Stages of illness, patient's rights, nursing process

1. Advanced Med.-Surgical Nursing 1
NRSG. 109

2. I. Describe the diff. stages of illness
Stage 1: Symptom Experience-includes awareness of physical change; assessment of change
related to severity; form of emotional reaction associated with assessment
Reaction
- Denial
- Acceptance of symptoms and entering the second stage
- Delay individual cannot make the decision waits for further development of symptoms – –
Stage 2: Assumption of the Sick Role –decision on adaptation to the sick role; illness
becomes a social phenomenon-the ill person seeks validation for sick role from other persons
 other persons in lay referral system deny request for sick role
 acceptance of illness and provisional sick role -leading to the third stage-medical care contact
Stage 3: Medical Care Contact-ill person leaves lay remedies and enters the professional care
system
 physician denies confirmation of request for sick role -patient accepts-patient refuses (‘shopping’
phenomenon)
 confirmation of illness–confirmation of request for sick role -entering the next stage-dependent-
patient role
Stage 4: Dependent-Patient Role –ill person makes decision on illness treatment and becomes
a patient
 patient resistance to treatment regimen–uncompliant patient–‘shopping’
 dependent patient strives insufficiently for recovery

3.  patient and physician working together on recovery–gradual resuming of normal roles
Stage 5: Recovery and Rehabilitation–
 recovery–patient accepts normal activities
 gradual recovery
 recovery process-relinquishing sick role -chronic patients/malingerers
 positive treatment outcome–patient joins the healthy
II. Enumerate the Bill of Rights
A. The Dying Person's Bill of Rights
The following "Bill of Rights" was created at a workshop (The Terminally Ill Patient and the Helping
Person) in Lansing Michigan, sponsored by the South Western Michigan In-service Education Council and
conducted by Amelia Barbus (1975), Associate Professor of Nursing, Wayne State University:
 I have the right to be treated as a living human being until I die.
 I have the right to maintain a sense of hopefulness however changing its focus may be.
 I have the right to express my feelings and emotions about my approaching death in my own
way.
 I have the right to participate in decisions concerning my care.
 I have the right to expect continuing medical and nursing attention even though cure goals must
be changed to comfort goals.
 I have the right not to die alone.
 I have the right to be free from pain.
 I have the right to have my questions answered honestly.
 I have the right not to be deceived.
 I have the right to have help from and for my family in accepting my death...
 I have the right to die in peace and with dignity.
 I have the right to retain my individuality and not be judged for my decisions which may be
contrary to the beliefs of others.
 I have the right to be cared for by caring, sensitive, knowledgeable people who will attempt to
understand my needs and will be able to gain some satisfaction in helping me face my death.
The American Journal of Nursing, January 1975, vol. 75, no. 1, p. 99 lists three more:
 I have the right to be cared for by those who can maintain a sense of hopefulness, however
changing this might be.
 I have the right to expect that the sanctity of the human body will be respected after death.
 I have the right to discuss and enlarge my religious and/or spiritual experiences, whatever these
may mean to others.
B. Filipino Patient’s Bill of Rights
 The patient has the right to considerate and respectful care irrespective of socio-economic
status.
 The patient has the right to obtain from his physician complete current information concerning
his diagnosis, treatment and prognosis in terms the patient can reasonably be expected to
understand. When it is not medically advisable to give such information to the patient, the
information should be made available to an appropriate person in his behalf. He has the right to
know by name or in person, the medical team responsible in coordinating his care.
 The patient has the right to receive from his physician information necessary to give informed
consent prior to the start of any procedure and/or treatment. Except in emergencies, such
information for informed consent should include but not necessarily limited to the specific
procedure and or treatment, the medically significant risks involved, and the probable duration
of incapacitation. When medically significant alternatives for care or treatment exist, or when

4. the patient requests information concerning medical alternatives, the patient has the right to
such information. The patient has also the right to know the name of the person responsible for
the procedure and/or treatment.
 The patient has the right to refuse treatment/life – giving measures, to the extent permitted by
law, and to be informed of the medical consequences of his action.
 The patient has the right to every consideration of his privacy concerning his own medical care
program. Case discussion, consultation, examination and treatment are confidential and should
be conducted discreetly. Those not directly involved in his care must have the permission of the
patient to be present.
 The patient has the right to expect that all communications and records pertaining to his care
should be treated as confidential.
 The patient has the right that within its capacity, a hospital must make reasonable response to
the request of patient for services. The hospital must provide evaluation, service and/or referral
as indicated by the urgency of care. When medically permissible a patient may be transferred to
another facility only after he has received complete information concerning the needs and
alternatives to such transfer. The institution to which the patient is to be transferred must first
have accepted the patient for transfer.
 The patient has the right to obtain information as to any relationship of the hospital to other
health care and educational institutions in so far as his care is concerned. The patient has the
right to obtain as to the existence of any professional relationship among individuals, by name
who are treating him.
 The patient has the right to be advised if the hospital proposes to engage in or perform human
experimentation affecting his care or treatment. The patient has the right to refuse or
participate in such research project.
 The patient has the right to expect reasonable continuity of care; he has the right to know in
advance what appointment times the physicians are available and where. The patient has the
right to expect that the hospital will provide a mechanism whereby he is informed by his
physician or a delegate of the physician of the patient’s continuing health care requirements
following discharge.
 The patient has the right to examine and receive an explanation of his bill regardless of source
of payment.
 The patient has the right to know what hospital rules and regulation apply to his conduct as a
patient.
III. Describe the different Steps of Nursing Process
The nursing process is the framework for providing professional, quality nursing care. It directs
nursing activities for health promotion, health protection, and disease prevention and is used by nurses in
every practice setting and specialty. “The nursing process provides the basis for critical thinking in nursing”
(Alfaro-LeFavre, 1998, p. 64).
Assessment
Assessment is the first step in the nursing process and includes collection, verification,
organization, interpretation, and documentation of data. The completeness and correctness of the
information obtained during assessment are directly related to the accuracy of the steps that follow.
Assessment involves several steps:
 Collecting data from a variety of sources
 Validating the data
 Organizing data
 Categorizing or identifying patterns in the data
 Making initial inferences or impressions
 Recording or reporting data

5. Diagnosis
The second step in the nursing process involves further analysis (breaking the whole down into
parts that can be examined) and synthesis (putting data together in a new way) of the data that have
been collected. Formulation of the list of nursing diagnoses is the outcome of this process. According to
the North American Nursing Diagnosis Association (NANDA) a nursing diagnosis is a clinical judgment
about individual, family, or community responses to actual or potential health problems/life processes.
Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which
the nurse is accountable. (Carroll-Johnson, 1990, p. 50)
The nursing diagnoses developed during this phase of the nursing process provide the basis for
client care delivered through the remaining steps.
Types of Nursing Diagnoses
Analysis of the collected data leads the nurse to make a diagnosis in one of the following
categories:
• Actual problems
• Potential problems (including those where risk factors exist and there are possible problems)
• Wellness conditions
• Collaborative problems
Outcome Identification and Planning
Planning is the third step of the nursing process and includes the formulation of guidelines that
establish the proposed course of nursing action in the resolution of nursing diagnoses and the
development of the client’s plan of care. Once the nursing diagnoses have been developed and client
strengths have been identified, planning can begin.
The planning phase involves several tasks:
• The list of nursing diagnoses is prioritized.
• Client-centered long- and short-term goals and outcomes are identified and written.
• Specific interventions are developed.
• The entire plan of care is recorded in the client’s record.
Implementation
The fourth step in the nursing process is implementation. Implementation involves the execution
of the nursing plan of care derived during the planning phase. It consists of performing nursing activities
that have been planned to meet the goals set with the client. Nurses may delegate some of the nursing
interventions to other persons assigned to care for the client—for example, the licensed practical nurses
and unlicensed assistive personnel.
Implementation involves many skills. The nurse must continue to assess the client’s condition
before, during, and after the nursing intervention. The nurse must also possess psychomotor skills,
interpersonal skills, and critical thinking skills to perform the nursing interventions that have been planned.
The implementation step also involves reporting and documentation.
Evaluation
Evaluation, the fifth step in the nursing process, involves determining whether the client goals
have been met, partially met, or not met. If the goal has been met, the nurse must then decide whether
nursing activities will cease or continue in order for status to be maintained.
Evaluation is an ongoing process. Nurses continually evaluate data in order to make informed
decisions during other phases of the nursing process.

6. V. Discuss in general concept the different Nursing
Responsibilities/Care of the nurse
a. Preoperatively
The preoperative phase begins when the decision to proceed with surgical intervention is made
and ends with the transfer of the patient onto the OR table. The scope of nursing activities during this time
involves establishing a baseline evaluation of the patient before surgery by carrying out a preoperative
interview (which includes a physical and emotional assessment, previous anesthetic and medical history,
and identification of known allergies or genetics issues that may affect the surgical outcome), ensuring
that necessary tests have been or will be performed in PAT, arranging appropriate consultations, and
providing education about recovery from anesthesia and postoperative care (Garcia-Miguel, Serrano-
Aguilar & Lopez-Bastida, 2003).
Examples of Nursing Activities in the Preoperative Phase of Care
Preadmission Testing
 Initiates initial preoperative assessment
 Initiates teaching appropriate to patient's needs
 Involves family in interview
 Verifies completion of preoperative testing
 Verifies understanding of surgeon-specific preoperative orders (e.g., bowel preparation,
preoperative shower)
 Assesses patient's need for postoperative transportation and care
Admission to Surgical Center or Unit
 Completes preoperative assessment
 Assesses for risks for postoperative complications
 Reports unexpected findings or any deviations from normal
 Verifies that operative consent has been signed
 Coordinates patient teaching with other nursing staff
 Reinforces previous teaching
 Explains phases in perioperative period and expectations
 Answers patient's and family's questions
 Develops a plan of care
In the Holding Area
 Assesses patient's status, baseline pain and nutritional status
 Reviews chart
 Identifies patient
 Verifies surgical site and marks site per institutional policy
 Establishes intravenous line
 Administers medications if prescribed
 Takes measures to ensure patient's comfort
 Provides psychological support
 Communicates patient's emotional status to other appropriate members of the health care team
b. Intraoperatively
The intraoperative phase begins when the patient is transferred onto the OR table and ends with
admission to the PACU. In this phase, the scope of nursing activities includes providing for the patient's
safety, maintaining an aseptic environment, ensuring proper function of equipment, providing the surgeon
with specific instruments and supplies for the surgical field, and completing appropriate documentation.
Nursing activities may include providing emotional support by holding the patient's hand during induction
of general anesthesia; assisting in positioning the patient on the OR table using appropriate principles of
body alignment; or acting as scrub nurse, circulating nurse, or registered nurse first assistant (RNFA).
Examples of Nursing Activities in the Intraoperative Phase of Care
Maintenance of Safety
 Maintains aseptic, controlled environment
 Effectively manages human resources, equipment, and supplies for individualized patient care
 Transfers patient to operating room bed or table
 Positions the patient
o Functional alignment
o Exposure of surgical site
 Applies grounding device to patient

7.  Ensures that the sponge, needle, and instrument counts are correct
 Completes intraoperative documentation
Physiologic Monitoring
 Calculates effects on patient of excessive fluid loss or gain
 Distinguishes normal from abnormal cardiopulmonary data
 Reports changes in patient's vital signs
 Institutes measures to promote normothermia
Psychological Support (Before Induction and When Patient Is Conscious)
 Provides emotional support to patient
 Stands near or touches patient during procedures and induction
 Continues to assess patient's emotional status
c. Postoperatively
The postoperative phase begins with the admission of the patient to the PACU and ends with a
follow-up evaluation in the clinical setting or home. The scope of nursing care covers a wide range of
activities including maintaining the patient's airway, monitoring vital signs, assessing the effects of the
anesthetic agents, assessing the patient for complications, and providing comfort and pain relief. Nursing
activities also focus on promoting the patient's recovery and initiating the teaching, follow-up care, and
referrals essential for recovery and rehabilitation after discharge. Each phase is reviewed in more detail in
this chapter and in the other chapters in this unit.
Examples of Nursing Activities in the Postoperative Phase of Care
Transfer of Patient to Post-Anesthesia Care Unit
 Communicates intraoperative information
o Identifies patient by name
o States type of surgery performed
o Identifies type of anesthetic used
o Reports patient's response to surgical procedure and anesthesia
o Describes intraoperative factors (e.g., insertion of drains or catheters; administration of
blood, analgesic agents, or other medications during surgery; occurrence of unexpected
events)
o Describes physical limitations
o Reports patient's preoperative level of consciousness
o Communicates necessary equipment needs
o Communicates presence of family and/or significant others
Postoperative Assessment Recovery Area
 Determines patient's immediate response to surgical intervention
 Monitors patient's physiologic status
 Assesses patient's pain level and administers appropriate pain relief measures
 Maintains patient's safety (airway, circulation, prevention of injury)
 Administers medications, fluid, and blood component therapy, if prescribed
 Provides oral fluids if prescribed for ambulatory surgery patient
 Assesses patient's readiness for transfer to in-hospital unit or for discharge home based on
institutional policy (e.g., Alderete score)
Surgical Unit
 Continues close monitoring of patient's physical and psychological response to surgical
intervention
 Assesses patient's pain level and administers appropriate pain relief measures
 Provides teaching to patient during immediate recovery period
 Assists patient in recovery and preparation for discharge home
 Determines patient's psychological status
 Assists with discharge planning
Home or Clinic
 Provides follow-up care during office or clinic visit or by telephone contact
 Reinforces previous teaching and answers patient's and family's questions about surgery and
follow-up care
 Assesses patient's response to surgery and anesthesia and their effects on body image and
function
 Determines family's perception of surgery and its outcome