Lewis 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 abilities;
(2) prevention of illness and injury; (3) alleviation of suffering through the diagnosis and
treatment of human response; and (4) advocacy in the care of individuals, families,
communities, and populations.

Nurses offer skilled care to those recuperating from illness or injury, advocate for
patients rights, teach patients so that they can make informed decisions, support patients
at critical times, and help them navigate the increasingly complex health care system.

Certification in nursing specialties (e.g., ambulatory care, critical care, gerontologic,
pediatric, psychiatric and mental health, and community health nursing) is offered
through a variety of nursing organizations.

Entry-level nurses with an associate or baccalaureate degree in nursing are prepared to
function as generalists. With additional preparation, nurses can assume roles such as
clinical nurse specialist and nurse practitioner.

The exact roles (i.e., independent, dependent, collaborative) of the nurse are often
determined by state and agency policies. In most cases, the nurses role is one of
interdependence and co-participation with the patient and other health team members.

Delegation of nursing interventions to licensed practical nurses/licensed vocational
nurses (LPNs/LVNs) and unlicensed assistive personnel (UAP) is an important function
of the professional nurse.

Healthy People 2010 is a broad-based program that involves government, private, public,
and nonprofit organizations in preventing disease and promoting health.

Evidence-based practice (EBP) is the conscientious use of the best evidence (e.g.,
findings from research) in combination with clinician expertise and patient preferences
and values in clinical decision-making.

Nursing informatics is a specialty that integrates nursing science, computer science, and
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 process are assessment, diagnosis, planning,
implementation, and evaluation. Once begun, the nursing process is not only continuous
but it is also cyclic in nature.

Standardized nursing terminologies can promote continuity of patient care and provide
data that can support the credibility of the profession.

Nursing diagnoses describe health states that nurses can legally diagnose and treat. A
three-part nursing diagnosis statement includes the problem, etiology, and signs and
symptoms.

Collaborative problems are potential or actual complications of disease or treatment that
nurses treat with other health care providers, most frequently physicians.

The Nursing Outcomes Classification (NOC) is a research-based, standardized
language for nursing outcomes. It is used to evaluate the effects of nursing interventions.
NOC is a list of measures that describes patient outcomes influenced by nursing
interventions.

The Nursing Interventions Classification (NIC) includes independent and collaborative
interventions that nurses carry out, or direct others to carry out, on behalf of patients.

A nursing intervention is any treatment based on clinical judgment and knowledge that
a nurse performs to enhance patient outcomes.

The setting of specific outcomes with outcome indicators is necessary for systematic
measurement of the patients progress.

Outcomes may be developed by writing specific outcome statements or choosing
outcomes from the Nursing Outcomes Classification (NOC).

The Nursing Interventions Classification (NIC) includes treatments (both physiologic and
psychosocial) that nurses perform in all settings and specialties.

NIC and NOC provide a common language for communication among nurses and
facilitate computer collection of standardized nursing data.

During the evaluation phase, the nurse determines whether the patient outcomes and
nursing interventions were realistic, measurable, and achievable.

Assessment, diagnosis, outcomes, interventions, and evaluation of the patients response
to care are a critical part of the patients record.

When nursing terminologies are used in information systems for documentation of
nursing practice, nurses can track and report on the benefits of nursing care.

Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition

Key Points

Chapter 2: Health Disparities

Determinants of health are those factors that influence the health of individuals.

Health disparities refer to differences in measures in the health status among groups of
people in a community, a state, or the entire nation.

Racial, ethnic, and cultural differences exist in the health screening behaviors, treatments
provided, and access to health care providers.

Factors such as stereotyping and prejudice can affect health care seeking behavior in
minority populations.

Discrimination and bias occur when negative treatment occurs based on race, ethnicity,
gender, aging, and sexual orientation.

Use of standardized evidence-based guidelines can reduce health disparities in diagnosis
and treatment.

Interpersonal skills such as active listening, relationship building, and effective
communication are basic to the delivery of high quality and equitable health care.




Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition

Key Points

Chapter 4: Health History and Physical Examination

The nurse and physician both obtain a patient history and perform a physical
examination, but they use different formats and analyze the data differently.

The nursing assessment includes both subjective and objective data.
o Subjective data are what the patient tells the nurse about himself or herself.
o Objective data are obtained using inspection, palpation, percussion, and
auscultation during the physical examination.

A comprehensive database includes information about the patients health status, health
maintenance behaviors, individual coping patterns, support systems, current development
tasks, and any risk factors or lifestyle changes.

When a patient is unable to provide data (e.g., the person is aphasic or unconscious), the
person assuming responsibility for the patients welfare can be asked about the patient.

Patients should be informed that federal legislation affects the exchange, privacy, and
security of an individuals health information.

Assessment data should be obtained and organized systematically so that they can be
analyzed to make judgments about the patients health status and health problems.

One framework for obtaining data uses the functional health patterns developed by
Gordon.

Subjective data include past health history, medications, surgery, or other treatments.

The two types of physical examinations are as follows:
o Screening
o Focused (problem-centered)



Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition

Key Points

Chapter 5: Patient and Family Teaching

Specific goals for patient education include health promotion, prevention of disease,
management of illness, and appropriate selection and use of treatment options.

A teaching plan includes assessment of the patients ability, need, and readiness to learn as
well as identification of problems that can be resolved with teaching.

Learning occurs when there is an internal mental change characterized by rearrangement of
neural pathways.

Teaching is a process of deliberately arranging external conditions to promote the internal
transformation that results in a change in behavior.

When teaching adults, it is important to identify what is valued by the person to enhance
motivation.

Reinforcement is a strong motivational factor for maintaining behavior. Positive
reinforcement involves rewarding a desired behavior with a positive stimulus to increase its
occurrence.

Required skills for the nurse as a teacher include knowledge of the subject matter,
communication skills, and empathy.

Because of shortened hospital stays and clinic visits, the nurse and the patient need to set
priorities of the patients learning needs so that teaching can occur during any contact with
the patient or family.

Education of family members is important because family members can promote the patients
self-care and prevent complications.

The teaching process involves development of a plan that includes assessment, diagnosis,
setting patient outcomes or objectives, intervention, and evaluation.

The patients experiences, rate of learning, and ability to retain information are affected by
age.

Pain, fatigue, and certain medications influence the patients ability to learn.

Anxiety and depression can negatively affect the patients motivation and readiness to learn.

An individuals belief in his or her capability to produce and regulate events in life affects
motivation, thought patterns, behavior, and emotions.

Health literacy is defined as the degree to which individuals have the capacity to obtain,
process, and understand basic health information and services needed to make appropriate
health decisions.

Each person has a distinct style of learning. The three learning styles are as follows:
(1) Visual (reading)
(2) Auditory (listening)
(3) Physical (doing things)

Learning objectives are written statements that define exactly how patients demonstrate their
mastery of the content.

Learning objectives contain the following four elements:
(1) Who will perform the activity or acquire the desired behavior
(2) The actual behavior that the learner will exhibit to demonstrate mastery of the objective
(3) The conditions under which the behavior is to be demonstrated
(4) The specific criteria that will be used to measure the patients success

Selecting a particular strategy is determined by at least three factors:
(1) Patient characteristics (e.g., age, educational background, nature of illness, culture)
(2) Subject matter
(3) Available resources

Because of extent of health illiteracy, it is now recommended that all patient education
materials be written at the 5th- to 6th-grade reading level.

Evaluation strategies for teaching include observing the patient directly, observation of verbal
and nonverbal cues, discussion with the patient or family member, using a standardized
measurement tool, and the patients self-evaluation of progress.



Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition

Key Points

Chapter 6: Older Adults

Ageism (negative attitude based on anothers age) can lead to discrimination and
disparities in health care provided to older adults.

Aging affects every body system. Biologic aging is a balance of positive (e.g., healthy
diet, exercise, coping, resources) and negative factors (e.g., smoking, obesity).

Biologic theories can be divided into stochastic and non-stochastic theories.

Older women are especially at risk for chronic health problems, including arthritis,
hypertension, strokes, and diabetes.

The frail elderly are individuals who are more vulnerable because of declining physical
health and limited resources.

Activities of daily living (ADL), including bathing, dressing, eating, toileting, and
transferring, are important for the nurse to assess in the older patient living with chronic
illness.

For the hospitalized older adult, there are special concerns related to high surgical risk,
acute confusional state, nosocomial infection, and premature discharge with an unstable
condition.

The intensity and complexity of caregiving place the caregiver at risk for high levels of
stress. This may lead to emotional problems, including depression, anger, and resentment.

Family members are perpetrators in approximately 9 out of 10 cases of domestic elder
abuse and neglect.

Continuing care retirement communities, congregate housing, and assisted living
facilities are housing options for the older adult.

Home health care services require physician recommendation and skilled nursing care for
Medicare reimbursement.

Ethical issues surrounding care of the older adult include using restraints, evaluating the
patients ability to make decisions, initiating resuscitation, treating infections, providing
nutrition and hydration, and advocating for an institutional ethics committee.

Reducing disability through geriatric rehabilitation is important to the quality of life of
the older adult.

Age-related changes in pharmacodynamics and pharmacokinetics of drugs, as well as
polypharmacy, put the older adult at risk for adverse drug reactions.

Depression is the most common mood disorder in older adults.

The comprehensive nursing geriatric assessment includes a thorough history using a
functional health pattern format, physical assessment, mood assessment, mental status
evaluation, ADL and instrumental ADL (IADL) evaluation, and social-environmental
assessment.



Lewis et al: Medical-Surgical Nursing: Assessment and Management of
Clinical Problems, 7
th
edition

Key Points

Chapter 7: Community-Based Nursing and Home Care

The focus of community-based nursing is the illness-oriented care of individuals and
families throughout the lifespan.

Many factors are changing the health care system, including socioeconomic status,
demographics, prevalence and type of illness, technology, and increased consumerism.

The goals of case management are to provide quality care along a continuum, decrease
fragmentation of care across many settings, enhance the patients qualify of life, and
contain cost.

The use of Diagnosis Related Groups (DRGs) has had a dramatic impact on health care.

Health care is constrained by third-party payer cost containment.

Community-based settings where nursing care is delivered include ambulatory care,
transitional care, and long-term care (skilled nursing, intermediate care, and residential
care facilities).

Community-oriented nursing involves the engagement of nursing in promoting and
protecting the health of populations.

Home health care may include health maintenance, education, illness prevention,
diagnosis and treatment of disease, palliative care, and rehabilitation.

Skilled nursing care may include observation, assessment, management evaluation,
teaching, training, administration of medications, wound care, tube feeding, catheter care,
and behavioral health interventions.

In home care situations, it is common for caregivers to become physically, emotionally,
and economically overwhelmed with responsibilities and demands of caregiving.

The home health care team may include the patient, family, nurses, physician, social
worker, physical therapist, occupational therapist, speech therapist, home health aide,
pharmacist, respiratory therapist, and dietitian.