Fundamentals of Nursing PDF

NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PRO...

NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT Fundamentals of Nursing DEFINITIONS OF NURSING ❖ American Nursing Association (2003) “Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities and populations”. ❖ Florence Nightingale “Act of utilizing ENVIRONMENT of the patient to assist him in his recovery”. ❖ Virginia Henderson The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge, and to do his in such a way as to help him gain independence as rapidly as possible. NURSING THEORIESAND CONCEPTUAL FRAMEWORK ❖ FLORENCE NIGHTINGALE (1820 – 1910) Considered the first nursing theorist and earned the title “Nursing with a Lamp” Environmental Theory Five environmental factors: ✓ Pure/fresh air ✓ Pure water ✓ Efficient drainage ✓ Cleanliness ✓ Light (direct sunlight) Deficiencies in this five factors produce lack of health or illness Stressed the importance of keeping the client warm, maintaining a noise free environment, attending the client’s diet ❖ VIRGINIA HENDERSON The Nature of Nursing Model Conceptualizes the nurse’s role as assisting sick or healthy individuals to gain independence in meeting the 14 Fundamental Needs: 1. Breathing normally 2. Eating and drinking adequately 3. Eliminating body wastes 4. Moving and maintaining a desirable position 5. Sleeping and resting 6. Selecting suitable clothes 7. Maintaining body temperature 8. Keeping the body clean and well groomed 9. Avoiding dangers and injuring others 10. Communicating with others 11. Worshipping according to one’s faith 12. Working in such a way that one feels a sense of accomplishments 13. Participating in various recreation 14. Learning, discovering or satisfying the curiosity that leads to normal development and health ❖ FAYE GLENN ABDELLAH Patient-Centered Approaches to Nursing Model Identifies 21 nursing problems Defines nursing as a service to individuals and families Conceptualizes nursing as an art and science that molds the attitudes, intellectual competencies and technical skills of the individual nurse into the desire and ability to help people, sick or well and cope with their needs ❖ DOROTHY E. JOHNSON Behavioral System Model Each person as a behavioral system is composed of 7 subsystem: ✓ Injective ✓ Eliminative 1 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT ✓ Affiliative ✓ Aggressive ✓ Dependence ✓ Achievement ✓ Sexual and role identity ❖ IMOGENE KING Goal Attainment Theory Viewed nursing as an interaction process between patient and nurse that lead to goal attainment Patient has 3 interacting system ✓ Operational system (individuals) ✓ Interpersonal system (nurse-patient) ✓ Social system (health care system) ❖ MADELEINE LEININGER Transcultural Nursing Model (Cultural Care Diversity and Universality Theory) Emphasizes that human caring, although universal, varies among cultures in its expressions, process and patterns; it is largely culturally derived Presents 3 intervention modes: ✓ Culture care preservation and maintenance ✓ Culture care accommodation, negotiation or both ✓ Culture care restructuring and re patterning ❖ MYRA ESTRIN LEVINE Four Conservation Principles Proposed principles which are concerned with the unity and integrity of the individuals ✓ Conservation of energy ✓ Conservation of structural integrity ✓ Conservation of personal integrity ✓ Conservation of social integrity ❖ BETTY NEUMAN Health Care System Model Asserted that nursing is unique profession in that is concerned with all the variables affecting the individuals response to stress, which are intrapersonal stressors (within the individual), interpersonal (occurs between individuals ) and extra personal (outside the person) in the nature Nursing interventions focus on retaining or maintaining system stability ❖ DOROTHEA OREM Self-care and Self-care deficit Nursing Theory Defines self-care as performing activities independently by individual throughout life to promote and maintain personal well being Identifies 3 types of nursing system: ✓ Wholly Compensatory- for individuals who are unable to control and monitor their environment and process information ✓ Partly Compensatory- designed for individuals who are unable to perform some, but not all self- care activities ✓ Supportive-Educative- for clients who need to learn to perform self-care measure and need assistant to do so ❖ HILDEGARD PEPLAU Psychodynamic (interpersonal relations) Model Use of therapeutic relationship between nurse and the client 4 phases: ✓ Orientation ✓ Identification ✓ Exploitation ✓ Resolution ❖ MARTHA ROGERS Science of Unitary Human Being Views the person as an irreducible whole, the whole being is greater than the sum of its parts According to Rogers, unitary man: ✓ Is an irreducible, four-dimensional energy field by pattern 2 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT ✓ Manifests characteristics different from the sum of the parts ✓ Interacts continuously and creatively with the environment ✓ Behaves as a totality ✓ As a sentient being, participates creatively in change ❖ SISTER CALLISTA ROY Adaptation Model Defines adaptation as the process and outcome whereby the thinking and feeling person uses conscious awareness and choice to create human and environmental integration Goal of model is to enhance life processes through adaptation in four adaptive modes: ✓ Physiologic Mode ✓ Self-concept mode ✓ Role-function mode ✓ Interdependence mode ❖ LYDIA HALL Care, Core and Cure Model Care- nurturance and is exclusive to nursing Core- involves the therapeutic use of self and emphasize the use of reflection Cure- focuses on nursing related to the physician’s orders ❖ IDA JEAN ORLANDO (1961) The Dynamic Nurse-Patient Relationship Model Nurses provide direct assistance to meet an immediate need for help in order to avoid or to alleviate distress or helplessness She advocated that the three elements composing the nursing situation are: ✓ Client behavior ✓ Nurse reaction ✓ Nurse action ❖ JEAN WATSON (1979) Human Caring Theory Practice of caring is central to nursing: it is the unifying focus for practice 10 curative factors 1. Formation of Humanistic- altruistic system of values 2. Instillation of faith and hope 3. Cultivation of sensitivity to one’s self and others 4. Development of helping – trusting relationship 5. Promoting and accepting the expression of positive and negative feelings 6. Systematically using the scientific problem-solving method for decision making 7. Promoting transpersonal teaching-learning 8. Provision of a supportive, protective and/or corrective mental, physical, societal and spiritual environment 9. Assisting with gratification of human needs 10. Allowance for existential- phenomenological - spiritual forces ❖ ROSEMARIE RIZZO PARSE Human Becoming Theory Proposed 3 assumptions about human becoming: 1. Human becoming is freely choosing personal meaning in situations in the inter subjective process of relating value priorities 2. Human becoming is co-creating rhythmic patterns or relating in mutual process with the universe 3. Human becoming is contrascending multidimensional with the emerging possibilities emphasizes how individuals choose and bear responsibility for patterns of personal health SCOPE OF NURSING PRACTICE ❖ PROMOTING HEALTH AND WELLNESS A process that engages in activities and behaviors that enhance quality of life and maximize personal potential Activities that enhance healthy lifestyle: ✓ Improving nutrition and physical fitness ✓ Preventing drug and alcohol misuse 3 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT ✓ Restricting smoking ✓ Preventing accidents and injury at home and workplace ❖ PREVENTING ILLNESS Goal of illness prevention program is to maintain optimal health by preventing disease which includes: ✓ Immunizations ✓ Prenatal and infant care ✓ Prevention of STI ❖ RESTORING HEALTH Focuses on the ill client and it extends from early detection of disease through helping the client during the recovery period Activities include: ✓ Providing direct care to the ill client ✓ Performing diagnostic and assessment procedures ✓ Teaching clients about recovery activities ✓ Rehabilitating clients to their optimal functional level ❖ CARING FOR DYING Comforting and caring for people of all ages who are dying which includes: ✓ Helping clients live as comfortably as possible until death ✓ Helping support persons to cope with death STANDARD OF NURSING PRACTICE ❖ ASSESSMENT Collect comprehensive data pertinent to the patient’s health or situation ❖ DIAGNOSIS Analyzes the assessment data to determine the diagnose or issue ❖ OUTCOME INDENTIFICATION Identifies expected outcomes for a plan individualized to the patient or the situation ❖ PLANNING Develops a plan that prescribe strategies and alternatives to attain expected outcomes ❖ IMPLEMENTATION Implements the identified plan ❖ EVALUTION Evaluates progress towards attainment of outcomes ❖ QUALITY OF PRACTICE Systematically enhance the quality and effectiveness of nursing practice ❖ EDUCATION Attains knowledge and competency that reflects current nursing practice ❖ PROFESSIONAL PRACTICE EVALUATION Evaluate one’s own practice in relation to professional practice standards and guidelines, relevant statutes, rules and regulation ❖ COLLEGIALITY Interacts with and contributes to the professional development of peers and colleagues ❖ COLLABORATION Collaborates with patients, family and others in the conduct of nursing practice ❖ ETHICS Integrates ethical provisions in all areas of practice ❖ RESEARCH Integrate research findings into practice ❖ RESOURCE UTILIZATION Considers factors related to safety, effectiveness, cost and impact on practice on the planning and delivery of nursing services ❖ LEADERSHIP Provides leadership in the professional practice setting and the profession 4 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT ROLES AND FUNCTIONS OF A NURSE ❖ CAREGIVER Encompasses activities that assist the client physically and psychologically while preserving the dignity of the client Nurse is primarily concerned with the client’s needs ❖ COMMUNICATOR Communicates the identified problem of the client to other health care team ❖ TEACHER Nurse teaches client about their health and procedures they need to perform to restore their health ❖ CLIENT ADVOCATE Acts to protect the client Nurse assist clients in exercising their rights and help them speak for themselves ❖ COUNSELOR Nurse provides emotional, intellectual and psychological support ❖ CHANGE AGENT Nurse assists clients to make modification in their behavior ❖ LEADER Influences others to work together to accomplish a specific goal ❖ MANAGER Nurse plans, give direction, develop staffs, monitors operation, give rewards fairly and represents both staff members and administration as needed. ❖ CASE MANAGER Works with multidisciplinary health care team to measure the effectiveness of the case management plan and monitor outcomes. ❖ RESEARCHER Nurse participates in scientific investigation and uses research findings to improve client care ❖ COLLABORATOR Nurse works in combined effort with all those involve in care delivery EXPANDED CAREER ROLES FOR NURSES ❖ NURSE PRACTITIONER Nurse who has advanced education & graduated from a nurse practitioner program Employed in health care agencies or community-based settings Deals with non-emergency acute or chronic illness & provide primary ambulatory care ❖ CLINICAL NURSE SPECIALIST Has an advanced degree or expertise and is considered to be an expert in a specialized area of practice (gerontology, oncology) Provides direct client care, educates others, conducts research, and manages care. ❖ CERTIFIED REGISTERED NURSE ANESTHETIST (CRNA) Completed advanced education in an accredited program in the anesthesiology Carries out pre-op and post-op visits and assessment Administers general anesthesia for surgery under the supervision of a physician prepared in anesthesiology and also assesses the postoperative status of clients ❖ NURSE-MIDWIFE RN who has completed a program in midwifery and gives prenatal & postnatal care and manages deliveries in normal pregnancies May also conduct pap smears, family planning and routine breast exams ❖ NURSE RESEARCHER Investigates nurse problems to improve nursing care and to refine and expand nursing knowledge Employed in academic institutions, teaching hospitals and research center, and usually has advanced education at the doctorate level ❖ NURSE ADMINISTRATOR Manages client care, including the delivery of nursing services Function: ✓ Budgeting ✓ Staffing and ✓ Planning programs 5 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT ❖ NURSE EDUCATOR Responsible for classroom and clinical teaching ❖ NURSE ENTREPRENEUR Manages health-related businesses PATRICIA BENNER’S STAGES OF NURSING EXPERTISE ❖ STAGE I (Novice) No experience (student nurse) Performance is limited, flexible, and governed by context-free rules and regulations rather than experience ❖ STAGE II (Advanced Beginner) Demonstrates marginally acceptable performance Recognizes meaningful “aspects” of a real situation Experienced enough real situations to make judgments about them ❖ STAGE III (Competent) 2-3 years of experience Demonstrates organizational and planning abilities Differentiates important factors from less important aspects of care Coordinates multiple complex care demands ❖ STAGE IV (Proficient) 3-5 years of experience Perceives situations as a whole rather than in terms of parts Uses maxims as guides for what to consider in a situation Has holistic understanding of the client, which improves decision making Focuses on long term goal ❖ STAGE V (Expert) Performance is fluid, flexible, and highly proficient No longer requires rules, guidelines, or maxims to connect an understanding of the situations to appropriate actions Inclined to take a certain action because “it felt right”. COMMUNICATION IN NURSING ❖ Interchange of information between two or more people: exchange of ideas and thoughts. In addition, thoughts are conveyed to other not only buy spoken or written words but also by gestures or body actions ❖ Verbal Communication uses spoken or written words ❖ Non-verbal communication uses gestures, facial expressions, posture/gait, body movements, physical appearance, eye contact and tone of voice ❖ Components of communication Sender- is the person who encodes and deliver message Message- the content of the communication, may contain verbal, nonverbal, and symbolic language Receiver - the person who receives and decodes the message Channel- means of conveying and receiving messages through visual, auditory and tactile senses Response/feedback- message returned by the receiver to the sender CHARACTERISTICS OF COMMUNICATION ❖ Simplicity – use of commonly understood words ❖ Pace and Intonation – modifies the feeling and the impact of the message ❖ Clarity and Brevity – message that is direct and simple ❖ Timing and Relevance – require choice of time and consideration of client’s interest and concern ❖ Adaptability – message needs to be altered in accordance with behavioral cues from the client ❖ Credibility – means worthiness of belief, trustworthiness, and reliability ❖ Humor – used to help clients adjust to difficult and painful situation DOCUMENTATION ❖ Written or computer-based ❖ Served as a permanent record of client’s information and progress care ❖ Formal, legal document that provide evidence of a client’s care 6 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT ❖ PURPOSES OF DOCUMENTATION Planning client care Communication For legal documents purposes For research For education Reimbursement For statistics, reporting, epidemiology Auditing health agencies Health care analysis ❖ TYPES OF RECORDS Source-Oriented Medical Record (Traditional Client Record/ SOMR) ✓ Each person or department makes notations in a separate section/s of client’s chart ✓ Specific information is easier to locate Components of SOMR ✓ Admission sheet ✓ Face sheet ✓ Medical history and physical examination and sheet ✓ Diagnostic finding sheet ✓ TPR graphic sheet ✓ Doctor’s treatment and order sheet ✓ Therapeutic sheet ✓ Special flow sheet ✓ Medication record ✓ Nurses notes ✓ Client discharge plan and referral summary ✓ Initial nursing assessment ❖ PROBLEM-ORIENTED MEDICAL RECORD Data about the client are recorded and arrange according to the sources of the information Records integrates all data about the problem, gathered by members of health team 4 BASIC COMPONENTS OF POMR 1. DATABASE- contains all information from the patient when he first entered the agency. It includes nursing assessment, physician’s history, social and family data, results of physician’s examination. 2. Problem Lists- contains all the aspects of the person’s life requiring health care -Kept in front of the chart -Problems are listed in the order, which they are identified -Continually updated as new problems are identified and others are resolved 3. Initial list of orders or plan of care- made with reference to the active problems and are generated by the person who lists the problem 4. Progress Notes- which includes nurses narrative notes (SOAPIE, SOAPIE, SOAPIER) ❖ KARDEX Provides a concise method of organizing and recording data about the client, making information readily accessible to all members of the health care team May be written in a pencil to ease in recording frequent change in details of client care A series to flip cards usually kept in portable file GENERAL GUIDELINES FOR RECORDING ❖ Date and Time For legal reasons and client’s safety Record the time in conventional manner (ex. 9:00 am or 3:15 pm) or according to 24-hour clock (military time) to avoid confusion about whether time was am or pm ❖ Timing Adjust the frequency a per client’s condition indicates No recording should be done BEFORE providing nursing care Documenting should be done as soon as possible after assessment/ intervention ❖ Legibility All entries must be easy to read prevent interpretation errors 7 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT ❖ Permanence Records are made in the dark permanent ink ❖ Use of accepted terminology Use only commonly accepted abbreviation, symbols and terms that are specified by the agency ❖ Correct Spelling Is essential for accuracy in recording If unsure how to spell, look it up in a dictionary or other resource book ❖ Signature Each recording in nursing notes is signed by the nurse making it Include name and title (ex. Ralf Jake M. Faustino RN) ❖ Accuracy Clients name should be written on each page of the clinical record Accurate notations consist of facts/ observations rather than opinions or interpretation ✓ e.g. Fact “ Client refused Medication” ✓ Opinion “ Client was Uncooperative” When recording MISTAKE is made, draw a line through it and write the words “mistaken entry” (avoid writing the word error) above or next to the original entry with your initials or name Do not erase, blot out or use correction fluid Write every line but not between line If a blank appears in the notation, draw a through the blank space and sign the notation ❖ Sequence Document events in the order which they occur ❖ Appropriateness Record only information that pertains to the client’s health problems and care Recording irrelevant information may be considered an invasion of the client privacy ❖ Completeness Information needs to be complete and helpful to the client and health care professionals Care that is omitted because of client’s refusal of treatment must also be recorded. Document what and why it is omitted and who was notified ❖ Conciseness Recording needs to be brief as well as completed to save time in communication ❖ Legal Prudence Accurate and complete documentation should be a legal protection to the client and health care team ❖ Confidentiality Only the health professionals who participate in the care of the client are allowed to read the chart ❖ Takes place when two or more people share information about client care, either face-face o via telephone Types of Reporting ❖ Change-of-shifts report or endorsement For continuity of care of clients by providing quick summary of health care needs and details of care to be given It is not merely reciting the content or the KARDEX ❖ Telephone Reports Provide clear, accurate and concise information: ✓ Date and time ✓ Name of the person giving the information ✓ Subject of information received ✓ Name and signature of the receiver Person receiving the information should repeat it back to the sender to ensure accuracy ❖ Telephone Orders Only RN’s may receive telephone orders. Another RN should listen in another telephone line to countercheck the details. Write the date and time the telephone order was received. Write the complete order and read it back. Question primary care provider about any order that is unusual or contraindicated to client’s condition 8 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT The order should be countersigned by the physician who made the order within the prescribed period of time (within 24 hours) ❖ Transfer Report Done when transferring a client to other unit NURSING PROCESS ❖ Purposes of nursing process 1. To identify client’s health status Actual health problem Potential health problems or needs 2. To establish plans to meet identified needs 3. To deliver specific nursing care and improve the quality of care CHARACTERISTICS OR NURSING CARE ❖ Cyclical (regularly repeated events) and Dynamic (continuously changing) ❖ Client-centered – organizes the plan or care according to client’s problems rather than nursing goal ❖ Focused on Problem Solving- nursing process is directed towards a client ‘s responses to disease and illness ❖ Decision making- involved in every phase of nursing process ❖ Interpersonal and Collaborative Communicates with the client and family Collaborates with other members of the health care team ❖ Universally applicable- used in all types of health care setting with the clients of all age group ❖ Nurses must use a variety of critical thinking skills to carry out the nursing process COMPONENTS OF THE NURSING PROCESS (ADPIE) ❖ Assessment ❖ Diagnosis ❖ Planning ❖ Implementation ❖ Evaluation ASSESSMENT ❖ Assessment is a systematic and continuous collection, organization, validation and documentation of data about the client health status Purpose: establish a database ❖ Activities during assessment Data Collection ✓ Gathering information about client, considering the physical, psychological, emotional, social- cultural, and spiritual factors that may affect his /her health status Sources of data ✓ Client (primary) ✓ Support people (secondary) ✓ Family members, friends, and caregivers who know the client well ✓ Client records ✓ Medical records- past and present health and illness patterns ✓ Records of therapies social – workers, nutritionist, dieticians, ✓ Physical therapist ✓ Laboratory record ✓ Health care professionals ✓ Literature ❖ Data collection methods Observing - gathers data by using the senses 2 aspects: ✓ Noticing the data ✓ Selecting, organizing and interpreting data Interviewing – is a planned communication or a conversation with a purpose 9 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT 2 approaches: ✓ Directive Highly structured and elicits specific information Uses closed-ended questions (YES/NO) The nurse stablishes the purposes & control the interview Used when you need to elicit specific data Used in emergency situation ✓ Non-directive (rapport-building) Nurse allow the client to control the purpose, subject matter & pacing Uses more open-ended questions Advantage: allows the patient to explain certain information ❖ Stages of Interview The Opening ✓ Most important ✓ Establish rapport ✓ Orientation The Body- the client communicates what he or she thinks, feels, and perceives in response to the question The Closing- termination of the interview ❖ Data Organization Clustering/ organizing of facts into group of information Nurse uses a written/computerized data systematically ❖ Validating Data Double checking or verifying data to confirm that it is accurate and factual ❖ Documenting Data Accurate documentation is essential and should include all data collected about the client’s health status ❖ 4 Types of Assessment Initial Assessment ✓ Perform within the specified time after admission ✓ Main purpose is to create data base for problem identification reference and future comparison Problem-focused Assessment ✓ Integrated throughout the nursing process ✓ Purpose is to determine the status of a specific health problem (ex. Hydration status every 15 minutes) Emergency assessment ✓ Done during an acute physiologic and psychologic crisis of the client ✓ Purpose: identify life-threatening condition and to identify new or overlooked problems ✓ Framework and principle in emergency assessment A- Airway B- Breathing C- Circulation ✓ Use either Maslow’s Hierarchy of needs or ABC principles Time-lapsed Assessment ✓ Done several months after initial assessment ✓ Purpose: to compare clients current status to base line data (initial assessment) previously obtained DIAGNOSIS ❖ 2ND PHASE of nursing process ❖ The process, which results to a diagnostic statement or nursing diagnosis. It is the clinical act of identifying problems. ❖ Purpose: to identify the client’s health care needs and to prepare diagnostic statement. ❖ Activities during diagnosing Organized cluster/group of data Compare data with standards (norm) Analyze data after comparing with standards Identifying gaps & inconsistencies in data Determine the client's health problems, risks, and strengths Final output: Nursing Diagnosis statement 10 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT ❖ Nursing diagnosis is a statement of client's potential or actual alteration of health status. It uses the critical- thinking skills of analysis and synthesis. ❖ Basic 2-part statements Problem (statement of the client's response) Etiology (factors contributing to or probable causes of the responses) The two parts are joined by the words "related to" (implies relationship) e.g.: Constipation related to prolonged laxative use e.g.: Ineffective breast feeding related to breast engorgement ❖ Basic 3-part statements (PES format) Problem Etiology Signs and symptoms (defining characteristics manifested by the client) e.g.: Situational low self-esteem related to rejection by husband as manifested by hypersensitivity to criticism; states "I don't know if I can manage by myself" and rejects positive feedback. ❖ One-part statements Consists of NANDA label only e.g.: Rape-Trauma syndrome; Anticipatory grieving ❖ Collaborative problems Suggested that all collaborative problems begin with diagnosing label “Potential Complications” e.g.: Potential complications of head injury: Increased intracranial pressure ❖ Purpose of NANDA To define, refine, and promote taxonomy (classification or system or set of categories arranged on basis of a single principle or set of principles) of nursing diagnostic terminology of general use to professional nurses Members ✓ Staff nurses ✓ Clinical specialists ✓ Faculty, directors of nursing ✓ Deans, theorists, and researchers ❖ Types of Nursing Diagnosis Actual diagnosis ✓ Client problem that is present at the time of the nursing assessment (based on the presence of associated signs and symptoms) eg: Ineffective breathing pattern; Anxiety Risk nursing diagnosis ✓ Clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene eg: Risk for Infection Wellness diagnosis ✓ Describes human responses to levels of wellness in an individual, family or community that have a readiness for enhancement" eg: Readiness for enhanced spiritual well -being; Readiness for enhanced family coping Possible nursing diagnosis ✓ Evidence about a health problem is incomplete or unclear ✓ eg: Possible social isolation related to unknown etiology Syndrome diagnosis ✓ Associated with a cluster of other diagnoses eg: Risk for disuse syndrome; Impaired physical mobility; Risk for infection; Impaired gas exchange PLANNING ❖ Deliberative, systematic phase of nursing process that involves decision making and problem solving ❖ Goal setting: to have criteria for evaluation ❖ For the goal to be useful during evaluation, it should be stated in BEHAVIORAL TERMS ❖ To be effective, involve the patient and family Types of Planning Initial Planning — done by the nurse who performs the admission assessment Ongoing Planning ✓ Done by all nurses who work with the client 11 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT ✓ Occurs at the beginning of a shift as the nurse plans the care to be given that day Discharge Planning ✓ Process of anticipating and planning for needs after discharge, is a crucial part of comprehensive health care. ✓ Begins at first client contact and involves comprehensive & ongoing assessment to obtain information about client's ongoing needs. ❖ The Planning Process 1. Setting priorities 2. Establishing client goals/desired outcomes 3. Selecting nursing interventions 4. Writing individualized nursing interventions on care plans ❖ Guidelines for Writing Nursing Care Plans 1. Date and sign the plan. 2. Use category headings. 3. Use standardized/approved medical or English symbols and key words rather than complete sentences to communicate your ideas unless the agency policy dictates otherwise. 4. Be specific. 5. Refer to procedure books or other sources of information rather than including all the steps on a written plan. 6. Tailor the plan to the unique characteristics of the client by ensuring that the client's choices such as preferences about the times of care and methods used are included. 7. Ensure that the nursing plan incorporates preventive and health maintenance aspects as well as restorative ones. 8. Ensure that the plan contains interventions for ongoing assessment of the client. 9. Include collaborative and coordination activities in the plan. 10. Include plans for the client's discharge and home care needs. Characteristics of the Planning Process (CSMART) C-Client-centered S-Specific M- Measurable A-Attainable R- Realistic T-Time bound IMPLEMENTATION ❖ Doing and documenting the activities that are specific nursing actions needed to carry out the interventions (or nursing orders) ❖ Reassessing the client before implementing an intervention ❖ Determining the nurse's need for assistance ❖ Implementing the nursing interventions ❖ Supervising the delegated care ❖ Documenting nursing activities REQUIREMENTS FOR IMPLEMENTATION ❖ Adequate knowledge ❖ Technical Skills ❖ Communication skills ❖ Therapeutic use of self ❖ Right attitude EVALUATION ❖ Collecting data, comparing data, and relating nursing activities to outcomes ❖ Drawing conclusions about problem status ❖ Continuing, modifying or terminating the NCP (Nursing Care Plan) TYPES OF EVALUATION ❖ On-going/Formative Evaluation Done during or immediately after the intervention Allows the nurse to decide and make on-the-spot modification/s in an intervention ❖ Intermittent Evaluation Done at a specified time & it shows the extent of progress of the patient 12 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT Enables the nurse to correct deficiencies and modify the nursing care plan ❖ Terminal/Summative Evaluation Done at or immediately before discharge Importance: It determines whether the goals are met, partially met or unmet When goals have been partially met or when goals have not been met, two conclusions may be drawn: ✓ The care plan may need to be revised, since the problem is only partially resolved ✓ Or the care plan does not need revision, because the client merely needs more time to achieve the previously established goal(s) CONCEPTS OF HEALTH AND ILLNESS ❖ Health is state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity (WHO). ❖ Health is the ability to maintain homeostasis or dynamic equilibrium. Homeostasis is regulated by the negative feedback mechanism (Walter Cannon). MODELS OF HEALTH AND ILLNESS Travis's Illness-Wellness Continuum ❖ The illness-wellness continuum developed by Travis ranges from high-level wellness to premature death. ❖ The model illustrates two arrows pointing in opposite directions and joined at a neutral point. ❖ Movement to the right of the neutral point indicates increasing levels of health and well-being for an individual. This is achieved in three steps: ✓ Awareness ✓ Education ✓ Growth ❖ In contrast, movement to the left of the neutral point indicates progressively decreasing levels of health. Health Belief Model ❖ The model of Becker (1975) which describes the relationship between a person's belief and behavior ❖ Individual perceptions and modifying factors may influence health beliefs and preventive health behavior ❖ Individual perceptions include the following: Perceive susceptibility to illness Perceive seriousness of an illness Perceive threat of an illness ❖ Modifying factors including the following Demographic variables (age, sex, race, etc.) Socio-psychologic variables (pressure from peers) Structural variables (knowledge about the disease) Cues to action (internal: fatigue; external: mass media) SMITH'S MODEL OF HEALTH ❖ Clinical model — identifies health as absence of signs and symptoms of disease or injury ❖ Role performance model — health is identified in terms of individual's ability to perform his/her work ❖ Adaptive model — Health is a creative process; disease is a failure in adaptation; focuses on the ability of the person to cope Eudemonistic model — health is seen as a condition of actualization or realization of person's potential LEAVELL AND CLARK'S AGENT-HOST- ENVIRONMENTAL MODEL (ECOLOGIC MODEL) ❖ States that there are three interactive factors that affect health and illness Agent — any factor or stressor that can cause or lead to illness Host — person who may or may not be at risk of acquiring the disease Environment — any factor external to the host that may or may not predispose the person to the development of the disease Illness — is the state in which the person's physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished or impaired compared with previous experiences Disease — an alteration in body functions resulting in reduction of capacities or a shortening of the normal life span ❖ COMMON CAUSES OF DISEASE Biologic agents (microorganisms) Inherited genetic defects (hemophilia) 13 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT Developmental defects (imperforated anus) Physical agents (hot and cold substances) Chemical agents (emissions from smoke) Tissue response to injury (inflammation) Faulty chemical / metabolic process (inadequate iodine — goiter) Emotional / physical reaction to strew (anxiety) STAGES OF ILLNESS ❖ Symptom Experiences Person comes to believe something is wrong ✓ Physical — experience of symptoms ✓ Cognitive- the interpretation of the symptoms in terms that have some meaning to the person. ✓ Emotional-fear and anxiety. ❖ Assumption of the sick role Acceptance of the illness Excused from normal duties and role expectations Confirmation from family and friends ❖ Medical care contact Seek advice of the health professionals for validation of real illness, explanation of symptoms, and reassurance or prediction of what the outcome will be ❖ Dependent Patient Role Client becomes dependent on the health professionals for help Accepts / rejects health professional's suggestions Later becomes more passive and accepting May regress to an earlier behavior stage ❖ Recovery or Rehabilitation Client is expected to relinquish the dependent role and resume former roles and responsibilities ❖ Risk factors — any situation, habit, environmental, physiologic psychologic condition or other variable that increases the vulnerability of the individual to illness or accident Genetic and physiological factors Age Environment Lifestyle LEAVELL AND CLARK'S THREE LEVEL OF PREVENTION ❖ PRIMARY PREVENTION To encourage optimal health and to increase the person's resistance to illness Seeks to prevent a disease or a condition at a pre-pathologic state Health promotion Specific protection ✓ Quit smoking ✓ Avoid / limit alcohol intake ✓ Exercise regularly ✓ Eat well-balanced diet ✓ Reduce fat intake and increase fiber in the diet ❖ SECONDARY PREVENTION It is also known as health maintenance Seeks to identify specific illnesses or conditions at an early stage with prompt intervention to prevent or limit disability Early diagnosis / detection / screening ✓ Prompt treatment to limit disability ✓ Have annual physical examination ✓ Regular pap’s smear test for women ✓ Monthly BSE for women ❖ TERTIARY PREVENTION Occurs after a disease or disability has occurred and the recovery process has begun 14 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT Intent is to halt the disease or injury process and assist the person in obtaining an optimal health status Rehabilitation ✓ Self-monitoring of blood glucose level among diabetics ✓ Physical therapy after CVA ✓ Undergoing speech therapy after laryngectomy PHYSIOLOGIC RESPONSES TO STRESS AND ILLNESS ❖ STRESS Is a universal phenomenon, All person experience it Is a condition in which the person responds to changes in the formal balanced state ❖ STRESSOR – is any event or stimulus that causes an individual to experience stress When a person faces stress, responses are called coping strategies, coping responses, or coping mechanism ❖ SOURCES OF STRESS Internal stressor – originate within the person (Depression in cancer patients) External stressors – originate outside the individual. (A death in family) Developmental stressors – occurs at predictable times throughout an individual’s life. (Getting started in an occupation by a young adult) Situational stressors – are unpredictable and may occur at any time during life, may be positive or negative. (Marriage or divorce, birth of a child) RESPONSE BASED MODEL OF STRESS (HANS SELYE) ❖ Adaptation The adjustments that a person make in different situations ❖ Type of Adaptation General Adaptation Syndrome (GAS) ✓ The entire body is involved wherever man responds to stress ✓ There are many similar manifestations that characterized different disease conditions; and there are very few specific manifestations that characterized by a particular disease Stage in GAS ❖ Alarm Reaction / Stage of Alarm ✓ Alerts the body’s defense ✓ The person becomes aware of the presence of threat or danger ✓ Levels of resistance are decreased ✓ Adaptive mechanism are mobilized ✓ If the stress in intense enough, even at the stage of alarm, death may ensure ❖ Shock/Resistance Phase ✓ The stressor may be perceived consciously or unconsciously by the person ✓ Autonomic nervous system reacts, and large amount of epinephrine (adrenaline) and cortisone are released into the body ✓ “Fight or Flight” ✓ This primary response is short, lasting from 1 minute to 24 hours ❖ Counter-shock/Exhaustion phase ✓ The changes produced in the body during the shock phase are reversed ✓ The person is best mobilized to react during the shock phases of the alarm reaction ❖ Stage of Resistance ✓ Is when the body’s adaptation takes place ✓ The body attempts to cope with the stressor and limit the stressor to the smallest area of the body that can deal with it ✓ The person moves back to homeostasis ❖ Stage of Exhaustion ✓ The adaptation that the body made during the second stage cannot be maintained ✓ The ways used to coped with the stressors have been exhausted ✓ If adaptation has not overcome the stressor, the stress affects may spread to the entire body ✓ At the end of this stage, the body may either rest and return to normal, or death may be the ultimate consequence ❖ Local Adaptation Syndrome (LAS) Man may respond to stress through a particular body part or body organ 15 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT (e.g. Inflammation, backache, headache and diarrhea) ❖ Homeostasis A state of dynamic equilibrium; stability, balance; uniformity It is now more commonly referred to as "hemodynamics", because it is characterized by constant change. It is regulated by negative feedback mechanism. ❖ Concepts of Homeostasis Sympatho-Adreno-Medullary Responses (Walter Cannon) ✓ SAMR or fight-or flight response ✓ Adreno-cortical Response ✓ Neurohypophyseal Response ❖ Local Physiologic Responses to Stress Inflammation involves mobilization of specific and nonspecific defense mechanism in response to tissue injury or infection Purposes of Inflammation ✓ To localize tissue injury ✓ To protect tissue from injury ✓ To prepare tissue for repair ❖ Cellular Response Neutrophils — are first to be launched at the site of injury Monocytes — perform phagocytosis in chronic tissue injury Lymphocytes — responsible for immune responses Processes Involved: Marginal / pavementation — phagocytes line up at the peripheral walls of the blood vessels Emigration / diapedesis — phagocytes shift out of the blood vessels Chemotaxis — impaired tissues release substances which exert magnet-like force to the phagocytes to bring them to the areas of injury Phagocytosis — phagocytes ingest or engulf the antigens ❖ EXUDATE PRODUCTION Inflammatory exudate is produced, consisting of fluid that escaped from the blood vessels, dead phagocytic cells, and dead tissue cells and products that they release Plasma protein fibrinogen (which is converted to fibrin when it is released into the tissues), thromboplastic (released by injured tissue cells), and platelets together form an interlacing network to wall off the area, and prevent spread of the injurious agent During this stage, the injurious agent is overcome, and the exudate is cleared away by lymphatic drainage ❖ Healing Process (Reparative Phase) Regeneration — involves replacement of damaged tissue cells by new cells which are identical in structure or function Scar Formation — involves replacement of damaged tissue cells by fibrous tissue formation ✓ Granulation tissue (pink or red, fragile gelatinous tissue — early stage) ✓ Cicatrix or scar — later stage, forms because the tissue shrinks and the collagen fibers contract ❖ Healing may also be classified as follows: First Intention — occurs in clean-cut wound. The wound edges are approximated and there is minimal or no scar tissue formation Second Intention — occurs when the wound is extensive and there is a great amount of tissue loss. The repair time is longer and the scarring is greater Third Intention — occurs when there is delayed surgical closure of infected wound ASSESSING VITAL SIGNS / CARDINAL SIGNS 1. Temperature 2. Pulse 3. Respirations 4. Blood Pressure 5. Pain – the fifth vital sign TEMPERATURE ❖ Body Temperature- balance between heat produced by the body and heat loss from the body 16 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT ❖ Types of Body Temperature Core Temperature ✓ Temperature of the deep tissues of the body such as abdominal and pelvic cavity. Surface temperature ✓ Temperature of skin, SQ tissue and fat. Rises and falls in response to the environment. ❖ Processes Involved in Heat Loss Radiation - transfer of heat from surface to surface of one object to surface of another w/o contact Conduction - transfer of heat from one surface to another through direct contact Convection - dispersion of heat by air currents Evaporation - vaporization of moisture from the respiratory tract, mucosa of the mouth and skin ❖ Factors Affecting Body Temperature Age Diurnal variation (circadian rhythms) ✓ Highest temp: 4pm to 6pm ✓ Lowest temp: 4am — 6am Exercise Hormones (progesterone raises body temp) Stress Environment ❖ Alterations in Body Temperature Pyrexia/Hyperthermia/Fever ✓ Body temperature is above the usual range Hyperpyrexia ✓ Very high fever, 41°C (105.8°F) and above Hypothermia ✓ Core body temperature is below the lower limit of normal ✓ May be caused by excessive heat loss, inadequate heat production or impaired hypothalamic thermoregulation ❖ Types of Fever Intermittent fever - body temperature alternates at regular intervals between periods of fever and normal or subnormal temperature Remittent fever - wide range of temp fluctuations more than 2°C for over 24 hrs, all of which are above normal Relapsing fever - short febrile periods of a few days are interspersed with periods of 1-2 days of normal temperature Constant fever - body temperature fluctuates minimally but always remains above normal. Fever spike (Staircase) —temperature rises to fever level rapidly following a normal temperature then returns to normal within a few hours ASSESSING BODY TEMPERATURE ❖ Oral ✓ Considered to be the most convenient and most accessible ✓ Wait for 30 mins. before taking oral temperature if the client has taken cold or hot drinks/food or smoked ✓ Contraindicated to patients with; ✓ Oral lesions/ surgery ✓ Dyspnea ✓ Cough ✓ Nausea and vomiting ✓ Presence of oro-nasal pack, NGT, ET ✓ Seizure prone ✓ Very young children ✓ Unconscious ✓ Restless, disoriented, confused Clean the thermometer before use (from bulb to stem), and after use (from stem to bulb) Place the bulb of the thermometer on either side of the frenulum Take oral temperature for 2-3 mins. Normal range: 36°C to 37.5°C 17 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*M EDTECH LET* PS YCH O M ET* RESPI RATOR Y THERAPY* CI VIL SERVICE*NAPOL COM NCL EX* DHA* HAAD* PROM ETRIC* UK- CBT ❖ Rectal Considered to be very accurate Contraindicated to patients with: o Anal or rectal conditions/surgery o Diarrhea o Quadriplegia and Myocardial Infarction Wear clean gloves and assist the client to assume lateral/sim's position Lubricate thermometer before insertion Instruction the client to take a slow deep breath during insertion Never force the thermometer if resistance is felt Insert 15 cm (6 in.) in adults and 11 cm for children Hold the thermometer in place for 2 mins. Normal range: 36°C to 37.8°C ❖ Axillary Safest and non-invasive Pat dry the axilla. Rubbing causes friction that may increase surface temperature The bulb is placed in the center of the axilla Place the arm tightly across the chest to keep the thermometer in place and leave it for 9 mins. ❖ Tympanic membrane Frequent site for estimating core body temperature Pull pinna back and upward (adults) Supine, head stabilized; pull pinna straight back and slightly downward for children