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Medical Surgical Nursing Notes latest 2022Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter 1: Nursing Practice Today
• Nursing involves the (1) protection, promotion, and optimization of health and
ailities!
(") prevention of illness and in#ury! ($) alleviation of suffering through the
diagnosis and
treatment of human response! and (%) advocacy in the care of individuals,
families,
communities, and populations&
• Nurses offer s'illed care to those recuperating from illness or in#ury,
advocate for
patients( rights, teach patients so that they can ma'e informed decisions,
support patients
at critical times, and help them navigate the increasingly comple) health care
system&
• Certification in nursing specialties (e&g&, amulatory care, critical care,
gerontologic,
pediatric, psychiatric and mental health, and community health nursing) is
offered
through a variety of nursing organizations&
• *ntry+level nurses ,ith an associate or accalaureate degree in nursing are
prepared to
function as generalists& -ith additional preparation, nurses can assume roles
such as
clinical nurse specialist and nurse practitioner&
• The e)act roles (i&e&, independent, dependent, collaorative) of the nurse are
often
determined y state and agency policies& .n most cases, the nurse(s role is one
of
/interdependence and co+participation0 ,ith the patient and other health team
memers&
• Delegation of nursing interventions to licensed practical nurses1licensed
vocational
nurses (2PNs123Ns) and unlicensed assistive personnel (45P) is an important
function
of the professional nurse&
• Healthy People 2010 is a road+ased program that involves government, private,
pulic,
and nonprofit organizations in preventing disease and promoting health&
• !idence-based "ractice (*6P) is the conscientious use of the est evidence
(e&g&,
findings from research) in comination ,ith clinician e)pertise and patient
preferences
and values in clinical decision+ma'ing&
• Nursing informatics is a specialty that integrates nursing science, computer
science, and
Copyright 7 "889 y :osy, .nc&, an affiliate of *lsevier .nc&
Key Points
information science in identifying, collecting, processing, and managing data
and
information to support nursing practice, administration, education, and
research&
• The five elements of the nursing "rocess are assessment, diagnosis, planning,
implementation, and evaluation& ;nce egun, the nursing process is not only
continuous
ut it is also cyclic in nature&
• Standardi#ed nursing terminologies can promote continuity of patient care and
provide
data that can support the crediility of the profession&
, Medical Surgical Nursing Notes latest 2022
• Nursing diagnoses descrie health states that nurses can legally diagnose and
treat& 5
three+part nursing diagnosis statement includes the prolem, etiology, and signs
and
symptoms&
• Collaborati!e "roblems are potential or actual complications of disease or
treatment that
nurses treat ,ith other health care providers, most fre<uently physicians&
• The Nursing $utcomes Classification %N$C& is a research+ased,
standardized language for nursing outcomes& .t is used to evaluate the
effects of nursinginterventions&
N;C is a list of measures that descries patient outcomes influenced y nursing
interventions&
• The Nursing 'nter!entions Classification %N'C& includes independent and
collaorative
interventions that nurses carry out, or direct others to carry out, on ehalf of
patients&
• 5 nursing inter!ention is any treatment ased on clinical #udgment and
'no,ledge that
a nurse performs to enhance "atient outcomes(
• The setting of specific outcomes ,ith outcome indicators is necessary for
systematic
measurement of the patient(s progress&
• ;utcomes may e developed y ,riting specific outcome statements or choosing
outcomes from the Nursing ;utcomes Classification (N;C)&
• The Nursing .nterventions Classification (N.C) includes treatments (oth
physiologic and
psychosocial) that nurses perform in all settings and specialties&
• N.C and N;C provide a common language for communication among nurses and
facilitate computer collection of standardized nursing data&
Copyright 7 "889 y :osy, .nc&, an affiliate of *lsevier .nc&
1+"
Key Points
• =uring the e!aluation phase, the nurse determines ,hether the patient outcomes
and
nursing interventions ,ere realistic, measurale, and achievale&
• 5ssessment, diagnosis, outcomes, interventions, and evaluation of the
patient(s response
to care are a critical part of the patient(s record&
• -hen nursing terminologies are used in information systems for documentation
of
nursing practice, nurses can trac' and report on the enefits of nursing care&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter ": >ealth =isparities
• Determinants of health are those factors that influence the health of
individuals&
• )ealth dis"arities refer to differences in measures in the health status among
groups of
people in a community, a state, or the entire nation&
• ?acial, ethnic, and cultural differences e)ist in the health screening
ehaviors, treatments
provided, and access to health care providers&
• @actors such as stereotyping and pre#udice can affect health care see'ing
ehavior in
minority populations&
• =iscrimination and ias occur ,hen negative treatment occurs ased on race,
ethnicity,
gender, aging, and se)ual orientation&
• 4se of standardized evidence+ased guidelines can reduce health disparities in
diagnosis
, Medical Surgical Nursing Notes latest 2022
and treatment&
• .nterpersonal s'ills such as active listening, relationship uilding, and
effective
communication are asic to the delivery of high <uality and e<uitale health care&
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Copyright 7 "889 y :osy, .nc&, an affiliate of *lsevier .nc&
1+$
Key Points
Chapter %: >ealth >istory and Physical *)amination
• The nurse and physician oth otain a patient history and perform a physical
e)amination, ut they use different formats and analyze the data differently&
• The nursing assessment includes oth su#ective and o#ective data(
o Sub*ecti!e data are ,hat the patient tells the nurse aout himself or herself&
o $b*ecti!e data are otained using inspection, palpation, percussion, and
auscultation during the physical e)amination&
• 5 comprehensive database includes information aout the patient(s health
status, health
maintenance ehaviors, individual coping patterns, support systems, current
development
tas's, and any ris' factors or lifestyle changes&
• -hen a patient is unale to provide data (e&g&, the person is aphasic or
unconscious), the
person assuming responsiility for the patient(s ,elfare can e as'ed aout the
patient&
• Patients should e informed that federal legislation affects the e)change,
privacy, and
security of an individual(s health information&
• 5ssessment data should e otained and organized systematically so that they can
e
analyzed to ma'e #udgments aout the patient(s health status and health prolems&
• ;ne frame,or' for otaining data uses the functional health "atterns developed
y
Aordon&
• Bu#ective data include past health history, medications, surgery, or other
treatments&
• The t,o types of physical e)aminations are as follo,s:
o Screening
o +ocused (prolem+centered)
Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition
Key Points
Chapter C: Patient and @amily Teaching
Copyright 7 "889 y :osy, .nc&, an affiliate of *lsevier .nc&
1+%
Key Points
• Bpecific goals for patient education include health promotion, prevention of
disease,
management of illness, and appropriate selection and use of treatment options&
• 5 teaching "lan includes assessment of the patient(s aility, need, and
readiness to learn as
,ell as identification of prolems that can e resolved ,ith teaching&
• Learning occurs ,hen there is an internal mental change characterized y
rearrangement of
neural path,ays&
• ,eaching is a process of delierately arranging e)ternal conditions to promote
the internal
transformation that results in a change in ehavior&
• -hen teaching adults, it is important to identify ,hat is valued y the person
, Medical Surgical Nursing Notes latest 2022
to enhance
motivation&
• -einforcement is a strong motivational factor for maintaining ehavior&
Positive
reinforcement involves re,arding a desired ehavior ,ith a positive stimulus to
increase its
occurrence&
• ?e<uired s'ills for the nurse as a teacher include 'no,ledge of the su#ect
matter,
communication s'ills, and empathy&
• 6ecause of shortened hospital stays and clinic visits, the nurse and the
patient need to set
priorities of the patient(s learning needs so that teaching can occur during any
contact ,ith the
patient or family&
• *ducation of family memers is important ecause family memers can promote the
patient(s
self+care and prevent complications&
• The teaching "rocess involves development of a plan that includes assessment,
diagnosis,
setting patient outcomes or o#ectives, intervention, and evaluation&
• The patient(s e)periences, rate of learning, and aility to retain information
are affected y age&
• Pain, fatigue, and certain medications influence the patient(s aility to
learn&
• 5n)iety and depression can negatively affect the patient(s motivation and
readiness to learn&
• 5n individual(s elief in his or her capaility to produce and regulate events
in life affects
motivation, thought patterns, ehavior, and emotions&
• )ealth literac. is defined as the degree to ,hich individuals have the
capacity to otain,
process, and understand asic health information and services needed to ma'e
appropriate
health decisions&
Copyright 7 "889 y :osy, .nc&, an affiliate of *lsevier .nc&
1+C
Key Points
• *ach person has a distinct style of learning& The three learning styles are as
follo,s:
(1) 3isual (reading)
(") 5uditory (listening)
($) Physical (doing things)
• Learning ob*ecti!es are ,ritten statements that define e)actly ho, patients
demonstrate their
mastery of the content&
• 2earning o#ectives contain the follo,ing four elements:
(1) -ho ,ill perform the activity or ac<uire the desired ehavior
(") The actual ehavior that the learner ,ill e)hiit to demonstrate mastery of
the o#ective
($) The conditions under ,hich the ehavior is to e demonstrated
(%) The specific criteria that ,ill e used to measure the patient(s success
• Belecting a particular strategy is determined y at least three factors:
(1) Patient characteristics (e&g&, age, educational ac'ground, nature of
illness, culture)
(") Bu#ect matter
($) 5vailale resources
• 6ecause of e)tent of health illiteracy, it is no, recommended that all patient
education
materials e ,ritten at the Cth+ to Dth+grade reading level&
• *valuation strategies for teaching include oserving the patient directly,
oservation of veral
and nonveral cues, discussion ,ith the patient or family memer, using a
standardized
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