Sandra Smith’s Review for NCLEX-RN 13the Edition

Chapter 2: Management Principles and Legal Issues 5. Monitor progress in client care through feed- back, evaluate outcomes, and follow-up on identified problems. B. Determining appropriate delegation to an unlicensed healthcare worker—ask these questions: 1. CantheUAPlegallydothisprocedureaccord- ing to the Nurse Practice Act in that state? 2. Has the UAP been trained to perform this procedure? 3. Can the UAP demonstrate this procedure safely and consistently? 4. Is the client status stable, and does this client require frequent assessment during the procedure? 5. Is the client response predictable? 6. When performing this task or activity, can the UAP or CNA obtain the same or similar results as the RN? 7. Can the UAP or CNA understand the rationale behind each task? C. Parameters of delegation: Many state boards of nursing have identified the parameters of delega- tion. Examples of these “five rights of delegation”: 1. Righttask—taskthatcanbelegallydelegatedto an LVN/LPN, CNA, PCT, or UAP. Check the state Nurse Practice Act to determine if the care- giver is trained to perform the task. Judge if the UAP or LVN is competent to perform the task. These include tasks that: a. Frequently reoccur in the daily care of a cli- ent or group of clients. b. Do not require the UAP to exercise nursing judgment that requires knowledge they do not have. c. Do not require complex and/or multidimensional application of the nursing process. d. The results are predictable and the potential risk is minimal. e. Utilize a standard and unchanging procedure. 2. Rightcircumstance—theLVN,CNA, PCT, or UAP understands the elements of the procedure and the RN is assured that the UAP can perform the procedure safely in an appropriate setting. Caregiver is able to collect the right supplies to perform the procedure. 3. Right person—the right person (RN or LVN) delegates the right task (legally can be delegated to a CNA or UAP) to the right person (legally can perform the task) on the right client (stable with predictable outcomes). 4. Right communication—person delegating the task (RN or LVN) has described |the task clearly including directions, special steps of the task, and the expected outcomes. 5. Rightsupervisor—theRNorLVNdelegating the activity answers the CNA’s or UAP’s ques- tions and is available to problem solve if neces- sary (the task cannot be completed or the client’s condition changes). The CNA, PCT, or UAP performing the task reports its completion and the client response to the nurse who delegated the activity. Modified from the National Council of State Boards of Nursing. D. Duties commonly delegated to unlicensed assistive personnel. 1. Take vital signs. 2. Obtain height and weight. 3. Assist a client to bed. 4. Escort a client out of the hospital. 5. Bathe and make beds. 6. Daily care activities. 7. Personal hygiene activities. 8. Move and turn clients and reposition. 9. Transfer clients. 10. Assigned to clients requiring infection control precautions. 11. Record drainage from an NG tube. 12. Serve a food tray and feed a client. 13. Provide oral hygiene. 14. Obtain specimens that are nonsterile and noninvasive. 15. Monitor specific gravity. 16. Check urine glucose. 17. Administer disposable enema or tap water enema. 18. Apply elastic hosiery. 19. Perform range-of-motion exercises. 20. Initiate CPR or perform Heimlich maneuver (with CPR certification). 21. Work with a dying client. 22. Give postmortem care. LEGAL ISSUES: NATURE OF THE LAW Definition: A system of principles and processes by which people who live in a society deal with their disputes and problems. Laws are rules of human conduct. Our legal sys- tem is continually changing as it responds to and is shaped by our society and its expectations and demands. The types of law that most directly affect nurses and their practice are civil and criminal. Key Legal Terms 19 Table 2-2 NURSING LIABILITY Civil Law Criminal Law Contract Assault Unintentional Tort Battery Intentional Tort Murder Negligence Manslaughter Table 2-3 CLASSIFICATIONS OF LAW RELATED TO NURSING Classification Example Constitutional Clients’ rights to equal treatment Administrative Licensure and the state BRN Labor Relations Union negotiations Contract Relationship with employer Criminal Handling of narcotics Tort Medical Malpractice Reasonable and prudent client care Product Liability Warranty on medical equipment Types of Law A. Civil. (See Table 2-2.) 1. The harm is against an individual, and guilt requires proof by a preponderance of the evidence. 2. Civil law covers contracts, labor issues, and, among other areas, tort law (normally involved in malpractice claims). (See Table 2-3.) 3. Punishment is generally the payment of mon- etary compensation. B. Criminal. 1. The harm is against society, and guilt requires proof beyond a reasonable doubt. 2. Crimes are classified as misdemeanors (lesser) or felonies (serious). 3. Examples are falsification of narcotics records, withholding life support from terminally ill clients, and administration of drugs that hasten a client’s death. 4. Punishment may be a payment of compensa- tion and/or imprisonment. KEY LEGAL TERMS Liability A. A nurse has a personal, legal obligation to provide a standard of client care expected of a reasonably competent professional nurse. B. Professional nurses are held responsible (liable) for harm resulting from their negligent acts or omis- sion to act. Respondeat Superior A. Legal doctrine that holds an employer liable for negligent acts of employees in the course and scope of employment. B. Physicians, hospitals, clinics, and other employ- ers may be held liable for negligent acts of their employees. C. This doctrine does not support acts of gross negligence or acts that are outside the scope of employment. Negligence A. The doctrine of negligence rests on the duty of every person to exercise due care in his or her con- duct toward others from which injury may result. B. Liability results from 1. A duty to provide care on the part of the nurse and a causal relationship between damage or harm to the client. 2. An act or an omission to act by the nurse. C. Gross negligence is the intentional failure to perform a duty in reckless disregard of the conse- quences affecting the client—a gross lack of care to such a level as to be considered willful and wanton. D. Criminal negligence consists of a duty on the part of the nurse and an act that is the proximate cause of the injury or death of a client. 1. Usually defined by statute and punishable as a crime. 2. The act being punished would be a flagrant and reckless disregard for the safety of others and/or a willful disregard for the injury liable to follow. 3. The act is converted to a crime when it results in personal injury or death. PROVING NEGLIGENCE • To prove negligence against a nurse, these four elements must be present: a. Failed a duty to provide a standard of care to the client. b. Failed to adhere to the standard of care. c. Failure to adhere to the standard of care caused injury to the client. d. Client suffered damages as a result of the nurse’s negli- gent action. • Documentation in the client’s chart must show that the nurse met the standard of care. 20 Chapter 2: Management Principles and Legal Issues E. A nurse is considered “negligent” if he or she fails to provide a client with the standard of care that a reasonably prudent nurse would exercise under similar circumstances. Malpractice A. Any professional misconduct that is an unreasonable lack of skill or fidelity in professional duties. B. Bad, wrong, or injurious treatment of a client. C. Results of treatment may include injury, unnecessary suffering, or death to a client proceeding from ignorance; carelessness; lack of professional skill; disregard of established rules, protocols, principles, or procedures; neglect; or a malicious or criminal intent. D. It is the nurse’s legal duty to provide competent, reasonable care to clients. 1. To ensure that these standards occur, the nurse must know the standards of care, develop pat- terns of practice that meet these standards, and document these actions. 2. Nursing actions that constitute a breach of standards of care and lead to client injury can be termed malpractice. E. Avoiding malpractice litigation: 1. Do not accept an assignment for which you have not been trained or which you do not feel competent to complete. 2. Be very careful and vigilant when administer- ing medications. 3. Document all nursing aspects of interventions, because poor, missing, or incorrect charting could result in legal complications. 4. Do not change charting without following the rules of change. You may never cover up a mis- take by changing a chart. F. Legal doctrine holds that an employer may also be liable for negligent acts of employees in the course and scope of employment. 1. Physicians, hospitals, clinics, and other employers may be held liable for negligent acts of their employees. 2. This doctrine does not support acts of gross negligence or acts that are outside the scope of employment. Professional Misconduct A. Nurses must meet certain standards. B. Any one of the following actions would be consid- ered misconduct. 1. Obtaining an RN license through misrepre- sentation or fraudulent methods. 2. Giving false information on an application for license. 3. Practicing in an incompetent or grossly negli- gent manner. 4. Practicing when ability to practice is severely impaired. 5. Being habitually drunk or dependent on drugs. 6. Furnishing controlled substances to himself or herself or to another person. 7. Impersonating another certified or licensed practitioner or allowing another person to use his or her license for nursing. 8. Being convicted of or committing an act constituting a crime under federal or state law. 9. Refusing to provide healthcare services on the grounds of race, color, creed, or national origin. 10. Permitting or aiding an unlicensed person to perform activities requiring a license. 11. Practicing nursing while one’s license is suspended. 12. Practicing medicine without a license. 13. Procuring, aiding, or offering to assist at a criminal abortion. 14. Holding oneself out to the public as a “nurse practitioner” without being certified by the BRN as a nurse practitioner (in some states). Risk Areas A. Certain areas of practice increase the risk of poten- tial liability for the nurse. B. These areas are increased nursing involvement, potential hazards involved in the nurse’s functions, and/or an increased social awareness on the part of clients and their families and associates. RIGHTS AND CONSENT A. A right or claim may be moral and/or legal. 1. A legal right can be enforced in a court of law. 2. Within the healthcare system, all clients retain their basic constitutional rights such as free- dom of expression, due process of law, freedom from cruel and inhumane punishment, equal protection, and so forth. B. Client rights may conflict with nursing functions. 1. Key elements of a client’s rights with which nurses should be thoroughly familiar include consent, confidentiality, and involuntary commitment. 2. The client’s rights may be modified by his or her mental or physical condition as well as by his or her social status. Client’s Right to Privacy (Confidentiality) A. Confidential information. 1. Clients are protected by law (invasion of privacy) against unauthorized release of personal clinical data such as symptoms, diagnoses, and treatments. 2. Nurses, as well as other healthcare profession- als and their employers, may be held personally liable for invasion of privacy, as well as other torts, should litigation arise from unauthorized release of client data. 3. Nurses have a legal and ethical responsibility to become familiar with their employers’ poli- cies and procedures regarding protection of clients’ information. 4. Confidential information may be released with consent of the client. 5. Information release is mandatory when ordered by a court or when state statutes require reporting child abuse, communicable diseases, or other incidents. B. Client care: Nurses have an ethical responsibility to protect the client’s personal privacy during treat- ment or hospitalization by means of gowns, screens, closed doors, etc. They are not to discuss client care with uninvolved clients or staff and they must be sure to conceal records/computer screens from unauthorized view. C. Medical records. 1. As the key written account of client informa- tion such as signs and symptoms, diagnosis, treatment, etc., the medical record fulfills many functions both within the hospital or clinic and with outside parties. a. Documents the care given to the client. b. Provides an effective means of communica- tion among healthcare personnel. c. Contains important data for insurance and other expense claims. d. May be utilized in court in the event of litigation. 2. Nurses have an ethical and legal obligation to maintain complete and timely records, and to sign or countersign only those docu- ments that are accurate and complete. Patient Care Partnership The Patient Care Partnership has replaced the AHA’s Patients’ Bill of Rights. This document informs clients about what they should expect during their hospital stay with regard to their rights and responsibilities. It addresses understanding client expectations, rights, and responsibilities including: 1. High quality hospital care. 2. A clean and safe environment. 3. Involvement in their care. 4. Protection of their privacy. 5. Help when they leave the hospital. 6. Help with their billing claims. Informed Consent (To Receive Health Services) A. Consent is the client’s approval to have his or her body touched by a specific individual (such as doctor, nurse, laboratory technician). 1. Types of consent: Expressed or implied— verbal or written. 2. Informed consent: Prior to granting consent, the client must be fully informed regard- ing treatment, tests, surgery, etc., and must understand both the intended outcome and the potentially harmful results. 3. The client may rescind a prior consent verbally or in writing. B. Authority to consent. 1. A mentally competent adult client must give his or her own consent. 2. In emergency situations, if the client is in immediate danger of serious harm or death, action may be taken to preserve life without the client’s consent. 3. Parents or legal guardians may give consent for minors. 4. Court-authorized persons may give consent for mentally incompetent clients. Rights and Consent 21 HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) • Enacted into law in 1996, phased in gradually. • Requires the Secretary of Health and Human Services (HHS) to devise standards. a. Improves Medicare and Medicaid programs—efficiency and effectiveness of healthcare system. b. Ensures continuing healthcare insurance if client has had existing group insurance. c. Proposes standards for electronic transactions and secu- rity of signatures. d. Ensures privacy of individual health information. • Privacy rule component became effective in April 2003. a. Requires healthcare providers to protect against unauthorized disclosures of personal medical information. b. Requires client consent for any information dispersed to others. c. Clients must receive written notice of privacy practices and their rights. d. Clients may access personal medical records more freely than before. 22 Chapter 2: Management Principles and Legal Issues C. Two major forms of consent are signed by clients in a healthcare facility. 1. The first consent is signed at the time of admission. a. Theclientsignstheformintheadmissions office or in the emergency department. b. Thisagreementindicatestheclientwillagree to such procedures as medical treatment, x-rays, blood transfusions, and injections. 2. The second type of consent is for invasive test- ing procedures, such as biopsies, surgery, or special studies involving dye injection or other procedures where risk is involved. D. Nurse’s liability. 1. The nurse who asks a client to sign a consent form may be held personally liable if the nurse knows or should know that the client has not been fully informed by the physicians, hospital staff, or others regarding potentially harmful effects of treatments, tests, surgery, and other acts. 2. Nurses must respect the right of a mentally competent adult client to refuse health care; however, a life-threatening situation may alter the client’s right to refuse treatment. E. Hospital admissions. 1. Voluntary admission. a. A person freely consents to enter an institu- tion for purposes of receiving medical, sur- gical, or psychiatric care and treatment. b. Clients who enter on a voluntary basis may leave at will. 2. Involuntary admission. a. An individual may legally be admitted to an institution without his or her own consent when that individual does not have the mental capacity or competency to under- stand his or her own acts and is a danger to self or others. b. Occurs when the client is judged by a court of law to be mentally ill or dangerous to self and others, and to require admission to a psychiatric ward or center. Advance Directives A. An advance directive is a document that allows clients to make legal decisions about how they wish to receive future medical treatment. It is written and signed before any such care becomes necessary. 1. It allows clients to participate in choosing healthcare providers (physicians and nurses). 2. It allows clients to choose the type of medical treatments they desire. 3. It allows clients to consent to or refuse certain types of medical treatments. B. Within this document, the client may indicate the person or persons he or she wishes to make medical decisions in situations in which the client is unable to do so. C. The document needs to be signed and witnessed, and copies should be kept on file in the physician’s office and the hospital. D. The witness to this document should not be a hospital employee, relative, or heir to the client’s estate. E. Advance directives vary among states and, there- fore, the nurse must be knowledgeable about the use and type of directives in the state in which he or she practices. Living Will A. A living will is a type of advance directive. B. The document indicates the client’s wishes regarding 1. Prolonging life using life support measures. 2. Refusing or stopping medical interventions. 3. Makingdecisionsabouthisorhermedicalcare. C. Living wills are executed while the client is compe- tent and able to make sound decisions. D. As conditions change, a living will needs to be evaluated for relevance. (States differ in their acceptance of living wills as legal documents.) Durable Power [of Attorney] for Health Care A. This is a legal document concerning health care for the client. 1. This document gives power to make healthcare decisions to a designated individual in the event that the client is unable to make compe- tent decisions for himself or herself. ADVANCE DIRECTIVES The Patient Self-Determination Act of 1990 (PSDA) is a federal law that imposes on states and providers of health care cer- tain requirements concerning advance directives as well as an individual’s right under state law to make decisions concerning medical care. The Omnibus Budget Reconciliation Act (OBRA) of 1990 requires states to provide advance directives as options for clients.This document should be completed and signed before treatment becomes necessary.The nurse should check with the client’s physician to determine that advance directives are on file. Documents include • Client’s choice in continuing medical care when the client is unable to speak or make decisions. • Living will, power of attorney for health care, or a notarized handwritten document. • Documents available in client’s medical record. • Documentswitnessedbypersonsotherthanmedicalper- sonnel or relatives of the client or heirs to the client’s estate. Legal Issues in Drug Administration 23 2. It must be prepared and signed while the client is competent. 3. The designated person is obligated to follow the directives outlined in the document. B. Decisions regarding withdrawing or using life sup- port, organ donation, or consent to treatment or procedures are included in the directives. 1. Aslongastheclientiscompetent,theagent does not have the right to make legal decisions. 2. The major difference between the living will and power of attorney is that the latter is more flexible. Do Not Resuscitate (DNR) A. A “Do Not Resuscitate” or DNR order is another type of advance directive. 1. DNR is a request to not have cardiopulmo- nary resuscitation (CPR) if the client ceases to breathe or is unable to sustain a heartbeat. 2. This form can be signed at any time before or during hospitalization. B. When a DNR order is signed, the physician places a DNR notation in the client’s medical chart. C. Nurse’s responsibilities. 1. Educate clients and their families about termination of treatment decisions and advance directives. 2. Encourage clients to think about end-of-life preferences in illness or a health crisis. 3. Support clients and their families to have end- of-life discussions with their physicians. 4. Ensure advance directives known by caregivers and are implemented. 5. Communicate known information relevant to end-of-life decisions to appropriate healthcare personnel. 6. Advocate for a client’s end-of-life preferences regardless of others’ desire to not honor them if indeed the preferences reflect beneficent care. LEGAL ISSUES IN DRUG ADMINISTRATION Definition: In their daily work, most nurses handle a wide variety of drugs. Failure to give the correct medication or improper handling of drugs may result in serious problems for the nurse due to strict federal and state statutes relating to drugs. (See Chapter 5 on pharmacology.) Regulation A. The Comprehensive Drug Abuse Prevention Act of 1970 provides the fundamental regulations (federal) for the compounding, selling, and dispensing of narcotics, stimulants, depressants, and other controlled items. D. Each state has a similar set of regulations for the same purpose. Violation A. Each state’s pharmacy act provides standards for dispensing drugs. o Burn o Other injuries • Manifestations of poor glycemic control o Diabetic ketoacidosis o Nonketotic hyperosmolar coma o Hypoglycemic coma o Secondary diabetes with ketoacidosis o Secondary diabetes with hyperosmolarity • Catheter-associated urinary tract infection (CAUTI) • Central line-associated bloodstream infection (CLABSI) • Surgical site infection, mediastinitis, following coronary artery bypass graft (CABG) • Surgical site infection following bariatric surgery for obesity o Laparoscopic gastric bypass o Gastroenterostomy o Laparoscopic gastric restrictive surgery • Surgical site infection following certain orthopedic procedures o Spine o Neck o Shoulder o Elbow • Surgical site infection following cardiac implantable elec- tronic device (CIED) • Deep vein thrombosis (DVT)/pulmonary embolism (PE) fol- lowing certain orthopedic procedures: o Total knee replacement o Hip replacement • Iatrogenic pneumothorax with venous catheterization Retrieved from: LEGAL ISSUES FOR MEDICARE As of 2013 Medicare will cease paying for the following hospital- acquired conditions (HAC) that could reasonably have been pre- vented.The new policy will save lives and millions of dollars. Hospital-Acquired Conditions • Foreign object retained after surgery • Air embolism • Blood incompatibility • Stage III and IV pressure ulcers • Falls and trauma o Fractures o Dislocations o Intracranial injuries o Crushing injuries 24 Chapter 2: Management Principles and Legal Issues LEGAL ASPECTS OF DRUG ADMINISTRATION A. Nurses must not administer a specific drug unless allowed to do so by the particular state’s Nurse Practice Act. 1. Nurses must not administer any drug without a specific physician’s order. 2. Nurses must not administer a controlled substance if the physician’s order is outdated. B. Nurses are to take every safety precaution in whatever action they perform. C. Nurses are to be certain that the employer’s policy allows them to administer a specific drug. D. A drug may not lawfully be administered unless all the above items are in effect. E. General rules for drug dispensing: 1. Never leave medicines unattended. 2. Always report errors immediately. 3. Send labeled bottles that are unintelligible back to the pharmacist for relabeling. 4. Storeinternalandexternalmedicinesseparatelyifpossible. B. Noncompliance with federal or state drug regula- tions can result in liability. C. Violation of the state drug regulations or licensing laws is grounds for BRN administrative disciplin- ary action. LEGAL ISSUES IN PSYCHIATRIC NURSING Statutes of Protection A. Laws of certain states protect individuals from themselves. 1. These laws require that such persons be evaluated by competent psychiatric personnel. 2. The laws protect clients’ rights and civil liber- ties by not allowing psychiatric clients to be hospitalized inappropriately. B. Laws also protect family members and the general community from persons who are dangerous or severely disturbed. Admission Procedures A. There are voluntary and involuntary admissions for psychiatric clients. B. Voluntary admission occurs when an individual recognizes that he or she needs treatment and signs in to a hospital. 1. After admission, the client is not free to leave before a specified period of time. 2. Such a client may leave the hospital against the physician’s advice if the client gives notice of such intent at least 1 or 2 days prior to leaving. 3. If the physician feels the client is too ill, he can legally assign the client to involuntary status. 4. A voluntary client loses none of his or her civil rights. C. Involuntary status occurs when the client is psychi- atrically evaluated to be too ill to function outside the hospital. 1. Admission is not initiated by the client. 2. When a client is committed, he or she cannot leave the hospital against medical advice. 3. Family members, a physician, a law officer, or a community member can institute commitment proceedings. 4. Clients are permitted to leave only when psy- chiatric evaluation indicates they are able to care for themselves or are not dangerous to themselves or others. 5. A client may retain some, all, or none of his or her civil rights. This depends on the individual state laws. 6. The different classifications include emergency admission (time limited), observational (diag- nostic evaluation or short term), and indefinite (formal commitment). Psychiatric Advance Directives (PAD) A. PAD is similar to advance directives prepared for end-of-life care. B. Specific components that may be included in the PAD: 1. Refusal of specific drugs, surgery, or treatments [e.g., electroconvulsive therapy (ECT)]. 2. Consent for specific psychiatric interven- tions and conditions under which they may be implemented. 3. Appointment of a trusted individual who may give consent for the client. 4. Willingness to participate in research studies. C. PADs are not accepted in every state. They are popular with mental health providers for providing guidance to family, staff, and the courts. RESTRAINTS A. Used as a last resort—legal only to protect the cli- ent or others from foreseeable harm. 1. Hospital policy and procedures must be fol- lowed when applying restraints. 2. Most states and facilities require a physician’s order for restraints. a. Orders must specify justification for restraint, type of restraint, length of time, and criteria for removal. b. Restraints may not be ordered prn; a nurse may legally restrain a client without an order if essential. 3. Legal implications for the nurse applying restraints. a. A nurse may be charged with assault if restraints are used when not needed. b. A nurse may be charged with negligence when client injury occurs. B. Types of restraints. 1. Physical restraints—application of a device to restrict movement. a. Prevent client falls. b. Discourage client from disconnecting vital equipment. c. Prevent client from harming self or others. 2. Chemical restraints—medications given to prevent certain behaviors. a. Prevent clients from disconnecting vital equipment. b. Assist in preventing client from harming self or others. c. Allow staff to care for all clients on a unit. D. Alternatives to restraints. 1. Encourage family and friends to monitor cli- ent; use sitters to monitor client. 2. Use a bed occupancy monitor or similar device to immediately notify nurses when a client is out of bed. 3. Provide appropriate and continuing stimula- tion and monitoring. D. Restraint guidelines. 1. Review hospital policy for the use of restraints. 2. Use restraints for the client’s protection and to prevent injury, not for the nurse’s convenience. 3. Use the least amount of restraint possible. A torso belt is least restrictive, limb restraint is more restrictive, and chemical (medication) is most restrictive. 4. Allow clients as much freedom of movement as possible. Use slipknots for quick release. Do not use square knots or bows. 5. Always explain the purpose of the restraint to the client and family. Afford as much dignity to the client as possible. 6. Remember that restraints can cause emotional, mental, and physical deterioration and increase the risk of injury if falls occur. 7. Remember that circulation and skin integrity can be affected by restraints. 8. Special precautions should be taken for adult females in restraints to protect breast tissue. 9. Clientsmustbeobservedevery15minutes and restraints released every 2 hours for at least 5 minutes to inspect tissues and provide joint range of motion and position change to prevent circulatory impairment. When a client is com- bative, release only one restraint at a time. 10. Assess and provide for client’s fluid and elimination needs, pain management, and position change every 2 hours. 11. Pad bony prominences, such as wrists and ankles, beneath a restraint. 12. Attempt to make restraints as inconspicuous as possible for the sake of the client’s relatives and friends, who may be upset by seeing restraints. 13. Notify families, significant others, or guardians if restraints are necessary. 14. Clearly document rationale and precautions taken for client safety. Adapted from Smith, S., Duell, D., & Martin, B. (2008). Clinical nursing skills (7th ed.). Upper Saddle River, NJ: Prentice Hall Health. ORGAN DONATION A. Legal aspects of donation. 1. The federal Omnibus Budget Reconciliation Act of 1986 states that all facilities receiving Medicare or Medicaid funding must have poli- cies in place to identify potential organ donors and to inform families about the option to donate. a. Laws do not require the consent of a family member to retrieve organs if the donor has already declared his wish to donate (must be 18 years of age or older). b. The choice to donate an organ must be a written document—a donor card, a will, or an advance directive signed by the client. c. Providers are reluctant to act without a family member’s permission because of fear of being sued. d. Some states have limited the family’s involvement in the donation process. 2. Legal definition of death. a. Death is defined legally as cardiac death— total failure of cardiopulmonary system. b. The second definition is neurologic or brain death—unresponsive to all stimuli, fixed pupils, and no brain stem reflexes. 3. Hospitals are required by law to contact donor team so they may give families the information they need to make an informed decision about organ donation. 4. The Uniform Anatomical Gift Act protects those who are involved in organ procurement from liability, but provider must “act in good faith” and must provide next of kin with com- plete and accurate information. Organ Donation 25 26 Chapter 2: Management Principles and Legal Issues B. Allocatingorgans. 1. United Network for Organ Sharing: Clients awaiting transplant (heart or kidney) are assigned priority according to medical need. (As of January 8, 2014, there were 120,990 people waiting for lifesaving organ transplants in the United States.) 2. Ethical question: Should more desperately ill receive preference or should priority be given to healthier clients? The answer varies accord- ing to facility. C. Organ donor potential. 1. Review specific facility’s death criteria. 2. Generally accepted criteria—brain death. a. Cause of client’s injury known. b. Exhibits no brain stem reflexes. c. No CNS depressants present. d. Temperature greater than 90°F. e. Exhibits no spontaneous responses. f. Unresponsive to noxious stimuli. BIBLIOGRAPHY American Hospital Association (AHA). (2001). A patient’s bill of rights. Chicago: Author. American Nurses’ Association (ANA). (2010). Standards of clinical nursing practice. Washington, DC: Author. American Nurses’ Association. (2013). Code of ethics for nurses with interpretive statements. Nursing World. Washington, DC: Author. Buppert, C. (2011). Three frequently asked questions about mal- practice insurance. Journal for Nurse Practitioners, 7(1):16–17. Butts, J. B., & Rich, K. L. (2014). Nursing ethics, across the cur- riculum and into practice. (3rd ed.). Burlington, MA: Jones & Bartlett Learning. Center for Medicare Services. (2014). Hospital-Acquired Conditions. Retrieved from Daley,K.A.(2013).FromyourANApresident:Helpingnurses strengthen their delegation skills. American Nurse Today, 8(3):18. Fernbach, A. (2011). Parental rights and decision making regard- ing vaccinations: Ethical dilemmas for the primary care pro- vider. Journal of the American Academy of Nurse Practitioners, 23(7):336–345. Guido G. W. (2013). Legal and ethical issues in nursing. Upper Saddle River, NJ: Pearson. Hickman, R. L. Jr., & Pinto, M. D. (2014). Advance directives lessen the decisional burden of surrogate decision-making for the chronically critically ill. Journal of Clinical Nursing, 23(5–6):756–65. Howie, W. O., Howie, B. A., & McMullen, P. C. (2012). To assist or not assist: Good Samaritan considerations for nurse practi- tioners. Journal for Nurse Practitioners, 8(9):688–693. Institute of Medicine. (2011). Health IT and patient safety: Build- ing safer systems for better care. Washington, DC: Author. Jenkins, B., & Joyner, J. (2013). Preparation, roles, and perceived effectiveness of unlicensed assistive personnel. Journal of Nurs- ing Regulation, 4(3):33–40. Kalisch, B. J. (2011) Risk management. The impact of RN-UAP relationships on quality and safety. Nursing Management; 42(9):16–22. Kossman, D. A. (2014). Prevalence, views, and impact of advance directives among older adults. Journal of Gerontological Nursing. 18:17. doi:10.3928/. LeMone, P., & Burke, K. (2010). Medical surgical nursing—critical thinking in client care (5th ed.). Upper Saddle River, NJ: Pren- tice Hall Health. Murray, T. L., Calhoun, M., & Philipsen, N. C. (2011). Privacy, confidentiality, HIPAA, and HITECH: Implications for the health care practitioner. Journal for Nurse Practitioners, 7(9):747–752. National League of Nursing (NLN). (2010). The NLN education competencies model. New York: Author. Plawecki, L., & Amrhein, D. (2010, August). Legal issues. A question of delegation: Unlicensed assistive personnel and the professional nurse. Journal of Gerontological Nursing, 36(8):18–21. Smith, S., Duell, D., & Martin, B. (2008). Clinical nursing skills (7th ed.). Upper Saddle River, NJ: Prentice Hall Health. Westrick, S. J. (2014). Essentials of nursing law and ethics (2nd ed.). Burlington, MA: Jones & Bartlett Learning. Review Questions 27 MANAGEMENT PRINCIPLES AND LEGAL ISSUES REVIEW QUESTIONS MANAGEMENT PRINCIPLES 1. An RN team leader observed an LVN beginning an IV without putting on gloves. When confronted, the LVN replied, “Oh, I was careful and didn’t get any blood on me.” How should the RN initially respond? 1. “The regulations state that all of us must wear gloves. If I see you without them, I will place you on report.” 2. “Tell me your understanding of what Standard Pre- cautions for all clients means.” 3. “Well, if you are absolutely sure that you can be care- ful—but I don’t think it is safe nursing practice.” 4. “I think we should clarify this with the charge nurse to see who is right.” 2. The RN is very short-staffed because two people did not show up for work. Of the following four clients, which one would the RN care for first? 1. A client just admitted with acute abdominal pain and possible cholecystitis. 2. A client with nephrotic syndrome with increasing edema; hourly urine checks and vital signs. 3. A confused client yelling because he is in soft restraints and cannot get out of bed. 4. A head-injury client (with an IV) who was just admitted to the unit. 3. The RN has a full workload and must reassign some of her clients to the UAP. The most appropriate client to reassign to the UAP would be a(n) 1. Client just returning from the recovery room follow- ing colostomy surgery. 2. Cerebrovascular accident (CVA) client who has been hospitalized for 2 days. 3. Oncology client who is in severe pain controlled by epidural anesthesia. 4. Newly admitted client with suspected pancreatitis. 4. The RN observes two nurses talking and laughing when in the room of a client in a coma. The appropriate response for the RN is to 1. Ignorethebehaviorbecausetheclientcannothearthem. 2. Call the nurses outside the room and ask them to be more professional. 3. Notify the charge nurse of this unprofessional behavior. 4. Point out to the nurses, outside the room, that the client might hear them. 5. The RN asked the nursing assistant (NA) to wash the client’s hair as part of her assignment. The RN will help the NA to understand that washing the client’s hair will 1. Raise her self-esteem. 2. Make her feel better. 3. Improve her physical condition. 4. Make her more presentable. 6. The nurse suspects a peer is abusing drugs. This suspi- cion would be based on the behavior of 1. Always arriving late for work and often taking a sick day. 2. Socializing with others and bargaining with cowork- ers to change hours. 3. Requesting to have clients who are located close to the bathroom. 4. Offering to dispense meds or to care for clients on pain meds. 7. The RN tells the LPN she is very busy and needs assis- tance. Which one of the following tasks cannot be del- egated to an LPN? 1. Checking the blood glucose level of a client and giv- ing the appropriate insulin dose. 2. Completing a peripheral vascular assessment that a nursing assistant identified as being different from the earlier assessment. 3. Completing an initial health assessment on a newly admitted client. 4. Completing client teaching for a client scheduled for discharge. The nursing unit is very busy. The nurse has five criti- cally ill clients (none are terminal; all are full codes and have required IV push medications). Seven clients are being discharged and two new clients, are being admit- ted with chest pain who are on lidocaine drips. One of the clients with chest pain had two runs of ventricular tachycardia in the ER. The nurse also has a comatose terminal client with a life expectancy of less than 72 hours. This client has a sump tube, a Foley catheter, and TPN running through a central line. His orders are comfort measures only. Questions 8–10 relate to this scenario. 28 Chapter 2: Management Principles and Legal Issues 8. Considering the information provided, who is the most appropriate person to take care of the critically ill clients? 1. RN. 2. LPN. 3. CNA. 4. UAP. 9. The most appropriate person to take care of the termi- nally ill client is the 1. RN. 2. LPN/LVN. 3. CNA. 4. UAP. 10. The most appropriate person to take care of the clients being discharged who need teaching reinforced would be the 1. RN. 2. LPN. 3. CNA. 4. UAP. 11. Which client is most critical and should be assessed by the RN? 1. Diabetic client being discharged and requiring dis- charge teaching. 2. Cardiac client with a history of ventricular tachycardia. 3. Client requiring IV push medication. 4. Comatose, terminally ill client. 12. The RN in charge of assignments, with limited available staff, must assign the following four clients. Which cli- ent would be most appropriate for the UAP? 1. A recent postsurgical TURP. 2. A head-injury client with stable intracranial pressure. 3. A client with heart failure. 4. A client with acute pancreatitis. 13. A new graduate RN has been assigned to work in a subacute nursing unit. The nurse has the help of two UAPs to care for 15 clients. When delegating client care, what is the most important concept for the nurse to keep in mind? 1. The length of time it takes to care for each client. 2. The skill level of the two UAPs. 3. The length of time each UAP has been on the job. 4. Which clients the RN has taken care of before. 14. InthepresenceoftheRN,aphysicianaskstheLVNto remove the sutures from the incision before the client is discharged. The initial response to the physician should be 1. LVNs cannot remove the sutures; the RN will do it. 2. Please write the order and the sutures will be removed. 3. We will remove them right away. 4. The LVN will get the suture removal set for you because he or she is not allowed to remove sutures. 15. A nurse in charge of a unit observes a certified nurs- ing assistant (CNA) listening to breath sounds. Which of these actions by the CNA would require immediate attention by the charge nurse? 1. Encouraging the client to cough and deep breathe. 2. Giving the client the incentive spirometer to use. 3. Administrating Combivent and Serevent to enhance breathing. 4. Completing pulse oxygenation on the client. LEGAL ISSUES 1. The civil rights of a client would not be jeopardized in which of the following situations? 1. Trying to forcibly detain a client who may suffer great harm by leaving the hospital. 2. Giving emergency medical care to a client without his or her consent or the consent of the family. 3. Giving a psychiatric client’s letters addressed to the President of the United States to his physician. 4. Givingtheclient’sinsurancebrokeraccesstohischart. 2. The primary purpose and criteria of licensure is to 1. Limit practice. 2. Define the scope of practice. 3. Protect the public. 4. Outline legislative action. 3. One of the elements of negligence is breach of the stan- dard of care. Standard of care may be defined as 1. Nursing competence as defined by the state Nurse Practice Act. 2. The degree of judgment and skill in nursing care given by a reasonable and prudent professional nurse under similar circumstances. 3. Healthservicesasprescribedbycommunityordinances. 4. Giving care to clients in good faith to the best of one’s ability. 4. The decision as to whether a nurse can lawfully restrain a client is made by the 1. Nurse. 2. Family. 3. Hospital administrator. 4. Physician. Review Questions 29 5. The physician wrote a medication order for a client. The nurse thought the dosage was incorrect. She questioned the physician, who said it was all right. Still questioning, she asked another nurse, who said it was all right. The nurse gave the medicine, and the client died from an overdose. Who is liable? 1. The physician and the two nurses. 2. The physician. 3. The nurse who gave the medication. 4. Both the physician and the nurse who gave the medication. 6. Which of the following best describes the function and purpose of the unusual occurrence (incident) report? 1. A legal part of the chart used to furnish data about the incident. 2. A hospital record used to record the details of the incident for possible legal reference. 3. A legal hospital business record that is subject to sub- poena and can be used against the hospital personnel. 4. A hospital record that is entered into the client’s chart if he or she dies. 7. If the nurse is involved in a situation in which he or she must countersign the charting of a paraprofessional, which of the following will most aid in decreasing legal liability? 1. Read the document before signing it. 2. Have personal knowledge of the information con- tained in the document. 3. Make sure the information is accurate. 4. Check with a second nurse to see if the information is accurate. 8. The nurse transcribing the physician’s order finds it dif- ficult to read. Which of the following people should the nurse consult for clarification of the order? 1. The head nurse who is familiar with the physician’s writing. 2. Another nurse working with the nurse. 3. The physician who wrote the order. 4. The nursing supervisor. 9. Which of the following would not constitute negligent conduct? 1. A medication error. 2. Failure to follow a physician’s order. 3. Failure to challenge a physician’s order. 4. Disagreeing with a physician. 10. The nurse is asked to do a TV commercial for hand lotion. In this commercial she will wear her nurse’s uniform and advocate the use of this lotion by nurses in their work setting. In doing this, the nurse is violating 1. Consumer fraud laws. 2. The Nurse Practice Act. 3. The code of ethics for nurses. 4. None of the above. 11. Nurse Practice Acts include 1. A definition of nursing practice. 2. Qualifications for licensure. 3. Grounds for revocation of a license. 4. All of the above. 12. Clients’ rights are 1. Specifically written into many laws. 2. A position paper that was developed by the Ameri- can Hospital Association. 3. A declaration of the World Health Organization. 4. Not supported by statutory law. 13. Which of the following statements concerning nursing liability is true? 1. A physician may assume personal liability for the negligent acts of the nurse. 2. The nurse is responsible for his or her own negligent acts. 3. The doctrine of respondeat superior always protects the nurse. 4. Malpractice insurance will always cover the damages assessed against the nurse. 14. Which of the following might negate liability on the part of the nurse in a negligent action? 1. The client consented to the act. 2. The harm was not reasonably foreseeable. 3. The nurse had not been taught to do the procedure in nursing school. 4. Other foreseeable acts occurred that added to the client’s injury. 15. The nurse’s liability in terms of the client’s consent to receive health services is to 1. Be certain that the physician has prepared the client. 2. Ensure that the client is fully informed before being asked to sign a consent form. 3. Check that the client understands the details of the surgery. 4. The nurse would not be liable—the physician would be. 30 Chapter 2: Management Principles and Legal Issues MANAGEMENT PRINCIPLES AND LEGAL ISSUES ANSWERS WITH RATIONALE MANAGEMENT PRINCIPLES 1. (2) The best way to determine what the LVN knows and/or understands or believes is to ask this basic question. Once the RN has baseline data, then teaching about the importance of always using Standard Precautions can be done. When a nurse becomes inconsistent in the use of these Standard Precautions, clients as well as the other healthcare team members are in jeopardy. Standard Precautions are to be used for all clients when there is a danger of coming into contact with body fluids. NP:I; CN:S; CA:M; CL:AN 2. (4) Head injury would take the first priority because the danger of increasing intracranial pressure must be assessed, and, if it is increasing or the level of con- sciousness is changing, these results must be reported immediately. This client has the most serious and potentially unstable condition; thus the nursing judg- ment would be to care for him first. The nephrotic client (2) is not in critical condition and the confused client (3) can also wait; the second priority would be the client with possible cholecystitis (1) because of the unstable condition. NP:AN; CN:S; CA:M; CL:AN 3. (2) The most appropriate client would be the CVA diagnosis. This client would have been in the hospital for 2 days, so the initial assessment would have been completed. In addition, this client does not require immediate intervention, as does the colostomy client (1) (assessing for hemorrhage, vital signs, etc.). The oncol- ogy client (3) must be assessed for effectiveness of pain control, and the RN or LVN is the only staff member who can do this. The newly admitted client with sus- pected pancreatitis (4) also requires a complete health assessment, and the RN is the only person who can complete this task. NP:AN; CN:S; CA:M; CL:AN 4. (4) It is the RN’s responsibility to teach those on her or his team. The RN should deal with the situation directly and teach the nurses so they understand that the last sense to disappear in a coma client is hearing. The nurses’ behavior is not only nontherapeutic, but also unprofessional. NP:I; CN:S; CA:M; CL:A 5. (1) Improving a person’s physical appearance as well as helping the client to be clean and attractive will raise her self-esteem, which in turn may have a posi- tive effect on her physical condition. It is important to give the NA a rationale for the task assigned so that she will understand the value—it will also raise her self-esteem. NP:I; CN:S; CA:M; CL:C 6. (4) If the nurse were abusing drugs, he or she would try to dispense drugs or care for clients on pain medi- cations. The nurse would not want to take days off, because he or she would not be near the drug source. NP:AN; CN:S; CA:M; CL:A 7. (3) Completing the initial health assessment on the client is the RN’s responsibility according to the legal guidelines. The LPN may update and perform a focus assessment on the client. All of the other interventions may be performed by the LPN. NP:P; CN:S; CA:M; CL:C 8. (1) An RN is responsible for the continuous assess- ment of clients. If they are critically ill, clients will need continuous assessment. These clients are not terminal; if they were, they could be cared for by the LPN. NP:P; CN:S; CA:M; CL:A Coding for Questions/Answers Abbreviations: Nursing Process: NP, Assessment: A, Analysis: AN, Planning: P, Implementation: I, Evaluation: E, Client Needs: CN, Safe, Effective Care Environment: S, Health Promotion and Maintenance: H, Psychosocial Integ- rity: PS, Physiological Integrity: PH, Clinical Area: CA, Medical Nursing: M, Surgical Nursing: S, Maternal/Newborn Nursing: MA, Pediatric Nursing: P, Psychiatric Nursing: PS, Cognitive Level: CL, Knowledge: K, Comprehension: C, Application: A, Analysis: AN 9. (4) UAP. This client is terminal and requires comfort measures only. The RN can assess and maintain the TPN rate via pump and irrigate the Foley catheter and sump as needed. The UAP can safely provide the care to keep the client comfortable. Any IV pain medications would be given by the RN. NP:P; CN:S; CA:M; CL:AN 10. (2) LPN. The RNs are needed for the other clients on the unit. Reinforcement of the teaching can be safely and effectively done by an LPN or an LVN. NP:P; CN:S; CA:M; CL:AN 11. (2) The cardiac client requires constant assess- ment with the possibility of immediate life sup- port intervention should he have another run of ventricular tachycardia. Given the instability of the client’s situation, the cardiac client is the most critical. NP:P; CN:S; CA:M; CL:AN 12. (3) The most appropriate choice, although not an ideal one, would be the heart failure client. The TURP client (1) must be assessed for hemorrhage; the head-injury client (2) must be monitored for a change in ICP; and the client with acute pancreatitis (4) requires vital signs, monitoring every 15 minutes, and frequent assessment for complications. NP:AN; CN:S; CA:M; CL:AN 13. (2) There are two UAPs who probably have differ- ent skill levels. It is important to consider their abili- ties and skill level (as well as the legal parameters for which tasks they can perform) when assigning clients and tasks. The other variables are important but should be taken into account after the skill level has been evaluated. NP:P; CN:S; CA:M; CL:A 14. (2) LVN/LPNs may remove sutures; however, both nurses must make sure that the physician has written the order to do so. A verbal order would not be suffi- cient in this situation. NP:I; CN:S; CA:S; CL:A 15. (3) The CNA does not have the knowledge, skills, or ability to assess lung sounds and make judgments based on this high level of assessment. In addition, CNAs do not administer medications. NP:P; CN:S; CA:M; CL:AN LEGAL ISSUES 1. (2) Key elements of a client’s rights are consent, confi- dentiality, and involuntary commitment. NP:AN; CN:S; CL:A 2. (3) The primary purpose of licensing nurses, both RN and LVN, is to safeguard the public by determining that the nurse is a safe and competent practitioner. NP:AN; CN:S; CL:K 3. (2) Nursing actions are evaluated against a set of stan- dards referred to as standards of performance. NP:AN; CN:S; CL:K 4. (4) To administer any form of restraint, there must be a physician’s order. NP:P; CN:S; CL:A 5. (4) The professional nurse and the physician who wrote the order are held responsible (liable) for harm resulting from their negligent acts. NP:AN; CN:S; CL:AN 6. (2)Themostaccurateansweris(2).Theotherpurposes are to help document the quality of care and to identify areas where more in-service education is needed. NP:AN; CN:S; CL:K 7. (2) To sign a document without having personal knowl- edge of what occurred would open the possibility of liability. NP:P; CN:S; CL:C 8. (3) Because the nurse will be responsible (and liable) if she transcribes the order incorrectly, the physician who wrote the order should be consulted. NP:P; CN:S; CL:A 9. (4) Because the nurse is a licensed professional with an education based on a defined body of knowledge, he or she had the right—indeed, the responsibility—to dis- agree with the physician. This is especially so when the health and welfare of the client is involved. NP:AN; CN:S; CL:K 10. (3) The code of ethics is a set of formal guidelines for governing professional action. This situation is not ille- gal—it is unethical. NP:AN; CN:S; CL:C Review Questions 31 32 Chapter 2: Management Principles and Legal Issues 11. (4) The Nurse Practice Act is a series of statutes enacted by a state to regulate the practice of nursing in that state. It includes all of these plus education. NP:AN; CN:S; CL:K 12. (1) All but 10 states have some provision for the rights of clients written into a law, and these rights can be enforced by the law. NP:AN; CN:S; CL:K 13. (2) The nurse is responsible for her or his own negligent acts; however, legal doctrine holds that an employer is also liable for negligent acts of employees. NP:AN; CN:S; CL:C 14. (2) If basic rules of human conduct are not violated, the elements of liability may not exist. There must be certain elements of liability present; for example, there must exist a causal relationship between harm to the client and the act by the nurse. There must be some damage or harm sustained by the client and there must be a legal basis—such as statutory law—for finding liability. NP:AN; CN:S; CL:A 15. (2) The client must be fully informed of potentially harmful effects of the treatment. If this is not done, it could result in the nurse’s being personally liable. NP:P; CN:S; CL:C StressandAdaptation............................34 Death and Children 45 Nursing Management 45 PainManagement...................................45 Theories of Pain 46 HumanSexuality....................................47 Overview of Human Sexuality 47 Sexual Behavior 47 Sexual Behaviors Related to Health 49 Sexuality and Disability 49 Child Sexual Abuse 50 Joint Commission National Patient Safety Goals, 2014................................... 50 Alternative and Complementary Therapies................................................. 51 CaseManagement..................................52 Quality and Safety Education for Nurses................................................ 52 Appendix 3-1. ISMP’s List of Confused Drug Names 54 Bibliography ............................................ 61 Nursing Concepts Review Questions ................................... 62 Nursing Concepts Answers with Rationale 64 Homeostasis 34 Stress 34 Stress and Disease 34 Selye’s Theory of Stress Psychological Stress 35 35 DevelopmentThroughthe Life Cycle................................................. 36 Early Adolescence 36 Adolescence to Young Adulthood 37 Adulthood...............................................38 Developmental Tasks 38 Values of Adulthood 39 Parenting in Adulthood 39 Physiological Changes Psychosocial Changes 39 40 TheAged.................................................40 Developmental Tasks 40 Physiological Changes 41 Major Health Problems 41 Psychosocial Changes 41 Cultural Sensitivity ................................. 42 The Grieving Process ............................. 43 Stages of Grief 43 Counseling Guidelines 44 Death and Dying ..................................... 44 The Concept of Death in the Aging Population 45 The icon denotes content of special importance for NCLEX®. Nursing Concepts 3 33 34 Chapter 3: Nursing Concepts STRESS AND ADAPTATION b. Wolff believed that a person’s total life situ- ation (with its positive as well as negative Homeostasis aspects) affects a person’s susceptibility to Definition: The maintenance of a constant state in the internal environment through self-regulatory techniques that preserve the organism’s ability to adapt to stresses. A. Dynamics of homeostasis. 1. Danger or its symbols, whether internal or external, result in the activation of the sympa- thetic nervous system and the adrenal medulla. 2. The organism prepares for fight or flight (attack–withdrawal; one’s immediate response to stress—an archaic and often inappropriate response, but part of our biological heritage). B. Adaptation factors. 1. Age—adaptation is greatest in youth and young middle life, and least at the extremes of life. 2. Environment—adequate supply of required materials is necessary. 3. Adaptation involves the entire organism. 4. The organism can more easily adapt to stress over a period of time than suddenly. 5. Organism flexibility influences survival. 6. Theorganismusuallyusestheadaptationmecha- nism that is most economical in terms of energy. 7. Illness decreases the organism’s capacity to adapt to stress. 8. Adaptation responses may be adequate or deficient. 9. Adaptation may cause stress and illness (e.g., ulcers, arthritis, allergy, asthma, and over- whelming infections). Stress A. Definitions of stress. 1. A physical, chemical, or emotional factor that causes bodily or mental tension and that may be a factor in disease causation; a state resulting from factors that tend to alter an existing equilibrium. 2. Selye’s definition of stress. a. The state manifested by a specific syn- drome that consists of all the nonspecifi- cally induced changes within the biologic system. b. The body is the common denominator of all adaptive responses. c. Stress is manifested by the measurable changes in the body. d. Stress causes a multiplicity of changes in the body. 3. Wolff ’s theory of stress. a. Poor adaptation to a life situation may lead to a breakdown in homeostasis with subse- quent development of disease. disease. c. Disease may result from attempts to restore homeostasis. B. General aspects of stress. 1. Body responses to stress are a self-preserving mechanism that automatically and immedi- ately becomes activated in times of danger. a. Caused by physical or psychological stress: disease, injury, anger, or frustration. b. Caused by changes in internal and/or exter- nal environment. 2. There are a limited number of ways an organ- ism can respond to stress (for example, a cor- nered amoeba cannot fly). Stress and Disease A. Stress and individual methods of coping are associated with heart disease, cancer, and other diseases. B. Actualphysicalchangesoccurwithhighstress levels. 1. Increased release of adrenalin, cortisol, and other hormones lead to increased heart rate, blood pressure, and platelet stickiness, which may accelerate atherosclerosis and other causes of heart disease. 2. Changes in immune system may interfere with individual ability to recognize and destroy can- cer cells. C. Stress can be both positive and negative. Individual must have adaptive mechanism to cope with stress to increase health and avoid risk for disease. DANGER SIGNALS OF STRESS • Depression, lack of interest in life • Uncontrolled hyperactive behavior • Lack of concentration, inability to focus • Feelings of unreality, feelings of dread • Loss of control, emotional instability • Pervasive high anxiety level • Physical manifestations o Irregular heartbeats o Tremors, tics o Gastrointestinal disturbance o Skin disturbance o Changes in respiratory patterns • Insomnia • Disease • Increased dependence on alcohol, drugs Adapted from Smith, S. F., Duell, D. J., & Martin, B. C. (2008). Clinical nursing skills (7th ed.). Upper Saddle River, NJ: Prentice Hall Health. Stress and Adaptation 35 Selye’sTheory of Stress A. General adaptive syndrome (GAS). 1. Alarm stage (call to arms). a. Shock: The body translates it as sudden injury, and the GAS becomes activated. b. Countershock: The organism is restored to its preinjury condition. 2. Stage of resistance: The organism is adapted to the injuring agent. 3. Stage of exhaustion: If stress continues, the organism loses its adaptive capability and goes into exhaustion, which is comparable to shock. B. Local adaptive syndrome (LAS). 1. Selective changes within the organism. 2. Local response elicits general response. 3. Example of LAS: a cut, followed by bleeding, followed by coagulation of blood. 4. The ability of parts of the body to respond to a specific injury is impaired if the whole body is under stress. C. Whether the organism goes through all the phases of adaptation depends on both its capacity to adapt and the intensity and continuance of the injuring agent. 1. Organism may return to normal. 2. Organism may overreact; stress decreases. 3. Organism may be unable to adapt or maintain adaptation, a condition that may lead to death. D. Objective of stres5s response. 1. Tomaintainstabilityoftheorganismduringstress. 2. To repair damage. 3. To restore body to normal composition and activity. (See Table 3-1.) Psychological Stress Definition: All processes that impose a demand or require- ment upon the organism, the resolution or accommodation of which necessitates work or activity of the mental apparatus. Characteristics A. May involve other structures or systems, but pri- marily affects mental apparatus. 1. Anxiety is a primary result of psychological stress. 2. Causes mental mechanisms to attempt to reduce or relieve psychological discomfort. a. Attack/fight. b. Withdrawal/flight. c. Play dead/immobility. Table 3-1 SELYE’S STRESS ADAPTATION SYNDROME Stage Function Interpersonal Behavioral Affective Cognitive Physiological 1. Alarm reaction Mobilization of body defenses Interpersonal communication effectiveness decreases Task-oriented Increased restlessness Apathy, regression Crying Feelings of anger, suspiciousness, helplessness Anxiety level increases Alert Thinking becomes narrow and concrete Symptoms of thought block- ing, forgetfulness, and decreased productivity Muscle tension Increase in epineph- rine and cortisone Stimulation of adrenal cortex and lymph glands Increase in blood pres- sure, heart rate, and blood glucose 2. Stage of resistance Adaptation to stresses Resistance increases Interpersonal communication is self-oriented Uses inter- personal relationships to meet own needs Automatic behaviors Self-oriented behaviors Fight or flight behavior apparent Increased use of defense mechanisms Emotional response