC acts as an accrediting agency for all levels of nursing education
g. Constructing, processing, and providing preadmission, achievement, and qualifying tests
h. Gathering and publishing information about trends in nursing, personnel needs, community nursing services, and schools of nursing
4. The official journal is Nursing and Health Care.
5. In 1982 (reaffirmed in 1987 and currently relevant as an archived document), the NLN Council of Practical Nursing Programs adopted a resolution in support of practical/vocational nursing (Box 2-3). In 1984 the Council recognized the NFLPN as the official organization for LPN/LVNs.
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