Nursing Ethics
➢ Bioethics
○ beneficence (do good)
○ autonomy (patient rights)
○ justice (fair & equality)
○ fidelity (loyalty)
○ veracity (truth)
➢ Confidentiality: HIPAA – Federal privacy rules for institutions like hospitals for disclosure, storage,
sharing, obtaining, etc.
■ Protected Health Information (PHI) as necessary for treatment, billing, mandatory
reporting, placement, etc.
■ ONLY people involved in the care of the patient and with a business need to know should
have access to PHI.
■ A court order may require disclosure of confidential information. A court can
subpoena you to discuss confidential information otherwise protected by HIPPA.
■ NO PHI to family without Pt’s consent.
■ Tarasoff- In California this is the duty to warn & there is a duty to protect identifiable
individuals threatened with harm which supersedes confidentiality.
■ Mandated report of abuse if suspicion exists, evidence NOT needed.
➢ Informed consent:
○ MD responsible
○ RN ensure implied or expressed or must intervene
○ must have for specific procedures:
■ ECT
■ HIV testing
■ Surgery
■ etc.
○ ALL patients have a right to informed consent (Voluntary & involuntary) AND can revoke
consent unless court ordered or emergency.
➢ Involuntary commitments/hospitalizations:
○ May be detained in a psychiatric facility if:
■ DTS (danger to self)
■ DTO (danger to others)
■ GD (gravely disabled)
○ In California this is called a 5150 - for minors 5585 72 hr hold
○ Pt’s can be held longer than 72-hrs if still DTS, DTO, or GD but cannot be held indefinitely.
Neurocognitive
➢ Delirium is NOT a Disorder; it’s a syndrome- a group of symptoms.
➢ Delirium is ALWAYS due to underlying physiological causes; tends to be short term & reversible.
Delirium Is the MOST frequent complication of hospitalization.
➢ Delirium: acute & abrupt cognitive disturbance, inability to direct & focus attention, disorganized
thinking & disorientation to time and place, agitation, assault, symptoms may fluctuate (change back
and forth, day or night), wandering, wanting to go home, climbing out of bed, pulling out lines,
drains, falling.
, ➢ Delirium is a medical emergency that requires
immediate attention to prevent irreversible or serious
neuro damage; ANY time your patient has an ACUTE
ONSET of CONFUSION, CONSIDER DELIRUM
➢ Physical S/S: may see increased pulse, sweating,
flushed face, dilated pupils, elevated BP
➢ Illusions = perception errors of sensory stimuli
(misinterpretations of something there whereas a
delusion or hallucination is not really there)
➢ Nursing Interventions: Priority = keep the patient
safe while attempting to ID the cause, early recognition
& report to provider, clinical assessment (MSE and
neuro), medication review ( especially polypharmacy &
antipsychotics in the frail elderly) , review labs & ask for
order if no current labs, and accurate interpretation of
the S/S, follow hospital protocols, minimize modifiable
risk factors; consistency is key, reduce stimuli, reorient
PRN, ensure sensory aids available(hearing aids,
eyeglasses), remove physical hazards, maintain
adequate lighting, communicate with simple directions,
distraction and redirection instead of demands or
confrontation, encourage family to stay with the patient
to minimize wandering or falls. The right attitude:
non-judgmental w/ positive regard for the patient &
family.
➢ Dementia
○ Mild neurocognitive disorders: baseline decline in cognitive functioning & interference w/ ADLs;
may or may not progress to major neurocognitive disorder. Need to know the patient’s baseline
or you won’t notice the change!
○ Major neurocognitive disorders: also known as advanced dementia; progressive and
irreversible
○ Dementia: broad term to describe progressive deterioration of cognitive functioning & global
impairment of intellect. NOT a specific disease per se, it’s a collection of symptoms with varying
levels of impairment. Progressive but does NOT mean it always progresses to major
neurocognitive disorders. Forgetfulness --> Disorientation
, ➢ 3 stages, progressively worse
neurodegenerative disease; no known cause or
cure, a few meds minimally effective to slow the
progression
➢ Apraxia: inability to perform once-familiar
and purposeful tasks (ADLs).
➢ Give repeated single step-by-step
directions with patience & kindness (breaking
down a task reduces the cognitive load and is
respectful, maintains dignity)
➢ Don’t ask, tell them. Take them to their
room, don’t ask if they remember where their
room is.
➢ Consistency and familiarity are helpful.
Have personal belongings nearby.
➢ Bipolar
○ Bipolar I: most severe, normal Fx fluctuating w/ highs, lows, or both; high-risk BH (High & Low)
○ Bipolar II: normal Fx fluctuating btwn at least 1 manic & 1 depressive episode (less High & Low)
○ Mania: major & persistent elevation, expansiveness, irritability, energy, racing thoughts, lack of sleep,
impulsive, distractible, push limits, hypersexual; 1+ week
○ Nursing Interventions: sleep hygiene, calm & firm, short & direct, reduce stimuli, safety!
○ Onset of episode may be caused by 3 S’s: Substances, Sleep(lack of), Stress (increased)
○ Acute phase- stabilize physiologic (safety &sleep) then psych issues (limit setting, self-control)
○ Maintenance phase- med adherence & relapse prevent & early recognize decompensation s/s
○ Cognitive dysfunction is present in 1/3 of patients w/ bipolar ( mood + though disorder)
○ Nurse may need to stay with/do with/be with the patient. Patient might not play well w/ others.
○ Pharm: mood stabilizers & 2nd gen antipsychotics for mania & agitation
○ Pressured speech: fast flowing speech, non-stop
○ Circumstantial speech: too many details, circles back to the actual point of the convo
○ Disorganized speech: incoherent, irrelevant, illogical, difficult to follow
○ Tangential: lose the point of the convo, never make it back
➢ Bioethics
○ beneficence (do good)
○ autonomy (patient rights)
○ justice (fair & equality)
○ fidelity (loyalty)
○ veracity (truth)
➢ Confidentiality: HIPAA – Federal privacy rules for institutions like hospitals for disclosure, storage,
sharing, obtaining, etc.
■ Protected Health Information (PHI) as necessary for treatment, billing, mandatory
reporting, placement, etc.
■ ONLY people involved in the care of the patient and with a business need to know should
have access to PHI.
■ A court order may require disclosure of confidential information. A court can
subpoena you to discuss confidential information otherwise protected by HIPPA.
■ NO PHI to family without Pt’s consent.
■ Tarasoff- In California this is the duty to warn & there is a duty to protect identifiable
individuals threatened with harm which supersedes confidentiality.
■ Mandated report of abuse if suspicion exists, evidence NOT needed.
➢ Informed consent:
○ MD responsible
○ RN ensure implied or expressed or must intervene
○ must have for specific procedures:
■ ECT
■ HIV testing
■ Surgery
■ etc.
○ ALL patients have a right to informed consent (Voluntary & involuntary) AND can revoke
consent unless court ordered or emergency.
➢ Involuntary commitments/hospitalizations:
○ May be detained in a psychiatric facility if:
■ DTS (danger to self)
■ DTO (danger to others)
■ GD (gravely disabled)
○ In California this is called a 5150 - for minors 5585 72 hr hold
○ Pt’s can be held longer than 72-hrs if still DTS, DTO, or GD but cannot be held indefinitely.
Neurocognitive
➢ Delirium is NOT a Disorder; it’s a syndrome- a group of symptoms.
➢ Delirium is ALWAYS due to underlying physiological causes; tends to be short term & reversible.
Delirium Is the MOST frequent complication of hospitalization.
➢ Delirium: acute & abrupt cognitive disturbance, inability to direct & focus attention, disorganized
thinking & disorientation to time and place, agitation, assault, symptoms may fluctuate (change back
and forth, day or night), wandering, wanting to go home, climbing out of bed, pulling out lines,
drains, falling.
, ➢ Delirium is a medical emergency that requires
immediate attention to prevent irreversible or serious
neuro damage; ANY time your patient has an ACUTE
ONSET of CONFUSION, CONSIDER DELIRUM
➢ Physical S/S: may see increased pulse, sweating,
flushed face, dilated pupils, elevated BP
➢ Illusions = perception errors of sensory stimuli
(misinterpretations of something there whereas a
delusion or hallucination is not really there)
➢ Nursing Interventions: Priority = keep the patient
safe while attempting to ID the cause, early recognition
& report to provider, clinical assessment (MSE and
neuro), medication review ( especially polypharmacy &
antipsychotics in the frail elderly) , review labs & ask for
order if no current labs, and accurate interpretation of
the S/S, follow hospital protocols, minimize modifiable
risk factors; consistency is key, reduce stimuli, reorient
PRN, ensure sensory aids available(hearing aids,
eyeglasses), remove physical hazards, maintain
adequate lighting, communicate with simple directions,
distraction and redirection instead of demands or
confrontation, encourage family to stay with the patient
to minimize wandering or falls. The right attitude:
non-judgmental w/ positive regard for the patient &
family.
➢ Dementia
○ Mild neurocognitive disorders: baseline decline in cognitive functioning & interference w/ ADLs;
may or may not progress to major neurocognitive disorder. Need to know the patient’s baseline
or you won’t notice the change!
○ Major neurocognitive disorders: also known as advanced dementia; progressive and
irreversible
○ Dementia: broad term to describe progressive deterioration of cognitive functioning & global
impairment of intellect. NOT a specific disease per se, it’s a collection of symptoms with varying
levels of impairment. Progressive but does NOT mean it always progresses to major
neurocognitive disorders. Forgetfulness --> Disorientation
, ➢ 3 stages, progressively worse
neurodegenerative disease; no known cause or
cure, a few meds minimally effective to slow the
progression
➢ Apraxia: inability to perform once-familiar
and purposeful tasks (ADLs).
➢ Give repeated single step-by-step
directions with patience & kindness (breaking
down a task reduces the cognitive load and is
respectful, maintains dignity)
➢ Don’t ask, tell them. Take them to their
room, don’t ask if they remember where their
room is.
➢ Consistency and familiarity are helpful.
Have personal belongings nearby.
➢ Bipolar
○ Bipolar I: most severe, normal Fx fluctuating w/ highs, lows, or both; high-risk BH (High & Low)
○ Bipolar II: normal Fx fluctuating btwn at least 1 manic & 1 depressive episode (less High & Low)
○ Mania: major & persistent elevation, expansiveness, irritability, energy, racing thoughts, lack of sleep,
impulsive, distractible, push limits, hypersexual; 1+ week
○ Nursing Interventions: sleep hygiene, calm & firm, short & direct, reduce stimuli, safety!
○ Onset of episode may be caused by 3 S’s: Substances, Sleep(lack of), Stress (increased)
○ Acute phase- stabilize physiologic (safety &sleep) then psych issues (limit setting, self-control)
○ Maintenance phase- med adherence & relapse prevent & early recognize decompensation s/s
○ Cognitive dysfunction is present in 1/3 of patients w/ bipolar ( mood + though disorder)
○ Nurse may need to stay with/do with/be with the patient. Patient might not play well w/ others.
○ Pharm: mood stabilizers & 2nd gen antipsychotics for mania & agitation
○ Pressured speech: fast flowing speech, non-stop
○ Circumstantial speech: too many details, circles back to the actual point of the convo
○ Disorganized speech: incoherent, irrelevant, illogical, difficult to follow
○ Tangential: lose the point of the convo, never make it back
