Nursing  IV  

Stress  Adaptation  1. Primary  appraisal  :  irrelevant,  benign-­‐positive,  stressful  

a. Perceived  stress  type  :  positive,  negative,  both  (challenge)  2. Secondary  appraisal:  when  the  primary  threat  is  perceived  as  harm/loss,  the  assessment  of  

skills,  resources,  and  knowledge  possessed  to  deal  with  the  situation.  3. The  interaction  between  the  two  determines  the  quality  of  the  adaptation  to  the  stressor  

Crisis  intervention:    Stressful  events  –  brief,  focused  event     Common  

  Time  limited  treatment:  very  effective  

1. Components  a. Social  

i. Marriage    b. Psychological  

i. Divorce  c. Biological  

i. Cancer  –  learning  you  have  it  d. Focused  e. Time  limited  

2. Crisis  Definition  a. Sudden  event:  acute  –  not  more  than  4  to  6  weeks  b. Disturbs  homeostasis  c. Past  coping  does  not  work  

3. Crisis  Characteristics  a. Stressful  or  perceived  treat  –  individual  b. Diagnosis  :  ineffective  individual  coping  

i. Anxiety  –  extreme  –  will  be  resolved  one  way  or  another  ii. Acute,  not  chronic  

4. Crisis  response  phases  a. Anxiety  (phase  1)  “what  led  you  to  seek  help  now?”  b. New  coping  mechanisms  

i. Use  all  possible  resources  to  hopefully  resolve  the  problem  1. Prayer,  exercise  

c. Psychological  disorganization  i. Tension,  panic,  cognitive  function  failures,  psychotic  thinking,  denial,  refuse  help  

d. Those  that  cope  are  the  people  that  accept  help  

5. Balancing  Factors  a. People  perceive  events  in  different  ways  (disrupted  balance)  b. Situational  supports  

i. How  were  they  supported  in  the  past  (identify  these  coping  patterns  (key))  c. Coping  mechanisms  are  key  

6. Successful  crisis  resolution  a. Realistic  view  of  events  

i. Could  be  negative  such  as  alcohol  and  drugs  –  suicide  1. Need  to  identify  quickly  

b. Situational  supports  –  what  worked  in  the  past  c. Growth  occurs  when  the  resolution  is  positive  (adequate  coping)  

7. Types  of  Crisis  a. Maturational  (developmental  events)      role  change  

i. Retirement  –  concerns  include  financial  ii. Childhood  changes  

b. Situational  (dispositional  [Townsend])  i. Such  as  sick,  removal  from  nursing  ii. Loss  of  job  iii. Divorce  iv. Failure,  witness  traumatic  event,  ect.  

8. Maturational  key  times  a. Adolescence  b. Parenthood  c. Marriage  d. Midlife  e. Retirement  

9. Situational  Crisis  a. Loss  of  a  job  b. Loss  of  a  loved  one  c. Onset  or  worsening  of  a  medical  condition  d. Divorce  

10. Crisis  components  –  must  have  three  components    (ALARM  STAGE)  a. Must  have:  

i. Human  organism  ii. Stressful  event  iii. State  of  disequilibrium  

11. Intervention  Goal  a. Short  term  therapy  –  solve  the  immediate  problem  

i. Limited  to  about  6  weeks  b. Support  the  patient’s  effort  to  return  to  the  pre-­‐crisis  level  of  function  c. Without  intervention,  they  may  choose  a  negative  way  

12. Phases  of  crisis  intervention  

a. Assessment  –  timing  is  everything  i. Levels  of  trust,  stress,  strengths,  defense  mechanisms,  tolerance  for  hearing  

another  perception  ii. Collect  the  data  

1. “What  leads  you  to  seek  help  now”  2. When  did  it  occur  3. Physical  and  mental  status  4. Experience  this  before,  how  did  they  cope  before,  did  they  do  that  now?  5. Did  they  use  alcohol?    Drugs?  6. Assess  risk  for  suicide,  homicide  7. What  are  their  coping  mechanisms,  problem  solving  skills  8. What  do  they  think  their  strengths  are.  

iii. Nursing  Diagnosis  1. Ineffective  coping  2. Anxiety  3. Disturbed  thought    processes  4. Fear  5. Rape  or  post  trauma  syndrome  

b. Planning  c. Intervention  d. Evaluation  

13.  Identify  the  precipitating  events  a. Needs  b. Events  that  threaten  the  needs  c. When  did  the  symptoms  appear  

14. After  the  crisis  is  over:    Symptoms  a. Anger,  crying  spells,  diminished  sex  drive,  flashbacks,  forgetfulness,  helplessness,  

nightmares,  overeat,  under  eat,  lack  of  concentration,  school  problems,  social  withdrawal,  survival  grief  

15. Needs  a. Determine  the  needs    b. Self  esteem  :  positive  c. Role  mastery  (how  successful  are  you)  d. Dependancy  :  what  kind  of  security  you  have  in  your  life  

i. Relationships  with  others  ii. Achieve  satisfying  interdependent  relationship  

e. Biological  function:  achieved  when  a  person  feels  safe,  unthreatened.  i. Stress  response  over  a  long  time  leads  to  decreased  resistance  to  disease  

16. Determine  area  that  needs  are  not  met  a. Issues  of  self  image  and  self  esteem  :  losing  control  of  their  life  

i. Ask  what  caused  the  crisis  (  gain  control)  b. areas  of  life  that  are  considered  a  success  

c. Relationships  with  others  d. Degree  of  safety  and  security  in  life  e. Look  for  obstacles  that  interfere  with  the  patient’s  needs  

17. Assess  ineffective  coping  patterns  and  symptoms  a. When  did  the  patient  begin  to  feel  anxious  

i. Their  perception  of  the  event  is  extremely  important  b. When  did  sleep  disturbances  begin?  

i. They  may  not  know  what  the  crisis  is  c. At  what  time  did  suicidal  thoughts  start.  

18. Assess  support  systems  and  coping  resources  a. Who  do  they  live  with  b. Who  are  they  close  with  c. Exercise,  talk,  shop,  ect.  

19. Planning  20. Stages  of  crisis  intervention  

a. Psychosocial  21. Five  core  interventions  

a. Restore  psychological  safety  i. Stop  suicidal  thought  patterns  ii. Regain  control  

b. Provide  information  i. Where  they  can  get  help  

c. Correct  incorrect  knowledge  d. Restore  and  support  effective  coping  e. Ensure  social  support  

22. Techniques  of  crisis  intervention:  do  not  attack  their  defenses  a. Encourage  good  defense  mechanisms  and  discourage  bad  ones  (tactful)  b. Reinforcement  of  behavior  :    

i. “that’s  the  first  time  you  were  able  to  defend  yourself  with  your  boss,  and  it  went  very  well”  

c. Catharsis  –  release  of  feelings  through  talking  about  the  problems  i. Ask  open  ended  questions  

1. “tell  me  how  you  have  been  feeling  since  you  lost  your  job”  ii. Non  verbal  is  better  than  verbal  iii. Use  “what,    when,  how,  where”  

d. Clarification:    encourage  the  patient  to  express  the  relationships  of  the  events  i. “I  have  noticed  that  after  you  have  an  argument  with  your  husband,  you  

become  sick  and  can’t  leave  her  bed”  The  crisis  is  she  can’t  leave  her  bed.  e. Suggestion:  try  to  influence  the  person  to  accept  an  idea  or  belief,  especially  if  you  

believe  that  this  will  help  the  person  and  it  will  help.  i. “Many  other  people  have  found  it  helpful  to  talk  about  this,  and  I  think  you  will  

too.”  

f. Raising  self  esteem  i. “You’re  a  very  strong  person  being  able  to  handle  the  family  with  all  these  

problems,  I  think  you  will  be  able  to  get  through  this  one  too.”  g. Support  of  defenses:  encourage  the  healthy  adaptive  defenses  and  discouraging  the  

maladaptive  i. “going  for  a  bike  ride  when  you  were  angry  was  helpful  because  when  you  

returned,  you  were  able  to  talk  to  your  wife  about  the  problem”  h. Exploration  of  solutions:  alternate  ways  to  solve  this  problem  i. Do  not  be  passive,  take  an  active  role  

23. Evaluation:  determine  if  the  outcome  was  met  a. Did  they  return  to  their  pre-­‐crisis  functioning  state?  

i. Are  their  needs  met  ii. Constructive  coping  mechanisms  iii. Referral  necessary  iv. Health  teaching  (always)  

Leadership  and  Management    

  Occurs  when  a  person  attempts  to  influence  the  behaviors,  beliefs,  and  opinions  of  another  person  or  group  

Theories  of  leadership  

1. Contingency  leadership    a. Able  to  adapt  

2. Situational  Leadership  a. Functioning  more  closely  to  the  situation  being  addressed  at  the  moment.    Selects  the  

most  appropriate  leadership  style.  b. Team  leader  and  how  you  assign  duties  

3. Interactional  leadership  :  based  on  trust  a. Behaviors  can  be  learned  and  not  taught  

4. Transformational  /  transactional  leadership  a. Concern  for  people:  leader  spends  much  time  talking  to  their  followers,  takes  time  to  

learn  about  their  goals  and  problems  b. Focus  is  more  on  potential  then  reality  c. Transactional:  focused  on  current  work  process  and  results  (presence  oriented)  

5. Natural  born  leader  a. What  do  you  think  it  takes  to  be  an  effective  leader  b. What  experiences  have  you  had  /  witnessed  that  you  want  to  role  model  c. What  experiences  have  you  had/witnessed  that  you  would  never  want  to  experience  

again.  

6. Management  a. Occurs  when  a  person  coordinates  people,  time  and  supplies  to  achieve  a  desired  

outcome  b. Nurse  managers  are  responsible  for  planning  and  organizing  what  is  to  be  done,  who  is  

to  do  it,  and  how  it  is  to  be  done  c. Management  includes  resolving  problems,  scheduling,  hiring,  evaluating  and  budgeting.  d. Theories  

i. Traditional  :  follows  rules  and  chain  of  command:  promotes  highest  productivity  ii. Behavioral:  humanistic  side:  employees  needed  to  be  addressed.  iii. Systems:  Looks  at  inputs,  transformations,  outputs,  and  feedback  

1. One  managers  decisions  would  affect  another  iv. Contingency/motivational:  Blends  previous  theories  to  what  best  motivates  

people  for  the  best  outcomes  e. Styles  

i. Autocratic  :  uses  authoritarian  approach,  makes  most  of  the  decisions  without  input  

ii. Democratic:  more  participation  in  the  process,  one  person  retains  final  say  over  all  decisions,  but  allows  others  to  have  insight.  

iii. Laissez  Faire  leader:  least  possible  guidance  to  sub  ordinance,  believe  that  people  excel  when  left  alone  to  work  to  the  best  of  their  ability.  

7. Leadership  verses  Management  (in  textbook)  8. Effective  communication  techniques  

a. Assertive:  Straight  forward,  open  expression  of  your  needs.  i. Involves  advocating  for  your  own  needs  as  well  as  your  patients,  while  still  

considering  the  needs  of  others.    (considerate  and  respectful)  ii. Always  congruence  between  verbal  and  nonverbal  messages.  iii. Rights  and  responsibilities  

b. Aggressive:  method  of  expressing  needs  and  desires  that  do  not  take  into  account  the  needs  of  others.  

i. Forces  their  ideas  on  others.  ii. Those  who  communicate  aggressively  are  perceived  as  selfish  and  unwilling  to  

compromise  iii. Usually  linked  to  a  desire  to  hurt  others.    Sometimes  to  exact  revenge.    May  

reflect  poor  emotional  development.  c. Principles  for  effective  communication  

i. Aim  for  clarity  and  focus  ii. Use  direct  and  exact  language  iii. Encourage  feedback  iv. Acknowledge  the  contributions  of  others  v. Use  the  most  direct  channels  of  communication  available.  

9. Conflict  

a. Conflict  results  in  real  or  perceived  differences  in  beliefs,  attitudes,  values,  feelings,  ideas,  actions,  or  goals  

b. Conflict  can  be  positive  or  negative,  healthy  or  dysfunctional  c. Need  to  identify  the  problem,  clearly  delineate,  use  knowledge  and  reason  to  resolve  d. Goal  is  a  win=win  situation.  e. Conflict  (mild  anxiety),  can  have  a  positive  side  

i. Heightened  sensitivity  to  an  issue  promoting  more  open,  cooperative  ways  of  working  together  

ii. Increases  creativity  iii. Helps  people  

f. Conflict  can  have  a  negative  side  i. Can  be  covert  and  inappropriate  ii. Aggressive  behavior  can  occur  iii. Stressful  symptoms  can  develop  such  as  anxiety,  sleeplessness,  and  withdrawal  iv. Bitterness,  anger,  and  even  violence  can  erupt  v. Horizontal  violence  (co-­‐worker)”talking  about  somebody”,  “withholding  

information  from  somebody”  1. Overt  and  covert  non  physical  hostility  (sabotage,  criticism,  infighting,  

withholding  information,  scapegoat,  bickering  vi. Lateral  violence:  manager  to  someone  lower  

g. Manage  conflict:    Listen,  Describe  the  conflict,  Identify  the  difference,  Brainstorm,  select  solution,  plan,  implement,  evaluate.  

10. Effective  ways  to  resolve  conflict  a. Win-­‐win  

i. Requires  one  to  be  assertive  and  responsible  ii. Negotiation/solutions  occurs  –  everyone  is  happy  with  the  outcome  iii. Creative  resolution  to  conflict  iv. Examines  thoughts  and  feelings  objectively  v. Formulates  an  accurate  definition  of  the  conflict  and  shares  the  assessment  

with  colleagues  vi. Continued  vigilance  

b. Win-­‐Lose  i. Resolve  conflict  that  resolved  YOUR  needs  ii. Irresponsible  aggressive  approach  iii. Thinks  fighting  is  required  to  get  what  you  want  iv. Only  seek  and  explore  ideas  that  support  your  own  v. Does  not  seek  out  opinions  and  assessment  of  colleagues  regarding  the  conflict  vi. Ignores  the  fact  that  others  are  not  satisfying  with  the  resolution  

c. Lose-­‐Win  i. Allow  your  colleagues  to  win  at  your  expense  ii. Nobody  is  happy  with  outcome  iii. Nonassertive,  irresponsible,  nonprofessional  approach  

iv. Does  not  collect  all  pertinent  data  to  resolve  conflict  successfully  v. Defines  conflict  vi. Both  parties  are  aware  of  conflict  but  choose  not  to  acknowledge  it  and  or  

resolve  it  vii. One  part  may  try  to  reduce  emotions  without  addressing  problem  viii. It  is  often  used  to  preserve  or  maintain  a  peaceful  environment  ix. Involves  sacrificing  goals  or  values  x. Problem  still  exists.  xi. One  party  may  try  to  reduce  emotions  without  resolving  it  (smoothing,  

suppressing)  11. Attributes  that  create  a  powerful  leadership  image  

a. Intelligence,  competence,  effective  communicator  12. Accepting  and  refusing  assignments  

a. Effective  communication  is  essential  b. Know  the  facts  and  carefully  document  c. Clarify  what  is  expected,  assess,  identify  options,  point  of  decision  

i. If    you  perceive  you  can  perform  the  assignment,  than  except  it.  d. Remain  calm,  leave  emotion  behind  e. Assess  yourself:  do  you  have  the  skills  to  do  this  f. Discuss  cross  training  g. Remember  professional,  ethical,  and  legal  responsibilities  

i. Relationship  begins  when  you  accept  the  assignment  and  receive  report.  

Management  of  Patient  Care  III    

Reality  Shock  

1. Honeymoon  phase  2. Shock  and  rejection  phase:  nurses  lost  in  this  phase  

a. Physical  ailments  related  to  stress  3. Recovery  phase  4. Professional  Ideals  

a. Comprehensive  holistic  care  b. Emphasis  on  quality  of  care  c. Explicit  expectations  

d. Balanced,  frequent  feedback  e. Assignments  that  make  sense  

5. Work  Realities  a. Mechanistic  fragmented  care  b. Emphasis  on  efficiency  c. Implicit  expectations  d. Intermittent,  often  negative  feedback  

• The  way  you  perceive  events  on  the  job  influences  how  you  will  feel  about  your  work  • Feeling  of  helplessness  and  powerlessness  at  work,  causes  frustration  and  unrelieved  job  stress.  

 

 

Health  Education  Use  an  organized  approach  to  health  education  

• Every  contact  a  nurse  has  with  a  health  care  customer,  whether  or  not  that  person  is  ill  or  has  a  disability,  is  an  opportunity  for  health  teaching  

• Measurement:    Did  their  behavior  change?  

Goals  of  patient  education  

1. Encourage  people  to  adhere  to  their  therapeutic  regimen.    Adherence  to  treatment  usually  requires  that  person  to  have  a  lifestyle  change.  

2. Strategy  to  promote  self  care  at  home  3. Allow  people  to  make  informed  decisions  about  their  health.  

Variables  that  influence  adherence  

1. Demographic  variables  :  age,  gender,  race,  socioeconomic  status,  education  2. Illness  variables:  severity,  relief  of  symptoms  from  therapy  3. Therapeutic  regimen  variables:  complexity  of  the  regimen,  side  effects.  4. Psychosocial  variables:  intelligence,  motivation,  significant  and  supportive  people,  attitudes  

toward  health,  profession,  acceptance  or  denial  of  illness,  substance  abuse,  religion  5. Financial  variables:  direct  and  indirect  costs  6. Cultural  

a. Mediterranean  –  very  passionate  b. South  America  –  macho  c. Japanese  –  formal,  do  not  tell  jokes  d. English  as  a  second  language  –  do  not  use  slang  

• The  variables  of  choice,  establishment  of  mutual  goals,  and  quality  of  patient-­‐provider  relationship  directly  influence  the  behavioral  changes  that  can  result  from  patient  education.  

Learning:  acquiring  knowledge,  attitudes,  or  skills  and  changes  behavior  in  a  measurable  way  as  a  result  of  an  experience.    “How  do  you  learn  best?”  

1. Can  be  conscious  or  unconscious  2. Most  effective  when  information  meaningful  to  the  learner  3. Influenced  by  anxiety,  difficulty  of  the  task  and  environment  4. Listening  is  the  most  overlooked  part  of  learning.    Give  yourself  a  reason  to  listen.  5. Adult  learners  

a. Will  learn  what  they  want  to  learn,  when  they  want  to  learn  it  

b. The  nurse  is  the  facilitator  c. A  change  in  behaviors  is  learning  d. It  needs  to  be  relevant.  

Teaching:  helping  another  person  learn  1. Teaching  process  

a. Assessment  :  what  does  she  or  he  already  know?    STAGES  of  READINESS  to  LEARN  i. Pre-­‐contemplation  ii. Contemplation:  they  are  not  too  sure.    Aware  that  a  problem  exists.  iii. Action:  Now  I  am  ready  to  change  my  behavior  (cut  down  on  cigarettes)  iv. Maintenance  stage:  daily  exercise  to  loose  weight,  tobacco  free  for  six  months  v. Termination:  habit  is  now  routine  

b. Assessment  :  identify  learning  needs  i. Need  identified  by  the  learner  have  the  highest  priority  ii. Needs  identified  by  the  nurse  must  be  validated  with  the  learner  iii. Questions  

1. Are  they  ready?    Are  they  motivated?    Motivated  to  Learn?  2. What  does  he  need  to  know?,    What  do  they  already  know?  3. What  are  the  barriers  and  facilitates  to  healthy  behavioral  change  

c. How  do  people  learn  i. Lecture  remember  20%  of  what  is  said  ii. SEE  –    30%  of  what  I  saw  iii. Say  or  write  it:  Teach  it  to  someone  or  write  it  70%  iv. Say  and  do  –  test  my  blood  and  explain  what  I  am  doing  90%  

d. Nursing  diagnosis:  knowledge  deficit  ;  how  ready    e. Planning  –  outcomes  f. Intervention  g. Evaluate  h. document  

 Lower  reading  level  by:  

1. Short  familiar  words  if  literacy  is  low  2. Avoid  medical  terminology  3. Short  sentences  4. Use  second  person  pronouns  5. Active,  not  passive  voice  “take  your  meds  at  mealtime”  6. Numbers  (3,4)  not  spelled  numbers  

Anxiety  influences  on  learning  1. Mild  to  moderate  –  increases  alertness  2. High  level  –  diminishes  learning  3. Low  level  –  diminishes  learning  

Motivation  • Self-­‐efficacy:  the  stronger  someone  believes  that  they  can  accomplish  something,  the  better  you  

will  feel  about  putting  the  effort  into  it,  the  longer  you  will  pursue  it.    The  stronger  you  believe  you  have  the  ability  to  do  something,  then  the  stronger  you  will  be  to  be  able  to  accomplish  it.  

• Nursing  role:  let  them  select  what  they  want  to  do.  o Learn  by  doing.  

• Give  feedback  on  progress  

• Breakdown  content  into  small  steps  that  are  achievable.  • External  motivation:    • Patient  is  most  motivation  for  the  first  12  months  of  an  illness.  

 Experiential  readiness:    past  experiences  that  influence  a  person’s  ability  to  learn  Learning  Theories:    

1. Behaviorist  method  a. Pavlov:  positive  reinforcement  b. Learning  occurs  when  an  unmet  need  produces  sufficient  motivation  to  satisfy  that  

need.  c. Learner  and  teacher  must  perceive  reinforcement  as  positive  d. Learner’s  response,  not  the  teachers’  stimulus,  is  the  key  to  behavior  change.  

2. Cognitive  theory:    Key  factor:  developmental  readiness.  a. Learning  is  an  interaction  between  the  learner  and  the  environment,  mediated  by  the  

teacher.    Developmental  readiness  is  a  key  factor  of  the  cognitive  approach  b. Thinking  and  conceptualizing  are  the  learner’s  major  activities;  teacher  evaluates  

cognitive  development  in  the  learner.  3. Humanistic  theory  

a. Teachers  and  learners  trust  each  other  to  be  competent  to  learn  by  self  discovery  b. Learning  is  a  process  of  developing  to  one’s  full  potential:  learners  decide  what  they  

want  to  learn  first.  c. Teaching  is  the  facilitation  of  learning  d. Teacher  assists  the  learner,  not  necessarily  the  initiator  of  the  process.  

Domains  of  learning  1. Affective  learning-­‐  attitudes,  emotions,  values,  and  feelings  2. Cognitive  learning  –  applying,  thinking,  analyzing  and  evaluating  3. Psychomotor  learning:  skills,  actions  

   

Nursing  Diagnosis:  Deficient  knowledge  diagnosis  is  too  broad.    Use:     Ineffective  therapeutic  regimen  management  related  to  a  lack  of  information  about  .  .  .  .  .     Knowledge  deficiet  

Patient  Education  1. Assessment  :  are  they  ready?  

a. Health  beliefs  and  behaviors?  b. Are  they  able  to  learn,  are  they  ready?  c. Order  of  non-­‐verbal  clues  

i. Skin  color  ii. Gender  iii. Age  iv. Appearance:    

v. Facial  expressions  :  face  can  be  controlled,  but  lower  body  is  more  difficult  to  control  consciously  

vi. Eye  contact  vii. Personal  space  

1. Children  are  touched  more  than  adults  2. Woman  more  than  men  3. Employees  more  than  the  boss  

viii. Movements  ix. touch  

d. What  are  their  expectations  2. Organize,  analyze,  synthesize  and  summarize  the  collected  data  3. Formulate  a  nursing  diagnosis  

a. Identify  the  learning  needs  b. Specify  immediate,  intermediate,  and  long  term  learning  goals  c. Establish  an  expected  outcome  d. Develop  the  teaching  plan  e. Involve  family,  significant  others,  nursing  team  members,  and  other  health  care  people  

4. Put  teaching  plan  into  action  a. Intervention  

i. Known  to    unknown  ii. Content  that  increases  anxiety  is  taught  first  iii. Teach  routine  first  then  variations  

b. Teach  new  concepts  3  times  before  it  is  learned  i. Example:  teaching  about  a  med:  

1. What  med  is  he  taking  2. How  much  of  it  he  takes  3. When  he  takes  it  

c. Do  –  Know  –  deficit  i. What  does  the  patient  have  to  do?  ii. What  does  he  have  to  know  in  order  to  do  that?  iii. What  does  he  already  know?  iv. Teach  the  deficit  

5. Provide  feedback  6. Evaluation  

a. Ask  questions  to  determine  if  the  person  understood.  b. Use  rating  scale  c. Outcome:  state  

i. What  is  to  be  done  ii. Who  is  to  do  it  iii. When  they  are  to  do  it  iv. How  and  where  they  are  to  do  it  v. How  well  they  are  to  do  it.  vi. Components  

1. Subject  “Mr.  Smith”  2. Verb  “will  walk”  

a. Measurable  verbs  (examples  –  use  only  one)  i. Cough,  demonstrate,  state,  sit,  walk  

b. DO  NOT  USE  

i. Know,  understand,  think,  appreciate,  feel  c. Cognitive:  teach,  discuss,  list  explore,  identify,  describe  d. Affective:  express,  value,  share,  listen,  communicate,  relate  e. Psychomotor:  demonstrate,  walk,  administer,  practice.  

3. Condition  “with  a  cane”  4. Criteria  “  to  the  end  of  the  hall  and  back  at  least  once”  5. Specific  time  “on  day  shift”  

7. Standards  of  care  a. When  establishing  outcomes  use  the  standards  of  care,  determined  by    

i. The  law  ii. The  ANA  iii. The  Institution  

 

BEGIN  UNIT  2  

Therapeutic  communication  Communication:  An  interactive  process  of  transmitting  information  between  two  or  more  entities  

1. Transactional  model:  both  parties  are  participating  simultaneously  2. Factors  of  communication  

a. Values,  Culture  or  religion,  social  status,  gender,  and  age  b. Nonverbal:  70-­‐90%  of  effective  communication  is  non-­‐verbal  

i. Physical  appearance,  Body  movement  &  posture,  touch,  facial  expression,  eye  behavior.  

3. Therapeutic  communication  focuses  on  the  receiver’s  needs  and  advance  the  promotion  of  healing  and  change.  

Group  Dynamics  Stages  of  group  development  

1. Definition:Two  or  more  people  who  share  a  common  definition  and  evaluation  of  themselves.    Or  it  is  a  collection  of  people  who  work  to  gether.    They  accept  rights  and  obligations,  and  a  share  a  common  identity.  

a. Criteria  i. Formal  social  structure  ii. Face  to  face  interaction  (does  not  mean  every  time  it  meets)  iii. Two  or  more  persons  with  a  common  fate  or  goals  iv. Self  definition  as  group  members,  and  receive  recognition  from  or  of  others  

b. Societies  can  be  seen  as  large  groups,  consisting  of  many  subgroups.  2. Stages  of  group  development  

a. Forming:  when  the  group  comes  together  and  begin  to  know  each  other  b. Storming:  chaotic  vying  for  leadership,  and  trialing  of  group  processes  

c. Norming:  Eventual  agreement  on  how  the  group  operates.  d. Performing:  When  the  group  practices  its  craft  and  becomes  effective  in  meeting  the  

objectives  and  goals  e. Adjourning:  Process  of  unforming  the  group  (goals  have  been  accomplished)  

3. Usually  have  two  major  goals:  Getting  things  done,  and  getting  along.  4. Types  of  groups  

a. Primary:  small  intimate  group  where  relationships  among  members  are  personal,  spontaneous,  cooperative,  and  inclusive.  

i. Family,  group  of  children,  informal  work  groups  ii. Set  standards  of  behavior  and  support  each  other  in  stressful  situations  iii. Group  a  sense  of  “we”  and  “our”  as  opposed  to  “I”  iv. Role  has  increasingly  been  recognized.  

b. Secondary:  larger  and  more  impersonal  i. Meeting  secondary  needs  for  control  and  problem  solving  

1. ADHOC  committee,  work  groups,  political  parties,  business  2. Members  view  these  groups  as  a  means  of  getting  things  done.  

5. Functions  of  the  groups  a. Interpersonal  perspectives  

i. Affection    ii. Affiliation  =  can  provide  opportunity  to  provide  emotional  relations  iii. Socializing  –  culture  of  the  organization  

1. Can  be  growth  and  development  (Primary)  iv. Social  support  for  members,  or  help  committee  v. Camaraderie  –  the  feeling  of  good  will  among  the  members  vi. Power  –  opportunity  for  individuals  to  exercise  their  need  for  power  over  others  

b. Functional  perspectives  i. Completion  of  tasks  that  are  beyond  the  scope  of  an  individual  ii. Information:  set  performance  goals,  establish  priorities,  and  share  special  

knowledge  iii. Normative  function:  development  of  definitions  and  standards  (mission  and  

goals)  iv. Empowerment:  empowering  the  group  members  and  thereby  encouraging  

change.  v. Governance:  provide  involvement  in  decision  making.  

6. Dysfunctional  group  personalities  a. Self  servers:  rules  of  the  group  do  not  apply  to  them,  they  are  late  and  usually  

unprepared.    They  think  their  special.    If  they  are  not  functional,  you  may  ask  them  to  leave  the  group.  

b. Critical  conservative:  “No  it  will  not  work”  They  criticize  all  suggestions  but  their  own.    Not  very  good  at  change.  

c. Motor  mouths:  never  shut  up,  interrupt,  talk  over  a  speaker’s  words,  talk  about  unrelated  issues.      

d. Defensive:  unproductive,  time  consuming,  and  inappropriate  to  the  function  of  the  group.    The  main  concern  of  the  member  is  to  find  status  in  the  group  and  find  their  own  agenda.  

e. Mouse:    7. Improving  communication  in  group  meetings  

a. Come  prepared,  listen,  keep  on  task,  present  your  ideas  or  opinions,  state  disagreements,  clarify  when  necessary.  

8. Group  process  skills  a. Active  listening  b. Focus  the  discussion  on  the  purpose  c. Check  perceptions  of  the  group  (body  language,  sidebars)  d. Reflecting:  convey  the  essence  of  what  a  group  member  has  said  e. Clarifying:  focus  on  key  underlying  issues,  and  sorting  out  conflicting  and  confusing  

feelings  f. Summarizing:  reflecting  major  ideas  and  points  g. Facilitating:  assisting  the  member  to  express  their  feelings  and  thoughts  openinly  h. Interpreting  i. Questioning:  if  overused,  can  be  frustrating  and  may  make  them  defensive  j. Confirming  k. Encouraging:  “I  see,  that’s  interesting,  tell  me  more”  

9. Responsibilities  of  the  group  leader  a. Ask  open  ended  questions,  and  encourage  questions  b. Respond  with  positive  statements  or  a  summary  each  time  a  participant  makes  a  

contribution  c. Reinforce  participants  contributions  by  giving  them  your  full  attention.  d. Avoid  making  negative  comments  about  group  members  contributions:  summarize  or  

restate  them  and  ask  other  team  members  for  their  thoughts  about  ideas  10. Committee  or  teams  

a. Consists  of  a  group  of  people  who  have  been  selected  to  manage  a  particular  topic  ro  issue  

i. Policy  committee,  quality  improvement  committee,  healthcare  planning  committee,  nursing  organizations  committee.  

ii. Can  be  referred  to  as  teams:  wound  care  team,  nursing  care  team.  iii. Send  out  an  agenda  ahead  of  time,  and  have  a  clear  purpose  iv. Take  minutes  v. Summarize  at  the  end  of  each  meeting  

11. Therapeutic  groupsf  a. What  is  the  difference?  When  psychosocial  treatment  takes  place,  sharing,  or  gaining  

personal  insight.    Improving  interpersonal  coping  strategies.  b. Therapeutic  group:  teach  participants  ways  to  deal  with  emotional  stress  arising  from  

situational  or  developmental  crisis  c. Open  ended  groups:  when  members  leave  and  others  leave  at  any  time.  

d. Closed  ended  group:  pre-­‐determined  timeframe,  all  members  join  and  terminate  at  the  same  time.    Usually  have  common  issues.  

e. Self  help  groups:  (AA,  Weight  Watchers,  Overeaters  Anonymous)  Usually  run  by  members  of  the  group,  and  leadership  often  rotates.  

f. Optimal  group  composition  number  (7-­‐8)  Depends  on  the  group.  12. Curative  factors  of  groups  

a. Instillation  of  hope  b. Universality  (misery  loves  company)  c. Good  for  imparting  information  d. Altruism:  mutual  caring  and  concern  for  each  other  

i. Support  for  others  creates  a  positive  self  image  e. Recapitulation  of  family  group:  revisit  painful  times,  attempt  at  resolution.  f. Development  of  social  techniques:  learn  new  skills  g. Imitative  behavior  (positive  role  model)  h. Interpersonal  learning:  interacting  with  others  i. Cohesiveness:  sense  of  belonging  j. Catharisis:  express  positive  and  negative  feelings  in  a  non-­‐threatening  atmosphere  k. Existential  factors:  help  members  teke  direction  of  their  own  lives  

13. Phases  of  group  development  a. 1  orientation  phase  

i. Group  activities:  roles  and  rules  established  ii. Leader  expections:  what  is  expected,  rules  are  followed  iii. Behaviors:  Members  are  usually  overly  polite.    Trust  has  not  been  established.    

A  power  struggle  may  occur  for  pecking  order  b. 2  middle  or  working  phase  

i. Group  activities:  productive  work  toward  the  task  at  hand  1. Cooperation  and  differences  can  be  resolved  

ii. Leader  becomes  a  facilitator:  some  leadership  functions  can  be  shared  1. Helps  resolve  conflict    

iii. Member  behaviors  1. Trust  has  been  established,  can  accept  criticism  from  each  other  2. Sub  groups  can  develop  3. Members  will  conspire  with  exclusion  of  the  rest  of  the  group  

c. 3  Termination  phase  i. Group  activities  

1. The  longer  the  group  has  formed,  the  more  painful  the  breakup  2. Termination  should  be  discussed  long  before  the  date  3. Leader  expectation:  encourage  the  group  to  reminise  

a. Reviews  goals,  discusses  outcomes,  encourage  members  to  provide  feedback  to  each  other.    D  

b. Discuss  the  loss  or  grief  if  necessary  4. Members  are  surprised  it’s  almost  over.f  

a. Can  lead  to  anger  b. Previous  losses  can  be  discussed  among  members    

14. Member  roles  within  the  group  a. Task  roles  

i. Coordinator:    Clarifies  ideas  and  brings  people  together  for  common  goals  ii. Evaluator:  looks  at  group  plans  and  performance,  measures  against  goals  iii. Elaborator:  explains  and  expands  idease  iv. Energizer:  encourages  and  motivates  optimal  potential  for  members  v. Initiator:  outlines  tasks  and  proposes  methods  for  solutions  vi. Orienteer:  maintains  direction  within  the  group  vii. Compomiser:  relieves  conflict,  assisting  to  reach  a  compromise  for  all  viii. Engourager:  encourages  and  accepts  other’s  idease  ix. Follower:  passive  participant,  listens  attentively.      x. Gatekeeper:  encourages  acceptance  of,  and  participation  by  all  group  members  xi. Harmonizer:  reduces  tension  when  there  are  disagreements  

b. Individual  roles  i. Aggressor:  negative  and  hostile:  may  use  sarcasm  in  effort  to  degrade  the  status  

of  others  ii. Blocker:  resists  group  effors  –  hates  change:  rigid  and  irrational,  can  impede  

progress  of  the  group.  iii. Dominator:  manipulates  others  to  gain  control  iv. Help-­‐seeker:  uses  the  group  to  gain  sympathy  

1. Lacks  concern  for  others  or  the  group  as  a  whole.  v. Monopolizer:  maintains  control  of  the  group  by  dominating  the  conversation  vi. Mute/silent  member:  don’t  participate.    May  feel  uncomfortable  with  self  

exposure.  vii. Recognition  seeker:  discuses  personal  accomplishments  to  gain  recognition  for  

themselves  viii. Seducer:  shares  intimate  details  about  self,  they  may  inhibit  others  by  early  self  

disclosure:  

Ethical  Issue    

Ethics:  Rules  or  principles  that  determine  which  human  actions  are  right  or  wrong.  

Nursing  Ethics:  Promote  health,  prevent  illness,  restore  health  and  alleviate  suffering.  

  Render  health  service  to  the  individual,  family,  and  the  community.  

 

Moral  or  ethical  principles  

1. Autonomy:  rights  of  individuals  to  self  determination  (consent-­‐  based  on  knowledge)  

2. Beneficence:  actions  that  promote  well  being  of  others  (Doing  good,  uphold  standards)  a. Obligated  to  do  actions  that  we  know  will  do  good.  

3. Nonmaleficence:  Do  no  harm  (Do  them  good  with  risks  vs.  Do    no  harm  (may  be  do  nothing))  a. Whether  intentional  or  unintentional  

4. Justice:  (fairness)  Duty  to  treat  clients  without  regard  to  age,  race,  socio-­‐economic  status.    Allocation  of  resources.  

5. Fidelity:  Faithfulness,  the  obligation  to  care  6. Veracity:  The  obligation  to  tell  the  truth.  

a. What  you  tell  the  patient,  what  you  document,  ect.  

Impact  of  ethics  on  care:  focus  on  care,  standards  of  care  for  all  individuals.  

Impact  on  caregivers:    

Approaches:  

1. Deontological:    a. Clear  direction  for  action  

i. Perceived  as  rigid  b. All  individuals  are  treated  the  same  

i. Does  not  consider  possible  negative  consequences  of  actions  2. Teleological  

a. Interest  of  the  majority  is  protected  i. Rights  of  individuals  may  be  overlooked/denied  

b. Results  are  evaluated  for  their  good  and  actions  may  be  modified  i. What  is  good?  Who  determines  good?  Morality  may  be  arbitrary  

3. Situational  a. Mirrors  the  way  most  individuals  actually  approach  day  to  day  decision  making  b. Merits  of  each  situation  are  considered,  each  situation  is  unique  c. Individual  has  more  control/autonomy  to  make  decisions  in  his  or  her  own  best  interest.  

i. Lack  of  rules  of  generalizability  limits  criticism  of  possible  abuse.  

Moral  courage:  commitment  to  stand  up  for/take  action  on  one’s  ethical  principles  

Moral  arrogance:  believing  one’s  own  stance/judgement  is  the  only  correct  one,  even  when  others  consider  different  options  morally  acceptable.  

Moral  certainty:  certitude  that  one  is  right-­‐have  no  reservations  about  the  rightness  of  their  belief  

Making  ethical  decisions  

• Assess:  collect  facts  and  data  for  an  accurate  picture  • Identify  the  ethical  issue/problem  (autonomy,  justice  .  .  .  )  • Plan:  consider  all  possible  courses  of  action  and  their  likely  outcomes:  

o Discuss  with  all  involved  parties  (client,  family,  health  care  team)  o Additional  resources  (interdisciplinary  ethics  committee  for  unbiased  review  and  

recommendation,  lawyer  for  legal  implications,  hospital  rep  for  policies/protocols  

• Nursing  code  of  ethics  supports  the  client’s  rights  to  information  and  counseling  in  making  decisions.  

Determining  who  owns  the  problem  

1. Determine  the  facts  a. Is  discussion  about  extraordinary  care  taking  place?  b. Clarify  the  institution’s  policy  regarding  CPR  and  DNRs  c. What  rights  does  the  family’s  decision  have    d. Explore  advance  directive  documents  e. Share  concerns  with  physician  

2. Identify  the  Ethical  issues  a. Is  the  physician  aware  of  the  living  will?  b. Institutional  policy  may  be  in  conflict  with  the  living  will    

3. Consider  course  of  action  and  their  related  outcomes  a. Advocate  for  the  patient:  ie.  Doctor,  Family  b. Encourage  sharing  of  feelings  c. Encourage  open  discussion    

4. After  a  course  of  action  has  been  done,  evaluate  the  outcome  

Professional  codes/guidelines  

• The  registered  nurse  practices  ethically  • Primary  responsibility  is  to  the  people  requiring  care  • Personal  responsibility  for  maintaining  competence.  • Determine  and  implement  standards  of  practice  • Takes  a  cooperative  relationship  with  coworkers  and  takes  appropriate  action  to  safeguard  

others.  

Abortion  

1. Your  own  values,  and  how  you  best  apply  those  values  to  your  work  and  possible  politics  2. ANA  Code  of  Ethics:  “The  nurse,  in  all  professional  relationships,  practices  with  compassion  and  

respect  for  the  inherent  dignity,  worth  and  uniqueness  of  every  individual,  unrestricted  by  considerations  of  social  or  economic  status,  personal  attributes,  or  the  nature  of  the  health  problem”  

3. This  refers  back  to  your  principals.    If  your  principals  do  not  agree,  don’t  work  there.    You  cannot  abandon  the  patient  OR  force  your  principals  upon  them.  

Organ  and  Tissue  Transplant  

1. Fetal  tissue  (from  elected  abortions)  

Euthanasia  –  painless  death  to  end  the  life  of  someone  suffering  from  a  terminal  disease  

1. Active:  Physician  or  person  takes  action  2. Passive:  withdrawal  of  care  3. Voluntary:  used  by  the  individual  

a. Institutions:  ethics  comities    

4. Futility?  a. Medical  futility:  use  of  medical  intervention  without  a  realistic  hope  of  benefit.  b. Economic:  Focus  on  ways  to  eliminate  unnecessary  interventions  c. Patients  or  families:  Can  they  demand  treatment  that  is  futile?  d. Doctors:  Can  they  refuse  treatments  they  believe  to  be  futile?  

Advanced  Directives  

1. Living  Will  (advanced  Directive)  a. Document  where  a  person  states  in  advance  that  life  sustaining  treatment  is  not  to  be  

administered  if  the  person  is  later  terminal  and  incompetent.  b. Can  include  anything  the  patient  wants  c. Does  not  carry  the  weight  of  a  medical  order,  no  requirement  to  follow  it.  d. Does  not  take  effect  until  the  person  losses  competence.  

2. Health  Care  Proxy  a. An  instrument  (or  document)  that  allows  a  patient  to  appoint  an  agent  to  make  health  

care  decisions  in  the  event  that  the  primary  individual  is  incapable  of  executing  such  decisions.  

3. DNR/DNI  orders  a.  A  binding  legal  document  that  states  resuscitation  should  not  be  attempted  if  a  person  

suffers  cardiac  or  respiratory  arrest.    Can  be  part  of  a  living  will.  4. Medical  orders  for  life  sustaining  treatment  (MOLST):  requires  review  with  the  physician  

a. Creates  treatment  guidelines  in  regards  to  care  during  the  last  6  months  of  a  person’s  life.    It  includes  DNR,  DNI,  Ventilation,  Antibiotics,  Feedings,  and  other  specific  areas.  

b. It  has  to  ability  to  be  modified  by  the  patient.  

Right  to  refuse  medication:  

  Involuntary  administration  of  psychotropic  medications  

Three  criteria:  Exhibit  behavior  that  is  dangerous  to  self  or  others,  medication  must  be  to  help,  person  must  be  declared  incompetent.  

Restraints:  right  to  least  restrictive  treatment:    

  What  is  least  restrictive:  chemical,  seclusion,  mechanical  

JACAHO  standards  

1. Can  a  nurse  initiate  mechanical  restraints.    YES  (emergency,  notify  physician  and  get  order  1hr)  2. Can  a  nurse  practitioner  or  physician’s  assistant  order  restraints  –  NO,  MD  only  3. Client  needs  assessment  every  10-­‐15  minutes  4. Physician  must  re-­‐evaluate  

Involuntary  commitment:  14th  amendment  (liberty  and  due  process)  

• Criteria:  danger  to  self  or  others.  • Observation  and  treatment  of  mental  illness  and  unable  to  make  informed  decision  and  inability  

to  care  for  basic  personal.  

Child  Abuse    

1. Abuse    a. Physical  abuse:  Any  physical  injury  as  a  result  of  punching,  beating,  kicking,  biting,  

burning,  shaking,  throwing,  stabbing,  choking,  hitting  (with  a  stick,  hand,  strap,  or  other  object),  or  otherwise  harming  a  child.    (non  accidental)  

b. Emotional  abuse:  a  pattern  of  behavior  on  part  of  the  parent  or  caretaker  that  results  in  serious  impairment  of  the  child’s  social,  emotional,  or  intellectual  function.  

i. Belittling,  rejecting,  ignoring,  blaming  for  things  he  or  she  has  no  control,  isolating  the  child  from  normal  social  experiences,  and  using  harsh  and  inconsistent  discipline.    

2. Nursing  assessment  a. Comprehensive  history  and  physical  examination  with  documentation  of  findings.  b. Consultation  with  social  service  agencies.  

3. Risk  factors  a. Single  parent  homes  have  a  higher  percentage  of  child  abuse.  (risk  factor)  b. Large  family  (risk  factor)  c. Low  socioeconomic  status  (risk  factor)  d. Family  that  moves  a  lot  (risk  factor)  

4. Underreported  a. Confusion  over  the  laws  and  procedures  b. Lack  of  knowledge  and  awareness  of  warning  signs  and  clues  c. Influence  of  own  values  

5. Child  abuse  definition  a. A  child  less  than  18  year  old  whose  parent  or  other  person  legally  responsible  for  the  

child’s  care:  b. Inflicts  or  allows  to  be  inflicted  physical  injury  c. Commits/allows  to  be  committed,  a  sex  offense.  d. Creates  or  allows  to  be  created  a  substantial  risk  of  physical  injury.  

6. Neglected  child  a. Physical,  mental,  or  emotional  condition  has  been  impaired  or  is  in  imminent  danger  of  

becoming  impaired  as  a  result  of  a  failure  by  parent  or  guardian.  7. Person  legally  responsible.  

a. Parental  substitute  b. Guardian  or  custodian  c. Anyone  who  allows  that  injury  to  happen  when  caring  for  the  child.  

8. Types  of  Abuse  a. Sex  abuse:  sexual  offense,  or  allows  a  sex  offense.  b. Physical  neglect:  withholding  or  failure  to  provide  a  child  with  adequate  food  and  

shelter,  adequate  supervision,  abandonment  which  impairs  or  imminent  risk  of  impairment  to  the  child.  

9. Possible  causes  a. Immaturity  b. Unmeet  emotional  needs  c. Stresses  of  child  care  d. Economic  crisis  e. Lack  of  parenting  knowledge  f. Drug  or  alcohol  problems  g. Hx  of  violence  as  normal  way  to  interact  

10. Accidental  vs  inflicted  injuries  a. 56-­‐60%  of  fractures  in  child  under  1  is  intentional  

i. Walking  infants  have  higher  change  of  accidental  injury  b. Accidental  injuries  usually  occur  at  bony  prominences  c. Inflicted  injuries  tend  to  be  in  the  face,  buttocks,  soles  of  feet.  d. Level  of  development  needs  to  be  considered.  Is  the  explanation  plausible  .  e. Scalding  is  a  common  form  of  physical  abuse.  

11. Excessive  physical  punishment  a. Lack  of  ability  to  understand  discipline  b. Is  a  less  severe  method  likely  effective.  c. Is  punishment  unnecessarily  degrading?  d. Punishment  inflicted  for  gratification  of  the  parent’s  rage?  e. Was  punishment  brutal?  

12. Possible  physical  indicators  of  abuse  a. The  more  injuries,  the  more  suspicious  b. Inconsistencies  of  explanation  vs  injury  c. Most  common  abuse  injuries  

i. Subdural  hematoma  ii. Retinal  hemorrhaging  iii. Broken  nose  iv. Broken/missing  teeth  v. Skull  fractures  vi. Broken  jaw  vii. Human  bite  viii. Broken  bones  in  various  stages  of  healing  ix. burns  

d. Blood  in  urine  e. Injuries  that  occur  after  the  weekend  f. Severe  apprehension  (can’t  cry  when  hurt)  

13. Sighs  of  possible  abuse:  look  for  multiple  indicators  a. Habit  disorder:  rocking,  sucking,  etc.  b. Self  injury  behavior  to  attract  attention  c. Covering  up  to  hide  injuries  d. Fire  setting  

e. Torturing  animals  14. Shaken  baby  syndrome  

a. Head  injury  &  leading  cause  of  death  of  child  abuse  b. Subdural  or  subarachnoid  hemorrhage  c. Neck  muscles  are  not  strong  enough  allowing  the  brain  to  move  back  and  forth  in  the  

skull.  d. Signs  

i. Seizures  ii. Retinal  hemorrhages  iii. Dilated  pupils  iv. Developmental  delays  v. Vomiting  vi. Coma  vii. Spinal  chord  damage  viii. Death  

e. Child  may  be  initially  seen  without  any  signs  of  head  trauma,  but  70-­‐75%  have  retinal  hemorrhages  

15. Munchausen’s  syndrome  by  proxy  a. Parent  hurts  the  child  to  get  attention  for  themselves  b. Usually  the  mother  fabricates  injury  or  causes  them.  c. Does  the  history  make  sense?    Is  mom  always  present  when  symptoms  occur  in  

hospital?  d. Symptoms  like  blackouts,  vomiting  blood,  seizures  that  only  mom  witnesses.  

16. Behavioral  indicators  of  child  abuse    a. Wary  of  adult  control    b. Apprehensive  when  children  cry  c. Aggressive,  withdrawn  or  extreme  mood  changes  d. Afraid  to  go  home  e. Report  of  injury  by  parents  f. Habit  disorder  g. Low  self  esteem  h. Suicide  attempts  

17. Physical  indicators  of  neglect  a. Failure  to  thrive  b. Lags  in  physical  development  c. Consistent  hunger  –  poor  hygene  d. Consistent  lack  of  supervision  e. Unattended  medical  needs  f. Chronic  truancy  g. Abandonment  

18. Neglect  behavioral  indicators  a. Begging,  stay  at  school,  fatigue,  constant  hunger,  seeks  affection  any  adult,  delinquency.  

19. Sexual  Abuse  a. The  sound  the  child  makes  when  sexually  assaulted  is  often  SILENCE  b. Erase  the  shame  and  place  the  blame.  c. Why  don’t  kids  tell?  

i. Too  young  to  recognize  their  victimization  or  put  it  into  words  ii. They  were  threatened  by  the  abuser  iii. Feel  confused  by  fearing  the  abuse  but  liking  the  attention  iv. Afraid  no  one  will  believe  them  v. Blames  themselves.  

d. Education  is  the  best  defense  against  child  sexual  assault.  e. Types  of  sexual  abuse  

i. Touching,  sexual  intercourse,  forcing  or  encouraging  engagement  in  sexual  activity  with  other  children  or  adults.  

20. Sexual  abuse  physical  indicators  a. Painful  or  itchy  genitalia  b. Bruises  to  hard  or  soft  pallet  c. STD  in  a  child,  pregnancy,  dysuria,  repeated  UTI  d. Foreign  body  in  vagina  or  rectum  

21. Sexual  abuse  behavioral  indicators  a. Will  not  change  for  gym  b. Withdrawal,  fantasy  or  infantile  behavior  c. Based  on  age,  increased  amount  of  sexual  knowledge  d. Poor  peer  relationships  e. Runaway  f. Fear  of  closeness  or  physical  contact  g. Low  self  esteem  h. Suicide  attempts  

22. Interviewing  (Sexual  abuse)  a. Be  non-­‐judgmental,  relaxed  atmosphere  b. Interview  parent  separate  from  child  c. Avoid  suggesting  answers  d. Listen  e. Give  support,  do  not  make  promises  f. When  talking  to  them  

i. Explain  your  role,  be  objective,  use  a  quiet,  neutral  setting,  use  child’s  own  words,  end  interview  on  positive  note.  

23. Emotional  abuse  a. Clues:  speech  disorders,  lags  in  physical  development,  failure  to  thrive  b. Grades  could  go  up  or  down  

24. If  you  suspect  abuse  a. Keep  calm  b. Believe  the  child  

c. Reassure  the  child  d. Listen  to  and  answer  questions  honestly  e. Never  pressure  the  child  to  talk  or  avoid  talking  about  the  abuse  f. Respect  the  child’s  privacy  g. Never  confront  the  offender  

25. Reasonable  cause  a. Distrust  or  doubt  is  enough  b. Based  on  observation  or  disclosure  c. Child  is  harmed  or  in  imminent  danger  of  harm  d. Must  be  able  to  entertain  the  possibility  that  it  could  have  been  neglect  or  non-­‐

accidental.  26. REPORT  ABUSE  

a. If  a  child  has  a  mark  or  a  bruise  and  reports  that  an  adult  caused  it,  you  are  mandated  to  report  it.  

b. Five  essential  elements  for  report  i. Child  is  under  18  ii. Jurisdiction  is  within  New  York  State  iii. Demographics  –  names,  addresses,  etc.  (where  is  going  on?)  iv. Allegations  (the  abuse  and/or  maltreatment  that  is  suspected)  Is  it  going  on  

now?    What  type  of  abuse,  is  it  an  ongoing  pattern  v. Person  legally  responsible  for  the  child’s  care  at  the  time  of  the  abuse.  

c. Mandated  report  line  :  1  800-­‐635-­‐1522  i. Child’s  age,  gender  and  race  ii. Where  is  the  child  iii. Person  responsible  for  causing  the  abuse  iv. Special  needs?  v. Concerns  for  local  CPS  (weapons?)  vi. Any  siblings  in  the  house?  vii. What  type  of  abuse  and  extent?  viii. When  does  it  happen,  when  was  the  last  time?  

d. Make  the  call:  get  the  case  number.    NY  State  Child  abuse  and  maltreatment  register.  i. Follow  up  the  call  with  a  written  report  within  48  hours.  ii. Local  district  response  

1. Investigation  will  begin  within  24  hours  and  will  verify  report  and  develop  a  plan.  

2. Determination  of  report  within  60  days.  e. Immunity:  report  made  in  good  faith,  presumed  the  action  is  done  in  good  faith  when  

done  in  the  course  of  their  official  duties  and  within  the  scope  of  their  employment.