FUNDA-ims-MIDTERMS (2).docx

Republic of the Philippines **ISABELA STATE UNIVERSITY** City of Ilagan Campus, Isabela **COLLEGE OF NURSING** **FUNDAMENTALS** **OF NURSING PRACTICE** **MIDTERMS** **SCOPE OF NURSING PRACTICE** **RA 9173** "Philippine Nursing Act of 2002": AN ACT PROVIDING FOR A MORE RE...

Republic of the Philippines **ISABELA STATE UNIVERSITY** City of Ilagan Campus, Isabela **COLLEGE OF NURSING** **FUNDAMENTALS** **OF NURSING PRACTICE** **MIDTERMS** **SCOPE OF NURSING PRACTICE** **RA 9173** "Philippine Nursing Act of 2002": AN ACT PROVIDING FOR A MORE RESPONSIVE NURSING PROFESSION, REPEALING FOR THE PURPOSE REPUBLIC ACT NO. 7164, OTHERWISE KNOWN AS "THE PHILIPPINE NURSING ACT OF 1991" AND FOR OTHER PURPOSES Link: [[Republic Act No. 9173 \| Official Gazette of the Republic of the Philippines]](https://www.officialgazette.gov.ph/2002/10/21/republic-act-no-9173/) **Sec. 28** Scope of Nursing Practice -- A person shall be deemed to be practicing nursing within the meaning of this Act when he/she singly or in collaboration with another, initiates and performs nursing services to individuals, families and communities in any health care setting. It includes, but not limited to, nursing care during **conception, labor, delivery, infancy, childhood, toddler, pre-school, school age, adolescence, adulthood and old age**. As independent practitioners, nurses are primarily responsible for the **promotion of health and prevention of illness**. As members of the health team, nurses shall collaborate with other health care providers for the **curative, preventive, and rehabilitative aspects of care, restoration of health, alleviation of suffering, and when recovery is not possible, towards a peaceful death**. It shall be the duty of the nurse to: \(a) Provide nursing care through the utilization of the nursing process. Nursing care includes, but not limited to, traditional and innovative approaches, therapeutic use of self, executing health care techniques and procedures, essential primary health care, comfort measures, health teachings, and administration of written prescription for treatment, therapies, oral, topical and parenteral medications, internal examination during labor in the absence of antenatal bleeding and delivery. In case of suturing of perineal laceration, special training shall be provided according to protocol established; \(b) Establish linkages with community resources and coordination with the health team; \(c) Provide health education to individuals, families and communities; \(d) Teach, guide and supervise students in nursing education programs including the administration of nursing services in varied settings such as hospitals and clinics; undertake consultation services; engage in such activities that require the utilization of knowledge and decision-making skills of a registered nurse; and \(e) Undertake nursing and health human resource development training and research, which shall include, but not limited to, the development of advance nursing practice; Provided, that this section shall not apply to nursing students who perform nursing functions under the direct supervision of a qualified faculty: Provided, further, that in the practice of nursing in all settings, the nurse is duty-bound to observe the Code of Ethics for nurses and uphold the standards of safe nursing practice. The nurse is required to maintain competence by continual learning through continuing professional education to be provided by the accredited professional organization or any recognized professional nursing organization: Provided, finally, That the program and activity for the continuing professional education shall be submitted to and approved by the Board. **Code of Ethics for Nurses** The code of ethics is the philosophical ideals of right and wrong that define the principles you will use to provide care to your clients. **Basic Principles to Maintain** - **Advocacy** -- refers to the support of a cue. As a nurse, you advocate for the health, safety and rights of the clients. - **Responsibility** -- refers to a willingness to respect obligations and to follow through on promises. - **Accountability** - refers to the ability to answer for one's own actions. - **Confidentiality** -- protection of client's personal health information. The legislation defines the rights and privileges of clients or protection of privacy without diminishing access to quality care. Nursing practice is governed by many legal concepts. It is important for nurses to know the basics of legal concepts, because nurses are accountable for their professional judgments and actions. **Accountability** is an essential concept of professional nursing practice and the law. Knowledge of laws that regulate and effect nursing practice is needed for two reasons: 1. To ensure that the nurse's decisions and actions are consistent with current legal principles. 2. To protect the nurse from liability. **Functions of the Law in Nursing** The law serves a number of functions in nursing: - It provides a framework for establishing which nursing actions in the care of clients are legal. - It differentiates the nurse's responsibilities from those of other health professionals. - It helps establish the boundaries of independent nursing action. - It assists in maintaining a standard of nursing practice by making nurses accountable under the law. **Civil and Common Law Issues in Nursing Practice** **TORTS** - An act or omission that gives rise to injury or harm to another and amounts to a civil wrong for which courts impose liability. - Classifications for torts include intentional, quasi-intentional, or unintentional. **Intentional Torts** - are willful acts that violate another's rights, such as assault, battery and false imprisonment. - wrongful civil acts done on purpose. a. **Assault** -- is any intentional threat to bring about harmful offensive contact. No actual contact is necessary. The law protects clients who are afraid of harmful contact. It is an assault for a nurse to threaten to give a client an injection or to threaten to restrain a client for an x-ray procedure when the client has refused consent. The key issue is the client's consent. In an assault lawsuit, if the client's give consent, the nurse is not responsible for assault. b. **Battery** -- is any intentional touching without consent. The contact can be harmful to the client and cause an injury or it can be harmful to the client and cause an injury, or it can be merely offensive to the client's personal dignity. A battery always includes an assault, which is why the terms assault and battery are commonly combined. c. **False Imprisonment** -- the tort of false imprisonment occurs with unjustified restraining of a person without legal warrant. For example, this occurs when nurses restrain a client in a bounded area to keep the person from freedom. **Quasi-intentional torts** - are acts where intent is lacking but volitional action and direct causation occur, such as found with invasion of privacy and defamation of character. a. **Invasion of Privacy** -- the tort of invasion of privacy protects the client's right to be free from unwanted intrusion into his or her private affairs. The four types of invasions of privacy torts are; - intrusion on seclusion - appropriation of name or likeness - publication of private or embarrassing facts - publicity placing one in a false light in the public eye b. **Defamation of Character** -- is the publication of false statements that result in damage to a person's reputation. The statements must be polished with malice in the case of a public official or public figure. **Unintentional tort** -- occurred when the tortfeasor\'s actions were unreasonably unsafe. a. **Negligence** -- is conduct that falls below a standard of care the law established the standard of care for the protection of other against an unreasonably great risk for harm. b. **Malpractice** -- malpractice is one type of negligence and often referred to as professional negligence. When nursing care falls below a standard of care, nursing malpractice results. To establish nursing malpractice, there are certain criteria: **THE FOUR ELEMENTS OF MALPRACTICE** **Duty** - The plaintiff must first show that the nurse had a duty to provide care for the plaintiff. The element of duty is usually straightforward and relatively easy for the plaintiff to prove because once nurses undertake care for their patients, they have a clear duty to provide care for that patient in a competent and reasonable manner. Nurses owe a clear duty of care to all of their patients. **Breach of Duty** - When applied to nursing, a breach of a duty occurs when a nurse does, or does not do, what a reasonable nurse would have done under the same, or similar, circumstances. This would mean that the nurse's care fell below the acceptable standard of care. The standard of care is a legal concept which reflects how a nurse is expected to act professionally. It incorporates the expectation that nurses conduct themselves with the degree of care, skill and knowledge that reasonably competent nurses would exhibit in a similar situation. **Injury** - To prove the element of injury the plaintiff must be able to establish that, in addition to pain and suffering, they have experienced a physical injury, lost money or have an actual reduction in the quality of their life. The injury which the plaintiff suffered will help to determine the monetary damages that will be awarded if the plaintiff succeeds at trial. **Causation** - is often the most difficult element of medical malpractice to prove. In order to prove that the defendant caused their injury, loss or harm, the plaintiff must show that the defendant\'s act or omission either caused, or was a substantial factor in causing, harm to the plaintiff. If the defendant proves that the harm would have occurred anyway, irrespective of the defendant's act or omission, then the negligence action will fail for lack of causation. **OTHER TERMINOLOGIES TO REMEMBER** **Consent** \- A signed consent form is required for all routine treatment, hazardous procedures such as surgery, some treatment programs such as chemotherapy, and research involving clients. \- If a client is deaf, illiterate, or speaks a foreign language, there needs to be an official interpreter to explain the terms of consent. A family member or acquaintance who speaks client's language should not interpret health information. Make every effort to assist the client in making an informed choice. **Informed Consent** \- Is a person's agreement to allow something to happen, such as surgery or an invasive diagnostic procedure, based on a full disclosure of risks, benefits, alternatives. And consequences of refusal. **Telephone Order** \- A telephone order involves a physician's or health care provider's stating prescribed therapy over the phone to a registered nurse. A verbal order may be accepted when there is no opportunity for a physician or health care provider to write the order, as an emergency situation. **Good Samaritan Law** \- Nurses act as Good Samaritans by providing emergency assistance at an accident scene. \- have their basis on the idea that consensus agreement favors good \"public policy\" to limit liability for those who voluntarily perform care and rescue in emergency situations. \- It is well known that medical emergencies outside of the umbrella \"medical setting\" or \"clinical environment\" are common. **Negligence in Nursing Practice (Three Doctrines)** **Doctrines of Res Ipsa Loquitor** - \"things speak for itself\"- and no further proof is required. **Doctrines of Respondeat Superior** - \"let the master answer the act of the subordinates\" **Doctrines of Force Majeure** - \"irresistible force that is unforeseen and inevitable" **Ethics** \- is the study of conduct and character. \- It is concerned with determining what is good or valuable for individuals, for groups of individuals, and for society at large. \- Acts that are ethical reflect a commitment to standards beyond personal preferences -- standards that individuals, professions, and societies strive to meet. \- When it comes to decision making in health care, however, differing values between individuals cause intense disagreement about the right thing to do. **BASIC TERMS IN HEALTH ETHICS** **Autonomy** - refers to the commitment to include clients' decisions about all aspects of care. For example, the consent that clients read and sign before surgery illustrates this respect for autonomy. The signed consent ensures that the health care team obtained permission from the client before proceeding with the surgery. **Beneficence** - refers to taking positive actions to help others. The practice of beneficence encourages the urge to do good for others. The agreement to act with beneficence also requires that the best interests of the client remain more important than self-interest. **e.g.** A child may ask pill to be crushed and mixed with favorite food, even though you know the child is able to swallow pills whole. Your commitment to do good for others guides you to comply with the child's wishes, even if you are having a busy day. **Nonmaleficence** -- maleficence refers to harm or hurt; thus, nonmaleficence is the avoidance of harm or hurt. In health care, ethical practice involves not only the will to do good, but also the equal commitment to do no harm. The health care professional tries to balance the risks and benefits of a plan of care while striving to do the least harm possible. **Justice** - refers to fairness. Health care providers agree to strive for justice in health care. The term often is used in discussions about health care resources. What constitutes a fair distribution of resources is not always clear. **Fidelity** - Refers to the agreement to keep promises. A commitment to fidelity supports the reluctance to abandon clients, even when disagreement occurs about decisions that a client makes. The standard of fidelity also includes an obligation to follow through with care offered to clients. Link for the Code of Ethics of Nurses in the Philippines: [[Board of Nursing-CE.pdf (prc.gov.ph)]](https://www.prc.gov.ph/uploaded/documents/Board%20of%20Nursing-CE.pdf) **Legal Aspects of Nursing** THE 1987 CONSTITUTION OF THE REPUBLIC OF THE PHILIPPINES -- ARTICLE III Link: [[THE 1987 CONSTITUTION OF THE REPUBLIC OF THE PHILIPPINES -- ARTICLE III \| Official Gazette of the Republic of the Philippines]](https://www.officialgazette.gov.ph/constitutions/the-1987-constitution-of-the-republic-of-the-philippines/the-1987-constitution-of-the-republic-of-the-philippines-article-iii/) **PATIENTS RIGHTS IN THE PHILIPPINES** **1. Right to Appropriate Medical Care and Humane Treatment.** - Every person has a right to health and medical care corresponding to his state of health, without any discrimination and within the limits of the resources, manpower and competence available for health and medical care at the relevant time. The patient has the right to appropriate health and medical care of good quality. In the course of such, his human dignity, convictions, integrity, individual needs and culture shall be respected. If any person cannot immediately be given treatment that is medically necessary, he shall, depending on his state of health, either be directed to wait for care, or be referred or sent for treatment elsewhere, where the appropriate care can be provided. If the patient has to wait for care, he shall be informed of the reason for the delay. Patients in emergency shall be extended immediate medical care and treatment without any deposit, pledge, mortgage or any form of advance payment for treatment. **2. Right to Informed Consent.** - The patient has a right to a clear, truthful and substantial explanation, in a manner and language understandable to the patient, of all proposed procedures, whether diagnostic, preventive, curative, rehabilitative or therapeutic, wherein the person who will perform the said procedure shall provide his name and credentials to the patient, possibilities of any risk of mortality or serious side effects, problems related to recuperation, and probability of success and reasonable risks involved: Provided, That the patient will not be subjected to any procedure without his written informed consent, except in the following cases: - in emergency cases, when the patient is at imminent risk of physical injury, decline of death if treatment is withheld or postponed. In such cases, the physician can perform any diagnostic or treatment procedure as good practice of medicine dictates without such consent; - when the health of the population is dependent on the adoption of a mass health program to control epidemic; - when the law makes it compulsory for everyone to submit a procedure; - When the patient is either a minor, or legally incompetent, in which case. a third-party consent Is required; - when disclosure of material information to patient will jeopardize the success of treatment, in which case, third party disclosure and consent shall be in order; - When the patient waives his right in writing. - Informed consent shall be obtained from a patient concerned if he is of legal age and of sound mind. In case the patient is incapable of giving consent and a third-party consent is required. the following persons, in the order of priority stated hereunder, may give consent: - If a patient is a minor, consent shall be obtained from his parents or legal guardian. If next of kin, parents or legal guardians refuse to give consent to a medical or surgical procedure necessary to save the life or limb of a minor or a patient incapable of giving consent, courts, upon the petition of the physician or any person interested in the welfare of the patient, in a summary proceeding, may issue an order giving consent. **3. Right to Privacy and Confidentiality.** - The privacy of the patients must be assured at all stages of his treatment. The patient has the right to be free from unwarranted public exposure, except in the Howing cases: - The patient has the right to demand that all information, communication and records pertaining to his care be treated as confidential. Any health care provider or practitioner involved in the treatment of a patient and all those who have legitimate access to the patient\'s record is not authorized to divulge any information to a third party who has no concern with the care and welfare of the patient without his consent, except: a) when such disclosure will benefit public health and safety; b) when it is in the interest of justice and upon the order of a competent court; and c) when the patients waives in writing the confidential nature of such information; d) when it is needed for continued medical treatment or advancement of medical science subject to de-identification of patient and shared medical confidentiality for those who have access to the information. - Informing the spouse or the family to the first degree of the patient\'s medical condition may be allowed; Provided that the patient of legal age shall have the right to choose on whom to inform. In case the patient is not of legal age or is mentally incapacitated, such information shall be given to the parents, legal guardian or his next of kin. **4. Right to Information.** - \- In the course of his/her treatment and hospital care, the patient or his/her legal guardian has a right to be informed of the result of the evaluation of the nature and extent of his/her disease, any other additional or further contemplated medical treatment on surgical procedure or procedures, including any other additional medicines to be administered and their generic counterpart including the possible complications and other pertinent facts, statistics or studies, regarding his/her illness, any change in the plan of care before the change is made, the person\'s participation in the plan of care and necessary changes before its implementation, the extent to which payment maybe expected from Philhealth or any payor and any charges for which the patient may be liable, the disciplines of health care practitioners who will furnish the care and the frequency of services that are proposed to be furnished. - The patient or his legal guardian has the right to examine and be given an itemized bill of the hospital and medical services rendered in the facility or by his/her physician and other health care providers, regardless of the manner and source of payment. He is entitled to a thorough explanation of such bill. - The patient or his/her legal guardian has the right to be informed by the physician or his/her delegate of his/her continuing health care requirements following discharge, including instructions about home medications, diet, physical activity and all other pertinent information to promote health and well-being. - \- At the end of his/her confinement, the patient is entitled to a brief, written summary of the course of his/her illness which shall include at least the history, physical examination, diagnosis, medications, surgical procedure, ancillary and laboratory procedures, and the plan of further treatment, and which shall be provided by the attending physician. He/she is likewise entitled to the explanation of, and to view, the contents of medical record of his/her confinement but with the presence of his/her attending physician or in the absence of the attending physician, the hospital\'s representative. Notwithstanding that he/she may not be able to settle his accounts by reason of financial incapacity, he/she is entitled to reproduction, at his/her expense, the pertinent part or parts of the medical record the purpose or purposes of which he shall indicate in his/her written request for reproduction. The patient shall likewise be entitled to medical certifICate, free of charge, with respect to his/her previous confinement. **5. The Right to Choose Health Care Provider and Facility.** - The patient is free to choose the health care provider to serve him as well as the facility except when he is under the care of a service facility or when public health and safety so demands or when the patient expressly waives this right in writing. - The patient has the right to discuss his condition with a consultant specialist, at the patient\'s request and expense. He also has the right to seek for a second opinion and subsequent opinions, if appropriate, from another health care provider/practitioner. **6. Right to Self-Determination.** - The patient has the right to avail himself/herself of any recommended diagnostic and treatment procedures. Any person of legal age and of sound mind may make an advance written directive for physicians to administer terminal care when he/she suffers from the terminal phase of a terminal illness: Provided That a) he is informed of the medical consequences of his choice; b) he releases those involved in his care from any obligation relative to the consequences of his decision; c) his decision will not prejudice public health and safety. **7. Right to Religious Belief.** - The patient has the right to refuse medical treatment or procedures which may be contrary to his religious beliefs, subject to the limitations described in the preceding subsection: Provided, that such a right shall not be imposed by parents upon their children who have not reached the legal age in a life-threatening situation as determined by the attending physician or the medical director of the facility. **8. Right to Medical Records.** - The patient is entitled to a summary of his medical history and condition. He has the right to view the contents of his medical records, except psychiatric notes and other incriminatory information obtained about third parties, with the attending physician explaining contents thereof. At his expense and upon discharge of the patient, he may obtain from the health care institution a reproduction of the same record whether or not he has fully settled his financial obligation with the physician or institution concerned. - The health care institution shall safeguard the confidentiality of the medical records and to likewise ensure the integrity and authenticity of the medical records and shall keep the same within a reasonable time as may be determined by the Department of Health. - The health care institution shall issue a medical certificate to the patient upon request. Any other document that the patient may require for insurance claims shall also be made available to him within forty-five (45) days from request. **9. Right to Leave.** - The patient has the right to leave hospital or any other health care institution regardless of his physical condition: Provided that - No patient shall be detained against his/her will in any health care institution on the sole basis of his failure to fully settle his financial obligations. However, he/she shall only be allowed to leave the hospital provided appropriate arrangements have been made to settle the unpaid bills: Provided. further, that unpaid bills of patients shall be considered as loss income by the hospital and health care provider/practitioner and shall be deducted from gross income as income loss only on that particular year. **10. Right to Refuse Participation in Medical Research.** - The patient has the right to be advised if the health care provider plans to involve him in medical research, including but not limited to human experimentation which may be performed only with the written informed consent of the patient: Provided, That, an institutional review board or ethical review board in accordance with the guidelines set in the Declaration of Helsinki be established for research involving human experimentation: Provided, further, that the Department of Health shall safeguard the continuing training and education of future health care provider/practitioner to ensure the development of the health care delivery in the country: Provided, furthermore, that the patient involved in the human experimentation shall be made aware of the provisions of the Declaration of Helsinki and its respective guidelines. **11. Right to Correspondence and to Receive Visitors.** - The patient has the right to communicate with relatives and other persons and to receive visitors subject to reasonable limits prescribed by the rules and regulations of the health care institution. **12. Right to Express Grievances.** - The patient has the right to express complaints and grievances about the care and services received without fear of discrimination or reprisal and to know about the disposition of such complaints. Such a system shall afford all parties concerned with the opportunity to settle amicably all grievances. **13. Right to be Informed of His Rights and Obligations as a Patient.** - Every person has the right to be informed of his rights and obligations as a patient. The Department of Health, in coordination with heath care providers, professional and civic groups, the media, health insurance corporations, people\'s organizations, local government organizations, shall launch and sustain a nationwide information and education campaign to make known to people their rights as patients, as declared in this Act such rights and obligations of patients shall be posted in a bulletin board conspicuously placed in a health care institution. - It shall be the duty of health care institutions to inform of their rights as well as of the institution\'s rules and regulations that apply to the conduct of the patient while in the care of such institution. **Different fields of Nursing** **1. Institutional Nursing (Hospital Staff Nursing)** Nursing in hospital and related health facilities such as extended care facilities, nursing homes, and neighborhood clinics, comprises all of the basic components of comprehensive patient care and family health. The nurse cares for the patient in the hospital or in the out-patient department and plans for the nursing care needs of the patient about to be discharged. The nurse performs nursing measure that will meet the patient's physical, emotional, social, and spiritual health needs while in the institution and helps him and his family plan for his further health care needs when he returns home. **2. Community Health Nursing (Public Health Nursing)** Public health nursing is also called community health nursing. The National Health Program of the Philippines gives as much emphasis on the promotion of health and prevention of diseases rather than care of the sick. **3. Nursing in Education** The career ladder in nursing education starts with a Clinical Instructor's position up to the Dean of a college of Nursing. A dean in a college of nursing should possess a Master's Degree in Nursing and must have at least five (5) years of experience in teaching and supervision as per R.A. 9173. Those teaching at the graduate Programs for Nurses must possess post- Master's Degree or a Doctoral Degree in Nursing. **4. Nursing in other Fields** **Nurse Practitioner** A nurse who has an advanced education and is a graduate of a nurse practitioner program. These nurses are certified by the American Nurses Credentialing Center in areas such as adult nurse practitioner, family nurse practitioner, school nurse practitioner, pediatric nurse practitioner, or gerontology nurse practitioner. They are employed in health care agencies or community-based settings. They usually deal with nonemergency acute or chronic illness and provide primary ambulatory care. **Clinical Nurse Specialist** A nurse who has an advanced degree or expertise and is considered to be an expert in a specialized area of practice. The nurse provides direct client care. Educates others, consults, conducts research, and manages care. **Nurses Anesthetist** A nurse who has completed advanced education in an accredited program in anesthesiology. The nurse anesthetist carries out preoperative visits and assessment, and administers general anesthetics for surgery under the supervision of a physician prepared in anesthesiology. The nurse anesthetist also assesses the postoperative status of clients. **Nurse Midwife** An RN who has completed a program in midwifery and is certified by the American College of Nurse Midwives. The nurse gives prenatal and postnatal care and manages deliveries in normal pregnancies. The midwife practices in associated with a health care agency and can obtain medical services if complications occur. The nurse midwife may also conduct routine papanicolaou smears, family planning, and routine breast examinations. **Nurse Researcher** Nurse researchers investigate nursing problems to improve nursing care and to refine and expand nursing knowledge. They are employed in academic institutions, teaching hospitals, and research centers such as the National Institute for nursing Research in Bethesda, Maryland. Nurse researchers usually have advanced education at the doctoral level. **Nurse Administrator** The nurse administrator manages client care, including the delivery of nursing services. The administrator may have a middle management position, such as head nurse or supervisor, or a more senior management position, such as director of nursing services. The functions of nurse administrator include budgeting, staffing, and planning programs. The educational preparation for nurse administrator positions is at least a baccalaureate degree in nursing and frequently a master's or doctoral degree. **Nurse entrepreneur** A nurse who usually has an advanced degree and manages a health-related business. The nurse may be involved in education, consultation, or research. **H. COMMUNICATION SKILLS** **1. EFFECTIVE COMMUNICATION** - Communication is the interchanged of information between two or more people; in other words, the exchange of ideas and thought. Communicating may have a more personal connotation than the interchange of ides and thoughts. - Nurses who communicate effectively are better able to collect assessment data, initiate intervention, evaluate outcomes of intervention, initiate change that promote health, and prevent legal problem associated with nursing practice. **Components of Communication** **Sender** - The sender, a person or group who wishes to convey a message to another, can be considered the source-encoder. **Message** - The second component of communication process is the message itself what is actually said or written, the body language that accompanies the words, and how the message is transmitted. **Receiver** - The receiver, the third component of the communication process, is the listener, who must listen, observe, and attend. - This person is the **decoder**, who must perceive what the sender intended (interpretation). Perception uses all the senses to receive verbal and nonverbal messages. **Response** - The fourth component of the communication process, the response, is the message that the receiver returns to the sender. It is also called **feedback**. **Feedback** can be either verbal, nonverbal, or both. **MODES OF COMMUNICATION** **Communication** is generally carried out in two different modes: verbal and nonverbal. ***Verbal communication*** uses the spoken or written word; ***nonverbal communication*** uses other forms, such as gestures of facial expressions, and touch. Another form of communication has evolved with technology -- electronic communication. The most common form of electronic communication is e-mail where an individual can send a message, by computer, to another person or group of people. **Verbal Communication** - is largely conscious because people choose the words they use. The words used vary among individuals according to culture, socioeconomic background, age and education. When choosing words to say or write, nurses need to consider pace and intonation, simplicity, clarity and brevity. Timing and relevance, adaptability, credibility and humor. - **PACE AND INTONATION**. The manner of speech, as in the pace or rhythm and intonation, will modify the feeling and impact of the message. The intonation can express enthusiasm, sadness, anger, or amusement. The pace of speech may indicate interest, anxiety, boredom or fear. - **SIMPLICITY**. Simplicity includes the use of commonly understood words, brevity, and completeness. Nurses need to learn to select appropriate, understandable terms based on the age, knowledge, culture, and education of the client. - **CLARITY AND BREVITY**. A message that is direct and simple will be more effective. Clarity is saying precisely what is meant, and brevity is using the fewest words necessary. - **TIMING AND RELEVANCE**. The timing needs to be appropriate to ensure that words are heard. More - over, the messages need to relate to the person or to the person's interest and concerns. - **ADAPTABILITY**. Spoken messages need to be altered in accordance with behavioral cues from the client. This adjustment referred to as adaptability. What nurse says and how it is said must be individualized and carefully considered. This requires astute assessment and sensitivity on the part of the nurse. - **CREDIBILITY**. Credibility means worthiness of belief, trustworthiness, and reliability. Nurses foster credibility by being consistent, dependable and honest. The nurse needs to be knowledgeable about what is being discussed and to have accurate information. Nurses should convey confidence and certainty in what they are saying, while being able to acknowledge their limitations. - **HUMOR**. The use of humor can be positive and powerful tool in the nurse-client relationship, but it must be used with care. Humor can be used to help clients adjust to difficult and painful situations. When using humor, it is important to consider the client's perception of what is considered humorous. Timing is also important to consider. **Nonverbal Communication** - sometimes called body language. It includes gestures, body movements, use of touch, and physical appearance, including adornment. - **PERSONAL APPEARANCE**. Clothing and adornments can be sources of information about a person. How a person dresses is often an indicator of how the person feels. Someone who is tired or ill may not have the energy or the desire to maintain their normal grooming. - **POSTURE AND GAIT**. The ways of people walk and carry themselves are often reliable indicators of self-concept, current mood, and health. Erect posture and an active, purposeful stride suggest a feeling of well-being. Slouched posture and a slow, shuffling gait suggest depression or physical discomfort. Tense posture and a rapid, determine gait suggest anxiety or anger. The posture of people when they are sitting or lying can also indicate feelings or mood. - **FACIAL EXPRESSIONS**. No part of the body is as expressive as the face. Feelings of surprise, fear, anger, disgust, happiness, and sadness can be conveyed by facial expressions. Although the face may express the person's genuine emotions, it is also possible to control these muscles so the emotion expressed does not reflect what the person is feeling. - **GESTURES**. Hand and body gestures may emphasize and clarify the spoken word, or they may occur without words to indicate a particular feeling or to give a sign. For people with special communication problems, such as the deaf, the hands are invaluable in communication. Many people who are deaf learn sign language. Ill persons who are unable to reply verbally can similarly devise a communication system using the hands. The client may be able to raise an index finger once for "yes" and twice for "no." Other signals can often be devised by the client and the nurse to denote other meanings. **Electronic Communication** **E-mail** - is the most common form of electronic communication. It is important for the nurse to know the advantage and disadvantages of e-mail and also other guidelines to ensure client confidentiality. **Advantages**. It is a fast, efficient way to communicate and it is legible. It provides a record of the date and time of the message that was sent or received. **Disadvantage**. The negative aspect of e-mail is the risk to client confidentiality. Another is one of socioeconomics. Not everyone has a computer. While there may be available access to a computer, not everyone has the necessary computer skills. E-mail may enhance communication with some clients but not all clients. Other forms of communication will be needed for clients who have limited abilities with speaking English, reading, writing, or using computer. ***When Not to Use E-mail.*** When the information is urgent and the client's health could be in jeopardy if he or she doesn't read it immediately. - Highly confidential information (e.g., HIV status, mental health, chemical dependency). - Abnormal lab data. If the information is confusing and could not prompt may question by the client, it is better to either see or telephone the person. **2. PURPOSE OF THERAPEUTIC COMMUNICATION** - Establishing a therapeutic provider-client relationship. - Identify client's concerns and problem. - Assess client's perception of the problem. - Recognize client's needs. - Guide client towards a satisfying and socially acceptable solution **Attentive Listening** - Attentive listening is listening actively, using all the senses, as opposed to listening passively with just the ear. - Attentive listening is an active process that requires energy and concentration. - It involves paying attention to the total message, both verbal and nonverbal, and noting whether this communication is congruent. - Attentive listening means absorbing both the content and the feeling the person is conveying, without selectivity. The listener does not select or listen solely to what the listener wants to hear; the nurse focuses not on the nurse's owns need but rather on the client's need. - Attentive listening conveys an attitude of caring and interest, thereby encouraging the client to talk. +-----------------------+-----------------------+-----------------------+ | **TECHNIQUE** | **DESCRIPTION** | **EXAMPLES** | +-----------------------+-----------------------+-----------------------+ | **Using Silence** | Accepting pauses or | Sitting quietly (or | | | silence that may | walking with the | | | extend for several | client) and waiting | | | seconds or minutes | attentively until the | | | without interjecting | client is | | | any verbal response | | | | | able to put thoughts | | | | and feelings into | | | | words | +-----------------------+-----------------------+-----------------------+ | **Providing General | Using statements or | Can you tell me how | | leads** | questions that | is it for you | | | | | | | \(a) encourage the | Perhaps you would | | | client to | like to talk about | | | verbalize, | | | | | Would it help to | | | \(b) choose a topic | discuss your | | | of conversation, | feelings? | | | and | | | | | Where would you like | | | \(c) facilitate | to begin? | | | continued | | | | verbalization | And then what? | +-----------------------+-----------------------+-----------------------+ | **Being specific and | Making statements | Rate your pain on | | tentative** | that are specific | scale 0- 10 (specific | | | rather than general, | statement) | | | and tentative rather | | | | than absolute | Are you in pain? | | | | (general statement) | | | | | | | | You seem unconcerned | | | | about your diabetes | | | | (tentative statement) | | | | | | | | You don't care about | | | | your diabetes and you | | | | never will (absolute | | | | statement) | +-----------------------+-----------------------+-----------------------+ | **Using open-ended | Asking broad question | I'd like to hear more | | question** | that led or invite | about that | | | the client to explore | | | | (elaborate, clarify, | Tell me about... | | | describe, compare, or | | | | illustrate) thoughts | How have you been | | | or feelings. Open | feeling lately? | | | ended questions | | | | specify only the | What brought you to | | | topic to be | the hospital? | | | | | | | | What is your opinion? | +-----------------------+-----------------------+-----------------------+ | | Discussed and invite | You said you were | | | answer that is | | | | | frightened yesterday. | | | longer than one or | How | | | two words. | | | | | do feel now? | +-----------------------+-----------------------+-----------------------+ | **Using touch** | Providing appropriate | Putting an arm on | | | forms of touch | client's | | | | | | | to reinforce caring | shoulder. Placing | | | feelings. Because | your hands | | | | | | | tactile contacts vary | over the client's | | | considerably | hand | | | | | | | among individuals, | | | | families, and | | | | | | | | cultures, the nurse | | | | must be sensitive | | | | | | | | to the differences in | | | | attitude and | | | | | | | | practices of client | | | | and self. | | +-----------------------+-----------------------+-----------------------+ | **Restating or | Actively listening | **Client:** I | | Paraphrasing** | for the client's | couldn't manage to | | | basic message and | eat any dinner last | | | then repeating then | night not even the | | | repeating those | dessert | | | thoughts and/or | | | | feelings in similar | **Nurse:** you have | | | words. This conveys | difficulty of eating | | | that the nurse has | yesterday | | | listened and | | | | understood the | **Client:** Yes, I | | | client's basic | was very upset after | | | message and also | my family left. | | | offers clients a | Client: I have | | | clearer idea of what | trouble talking to | | | they have said. | strangers. | | | | | | | | **Nurse:** You find | | | | it difficult talking | | | | to people you do not | | | | know? | +-----------------------+-----------------------+-----------------------+ | **Seeking | A method of making | I'm puzzled | | clarification** | the client's broad | | | | over all meaning of | I'm not sure I | | | the message more | understand that Would | | | understandable. It is | you please say that | | | used when par | again? | | | phrasing is difficult | | | | or when the | Would you tell me | | | communication is | more? | | | rambling or garbled. | | | | To clarify the | I meant this rather | | | message, the nurse | than that | | | can restate the basic | | | | message or confess | I'm sorry that wasn't | | | confusion and ask the | very clear. Let me | | | client to repeat or | try to explain | | | restate the | another way | | | | | | | message. Nurses can | | | | also clarify their | | | | own message with | | | | statements. | | +-----------------------+-----------------------+-----------------------+ | **Perception checking | A method similar to | Client: My husband | | or seeking** | clarifying that | never gives me any | | | verifies the meaning | present | | **Consensual | of specific words | | | validation** | rather than the | Nurse: You mean he | | | overall meaning of a | has never given you a | | | message. | present for your | | | | birthday or | | | | Christmas? | | | | | | | | Client: Well not | | | | never. He does get me | | | | something for my | | | | birthday and | | | | Christmas but he | | | | never thinks of | | | | giving anything at | | | | any other time. | +-----------------------+-----------------------+-----------------------+ | **Offering self** | Suggesting one's | I'll stay with you | | | presence, interest, | until your daughter | | | or wish to understand | arrives. | | | the client without | | | | making any demands or | We can sit here | | | attaching conditions | quietly for a while; | | | that the client must | we don't need to talk | | | comply with to | unless you would like | | | receive the nurse's | to | | | attention. | | | | | I'll help you to | | | | dress or go home if | | | | you like. | +-----------------------+-----------------------+-----------------------+ | **Giving | Providing in a simple | Your surgery is | | Information** | and direct manner, | scheduled for 11 AM | | | specific factual | tomorrow. | | | information the | | | | client may or may not | You will feel a | | | request. When | pulling sensation | | | information is not | when the tube is | | | known, the nurse | removed from your | | | state this and | abdomen. | | | indicates who has it | | | | or when the nurse | | | | will obtain it | | +-----------------------+-----------------------+-----------------------+ | **Acknowledging** | Giving recognition, | You trimmed your | | | in a non-judgmental | beard and mustache | | | way, of a change in | and washed your hair. | | | behavior, an effort | | | | the client has made, | I notice you keep | | | or a contribution to | squinting your eyes. | | | a | Are you having | | | | difficulty seeing? | | | communication. | | | | | You walked twice as | | | Acknowledgement may | far today with your | | | be with or without | walker. | | | understanding, verbal | | | | or non-verbal. | | +-----------------------+-----------------------+-----------------------+ | **Clarifying time and | Helping the client | **Client:** I vomited | | sequence** | clarify an event, | this morning | | | situation, or | | | | happening in | **Nurse:** Was that | | | relationship to time. | after breakfast? | | | | | | | | **Client:** I feel | | | | that I have been | | | | asleep for weeks. | | | | | | | | **Nurse:** You had | | | | your operation | | | | Monday, and today is | | | | Tuesday. | +-----------------------+-----------------------+-----------------------+ | **Presenting | Helping the client to | That telephone ring | | reality** | differentiate the | came from the program | | | real from the unreal. | in Television. I see | | | | shadows from the | | | | windows coverings. | | | | | | | | Your magazine is here | | | | in the drawer. It has | | | | not been stolen. | +-----------------------+-----------------------+-----------------------+ | **Focusing** | Helping the client | Client: My wife says | | | expand on and develop | she will look after | | | a topic of | me, but I don't think | | | importance. It is | she can, what with | | | important for the | the children to take | | | nurse to wait until | care of, and they're | | | the client finishes | always | | | stating the main | | | | concerns before | after about | | | attempting to focus. | something-clothes, | | | The focus may be an | homework, what's for | | | idea or a feeling; | dinner that night. | | | however, the nurse | | | | often emphasizes a | Nurse: Sounds like | | | feeling to help the | you are | | | client recognize an | | | | emotion disguised | worried about how | | | behind words. | well she | | | | | | | | can manage. | +-----------------------+-----------------------+-----------------------+ | **Reflecting** | Directing ideas, | **Client:** What can | | | feelings, questions, | I do? | | | or content back to | | | | clients to enable | **Nurse:** What do | | | them to explore their | think would be | | | own ideas and | helpful? | | | feelings about a | | | | situation. | **Client:** Do you | | | | think I should tell | | | | my husband? | | | | | | | | **Nurse:** You seem | | | | unsure about telling | | | | your husband. | +-----------------------+-----------------------+-----------------------+ | **Summarizing and | Stating the main | During the past half | | planning** | points of a | hour, we have talked | | | discussion to clarify | about... | | | the relevant points | | | | discussed. This | Tomorrow afternoon we | | | technique is useful | ay explore this | | | at the end of an | further. | | | interview or to | | | | review a health | In new days I'll | | | teaching session. It | review what you have | | | often acts as an | learned about the | | | introduction to | actions and effects | | | future care planning. | of your insulin. | | | | | | | | Tomorrow I will look | | | | at your feeling | | | | journal. | +-----------------------+-----------------------+-----------------------+ **3. GUIDELINES FOR THE USE OF TOUCH** - **Touch** may be used for all of the following reasons: - for communication - social interaction or Intensive Interaction - to support, prompt and guide - as part of therapy - for emotional support - for comfort - during personal care - for medical and nursing care - to give physical support; and for protection. - Touch should always be appropriate for the person and the situation as described in their care plan or **Essential Lifestyle Plan (ELP)**. The following guidelines should be considered: - Have consent from the person - Document it - Have agreement about the best way to work with someone - Ensure physical contact is appropriate - To keep staff and service users safe - Always follow the person's care plan or ELP guidelines - Be prepared to explain your practice - Have others present, in the same room or nearby Although it may not always be possible, the most basic safeguard for staff and service users is to have others present in the room or nearby whenever possible in situations where physical contact is likely to be used. However, if this is not possible it should not prevent appropriate physical contact from happening. - Be prepared to discuss and explain your practice - Know when to seek advice - if you think the person does not like to be touched - if you are unsure how someone likes to experience touch - if the person interprets physical contact in a sexual way - if you have any concerns about working with someone because of any aspect of their behavior **4. GENERAL GUIDELINES FOR TRANSCULTURAL COMMUNICATION** 1\. Use a translator/interpreter if you are not thoroughly effective and fluent in the patient's language. 2\. Obtain a translator of the same sex as the patient, if possible 3\. Learn basic words and sentences in the patient's language 4\. Slow down and be patient when using long explanatory phrases 5\. Address the patient directly, not indirectly through the interpreter as if the patient did not exist 6\. Return to the same question when: - Suspecting a problem with the patient - Getting a negative response - Noticing a puzzled look from the patient 7\. Always be sure that the Interpreter knows what you want to ask precisely 8\. Provide instructions in an orderly manner, and have patients repeat their understanding of the medical or nursing procedure or therapy 9\. Avoid complicated technical terminology and professional jargon 10\. Use drawings and communication boards when you think they may be helpful communication aids 11\. Plan what you want to say ahead of time and do not confuse the interpreter by backing up, rephrasing, or by using abstract phrases or metaphors. 12\. Speak slowly and use a normal tone of voice. 13\. Do not shout or speak louder because usually misunderstandings do not occur because patients cannot hear you, but because they need a longer time to process the information from the nurse's language into their native language, and then back to English to respond 14\. Use only necessary words Too many unnecessary words can frustrate the patient **I. NURSING PROCESS** "Critical thinking in nursing practice is a discipline specific, reflective reasoning process that guides a nurse in generating, implementing, and evaluating approaches for dealing with client care and professional concerns". **Critical Thinking** - is essential to safe, competent, skillful nursing practice. The amount of knowledge that nurses must use and the continuing rapid growth of this knowledge prevent nurses from being effective practitioners if they attempt to function with only the information acquired in school or outlined in books. ***Nurses use critical-thinking skills in a variety of ways:*** - Nurses use knowledge from other subjects and fields. - Nurses deal with change in stressful environments. - Nurses make important decisions. **Creativity** is thinking that results in the development of new ideas and products. Creativity in problem solving and decision making is the ability to develop and implement new and better solutions. **Skills in Critical Thinking** Complex mental processes such as analysis, problem solving, and decision making require the use of cognitive critical-thinking skills. - **Critical analysis** is the application of a set of questions to a particular situation or idea to determine essential information and ideas and discard superfluous information and ideas. The questions are not sequential steps: rather, they are a set of criteria for judging an idea. Not all questions will need to be applied to every situation, but one should be aware of all the questions in order to choose those questions appropriate to given situations. - **Socratic questioning** is a technique one can use to look beneath the surface, recognize and examine assumptions, search for inconsistencies, examine multiple points of view, and differentiate what one knows from what one merely believes. Nurses should employ Socratic questioning when listening to an end-of-shift report, reviewing a history or progress notes, planning care, or discussing a client's care with colleagues. - **Inductive reasoning** generalizations are formed from a set of facts or observations. When viewed together, certain bits of information suggest a particular interpretation. Inductive reasoning moves from specific examples (premises) to a generalized conclusion. - Deductive reasoning by contrast, is reasoning from the general premise to the specific conclusion. In critical thinking, the nurse also differentiates statement of facts, inference, judgment, and opinion. **Attitudes that Foster Critical Thinking** A critical thinker works to develop the following attitudes or traits: - independence - fair-mindedness - insight - intellectual humility - intellectual courage - integrity - perseverance - confidence - curiosity **ASSESSMENT** - is the deliberate and systemic collection of data to determine a client's current and past health status and functional status and to determine the client's present and past coping patterns. Nursing assessment includes two steps: - Collection and verification of data from a - **primary source** (the client) and - **secondary source** (e.g., family, health professionals, and medical record) - The analysis of all data as a basis for developing nursing diagnoses, identifying collaborative problems, and developing plan of individualize care. **4 TYPES OF ASSESSMENT** **1. Initial nursing assessment:** Performed within specified time after admission. To establish a complete database for problem identification. e.g. Nursing admission assessment **2. Problem-focused assessment:** To determine the status of a specific problem identified in an earlier assessment. e.g. hourly checking of vital signs of fever patient **3. Emergency assessment:** During emergency situation to identify any life-threatening situation. e.g. Rapid assessment of an individual's airway, breathing status, and circulation during a cardiac arrest. **4. Time-lapsed reassessment:** Several months after initial assessment. To compare the client's current health status with the data previously obtained. **Data Collection** - is the process of gathering information about a client's health status. It includes the health history, physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. - As you begin a client assessment, think critically about what to assess. Determine what questions or measurements are appropriate based on your clinical knowledge and experience and your client's health history and response. **Types of Data** - **Subjective data** are your client's verbal description of their health problems. e.g. ITCHING, PAIN, FEELINGS OF WORRY - **Objective data** are observations or measurements of a client's health status. Inspection of the condition of a wound, a description of an observed behavior, and the measurement of blood pressure. e.g. DISCOLORATION OF SKIN, BLOOD PRESSURE, BODY TEMPERATURE\.... **SOURCES OF DATA** 1\. **Primary:** It is the direct source of information. The client is the primary source of data. 2\. **Secondary:** It is the indirect source of information. All sources other than the client are considered secondary sources. Family members, health professionals, records and reports, laboratory and diagnostic results are secondary sources. **Methods of Data Collection** As a nurse, you will use the client interview, nursing health history, physical examination, and results for laboratory and diagnostic tests to establish a client's assessment database. **Interview and Nursing Health History** - The first step in establishing a database is to collect subjective information by interviewing the client. - An interview is an organized conversation with the client. - The initial formal interview involves obtaining the client's health history and information about the current illness. - During the initial interview you have the initial interview you have the opportunity to do the following: - Introduce yourself to the client, explain your role, and explain the role of others during care. - Establish a caring therapeutic relationship with the client - Get insight about the client's concerns and worries - Determine the client's goals and expectations of the health care system - Obtain cues about which parts of the data collection phase require further in-depth investigation - An interview helps clients relate their own interpretation and understanding of their condition. Therefore, you and the client became partners during the interview consists of 3 phases: orientation, working and termination. - - - **DOCUMENTATION OF DATA** To complete the assessment phase, the nurse records client data. Accurate documentation is essential and should include all data collected about the client's health status. **DIAGNOSIS/ NURSING DIAGNOSIS** The term ***diagnosing*** refers to the reasoning process, whereas the term **DIAGNOSIS** is a statement or conclusion regarding the nature of a phenomenon. The standardized ***NANDA*** names for the diagnoses is called **Diagnostics Labels**; the client's problem statement, consisting of diagnostic label plus etiology is called nursing diagnosis. **3 Process of Nursing Diagnosis** - Analyze Data - Identify the health problems, risks and strengths - Formulate diagnostic statements **Types of Nursing Diagnosis** 1\. **Actual diagnosis** - is a client problem that is present the time of nursing assessment. 2\. **Risk nursing Diagnosis** - is a clinical judgment that a problem does not exists, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. 3\. **Wellness diagnosis** - "describe human responses to level of wellness is an individual, family or community that have a readiness for enhancement" 4\. **Possible nursing diagnosis** - is one in which evidence about a health problem is incomplete or unreal. 5\. **Syndrome Diagnosis** - is a diagnosis that is associated with a cluster of other diagnoses. **Defining Characteristics** Defining Characteristics are the clusters of signs and symptoms that indicate the presence of a particular diagnostic label. For actual nursing diagnoses, the defining characteristics are the client\'s signs and symptoms. The NANDA lists of defining characteristics are still being developed and refined. Characteristics are listed separately according to whether they are subjective or objective in nature. **The Diagnostic Process** The diagnostic process is continuously used by most nurses. An experience nurse may enter a client's room and immediately observe significant data and draw conclusions about the client. As result of attaining knowledge, skills and expertise in to practice setting the expert nurse may see to perform these mental processes automatically. Novice nurses, however, need guidelines to understand and formulate nursing diagnoses. The diagnostic steps have three steps: **Analyzing Data** An RN uses a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well. For example, a nurse's assessment of a hospitalized patient in pain includes not only the physical causes and manifestations of pain, but the patient's response---an inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or request for more pain medication. In the diagnostics process, analyzing involves the following steps: - Compare data against standards - Cluster cues - Identify gaps and inconsistencies **Identifying Health Problems, Risks and Strength** A health risk assessment (HRA) is a health questionnaire, used to provide individuals with an evaluation of their health risks and quality of life. Commonly a HRA incorporates four key elements -- an extended questionnaire, a risk calculation or score, and some form of feedback i.e. face-to-face with a health advisor or an automatic online report. The Centers for Disease Control and Prevention define a HRA as: "a systematic approach to collecting information from individuals that identifies risk factors, provides individualized feedback, and links the person with at least one intervention to promote health, sustain function and/or prevent disease." There are a range of different HRAs available, however most capture information relating to: - Demographic characteristics -- age, sex - Lifestyle -- exercise, smoking, alcohol intake, diet - Personal and family medical history - Physiological data -- weight, height, blood pressure, cholesterol - Attitudes and willingness to change behavior in order to improve health The main objectives of a HRA are to: - Assess health status - Estimate the level of health risk - Inform and provide feedback to participants to motivate behavior change to reduce health risks **Formulating Diagnostic Statements** Most nursing diagnoses are written as two part or three-part statements, but there are variations of these. **Problem** - this is the nursing diagnosis. a nursing diagnosis is actually a label. to be clear as to what the diagnosis means, read its definition in a nursing diagnosis reference or a care plan book that contains this information. e.g. - Activity Intolerance - Constipation **Etiology** - also called the related factor by NANDA. This is what is causing the problem. it is the reason the problem exists and reasons can be many and varied. Ask yourself \"why did this happen?\" or \"how did this problem come about?\" \"What caused this to become a problem in the first place?\" and dig deep. e.g. - Activity Intolerance related to generalized weakness or obesity - Constipation related to inadequate fluid intake **Symptoms** - also called defining characteristics by NANDA, these are the abnormal data items that are discovered during the patient assessment. They can also be the same signs and symptoms of the medical disease the patient has, the patient\'s responses to their disease, and problems accomplishing their ADL's. They are evidence that prove the existence of the nursing problem. e.g. - Activity Intolerance related to generalized weakness or obesity as evidence by Impaired response to activity - Constipation related to inadequate fluid intake as evidence by straining to have bowel movements or having lumpy or hard stool