Republic of the Philippines

Laguna State Polytechnic University

Province of Laguna

College of Nursing and Allied Health

Nursing as a Profession 1
Nursing 2
History of Nursing History of Nursing in the World 4
History of Nursing in the Philippines 6
History of College of Nursing & Allied Health 8
Development of Modern Nursing 10
Growth of Professionalism 12
Carper’s 4 Patterns of Knowing 13
Overview of the Professional Nursing Practice Level of Proficiency accdg. To Benner 14
Roles and Responsibilities of a Professional Nurse 15
Scope of Nursing Practice based on RA 9173 16
Different Fields in Nursing 17
Communication Skills 20
Nursing Process 23
Health and Illness 35
Levels of Care 38
Basic Interventions to Maintain 40
Meeting needs related to Death and Dying/ Grief and Grieving 43
Nursing as an Art 51
 Nursing as a Profession
PROFESSION
A profession is an occupation that requires
extensive education or a calling requiring
advanced training that requires special
knowledge, skill, and preparation.
Nursing is a healthcare profession that
involves years of training and continued
specialized education to care for patients in a
variety of settings.
2 TERMS OF PROFESSION
PROFESSIONALISM
- Refers to professional character, spirit, or
method. It is a set of attributes, a way of
life that implies responsibility and
commitment.
PROFESSIONALIZATION
- Process of becoming professional, that is,
of acquiring characteristics considered to
be professional.
CRITERIA OF A PROFESSION
• A profession must satisfy an indispensable
social need and must be based upon well
established and socially accepted scientific
principles.
• It must have developed a scientific technique
which is the result of tested experience.
• It must have sufficient self-impelling power to
retain its members throughout life. It must not
be used as a mere stepping stone to other
occupations.
• It must recognize its obligations to society by
insisting that its members live up to an
established code of ethics.
Nursing as a profession is constantly expanding its scope
of practice and challenging its workforce to continue its
education.
A profession is generally
distinguished from other kinds of
occupation by:
A. Specialized Education
Undergraduate nursing curriculum
should include liberal arts education.
B. Body of Knowledge
A number of nursing conceptual
frameworks contribute to the knowledge
base of nursing and give direction to
nursing practice, education, and going
research.
C. Service Orientation
Nursing has a tradition of service
to others. The service must be guided by
certain rules, policies, or code of ethics.
D. On-going Research
Increasing research in nursing is
contributing to nursing practice. Evolution in
the nursing research.
E. Code of Ethics
Nursing has developed its own
code of ethics and in most instances has set
up means to monitor the professional
behaviour of its members.
F. Autonomy
A profession is autonomous if it
regulates itself and sets standards for its
members. For nursing to have professional
status, it must function autonomously in the
information of policy and in the control of
its activity.
G. Professional Organization
For nursing there is the Philippine
Nurses Association (PNA), and so other
professional organizations.
 Nursing
Nursing encompasses autonomous and
collaborative care of individuals of all ages, families,
groups and communities, sick or well and in all settings.
Nursing includes the promotion of health,
prevention of illness, and the care of ill, disabled and
dying people.
Advocacy, promotion of a safe environment,
research, participation in shaping health policy and in
patient and health systems management, and education
are also key nursing roles.
CONTEMPORARY NURSING PRACTICE
Includes a look at definition of nursing, recipients
of nursing, scope of nursing practice, nursing practice acts,
and current standards of clinical nursing practice.
Certain themes are common to these
definitions:
 Nursing is caring
 Nursing is an art
 Nursing is a science
 Nursing is a client centered
 Nursing is a holistic
 Nursing is adaptive
 Nursing is a helping profession.
ANA STANDARD OF PROFESSIONAL
PERFORMANCE
1. Ethics: The registered nurse practices ethically.
2. Education: The registered nurse attains
knowledge and competency that reflects current
nursing practice.
3. Evidence-Based Practice and Research: The
registered nurse integrates evidence and research
findings into practice.
4. Quality of practice: The registered nurse
contributes to quality nursing practice.
5. Communication: The registered nurse
communicates effectively in all areas of practice.
6. Leadership: the registered nurse demonstrates
leadership in the professional practice setting and
profession.
7. Collaboration: The registered nurse collaborates
with health care consumer, family, and others in
the conduct of nursing practice.
NURSING
Nursing as an art
Is the art of caring sick and well
individual.
It refers to the dynamic school and
methods in assisting sick and well
individual in their recovery in the
promotion of health.
Nursing as a science
“Body of abstract knowledge”
The scientific knowledge and skill in
assisting individual to achieve optimal
health. It is diagnosis and treatment of
human responses to actual or potential
problem.
Nursing as a profession
A calling in which its members
profess to have acquired Special
knowledge by training or experiences, or
both so that they may guide, advise or
save others in that special field.
8. Professional Practice Evaluation: The
registered nurse evaluates her/his own
nursing practice in relation to professional
practice standard.
9. Resources: The registered nurse uses
appropriate resources to plan and
provide nursing services that are safe,
effective and financially responsible.
10. Environmental health: The registered
nurse practices in an environmentally safe
and healthy manner.
REFERENCE:
 Fundamentals of Nursing Ninth Edition,
Potter, Perry, Stockert and Hall, Nursing
Today, p2-5.
 https://www.icn.ch/nursing-
policy/nursing-
definitions?fbclid=IwAR0EpccykpMbUk4
v0_4qCKFsQlNj3Mh9CZ5Gz76LkDE6bIX
0JTfqhYdkvZE
c

Nursing
ESSENTIAL PERSONALITY CHARACTERISTICS
AND SKILLS FOR THE NURSING PROFESSION.
CHARACTERISTICS OF A
 Caring
NURSE
 Social Skill
o Patient Interaction
o Positive attitude Compassion
o Ability to listen - Empathy for others suffering and a
o Empathy desire to fix it.
Composure
 Prioritization Caring
 Patience
(Three elements of central to caring)
- Preservation of a patient’s dignity
PERSONAL AND PROFESSIONAL - Maintaining a desire to care and
QUALITIES OF A NURSE commit to a personal connection
with patient.
- Moments during which the nurse
Personal comes in contact with the patient to
provide care. (Dr. Jean Watson)
 Must have a Bachelor of Science degree in
Nursing. 4 Elements of Caring (Joan Tronto)
 Must be physically and mentally fit.
- Attentiveness
 Must have a license to practice Nursing in the
- Responsibility
country.
- Competence
Professional - Responsiveness of Care Receiver
 A person who completed a basic nursing education
program and licensed in his country to practice
professional nursing. Mindfulness
- Requires nurses to be aware on
their thoughts, feelings, emotions
QUALITIES OF A NURSE and desires and not allowing these
factors to get in the way of the
 Leadership and Management nurses ability to care for patients.
 Effective Communication REFERENCES:
 Critical Thinking
 Collaboration https://academicpartnerships.uta.edu/art
icles/healthcare/best-qualities-to-have-
 Continue to learn and grow
as-a-nurse.aspx
 Pursue higher education
 Keep up with current Nursing Literature
 Donate Time
 Join Professional Organization
 History of Nursing in the
World
Concept of Nightingale on Nursing School:

 School of Nursing should be self – supporting

not subject to the whimps of the Hospital.
 Have decent living quarters for students and
pay Nurse instructors
 Correlate theories to practice
 Support Nursing research and promote
continuing education for nurses
Nursing Association that upgraded nursing practice in U.S.:
EDUCATIVE PERIOD
Began in June 15, 1860 when Florence
Nightingale School of Nursing opened at
St. Thomas Hospital in London England,
where 1st program for formal education of
Nurses began and contributed growth of
Nursing in the US.

 American Nurses Association Factors That Influenced Development

Of Nursing Education:
 National League for Nursing Education
 Social forces
WELL-KNOWN PERSONA  Trends resulting from war
THEODORE FLIEDNER  Emancipation of women
 Increased educational
He is a pastor, reconstituted the deaconesses and opportunities
later be established the School of Nursing at
Kaiserswerth, Germany where Florence Nightingale had
Linda Richards, the first graduate
her 1st formal training for 3 months as nurse
nurse in U.S. She graduated in September
FLORENCE NIGHTINGALE 1, 1873.

Practiced her profession during the Crimena War.

Known as the “Lady with a lamp”. She came from a well- CONTEMPORARY PERIOD
known family. She then went to Germany to study.
Started from WWII up to present
day. This era includes scientific and
Nightingale, born on May 12, 1820 in Florence, Italy. technological development, social changes
occurring after the war. Nursing are now
then offered in college and university.
The Dark Period of Nursing
From 17th century – 19th century. Also called the W.H.O established by U.N to fight
Period of Reformation until the American Civil War. diseases by providing health information,
Hospitals were then closed. proper nutrition, living standards,
environmental conditions.
Nursing were the works of the least desirable people
(criminals, prostitutes, drunkards, slaves,and opportunists). Factors affecting Nurses/ Nursing
Nurses were uneducated, fithy, harsh, ill-fed, overworked. today:
There is a Mass exodus for nurses
 Economics
The American civil war was led by Martin Luther, the  Concumer’s demand
war was a religious upheaval that resulted to the  Family Structure
destruction in the unity of Christians. The conflict swept
 Information& telecomm.
everything connected to Roman Catholicism in schools,
 Legislations
orphanages, and hospitals
 History of Nursing in the
World
Rise of Civilization
From the mode of Nomadic life → agrarian society
→ gradual development of urban community life.
Start of scientific knowledge → more complex life →
increase in health problems → demand for more nurses
Three religious ideologist:
 Judaism
 Christianity
 Mohammedism or Islam
Near East culture was adopted by the Greeks and
Romans combined with the wonders of the Far East .
New World – a tiny area known as a birth of
monotheism that lies between tigris and Euprates river.
Different Civilization
Babylonians: Code of Hammurabi
Egyptian: Art of Enabling
Hebrew: Teaching of Moses
China: MateriaMedica
India: Sushuruto
Greece: Aesculapus- Father of Medicine
Hipocrates- Father of Modern Medicine
Caduceus- Insignia of Medicine
“If you are Strong, You are Healthy”
Military Religious Orders & Their Work:
Knight of St. John of Jerusalem (Italian)
Establish to give care. AKA “Knight of the
Hospitalers”
Teutonic Knights (German)
Carried for the injured and establish hospitals in
the military camps.
Knight of St. Lazarus
Care for those who suffered leprosy, syphilis &
chronic skin disease.
Alexian Brothers
A monasteric order founded in 1348. They
established the Alexian Brothers School of Nursing.
INTUITIVE PERIOD
From pre-historic up to early
Christian Era. It focuses more on intuition
for diagnosing a condition.
Composed of people called
NOMADS, who prefer travelling from one
area to another in search for cure.
Individuals type of living are called
Survival of the Fittest in where they have
to strive hard to save their lives from the
environment due to lack of resources.
In this era, they believed that
sickness is due to VODOO. Nursing is only
given by women.
Nursing is performed:
 Out of feeling of compassion.
 Out of desire to help.
 Out of wish to do good.
APPRENTICE PERIOD
From 11th Century up to 1836. Also
called as “On the Job” training period. It
refers to beginner (OJT). It means care
performed by people who are directed
by more experienced nurses. Starts from
the founding of Religious Orders in the 6th
century .
There was a struggle for religious,
political, and economic power. Crusades
took place in order to gain religious,
political, and economic power or for
adventure.
In this period, it happened as an
attempt to recapture the Holy Land from
the Turk who obtained and gain control of
the region as a result of power stuggle.
Christians were divided due to several
religious war and Christians were denied
visit to The Holy Sepulcher.
c

History of Nursing in the

Philippines
Early Beliefs & Practices
(Mysticism and Superstitions) EARLY HOSPITALS DURING
These were the early beliefs of health and illness THE SPANISH REGIME
in the Philippines. The cause of a disease was primarily 1. Hospital Real de Manila (1577)
believed to be due to either another person, whom which
was an enemy, or a witch or evil spirits. In the early times, – it was established mainly to
Filipinos were very cautious not to disturb other people or care for the Spanish king’s soldiers,
the evil spirits for the good of their health. These evil spirits
but also admitted Spanish civilians;
could be driven away by persons with power to banish
demons. founded by Gov. Francisco de
Sande.
Albularyo is a Filipino term for a witch doctor, folk
healer or medicine men. 2. San Lazaro Hospital (1578)
Early Care of the Sick – founded by Brother Juan
Clemente and was administered for
The early Filipinos subscribed to superstitious
belief and practices in relation to health and sickness.
many years by the Hospitalliers of
Herb men were called “herbicheros” meaning one who San Juan de Dios; built exclusively
practiced witchcraft. Persons suffering from diseases for patients with leprosy.
without any identified cause were believed bewitched
by “mangkukulam” or “manggagaway”. Difficult childbirth 3. Hospital de Indios (1586)
and some diseases (called “pamao”) were attributed – established by the
to “nunos”. Midwives assisted in childbirth.
Franciscan Order; service was in
During labor, the “mabuting hilot” (good midwife) general supported by alms and
was called in. If the birth became difficult, witches were contributions from charitable
supposed to be the cause. To disperse their influence, persons.
gunpowder were exploded from a bamboo cane close to
the head of the sufferer. 4. Hospital de Aguas Santas
(1590)

HEALTH CARE DURING THE SPANISH – established in Laguna; near

a medicinal spring, founded by
REGIME
The context of nursing has manifested Brother J. Bautista of the Franciscan
through simple nutrition, wound care, and taking Order.
care of an ill member of the family. Certain 5. San Juan de Dios Hospital
practices when taking care of sick individuals (1596)
entails interventions from babaylan (priest
physicians) or albularyo (herb doctor). In 1578, – founded by the
male nurses were acknowledged as Spanish Brotherhood of Misericordia and
Friars’ assistants for caring sick individuals in the administered by the Hospitaliers of
hospital. These male nurses were referred San Juan de Dios; support was
as practicante or enfermero. delivered from alms and rents;
rendered general health service to
the public.
 History of Nursing in the
Philippines
NURSING DURING THE
PHILIPPINE REVOLUTION
In the late 1890’s, the war between Philippines and
Spain emerges which resulted to significant amount of
casualties. With this, many women have assumed the role of
nurses in order to assist the wounded soldiers. The
emergence of Filipina nurses brought about the
development of Philippines Red Cross.
1. Josephine Bracken — wife of Jose Rizal, installed a
field hospital in an estate house in Tejeros. She provided
nursing care to the wounded night and day.
2. Rosa Sevilla de Alvero converted their house into
quarters for the Filipino soldiers; during the Philippine-
American War that broke out in 1899
3. Dona Hilaria de Aguinaldo — wife of Emilio Aguinaldo
who organized that Filipino Red Cross under the inspiration
of Mabini.
4. Melchora Aquino a.k.a. “Tandang Sora” nursed the
wounded Filipino soldiers and gave them shelter and food.
5. Agueda Kahabagan — revolutionary leader in Laguna,
also provided nursing services to her troops
6. Dona Maria Agoncillo de Aguinaldo — second wife of
Emilio Aguinaldo; provided nursing care to Filipino soldiers
during the revolution, President of the Filipino Red Cross
branch in Batangas.
7. Trinidad Tecson (“Ina ng Biak-na-Bato”) — stayed in the
hospital at Biak na Bato to care for wounded soldiers
8. Capitan Salome — a revolutionary leader in Nueva
Ecija; provided nursing care to the wounded when not in
combat.
9. Anastacia Giron Tupas- Founder of Filipino Nurses
Association
10. Cesaria Tan- 1st Filipino who received Masteral Degree
in Nursing Abroad
11. Soccoro Sirilan- Pioneer in Social Service at San Lazaro
Hospital
12. Fransico Delgado – 1st president of Filipino Nurses
Association
13. Soccoro Diaz- 1st editor of PNA magazine called “the
message”
14. Conchita Ruiz- Full time editor of the
PNA newly named magazine, “The Filipino
nurses”
15. Sor Ricarda Mendoza- Pioneer in
nursing education
16. Loreto Tupaz- Dean of the Philippine
Nursing. Florence of ILO-ILO
HOSPITALS AND NURSING
SCHOOLS
Americans began training the first
Filipino nursing students in 1907. Nursing
students in the Philippines studied many of
the same subjects as nursing students in the
U.S. However, it was believed that the
curriculum in the Philippines “was never a
mirror-image reproduction of the
American nursing curriculum” and involved
more than a simple transfer of knowledge
from American nurses to Filipino nurses.
The first Filipino nursing students
also studied subjects that were more
relevant to their patients, such as “the
nursing of tropical diseases” and
“industrial and living conditions in the
islands,” as described by Lavinia L. Dock’s
1912 book A History of Nursing: From the
Earliest Times to the Present Day with
Special Reference to the Work of the Past
Thirty Years.
Hospital School of Nursing’s
Formal Training (1901 – 1911)
Formal training in hospital school of nursing
transpire. This began when American
missionary doctors and nurses realized
that they manpower is insufficient. Thus it
resulted to a decision of training Filipino
nurses that would be catering to the
hospitals that Americans established in the
20th century.
c
History of Nursing in the
Philippines
The first hospital in the Philippines which trained Filipino
nurses in 1906 was Iloilo Mission Hospital, established by
the Baptist Missionaries. When this health institution was
built, there were no strict requirements for the applicants
as long as they are all willing to work. This has been the
beginning of development of more nursing schools in the
country. In this period, Pensionado Act of 1903 (or Act
854) was mandated, allowing Filipino nursing student to
study in United States. Among of the first wave of nurses
who went to United States
SCHOOL OF NURSING
1. Iloilo Mission Hospital School of Nursing (Iloilo City,
1906)
2. Philippine General Hospital School of Nursing (Manila,
1907)
3. Saint Paul’s Hospital School of Nursing (Manila, 1907)
4. St. Luke’s Hospital School of Nursing (Quezon City,
1907)
5. Mary Johnston Hospital and School of Nursing (Manila,
1907)
6. Philippine Christian Mission Institute Schools of Nursing
7. Sallie Long Read Memorial Hospital School of Nursing
(Laoag Ilocos Norte, 1903)
FIRST COLLEGES OF NURSING IN THE
PHILIPPINES
 University of Santo Tomas-College of
Nursing (1946)
 Manila Central University-College of
Nursing (1947)
 University of the Philippines Manila-College
of Nursing (1948)
REFERENCES:
Berman, A., Synder, S. J., Frandsen, G., (2016, p.31-50).
Kozier Fundamentals of Nursing (10th Ed.). 221 River
Street, Hoboken, New Jersey, 07030: Pearson Education,
Inc.
HISTORY OF COLLEGE OF
NURSING AND ALLIED
HEALTH OF LAGUNA STATE
POLYTECHNIC UNIVESITY
The College of Nursing was upon
the idea of the president and the
administration (Merestela, 2019). Amidst
the courses that are about to be
established on the institution, they invested
for the course that would touch the lives of
other people—the nursing program. There
was no college of nursing established
instantly on Laguna State Polytechnic
University. On 2005, Nursing is still under
the College of Arts and Sciences (CAS) –
ASHE program, under the CHED
memorandum order no. 30 where students
can take a 2 year course and decide
whether they will continue the bachelor
program or serve on the hospital as a
nursing aid. After the graduation of the
students under the laddered course,
Bachelor of Science in Nursing was finally
offered in the institution. Under the CHED
Memorandum Order No. 14, the course
was doing well, running under 30 students.
However, as the accreditation of CHED for
the LSPU to run the program of Nursing,
the institution should build at least its own
building and acquire paraphernalia and
equipment to be used by the students.
Subsequently, on July 5, 2010 by
the Commission on Higher Education in
accordance with pertinent provisions of
R.A. 7722 also known as the higher
education act of 1994. Section 14 states
that the CHED has the right to accredit the
course and the institution itself for the
brand reputation—whereas the school
should comply to the order. Hence, the
College of Nursing and Allied Health were
established—with allied health courses
(related to medicine) to be offered in the
latter years.
 History of College of Nursing
and Allied Health
HISTORY OF COLLEGE OF NURSING
AND ALLIED HEALTH OF LAGUNA
STATE POLYTECHNIC UNIVESITY
(cont.)
Furthermore, in accordance with pertinent provisions
of RA No. 7722, otherwise known as the Higher Education
Act of 1994 and for the purpose of rationalizing Nursing
Education in the country with the end in view of meeting the
health needs of the people through quality health services
and keeping it relevant and apace with the demands of
global competitiveness, the following policies and standards
for Nursing Education are hereby adopted and
promulgated by the Commission.
According to Sy (2019), the progress of the now 3-
storey building was in slowly-but-surely phase. Every year,
every floor was built in order to cater the needs of every
student every year. Furthermore, as the college department
progresses, on 2013 the department opened a new
program, the Bachelor of Science in Midwifery. Conversely,
due to the low demand every year, it was dropped on
2016. The long-running dean of the department, Ms. May
Veridiano, M.A.N, FRIN has been guiding every student to
continue to champion good quality of education and
excellence to keep the College of Nursing and Allied Health
on top. Thus, with her good guidance, all the efforts of the
department were not put into waste as in every board
exam, the passing rate for Registered Nurses were always
above the national passing rate.
Recently, The College of Nursing and Allied Health
of Laguna State Polytechnic University got a total Average
Passing Rate of 83.33% in the November Philippine Nursing
Licensure Examination (PNLE) released by the Professional
Regulation Commission last December 14, 2016. There
were 6,836 passers among the 14,322 takers nationwide
in the Philippine Nursing Licensure Examination (PNLE)
administered by the PRC Board of Nursing with a National
Passing Rate of 47.7%. The test draws basic knowledge,
skills, and attitudes in the major subject areas specifically in
Fundamental of Nursing, Community Health and
Communicable Disease Nursing, Nursing of Adolescents,
Adults, and Aged, and Mental Health and Psychiatric
Nursing. Also The College of Nursing and Allied Health
conducted a symposium in partnership with the Gender and
Development Services (Santa Cruz Campus) on February
27, 2016. The objective of which was to provide students’
awareness that in Nursing course, both men and women
could become equally competent in the field.
AFFILIATION
The hospitals affiliated with the
Laguna State Polytechnic University that
helped in shaping the successful and
competent nurses are as follows:
1. Calamba Medical Center
Calamba Medical Center or CMC is a
private hospital in Calamba City, province
of Laguna, Philippines. Calamba Medical
Center is Laguna’s premiere Medical Center
and a referral center for acute care. CMC
is Laguna’s Premiere Medical Center, a
modern 122-bed tertiary hospital, fully
equipped to treat most major illnesses and
injuries.
2. Philippine Orthopaedic Hospital
The Philippine Orthopedic Center is a 700
bed tertiary special hospital under the
Department of Health of the Philippines. The
hospital is located at Banawe Avenue corner
Maria Clara Street, Santa Mesa Heights,
Quezon City. The Philippine Orthopedic
Center caters mainly to a patient clientele
with Orthopedic, Musculoskeletal problems
and Neuromuscular conditions. The Center is
also the major referral center for Spinal
injuries in the country.
3. United Candelaria Doctors Hospital
United Candelaria Doctors Hospital is the
newly built medical facility of Candelaria,
opened in February 2009. United
Candelaria Doctors Hospital is situated in
Quezon Province,Philippines. They offer
private hospital services.
4. National Center for Mental Health
The National Center for Mental Health is
dedicated to delivering preventive, curative
and rehabilitative mental health care
services
5. San Lazaro Hospital
San Lazaro Hospital is a referral facility for
Infectious/ Communicable Diseases. It is one
of the retained special tertiary hospital of
the Department of Health (DOH) which is
subsidized by the national government.
 Development of Modern
Nursing
 The intellectual revolution of the 18th and
19th centuries led to a scientific revolution.
 The Industrial Revolution displaced workers from Florence Nightingale
cottage craftsmen to factory laborers. With these
changes came stressors to health. New illnesses,
transmitted in the holds of ships by seamen and  Florence Nightingale, the most
stowaway rodents, jumped national boundaries famous Kaiserswerth pupil,
and continents. was born to a wealthy and
 Lack of prenatal care, inadequate nutrition, and intellectual family.
poor delivery techniques resulted in a high rate of
material and infant mortality.
 Nightingale believed she was
 Many orphaned children died in workhouses of “called by God to help others
neglect or cruelty. and to improve the well-being
of mankind” (Schuyler 1992,
p.4).
 During this time, a “proper” woman’s role
in life was to maintain a gracious and  She was determined to
elegant home for her family. become a nurse, in spite of
 The common women worked as servants in opposition from her family
private homes or were dependent on their and the restrictive societal
husbands’ wages. code for affluent young
 The provision if care for the sick in English women.
hospitals or private homes fell to the
uncommon women – often prisoners or
prostitutes who had little or no training in
nursing.
 Because of this nursing had little CRIMEAN WAR
acceptance and no prestige. The only
acceptable nursing role was within a
religious order where services were  During the Crimean War, the
provided as part of Christian. inadequacy of care for the
soldiers led to public outcry.
PROTESTANT OF DEACONESSES  Florence Nightingale was
asked by Sir Sidney Herbert
 The creation of the institute of of the British War
Protestant Deaconesses at Department to recruit a
Kaiserswerth, Germany, changed contingent of female nurses to
the Order of Deaconesses ignited provide care to the sick and
recognition of the need for the injured in the Crimea.
services of women in the care of the
sick, the poor, children, and female (Continue to next page)
prisoners.
 The training school for nurses at
Kaiserswerth included care of the
sick in hospitals, instruction in visiting
nursing, instruction in religious
doctrine and ethics, and pharmacy.
 The deaconess movement eventually
spread to four continents, including
North America, North Africa, Asia,
and Australia.
 Development of Modern
Nursing
CRIMEAN WAR (cont.)
 Nightingale and her nurses transformed the
military hospital by setting up diet kitchens,
a laundry, recreation centers, and reading
rooms, and organizing classes for orderlies.
 Nightingale develop the Nightingale
Training School for Nurses, which opened in
1860.
 The school served as a model for other
training schools. Its graduates traveled to
other countries to manage hospitals and
institute nurse training programs.
 The efforts of Florence Nightingale and her
nurses changed the status of nursing to a
respectable occupation for women.
REFERENCE:
https://www.nursingbuddy.com/2010/04/27/the-
development-of-modern-nursing
http://www.nursing-theory.org/articles/modern-
nursing.php
http://www.rncentral.com/nursing-
library/the_impact_of_florence_nightingale_on_nursin
g/
MODERN NURSING
 Major changes began to take
place in the field of nursing
with the work of Florence
Nightingale.
 Today, nursing is a much more
diverse field of health care
practice, have a higher
reputation, as well. They are
no longer seen as simply
assistants to physicians who
do the things physicians won't
do.
 The field of nursing continues
to change as quickly as
medicine and health care
changes. As researchers
develop new technology,
treatments, techniques, and
medications to help patients
get healthy.
 The nursing profession we
recognize today is a far cry
from where it once was.
 Growth of Professionalism
PROFESSION
- is an occupation that requires extensive
education or a calling requinning
advanced training that requires special
knowledge, skill and preparation.
DISTINCTION OF PROFESSION FROM
OTHER KINDS OF OCCUPATION
A. SPECIALIZED EDUCATION
- an important aspect of professional status.
- In modern times, the trend in education for the
professions has shifted toward programs in
colleges and universities.
- Many nursing educators believe that the
undergraduate nursing curriculum should include
liberal arts education in addition to biological and
social sciences and the nursing discipline.
B. BODY OF KNOWLEDGE
- As a profession, nursing is established a well-
defined body of knowledge and expertise.
- A number of nursing conceptual frameworks
contribute to the knowledge base of nursing and
give direction to nursing practice, education, and
ongoing research.
C. SERVICE ORIENTATION
- differentiates nursing from an occupation pursued
primarily for profit.
- Many consider altruism (selfless concern for
others) the Hallmark of a profession. Nursing has
a traditional of service to others. This service,
however, must be guided by certain rules, policies,
or code of ethics.
- Today, nursing is also an important competent of
health care delivery system.
D. CODE OF ETHICS
- Nurses have traditionally placed a
high valueon the worth and dignity
of others.
- The nursing profession requires
integrity of it's members; that is, a
member is expected to do what is
considered right regardless of the
personal cost.
- Ethical codes change as the needs
and values of society change.
- Nursing has developed its own
codes of ethics and in most
instances has set up means to
monitor the professional behavior
of its members.
E. AUTONOMY
- A profession is autonomous if it
regulates itself and sets standards
for its members.
- Providing autonomy is one of the
purposes of a professional
association.
- If nursing is to have a professional
status, it must function
autonomously in the formation of
policy and in the control of its
activity.
- To be autonomous, a professional
group must be granted legal
authority to define the scope of its
practice, describe its particular
functions and roles, and determine
its goals and responsibilities in
delivery of its services.
- To practitioners of nursing,
autonomy means independence at
work, responsibility, and
accountability for one's action.
 Carper’s Four Patterns of
Knowing
These types of knowing were identified by
Barbara A. Carper (2009) from her observation
of nurse’s activity.
An understanding of each part of
knowledge is important for the student of nursing
because only by integrating all ways of knowing
can the nurse develop a professionals nursing.
1. EMPIRICAL KNOWING
(The Science of Nursing)
 Knowledge about the empirical world is
systematically organized into laws and
theories for the purpose of describing,
explaining and predicting phenomena of
special concern to the discipline of nursing.
2. ETHICAL KNOWING
(The Moral Component)
 Focuses on “matters of obligation or what
ought to be done” and goes beyond simply
observing the nursing code of ethics.
 Nursing can involve a series of deliberate
actions or choices that are subject to the
judgment of right or wrong.
REFERENCE:
Berman, A. B., Snyder, S. J., & Frandsen, G. E.
(2016). KOZIER AND ERB'S Fundamentals of
Nursing. Singapore: Pearson Education Inc. .
3. AESTHETIC KNOWING
(The Art of Nursing)
 Is the art of nursing and is
expressed by the individual
nurse through his or her
creativity and style in meeting
the needs of clients.
 The nurse uses aesthetic
knowing to provide care that
is both effective and
satisfying.
PERSONAL KNOWING
(The Therapeutic Use of Self)
 Personal knowledge is
concerned with the knowing
encountering, and actualizing
of the concrete, individual
self. Because the nursing is an
interpersonal process, the
nurse’s view of self, as well as
the client, is a critical factor in
the therapeutic relationship.
 Overview of the Professional
Nursing Practice
LEVEL OF PROFECIENCY
ACCORDING TO BENNER
STAGE IV. PROFICIENT
STAGE I. NOVICE
 Beginner with no experience.
 Performance is limited, inflexible, and
governed by context-free rules and regulations
rather than experience.
 Beginning nursing student or any nurse entering a
situation in which there is no previous level of
experience. The learner learns via specific of rule
or procedures, which are usually step wise and
linear.
STAGE II. ADVANCED BEGINNER
 Demonstrates marginally acceptable
performance.
 Recognizes the meaning “aspects” of a real
situation.
 Has experienced enough in real situations to make
judgments about them.
STAGE V. EXPERT
 A nurse who has had some level of experience with
the situation. This experience may only be
observational in nature, but the nurse is able to
identify meaningful aspects or principles of nursing
care.
 appropriate action.
STAGE III. COMPETENT
 Have 2 or 3 years of experience.
 Demonstrates organizational and planning
abilities
 Differentiates important factors from less
important aspects of care.
 Coordinates multiple complex care demands.
 A nurse who has been in the same clinical position
for 2 to 3 years. This nurse understands the
organization and specific care required by the
type of patients.
 Have 3 or 5 years of experience.
 Perceives situations as wholes
rather than in terms of parts as in
stage II.
 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 goals.
 This nurse perceives a patient’s
clinical situation as a whole, is able
to assess an entire situation, and
can readily transfer knowledge
gained from multiple previous
experiences to a situation. This
nurse focuses in managing care as
opposed to managing and
performing skills.
 Performance is fluid, flexible, and
highly proficient.
 No longer requires rules,
guidelines, or maxims to connect an
understanding of the situation to
 Demonstrates highly skilled
intuitive and analytic ability in new
situation Is inclined to take a certain
action because “it felt right”.
 A nurse with diverse experience
who has an intuitive grasp of an
existing potential clinical problem.
 This nurse is able to zero in on the
problem and focused multiple
dimension of the situation. He or she
is killed at identifying both patient-
centered problems related to the
health care system or perhaps the
needs of the novice nurse.
c

Overview of the Professional

Nursing Practice
ROLES AND RESPONSIBILITIES OF A
PROFESSIONAL NURSE CODE OF ETHICS
1. Provider of service
Responsibilities • A code of ethics is a formal statement
of a groups ideal and values.
- To provide safe and competent care commensurate
w/ the nurse’s preparation, experiences and • Code of ethics usually have higher
circumstances. requirements than legal standards,
and they are never lower than the
- To provide adequate supervision & evaluation of legal standard of the professions
others for whom the nurse is responsible.
• Nurses are responsible for being
Rights: familiar with the code that governs
- Right to adequate and qualified assistance as their practice.
necessary
- Right to reasonable and prudent conduct from • International, national and state
clients. nursing associations have established
code of ethics.
2. Employee or contractor for service • The international council of nurses (ICN)
first adopted a code of ethics in 1053,
Responsibilities:
and the most recent revisions (2005)
• To fulfil the obligations of contacted service with
the employer.
• To respect the employer.
SCOPE OF NURSING PRACTICE
• To respect the rights and responsibilities of other
health care providers.
BASED ON RA 9173
Rights: An act providing for more
• Right adequate working conditions. responsive nursing for a more
responsive nursing professions,
• Right to compensation for services rendered. repealing for the purpose republic
act no. 7164, otherwise known As
“The Philippine Nursing Act of
3. Citizen 1991”and for other purpose.

Responsibilities:
REFERENCES:
- To protect the rights of the recipient of care. Berman, A. B., Snyder, S. J., & Frandsen, G. E.
(2016). KOZIER AND ERB'S
Rights: Fundamentals of Nursing. Singapore:
- Right to respect by other of the nurses own rights Pearson Education Inc. .
and responsibilities https://studylib.net/doc/7070653/legal-
- Right to physical safety. aspects-of-nursing-the-philippine-nursing-law
 Overview of the Professional
Nursing Practice
NURSING CODE OF ETHICS HAVE THE
FOLLOWING PURPOSES
1. Inform the public about the minimum standards of
the profession and help them understand
professional nursing conduct.
2. Inform the public about the minimum standards of
the profession and help them understand
professional nursing conduct.
3. Inform the public about the minimum standards of
the profession and help them understand
professional nursing conduct.
4. Inform the public about the minimum standards of
the profession and help them understand
professional nursing conduct.
5. Inform the public about the minimum standards of
the profession and help them understand
professional nursing conduct.
6. Inform the public about the minimum standards of
the profession and help them understand
professional nursing conduct.
7.
PHILIPPINE NURSING ACT OF 2002
Nursing Jurisprudence
 Department of law which comprises all
legal rules and principles effecting the practice
of nursing
 Includes the study and interpretation of rules and
principles and their application in the regulation of
the practice of nursing
Functions of Law in Nursing
 Provides a framework for establishing what
nursing actions in the care of patients are legal
 Delineates the nurse’s responsibilities from those of
other professionals
 Helps to establish the boundaries of independent
nursing actions
 Assists in maintaining a standard of nursing
practice by making nurses accountable to the law.
SEC. 28. Scope of Nursing. — 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;
Different Fields of Nursing
INSTITUTIONAL NURSING
 Biggest field
 Work in the hospital facility
 Plan and provide medical and nursing care
to patients in hospital, at home or in other
settings who are suffering from chronic or
acute physical or mental ill health.
MILITARY NURSE
 They serve in most major branches of
the military, including the Army, Navy, and
Air Force.
 They provide direct patient care for service
members and their families, perform
medical duties for wounded soldiers, and
may pursue the same areas of practice
specialization that nurses in civilian roles
would.
 Military nurses might work either at home or
in foreign countries. The most common
settings for military nurses to work include
military bases, military hospitals, and clinics.
SCHOOL NURSING
 A specialized practice of public
health nursing that protects and
promotes student health, facilitates normal
development, and advances academic
success.
 School nurses, grounded in ethical and
evidence-based practice, are the leaders
that bridge health care and education,
provide care coordination, advocate for
quality student-centered care, and
collaborate to design systems that allow
individuals and communities to develop their
full potentials.
PRIVATE DUTY NURSE
 Is a registered nurse who
undertakes to give
comprehensive nursing care to
a client on a one-to-one ratio.
 Private duty nurses provide
services to patients that need
in-home monitoring, those who
require adjustments to
treatment regimens often, and
patients with medical conditions
that require frequent
assessments and care plan
changes.
Two categories of Private Duty
Nurse:
1. General Private Duty Nurse
- providing basic nursing care
to any type of patient.
2. Private Duty Nurse Specialist
- requires skills in
complicated devices, interpreting,
observing signs and symptoms.
CLINIC NURSING
 They typically work in
medical clinics, where they
collect patient information,
perform or aid in medical tests,
and help with patient
education.
 In this role, the clinic nurse
works closely with doctors,
specialists, and other care
providers to deliver short- and
long-term care to patients.
c

Different Fields of Nursing

COMMUNITY HEALTH NURSE

 Also called Public Health Nurse
 A nurse who works in the community where SPECIALIZED FIELDS OF
most of the people spend most of their times. NURSING
 Focus on preventing health issues from
sweeping through a community. In order to
do this, these nurses will often need to
circulate through the community in question
EMERGENCY NURSING
and interact directly with community
members.  Treats patients in emergency
situation.
 They will often provide affordable care to
community members that are ill or suffering  Quickly recognizes life
from another health-related matter. threatening problems and are
trained to help, solve them on
 Like other nurses, community health nurses
the spot.
can often find employment in healthcare
facilities like local hospitals, trauma centers,  They can work on hospitals
and clinics. They can also be found working emergency rooms.
in health-related government agencies and
non-profit organizations, as well as PEDIATRIC NURSING
community health centers and research  Nursing of little babies,
facilities. teenagers etc. is the
responsibility of a pediatric
INDEPENDENT NURSING PRACTICE nurse
 A master’s degree in nursing
 An independent practice nurse is
is one of the most basic
defined as, “A registered nurse who
pediatric nurse’s
provides professional nursing services,
requirements.
as a proprietor of a business, through
direct patient care, education, research,  A neonatal nurse practioner
administration or consultation.” has a somewhat similar job.
 Self-employed and provides
professional nursing services to patients ANESTHETIC NURSING
and their families.
 Provision of anesthesia to
 Also called Industrial Nursing, surgical, obstetrical and
Occupational Health Nursing. trauma patients is a job of a
 Provides and delivers health care services nurse anesthetist.
to workers.  This is said to be the one of
The practice focuses on promotion, the most lucrative careers in
protection, and supervision of workers the U.S
health within the context of a safe and
healthy environment.
 They may be responsible for providing
general first aid when needed, along with
assessing employee health risks and
promoting employee health.
Different Fields of Nursing

SPECIALIZED FIELDS OF CARDIAC CARE

NURSING (cont.) NURSING
 A nursing speciality that
AMBULATORY CARE NURSING works with patients who
 Is the nursing care of patients who receive suffers from various
treatment on an outpatient basis; they do not conditions of the
require admission to a hospital for an cardiovascular system.
overnight stay.  Cardiac nurses help treat
 The setting can vary widely from hospital conditions such as unstable
based clinics to patient homes. angina cardiomyopathy,
 Nursing in this field involves taking care of coronary artery disease,
illnesses in patients periodically. congestive heart failure,
myocardial infraction and
cardiac dysrhythmia under
GERIATRIC NURSING the direction.
 Nurses who work in the field of geriatrics FORENSIC NURSING
also known as gerontology focus on caring
for older adults.  Nurses providing medication to
 Taking care of old people either hospitals victims of crime and patients in
or at the patient’s home is the job of a prison etc. are called forensic
geriatric nurse. nurses.
 Forensic nurses help investigate
crimes like sexual and physical
UROLOGY NURSING assault and accidental death.

 All specialties such as infertility,

oncology, sexual glitches and lithotripsy
are responsibilities of urology nurses.
MIDWIFE NURSING
 All processes associated with
childbirth come under this field of
nursing.
 A midwife nurse is responsible for
taking care of the expecting
mother.
GASTRORNTEROLOGY
NURSING
 Also known as endoscopy
nurses.
 They diagnose and treat
patients experiencing problems
with their digestive system and
gastrointestinal tract.
REFERENCE:
https://www.scribd.com/doc/37718437
/Different-Fields-of-Nursing
 Communication Skills
 Communication is the interchanged of
information of information between two or
more people; in other words the exchanged of VERBAL COMMUNICATION
ideas and thought.
 It can be a transmission of feelings or a more
personal and social interaction between Verbal Communication
people.
 The intent of communication is to elicit a is largely conscious because
response. Thus communication is a process. people choose the words they use. The
 It has two main purposes: To influence others words used vary among individuals
and to obtain information. according to culture, socioeconomic
background, age and education.
COMPONENTS OF COMMUNICATION a) PACE AND INTONATION
b) SIMPLICITY
SENDER The sender, a person or group who wishes to c) TIMING AND RELEVANCE
make a message to another, can be considered the d) ADAPTABILITY
source-encoder.
e) CREDIBILITY
MESSAGE What actually said or written, the body f) HUMOR
language that accompanies the words, and how the
message is transmitted.
RECEIVER The third component of the communication
NONVERBAL
process is the listener, who must listen, observe, and COMMUNICATION
attend. This person is the decoder, who must perceive what
the sender intended (interpretation). Nonverbal Communication
RESPONSE The fourth component of the communication Sometimes called body
process, the response, is the message that the receiver language. It includes the gesture,
returns to the sender. Also called feedback, feedback can body, movements, use of touch, and
be either verbal, nonverbal or both. physical appearance, including
adornment.
MODES OF COMMUNICATION a) PERSONAL APPEARANCE
b) POSTURE AND GAIT
Communication is generally carried out in c) FACIAL EXPRESSIONS
two different modes: d) GESTURES

 Verbal communication Communication thus alters in

accordance with four distances, each
 Nonverbal
with a close and a far phase.
communication
1. Intimate: touching to 11/2 feet
2. Personal: 11/2 to 4 feet
3. Social: 4 to12 feet
4. Public: 12 o 15 feet
c

Communication Skills
CRITERIA FOR EFFECTIVE VERBAL COMMUNICATION

 Openness and Respect

 Empathy Honesty, Authenticity, and Trust Patients
 Caring Expert
 Competence 1. Always speak directly to the person
 Rapport builders Rapport 2. Offer to shake hands
 Comfortable competent 3. Identify yourself when speaking to a
 Privacy person who is blind
 Confidentiality 4. Wait for a response and instructions
when offering assistance
5. Treat adults as adults
GUIDELINES FOR ACTIVE AND EFFECTIVE 6. Do not hang or lean on a person’s
LISTENING wheelchair
7. Listen attentively and never pretend to
 Is a skill that involves both hearing and interpreting
understand
what the other says? It requires attention and
8. Speak to people at eye level
concentration to sort out, evaluate, and validate clues
to better understand the true meaning of what is being 9. Wave your hand or tap a person who
said. is deaf on the shoulder.

 Think before responding to the patient. Responding 10. Relax

impulsively tends to disrupt communication and
listening.
APPROACH FOR COGNITIVELY
 Think before responding to the patient. Responding CHALLENGED CLIENTS
impulsively tends to disrupt communication and
listening.
1. Try to address the patient directly,
 Think before responding to the patient. Responding even if his or her cognitive capacity
impulsively tends to disrupt communication and is diminished.
listening. 2. Gain the person's attention. Sit in
front of and at the same level as him
 Keep the conversation as natural as possible, and or her and maintain eye contact.
avoid sounding overly eager. 3. Speak distinctly and at a natural
rate of speed. Resist the temptation
to speak loudly.
4. Help orient the patient. Explain (or
GUIDELINES FOR USE OF TOUCH re-explain) who you are and what
Touch is a powerful means of communication with multiple you will be doing.
meanings. It can connect people; provide affirmation, 5. If possible, meet in surroundings
familiar to the patient. Consider
reassurance and stimulation, decrease loneliness, increase
having a family member or other
self-esteem, and share warmth, intimacy, approval, and familiar person present at first.
emotional support. 6. Support and reassure the patient.
Acknowledge when responses are
Touch is a powerful means of communication with multiple correct.
meanings. It can connect people; provide affirmation, 7. If the patient gropes for a word,
reassurance and stimulation, decrease loneliness, increase gently provide assistance.
8. Make it clear that the encounter is
self-esteem, and share warmth, intimacy, approval, and
not a "test" but rather a search for
emotional support. information to help the patient.
 Communication Skills
APPROACH FOR COGNITIVELY CHALLENGED
CLIENTS (cont.)
ELECTRONIC
9. Use simple, direct wording. Present one question, COMMUNICATION
instruction, or statement at a time.
10. If the patient hears you but does not understand you, E-MAIL
rephrase your statement.
11. Although open-ended questions are advisable in is the most common form of
most interview situations patients with cognitive electronic communication. It is
impairments often have difficulty coping with them
consider using a yes-or-no or multiple format. important for the nurse to know the
12. Remember that many older people advantage and disadvantages of e-
have hearing or vision problems which can add to mail and also other guidelines to
their confusion. ensure client confidentiality.

GENERAL GUIDELINES OF THERAPEUTIC ADVANTAGE

CULTURAL COMMUNICATION
1. Assess your personal beliefs surrounding people from
It is a fast, efficient way to
different cultures. communicate and it is legible. It
2. Assess communication variables from a cultural provides a record of the date and
perspective. time of the message that was sent or
3. Plan care based on the needs communicated needs and received.
cultural background.
4. Modify communication approaches to meet cultural.
5. Understand that respect for the patient and
communicated needs is central to the therapeutic DISADVANTAGE.
relationship. The negative aspect of e-mail is the
6. Communicate in a nonthreatening man
risk to client confidentiality. Another
7. Use validating techniques in communication.
computer is one of the
8. Be considerate of reluctance to talk when the subject
involves sexual matters. socioeconomics, not everyone has a.
9. Adopt special approaches when the patient speaks a While there may be available
different language. access to a computer, not everyone
10. Use interpreters to improve communications. has the necessary computer skills.

REFERENCE:
Berman, A. B., Snyder, S. J., & Frandsen, G. E.
(2016). KOZIER AND ERB'S
Fundamentals of Nursing. Singapore:
Pearson Education Inc. .
 Nursing Process
NURSING PROCESS

The nursing process is a systematic, rational  The universally applicable

characteristics of the nursing
method of planning and providing individualized nursing process means that it is used as a
care. framework for nursing care in all
types of health care settings, with
clients of all age group.
The nursing process is a regularly repeated event
 Nurses must use a variety of
or sequence of events (a cycle) that is continuously critical thinking skills to carry out
changing (dynamic) rather than staying the same (static). the nursing process.
 Nurses must utilize clinical
reasoning throughout the delivery
HISTORY OF NURSING PROCESS of nursing care.

 Hall originated the term nursing process in 1955, ASSESSING

and Johnson (1959), Orlando (1961), and
Wiedenbach (1963) were among the first to use - is the systematic and continuous
collection, organization, validation,
it to refer to a series of phases describing the
and documentation of data
practice of nursing. (information). In effect, assessing is a
 Since then, various nurses have described the continuous process carried out during
all phases of the nursing process.
process of nursing and organized the phases in
FOUR DIFFERENT TYPES OF
different ways. ASSESSMENT:

PURPOSES OF NURSING PROCESS: 1. Initial nursing

assessment
2. Problem-focused
• To identify a client’s health status and actual or
assessment
potential health care problems or needs, to 3. Emergency assessment
establish plans to meet the identified needs, and 4. Time-lapsed
to deliver specific nursing interventions to meet reassessment

those needs. - Assessments vary according to their

• Each phase of the nursing process affects the
others; they are closely interrelated.
ASSESSING: Collecting Data
CHARACTERISTICS OF NURSING
 Data from each phase provide input into the next
phase.
 The nursing process is client centered.
 The nursing process is an adaptation of problem
solving and system theory.
 Decision making is involved in every phase of the
nursing process.
 The nursing process is interpersonal and
collaborative.
purpose, timing, time available, and
client status.
• Is the process of gathering status.
• Must be both systematic and
continuous to prevent the omission
of significant data and reflect a
client’s changing health status.
• Allows the nurse, client, and health
care team to identify health-
related problems or risk factors
that could cause changes in a
client’s health status.
c

Nursing Process
A database contains all the information about a client; it
includes the nursing health history, physical assessment,
primary care provider’s history and physical examination, Observing
results of laboratory and diagnostic tests, and material - Occurs whenever the nurse is in
contributed by other health personnel. Client data should contact with the client or support
include past history as well as current problems. persons. To observe is to gather
data by using the senses.
Observing is a conscious,
deliberate skill that is developed
ASSESSING: Sources of Data through effort and with an
• Client - The best source of data is usually the organized approach.
client, unless the client is too ill, young, or confused
Interviewing
to communicate clearly.
- Is used mainly while taking the
• Support People - Family members, friends, and nursing health history. It is a
caregivers who know the client well often can planned communication or
supplement or verify information provided by the conversation with a purpose.
client. • Focused interview the nurse asks
the client specific questions to
• Client Records - include information documented collect information related to the
by various health care professionals. client’s problem. This allows the
nurse to collect information that
may have previously been missed
Types of Client Record and yields more in-depth
• Medical records - (e.g., medical history, physical information (D’Amico &Barbarito,
examination, operative report, progress notes, 2013).
and consultations done by primary care providers)
are often a source of a client’s present and past Examining
health and illness patterns. - Is the major method used in the
physical health assessment.
• Records of therapies - provided by other health
professionals, such as social workers, nutritionists,
dietitians, or physical therapists, help the nurse 2 APPROACHES TO INTERVIEWING:
obtain relevant data not expressed by the client.
1. Directive Interview
• Laboratory records - also provide pertinent health - is highly structured and elicits
information. specific information. The nurse
establishes the purpose of the
• Health Care Professionals - Sharing of information
among professionals is especially important to interview and controls the
ensure continuity of care when clients are interview, at least at the outset.
transferred to and from home and health care
agencies. 2. Nondirective Interview (rapport-
• Literature - The review of nursing and related building interview)
literature, such as professional journals and - the nurse allows the client to
reference texts, can provide additional control the purpose, subject matter,
information for the database.
and pacing.
- Rapport is an understanding
Data Collection Method between two or more people.
- The principal methods used to collect data
are observing, interviewing, and
• examining.
 Nursing Process
Types of Interview Questions:
• Closed Questions
- used in the directive interview, are restrictive and
generally require only “yes” or “no” or short
factual answers that provide specific information.
• Open- ended Questions
- associated with the nondirective interview, invite
clients to discover and explore, elaborate, clarify,
or illustrate their thoughts or feelings.
- it is useful at the beginning of an interview or to
change topics and to elicit attitudes.
• Neutral Question
- is a question the client can answer without
direction or pressure from the nurse, is open
ended, and is used in nondirective interviews.
• Leading Question
- is usually closed, used in a directive interview,
and thus directs the client’s answer.
- it gives client less opportunity to decide whether
the answer is true or not.
ASSESSING: Types of Data
• Subjective data, also referred to as symptoms or
covert data, are apparent only to the person
affected and can be described or verified only by
that person.
- Itching, pain, and feelings of worry are examples
of subjective data.
- Subjective data include the client’s sensations,
feelings, values, beliefs, attitudes, and perception
of personal health status and life situation.
• Objective data, also referred to as signs or overt
data, are detectable by an observer or can be
measured or tested against an accepted
standard.
- They can be seen, heard, felt, or smelled, and
they are obtained by observation or physical
examination.
• Constant data is information that
does not change over time such as
race or blood type.
• Variable data can change quickly,
frequently, or rarely and include
such data as blood pressure, level
of pain, and age.
• A complete database provides a
baseline for comparing the client’s
responses to nursing and medical
interventions.
DIAGNOSING
• Diagnosing is the second phase of
the nursing process. In this phase,
nurses use critical thinking skills to
interpret assessment data and
identify client strengths and
problems.
• Diagnosing is a pivotal step in the
nursing process.
• Activities preceding this phase are
directed toward formulating the
nursing diagnoses; the care
planning activities following this
phase are based on the nursing
diagnoses.
• The official NANDA definition of
a nursing diagnosis is:
“. . . a clinical judgment concerning
a human response to health
conditions/life processes, or a
vulnerability for that response, by
an individual, family, group, or
community” (Herdman&Kamitsuru,
2014, p. 464).
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Nursing Process
DIAGNOSING: Status of the Nursing
Diagnoses
• “Status of the nursing diagnosis refers to the
actuality or potentiality of the problem/syndrome
or the categorization of the diagnosis as a health
promotion diagnosis” (Herdman&Kamitsuru,
2014, p. 100).
Nursing diagnoses can be actual, potential, possible, or
collaborative problems as well as wellness issues.
• An actual nursing diagnosis identifies an
occurring health problem for your patient.
• A potential nursing diagnosis identifies a high-
risk health problem that most likely will occur
unless preventive measures are taken.
• A possible nursing diagnosis is one that needs
further data to support it.
• A collaborative problem is a potential medical
complication that warrants both medical and
nursing interventions.
• Wellness diagnoses focus on promoting or
enhancing a patient’s level of wellness.
DIAGNOSING: Kinds of Nursing Diagnoses
1. Actual diagnosis is a client problem that is present
at the time of the nursing assessment.
Examples are Ineffective Breathing Pattern and
Anxiety. An actual nursing diagnosis is based on the
presence of associated signs and symptoms.
2. A health promotion diagnosis relates to clients’
preparedness to implement behaviors to improve
their health condition. These diagnosis labels
begin with the phrase Readiness for Enhanced, as
in Readiness for Enhanced Nutrition.
3. A risk nursing diagnosis is a 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.
4. A syndrome diagnosis is assigned by a nurse’s
clinical judgment to describe a cluster of nursing
diagnoses that have similar interventions
(Herdman&Kamitsuru, 2014, p. 23).
DIAGNOSING: Components
of a NANDA Nursing Diagnosis
Problem (Diagnostic Label) and
Definition
The problem statement, or
diagnostic label, describes the client’s
health problem or response for which
nursing therapy is given. It describes the
client’s health status clearly and concisely
in a few words. Its purpose is to direct the
formation of client goals and desired
outcomes and may also suggest some
nursing interventions.
Etiology (Related Factors and Risk
Factors)
The etiology component of a
nursing diagnosis identifies one or more
probable causes of the health problem,
gives direction to the required nursing
therapy, and enables the nurse to
individualize the client’s care.
Defining Characteristics
Defining characteristics are the
cluster of signs and symptoms that indicate
the presence of a particular diagnostic
label.
Diagnosing: The Diagnostic
Process
The diagnostic process uses the
critical thinking skills of analysis and
synthesis.
 In critical thinking, a person
reviews data and considers
explanations before forming an
opinion.
 Analysis is the separation into
components, that is, the breaking
down of the whole into its parts
(deductive reasoning).
 Synthesis is the opposite, that is,
the putting together of parts into
the whole (inductive reasoning).
 Nursing Process
3 Steps in Diagnostic Process:
Diagnostic Process: Analyzing Data
In the diagnostic process, analyzing involves the
following steps:
1. Comparing Data with Standards
Nurses draw on knowledge and experience to compare
client data to standards and norms and identify
significant and relevant cues.
A standard or norm is a generally accepted measure,
rule, model, or pattern.
2. Clustering Cues
Data clustering or grouping of cues is a process of
determining the relatedness of facts and determining
whether any patterns are present, whether the data
represent isolated incidents, and whether the data are
significant. This is the beginning of synthesis.
3. Identifying Gaps and Inconsistencies In Data
Skilful assessment minimizes gaps and
inconsistencies in data. However, data analysis should
include a final check to ensure that data are complete
and correct.
Diagnosing: Formulating Diagnostic Statements
 BASIC TWO-PART STATEMENTS
The basic two-part statement includes the following:
1. Problem (P): statement of the client’s response (NANDA
label)
2. Etiology (E): factors contributing to or probable causes
of the responses.
 BASIC THREE-PART STATEMENTS
The basic three-part nursing diagnosis statement is
called the PES format and includes the following:
1. Problem (P): statement of the client’s response
(NANDA label)
2. Etiology (E): factors contributing to or probable
causes of the response
3. Signs and symptoms (S): defining characteristics
manifested by the client.
 ONE-PART STATEMENTS
Some diagnostic statements, such as health promotion
diagnoses and syndrome nursing diagnoses, consist of a
NANDA label only. As the diagnostic labels are refined,
they tend to become more specific, so that nursing
interventions can be derived from the label itself.
Therefore, an etiology may not be needed.
Avoiding Errors in Diagnostic
Reasoning
The following suggestions help to minimize
diagnostic error:
• Verify.
Hypothesize possible explanations of the
data, but realize that all diagnoses are
only tentative until they are verified.
• Build a good knowledge base and
acquire clinical experience.
Nurses must apply knowledge from many
different areas to recognize significant
cues and patterns and generate
hypotheses about the data.
• Have a working knowledge of
what is normal.
Nurses need to know the population norms
for vital signs, laboratory tests, speech
development, breath sounds, and so on.
• Consult resources.
Both novices and experienced nurses
should consult appropriate resources
whenever in doubt about a diagnosis.
• Base diagnoses on patterns—that
is, on behavior over time— rather than on an
isolated incident.
• Improve critical thinking skills.
These skills help the nurse to be aware of
and avoid errors in thinking, such as
overgeneralizing, stereotyping, and
making unwarranted assumptions.
PLANNING
Planning is a deliberative, systematic
phase of the nursing process that involves
decision making and problem solving.
In planning, the nurse refers to the
client’s assessment data and diagnostic
statements for direction in formulating
client goals and designing the nursing
interventions required to prevent, reduce,
or eliminate the client’s health problems.
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Nursing Process
PLANNING: Types of Planning
• INITIAL PLANNING
The nurse who performs the admission assessment
usually develops the initial comprehensive plan of care.
This nurse has the benefit of seeing the client’s body
language and can also gather some intuitive kinds of
information that are not available solely from the written
database. Planning should be initiated as soon as possible
after the initial assessment.
• ONGOING PLANNING
All nurses who work with the client do ongoing
planning. Ongoing planning also occurs at the beginning
of a shift as the nurse plans the care to be given that day.
Using ongoing assessment data, the nurse carries out daily
planning for the following purposes:
1. To determine whether the client’s health status has
changed
2. To set priorities for the client’s care during the shift
3. To decide which problems to focus on during the
shift
4. To coordinate the nurse’s activities so that more
than one problem can be addressed at each client
contact.
• DISCHARGE PLANNING
Discharge planning, the process of anticipating
and planning for needs after discharge, is a crucial part
of a comprehensive health care plan and should be
addressed in each client’s care plan.
PLANNING: Developing Nursing Care Plan
• The end product of the planning phase of the
nursing process is a formal or informal plan of
care.
• An informal nursing care plan is a strategy for
action that exists in the nurse’s mind.
- For example, the nurse may think, “Mrs. Phan
is very tired. I will need to reinforce her
teaching after she is rested.”
• A formal nursing care plan is a written or
computerized guide that organizes information
about the client’s care.
- The most obvious benefit of a formal written
care plan is that it provides for continuity of
care.
• A standardized care plan is a
formal plan that specifies the
nursing care for groups of clients
with common needs (e.g., all clients
with myocardial infarction). These
are pre developed guides for the
nursing care of a client who has a
need that arises frequently in the
agency (e.g., a specific nursing
diagnosis or all nursing diagnoses
associated with a particular
medical condition). They are
written from the perspective of
what care the client can expect.
• An individualized care plan is
tailored to meet the unique needs
of a specific client—needs that are
not addressed by the
standardized plan.
PLANNING: Formats for Nursing
Care Plans
Although formats differ from agency to
agency, the care plan is often organized
into four sections:
• (1) problem/nursing diagnoses,
• (2) goals/desired outcomes,
• (3) nursing interventions, and
• (4) evaluation
Some agencies use a three-section plan in
which evaluation is done with the goals or
in the nurses’ notes; others have five
sections that add assessment data
preceding the problem/nursing diagnosis.
STUDENT CARE PLAN
- A rationale is the evidence-based
principle given as the reason for
selecting a particular nursing
intervention. Students may also be
required to cite supporting literature
for their stated rationale.
- A concept map is a visual tool in which
ideas or data are enclosed in circles
or boxes of some shape, and
relationships between these are
indicated by connecting lines or
arrows.
 Nursing Process

COMPUTERIZED CARE PLAN

- Computers are increasingly being used to create and
store nursing care plans. The computer can generate
both standardized and individualized care plans.
PLANNING PROCESS
Setting Priorities
• Priority setting is the process of
MULTIDISCIPLINARY CARE PLAN establishing a preferential
sequence for addressing nursing
- A multidisciplinary care plan is a standardized plan diagnoses and interventions.
that outlines the care required for clients with • The nurse and client begin
common, predictable—usually medical— conditions. planning by deciding which nursing
- Such plans, also referred to as collaborative care diagnosis requires attention first,
plans and critical pathways, sequence the care that which second, and so on.
must be given on each day during the projected • Instead of rank-ordering
length of stay for the specific type of condition. diagnoses, nurses can group them
as having high, medium, or low
priority.
PLANNING: GUIDELINES FOR WRITING
Establishing Client Goals/ Desired
NURSING CARE PLANS Outcomes
The nurse should use the following guidelines when • After establishing priorities, the
writing nursing care plans: nurse and client set goals for each
1. Date and sign the plan. The date the plan is written is nursing diagnosis.
• On a care plan, the goals/ desired
essential for evaluation, review, and future planning. outcomes describe, in terms of
2. Use category headings. “Nursing Diagnoses,” observable client responses, what
“Goals/Desired Outcomes,” “Nursing Interventions,” and the nurse hopes to achieve by
implementing the nursing
“Evaluation” are the common headings. Include a date for interventions.
the evaluation of each goal.
3. Use standardized/approved medical or English
PURPOSE OF GOALS/DESIRED
symbols and key words rather than complete sentences to OUTCOMES
communicate your ideas unless agency policy dictates
otherwise.
- Although goals and outcomes are not
4. Be specific. Writing down specific times during the 24- necessarily the same concept, the terms
hour period will help clarify. are used by some people interchangeably.
5. Refer to procedure books or other sources of If referenced to NOC, goals are
considered to be met or not met, while
information rather than including all the steps on a written progress toward outcomes can be
plan. described along a continuum and in
6. Tailor the plan to the unique characteristics of the client comparison to previous status (Moorhead
by ensuring that the client’s choices, such as preferences et al., 2013).
Goals/desired outcomes serve the
about the times of care and the methods used, are following purposes:
included 1. Provide direction for planning
7. Ensure that the nursing plan incorporates preventive nursing interventions.
and health maintenance aspects as well as restorative 2. Serve as criteria for evaluating
client progress.
ones. 3. Enable the client and nurse to
8. Ensure that the plan contains ongoing assessment of the determine when the problem has been
client resolved.
4. Help motivate the client and
9. Include collaborative and coordination activities in the nurse by providing a sense of
plan. achievement.
10. Include plans for the client’s discharge and home care
needs.
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Nursing Process

COMPONENTS OF GOAL/DESIRED OUTCOME

STATEMENTS
- Goal/desired outcome statements should have the
following four components: IMPLEMENTING
1. Subject. The subject, a noun, is the client, any
part of the client, or some attribute of the client, such as • Implementing is the action phase in
the client’s pulse or urinary output. which the nurse performs the
2. Verb. The verb specifies an action the client is nursing interventions.
to perform, for example, what the client is to do, learn, or • Using Nursing Interventions
experience. Classification (NIC) terminology,
3. Conditions or modifiers. Conditions or modifiers implementing consists of doing and
may be added to the verb to explain the circumstances
under which the behavior is to be performed. documenting the activities that are
4. Criterion of desired performance. The criterion the specific nursing actions needed
indicates the standard by which a performance is to carry out the interventions.
evaluated or the level at which the client will perform the • The fifth standard of the American
specified behavior. Nurses Association (ANA)
SELECTING NURSING INTERVENTIONS AND Standards of Practice is
ACTIVITIES implementation.
• Nursing interventions and activities are the actions • Three of the implementation
that a nurse performs to achieve client goals. The substandards apply to all
specific interventions chosen should focus on registered nurses: coordination of
eliminating or reducing the etiology of the nursing care, health teaching and health
diagnosis, which is the second clause of the promotion, and consultation.
diagnostic statement. • The fourth substandard,
prescriptive authority and
TYPES OF NURSING INTERVENTIONS
treatment, applies only to
• Nursing interventions are identified and written
during the planning step of the nursing process; advanced practice nurses (ANA,
however, they are actually performed during the 2010).
implementing step. Nursing interventions include
both direct and indirect care, as well as nurse-
initiated, physician-initiated, and other provider- IMPLEMENTING:
initiated treatments. Implementing Skills
• Direct care is an intervention performed by the • To implement the care plan
nurse through interaction with the client. successfully, nurses need cognitive,
• Indirect care is an intervention delegated by the interpersonal, and technical skills.
nurse to another provider or performed away
from but on behalf of the client such as • Cognitive skills (intellectual skills)
interdisciplinary collaboration or management of include problem solving, decision
the care environment. making, critical thinking, clinical
• Independent interventions are those activities that reasoning, and creativity.
nurses are licensed to initiate on the basis of their
knowledge and skills. They include physical care, • Interpersonal skills are all of the
ongoing assessment, emotional support and activities, verbal and nonverbal,
comfort, teaching, counseling, environmental people use when interacting
management, and making referrals to other health directly with one another.
care professionals.
• Dependent interventions are activities carried out • Technical skills are purposeful
under the orders or supervision of a licensed “hands-on” skills such as
physician or other health care provider authorized manipulating equipment, giving
to write orders to nurses. injections, bandaging, moving,
• Collaborative interventions are actions the nurse lifting, and repositioning clients.
carries out in collaboration with other health team
members, such as physical therapists, social
workers, dietitians, and primary care providers.
 Nursing Process
IMPLEMENTING: Process of
Implementing
REASSESSING THE CLIENT
• Just before implementing an intervention, the nurse
must reassess the client to make sure the
intervention is still needed. Even though an order
is written on the care plan, the client’s condition
may have changed.
DETERMINING THE NURSE’SNEED FOR ASSISTANCE
• When implementing some nursing interventions,
the nurse may require assistance for one or more
of the following reasons:
• The nurse is unable to implement the nursing
activity safely or efficiently alone (e.g.,
ambulating an unsteady obese client).
• Assistance would reduce stress on the client (e.g.,
turning a person who experiences acute pain when
moved).
• The nurse lacks the knowledge or skills to
implement a particular nursing activity (e.g., a
nurse who is not familiar with a particular model
of traction equipment needs assistance the first
time it is applied).
IMPLEMENTING THE NURSING INTERVENTIONS
• It is important to explain to the client what
interventions will be done, what sensations to
expect, what the client is expected to do, and
what the expected outcome is.
• For many nursing activities it is also important to
ensure the client’s privacy, for example, by closing
doors, pulling curtains, or draping the client.
• Base nursing interventions on scientific knowledge,
nursing research, and professional standards of
care (evidence-based practice) when these exist.
• Clearly understand the interventions to be
implemented and question any that are not
understood.
• Adapt activities to the individual client.
• Implement safe care.
• Provide teaching, support, and comfort.
• Be holistic.
• Respect the dignity of the client and enhance the
client’s self- esteem.
• Encourage clients to participate actively in
implementing the nursing interventions.
SUPERVISING DELEGATED CARE
• If care has been delegated to other health care
personnel, the nurse responsible for the client’s
overall care must ensure that the activities have
been implemented according to the care plan.
• The nurse validates and responds
to any adverse findings or client
responses. This may involve
modifying the nursing care plan.
DOCUMENTING NURSING ACTIVITIES
 After carrying out the nursing
activities, the nurse completes
the implementing phase by
recording the interventions and
client responses in the nursing
progress notes.
EVALUATING
• To evaluate is to judge or to
appraise.
• Evaluating is the fifth phase of
the nursing process.
• In this context, evaluating is a
planned, ongoing, purposeful
activity in which clients and health
care professionals determine (a)
the client’s progress toward
achievement of goals/ outcomes
and (b) the effectiveness of the
nursing care plan.
• It is an important aspect of the
nursing process because
conclusions drawn from the
evaluation determine whether
the nursing interventions should
be terminated, continued, or
changed.
• Evaluation is the sixth standard of
the ANA Standards of Practice
and states that “The registered
nurse evaluates progress towards
attainment of outcomes” (2010,
p. 45).
• Evaluation is continuous.
Evaluation done while or
immediately after implementing
a nursing order enables the nurse
to make on the-spot modifications
in an intervention.
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Nursing Process
EVALUATING (cont.)
• Evaluation performed at specified intervals (e.g.,
once a week for the home care client) shows the
extent of progress toward achievement of
goals/outcomes and enables the nurse to correct
any deficiencies and modify the care plan as
needed.
• Evaluation continues until the client achieves the
health goals or is discharged from nursing care.
• Evaluation at discharge includes the status of goal
achievement and the client’s self-care abilities with
regard to follow-up care. Most agencies have a
special discharge record for this evaluation.
• Through evaluating, nurses demonstrate
responsibility and accountability for their actions,
indicate interest in the results of the nursing
activities, and demonstrate a desire not to
perpetuate ineffective actions but to adopt more
effective ones.
EVALUATING: Process of Evaluating
Client Responses
Before evaluation, the nurse identifies the
desired outcomes (indicators) that will be used to
measure client goal achievement. (This is done in
the planning step.) Desired outcomes serve two
purposes: They establish the kind of evaluative
data that need to be collected and provide a
standard against which the data are judged.
The evaluation phase has five components:
• Collecting data related to the desired
outcomes (NOC indicators)
• Comparing the data with desired outcomes
• Relating nursing activities to outcomes
• Drawing conclusions about problem status
• Continuing, modifying, or terminating the
nursing care plan.
Collecting data related to the
desired outcomes (NOC indicators)
- Using the clearly stated, precise, and
measurable desired outcomes as a
guide, the nurse collects data so that
conclusions can be drawn about
whether goals have been met. It is
usually necessary to collect both
objective and subjective data.
- If the first two parts of the evaluating
process have been carried out
effectively, it is relatively simple to
determine whether a desired outcome
has been met. When determining
whether a goal has been achieved,
the nurse can draw one of three
possible conclusions:
1. The goal was met; that is, the client
response is the same as the desired
outcome.
2. The goal was partially met; that is,
either a short-term outcome was achieved
but the long-term goal was not, or the
desired goal was incompletely attained.
3. The goal was not met.
After determining whether or not a
goal has been met, the nurse writes an
evaluation statement (either on the care
plan or in the nurse’s notes).
An evaluation statement consists
of two parts: a conclusion and supporting
data.
The conclusion is a statement that
the goal/desired outcome was met,
partially met, or not met. The supporting
data are the list of client responses that
support the conclusion.
 Nursing Process
Relating Nursing Activities to Outcomes
The third phase of the evaluating process is
determining whether the nursing activities had any relation
to the outcomes.
It should never be assumed that a nursing activity
was the cause of or the only factor in meeting, partially
meeting, or not meeting a goal.
Drawing Conclusions about Problem
The nurse usesStatus
the judgments about goal
achievement to determine whether the care plan was
effective in resolving, reducing, or preventing client
problems.
Examples:
 The potential problem stated in the nursing
diagnosis is being prevented, but the risk factors
are still present. In this case, the nurse keeps the
problem on the care plan.
 The actual problem still exists even though some
goals are being met. For example, a desired
outcome on a client’s care plan is “Will drink 3,000
mL of fluid daily.” Even though the data may show
this outcome has been achieved, other data (dry
oral mucous membranes) may indicate that the
nursing diagnosis Deficient Fluid Volume is
applicable. Therefore, the nursing interventions
must be continued even though this one goal was
met.
 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. The revisions
may need to occur during the assessing,
diagnosing, or planning phases, as well as
implementing.
Continuing, Modifying, or Terminating the
Nursing Care Plan
After drawing conclusions about the status of the
client’s problems, the nurse modifies the care plan as
indicated. Depending on the agency, modifications may
be made by drawing a line through portions of the care
plan, marking portions using a highlighting pen, or
indicating revisions as appropriate for electronic charting
systems. The nurse may also write “Discontinued” (“dc’d”),
“goal met,” or “problem resolved” and the date.
Evaluating: the Quality of Nursing
Care
QUALITY ASSURANCE
A quality assurance (QA) program
is an ongoing, systematic process designed
to evaluate and promote excellence in the
health care provided to clients. Quality
assurance frequently refers to evaluation
of the level of care provided in a health
care agency, but it may be limited to the
evaluation of the performance of one
nurse or more broadly involve the
evaluation of the quality of the care in an
agency, or even in a country.
Three Components of QA
 Structure evaluation focuses on the
setting in which care is given.
 Process evaluation focuses on how
the care was given.
 Outcome evaluation focuses on
demonstrable changes in the
client’s health status
QUALITY IMPROVEMENT
 follows client care rather than
organizational structure, focuses on
process rather than individuals,
and uses a systematic approach
with the intention of improving the
quality of care rather than
ensuring the quality of care. QI
studies often focus on identifying
and correcting a system’s
problems, such as duplication of
services in a hospital. QI is also
known as continuous quality
improvement (CQI), total quality
management (TQM), performance
improvement (PI), or persistent
quality improvement (PQI).
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Nursing Process

NURSING-SENSITIVE INDICATORS

 The National Qualify Forum (NQF) is a nonprofit PURPOSES OF CLIENT RECORDS

organization focused on improving health care.
The NQF identified and endorsed national • Client records are kept for a number
voluntary standards for nursing-sensitive care of purposes including
including evidence-based performance measures, - communication,
a framework for measuring nursing-sensitive care, - planning client care,
and related research recommendations.
- auditing health agencies,
- research,
DOCUMENTING AND - education,
- reimbursement,
REPORTING - legal documentation, and
- health care analysis
• Effective communication among health professionals CLINICAL ALERT!
is vital to the quality of client care.
• Generally, health personnel communicate through • An accurate client health record
discussion, reports, and records. provides details about the care a
• A discussion is an informal oral consideration of a client has received and the client’s
subject by two or more health care personnel to overall response to care.
identify a problem or establish strategies to resolve • Accurate documentation provides the
a problem. staff with a means for accountability
• A report is oral, written, or computer-based and reflection on the delivery of client
communication intended to convey information to care (Prideaux, 2011).
others. • To enhance the accuracy in
documenting care, Paans, Sermeus,
• A record, also called a chart or client record, is a Nieweg, and van der Schans (2010)
formal, legal document that provides evidence of a identified the PES structure as a
client’s care and can be written or computer based. guideline for nursing care. The letter P
• Although health care organizations use different represents the client’s problem or
systems and forms for documentation, all client diagnosis.
records have similar information. • The etiology or cause of the problem
• The process of making an entry on a client record is is represented by E, and S represents
called recording, charting, or documenting. the signs and symptoms the nurse
should be assessing. The use of this
ETHICAL AND LEGAL CONSIDERATIONS structure enhances nurses’ ability to
exercise clinical reasoning.
• The American Nurses Association Code of • Examples of documentation systems
Ethics (2001) states that “. . . the nurse has a include source oriented, problem
duty to maintain confidentiality of all patient oriented, PIE, focus charting, charting
by exception, computerized
information” (p. 12). The client’s record is also documentation, and case
protected legally as a private record of the management
client’s care. Access to the record is restricted
REFERENCE:
to health professionals involved in giving care
to the client. The institution or agency is the Berman, A. B., Snyder, S. J., & Frandsen, G. E.
rightful owner of the client’s record. This does (2016). KOZIER AND ERB'S
Fundamentals of Nursing. Singapore:
not, however, exclude the client’s rights to the Pearson Education Inc. .
same records.
 Health and Illness

HEALTH
Health is a state of complete physical, mental,
social (totality) well-being and not merely the
absence of disease or infirmity.
WELLNESS
6. SPIRITUAL DIMENSION
Refers to the recognition and ability to
practice moral or religious principles of
beliefs; recognition and maintenance of a
harmonious relationship with a supreme
being.

7. OCCUPATIONAL DIMENSION
Is a state of well - being. Basic aspect of
The ability to achieve a balance between
wellness includes self - responsibility, ultimate goal,
work and leisure time. A person’s beliefs
dynamic, growing process, daily decision making. about education, employment and home
influences personal satisfaction and
relationship with others.
DIMENSIONS OF WELLNESS
WELL – BEING
1. PHYSICAL DIMENSION Is a subjective perception or vitality
and feeling well can be deceived
Genetic makeup, age developmental level, race and sex
objectively, experienced and
are all part of individual’s physical dimension and strongly measured.
influence health status and health practices.

2. EMOTIONAL DIMENSION
Refers to the feelings affect and person’s ability to MODELS OF HEALTH
express those emotions.
Long-term stress affects the body’s system and anxiety
AND WELLNESS
affects health habits: conversely, calm acceptance and
relaxations can actually change body responses to illness. CLINICAL MODEL
- The narrowest interpretation of
3. INTELLECTUAL DIMENSION health occurs in this.
Encompasses cognitive abilities, educational background - People are viewed as
and past experiences, positive sense of purpose. physiological systems with related
These influence a client’s response to teaching about functions and health is identified by
health and reactions to health care during illness. signs and symptoms of disease or
injury.
4. ENVIRONMENTAL DIMENSION
The ability to promote health measures that improve the
standard of living and quality of life in the community. ADAPTIVE MODEL
Includes influences such as foods, water an air, - Health is creative process; disease
is a failure in adaptation or mal
adaptation.
5. SOCIO-CULTURAL DIMENSION - The aim of treatment is to restore
Concerns the sense of having support available from the ability of person to adapt and
family and friends practices, values and beliefs that
to cope.
determine health.
c

Health and Illness

MODELS OF HEALTH AND WELLNESS EXTERNAL VARIABLES

(cont.)
 ENVIRONMENT
EUDAIMONISTIC MODEL - People are becoming aware
- Incorporate a comprehensive view of health is of their environment and how it
seen as a condition of actualization or realization affects their health and level of
of person’s potential. wellness.
- Actualization is highest aspiration in Abraham  STANDARD OF LIVING
Maslow. - Reflecting occupation, income
and education is related to
AGENT HOST ENVIRONMENT MODEL health, morbidity and
- Also called the ECOLOGIC MODEL it has been mortality.
expanded into a general theory of multiple causes  FAMILY AND CULTURAL BELIEFS
of disease used in predicting illness and promoting - The family passes on patterns
wellness. of daily living and lifestyle to
offspring.
3 DYNAMIC INTERACTIVE ELEMENTS  SOCIAL SUPPORT NETWROK
 AGENT environment factor or stressor - Family, friends or a confidant
and job satisfaction helps
 HOST person
people avoid illness.
 ENVIRONMENT all external factors

DUNN’S HIGH LEVEL WELLNESS GRID HEALTH CARE ADHERENCE

1. High Level Wellness in Favourable Environment
2. Emergent High Level Wellness in an Unfavourable ADHERENCE
Environment Is the event to which an individual’s
3. Protected Poor Health EF behaviour concedes with medical or health
4. Poor Health UFE care advices.

VARIABLES INFLUENCING HEALTH STATUS, FACTORS INFLUENCING

BELIEFS AND PRACTICES ADHERENCE

INTERNAL VARIABLES  Client motivation to become well.

 Degree of lifestyle change
 BIOLOGICAL DIMENSION necessary.
- Genetic makeup, age, sex and development
 Perceived severity.
level all significantly influence a person’s
health.  Value placed on reducing threat of
illness.
 COGNITIVE DIMENSION
- Also known as INTELLECTUL FACTORS  Degree of inconvenience.
influencing health include life style choices and  Complexity, side effects and
spiritual and religious beliefs. duration.
 PSYCHOLOGICAL DIMENSION  Cultural heritage, beliefs or
- Are emotional factors influencing health practices.
include body interaction and self-concept.  Degree of satisfaction and quality.
 Overall cost.
 Health and Illness

FACTORS INFLUENCING ADHERENCE

NON ADHERENCE STEPS: Stage 4: DEPENDENT CLIENT
 Establish why client not following the regimen. ROLE
 Demonstrate caring. - After accepting illness and
 Encourage healthy behaviours through positive seeking treatment, client
reinforcement. comes dependent on
 Use aids to reinforce teaching. professional help.
 Establish therapeutic relationship.
Stage 5: RECOVERY OR
REHABILITATION
ILLNESS AND DISEASE - Client is expected to
relinquish the dependent role
ILLNESS and resume roles and
- Is highly personal state, in which the person’s responsibilities.
physical, emotional, intellectual, social
development or spiritual functioning is through to
be diminished.
DISEASE
- Can be described as an alteration in body
functions resulting in reduction or capacities or
shortening of normal life span.

CLASSIFICATION OF ILLNESS AND

DISEASE
 ACUTE ILLNESS REFERENCES:
- Characterized by symptoms of relatively short
duration. https://www.slideshare.net/mobile/ludymae/i
 CHRONIC ILLNESS llness-wellness-and-health-scope-of-nursing
- One that last for an extended period usually
6months or longer. Berman, A. B., Snyder, S. J., & Frandsen, G. E.
- One that has period of remission and (2016). KOZIER AND ERB'S
exacerbation
REMISSION Fundamentals of Nursing. Singapore:
- Symptoms disappear. Pearson Education Inc. .
EXACERBATION
- Symptoms reappear.

SUCHMAN FIVE STAGES OF ILLNESS

Stage 1: SYMPTOMS EXPERIENCES
- Person comes to believe something is wrong.

Stage 2: ASSUMPTION OF THE SICK ROLE

- Individual now accept the sick role and seek
confirmation from family or friends

Stage 3: MEDICAL CARE CONTACT

- Sick people seek the advice of a health
professional.
c
Levels of Care
1. HEALTH PROMOTION
- is the process of enabling people to increase
control over, and to improve, their health.
• It moves beyond a focus on individual behaviour
towards a wide range of social and environmental
interventions.
• The purpose of health promotion is to positively
influence the health behaviour of individuals and
communities as well as the living and working
conditions that influence their health.
2. DISEASE PREVENTION
- is a procedure through which individuals,
particularly those with risk factors for a disease,
are treated in order to prevent a disease from
occurring.
- Treatment normally begins either before signs and
symptoms of the disease occur, or shortly
thereafter.
- Treatment can include patient education, lifestyle
modification, and drugs.
- These services include immunizations to prevent
disease, screening tests to detect disease at an
early stage, and behavioural counselling to avoid
or reduce risk factors for disease. You may also
participate in health education programs to help
you develop healthy living skills and manage your
health problems.
- The first and second of these goals are embodied
in the word "prevention" which for simplicity is
often divided into three levels. Note that this is a
simplification, but it is a useful place to begin:
TYPES OF DISEASE
PREVENTION
• PRIMARY PREVENTION
- is concerned with preventing
the onset of disease; it aims to
reduce the incidence of disease.
- It involves interventions that are
applied before there is any
evidence of disease or injury.
- Examples include protection
against the effects of a disease
agent, as with vaccination. It
can also include changes to
behaviours such as cigarette
smoking or diet. The strategy is
to remove causative risk factors
(risk reduction), which protects
health and so overlaps
with health promotion.
• SECONDARY PREVENTION
- is concerned with detecting a
disease in its earliest stages,
before symptoms appear, and
intervening to slow or stop its
progression: "catch it early."
- The assumption is that earlier
intervention will be more
effective, and that the disease
can be slowed or reversed.
- It includes the use of screening
tests or other suitable
procedures to detect serious
disease as early as possible so
that its progress can be
arrested and, if possible, the
disease eradicated
 Levels of Care
• TERTIARY PREVENTION
- Occurs when the defect or disabiity is
permanent and irreversible it involves
minimizing the Effects of long term disease or
disability by interventions directed at
preveting complications and deteriorization.
3. HEALTH MAINTENANCE
- Is a guiding principle in health care that
emphasizes health promotion and disease
prevention rather than the management of
symptoms and illness.
- It includes the full array of counselling, screening,
and other preventive services designed to
minimize the risk of premature sickness and death
and to assure optimal physical, mental, and
emotional health throughout the natural life cycle.
- The organization of medical care to encourage
health maintenance includes removing financial,
physical, and psychological barriers to obtaining
health promotion and disease prevention services
in clinical settings; the use of media to deliver
health education messages; and advocacy of
health policies that reduce the risk of injury; that
reduce exposure to toxins in the water, air, and
workplace; and that ensure the availability of
recreational facilities.
4. CURATIVE
- Involves treatment intended to
alleviate the symptoms or cure a
current medical condition
- Strives to reduce pain, improve
function, and help improve the
quality of life for patients
- Examples are:
o Medications
o Casts and splints for broken
bones
5. o Dialysis for kidney conditions
REHABILITATIVE/REHABILITATION
o Chemotherapy for cancer
• Health care services that help you
keep, get back, or improve skills and
functioning for daily living that have
been lost or impaired because you
were sick, hurt, or disabled.
• Nurse assists patients with
temporary and long-term
disabilities or chance illnesses
• Nurse also assists in adapting to
their highest potential and living
more independent lives.
• Nurses prepare patients and
caregivers for changes that occur in
rehabilitative treatment.
 Basic Interventions to
Maintain
TEMPERATURE REGULATION
- A nursing intervention from the Nursing
Interventions Classification (NIC) defined
as attaining and/or maintaining body
temperature within a normal range.
NURSING INTERVENTIONS FOR CLIENTS
WITH FEVER:
1. Monitor vital signs.
2. Assess skin color and temperature.
3. Remove excess blankets when the client
feels warm, but provide extra warmth
when the client feels chilled.
4. Measure intake and output.
5. Provide dry clothing and bed linens.
 Mobility and exercise
- Mobility, the ability to move freely,
easily, rhythmically, and purposefully in
the environment, is an essential part of
living.
- People must move to protect themselves
from trauma and to meet their basic
needs.
- Mobility is vital to independence; a
fully immobilized person is as
vulnerable and dependent as an infant
The client will have:
1. Increased tolerance for physical activity
2. Restored or improved capability to
ambulate and/or participate in ADLs
3. Absence of injury from falling or improper
use of body mechanics
4. Enhanced physical fitness
5. Absence of any complications associated
with immobility
HYGIENE AND COMFORT
Assessing patient hygiene
and personal care is important to
ascertain how well patients care for
themselves or a caregiver cares for
them.
Hygiene is necessary for
health, comfort, well-being, and
safety.
Assess hygiene by examining
a patient's clothing, skin, mouth, hair,
and nails.
SAFETY, SECURITY AND PRIVACY
Patient safety is a discipline
that emphasizes safety in health
care through the prevention,
reduction, reporting, and analysis of
medical error that often leads to
adverse effects.
PSYCHOSOCIAL AND SPIRITUAL
CONCERNS
Psychosocial spiritual care is
defined as aspects of care
concerning patient emotional state,
social support and relationships, and
spiritual well-being.
Psychosocial and spiritual
concerns:
1. Listen to stories or life reviews
2. Allow expression of anger, guilt,
hurt and fear.
3. Explain that it is alright to cry;
tears are normal and show caring.
 Basic Interventions to
Maintain
HEALTHY LIFESTYLE
Everyone needs to pay attention to nutrition and
exercise, and to avoid unhealthy lifestyle practices. FLUID AND ELECTROLYTE
Key words for a healthy lifestyle are balance and
moderation. HOMEOSTASIS
These lifestyle practices are supplemented by - tendency of the body to
regular physical examinations and health screenings. maintain a state of balance or
equilibrium while continually
changing; a mechanism in which
5 simple ways to a healthy lifestyle: deviations from normal state a
sensed and counteracted.
1. Get active each day
2. Choose water as drink
3. Eat more fruit and vegetables
4. Switch off the screen and get active PROMOTING FLUID AND
5. Eat fewer snacks and select healthier ELECTROLYTES BALANCE:
alternatives.
1. Consume 6-8 glasses of water
daily.
2. Eat well-balanced diet
OXYGENATION/RESPIRATION including milk.
- Process of gas exchange between 3. Limit alcohol intake.
individuals and environment. 4. Increase fluid intake before,
during and after exercise.
5. Maintain normal body
weight.
MEASURE THAT PROMOTES ADEQUATE 6. Monitor side effects of
RESPIRATORY FUNCTIONS: medications.
1. Adequate oxygen supply from the 7. Recognize risk factors of
environment. fluid/electrolytes imbalance-
2. Deep breathing and coughing exercise to vomiting, watery stool.
promote maximum lung expansion and loosen 8. Prompt professional health
mucous secretions. care for signs of fluid
3. Positioning semi fowler’s or high fowler’s imbalance- weight gain loss,
position promotes maximum lung expansion. decrease urine, swollen
4. Patent airway to promote gaseous exchange ankles, dyspnea, dizziness,
between person and maintain. confusion.
5. Adequate hydration to maintain moisture of
mucous membrane lining and respiratory tract.
6. Avoid environmental pollutants, alcohol and
smoking.
 Basic Interventions to
Maintain
NUTRITION
- Sum of all interactions betweem an FECAL ELIMINATION
organism and the food it consumes.
- What a person eats and how the body uses  Defecation is the expulsion of
it. feces from the rectum.
 It has an involuntary phase.
Interventions in Providing Client Meals:  When the feces enters the
1. Provide familiar food that the person likes. rectum, local distension and
2. Select small portions so as not to the pressure give rise to
discourage anorexic client. sensory impulses that initiate
3. Avoid unpleasant/ uncomfortable reflex impulses to the internal
treatment immediately before or after a anal sphincter and to the
meal. muscle tissue of sigmoid colon
4. Provide tidy, clean environment. and the rectum.
5. Encourage/ provide oral hygiene.
6. Relieve illness symptoms that depress
NURSING INTERVENTIONS TO
appetite.
PREVENT/ RELIEVE
7. Reduce stress.
8. Assist client to a comfortable position. CONSTIPATION:
9. Clear over bed table so that there is space
for food tray. 1. Adequate fluid intake.
10. Check each tray for client’s name, 2. High fiber diet.
type of client, completeness. 3. Establish regular pattern of
11. Assist client as required. defecation.
12. For a blind person, identify the 4. Minimize stress
placement of food as you would describe 5. Adequate activity/ exercise
the time on a clock. promotes muscle tone/
13. If a client is on special diet record peristalsis.
amount of food eaten and any pain, 6. Assume sitting/ semi squatting
fatigue or nausea experienced. position.
14. If the client is not eating, document 7. Administer laxative as
this. ordered (avoid overuse of
laxative because natural
defecation reflexes are
REFERENCE: inhibited, rebound
https://www.scribd.com/document/346512560/basic- constipation occurs).
intervention-to-maintain-healthy-lifestyle
Berman, A. B., Snyder, S. J., & Frandsen, G. E. (2016). KOZIER
AND ERB'S Fundamentals of Nursing. Singapore:
Pearson Education Inc. .
 Loss, Grief, Dying and
Death
Loss
- An aspect of self no longer available to a person
Death Losses may be actual or perceived.
- Cessation of life  Actual loss is easily identified.
Grief  A woman who has a
- Pattern of physical and emotional responses to mastectomy
bereavement  Perceived loss is less obvious.
Grief Work  Loss of confidence
- Adaptation process of mourning a loss
 A women who hopes to give
Mortality
birth to a female child delivers
- The condition of being subject to death a male child instead
 Perceived losses are easily
Changes in Health Care Related to Dying and Death overlooked or misunderstood,
 Before the1950s, it was common for patients to die at yet the process of grief
home in their own beds with assistance from family. involved is the same as an
 From the 1950s to 1980s, the health care system actual loss.
became highly mechanized and dying occurred
mostly in institutions.
 By the early 1980s, when diagnosis related groups MATURATIONAL LOSS
(DRGs) came into play, this trend changed.
 Currently, the recuperating or terminally ill patient is  Loss resulting from normal life
often discharged to home, a convalescent home, or a transitions
nursing home.  Loss of childhood dreams, the loss
felt in adolescents when a romance
fails, loss felt when leaving family
HISTORICAL OVERVIEW home for college or marriage and
1960s establishing a home of one’s own
- Pioneers in death and dying theory, such as
Kübler-Ross and Glassner and Strauss, produced  As an individual ages, they
works that stimulated the health care industry to experience menopause and loss of
research topics about death and dying. hair, teeth, hearing, sight, and
1970s “youth.”
- Hospices became recognized as health care
delivery systems. SITUATIONAL LOSS
1980s
- Grief therapy was introduced when Benoliel and
 A loss occurring suddenly in
Martocchio added new insights into the needs and
response to a specific external
care of the dying patient.
event
Sudden death of a loved one, or
the unemployed person who
LOSS suffers low self-esteem.
Not all losses are obvious or immediate.
 Obvious losses
PERSONAL LOSS
 Death of a loved one  Any loss that requires adaptation
 Divorce through the grieving process
 Breakup of a relationship  Loss occurring when something or
 Loss of a job someone can no longer be seen,
 Not-so-obvious losses felt, heard, known, or experienced;
 Illness individuals respond to loss
 Aging differently
 Changing schools, jobs, or neighborhoods
c
Loss, Grief, Dying and
Death
Grief
 The subjective response of emotional pain to
actual or anticipated loss
 The total process of reacting and responding to
the losses in one’s life
Bereavement
 A common depressed reaction to the death of a
loved one
Mourning
 A reaction activated by a person to assist in
overcoming a great personal loss
Morbidity
 An illness or an abnormal condition or quality
 Both physical and mental morbidity after
significant loss
 Increased incidence of divorce after the loss of a
child or after a partner loses a body part or
function
TASKS OF GRIEF TO FACILITATE
HEALTHY ADJUSTMENT TO LOSS
 Accepting the reality of the loss
 Experiencing the pain of grief
 Adjusting to an environment that no longer includes
the lost person, the object, or the aspect of self
 Reinvesting emotional energy into new
relationships
 These tasks are not sequential; may work on all
four tasks simultaneously, or only one or two may
be priorities
NURSE’S ROLE
 Assess for grieving behaviors.
 Recognize the influence of grief on behavior.
 Provide empathetic support.
ANTICIPATORY GRIEF
 This type of grief is to expect, await, or prepare
oneself for the loss of a family member or
significant other
 It is somewhat easier to cope with
loss if it is expected.
 Having time for anticipation does
not necessarily ease the pain of
loss.
 Emotions expressed at this time can
make the loss less conflicted.
 Sudden death of someone who is
not “supposed to” die is the most
difficult grief to bear.
 Parents and siblings are often
wracked by powerful and personal
emotions of guilt, denial, and
anger, as well as sorrow.
 Blame and guilt can destroy a
family just when family members
need each other most.
NURSE’S GRIEF
 Nurse must come to grips with
 Understanding the grief
process
 Appreciating the experience
of the dying patient
 Using effective listening skills
 Acknowledging personal
limits
 Knowing when there is a
need to get away and take
care of the self
BEREAVEMENT OVERLOAD
 The initial loss was compounded
with an additional loss before
resolution of the initial loss
 When nurses experience multiple
losses and fail to adequately
process them
BURNOUT
 The stresses exceed the rewards of
the job and the individual nurse
lacks the support of peers
 Loss, Grief, Dying and
Death
STAGES OF GRIEF AND DYING
SUPPORTIVE CARE DURING THE
Kübler-Ross Stages of Grieving/dying
1. Denial and isolation DYING AND GRIEVING PROCESS
2. Anger
3. Bargaining Assessment
4. Depression To give compassionate nursing care
5. Acceptance and support to the family and patient
during the grieving and dying process, the
Mustachio's Manifestations of Grief and Bereavement nurse should consider the five aspects of
1. Shock and disbelief human functioning:
2. Yearning and protest
3. Anguish, disorganization, and despair
1. Physical assessment
4. Identification in bereavement
5. Reorganization and restitution  Sleeping patterns
 Body image
Bereavement is a state of great risk physically, as well as  Activities of daily living (ADLs);
emotionally and socially. mobility
Unresolved grief  General health
 There have been some disturbances of the normal  Medications
progress toward resolution.  Pain
Dysfunctional grieving  Basic needs: nutrition,
 There is a delayed or exaggerated response to a elimination, oxygenation,
perceived, actual, or potential loss. activity, rest, sleep, and safety
 Dysfunctional grief occurs when an individual
 Gets “stuck” in the grief process and
becomes depressed 2. Social assessment
 Is unable to express feelings  Assessment of the patient’s and
 Cannot find anyone in daily life who acts as family’s support systems is
the listener he or she needs valuable.
 Suffers a loss that stirs up other, unresolved  Ascertain whether family
losses members desire to assist in the
 Lacks the reassurance and support to trust patient’s daily care. Never
the grief process and fails to believe that assume they do; many do,
he or she can work through the loss others do not.
 When families choose to take
Signs, Symptoms, and Behaviors of Dysfunctional the patient home for care, be
Grieving sure that they are well-
 Acquisition of symptoms belonging to the last prepared before discharge for
illness of the deceased what they need to know and
 Alteration in relationships with friends and do.
relatives
3. Intellectual assessment
 Lasting loss of patterns of social interaction
 Evaluation of the patient’s and
 Actions detrimental to one’s social and economic
family’s educational level, their
well-being
knowledge and abilities, and
 Agitated depression with tension, insomnia, expectations they have in
feelings of worthlessness, bitter self-accusation, regard to how and when death
obvious needs for punishment, and even suicidal will occur
tendencies
 A feeling that the death occurred yesterday, even
though the loss took place months or years ago
c
Loss, Grief, Dying and
Death
4. Emotional assessment
 Patient’s and family’s anxiety level, guilt,
anger, level of acceptance, and identification
 Major fears: abandonment, loss of control,
pain and discomfort, and the unknown
5. Spiritual assessment
 Assess the spiritual dimension by gaining
insight into the patient’s philosophy of life,
religious resources, and how the rituals of the
particular faith group have significance in
dealing with his or her death.
PERINATAL DEATH
 The death of a child before, during, or shortly
after birth
 Often viewed as one of the most devastating
losses that can occur in a family
 When possible, the parents should see, touch, and
hold the infant, so that the reality of the situation
can be faced and resolution of the grief can occur.
PEDIATRIC DEATH
 Nurses should be aware of how children view or
understand death, both for themselves and for
others.
 They need to be told the truth in language they
can understand and be allowed to share fears,
feelings, and opinions.
 Parents may express hostility and anger toward
health care providers, a higher power, or the
world in general.
SUICIDE
 Survivors of a person who has committed suicide
suffer all the emotions of grief, in addition to
profound guilt or shame.
 Survivors fear rejection and lack of social and
religious support.
 Survivors are at risk for suicide themselves, and a
grief counselor may be helpful.
GERONTOLOGIC DEATH
 The older patient must be treated
as an individual, and the nurse
should assess the patient’s needs in
the same way as for any patient
facing a terminal illness.
 Families who suffer the loss of an
older person may accept the death
but nonetheless must experience
the grieving process.
SUDDEN OR UNEXPECTED DEATH
 Accident, homicide, and sudden
illness are difficult to cope with.
 There is “unfinished business,” such
as things left unsaid or undone.
 There can be an obsessive need to
understand or know why this has
happened.
EUTHANASIA
 Active euthanasia
- An action deliberately taken with
the purpose of shortening life to
end suffering or to carry out the
wishes of a terminally ill patient
 Passive euthanasia
- Permitting the death of a patient
that takes the form of withholding
treatment that might extend life,
such as medication, life-support
systems, or feeding tubes
 Loss, Grief, Dying and
Death
DO NOT RESUSCITATE (DNR)
 Patients and families should control any decisions
relative to any conditions that withhold or
withdraw treatment.
 DNR decision should be a joint decision of the
patient, family, and health care providers.
 DNR means only not to resuscitate; it does not
mean to withhold any other care.
 All DNR orders and the discussion with the patient
and family should be thoroughly documented in
the patient’s chart.
ADVANCE DIRECTIVES
 Signed and witnessed documents providing
specific instructions for health care treatment in the
event that a person is unable to make those
decisions personally at the time they are needed
 Living wills
 Written documents that direct treatment
in accordance with patient’s wishes in
the event of a terminal illness or
condition
 Durable powers of attorney
 Designates an agent, a surrogate, or a
proxy to make health care decisions on
patient’s behalf
ORGAN DONATIONS
 Legally competent people are free to donate their
bodies or organs for medical use.
 In most states (National Organ Transplantation
Act), required request laws stipulate that at the
time of a person’s death, a qualified health care
provider must ask family members to consider
organ or tissue donation.
 The Uniform Anatomical Gifts Act addresses many
problems of organ donation and stipulates that
the physician who certifies death shall not be
involved in removal or transplantation of organs.
RIGHTS OF DYING PATIENTS
 Death with dignity is the goal in caring for the
dying patient.
 “The Dying Person’s Bill of Rights” is honored at
hospitals and other health care agencies and is
posted in prominent areas.
FRAUDULENT METHODS OF
TREATMENT
 Often patient and family seek
unconventional methods of treatment
to prolong the patient’s life.
 Treatments that are misrepresented,
whether by concealment or
nondisclosure of facts, for the
purpose of inducing another to use
the product are fraudulent.
COMMUNICATING WITH
THE DYING PATIENT
 Therapeutic communication
expresses respect for the patient,
maintains realistic hope, and offers
appropriate reassurance and
support.
 Careful attention to what the patient
expresses verbally and nonverbally
is required.
 If patients do not wish to
communicate at a particular time,
they need to know that this is
acceptable and will be respected.
ASSISTING THE PATIENT IN
SAYING GOODBYE
 This may be expressed in verbal,
nonverbal, concrete, and symbolic
ways.
 Provide a private, comfortable
environment.
 They should be encouraged to
express those feelings and thoughts
they would most want their loved
ones to know in their absence.
c

Loss, Grief, Dying and

Death
(cont.)
ASSESSMENTS AND
PHYSICAL CARE INTERVENTIONS FOR THE
DYING PATIENT
 Provide adequate nutrition and maintain
elimination patterns.  As death becomes imminent
 Keep the patient clean, dry, well-groomed, odor-  Pupils dilated and fixed
free, and comfortable; provides the patient with  Cheyne-Stokes respirations
feelings of self-esteem and self-worth.  Pulse weaker and more
 Adjusting the environment to increase comfort and rapid
safety is paramount.  Blood pressure continues to
fall
 Skin cool and clammy
PALLIATIVE CARE  Profuse diaphoresis
 Death rattle: noisy
 According the the World Health Organization, respirations
when health care providers deliver palliative care,
they do the following: CLINICAL SIGNS OF DEATH
 Provide relief from pain and other distressing
symptoms  Unreceptivity and
 Affirm life and regard dying as a normal process unresponsiveness
 Neither hasten nor postpone death  No movement or breathing
 Integrate psychological and spiritual aspects of  No reflexes
patient care  Flat encephalogram
 Offer a support system to help patients live as  Absence of apical pulse
actively as possible until death  Cessation of respirations
 Offer a support system to help families cope
during the patient's illness and their own POSTMORTEM CARE
bereavement
 Enhance the quality of life  This is care of the patient’s
body after death.
ASSESSMENTS AND INTERVENTIONS FOR
 The body should be cared for
THE DYING PATIENT as soon as possible after
 Most crucial needs are control of pain, death to prevent tissue
preservation of dignity and self-worth, and damage or disfigurement.
love and affection.  Offer the family the
 Assessing for impending death opportunity to view the body.
 Restlessness  Before the family views the
 Discoloration of arms and legs body, prepare it and the
 Changes in vital signs: slow, weak, room to minimize the stress of
and thready pulse; lowered blood the experience.
pressure; rapid, shallow, irregular, or  The body should be made to
abnormally slow respirations look as natural and
comfortable as possible
 Loss, Grief, Dying and
Death
SPECIAL CONSIDERATIONS FOR
CHILDREN
STAGES OF DYING (cont.)
 The child’s developmental level determines the
amount and type of detailed information that Depression: sad mood; realization
should be discussed with the child. that death will come sooner rather than
later
DOCUMENTATION Acceptance: attitude of
complacency that occurs after clients have
 It must be objective, complete, legible, and dealt with their losses
accurate.
 It should be frequent and include the signs of Promoting acceptance: nurses
impending death as they occur. can help client to pass from one stage
 The last entry should state where and to whom the to another by providing emotional
body was transferred. support and supporting client’s choice
regarding terminal care.
 Emotional support: part of
missing nursing care; more
necessary for dying clients
 Arrangements for care:
SUPPORT respecting the rights of dying
clients
 The needs of the grieving family and significant  Home care
others should be met by a caring, compassionate  Respite care: relief
health care provider.
for the caregiver by
RESOLUTION OF GRIEF a surrogate
 Hospice care
 Begins when the grieving person can complete the  Eligibility for hospice
following tasks care: 6 months or less
 Have positive interactions, participate in to live
support groups, establish goals and work to  Hospice services:
achieve them, discuss the meaning of the clients receive care in
loss and its effect their own homes;
multidisciplinary
team of hospice
professionals and
Terminal illness: recovery from the condition is volunteer support
beyond reasonable expectations. are provided
 Terminating hospice care
 Residential care:
STAGES OF DYING form of intermediate
Denial: psychological defense mechanism; refusal care
to believe certain information; helps to cope with reality  Acute care:
of death sophisticated
Anger: emotional response to feeling victimized; technology and
occurs because there is no way to retaliate against fate labor-intensive
Bargaining: psychological mechanism to delay treatment
the inevitable
c

Loss, Grief, Dying and

Death
PROVIDING TERMINAL CARE

GRIEVING
Hydration: maintenance of adequate fluid
volume
 Nourishment: tube feeding and parenteral
nutrition  Process of feeling acute
 Elimination: catheterization; enemas or sorrow over a loss
suppositories; skin care  Pathologic grief:
 Hygiene: clean, well groomed, and free of dysfunctional grief; refusing
unpleasant odors to accept the client’s deat
 Positioning: promote comfort and circulation
 Resolution of grief: time
 Comfort: keep clients free from pain
taken for mourning; ability to
Family involvement: maintain family bonds to help talk about the dead person;
coping with future grief controlling emotions
Approaching death: decrease and ultimate cessation of
function
 Multiple organ failure: two or more organs cease GENERAL
to function
 Family notification: family should be aware of GERONTOLOGIC
approaching death
 Meeting relatives to promote smooth CONSIDERATIONS
transition
 Discussing organ donation  Understand that the dying
 Confirming death: determined on the basis that older client is a living person
breathing and circulation have ceased who may want to maintain the
 Brain death: irreversible loss of function of same interpersonal
the brain relationships as someone who is
 Death certificate not dying
 Permission for autopsy: examination of  Encouraging older clients, who
organs and tissues of human body after have experienced the death of
death a close friend or family
member, to express feelings
associated with grieving is
PERFORMING POSTMORTEM CARE: important
 Cleaning and preparing the body to  Reading obituaries can be an
effective coping mechanism in
enhance its appearance during viewing at
helping to develop a peaceful
the funeral home and accepting attitude toward
 Proper identification death
 Releasing the body to mortuary personnel
REFERENCE:
Potter, P.A., Perry, A.G. (2005).
Fundamentals of nursing. 6th
edition. St. Louis: Mosby
 Nursing as an Art
"Nursing is an art: and if it is to be made an art, it
requires an exclusive devotion as hard a
preparation as any painter's or sculptor's work; for
what is the having to do with dead canvas or dead
marble, compared with having to do with the living
body, the temple of God's spirit? It is one of the
Fine Arts: I had almost said, the finest of Fine Arts."
— Florence Nightingale
Definition of Art
• It is a skill acquired by experience, study, or
observation.
• Art is the final outcome of anyone’s passion, skill,
creative imagination, and devotion.
Aesthetic Knowing: The Art of Nursing
 Aesthetic knowing is the art of nursing and
is expressed by the individual nurse
through his or her creativity and style in
meeting the needs of the clients.
 The nurse uses aesthetic knowing to provide
care that is both effective and satisfying.
Empathy, compassion, holism, and
sensitivity are important modes in the
aesthetic pattern of knowing.
Empirical Knowing: The Science of
Nursing
 Knowledge about the empirical world is
systematically organized into laws and
theories for the purpose of describing,
explaining, and predicting phenomena of
special concern to the discipline of nursing.
 Empirical knowing ranges from factual,
observable phenomena (e.g., anatomy,
physiology, chemistry) to theoretical
analysis (e.g., developmental theory,
a d a p t a t i o n t h e o r y ) .
Concepts Related To The Art
Of Nursing
• Human Beings
- Humans are viewed as valued
persons to be respected, nurtured
and understood with the right to
make informed choices regarding
their health.
• Environment
- Environment is the landscape and
geography of human social
experience, the settings or context
of experience as everyday life
and includes variations in space,
time and quality.
• Health
- A dynamic process, Is the synthesis
of wellness and illness and is
defined by the perception of the
client across the life span. This view
focuses on the entire nature of the
client in physical, social, aesthetic
and moral realms.
SELF-CONCEPT
 Is one’s mental image of oneself.
 Involves all of the self-perceptions-
appearance, values, and beliefs-
that influence behaviour and are
referred to when using the words I
or me.
 Self-concept is a complex idea
that influences the following:
 How one thinks, talks and
acts
 How one sees and treats
another person
 Choices one makes
c

Nursing as an Art
 Ability to give and receive love
 Ability to take action and to change
things.
FOUR DIMENSION OF SELF-CONCEPT 6 C’S OF CARING (cont.)
 Self-knowledge Confidence
- The quality that fosters trusting
The knowledge that one has about oneself,
including insights into one’s abilities, nature and relationships. Comfort with self,
limitations. client, and family.
Conscience
- Moral, ethics and an informed
 Self-expectation sense of right and wrong.
Awareness of personal
What one expects of oneself; may be a realistic responsibility.
or unrealistic expectation
Commitment
 Social self
- Convergence between one’s
How a person is perceived by others and society desires and obligations and the
deliberate choice to act in
SELF ENHANCEMENT accordance with them.
Compartment
 • Social evaluation
A type of motivation that works to make people
good about themselves and to maintain self- - Appropriate bearing, demeanor,
esteem.
The appraisal of oneself in relationship to others, dress and language that is in
• events or situations.involves a preference positive
Self- enhancement harmony with a caring presence.
over negative self-views. Presenting oneself as someone who
respects others and demands
respect.
NURSE-CLIENT RELATIONSHIP
CARING: An Integral Component of
Nursing It is the nurse-client interaction that is
toward enhancing the client’s well-being,
• Caring is central to all heaping professions and and the client may be an individual, a
enables person to create meaning in their lives. family, a group or a community.
• Caring means that people, relationships and • Pre-orientation/Pre-introductory
things matter. Phase
6 C’S OF CARING -Self assessment examine
own feelings, fears, anxieties.
Compassion
• Orientation/Introductory Phase
- Awareness of one’s relationship to others, sharing
their joys, sorrows, pain, and accomplishments. -establish trust, share
information with client; discrete
Competence
self-disclosure. Convey support,
- Having knowledge, judgment, skills, energy, facilitate healing educate.
experience and motivation to respond
adequately to others within the demands of
professional responsibilities
 Nursing as an Art

NURSE-CLIENT RELATIONSHIP (cont.)

Therapeutic Communication
• Working Phase
Techniques
-problems identified
• Termination Phase/Resolution Phase • Using silence
• Providing general leads
• Being specific and tentative
THERAPEUTIC COMMUNICATION
• Using open-ended questions
Therapeutic communication refers to the
process in which the nurse consciously • Using touch
influence a client or helps the client to a • Restating or paraphrasing
better understanding through verbal and
• Seeking clarification
nonverbal communication.
• Perception checking or seeking
Therapeutic communication involves the consensual validation
use of specific strategies that encourage
the patient to express feelings and ideas • Offering self
and that convey acceptance and respect. • Giving information
• Acknowledging
• Clarifying time or sequence
FOCUS OF NURSING • Presenting reality
Nursing care focuses on protecting and • Focusing
promoting physical and mental health for patients and
for the community. • Reflecting
• Summarizing and planning
REFERENCES:
Hawkinson, D. (2015) Character for Life: An American REFERENCES:
Sedikides, C.; Strube, M. J. (1995), "The
Heritage- Profiles of Great Men and Women Of Faith
Multiply Motivated Self", Personality and
who shaped Western Civilization (1st ed.) China, New Social Psychology Bulletin, 21 (12): 1330
Leaf Press 1335, CiteSeerX 10.1.1.561.6126, doi:10.1
Kozier, Barbara, Erb, Glenora Lea, Berman, 177/01461672952112010, ISSN 0146-
Audrey, Snyder, Shirlee, Levett-Jones, Tracy, Dwyer, 1672, The self-enhancement motive refers to
Trudy, Hales, Majella, Harvey, Nicole,Moxham, people's desire to enhance the positivity or
Lorna, Park, Tanya, Parker, Barbara, Reid-Searl, Kerry, decrease the negativity of the self-concept.
andStanley, David (2015) Kozier and Erb's Fundamentals Roach, M. S. (2002). Caring, the Human mode
of Nursing [3rd Australian edition]. Pearson Australia, of being (2nd ed.). Ottawa, Ontario, Canada;
Melbourne, VIC, Australia. CHA Press.
Smith, M. C., & Parker, M. E. (2015).Nursing theories and Mosby’s Medical dictionary, 8th edition. ©
2009 elsevier.
nursing practice. FA Davis.
https://www.rnpedia.com/nursing-
Berman, A., Snyder, S., Kozier, B., Erb, G., (2008) notes/fundamentals-in-nursing-
KOZIER AND ERB’S FUNDAMENTALS OF NURSING (8TH notes/therapeutic-communication/
ed.) Philippines, Pearson Education Inc. https://work.chron.com/fundamental-
nursing-concepts-18808.html
 Republic of the Philippines

Laguna State Polytechnic University

Province of Laguna

College of Nursing and Allied Health