NCLEX: Safe, Effective Care Environment

 Safe, Effective Care Environment: DEVELOPMENTAL DISABILITIES

Focus topic: Safe, Effective Care Environment

I. DOWN SYNDROME

A. Introduction: Down syndrome (trisomy 21) is a chromosomal abnormality involving an extra chromosome #21 and resulting in 47 chromosomes instead of the normal 46 chromosomes. As a consequence, the child usually has varying degrees of mental retardation, characteristic facial and physical features, and other congenital anomalies. Down syndrome is the most common chromosomal disorder, occurring in approximately 1 of 800 to 1000 live births. Perinatal risk factors include advanced maternal age, especially with the first pregnancy (although average maternal age is now 25-28 years for an infant with Down’s); paternal age is thought to be a related factor. Multiple causality is suspected.

B. Assessment:

1. Physical characteristics

a. Brachycephalic (small, round head) with oblique palpebral fissures (almond-shaped eyes) and Brushfield spots (speckling of iris)— depressed nasal bridge (“saddle nose”) and small, low-set ears.

b. Mouth

  • Small oral cavity with protruding tongue causes difficulty sucking and swallowing.
  • Delayed eruption/misalignment of teeth.

c. Hands

  • Clinodactyly—incurved little finger.
  • Simian crease—transverse palmar crease.

d. Muscles: hypotonic (“floppy baby”) with hyperextensible joints.

e. Skin: dry, cracked.

2. Genetic studies reveal an extra chromosome #21 (“trisomy 21”).

3. Intellectual characteristics

  • Mental retardation—varies from severely retarded to low-average intelligence.
  • Most fall within “trainable” range, or IQ of 36 to 51 (“moderate mental retardation”).

4. Congenital anomalies/diseases

  • 40% to 45% have congenital heart defects: mortality highest in clients with Down syndrome and cyanotic heart disease.
  • GI: tracheoesophageal fistula (TEF), Hirschsprung’s disease.
  • Thyroid dysfunction, especially hypothyroidism.
  • Visual defects: cataracts, strabismus.
  • Hearing loss.
  • Increased incidence of leukemia.

5. Growth and development

  • Slow growth, especially in height.
  • Delay in developmental milestones.

6. Sexual development

  • Delayed or incomplete.
  • Women—small number have had offspring (majority have had abnormality).
  • Men—infertile.

7. Aging

  • Premature aging, with shortened life expectancy.
  • Death—generally related to respiratory complications: repeated infections, pneumonia, lung disease.

Safe, Effective Care Environment

C. Analysis/nursing diagnosis:

  • Risk for aspiration related to hypotonia.
  • Altered nutrition, less than body requirements, related to hypotonia or congenital anomalies.
  • Altered growth and development related to Down syndrome.
  • Self-care deficit related to Down syndrome.
  • Altered family processes related to birth of an infant with a congenital defect.
  • Knowledge deficit related to Down syndrome.

D. Nursing care plan/implementation:

1. Goal: prevent physical complications.

a. Respiratory

  • Use bulb syringe to clear nose, mouth.
  • Vaporizer.
  • Frequent position changes.
  • Avoid contact with people with upper respiratory infections.

b. Aspiration

  • Small, more frequent feedings.
  • Burp well during/after infant feedings.
  • Allow sufficient time to eat.
  • Position after meals: head of bed elevated, right side—or on stomach, with head to side.

c. Observe for signs and symptoms of: heart disease, constipation/GI obstruction, leukemia, thyroid dysfunction.

2. Goal: meet nutritional needs.

  • Suction (before meals) to clear airway.
  • Adapt feeding techniques to meet special needs of infant/child (e.g., use long, straight handled spoon).
  • Monitor height and weight.
  • As child grows, monitor caloric intake (tends toward obesity with advancing age).
  • Offer foods high in bulk to prevent constipation related to hypotonia.

3. Goal: promote optimal growth and development.

  • Encourage parents to enroll infant/toddler in early stimulation program and to follow through with suggested exercises at home.
  • Preschool/school-age: special education classes.
  • Screen frequently, using Denver II to monitor development.
  • Help parents focus on “normal” or positive aspects of infant/child.

4. Goal: health teaching.

  • Explain that tongue-thrust behavior is normal and that child should be re-fed.
  • Before adolescence—counsel parents and child about delay in sexual development, decreased libido, marriage and family relations.
  • In severe cases, assist parents to deal with issue of placement/institutionalization.

E. Evaluation/outcome criteria:

  • Physical complications are prevented.
  • Adequate nutrition is maintained.
  • Child attains optimal level of growth and development.

 

II. ATTENTION DEFICIT–HYPERACTIVITY DISORDER (ADHD); BEHAVIORAL DISORDER (DSM-IV)

A. Introduction: As defined by the American Psychiatric Association (APA), this diagnostic term includes a persistent pattern of inattention or hyperactivity-impulsivity. The exact cause and pathophysiology remain unknown. The major symptoms include a greatly shortened attention span and difficulty in integrating and synthesizing information. This disorder is three times more common in boys than girls, with onset before age 7; the diagnosis is based on the child’s history rather than on any specific diagnostic test.

B. Assessment:
1. The behaviors exhibited by children with ADHD are not unusual behaviors seen in children. The behavior of children with ADHD differs from the behavior of non-ADHD children in both quality and appropriateness:

  • Motor activity is excessive.
  • Developmentally “younger” than chronological age.

2. Inattention

  • Does not pay attention to detail.
  • Does not listen when spoken to.
  • Does not do what he or she is told to do.

3. Hyperactivity

  • Fidgets and squirms excessively.
  • Cannot sit quietly.
  • Has difficulty playing quietly.
  • Seems to be constantly in motion, moving or talking; always “on.”

4. Impulsiveness

  • Blurts out answers before question is completed.
  • Has difficulty awaiting turn. Interrupts others.

C. Analysis/nursing diagnosis:

  • Altered thought processes related to inattention and impulsiveness.
  • Impaired physical mobility related to hyperactivity.
  • Risk for injury related to impulsivity.
  • Self-esteem disturbance related to hyperactivity and impulsivity.
  • Knowledge deficit related to behavioral modification program, medications, and follow-up care.

D. Nursing care plan/implementation:

1. Goal: teach family and child about ADHD.

  • Provide complete explanation about disorder, probable course, treatment, and prognosis.
  • Answer questions directly, simply.
  • Encourage family to verbalize; offer support.

2. Goal: provide therapeutic environment using principles of behavior modification and/or psychotherapy.

  • Reduce extraneous or distracting stimuli.
  • Reduce stress by decreasing environmental expectations (home, school).
  • Provide firm, consistent limits.
  • Special education programs.
  • Special attention to safety needs.

3. Goal: reduce symptoms by means of prescribed medication.

a. Medications: Ritalin and Cylert—both are CNS stimulants but have a paradoxical calming effect on the child’s behavior. Tofranil and Norpramin—both are tricyclic
antidepressants that ↑ action of norepinephrine and serotonin in nerve cells, but also can have paradoxical calming effect on child’s behavior. Must monitor for development of tics and arrhythmias.

b. Health teaching (child and parents).

  • Need to take medication regularly, as ordered. Avoid taking medication late in the day because it may cause insomnia; monitor neurological and cardiac status. Assess for ↓ appetite → ↓ weight; avoid caffeine.
  • Need for long-term administration, with probable decreased need as child nears adolescence.

4. Goal: provide safe outlet for excess energy.

  • Alternate planned periods of outdoor play with schoolwork or quiet indoor play.
  • Channel energies toward safe, large-muscle activities: running track, swimming, bicycling, hiking.

E. Evaluation/outcome criteria:

  • Family and child verbalize understanding of “attention deficit disorders.”
  • Therapeutic environment enhances socially acceptable behavior.
  • Medication taken regularly, with behavioral improvements noted.
  • Excess energy directed appropriately.

Safe, Effective Care Environment: RELIGIOUS AND SPIRITUAL INFLUENCES ON HEALTH

Focus topic: Safe, Effective Care Environment

Religious and spiritual beliefs can have a major impact on health and illness. Each religion has its own rituals and traditions that must be observed, with the belief that if these are not followed, the outcomes may negatively affect the client’s well-being or their family.

I. DEFINITION OF TERMS

  • Religion—an organized belief system in God or supernatural, using prayer, meditation, or symbols
  • Spirituality—encompasses more than religious beliefs; includes values, meaning, and purpose in life; can provide inspiration and sustain a person or group during crisis
  • Values clarification—aligns values and beliefs so that they are consistent with goals

II. ASSESSMENT OF RELIGIOUS AND SPIRITUAL BELIEFS

  • Beliefs about birth and what follows death
  • Code of ethics about right and wrong
  • View of health, causes of illness, or what may be the cure for the problem
  • Dietary laws
  • Relationship of mind, body, and spirit
  • Importance of work and money as they relate to religion
  • Pain: purpose of, response to, treatment for
  • Importance of family
  • Meaning of life, individual sources of hope and strength
  • Religious practices that conflict with health practices and use of health services

III. ANALYSIS/NURSING DIAGNOSIS

  • Risk for spiritual distress related to prolonged pain; health-care choices that are in conflict with religious practices; anxiety and guilt due to violating religious beliefs; lashing out against the religion

IV. NURSING CARE PLAN/IMPLEMENTATION

A. Acknowledge client’s beliefs

  • Provide contact with clergy of choice.
  • Provide opportunity to carry out practices not detrimental to client’s health.

B. Do not impose beliefs and values of health-care system

V. EVALUATION/OUTCOME CRITERIA

  • Increased satisfaction related to medical care decision
  • Decrease in feelings of stress, guilt, depression, anger

Safe, Effective Care Environment: NURSING ETHICS

Focus topic: Safe, Effective Care Environment

Nursing ethics involves rules and principles to guide right conduct in terms of moral duties and obligations to protect the rights of human beings. In nursing, ethical codes provide professional standards and formal guidelines for nursing activities to protect both the nurse and the client.

I. CODE OF ETHICS

—serves as a frame of reference when judging priorities or possible courses of action. Purposes:

  • To provide a basis for regulating relationships between nurse, client, coworkers, society, and profession.
  • To provide a standard for excluding unscrupulous nursing practitioners and for defending nurses unjustly accused.
  • To serve as a basis for nursing curricula.
  • To orient new nurses and the public to ethical professional conduct.

II. ANA CODE OF ETHICS FOR NURSES 

Demonstrate respect for human dignity and uniqueness of individual regardless of health problem or socioeconomic level

  • Maintain client’s right to privacy and confidentiality
  • Protect the client from incompetent, unethical, or illegal behavior of others
  • Accept responsibility for informed individual nursing judgment and behavior
  • Maintain competence through ongoing professional development and consultation
  • Maintain responsibility when delegating nursing care, based on competence/qualification criteria
  • Work on maintaining/improving standards of care in employment setting
  • Protect consumer from misinformation/ misrepresentation

III. BIOETHICS

—a philosophical field that applies ethical reasoning process for achieving clear and convincing resolutions to issues and dilemmas (conflicts between two obligations) in health care.†

A. Purpose of applying ethical reflection to nursing concerns:

  • Improve quality of professional nursing decisions.
  • Increase sensitivity to others.
  • Offer a sense of moral clarity enlightenment.

B. Framework for analyzing an ethical issue:

  • Who are the relevant participants in the situation?
  • What is the required action?
  • What are the probable and possible benefits and consequences of the action?
  • What is the range of alternative actions or choices?
  • What is the intent or purpose of the action?
  • What is the context of the action?

C. Principles of bioethics:

  • Autonomy—the right to make one’s own decisions.
  • Nonmal feasance—the intention to do no harm.
  • Beneficence—the principle of attempting to do things that benefit others.
  • Justice—the distribution, as fairly as possible, of benefits, resources, and burdens.
  • Veracity—the intention to tell the truth.
  • Confidentiality—the social contract guaranteeing another’s privacy.
  • Respect—acknowledge the rights of others.
  • Fidelity—keep promises and commitments.
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IV. CLIENT’S BILL OF RIGHTS†

A. Right to appropriate treatment that is most supportive and least restrictive to personal freedom.

B. Right to individualized treatment plan, subject to review and reassessment.

C. Right to active participation in treatment, with the risk, side effects, and benefits of all medication and treatment (and alternatives) to be discussed.

D. Right to give and withhold consent (exceptions: emergencies and when under conservatorship).

1. Advance directives: legal, written, or oral statements made by a person who is mentally competent about treatment preferences. In the event the person is unable to make these determinations, a designated surrogate decision maker can do so. Each state has own specific laws with restrictions.

  • Living will: legal document that specifically identifies treatment desires and states that the person does not wish to have extraordinary lifesaving measures (e.g., DNR) when not able to make decisions about own care.
  • Durable power of attorney (health care proxy): legal document giving designated person authority to make health-care decisions on client’s behalf when client is unable to do so.

E. Right to be free of experimentation unless following recommendations of the National Commission on Protection of Human Subjects (with informed, voluntary, written consent).

F. Right to be free of restraints and seclusion except in an emergency.

G. Right to humane environment with reasonable protection from harm and appropriate privacy.

H. Right to confidentiality of medical records.

I. Right of access to personal treatment record.

J. Right to as much freedom as possible to exercise constitutional rights of association (e.g., use of telephone, personal mail, having visitors) and expression.

K. Right to information about these rights in both written and oral form, presented in an understandable manner at outset and periodically thereafter.

L. Right to assert grievances through a grievance mechanism that includes the power to go to court.

M. Right to obtain advocacy assistance.

  • Definition: an advocate is a person who pleads for a cause or who acts on a client’s behalf.
  • Goals: help client gain greater self-determination and encourage freedom of choices; increase sensitivity and responsiveness of the health-care, social, political systems to the needs of the client.
  • Characteristics: assertiveness; willingness to speak out for or in support of client; ability to negotiate and obtain resources for positive outcomes; willingness to take risks, and take necessary measures in instances of incompetent, unethical, or illegal practice by others that may jeopardize client’s rights.

N. Right to criticize or complain about conditions or services without fear of retaliatory punishment or other reprisals.

O. Right to referral to complement the discharge plan.

V. CONFLICTS AND PROBLEMS

—ETHICAL DILEMMAS

A. Personal values versus professional duty—nurses have the right to refuse to participate in those areas of nursing practice that are against their personal values, as long as a client’s welfare is not jeopardized.
Example: therapeutic abortions.

B. Nurse versus agency—conflict may arise regarding whether or not to give out needed information to a client or to follow agency policy, which does not allow it. Example: a teenager who is emotionally upset asks a nurse about how to get an abortion, a discussion that is against agency policy.

C. Nurse versus colleagues—conflict may arise when determining whether to ignore or report others’ behavior. Examples: you see another nurse steal medications; you know that a peer is giving a false reason when requesting time off; or you observe a colleague who is intoxicated.

D. Nurse versus client/family—conflict may stem from knowledge of confidential information. Should you tell? Example: client or family member relates a
vital secret to the nurse.

E. Conflicting responsibilities—to whom is the nurse primarily responsible when needs of the agency and the client differ? Example: a physician asks a nurse not to list all supplies used for client care, because the client cannot afford to pay the bill.

F. Ethical dilemmas—stigma of diagnostic label (e.g., AIDS, schizophrenia, addict); involuntary psychiatric confinement; right to control individual freedom; right to suicide; right to privacy and confidentiality.

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FURTHER READING/STUDY:

Resources:

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