Chapter 18: Communication and Relational Practice (pg.

279-280)

Metacommunication
● Refers to all factors influencing how a message is perceived by other
people

● Involves awareness of the tone of a verbal response and the

nonverbal behaviour associated with it, ensuring a better understanding
of patient’s feelings and concerns

Nurse-Patient Helping Relationships

● Helping relationships are the foundation of clinical nursing practice

● Enforced through care, skill, and development of trust

● Relationship is therapeutic, promoting an environment that facilitates

positive change and growth

● Therapeutic communication allows patients to achieve their health care

and attain optimal personal growth

● A goal-directed approach, an explicit time frame, and confidentiality

● Four goal-directed phases: preinteraction, orientation, working,

termination

● Nurse establishes, directs, and takes responsibility for the interaction

● Patient’s needs take priority over the nurse’s needs

● Relationship is further characterized by nurse’s nonjudgemental
acceptance of patient

● Acceptance refers to conveying a willingness to hear and acknowledge

patient’s feelings, despite disapproving with patient’s decisions/actions

● Therapetic interactions are typically difficult, intense, and

uncomfortable

● Nurses must get beyond social conversation to talk about issues or

concerns affecting patient’s health

● Nurses should be skillful in using judgement about what to share and

provide minimal information or deflecting certain questions with gentle
humour and redirecting conversations back to patient

● Creating a therapeutic environment depends on one’s ability to

communicate, comfort, and help patients meet their needs

● Comfort is crucial in the practice of nursing

● Therapeutic interactions increase feelings of personal control by

helping patients feel secure, informed, and valued

● Optimizing personal control facilitates emotional comfort, minimizing

physical discomfort and promoting recovery
 ● Nurses often encourage narrative interactions by allowing patients to
share personal stories

● Collaborative communication promotes personal responsibility, enables

self-expression, and strengthens patient’s problem-solving abilities

Preinteraction Phase - Before meeting the patient, the nurse should:

★ Review available data, including medical and nursing history

★ Talk to other caregivers who may have information about the patient

★ Anticipate health care concerns or issues that may arise

★ Identify a location that will foster comfortable, private interactions with

patient

★ Plan enough time for initial interaction

Orientation Phase - When the nurse and patient meet, the nurse
should:
★ Set the tone for the relationship by adopting a warm, empathetic,
caring manner

★ Expect the patient to test the nurse’s competence and commitment

★ Closely observe patient and expect the same treatment by the patient

★ Form judgements and make inferences about patient’s behaviours

 ★ Assess patient’s health status

★ Prioritize patient’s problems and identify their goals

★ Clarify patient’s and nurse’s roles

★ Negotiate a contract with patient that specifies who will do what

★ Let patient know when to expect relationship to be terminated

Working Phase - When the nurse and patient work together to solve
problems and achieve goals, the nurse should:
★ Encourage and help patient express feelings about their health

★ Encourage and help patient express their own feelings and thoughts

★ Provide information that the patient needs to understand and to

change behaviour

★ Encourage and help patient set goals

★ Use therapeutic communication skills to facilitate successful

interactions

★ Use appropriate self-disclosure and confrontation

Termination Phase - During the end of the relationship, the nurse

should:
★ Remind the patient that the relationship termination is near
 ★ Evaluate goal achievement with patient

★ Reminisce about the relationship with patient

★ Separate from patient by relinquishing responsibility for their care

★ Facilitate a smooth transition for patient to other caregivers as

needed

Elements of Professional Communication

● Common courtesy
● Proper use of names
● Trusworthiness
● Autonomy (self-regulation and independent in accomplishing goals)
● Assertiveness

Chapter 10: Legal Implications in Nursing Practice (pg. 124)

Invasion of Privacy
● Tort of invasion of privacy protects patient’s right to be free from
unwanted intrusion into their private affairs

● Patients are entitled to confidential healthcare

● Invasion of privacy includes releasing patient’s medical information to
an unauthorized person, such as a member of the press, patient’s
employer, or via social media
● Information contained in a patient’s medical record is a confidental
communication and should only be shared with healthcare providers for
the purpose of medical treatment

● Confidentiality is not an absolute value, however, and in certain

circumstances breaching confidentiality is justifiable

● A nurse may be required by law (statutory duty) to breach

confidentiality and disclose information to a third party
○ Eg. Reporting suspected child abuse to CPS or the notification
of the police when patient has sustained a gunshot or stab
wound

● Nurses are under no legal obligation to release confidential information

to the police except when life, safety, or health of patient or innocent
third party is in jeaopardy
○ Eg. If patient tells nurse that they intend to hurt or kill someone,
it should be reported to employer’s administration or legal
counsel before being released to police, according to Canadian
Nurses Protective Society (CNPS)

● Conflict between confidentiality and risk of public harm is sometimes

unclear
○ Eg. If HIV+ patient admits to having unsafe sex or donating blood,
nurse should first strongly encourage patient to disclose such
information

● Need for privacy and confidentiality of privileged communication and

need for public safety should be weighed carefully
False Imprisonment
● Tort of false imprisonment serves to protect a person’s individual
liberty and basic rights

● Preventing a patient from leaving a health care facility voluntarily may

constitute the tort of false imprisonment

Negligence
● Tort of negligence is referred to as malpractice

● Does not meet a standard of care established by law

● Involves carelessness, such as not checking an identification bracelet,

resulting in the administration of the wrong medication

● Defined as the failure to use degree of skill or learning ordinarily used

under the same or similar circumstances by members of the nursing
profession

Chapter 10: Legal Implications in Nursing Practice (pg. 126-127)

Consent
● A signed consent form is required for all routine treatment,
procedures such as surgery, some treatment programs such as
chemotherapy, and research involving patients
● If a patient is deaf or does not communicate in the language of the
health care providers, an official interpreter must be used to explain
the terms of consent

● A caregiver or acquaintance who can speak a patient’s language should

not be used to interpret health information except as a last resort

● In general, the following factors must be verified for consent to be

legally valid:
○ The patient must have the legal and mental capacity to make a
treatment decision
○ The consent must be given voluntarily and without coercion
○ The patient must understand the risks and benefits of the
procedure or treatment, the risks of not undergoing the
procedure or treatment, and any available alternatives to the
procedure or treatment

● Informed Consent is a person’s agreement to allow a medical action to

happen, such as surgery or an invasive procedure, based on full
disclosure of the likely risks and benefits of the action, alternatives to
the action, and the consequences of refusal

● Creates a legal duty for the physician or other health care provider to
disclose material facts in terms that the patient can reasonably
understand in order to make an informed choice
○ The explanation should also describe treatment alternatives, as
well as the risks involved in all treatment options

● The following elements are required for informed consent to be valid

 ○ Capacity to consent - The person must be capable of making
an informed decision about the specific intervention proposed
○ Information: - The person must be provided with enough
information to make the decision
○ Voluntariness - The decision must be voluntary and not the
result of coercion or undue influence

● A legally capable person’s consent is considered informed if they have

received adequate information about nature and purpose of the
proposed treatment, its expected benefits, and its material risks
(including the risks of possible harm, permanent damage, or death, as
well as the risks of not proceeding)

● Informed consent is part of the relationship between health care

providers and patients

● When nurses provide consent forms for patients to sign, the patients
should be asked whether they understand the procedures to which
they are consenting. If they deny understanding or if the nurse
suspects that they do not understand, the nurse must notify the
physician or nursing supervisor

● If a patient refuses treatment, this should also be written, signed, and

witnessed

● Many of the procedures that nurses perform do not require formal

written consent; nonetheless, a patient’s right to consent to or refuse
treatment must be protected
 ● If the patient resists the injection either verbally or through actions, the
nurse must not proceed with the injection

● Parents are usually the legal guardians of pediatric patients and are
therefore responsible for signing the consent forms for treatment

● In some instances, obtaining informed consent is difficult or simply not

possible

● Other surrogate decision makers may have legally been delegated this
authority through proxy directives or court guardianship procedures

● If it is impossible to obtain consent from the patient or an authorized

person, the procedure required to benefit the patient or save the
patient’s life may be undertaken without liability for failure to obtain
consent
○ In such cases, the law assumes that the patient would wish to
be treated (this is referred to as the emergency doctrine)

● Patients with mental health issues and frail older persons must also
be given the opportunity to give consent

Legal Liability
● Nursing students must know their own capabilities and competencies
and must not perform nursing actions unless competent to do so

● If a student nurse performs a nursing action, the student will be held

to the same standards as a reasonable, competent professional
 nurse and may be subject to the same legal consequences for actions
that fail to meet those standards

Chapter 16: Documenting and Reporting (pg. 236-237)

Education
● By reading a patient record, one can learn the nature of an illness and
an individual’s response to it

● Patient record includes diagnoses, signs and symptoms of disease,

successful and unsuccessful therapies, diagnostic findings, and patient
behaviours

● Reviewing records of patients who have similar health problems can

identify patterns of information and anticipate the type of care
required of a patient

Electronic Records
● The electronic health record (EHR) is used increasingly to refer to a
lifetime record of all healthcare encounters

● The electronic medical record (EMR) is the legal record that describes
a single encounter or visit by a patient to a hospital or outpatient
health care setting and is the source of data for the EHR

● EHR has the ability to integrate all patient information into one record,
regardless of the number of times a patient enters a healthcare
system
● EHR also includes the results of diagnostics studies, which may include
diagnostic images and decision support software programs

● Healthcare providers can access clinical data to identify quality issues,

link interventions with positive outcomes, and make evidence-informed
decisions
● EHR includes tools to guide and critique medication administration and
basic decision-support tools such as physician order sets and
itnerdisciplinary treatment plans

● EHR gives nurses a way to compare current clinical data about a

patient with data from previous healthcare encounters, and a way to
maintain an ongoing record of health education provided to a patient

● The quality of patient care depends on the nurse’s ability to

communicate with other members of the healthcare team

● When a plan is not communicated to all members of the healthcare

team, care becomes fragmented, tasks are repeated, and delays in
care often occur

● Nurses are legally and ethically obligated to keep information and

patients confidential

● Only members of the healthcare team who are directly involved in a

patient’s care have authorized access to the medical record
● The nurse may discuss a patient’s diagnosis, treatment, assessment,
and any personal conversations only with members of the healthcare
team involved in that patient’s care

● Patients have the right to request copies of their medical records and
read the information contained therein

● Most times, patients are required to give written permission for

release of medical information

● To protect patient confidentiality, nursing students must ensure that

written or electronic materials used in a student clinical practice do
not include patient identifiers (eg. room number, date of birth,
demographic information), and information from an EHR should never
be printed for personal use

● Students need to make sure that the patient-identifiable information

(eg. files, stickers, information in notebooks, worksheets) is not taken
home and that it is disposed of correctly in a secure bin for
shredding

● Examples of breaches of confidentiality include accessing information

not related to one’s duties; discussing patient information in an
innapropriate area, such as in an elevator or on public transport;
revealing confidential patient or co-worker details to a caller; emailing
patient information through a public network such as the Internet; and
leaving confidential material in a public area
 ● The Personal Information Protection and Electronic Documents Act
(PIPEDA) is a federal legislation that protects personal and health
information

● PEPEDA delegates how private-sector organizations may collect, use,

or disclose personal information

● Healthcare agencies track who accesses patient records and when

they access them

● Historically, the main source for unauthorized disclosure of personal

health information (PHI) occurred wheen information was printed from
a patient record or faxed to other healthcare providers. Thus, nurses
need to destroy all papers containing PHI immediately after
using/faxing them

Chapter 2: The Canadian Health Care Delivery System (pg. 30)

Rehabilitation
● The aim of rehabilitation nursing is to improve the health and quality of
life of individuals who are facing life-altering conditions, regardless of
age or circumstance

● Rehabilitation occurs after a physical or mental health illness, injury,

chemical addiction, chronic illness, disability, fraility, and aging occur
● Begins the moment a patient enters a healthcare setting as part of
an interdisciplinary effort
 ● Assists patients with returning to their previous level of function or
reaching an optimal level of function, establishing quality of life while
promoting independence and self-care

Supportive Care
● Chronic (i.e., long term) or progressive (i.e., worsen over time)
illnesses or disabilities may require supportive care

● Supportive care consists of health, personal, and social services

provided over a prolonged period to people who are disabled, do not
function independently, or have a terminal disease

● Demand for supportive care will continue to grow in response to

increasing lifespans, escalating chronic conditions, and the expanding
diversity of care settings

● Palliative and respite care are examples of supportive care

Challenges to Healthcare System

● Successful health care system must continue to evolve and realign
resources to meet changing population needs, foster evidence-
informed care, ensure equitable access to care, and contain costs

● Rising costs and increasing wait times have fueled an ideological

debate about how the health care system should be funded and
delivered

● Right-wing political groups assert that health care costs are rising at
unsustainable rates and call for privatization, whereas left-wing political
 groups argue for system restructuring and increased breadth of
coverage

● Canadians will be faced with increasing extreme cold and heat events,
weather-related natural disasters, poor air quality, waterborne and
foodborne contamination, exposure to ultraviolet light, and changing
patterns of vectorborne and zoonotic diseases

● Extent of impacts on human health will depend on how fast climate

changes and how well healthcare systems can adapt to cope with
associated challenges and health risks

Chapter 35: Medication Administration and Management (pg. 744)

Administering the Right Dose

● When performing a medication calculation or conversion, ensure that
another nurse verifies the calculated dose

● Only tablets that are scored by the manufacturer should be broken

● Discard tablets that do not break evenly

● Nurse should verify with the employer policy before administering a

tablet that has been opened, cut, and repackaged

Right Patient
● To identify a patient correctly, ask the patient to state their name
 ● Compare the patient’s name and another identifier (e.g., hospital
identification number) on the MAR against the information on the
patient’s identification bracelet

● Scan the patient’s barcode on their identification bracelet, if applicable

Right Time and Frequency

● Medications prescribed to follow an ongoing, consistent, standard dosing
schedule are referred to as routine

● When a preoperative medication is to be given on call the nurse needs

to administer the medication when notified that the patient can be
transferred for surgery by health care providers in the operating room

● A medication prescribed pc (after meals) is to be given within half an

hour after a meal, when the patient has a full stomach

● A stat medication is to be given immediately

Chapter 35: Allergic Reactions (pg. 730-731)

Membrane Permeability
● Some membranes serve as barriers to the passage of medications
● Eg. the blood–brain barrier allows only fat-soluble medications to pass
into the brain and cerebrospinal fluid
● Therefore, central nervous system (CNS) infections require treatment
with antibiotics that selectively cross the blood–brain barrier

Protein Binding
 ● The degree to which medications bind to serum proteins (e.g., albumin)
affects medication distribution

● Most medications bind to proteins and then become inactive

● The unbound, or free, medication is the active form of the medication

● Patients who have liver disease or malnutrition and older persons have
a decrease in albumin circulating in their blood to bind to medication
and therefore can experience increased or toxic effects of medication
Metabolism
● After a medication reaches its site of action, it metabolizes into a
less active/inactive form that is more easily eliminated

● Biotransformation occurs when enzymes detoxify, degrade (break

down), and remove the biologically active substance or drug

Elimination
● After medications are metabolized, they exit the body through the
kidneys, liver, bowel, lungs, or exocrine glands

● The chemical makeup of a medication determines the organ of

elimination

● Gaseous and volatile medications, such as nitrous oxide and alcohol,

exit through the lungs

● Deep breathing and coughing help the postoperative patient to

eliminate anaesthetic gases more rapidly
 ● The exocrine glands (e.g., sweat glands) eliminate lipid-soluble
medications, often causing skin irritation

● Medications eliminated through the mammary gland place a

breastfeeding infant at risk of ingesting the chemicals

● Factors that increase peristalsis (e.g., laxatives and enemas)

accelerate medication elimination through the feces, whereas factors
that slow peristalsis (e.g., inactivity and improper diet) may prolong a
medication’s effects

● The kidneys are the main organs for medication elimination

● If renal function declines, a patient is at risk for medication toxicity

● If the kidneys cannot effectively eliminate a medication, the dose may

need to be reduced

● Maintenance of an adequate fluid intake (50 mL/kg/day) promotes

proper elimination of medications for the average adult

● The therapeutic effect is the expected or predictable physiological

response that a medication causes

Allergic Reactions
● Allergic reactions are unpredictable responses to a medication. Some
patients become immunologically sensitized to the initial dose of a
medication
 ● The medication or chemical acts as an antigen, triggering the release of
the body’s antibodies

● Anaphylactic reactions are severe reactions that are life-threatening

and are characterized by sudden constriction of bronchial muscles,
edema of the pharynx and larynx, severe wheezing, shortness of
breath, and circulatory collapse
○ Immediate use of antihistamines, epinephrine, or bronchodilators
is required to treat anaphylactic reactions

● A patient with a known history of an allergy to a medication needs to

avoid exposure to that medication and must wear a bracelet or medal
engraved with emergency medical information, including medication
allergies

Medication Interactions
● When one medication modifies the action of another medication, a
medication interaction occurs

● Medications that do not interact are referred to as compatible

● When two medications have a synergistic effect, the combined effect

of the two medications is greater than the effect of the medications
when given separately
○ For example, alcohol acts as a depressant on the CNS and has
a synergistic effect (i.e., increases sedation effects of)
antihistamines, antidepressants, barbiturates, and opioids
Chapter 5: Practical Nursing in Canada (pg. 68)

Acts That Govern Health Care Professions

● Separate acts for individual healthcare professions are being removed
and replaced with a single, generic umbrella act that applies to all
healthcare professions

● Umbrella acts enable consistency in rules and processes across all

aspects of regulation and enable the public to better understand
these processes

● Nonexclusibity of controlled/reserved acts allow greater practice

flexibility and interprofessional care

● Controlled or authorized acts (called restricted acts in BC and

reserved acts in Manitoba) are acts that are harmful unless
performed by qualified persons

Regulatory Bodies
● Each profession must have a regulatory body that governs it
● Primary mandate of nursing regulatory bodies is protection of the
public, which is accomplished through self-regulation

● Responsible for ensuring that the professional title of registered

members is protected or reserved

● Regulatory body in each province and territory determines whether

applicants have sufficient educational background and competency for
registration as a practical nurse