RANDEL DALAUTA,RN

Doctrine of Respondeat Superior “master servant rule”

*liability: a. agent/employee – direct liability

b. principal/employer – vicarious liability *criteria: a. establish the employee/employer relationship b. act must be committed as harm is done to the patient c. act must be committed with in the scope of employment

Doctrine of Res ipsa Louitur“things speak for itself”

3 conditions: a. injury does not normally occur unless there was negligence b. injury caused by an agent with in the control of the defendant c. plaintiff did not engage in any manner that would tend to bring about the injury

Captain of the Ship Doctrine“command responsibility”

Force Majeure “superior force/irresistible force/ Act of God;fortuitous event” *liability:

- free both parties from liability or obligation when extraordinary event or circumstances beyond the control of the parties - defendant must have nothing to do with the events happening *elements: a. Externality – defendant must have nothing to do with the event b. Unpredictability – if event could be forseen, the defendant is

obliged to have prepared it. c. Irresistibility – consequences of the event must have been

unpreventable. *not answerable unless a. Specified by Law b. Obligation require assumption of risk c. Stipulation

TORTS

ASSAULT

FALSE IMPRISONMENT OR ILLEGAL DETENTION

BATTERY

SEC.4.THE RIGHTS OF PATIENTS

(4) Right to Information

In the course of his/her treatment and hospital care, the patient or his/her legal guardian has a right to be informed of the result of the evaluation of the nature and extent of his/her disease, any other additional or further contemplated medical treatment on surgical procedure or procedures, including any other additional medicines to be administered and their generic counterpart including the possible complications and other pertinent facts, statistics or studies, regarding his/her illness, any change in the plan of care before the change is made

Informed Consent“An informed consent is an autonomous

authorization by individuals of a medical intervention or of involvement in research”

Element: the nature of the decision/procedure reasonable alternatives to the proposed intervention the relevant risks, benefits, and uncertainties related to each

alternative assessment of patient understanding the acceptance of the intervention by the patient

*patient must be competent & consent voluntarily given*competence should be determined by

professionals, approved by the court under the law.

When medically significant alternatives for care or treatment exist, or when the patient requests information concerning medical alternatives, the patient has the right to such information.

The patient has the right to examine and receive an explanation of his bill regardless of source of payment.

Competence

Legal age

Not under influence or against freewill

Sound mind

Not suffering from physical disability such as those who are mentally incompetent

Criteria/elements Determinant

On the basis of the

law

Autonomy

Expert and approved by the court

Emphysema vs Chronic Bronchitis

Chronic Bronchitis EmphysemaChronic BronchitisEmphysema

Pink puffer Blue Bloater

Acyanotic Cyanotic

Alveolar destruction Bronchial Inflammation

P’s

Persistent SOBProgressive DyspneaProminent Barrel Chest

C’s

Chronic cough Copious sputum Priority: COMFORT

COR PUMONALLE

METHODS OF CARE DELIVERYa. PRIMARY NURSING

- total care; 24/7

- sole accountability

b. CASE METHOD

- Oldest Method; 1:1

- client centered

- e.g. ICU nurse

c. FUNCTIONAL METHOD

- 1nurse 1 task

- task oriented

d. TEAM METHOD

- 1 team 1 group of patient

- collaboration oriented

* team composition

a. RN team leader c. Nursing Aides

b. License Practical nurse

e. CASE MANAGEMENT

- management of specific case through out hospitalization

* criteria of cases:

a. with specific physician c. by diagnosis

b. geographic proximity

Readiness to Learn Typesa. Physical Readiness (Skills)

- focus away from physical status- anything that using up energy

and timeb. Emotional readiness (Attitude)

- ready/asking about self care activities

- not ready: extremely anxious, depressed, & grievingc. Cognitive (Knowledge)

- asking about the disease process

- cause & details

Remember:

client is ready if;

- Ask questions

- Search information

- Knowingly shows interest

client is not ready if;

- Lack of attention

- Avoid subjects when brought up

- Missed appointments

- Express disinterest

Nurse Role:Providing physical & emotional support

Providing opportunities to learn

How to Increase Motivation

Relating the learning to values

Encouraging self direction &

independence

Assisting client identify benefits of changing behavior

Create learning situation which likely for success (small/easy task)

Helping make learning pleasant & nonthreatening

(+) - reinforcement

- attitude demonstrated by the nurse

maslow's hierarchy of needs

Communication the exchange of thoughts, feelings,

and other information

Evidence of Mental health

Basic needs meet

Effective Coping Skills

Emotional stability

Satisfying relationship

+ self concept

Using An Extinguisher

Pull the Pin on the extinguisher

Aim the nozzle of the extinguisher at

the base of the fire

Squeeze the trigger

Swipe the nozzle sideways

DIFFERENT PRECAUTIONSIsolation Technique Handwashing Private

RoomGloving Gowning Mask

Strict / / / / /

Contact / / / / /

Respiratory / / / /

Universal / / / /

TB / / /

Enteric / /

Drainage / /

Simple Formula

IVF

Temp

C to F :Centigrade x 1.8 + 32 = F

Meds

F to C: Fahrenheit – 32 / 1.8 = C

Desired Available

Quantity

Enema

EnemaTypes of Enemas

Type Solution Indication

Cleansing Tap waterSoap sudsNormal saline

Evacuate lower bowel before diagnostic studies or surgery

Retention (should be retained

for at least 30 min)

Emollient (oil) Soften and lubricate stool for easy evacuation

Carminative (return flow)

Tap waterNormal saline

Relief of distension due to flatus

Medication Normal salineSterile water mixed with prescribed medication

Will depend on what medication is introduced

Miller-abott tube

Subcutaneous emphysema

AGE Psychosocial DEV’T. TASK PSYCHOSEXUAL MORAL (KOHLBERG)

0 - 18 Infancy Trust vs Mistrust Oral (“id”) Pre-religious

18 – 3 Toddler Autonomy vs Shame&Doubt

Anal (“ego”) reality

Pre-conventional stage I- do good because

someone telling you(toddler to 7

Punishment)

3 – 6 Pre-Schooler

Initiative vs Guilt Phallic(“super ego”)

conscience

Pre-conventional stage II-instrumental relativist

-do good of self interest- Good boy & girl

6 - 12 SchoolAge

Industry vs Inferiority Latency ConventionalStage III

- Nice girl , Nice Boy- Role oriented

12 - 18 Adolescent Identity vs Role Confusion

(personality)

Genital Post conventional stage IV

-follow social norm-Moral values

18 - 45 Early Adulthood

Intimacy vs Isolation UniversalEthical Principle

45 - 65 Middle Adulthood

Generativity vs Stagnation

65 up Late Adulthood Ego Integrity vs Despair

ANIMISM – all inanimate objects are given living meaning

EGOCENTRIC SPEECH – occurs when the child talks just for fun and cannot see another point of view.

OBJECT PERMANENCE – realization that something out of sight still exist, occurs in the later stages of sensorimotor stage development.

GLOBAL ORGANIZATION – means that if any part of an object or situation changes, the whole thing has changed.

Cerebral Palsy

Rhizotomy

- locate and cut dorsal root of the nerve that provide over stimulation to specific parts of the body

Aspiration precaution- thickened feeding

- add rice to the food

Drugs- Methocarbamol (Robaxin) muscle relaxant

- Baclofen (Lioresal) treat spacity (palambot ng katawan)

TONSILECTOMYAVOID

C

C

R

A*Milk & Milk products, blowing of nose

itrus, carbonated food

rying, coughing,Clearing throat

ed/Brown Colored Foods Rough Foods

spirin

DIET

1. Cool clear liquid

2. Ice chips

3. Gelatin

4. Ice pop/Popsicle

5. Fruit sherbet

6. Apple juice

CHF

Leftside Rigthside

= Pulmonary S/sx= =Systemic S/Sx=

C = oughing & Dyspnea

H = ematomegaly

H = emoptysis E = dema

O = rthopnea A = scites

P = ulmonary congestion

D = istended neck viens

Cleft Lip Cleft Palate

Lalaki PemalecheiLoplasty Palatoplasty

Liedown sideLyingUnaffected side

Prone position

Little utensils – straw - asepto syringe

Pala (big utensils)

Post-op priority: prevent trauma to suture line

Logan’s Bar – to avoid trauma Elbow restraints

AGE DANGERS FEARS DEATHCONCEPT

OTHERS VIRTUE PLAY

0 - 18 -choking-aspiration

- stranger anxiety

No idea - thumbsuck/pacifier hope solitary

18 – 3 - Falls- Poisoning

Separation Anxiety

No idea -Negativism – offer choices-Temper tantrums-ignore - safety-Toilet training ready when child; (1) sit (2) stand (3) walk (4) verbalize urge

well

Parallel

3 - 6 - Accidents - Castration Anxiety

-Sleeping-Temporary-Reversible

-Masturbation = penis envy = delay surgery-Why Q – answer honestly- Bring child back to school

Motivation Associative

6 - 12 -Accidents- CDs

-School Phobia- Teacher Rejection

-Permanentbut I won’t

-Bring back child to school

Competence Associative

12 - 18 -STDs- VehicularAccidents

- Peer Rejection

- Religious/ Philisopy

Competence

Cooperative &

Competitive

18 - 45 Love

45 - 65 Care

65 up Wisdom

Epispadias Hypospadias

Surgery: 1. Meatotomy2. Urethroplasy3. Circumcision – skin graft

Intervention: post-op4. Urinary Diverion /Stenta. Avoid tub bath until stent

removeb. Asses patency of stentc. Pain Medsd. Anti cholinergic – relieve

spasme. Increase Fluid Intakef. Follow up check after 4 days

Prone to infection

UP/Dorsal Down/Ventral

Less Prone

Cpx: Extrophy of the Bladder

Cpx: Chordee

Remember: Do not circumcise

right after birth Surgery before

toilet training (2 y.o.)

Asses stream of Urine

USE OF PROTECTIVE EQUIPMENT

EQUIPMENT

PURPOSE

Gloves Direct contact

Mask

All patients with respiratory problemsN95 mask for airborne transmitted dse.

GownFor procedures with potential splashes of blood and body fluidsEye

Protection

Kaposis sarcoma

Acute cellulitis

Nasogastric Tube Insertion:

- NEX- High Fowler’s position- Sips of water and advance tube as client swallows- Do not force the tube!

Confirm placement of NGT Monitor and record residual volume q4h by aspirating stomach

content with a syringe. A residual volume of >100-150 ml indicates delayed gastric emptying. Notify MD.

During and after feeding keep HOB 30 degrees to prevent aspiration; For continuous feedings, keep the patient in a semi-Fowler’s position at all times

Flush/Irrigate tube feeding with 30-60ml of water q4h during continuous feeding, before and after each intermittent feeding, before and after administering meds, after each time you check residual volume

Feeding set changed q24h. Bag rinsed q4h.

LMR

juris

Human Motivational Theory

Theory A -American style - Predominantly

downward communication pattern

- Rapid evaluation & promotion

- Segmented concern for employees

Category Theory X Adhocracy

assumption People dislike work

People like work

workers are; Lazy, unmotivated, irresponsible,

unintelligent, not interested to

work, negativistic

self directed, responsible, creative, self possessed,

problem solver and will accept responsibility

emphasis Organizational goals

Individual goals

approach Control & threaten

encourage develop full

potential

Theory X and Theory Y (Douglas Mc Gregor, 1960)

Theory Z (William Ouchi, 1981)

- promotes a relationship-oriented, democratic leadership style

- work is natural & a source of satisfaction

Elements: 1. Collective decision

making 2. Long term employment 3. Slower but more

predictable promotions 4. Holistic concern for

employees

Category Bureaucracy Adhocracy

form hierarchy non hierarchical

decision making

centralized decentralized

nature autocratic democratic

responsibilities definition

individualized or

specialization

organic

approach structured flexible

Social System Model for Hospitals

Process Structure OutputsInputs

EFFICIENT PATIENT CARE

-Lesser hospital stay-Improve vitals sign-Zero infection & complications

Discrepancy between Actual and Expected

Performance

Environment

PeopleA. StaffB. PatientsMaterial• Drugs & chemicals• Equipment• DietMoney• To maintain staff,

facilities & procure materials

Communication•Between *Upward•Downward *Lateral

Decision MakingFor:•Cure, Diagnosis, Treatment•Patient Care•Procurement of materialsAction:

• Putting decisions into practice• Balanced mix of

communication, decision making & action STANDARDS

Types of Budgeta. Open-ended Budget - single cost estimate

b. Fixed ceiling Budget - uppermost spending limit

- set by the top executive

c. Flexible Budget - set for each level of activity or different operating conditions

d. Performance Budget - based on the function and activities of personnel

e. Program Budget - program budget cost

f. Zero-based Budget - justifies in detail the cost of all programs

- old and new

g. Sunset Budget - designed to self destruct within a prescribed period to ensure cessation of the funded

program

Managerial Level

Top Level manager

- organizational decision makers- commands over the middle manager- conceptual ability; strategic (long term planning)

Middle manager

- coordinate nursing activities to several nursing units- receive broad strategies & policies from to managers- supervise 1st line managers

First Level manager

- in-charge of day to day operation- responsible for non managerial staff- clinical operation in-chargee.g. nursing supervisor

Different leadership styles:

1. Autocratic -leaders exert total control over members

2.Democratic/ Participative

-leader shares control with

group members

3. Laissez-faire/ Permissive/ ultraliberal

-leader relinquishes

control to group members.

4.Consultative

Leadership - focuses on using the

skills, experiences, and ideas of others

- leader: retains the final decision-making power (veto power)

- involved others in decision making

4. Multi critic/ Situational/ Contingency

-leader utilizes varying styles depending on the situation

- should be complementary to manager’s style, expectations & characteristics of workers

-how to accomplish? “Aligning closely the forces in the manager, worker & situation”

Elements of Bureaucracy

Division of labor

Hierarchy of authority

Impersonality

Employment based on technical qualifications

Structured written rules & regulation

METHODS OF CARE DELIVERYa. PRIMARY NURSING

- total care; 24/7

- sole accountability

b. CASE METHOD

- Oldest Method; 1:1

- client centered

- e.g. ICU nurse

c. FUNCTIONAL METHOD

- 1nurse 1 task

- task oriented

d. TEAM METHOD

- 1 team 1 group of patient

- collaboration oriented

* team composition

a. RN team leader c. Nursing Aides

b. License Practical nurse

e. CASE MANAGEMENT

- management of specific case through out hospitalization

* criteria of cases:

a. with specific physician c. by diagnosis

b. geographic proximity

Communication steps

CHANGING PEOPLE’S BEHAVIOR

UNFREEZING Knowledge: Individual is introduced to change and begin to comprehend

REFREEZING Confirmation : looks for confirmation that the

choice was right

CONFLICT RESOLUTION:

1. Avoidance – reduce tension

2. Accommodation - self sacrifice

3. Collaboration – mutual attention

4. Compromise - both seek acceptable solution

5. Withdrawing – one party is removed

6. Forcing – immediate end but cause unresolved

“MANAGEMENT BY OIDO”

By ear, based on practical

“MANAGEMENT BY LUSOT”

Avoid much work, extrovert, &

informal

“MANAGEMENT BY LIBRO”By the book

established rules, systematic &

analytical

“MANAGEMENT BY KAYOD”Hard working,

dedication, INTROVERT &

formal

“MANAGEMENT BY UGNAYAN”

Situational, integritive, most

ideal pinoy manager

Content oriented

Process oriented

Total Quality Management (TQM)

- Based on theory Y & Z- Centered on QUALITY- Based on all member

participation/involvement- Aim is long term success

& improvement- Achieve customer

satisfaction

Hypothesis vs Assumption

Hypothesis AssumptionDefinition - Theoretical

explanations of a phenomenon

- Intellectual proposition formulated to explain observed facts

Assertions related to the problem usually drawn from the theoretical framework

Characteristics/ Criteria

Stated in declarative form

Universally accepted truths which do not need any testing

Variables are identifiedIdentifies the population

Theories applicable to a particular field of study

Reflects the problem statement

Refers to findings of previous related researches

Empirically testable

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com

CLASSIFICATION OF PERSONS

CRIMINALLY LIABLE:Principal:

a. By direct participation- doer of the act

b. By inducement-directly force or induce others

c. By cooperation- indispensable

ACCOMPLICE: a person who cooperates “ accessory before the

fact”- absent at the time crime is committed.

ACCESSORY:“accessory after the fact”

a. Profits

b. Conceals/ destroys evidence

c. Assists in the escape of the principal

Administering Ear Medications

Place the client in a side-lying position with the affected ear facing up.

Straighten the ear canal by pulling the pinna down and back for children less than 3 years of age or upward and outward in adults and older children.

Instill the drops into the ear canal by holding the dropper at least 1⁄2 inch above the ear canal

Ask the client to maintain the position for 2–3 minutes.

Catheterization

Length of catheter insertion

male: 6-9 inchesfemale: 3-4 inches

Enema Prepare the solution, assure temperature within range of 99° to

102°F by using a thermometer or placing a few drops on your wrist.

Wash hands and don gloves. Assist patient to left side-lying position, with right knee bent. Hang bag of enema solution 12 to 18 inches above anus. Lubricate 4 to 5 inches of catheter tip. Separate buttocks, insert catheter tip into anal opening, slowly

advance catheter approximately 4 inches. Slowly infuse solution via gravity flow If client complains of increased pain or cramping, or if fluid is

not being retained, stop procedure, wait a few minutes, then restart

Clamp tubing when fluid finishes infusing; remove catheter tip. Assist client to bedpan, commode, or toilet;

Enema If “enema till clear” is ordered, no more than 3 L

fluid should be administered in any one series of enemas. Repeated enemas produce irritation of bowel mucosa and perianal area, as well as electrolyte loss and exhaustion. If returns are not clear, consult physician for further instructions.

TRANSMISSION BASED PRECAUTION

Airborne precaution

• mask N95; less than 5 micron or smaller (TB)

Droplet Precaution

• mask; larger than 5 micron particles

Contact Precaution

• if there is direct and indirect

Anaphylactic Reaction

acute systemic hypersensitivity reaction that occurs within seconds or minutes after exposure to certain foreign substances

Anaphylactic Reaction• Ask the patient about

PREVIOUS ALLERGIES • Avoid giving PARENTERAL

MEDICATIONS unless absolutely necessary

• Perform a SKIN TEST (negative skin test results do not always indicate safety)

• Outpatient, keep at least 30 minutes after injection

• Wear medical identification tags or bracelets

MANAGEMENT• airway and

ventilation is essential

• aqueous epinephrine administered

Anaphylactic ReactionLIMITING EXPOSURE TO STINGING INSECTS• Avoid places where

stinging insects congregate

• Wear adequate covering

• Avoid perfumes, scented soaps, and bright colors

• Keep car windows closed

Anaphylactic Reaction

If stung: • Inject self immediately

with EPINEPHRINE • Remove the stinger with

one quick scrape of the fingernail. (Do not squeeze)

• Clean with soapy water, and apply ice.