Chapter 17: Loss, Grief, & Dying

What Are the Main Points in This Chapter?

Grief is the physical, psychological, and spiritual response to loss.
People do not move neatly from one stage of grief or dying to the next; there is
constant movement and overlap between and among them.
The grieving process is affected by the significance and circumstance of the loss, the
timeliness of the death, the amount of support for the bereaved, spiritual beliefs,
cultural values, the person's developmental stage, and conflicts existing at the time of
death.
Patients experience loss of independence, body image, self-esteem, and so on, when
they are ill and/or hospitalized. Recognizing these as losses, you can assist the patient
with the grieving process, thus promoting physical, emotional, and spiritual healing.
The Uniform Determination of Death Act states that death has occurred when "An
individual . . . has sustained either (1) irreversible cessation of circulatory and
respiratory functions, or (2) irreversible cessation of all functions of the entire brain,
including the brain stem."
Palliative care means providing comfort care and symptom relief but without further
efforts to stop the disease process or prevent death.
Hospice care is a movement and an approach to allow terminally ill persons to face
death with dignity and to be surrounded by the comfort of their home and family.
Healthcare providers are responsible for educating staff and patients about advance
directives.
A do not attempt resuscitation (DNAR) order is a specific order to not do
cardiopulmonary resuscitation.

Nurses should be aware of what is involved with assisted suicide and euthanasia. You
should think ahead about what your response might be if a patient wants to discuss
these topics. You may find the American Nurses Association (ANA) position statement
on assisted suicide and euthanasia helpful.
An autopsy is a medical examination of the body to determine the cause of death.
When a patient is dying or has experienced a loss, you should perform a thorough,
holistic assessment.
Most grief is normal, not dysfunctional; you should not diagnose Complicated
Grieving for every person who is grieving a loss.
You can facilitate grief work by validating feelings ("It's normal to feel that way") and
providing an opportunity and encouragement to talk about the lost person or object.
At the moment of death, do not interrupt or intrude upon the family; give them as
much time as they need to say good-bye to their loved one. Express your sympathy.
Active dying usually occurs over a 10- to 14-day period, although it can take as little
as 24 hours. During the final 4 to 48 hours, failure of body systems results in death.
When the patient is very near death, focus on relieving physical symptoms and
emotional distress. If the patient can communicate, ask about immediate concerns,
such as, "Who do you want in the room right now?"
Care of the body includes making it presentable for the family, carefully placing
identification tags, and arranging to have the body sent to the morgue.
The death certificate must be signed by the person who legally pronounced the
death (usually a physician).
It is normal for the nurse to feel grief when a patient dies.

Chapter 46: Holistic Healing (Refer to DavisPlus)

What Are the Main Points in This Chapter?
Holistic healthcare is founded on the belief that each person is a whole in constant
interaction with the environment. There is no separation between body, mind, or
spirit. The conventional medical approach is often referred to as allopathy, a term
used to denote medical practice that is focused on counteracting symptoms.
A complementary modality is one that is used in conjunction with traditional Western
medical care.
An alternative modality is one that is used instead of traditional Western medical
care.
Integrative healthcare refers to coordinated care that encompasses all treatments and
health practices used by a patient.
In holistic care, treatment outcomes are enhanced if both the practitioner and the
patient believe that the treatment will be effective.
Holism contends that all healing is self-healing.
Absence of spirituality creates a sense of disconnection from one's true source, a loss
of meaning to one's life, and a state of disease.
Women, people with higher education and income levels, and people who have been
hospitalized in the past year are more likely to use complementary and alternative
modalities (CAMs).
Alternative medical systems predate the traditional Western health system. They
include ayurveda, traditional Chinese medicine, acupuncture, homeopathy, and
naturopathy.
Mindbody interventions target the mood and reaction to stress to enhance health.
They include prayer, meditation, imagery, humor, music therapy, yoga, hypnosis, and

biofeedback.
They include dietary therapies, herbs and aromatherapy, and nonherbal dietary
supplements (e.g., probiotics, vitamins, and hormones). These therapies are readily
available and are often practiced in conjunction with traditional healthcare and other
CAMs.
Manipulative and body-based therapies focus on moving the body to improve health.
They include chiropractic, massage, and osteopathy.
Energy therapies manipulate the energy fields that surround the body. They are
among the most widely used forms of CAM. They include therapeutic touch, t'ai chi
and Qigong, Reiki, and magnet therapy. Holistic nursing practice is a theory-based,
relationship-centered, potent solution to a number of problems facing contemporary
nursing and healthcare.
You should facilitate communication about CAM between patients and their
healthcare providers.
As a holistic healer, you should use self-care practices to promote your own health
and wholeness.
You should assess patients' use of CAM and integrate CAM into your nursing care as
appropriate. Encourage practices that are effective but not harmful; "allow" practices
that are safe, but not known to be effective; and discourage practices that are unsafe.

Chapter 16: Spirituality

What Are the Main Points in This Chapter?
Spirituality is a powerful force in the lives of many patientsa force that has the
potential to affect their health and perception of well-being. Nursing has historical
roots in religion and spirituality.
Nurses work with other disciplines to provide spiritual care.
Religion is a sort of "map" that outlines and integrates essential beliefs, values, and
codes of conduct into a manner of living.
Spirituality, like a journey, takes place over time and involves the accumulation of life
experiences and understandings. It is the attempt to find meaning, value, and
purpose in life. Spiritual development involves struggles with faith, hope, and love.
Religion and spirituality affect health and well-being; in turn, health and well-being
affect a person's religion and spirituality.
Research suggests that religion and spirituality are important to healthcare outcomes;
however, it does not explain how or why this is so.
The more you know about similarities in and differences among the world's major
religions, the more you will be able to offer comprehensive, compassionate care to
patients.
People, even within the same religion, vary greatly in the degree to which they follow
the rituals and practices of their religion.
Self-knowledge helps you to avoid abuses of spiritual care (e.g., imposing your
religion on a patient).
Barriers to spiritual care include (1) lack of awareness of spirituality in general and of
your own spiritual belief system, (2) differences in spirituality between you (the nurse)

and the patient, (3) fear that your spiritual knowledge is insufficient, and (4) fear of
where spiritual discussions might lead.
Various ready-made tools are available for performing an in-depth spiritual
assessment.
NANDA-I labels describing spiritual needs are Moral Distress, Spiritual Distress, Risk
for Spiritual Distress, Readiness for Enhanced Spiritual Well-Being, Impaired
Religiosity, Risk for Impaired Religiosity, and Readiness for Enhanced Religiosity.
Spiritual Pain is a non-NANDA-I diagnosis that may be useful.
Nursing interventions related to spiritual care require you to be self-aware, fully
present, supportive, empathetic, and nonjudgmental and to have a wish to benefit
the patient.
When a patient asks you to pray, you must determine whether he wishes you to pray
for or with him, and you should ask what he would like you to especially address in
the prayer.
A miracle does not necessarily involve the notion of a cure; miracles are more often
events that proceed according to natural law but still have a powerful impact on the
person's expectations.
Nurses who are open to diversity, who exhibit multiple understandings of religion,
and who fashion for themselves different means of spiritual expression are
comfortable in the spiritual care domain.

Chapter 27: Health Promotion

What Are the Main Points in This Chapter?
Health promotion refers to helping clients develop an optimal state of health.
Intention is the difference between health promotion and health protection (illness
prevention).
There are three levels of activities for health protection: primary, secondary, and
tertiary prevention. Primary interventions are designed to prevent or slow the onset
of disease. Secondary interventions are designed to detect illnesses in early stages.
Tertiary interventions focus on stopping the disease from progressing and on
rehabilitation.
The Healthy People 2020 initiative is designed to achieve four overarching goals:
Attain high quality, longer lives free of preventable disease, disability, injury, and
premature death. Achieve health equity, eliminate disparities, and improve the health
of all groups.
Create social and physical environments that promote good health for all.
Promote healthy development and healthy behaviors across every stage of life.
Pender's Health Promotion Model (HPM) identifies three groups of variables that
affect health behavior: (1) individual characteristics and experiences; (2) behaviorspecific cognitions and affect; and (3) behavioral outcome.
A wellness wheel identifies six dimensions of health: emotional, intellectual, physical,
spiritual, social/family, and occupational.
The transtheoretical model of change identifies four stages of change: contemplation,
determination, action, and maintenance.
Health promotion activities for all age groups include nutrition, exercise, safety
concerns, changing unhealthy lifestyles, immunizations, and screenings. Health

promotion activities may be conducted in acute care facilities, the workplace, local
communities, or schools.
A health promotion assessment involves obtaining a health history, physical
examination, fitness assessment, lifestyle and risk appraisal, life stress review,
assessment of healthcare beliefs, nutritional assessment, and screening activities.
Health screening activities are designed to detect disease at an early stage so that
treatment can begin before there is an opportunity for disease to spread or reduce
the quality of life.
Health screening activities vary based on developmental stage and identified risk
factors.
Nurses promote health through role models, counseling, health education, and
providing and facilitating support.

Chapter 8: Theory, Research, & Evidence-Based Practice

What Are the Main Points of This Chapter?
According to Florence Nightingale, nursing theories describe "what is" and "what is
not" nursing.
The four basic components of a nursing theory are person, nurse, environment, and
health.
A theory is developed by recognizing a need in nursing or by having an idea, using
research to determine whether the idea is effective, and then using the research
results to define a theory.
Theories help nurses (a) find meaning in their experiences of nursing; (b) organize
their thinking around pertinent ideas; and (c) develop new, evidence-based ideas and
insights into the work they do. Nurses use theories as an evidence-based framework
for their nursing practice.
Three leaders in nursing caring theories are Dr. Jean Watson, Dr. Patricia Benner, and
Dr. Madeleine Leininger.
Nursing research is a systematic, objective process of analyzing phenomena of
importance in nursing.
Quantitative research may be generalized to populations similar to the one studied. It
has tight controls and large numbers of participants, and the data are statistically
analyzed.
Qualitative research tells the lived experience of a person or group of people. It is
analyzed by examining the words and actions of a small number of participants.
The research process is a systematic way of organizing, preparing, and presenting
research.
Research participants (people in a research study) are protected from harm by specific

laws and regulations.

Research reports are critiqued by reading analytically and using preselected criteria.
Nursing research evolved slowly. The advanced education currently available to
nurses is propelling research forward.
Evidence-based nursing requires evaluating research to find the best evidence and
then applying it in practice.
The process of finding best evidence consists of identifying a clinical nursing problem,
formulating a searchable question, searching the literature, evaluating the quality of
the research, and integrating the research into practice.
The parts of a PICO question are Patient problem, Intervention, Comparison
intervention, and Outcome.

Chapter 18: Documenting & Reporting

What Are the Main Points in This Chapter?
The client record is a collection of documents that form a legal record of the client's
healthcare experience.
The client record is used by health professionals to communicate about the client's
care, to legally document the care delivered to the client and the client's responses to
that delivered care, to document care for reimbursement, to educate students, to
determine whether care is adequate, as a data source for health research, and as the
basis for determining the cost of care.
In source-oriented records, members of each discipline record findings in a separately
labeled section.
In problem-oriented records, members of each discipline chart on shared notes, and
the record is organized around a problem list.
In electronic health records (EHRs), members of each discipline all chart inside the
same EHR. The EHR can be organized as source oriented, problem oriented, or a
combination of the two.
The EHR can be accessed by many members of the healthcare team at the same time.
In narrative charting, the writer tells the story of what has occurred in a chronological
format.
SOAP(IER) is an acronym for Subjective data, Objective data, Assessment, Plan (and
Intervention, Evaluation, and Revision). This format may be used to address a single
problem or to document summative notes on a patient.
In Focus Charting, data are entered in a Data/Action/Response (DAR) format.
Charting by Exception (CBE) utilizes preprinted or electronic flow sheets to document
most aspects of care. CBE assumes that unless a separate entry is madean

exceptionall standards have been met and the patient has responded as expected.
Paper and electronic flow sheets and graphic records are used to record recurring
assessments, such as vital signs, intake and output, weight, hygiene, and ADLs.
Paper progress notes are used to document the patient's responses to care. They
may be in the form of narrative, SOAP(IER), PIE, or Focus-style notes.
A discharge summary should be completed when the patient is discharged from the
organization. A transfer form should be completed when the patient is transferred
within the organization.
An occurrence report, or incident report, is a formal record of an unusual occurrence
or accident that is not part of the patient's chart.
The most commonly used paper and electronic home health documentation form is
OASIS, a federally required form that includes history, assessment, demographics,
and information about the client's and caregiver's abilities.
Federal law requires that a resident in long-term care must be evaluated using the
Minimum Data Set for Resident Assessment and Care Screening (MDS) within 4 days
of admission. The MDS must be updated every 3 months and with any significant
change in client condition.
The handoff report is designed to alert the next nurse about the client's status,
changes in the client condition, planned activities, scheduled tests or procedures, or
concerns that require follow-up.
Nurses should not take verbal and telephone orders unless the ordering physician,
physician assistant, or nurse practitioner is in a situation where the order cannot be
written or entered or the patient is in a life-threatening situation.
Telephone orders offer more room for error because of unfamiliar terminology and
differences in background noise.

Charting should be accurate and nonjudgmental.

You should document as soon as possible after you make an observation or provide
care.
You should never share your electronic username or password with someone else.
Document any significant events or changes in condition, teaching performed, the
use of restraints, and patient refusal of treatment or medications.
You are responsible for documenting the care you provided. Never chart the actions
of others as though you had performed them.
If you believe a provider's order is inappropriate or unsafe, you are legally and
ethically required to question the order.

Chapter 26: Teaching & Learning

What Are the Main Points in This Chapter?
Teaching is an essential component of professional nursing.
Nurses do formal and informal teaching for individuals and groups.
To be effective, teaching requires cooperation between the learner and the teacher.
Learning is a change in behavior, knowledge, skills, or attitudes that occurs as a result
of exposure to environmental stimuli.
Bloom and Krathwohl (1956) identified three domains of learning: cognitive,
psychomotor, and affective.
Teaching includes motivating the learner.
Teaching is interactive and requires communication.
Readiness means that the learner is both motivated and able to learn at a specific
time.
Other factors that affect learning include emotions, timing, active involvement,
feedback, repetition, environment, amount and complexity of the content,
communication, developmental stage, culture, and literacy.
Common barriers to teaching in the hospital setting include failure to see teaching as
a priority and lack of time, preparation, space, privacy, and third-party reimbursement
for teaching.
Barriers to learning include illness, physical discomfort, anxiety, low health literacy,
environmental distraction, overwhelming amount of behavioral change needed, lack
of positive reinforcement, and feelings of discouragement.
The teaching process is similar to the nursing process.
The nursing diagnosis Deficient Knowledge may be the primary problem or the
etiology of other problems; this diagnosis is often used incorrectly.

A teaching plan is similar to a nursing care plan, except that (1) interventions are
actually teaching strategies and (2) the plan includes the content of the teaching, the
sequencing of the content, and the materials to be used.
Demonstration and return demonstration are the most effective strategies for
teaching psychomotor skills.
A certain amount of forgetting is normal. You can aid learner retention by using
strategies that require learner participation and by providing printed materials to use
at a later time.
It is important to document specifically what teaching you did as well as your
evaluation of the learning that occurred.