NCM 106 Acute Biologic Crisis

Catanduanes State Colleges
Virac, Catanduanes
College of Health Sciences
NCM 106 CARE OF THE CLIENTS WITH

PROBLEMS IN ACUTE BIOLOGIC CRISIS
Course Description:
It deals with the principles and techniques of

nursing care management of sick clients across
the lifespan with the emphasis on the adult and
older person with alteration/problems in acute
biologic crisis.
Objectives:
At the end of the course, and given actual
clients with problems in acute biologic crisis,
the student should be able:
1.Academic Excellence
a. Utilize the nursing process in the care of

individuals, families, in community and hospital
settings.
i. Assess with the client his/her condition/health
status through interview, physical examination,
interpretation of laboratory findings
ii. Identify actual and potential diagnosis
iii. Plan appropriate nursing interventions

with client and family for identified nursing
diagnosis
iv. Implement plan of care with client and family
v. Evaluate the progress of the client’s condition

and outcomes of care

b. Ensure a well-organized and accurate
documentation system
2. Virtues
A.Observe bioethical principles and the core
values (love of God, caring, love security and of
people
Utilize the bioethical principle and core
values and nursing standards in the care
of client
c. Integrate the various principles, concept and
application of bioethics in the care of the client.
3. Communities (Community Service)
A.Determine the different principles and tech
niques of nursing care management inpromot
ing the health of the community
.be taken part in the community projects

that would require the utilization
of appropriate health promotion and disease
prevention
.correlate with client and their family and the

health team appropriately.
Promote personal and professional growth

of self and others.

Cardiac Failure
D e s c r i p t i o n - I s t h e i n a b i l i t y o f
the heart to pump sufficient b
l o o d t o m e e t t h e needs of the tissues fo
r oxygenation and nutrients
-CHF is most commonly used when referring
to left-sided and right-sided failure
- Formerly called Congestive Heart Failure
Etiologic Factors:
-Increased metabolic rate (egg. fever,

thyrotoxicosis)
-Hypoxia
-Anemia Pathophysiology:
Cardiac failure most commonly occurs with disord
ers of cardiacmuscles that result in decreased
contractile properties of the heart. Common
underlying conditions that lead to decreased
myocardial contractility include myocardial
dysfunction, arterial hypertension, and alular
dysfunction. Myocardial dysfunction may be
due to coronary artery disease, dilated
cardiomyopathy, or inflammatory and
degenerative diseases of the myocardium.
Atherosclerosis of the coronary arteries is the
primary cause of heart failure. Ischemia
causes myocardial dysfunction because of
resulting hypoxia and acidosis (from
accumulation of lactic acid). Myocardial
infarction causes focal my cellular necrosis, the
death of myocardial cells, and a loss of
contractility; the extent of the infarction is
prognostic of the severity of CHF. Dilated
cardiomyopathy causes diffuse cellular
necrosis, leading to decreased contractility.
Inflammatory and degenerative diseases of the
myocardium, such as myocarditis, may also
damage myocardial fibers, with a resultant
decrease in contractility. Systemic or
pulmonary HPN increases afterload which
increases the workload of the heart and in turn
leads to hypertrophy of myocardial muscle
fibers; this can be considered a compensatory
mechanism because it increases contractility.
Alular heart disease is also a cause of cardiac
failure. The valves ensure that blood flows in
one direction. With alular dysfunction, valve
has increasing difficulty moving forward. This
decreases the amount of blood being ejected,
increases pressure within the heart, and
eventually leads to pulmonary and venous
congestion.
Left-Sided Cardiac Failure-

Pulmonary congestion occurs when the left ve
ntricle cannot pump the blood out of the
chamber. This increases pressure in the left
ventricle and decreases the blood flow from
the left atrium. The pressure in the left atrium
increases, which decreases the blood flow
coming from the pulmonary vessels. The
resultant increase in pressure in the pulmonary
circulation forces fluid into the pulmonary
tissues and alveoli; which impairs gas
exchange.
Clinical Manifestations
- Dyspnea on exertion
- Cough
- Adventitious breath sounds
- Restless and anxious
- Skin appears pale and ashen and feels
cool and clammy
- Tachycardia and palpitations
- Weak, thread pulse
Easy fatigability and decreased activity
tolerance
Right-Sided
Cardiac Failure
- When the right ventricle fails,
congestion of the viscera and the peripheral
tissues predominates. This occurs because the
right side of the heart cannot eject blood and
thus cannot accommodate all the blood that
normally returns to it from the venous
circulation.
Edema of the lower extremities (dependent e
dema)
- Weight gain
- Hepatomegaly (enlargement of the liver)
- Distended neck veins
- Ascites (accumulation of fluid in the peritone
al cavity) - Anorexia and nausea
- Nocturnal (need to urinate at night)
- Weakness
Diagnostics
-
Chest X-ray (may show cardiomegaly or
vascular congestion)
-
Echocardiogram (shows decreased ventricular
function and decreased ejection fraction
CVP (elevated in right-sided failure)
*pulmonary artery pressure monitoring may
be used as guide treatment in serious case of
pulmonary edema
Nursing Diagnoses-
Activity intolerance r/t imbalance bet

ween oxygen supply anddemand
secondary to decreased CO
- Excess fluid volume r/t excess fluid/sodium
intake or retention secondary to CHF and its
medical therapy
Anxiety r/t breathlessness and restlessness s
econdary to inadequate oxygenation
- Non-compliance r/t to lack of knowledge-
Powerlessness r/t inability to perform role res
ponsibilitiessecondary to chronic illness and
hospitalizationNursingManagementa. Acute
phase
- Monitor and record BP, pulse, respirations,
ECG and CVP to detect changes in cardiac
output
- maintain client in sitting position to decrease
pulmonarycongestion and facilitate improved
gas exchange
- auscultate heart and lung sounds frequently:
increasing crackles, increasing dyspnea,
decreasing lung sounds indicate worsening
failure
- administer O2 as ordered to improve gas ex
change and increaseoxygenation of blood;
monitor arterial blood gases (ABG) as ordered
to assess oxygenation
- administer prescribed medications on accura
te schedule
- Monitor serum electrolytes to detect hypokal
emia secondary to diuretic therapy
- Monitor accurate input and output (may requ
ire Foley catheter tallow accurate
measurement of urine output) to evaluate fluid
status
- If fluid restriction is prescribed, spread the flu
id throughout the dayto reduce thirst
- encourage physical rest and organized activi
ties with frequentrest periods to reduce the
work of the
heart- provide a calm reassuring environment
to decrease anxiety; thisdecreases oxygen
consumption and demands on the heart.
Chronic heart
failure- educate client and family about the rati
onale for the regimen- establish baseline asse
ssment for fluid status and functionalabilities-
monitor daily weights to evaluate changes in fl
uid status- assess at regular intervals for chan
ges in fluid status or functionalactivity
level PharmacologicTherapy- ACE Inhibitors (
promotes vasodilation and diuresis by decrea
singafterload and preload eventually
decreasing the workload of the
heart.)- Diuretic Therapy. A diuretic is one of
the first medications prescribed to a patient
with CHF. Diuretics promote the excretion of
sodium and water through the
kidneys- Digitalis
(increases the force of myocardial
contraction and slows conduction through the
AV node. It improves contractility thus,
increasing left ventricular output.)-
.
(Dobutrex) is an intravenous medication given
topatients with significant left ventricular
dysfunction. Acatecholamine, it stimulates the
beta1-adrenergic receptors. Itsmajor action is
to increase cardiac
contractility.- Milrinone (Primacor). A phospho
diesterase inhibitor that prolongsthe release
and prevents the uptake of calcium. This in
, causing a decrease in preload and afterload
The workload of the heart.
- Nitroglycerine (a vasodilator reduces preload
) - Morphine to sedate and vasodilator,
decreasing the work of theheart- Anticoagulan
ts may be prescribed. Beta-adrenergic
blockersmaybe indicated in patients with mild
or moderate failure Client Education
-
Include family member or others in teaching as
appropriate
-
Weight monitoring: teach client the importance
of measuring and recording daily weights and
report unexplained increase of 3-5pounds
-
Diet: sodium restriction to decrease fluid
overload and potassium rich foods to replenish
loss from medications; do not restrict
water intake unless directed
-
Medication regime: explain the importance of
following all medication instruction
-
Activity: help client plan paced activity to
maximize available cardiac output
-
Symptoms: report to MD promptly any of the
following: chest pain, new onset of dyspnea on
exertion, paroxysmal and nocturnal dyspnea
-
Report even minor changes to MD as they
may be an early signoff
Myocardial Infarction Description- Occurs

when the heart muscle is deprived of
oxygen and nutrient-rich blood. However, in
the case of MI, this deprivation occurs over a
sustained period to the point at which
irreversible cell death and necrosis take place.
Infarction results from sustained ischemia and
is irreversible causing cellular death and
necrosis.
Etiologic factors
- Physical exertion
- Emotional stress- Weather extremes
- Digestion after a heavy meal
- Valsalva maneuver
- Hot baths or showers
- Sexual excitation
Pathophysiologic characteristic (Coronary arte
ry disease)
Pathophysiology
Coronary artery blood flow is blo
c k e d b y a t h e r o s c l e r o t i c narrowing,
thrombus formation or persistent vasospasm;
myocardium supplied by the arteries is
deprived of oxygen; persistent ischemia may
rapidly lead to tissue death
ClinicalManifestations
- Chest pain or discomfort (described as
aching or squeezing pain, most common
location is sub sternal, radiating to neck, jaw,
back, shoulders, left arm or occasionally the
right arm)
-Complain of heartburn or indigestion
-pallor, diaphoresis, cold skin, shortness of
breath, weakness, dizziness, anxiety, and
feelings of impending doom.
DiagnosticsLaboratory Tests
- Electrocardiogram (12-lead)
– capable of diagnosing MI in 80% of patients
, making it an indispensable, noninvasive, and
cost-effective tool. Reading shows ST
elevation, accompanied by T-wave inversion;
and later new pathologic Q wave
-Cardiac Enzymes – elevated CK with MB is

enzymes >5percent (early diagnosis); elevated
Troponin (early to late diagnosis); or elevated
LDH with “flipped” is enzymes (late diagnosis)
-WBC count – leukocytosis (10,000/mm3 to

20,000/mm3) appears on the second day after
AMI and dis appears after 1 week
-Positron Emission Tomography (PET) is used

to evaluate cardiac
Imaging Studies
metabolism and to asse
ss tissue perfusion
-Magnetic Resonance Imaging helps
identify the site and extent of an MI
-Tran esophageal Echocardiography
(TEE) is an imaging technique in which
transducer is placed against the wall of
the esophagus; the image of the
myocardium is clearer when the
esophageal sites used. Nursing
Diagnoses
-Acute Pain related to myocardial
ischemia resulting from coronary artery
occlusion
-Ineffective Tissue Perfusion related to
thrombus in coronary artery
-Decreased Cardiac Output related to
negative inotropic changes in the heart
secondary to myocardial ischemia
-Impaired Gas Exchange related to
decreased cardiac output
-Anxiety and Fear related to hospital
admission and fear of death Nursing
Management
-Assess pain status frequently with pain
scale
-Assess hemodynamic status including
BP, HR, LOC, skin color, and
temperature (every 5 minutes during
with pain; every 15minutes)
-Monitor continuous ECG to detect
dysrhythmias
-Perform 12-lead ECG immediately with
new pain or changes in level of pain
-Monitor respirations, breath sounds,
and input and output to dtectearly signs
of heart failure
-Monitor O2 saturation and administer
O2 as prescribed
-Provide for physiological rest to
decrease oxygen demands on heart
-Keep client NPO or progress to liquid
diet as ordered; maintain I access for
medication as needed
-Provide a calm environment and
reassure client and family to decrease
stress, fear and anxiety
-Report significant changes
immediately to physician to ensure
rapid treatment of complications
-Maintain bed rest for 24 to 36 hours
and gradually increase activity as
ordered while closely monitoring CO,
ECG and
painstatusPharmacologicTherapy
-Nitroglycerine (to dilate coronary
vessels and increase blood flow)
-Morphine Sulfate (to relieve chest pain)
-Anticoagulant (heparin) and
Antiplatelet (aspirin) - to prevent
additional clot formation
-Streptokinase (to dissolve clot)
-Beta blockers (to decrease cardiac
work)
-Anti-dysrhythmia
Surgical Interventions
-Percutaneous Trans luminal coronary
angioplasty (PTCA) –involves the
passage of an inflatable balloon
catheter into thestenonic coronary
vessel, which is then dilated, resulting in
compression of the atherosclerotic
plaque and widening of the vessel
-Coronary artery bypass grafting
(CABG) – done by harvesting either a
saphenous vein from the leg or the left
internalmammaryartery and then used
to bypass areas of obstruction in the
heart Client
Education
-Include appropriate family members
whenever possible
-Explain cardiac rehabilitation program
if ordered
-Explain modifiable risk factors and
develop a plan with client including
supportive resources to change lifestyle
to decrease these factors
-Explain medication regime as
prescribed; identify side effects to
report (provide written instructions for
later reference)
-Stress the importance of immediate
reporting of chest pain or signs of
decreased CO2
-Instruct about bleeding precautions if
client is on anticoagulant therapy: use
soft toothbrush, electric razor, avoid
trauma or injury; wear or carry medical
alert identification.
Acute Pulmonary Failure
Description
Definedasafall in arterial
oxygentension and a rise
i n a r t e r i a l carbon dioxide tension.
- The ventilation and/or
perfusion mechanisms in the lung are
impaired.
Etiologic factors
-Alveolar hypoventilation
-Diffusion abnormalities
-Ventilation-perfusion mismatching
-Shunting Pathophysiology
-Progression of pulmonary edema
occurs when capillary hydrostatic
pressure is increased, promoting
movement of fluid into the interstitial
space of the alveolar-capillary
membrane. Initially, increased
lymphatic flow removes the excess
fluids, but continued leakage eventually
overwhelms this mechanism. Gas
exchange becomes impaired by the
thick membrane. Increasing interstitial
fluid pressure ultimately causes leaks
into the alveolar sacs, impairing
ventilation and gas exchange.
-Tachypnea
-Tachycardia
-Cold, clammy skin and frank
diaphoresis are apparent especially
around the forehead and face
-Percussion reveals hyper resonance in

patients with COPD; dull or flat on
patients with atelectasis or pneumonia
-Diminished breath sounds; absence of
breath sounds of the affected lung in
patients with pneumothorax; wheezes
on patients with asthma; rhonchi on
patients with bronchitis and crackles
may reveal suspicion of pulmonary
edema Diagnostics
-ABG analysis indicates respiratory
failure when PaO2 is low andPaCO2 is
high and the HCO3 level is normal
-Chest X-ray is used to identify
pulmonary diseases such as
emphysema, atelectasis,
pneumothorax, infiltrates and effusions
-Electrocardiogram (ECG) can
demonstrate arrhythmias, commonly
found with core pulmonale and
myocardial hypoxia
-Pulse oximetry reveals a decreasing
SpO2 level
-WBC count aids detection of an
underlying infection; abnormally low
hemoglobin and hematocrit levels
signal blood loss, indicating decrease
oxygen carrying capacity
-PA catheterization is used to
distinguish pulmonary causes from
cardiovascular causes of acute
respiratory failure Nursing Diagnoses
-Impaired Gas Exchange related to
capillary membrane obstruction from
fluid
-Excess Fluid Volume related to excess
preloadNursingManagement
-Assess the patient’s respiratory status
at least every 2 hours or more as
indicated
-Position the patient for optimal
breathing effort when he isn’t intubated.
Put the call bell within easy reach to
reassure the patient and prevent
necessary exertion
-Maintain the norm thermic environment
to reduce patient’s oxygen demand
-Monitor vital signs, heart rhythm, and
fluid intake and output, including daily
weights, to identify fluid overload or
impending dehydration
-After intubation, auscultate the lungs to
check for accidental intubation of the
esophagus or main stem bronchus.
-Don’t suction too often without
identifying the underlying cause of an
equipment alarm.
-Watch oximetry and scenography
values because these may indicate
changes in patient’s condition
-Note the amount and quality of lung
secretions and look for changes in the
patient’s status
-Check cuff pressure on the ET tube to
prevent erosion from an overinflated
cuff
-Implement measures to prevent nasal
tissue necrosis
-Be alert of GI bleeding
-Provide a means of communication for
patients who are intubated and
alertPharmacologicTherapy
-Reversal agents such as Naloxone
(Narran) are given if drug overdose is
suspected
-Bronchodilators are given to open
airways
-Antibiotics are given to combat
infection
-Corticosteroids may be given to reduce
inflammation
-Continuous IV solutions of positive
inotropic agents may be given to
increase cardiac output, and
vasopressors may be given
Vasoconstrictions to improve or
maintain blood pressure
-Diuretics may be given to reduce fluid
overload and
edemaC l i e n t E d u c a t i o n - I n c l u d
e family member or others in
teaching as appropriate
-Weight monitoring: teach client the
importance of measuring and recording
daily weights and report unexplained
increase of 3-5pounds
-Diet: sodium restriction to decrease
fluid overload and potassium rich foods
to replenish loss from medications; do
not restrict water intake unless directed
-Medication regime: explain the
importance of following all medication
instructions
-Instruct client and family to maintain
elevation of the head of the client at
least 45 degrees; position increases
chest expansion and mobilizes fluid
from the chest into more dependent
areas Acute Renal Failure Description
-a sudden loss of kidney function
caused by failure of renal circulation or
damage to the tubules or glomeruli.
Etiologic factor.
Prerenal - caused by decrea
se blood flow to kidneys like
s e v e r e dehydration,diuretic therapy,
circulatory collapse,hypovolemia
or shock; readily reversible when
recognized and treatedb.Intrarenal –
caused by disease process,
ischemia, or toxic conditions such as
acute glomerulonephritis, vascular
disorders,toxicagents, or severe
infection
Post renal – caused by any condition
that obstructs urine flow such as benign
prostatic hyperplasia, renal or urinary
tract calculi, or tumors.
Pathophysiology
-Acute renal failure is classified as
perennial, intracranial or post renal. All
conditions that lead to perennial failure
impair blood flow to the kidneys (renal
perfusion), resulting in a decreased
glomerular filtration rate and increased
tubular desorption of sodium and water.
Intracranial failure results from damage
to the Kidneys. Post renal failure results
from obstructed urine flow.
*A change in blood pressure and
volume signals pre renal failure,
the patient may have the following:
-Oliguria
-Tachycardia
-Hypotension
-Dry mucous membranes
-Flat jugular veins
-Lethargy progressing to coma
-Decreased cardiac output and cool,
clammy skin in patient with heart
failure
*As renal failure progresses, the patient
may manifest the following signs and
symptom:
- uremia
- confusion
- GI complaints
- fluid in the lungs
- infection
Diagnostics
-Blood studies reveal elevated BUN,
serum keratinize, and potassium levels
and decreased blood pH, bicarbonate,
HCT, and Hob levels
-Urine studies show cats, cellular
debris, decreased specific gravity and,
in glomerular diseases, proteinuria and
urine osmolality close to serum
osmolality.
-Keratinize clearance testing is used to
measure the GFR and estimate the
number of remaining functioning
nephrons
-Electrocardiogram (ECG) shows tall,
peaked T waves, widening QRS
complex, and disappearing P waves if
increased potassium is present
*Other studies used to determine the
cause of renal failure
:- kidney ultrasonography
- plain films of the abdomen
- KUB radiography
- excretory urography
- renal scan
- retrograde pyelography
computed tomography scan and nephr
otomography
Nursing Diagnoses
-Excess Fluid Volume
-Imbalanced Nutrition: Less than Body
Requirements
-Deficient Knowledge
-Riskfor Infection
NursingManagement
-Monitor intake and output
-Observe for oliguria followed
by polyuria
-Weigh daily and observe for edema
-Monitoring of complications of
electrolyte imbalances, such as
acidosis and hyperkalemia
-Allow client to verbalize concerns
regarding disorder
-Encourage prescribed diet: moderate
protein restriction, high in
carbohydrates, restricted potassium
-Once diuresis phase begins, evaluate
slow return of BUN, keratinize,
phosphorus, and potassium to
normalPharmacologicTherapy
-Use volume expanders are prescribed
to restore renal perfusion in
hypotensive clients and Dopamine IV to
increase renal blood flow
-Loop diuretics to reduce toxic
concentration in nephrons and establish
urine flow
-ACE inhibitors to control hypertension
-Antacids or H2 receptor antagonists to
prevent gastric ulcers
-Kayexelate to reduce serum potassium
levels and sodium bicarbonate to treat
acidosis
*Avoid nephrotoxic drugs
Client Education
-Dietary and fluid restrictions, including
those that may be continued after
discharge
-Signs of complications such as fluid
volume excess, CHF, and
hyperkalemia
-Monitor weight, blood pressure, pulse,
and urine output
-Avoid nephrotoxic drugs and
substances: NSAIDs, some antibiotics,
radiologic contrast media, and heavy
metals; consult care provider prior to
taking any OTC drugs
-Recovery of renal function requires up
to 1 year; during this period, nephrons
are vulnerable to damage from
nephrotoxinsStroke/Cerebrovascular
accident Description
-Is a condition where neurological
deficits occur as a result of decreased
blood flow to a localized area of the
brain?
-Thrombosis of the cerebral arteries

supplying the brain or of the Intracranial
vessels occluding blood flow
-Embolism from a thrombus outside the
brain, such as in the heart, aorta, or
common carotid artery
-Hemorrhage from an intracranial artery
or vein, such as from hypertension,
ruptured aneurysm, AVM, trauma,
hemorrhagic disorder, or septic
embolism
Pathophysiology
-the underlying event leading to stroke
is oxygen and nutrient deprivation; if the
arteries become blocked, auto
regulatory mechanisms maintain
cerebral circulation until collateral
circulation develops to deliver blood to
the affected area; if the compensatory
mechanisms become overworked or
cerebral blood flow remains impaired
for more than a few minutes, oxygen
deprivation leads to infarction of brain
tissue
Risk factors
-Hypertension
-Family history of stroke
-History of TIA
-Cardiac disease, including
arrhythmias, coronary artery disease,
acute myocardial infarction, dilated
myopathy, and alular disease
-Diabetes mellitus
-Familial hyperlipidemia
-Cigarette smoking
-Increased alcohol intake
-Obesity, sedentary lifestyle
-Use of hormonal
contraceptivesClinicalManifestations
-Hemiparesis on the affected side (may
be more severe in the face and arm
than in leg)
-Unilateral sensory defect (such as
numbness, or tingling) generally on the
same side as the hemiparesis
-Slurred or indistinct speech or the
inability to understand speech
-Blurred or indistinct vision, double
vision, or vision loss in one eye (usually
described as a curtain coming down or
gray-out of vision)
-Mental status changes or loss of
consciousness (particularly
if associated with one of the above
symptoms)
-Very severe headache (with
hemorrhagic)
*A stroke in the left hemisphere
produces symptoms on the right side of
the body; in the right hemisphere,
symptoms on the left side
Diagnostics
-CT scan discloses structural
abnormalities, edema, and lesions,
such as no hemorrhagic infarction and
aneurysms
-MRI is used to identify areas of
ischemia, infarction and cerebral
swelling
-DSA is used to evaluate patency of the
cerebral vessels and shows evidence of
occlusion of the cerebral vessels, a
lesion or Vascular abnormalities
-Cerebral angiography shows details of
disruption or displacement of the
cerebral circulation by occlusion
or hemorrhage
-Carotid Duplex scan is a high
frequency ultrasound that shows blood
flow through the carotid arteries and
reveals stenosis duet atherosclerotic
plaque and blood clots
-Tran’s cranial Doppler studies are
used to evaluate the velocity of blood
flow through major intracranial vessels,
which can indicate vessel diameter
-Brain scan shows ischemic areas but
may not be conclusive for up to 2
weeks after stroke
-Single photon emission CT scanning
and PET scan show areas of altered
metabolism surrounding lesions that
aren’t revealed bother diagnostic tests
-Lumbar puncture reveals bloody CSF
when stroke is hemorrhagic
-EEG is used to identify damaged
areas of the brain and to differentiate
seizure activity from stroke
-A blood glucose test shows whether
the patient’s symptoms are related to
hypoglycemia
-Hemoglobin and hematocrit level may
be elevated in severe occlusion
-Baseline CBC, platelet count, PTT, PT,
fibrinogen level and chemistry panel are
obtained before thrombolytic therapy
Nursing Diagnoses
-Ineffective Tissue Perfusion related to
decreased cerebral blood flow
-Risk for Prolonged Bleeding related to
use of thrombolytic agents
-Increased Risk for Aspiration related to
depressed gag reflex, Impaired
swallowing
-Impaired Physical Mobility related to
loss of muscle
toneNursingManagement
-Encourage active range of motion on
unaffected side and passive range of
motion on the affected side
-Turn client every 2 hours
-Monitor lower extremities for
thrombophlebitis
-Encourage use of unaffected arm for
ADLs
-Teach client to put clothing on affected
side first
-Resume diet orally only after
successfully completing swallowing
evaluation
-Collaborate with occupational and
physical therapists
-Try alternate methods of
communication with aphasia patients
Accept client’s frustration and anger as normal to loss of function
-Teach client with homonymous hemianopia to overcome the
deficit by turning the head side to side to be able to fully scan the
visual fieldPharmacologicTherapy
-Thrombolytic for emergency treatment of ischemic stroke
-Aspirin or Ticlopidine (Tic lid) as an antiplatelet agent to prevent
recurrent stroke
-Benzodiazepines to treat patients with seizure activity
-Anticonvulsants to treat seizures or to prevent them after the
patient’s condition has stabilized
-Stool softeners to avoid straining, which increase ICP
-Antihypertensive
And antiarrhythmic to treat patients with risk factors for
recurrent stroke
-Corticosteroids to minimize associated cerebral edema
-Hyperosmolar solutions (Manito) or diuretics are given to clients
with cerebral edema
-Analgesics to relieve the headaches that may follow
hemorrhagic stroke Surgical Intervention
-Craniotomy to remove hematoma
-Carotid endarterectomy to remove atherosclerotic plaques from
the inner arterial wall
-Extra cranial bypass to circumvent an artery that’s blocked by
occlusion or stenosis Client Education
-Educate client and family about CVA and CVA prevention
-Educate client and family about community resources
-Educate client and family about physical care and need
for psychosocial support
-Educate client and family about medication Increased
Intracranial Pressure
Description- prolonged pressure grea
ter than 15mmHg or 180mmH2O measu
r e d i n the lateral ventricles
Etiology
-Cerebral Edema is an increase in volume of brain tissue due to
alterations in capillary permeability, changes in functional or the
structural integrity of the cell membrane or an increase in the
interstitial fluids
-Hydrocephalus is an increase in the volume of CSF within the
ventricular system; it may be no communicating hydrocephalus
where the drainage from the ventricular system is impaired
Pathophysiology
-Blood flow exerts pressure against a weak arterial wall,
stretching it like an overblown balloon and making it to rupture;
rupture is followed by a subarachnoid hemorrhage, in which
blood spills into space normally occupied by CSF. Sometimes,
blood spills into brain tissue, where a clot can cause potentially
fatal increased ICP and brain tissue.
Clinicalmanifestations
-Blurring of vision, decreased visual acuity and diplopia are the
earliest signs of increased ICP
-Headache, papilledema or the swelling of optic disk
and vomiting
-Change of LOCDiagnostics
-Skull radiography
-CT scan
-MRI
* Lumbar puncture is not performed because of brain herniation
caused by sudden release of pressure*Laboratory tests are
performed to augment and monitor treatment approaches;
serum osmolality monitors hydration status and ABGsmeasure
pH, oxygen and carbon dioxide
Nursing Diagnoses
-Ineffective Cerebral Tissue Perfusion related to Increased ICP
-Risk for Infection
-Impaired Physical Mobility
-Risk for Ineffective Airway Clearance
NursingManagement
- Assess neurological status every 1 to 2 hours and report any
deterioration; include LOC, behavior, motor/sensory function,
pupil size and response, vital signs with temperature
-Maintain airway; elevate head of 30 degree or keep flat as
prescribed; maintain head and neck in neutral position to
promote venous drainage
-Assess for bladder distention and bowel constipation; assist
client when necessary to prevent Val Sava maneuver
-Plan nursing care so it is not clustered because prolonged
activity may increase ICP; provide quiet environment and limit
noxious stimuli; limit stimulants such as radio, TV and
newspaper; avoid ingesting stimulants such as coffee, tea, cola
drinks and cigarette smoke
-Maintain fluid restriction as prescribed
-Keep dressings over catheter dry and change dressings as
prescribed; monitor insertion site for CSF leakage or infection;
monitor clients for signs and symptoms of infection; use aseptic
technique when in contact with ICP monitor
Pharmacologic therapy
-Osmotic diuretics such as Manito and loop diuretics such as
Furosemide (Lasix) are mainstays used to decrease ICP
-Corticosteroids are effective in decreasing ICP especially
withtumorsSurgical Intervention
-A drainage catheter, inserted via ventriculostomy into lateral
ventricle, can be done to monitor ICP and to drain CSF to
maintain normal pressure; if used the system is calibrated with
transducer is leveled 1 inch above the ear; sterile is of utmost

Importance Client Education

-Teach the client at risk for increased ICP to avoid coughing,
blowing the nose, straining for bowel movements, pushing
against the bed side rails, or performing isometric exercises
-Advice the client to maintain neutral head and neck alignment
-Encourage the family to maintain quiet environment and
minimize stimuli
-Educate the family that upsetting the client may increase ICP
METABOLIC EMERGENCIES DKA

Description
-Life threatening metabolic acidosis resulting from persistent
hyperglycemia and breakdown of fats into glucose, leading to
presence of ketones in blood; can be triggered by emotional
stress, uncompensated exercise, infection, trauma, or
insufficient or delayed insulin administration
Etiology
-Decreased or missed dose of insulin
-Illness or infection
-Undiagnosed and untreated diabetes Pathophysiology
-In the absence of endogenous insulin, the body breaks down
fats for energy. In the process, fatty acids develop too rapidly
and are converted to ketones, resulting to severe metabolic
acidosis. As acidosis worsens, blood glucose levels increase
and hyperkalemia worsens. The cycle continues until coma and
death occur.
Clinical manifestations
- Acetone breath
- Poor appetite or anorexia
- Nausea and vomiting
- Abdominal pain
- Blurred vision
- Weakness
- Headache
- Dehydration
- Thirst or polydipsia
- Orthostatic hypotension
- Hyperventilation (Kussmaul respirations)
- Mental status changes in DKA vary from patient to patient
- weight loss
- Muscle wasting- leg cramps- recurrent infections
Diagnostics
-Serum glucose is elevated (200 to 800 mg/dl)
-Serum Ketone Level is increased
-Urine acetone test is positive
-Arterial Blood Gas analysis reveals metabolic acidosis
-ECG findings shows tall tented T waves and widened
QRScomplex changes related to hyperkalemia; later with
hypokalemia, shows flattened T wave and the presence of
Wave
-Serum osmolality is elevated
Nursing Diagnoses
-Deficient Fluid Volume
-Risk for Injury
-Risk for Skin Impaired Integrity
-Ineffective Breathing Pattern
-Disturbed Sensory Perception
-Knowledge Deficit
-Anxiety
Nursing Management
-Restore fluid, electrolyte and glucose balance with IV infusions
and medications, analyze intake and out, blood glucose, urine
ketones, vital signs, oxygenation and breathing pattern
-Maintain skin integrity; promote healing of impaired skin;
prevent infection by turning and positioning client every 2 hours;
provide pressure relief as indicated; manage incontinence and
perspiration with skin protective barriers and cleansing; provide
appropriate nutrition and oxygen support
-Promote safety by analyzing vital signs, client communication,
LOC and emotional response, and activity tolerance; implement
falls prevention measures
-Assist client to verbalize concerns and cope effectively with
illness and fears
-Assist client to update Medic-Alert bracelet information
asappropriatePharmacotherapy
-Administer IV Insulin and fluid and electrolyte replacements
based on laboratory test results Client
Education
-Instruct client about the nature and causes of DKA (such as
excess glucose intake, insufficient medications or physiological
and/or psychological stressors) any new medications.
HYPEROSMOLAR HYPERGLYCEMIC NONKETOTIC

COMA
Description
-Life threatening metabolic disorder of hyperglycemia usually
recurring with DM types 2 medications, infections, acute illness,
invasive procedure, or a chronic illness
Etiology
-Medications
-Infections
-Acute illness
-Invasive procedure
-Chronic illness
Pathophysiology
-glucose production and release into the blood is increased
or glucose uptake by the cells is decreased; when the cells don’t
receive glucose, the liver responds by converting glycogen to
glucose for release into the bloodstream; when all excess
glucose molecules remain in the serum, osmosis cause fluid
shifts.; the cycle continues until fluid shifts in the brain cause
coma and death.
-Severe dehydration
-Hypotension and tachycardia
-Diaphoresis
-Tachypnea
-Polyuria, polydipsia and polyphagia
-Lethargy and fatigue
-Vision changes
-Rapid onset of lethargy
-Stupor and coma
-Neurologic changes
Diagnostics
-Serum glucose is elevated, sometimes 800 to 2,000 mg/dl
-Ketones are absent, urine and serum ketones are absent
-Urine glucose levels are positive
-Serum osmolality is increased
-Serum Sodium levels are elevated and the serum potassium
level is usually normal
-ABG results are usually normal, without evidence of acidosis
Nursing Diagnoses
-Decreased Cardiac Output
-Hyperthermia
-Disturbed Sensory Perception
-Risk for Impaired Skin Integrity
-Risk for Aspiration
-Deficient Knowledge
Nursing Management
-Assess the patient’s LOC, respiratory status and oxygenation
-Monitor the patient’s VS; changes may reflect the patient’s
hydration status
-Monitor patient’s blood glucose and serum electrolytes
-Administer regular insulin IV as ordered, by continuous infusion
and titrate dosage based on the patient’s blood glucose levels
-Maintain intact skin integrity by turning every 2 hours, use
of pressure relief aids, nutritional support, use of skin
moisturizers and barriers, and management of incontinence
-Prevent aspiration by using appropriate feeding precautions,
elevate head of bed 15 to 30 degrees during and after feeding
for 1 hour; if BP is too unstable to elevate head of bed with
feeding, then withhold oral feedings.
Pharmacotherapy
-IV infusion of NS to replace fluids and sodium, regular insulin
Ivo manage the hyperglycemia, and potassium to replace losses
and shifts
Client Education
-Instruct client and family about HHNK, symptoms to report, and
administration of new medications
-Provide patient and family education to foster prevention
of future episodes.
Massive Bleeding
Description
-Uncontrolled bleeding
Etiology
-Result of blunt or penetrating trauma
-Gastrointestinal or genitourinary bleeding
-Hemoptysis
Pathophysiology
-Due to the lack of adequate circulating blood volume causing
creased tissue perfusion and metabolism resulting in hypoxia,
vasoconstriction and shunting of the available circulating blood
volume to the vital organs(heart and brain);
Symphatheticnervous system stimulation, hormonal release of
antidiuretic hormone and the angiotensin-renin mechanisms and
neural responses attempt to compensate for the loss of
circulating volume but eventually metabolic acidosis, multi organ
system failure occurs.
Clinical lManifestations
-Cool, clammy, pale skin (esp. distal extremities)
-Delayed capillary refill (>3 seconds)
-Weak, rapid pulses
-Decreased blood pressure (systolic pressure <90mmHg)
-Rapid shallow respirations (>28/ min)
-Restless, anxious, decreased LOC
-Cardiac dysrhythmias (abnormalities of cardiac rhythm)
-Decreased urinary output
Diagnostics
-Evidence of bleeding from thoracotomy that indicates bleeding
from chest area
-Abdominal or pelvic CT scan, abdominal ultrasound or
peritoneal lavage indicate intra-abdominal bleeding
-Endoscopy indicates upper or lower GI bleeding
-Angiography procedures diagnose severe vascular damage
-Extremity radiographs show long bone fractures
-Hemoglobin and hematocrit from the CBC are decreased due
to blood loss
-Elevated serum lactate if bleeding continues and client
becomes acidotic
-ABGs show metabolic acidosis as blood loss continues
-Baseline coagulation studies should be reviewed; initial
PT/Stand platelet counts will be within normal limits but as
coagulation factors become depleted, clotting times will increase
and platelet counts will decrease
-Serum electrolytes to assess renal function
Nursing Diagnoses
-Impaired Tissue Perfusion
-Deficient Fluid volume
-Decreased cardiac Output
Nursing Management
-Establish an adequate airway, breathing pattern, and applying
supplemental oxygen
-Give priority interventions to control bleeding such as direct
pressure to wound site, or assisting with surgical interventions
-Establish IV access and begin with fluid replacement
-Draw blood specimens as ordered to assist in evaluation
of hemoglobin, hematocrit, electrolyte, and oxygenation
andhydrationstatus
-Insert an indwelling catheter and NG tube to assist in accurate
recording of fluid balance status
-Perform and document continuous serial assessments
of hemodynamic parameters such as VS, capillary refill, CVP,
cardiac rhythm, LOC, urinary output and laboratory findings
Pharmacotherapy
-Crystalloids and blood products to maintain adequate
circulating volume status
-Sodium Bicarbonate to correct acidosis state
-Vasopressor such as Dopamine
Client Education
-Explain procedures to the client
-Support the family by explaining emergency measures
BURNS
Description
-An alteration in skin integrity resulting in tissue loss or injury
caused by heat, chemicals, electricity or radiation
E t i o l o g y
T y p e s o f b u r n
i n j u r y
a.Thermal: results from dry heat (flames) or moist
heat (steam or hot liquids); it is the most common type; it
causes cellular destruction that results in vascular, bony,
muscle, or nerve complications; thermal burns can also lead to
inhalation injury if the head and neck area is affected
b.Chemical burns are caused by direct contact with

either acidic or alkaline agents; they alter tissue perfusion
leading to necrosis
C.Electrical burns; severity depends on type and duration

of current and amount of voltage; it follows the path of least
resistance (muscles, bone, blood vessels and nerves); sources
of electrical injury include direct current, alternating current
andlightning
d.Radiation burns: are usually associated with

sunburn or radiation treatment for cancer; are usually
superficial; extensive exposure to radiation may lead to tissue
damage
Pathophysiology
-It depends on the cause and classification of the burn; the
injuring agents denatures cellular proteins; some cells die
because of traumatic or ischemic necrosis; loss of collagen
cross-linking also occurs with denaturation, creating abnormal
osmotic and hydrostatic pressure gradients that cause
intravascular fluid to move into interstitial spaces; Cellular
injury triggers the release of mediators of inflammation,
contributing to local and in the case of major burns , systemic
increases in capillary permeability.
-Localized pain and erythema, usually without blisters in the
first24 hours (first degree burn)
-Chills, headache, localized edema, nausea and vomiting (most
severe first degree burn)
-Thin-walled, fluid filled blisters appearing within minutes of the
injury, with mild to moderate edema and pain (second degree
superficial partial thickness burn)
-White, waxy appearance to damaged area (second degree
partial-thickness burn)
-White, brown or black leathery tissue and visible
thrombosedvessels due to destruction of skin elasticity (dorsum
of hand, most common site of thrombosis veins), without blisters
(third-degree burn)
-Silver-colored, raised or charred area, usually at the site
of electrical contact
D i a g n o s t i c s *
Rule of Nines chart determines the percentage of body surface
area (BSA) covered by the burn
-ABG levels may be normal in the early stages but may reveal
hypoxemia and metabolic acidosis
-Carboxyhemoglobin level may reveal the extent of smoke
inhalation due to the presence of carbon monoxide
-Complete blood count may reveal decrease hemoglobin due
O hemolysis, increased hematocrit and leukocytosis
-Electrolyte levels show hypernatremia and hyperkalemia,
other laboratory tests reveals elevated BUN, decreased total
protein and albumin
-Keratinize kinase (CK) and myoglobin levels may be elevated
-Presence of myoglobin in urine may lead to acute
tubular necrosis
Nursing Diagnoses
-Risk for Deficient Fluid Volume

-Risk for Infection
-Impaired Physical Mobility
-Imbalanced Nutrition: Less than Body Requirements
-Risk for Impaired Gas Exchange
-Anxiety
-Risk for Ineffective Thermoregulation
-Pain
-Impaired Skin Integrity
Nursing Management
-Assess patient’s ABCs; monitor arterial oxygen saturation and
serial ABG values and anticipate the need for ET intubation and
mechanical ventilation
-Auscultate breath sounds
-Administered supplemental humidified oxygen as ordered
-Perform or pharyngeal or tracheal suctioning as indicated by
the patient’s inability to clear his airway
-Monitor the patient’s cardiac and respiratory status
-Assess LOC for changes such as confusion, restlessness
or decreased responsiveness
-solution for chemical burns
-Place the patient in semi-Fowler’s position to maximize chest
expansion; keep patient as quiet and comfortable to minimize
oxygen demand
-Prepare the patient for an emergency escharotomy of the chest
and neck for deep burns
-Administer rapid fluid replacement therapy as ordered
*For burn patient in shock -
-Monitor VS and hemodynamic parameters

-Assess patient’s intake and output every hour, insert an
indwelling catheter
-Assess the patient’s level of pain, including nonverbal indicators
and administer analgesics such as Morphine Sulfate IV as
ordered
-Keep the patient calm, provide periods of uninterrupted rest
between procedures and use no pharmacologic pain
relief measures as appropriate
-Obtain daily weights and monitor intake, including daily calorie
counts; provide high calorie, high protein diet
-Administer histamine 2 receptor antagonists as ordered to
reduce risk of ulcer formation
-Assess the patient’s sign and symptoms of infection; may
obtain wound culture and administer antimicrobials antipyretics
as ordered
-Administer tetanus prophylaxis if indicated
-Perform burn wound care as ordered; prepare patient
for grafting as indicated
-Assess the neurovascular status of the injured area, including
pulses, reflexes, parenthesis, color and temperature of the
injured area at least 2 to 4 hours or more frequently as indicated
-Assist with splinting, positioning, compression therapy and
exercise to the burned area as indicated; maintain the burned
area in a neutral position to prevent contractures and minimize
deformity
-Explain all procedures to the patient before performing them
Pharmacotherapy
-Antibiotic prophylaxis will eradicate bacterial component
-Pain therapy
-Tetanus prophylaxis
-Topical antimicrobial
-Enzymatic debriding agents such as collagenase, fibrinolysin-
desoxyribonuclease, pain or sustains are used with a moisture
barrier to protect surrounding tissue
-Recommended dressings include polyurethane films (Op-site,
Tegaderm), absorbent hydrocolloid dressings (Dodder)
Client Education
-Environmental safety: use low temperature setting for hot
water heater, ensure access to and adequate number of
electrical cords/outlets, isolate household chemicals, and avoid
smoking imbed
-Use of household smoke detectors with emphasis on
maintenance
-Proper storage and use of flammable substances-
Evacuation plan for family
-Care of burn at home
-Signs and symptoms of infection
-How to identify risk of skin changes
-Use of sunscreen to protect healing tissue and other protective
skin care
Poisoning
Description
-Substances that are harmful to humans that are inhaled,
ingested (food, drug overdose) or acquired by contact
Etiology
-Carbon monoxide inhalation
-Food poisoning
-Drug overdose
-Insecticide surface absorption
Pathophysiology
-The pathophysiology of poisons depends on the substance
that’s inhaled or ingested. The extent of damage depends on the
of the substance, the amount ingested, its form and the length of
exposure to it. Substances with an alkaline pH cause tissue
damage by liquefaction necrosis, which softens the tissue. Acids
produce coagulation necrosis. Coagulation necrosis denatures
proteins when substance contacts tissue. This limits the extent
of the injury by preventing penetration of the acid into the tissue.
-*The mechanism of action for inhalants is unknown, but they’re
believed to act on the CNS similarly to a very potent anesthetic.
Hydrocarbons sensitize the myocardial tissue and allow it to be
sensitize to catecholamine’s, resulting in arrhythmias.
a.Carbon monoxide inhalation: mild exposure –
nausea, vomiting, mild throbbing headache, flu-like symptoms;
moderate exposure – dyspnea, dizziness, confusion, increased
severity of mild symptoms; severe/prolonged exposure –
seizures, coma,respiraotory arrest, hypotension and
dysrhythmias
B.Food poisonings: nausea, vomiting, diarrhea, abdominal
cramps, fever , chills, dehydration, headache
c.Drug overdose: depends upon the substance
ingested; symptoms may include nausea, vomiting, CNS
depression or agitation, altered pupil response, respiratory
changes such as tachypnea or bradypnea, alterations in
temperature control, seizures or cardiac arrest
D.Surface absorption of insecticides (organophosphates

or carbonates): nausea, vomiting, diarrhea, headache,
dizziness, weakness or tremors, mild to severe respiratory
distress, slurred speech, seizures, and cardio-pulmonary arrest
D i a g n o s t i c s *
The diagnosis of many poisonings is based on a thorough
client history and clinical manifestations
laboratory toxicology screens (serum,vomitus, stool and urine)d
etermine the extent of the absorption
baseline blood work such as CBC, electrolytes, renal and
hepatic studies enable future determination of organ and tissue
damage
Chest Xray may show aspiration pneumonia in inhalation
poisoning
-Abdominal X-rays may reveal iron pills or other radiopaque
substances
-ABG analysis used to evaluate oxygenation Nursing Diagnoses
-Risk for Ineffective Airway Clearance
-Risk for Decreased Cardiac Output
-Risk for Injury
-Anxiety
-Risk for Self-directed Violence
-Hopelessness
Nursing Management
-Assist with the management of an effective airway, breathing
pattern and circulatory status
-Give treatment of life-threatening dysrhythmias and conditions
as ordered; continual monitoring of vital signs, cardiac rhythm
and neurological status and supportive care is essential
-Assist in the hastening in the elimination of the medication
or poison, decrease the amount of absorption and
administer antidotes as ordered
-for specific treatment contact the poison center
Pharmacotherapy
*antidotes will vary with medication

i n g e s t e d - Ipecac syrup 30ml PO followed by 240ml water
is used for adults- Activated charcoal powder slurry
30 to 100g PO or per NG tube
- Magnesium Citrate will be used for GI evacuation
Naloxone (Narcan) for respiratory depression caused by narcot
icoverdose
-Flumazenil (Romazicon) for benzodiazepine ingestions
Client Education
-Assist the client and family in seeking the appropriate referrals
and provide client education to further complications
or incidence of overdose
-Ensure that the client and family understand discharge
instruction for follow up care or reason for admission.
Multiple Injuries
Description
-Is a physical injury or wound that’s inflicted by an external
or violent act; it may be intentional or unintentional; involve
injuries to more than one body area or organ
Etiology
-Weapons
-Automobile collision
-Physical confrontation
-Falls
-Unnatural occurrence to the body
*Type of trauma which determines the extent of injury
-Blunt trauma – leaves the body intact
-Penetrating trauma – disrupts the body surface
-Perforating trauma – leaves entrance and exit Pathophysiology
-A physical injury can create tissue damage caused by stress
and strain on surrounding tissue which results to infection, pain,
swelling and potential compartment syndrome or it can be life-
threatening if it affects a highly vascular or vital organ
Diagnostics
-Chest X-ray – detect rib and sterna fractures, pneumothorax,
flail chest, pulmonary contusion and lacerated or ruptured aorta
-Angiography studies – performed with suspected aortic
laceration or rupture
-Ct scan, cervical spine X-rays, skull X-rays, Angiogram – test
for a patient with head trauma
-ABG analysis to evaluate respiratory status and determine
acidotic and alkaloid states
-CBC to indicate the amount of blood loss
-Coagulation studies to evaluate clotting ability
-Serum electrolyte levels to indicate the presence of
electrolyteimbalances
Nursing Diagnoses
-Ineffective Airway Clearance
-Impaired Gas Exchange
-Decreased Cardiac Output
-Impaired Skin Integrity
-Risk for infection
-Anxiety
-Pain
-Disturbed Body Image
Nursing Management
-Assess the patient’s ABCs and initiate emergency measures

-Administer supplemental oxygen as ordered
-Immobilize the patient’s head and neck with an immobilization
device, sandbags, backboard and tape
-Assist with cervical X-rays
-Monitor VS and note significant changes
-Immobilize fractures
-Monitor the patient’s oxygen saturation and cardiac rhythm
for arrhythmias
-Assess the patient’s neurologic status, including LOC and
papillary and motor response
-Obtain blood studies, including type and crosshatch
-Insert large bore IV catheter and infuse normal saline or
lactated Ringer’s solution
-Assess the patient for multiple injuries
-Assess the patient’s wounds and provide wound care as
appropriate; cover open wounds and control bleeding by
applying pressure and elevating extremities
-Assess for increased abdominal distention and increased
diameter of extremities
-Administer blood products as appropriate
-Monitor the patient for signs of hypovolemic shock
-Provide pain medication as appropriate
-Provide reassurance to the patient and his family
Pharmacotherapy
-Tetanus immunization
-Antibiotics for infection control
-Analgesics for pain Client Education
-Provide explanations of all procedures done
-Families usually require emotional support and honest
discussions about therapeutic interventions and plans

-Assist with cervical X-rays

-Monitor VS and note significant changes
-Immobilize fractures
-Monitor the patient’s oxygen saturation and
cardiac rhythm for arrhythmias
-Assess the patient’s neurologic status,
including LOC and papillary and motor
response
-Obtain blood studies, including type and
crosshatch
-Insert large bore IV catheter and infuse
normal saline or lactated Ringer’s solution
-Assess the patient for multiple injuries
-Assess the patient’s wounds and provide
wound care as appropriate; cover open
wounds and control bleeding by applying
pressure and elevating extremities
-Assess for increased abdominal distention
and increased diameter of extremities
-Administer blood products as appropriate
-Monitor the patient for signs of hypovolemic
shock
-Provide pain medication as appropriate
-Provide reassurance to the patient and his
family
- Pharmacotherapy
Tetanus immunization
-Antibiotics for infection control
-Analgesics for pain Client Education
-Provide explanations of all procedures done
-Families usually require emotional support
and honest discussions about therapeutic
interventions and plans
2. Assessment
: A systematic procedure for collecting
qualitative and quantitative data to describe
progress and ascertain deviations from
expected outcomes and achievements.
3. Attributes: Characteristics that underpin
competent performance.
4. Benchmark: Essential standard
5. Client: An individual, family, group or
community that is a consumer of nursing
service.
6. Competence: The combination of skills,
knowledge, attitudes, values and abilities that
underpin effective performance as a nurse.
7. Competent: The person has competence
across all domains of competencies applicable
tithe registered nurse, at a standard that is
judged to appropriate for the level of nurse
beingassessed.
8. Competency: A defined area of skilled
performance.
9. Context: The setting/environment where
competence can be demonstrated or applied.
10. Domain: An organized cluster of
competencies in nursing practice.
11. Effective: Having the intended outcome.
12. Enrolled nurse: A nurse registered under
the enrolled nurse scope of practice.
13. Indicator: Key generic examples of
competent performance. They are
neither comprehensive nor exhaustive.
They assist the assessor when using their
professional judgment in assessing nursing
practice. They further assist curriculum
development.
14. Performance criteria: Descriptive
statements that can be assessed and that
reflect the intent of a competency in terms of
performance, behavior and circumstance.
15. Registered nurse: A nurse registered under
the registered nurse scope of practice
16. Reliability: The extent to which a tool will
function consistently in the same way with
repeated use.
17. Validity: The extent to which a
measurement tool measures what it purports
to measure.
Pre – Test CLINICAL COMPETENCE
DIRECTION: Circle the one best answer for

each test question. Write your rationale
for selecting the answer. To enhance your
learning and test taking skill, discuss
your answer and rationale with a partner.
A: Physical Examination 5 pts. Each (15 items)
1.The nurse is using a digital thermometer
to take an oral temperature. After taking the
oral temperature, the nurse obtains a reading
of 94.2 degree F. Which of the follow-up
actions is most appropriate for the nurse to do?
A.used another digital thermometer to
retake the temperature
b.Feel the client’s skin temperature
c.Takea rectal temperature
d.Document the findings Rationale for
your selection:
_____________________________________
_______________________ _____________
_____________________________________
______
2.The nurse obtains an axillary temperature
of 97.4 degree F on a client. In graphing the
temperature, it is most appropriate for the
nurse to:
a.Write “see nurse’s notes” above the
temperature reading
b.Identify the temperature
reading with an “Ax”
c.Graph the oral equivalent temperature
of 98.4 degree
d. Adjust graph 97.4 degree F on
the form. Rationale for
your selection:_________________________
_____________________________________
_ __________________________________
________________________
3.The nurse is caring for a client who has
an oral temperature of 99.6 degree F
at8:00AM, the start of the day shift. The client’s
RAND indicates that the vital signs should be
taken once a shift. In planning care for the
client, which action is most appropriate?
a.Ensure that the temperature is taken
promptly at 4:00PM
b.Call the doctor for a more frequent
order.
c.Take the temperature as necessary
d.Begin cooling measures Rationale for
your selection__________________________
__________________________________ _
_________________
KEY ANSWER: 1.The nurse is using

a digital thermometer to take an oral
temperature. After taking the oral
temperature, the nurse obtains a reading of
94.2 degree F. Which of the follow-up actions
is most appropriate for the nurse to do?
Abused another digital thermometer to
retake the temperatureb.Feel the
client’s skin temperaturec.Take
a rectal temperatured.Document
The findings Rationale: A is the answer.
Since the nurse is using a digital thermometer,
it is important for the nurse to ensure that the
equipment is functioning. The temperature
recording should be low and should be taken
again. Option B & C are not appropriate: option
D should be done after verifying
the temperature.2.The nurse obtains an
axillary temperature of 97.4 degree F on a
client. In graphing the temperature, it is most
appropriate for the nurse to:a.Write “see
nurse’s notes” above the temperature
readingb.Identify the temperature
reading with an “Ax”c.Graph the oral
equivalent temperature of 98.4 degree
Adjust graph 97.4 degree F on
the formRationale:B is the answer. It is
important for the nurse to identify the
appropriate information on where the
temperature was taken. Option A, C, & D do
not accurately document the temperature
information.3.The nurse is caring for a
client who has an oral temperature of
99.6 degree F at8:00ARE, the start of the day
shift. The client’s RAND indicates that the vital
signssould be taken once a shift. In planning
care for the client, which action is most
appropriate? A.Ensure that the
temperature is taken promptly at
4:00PMb.Call the doctor for a more
frequent order.c.Take the temperature
as necessaryd.Begin cooling
measures Rationale: C is the answer. The
nurse can make an independent decision to
take the temperature more frequently to ensure
safe nursing care. Option A does not allow
for through ongoing assessment. Option B & D
are not necessary at this time.
Lesson A.
1CORE COMPETENCIES
“Tell me, I might forget; teach me and
I might remember; involve me and I learn!”-
Benjamin Franklin
Definition:

A competency appraisal is a process in which
an individual is assessed for his or
her competence in a particular area of
employment. The main objective of the
competency appraisal is to ascertain whether
an employee is able to carry out his or her
duties in a professional role. A typical scenario
would involve an employee — the person
being assessed for competence — and one or
more of his or her seniors. It normally
Would take place in a private location, such as
an unused office. The duration of a
competency appraisal depends on the nature
of the appraisal; the actual meeting between
the senior professional and the employee
typically lasts one to two hours.
Legal Basis:
Article 3 Sec.9 (c) of R.A. 9173/ “Philippine
Nursing Act 2002"Board shall monitor &
enforce quality standards of nursing practice
necessary to ensure the maintenance of
efficient, ethical and technical, moral and
professional standards in the practice of
nursing taking into account the health needs of
the nation.
SIGNIFICANCE OF CORE COMPETENCY
STANDARDS
There are certain professions in which a
competency appraisal is of critical importance,
such as medical professions in which
human safety is an essential priority. If patients
are exposed to incompetent medical
practitioners, this could be a potential threat to
the patient's health and safety. In developed
nations, competency appraisal in the medical
professional is highly prevalent as it is
considered to be absolutely necessary;
medical practitioners, particularly in their first
years of practice, are monitored closely by
senior medical professionals.
•Unifying framework for nursing practice,
education, regulation
•Guide in nursing curriculum development
•Framework in developing test syllabus for
nursing profession entrants
•Tool for nurses’ performance evaluation
•Basis for advanced nursing practice,
specialization
•Framework for developing nursing training
curriculum
•Public protection from incompetent
practitioners
•Yardstick for unethical, unprofessional nursing
practice
Phases of developing competency
standards
○ 1st Phase Competency identification through
Developing a Curriculum (DACUM)

Workshop and series of focus group
discussions with the participation of nurse
experts

And consumers of nursing practice such as
administrators, doctors and clients○ 2nd Phase
Verification of identified competencies

among nursing experts from the different
regions of the country○ 3rd Phase Pilot testing
( senior student in 8 nursing colleges)○ 4th
Phase Benchmarking with exiting standards
from 3 countries as well as International
Council for Nurses (ICN)
FOUR DOMAINS OF COMPETENCIES
There are four domains of competence for the
registered nurse scope of practice. Evidence
of safety to practice as a registered nurse is
demonstrated when the applicant meets the
competencies within the following domains:
Domain one: Professional responsibility This
domain contains competencies that relate to
professional, legal and ethical responsibilities
and cultural safety. These include being able to
demonstrate knowledge and judgment and
being accountable for own actions and
decisions, while promoting an environment that
maximizes clients’ safety, independence,
quality of life and health. Domain two:
Management of nursing care This domain
contains competencies related to client
assessment and managing client care, which
is responsive to clients’ needs, and which is
supported by nursing knowledge and evidence
based research. Domain three: Interpersonal
relationships this domain contains
competencies related to interpersonal and
therapeutic communication with clients, other
nursing staff and inter professional
communication and documentation. Domain
four: Inter professional health care & quality
improvement this domain contains
competencies to demonstrate that, as a
member of the health care team, the nurse
evaluates the effectiveness of care and of the
team.
Competencies and Indicators
•
The competencies in each domain have a
number of key generic examples
of competence performance called indicators.
•
These are neither comprehensive nor
exhaustive; rather they provide examples
of evidence of competence.
The indicators are designed to assist the

assessor when using his/her
professional judgment in assessing the
attainment of the competencies.
•
The indicators further assist curriculum
development for bachelors’ degrees in nursing
or first year of practice
programmes.Registered nurses are required to
demonstrate competence. They are
accountable for their actions and take
responsibility for the direction of nurse
assistants, enrolled nurses and others. The
competencies have been designed to be
applied to registered nurse practice in a variety
of clinical contexts. They take into account the
contemporary role of the registered nurse, who
utilizes nursing knowledge and complex
nursing judgment to assess health needs,
provide care, and advice and support people to
manage their health. The registered nurse
practices independently and in collaboration
with other health professionals. The registered
nurse performs general nursing functions, and
delegates to, and directs enrolled nurses and
nurse assistants. The registered nurse also
provides comprehensive nursing assessments
to develop, implement, and evaluate an
integrated plan of health care, and provides
nursing interventions that require substantial
scientific and professional knowledge and
skills. This occurs in a range of settings in
partnership with individuals, families, and
communities. Nursing students are supervised
in practice by a registered nurse. Nursing
students are assessed against all
competencies on an ongoing basis, and will be
assessed for entry to the registered nurse
scope of practice at the completion of their
program. Nurses involved in management,
education, policy and research The
competencies also reflect the scope statement
that some registered nurses use their nursing
expertise to manage, teach, evaluate and
research nursing practice. Registered nurses,
who are not practicing in direct client care, are
exempt from those competencies in domain
two(management of nursing care) and domain
three (interpersonal relationships) that only
apply to clinical practice. There are specific
competencies in these domains for nurses
working in management, education, policy
and/or research. These are included at the end
of domains two and three. Nurses who are
assessed against these specific competencies
are required to demonstrate how they
contribute to practice. Those practicing in direct
client care and in management, education,
policy and/or research must meet both sets of
competencies.
Concepts and Definitions of 11 Key areas
of Responsibility
. SAFE AND QUALITY NURSING CARE
CORE COMPETENCY 1:Demonstrate
knowledge based on health/illness status of
individual/ groups Indicators :○ Identifies health
needs of patients/groups○ Explains
patient/group status CORE COMPETENCY
2:Provides sound decision making in care of
individual/groups considering their beliefs,
values Indicators :○ Problem identification○
Data gathering related to problem○ Data
analysis○ Selection appropriate action○
Monitor progress of action taken
CORE COMPETENCY 3:Promotes patient

safety and comfort Indicators :○ Performs age-
specific safety measures and comfort measure
in all aspects of patient care CORE
COMPETENCY 4:Priority setting in nursing
care based on patients’ needs Indicators :○
Identifies priority needs of patients○ Analysis of
patients’ needs○ Determine appropriate
nursing care to be provided CORE
COMPETENCY 5:Ensures continuity of care
Indicators :○ Refers identified problems to
appropriate individuals/ agencies○ Establish
means of providing continuous patient care
CORE COMPETENCY 6:Administers
medications and other health therapeutics
Indicators :○ Conforms to the 10 golden rules
in medication administration and health
therapeutics CORE COMPETENCY 7:Utilizes
nursing process as framework for nursing.
Performs comprehensive, systematic nursing
assessment Indicators :○ Obtains consent○
Complete appropriate assessment forms○
Performs effective assessment techniques○
Obtains comprehensive client information○
Maintains privacy and confidentiality○ Identifies
health needs CORE COMPETENCY
8:Formulates care plan in collaboration with
patients, other health team members Indicators
:○ Includes patients, family in care planning○
States expected outcomes in nursing
interventions○ Develops comprehensive
patient care plan○ Accomplishes patient
centered discharge plan CORE
COMPETENCY 9:Implements NCP to achieve
identified outcomes Indicators :○ Explain
interventions to patient, family before carrying
them out○ Implement safe, comfortable
nursing interventions○ Acts according to
client’s health conditions, needs○ Performs
nursing interventions effectively and in timely
manner CORE COMPETENCY 10:
Implements NCP progress toward expected
outcomes Indicators :○ Monitors effectiveness
of nursing interventions○ Revises care plan
PRNCORE COMPETENCY 11:Responds to
urgency of patient’s condition Indicators :○
Identifies sudden changes in patient’s health
conditions○ Implements immediate,
appropriate interventions
II. MANAGEMENT OF RESOURCES AND
ENVIRONMENT
CORE COMPETENCY 1:Organizes workload
to facilitate patient care Indicators:○ Identifies
task or activities that need to be
accomplished○ Plans the performance of task
or activities based on priority○ Finishes work
assignment on time CORE COMPETENCY
2:Utilizes resources to support patient care
Indicators:○ Determines the resources needed
to deliver patient care○ Control the use of
equipment CORE COMPETENCY 3:Ensures
the functioning of resources Indicators:○ Check
proper functioning of the equipment○ Refers
Malfunctioning equipment to appropriate unit
CORE COMPETENCY 4:Check the Proper
functioning of the Equipment Indicators:○
Determines the task and procedures that can
be safely assigned to the other members of the
team○ Verifies the competence of the staff
prior to delegating tasks CORE
COMPETENCY 5:Maintains safe Environment
Indicators:○ Observe proper disposal of
waste○ Adheres to policies, procedures and
protocols on prevention and control of
infection○ Defines steps to follow incase of
fire , earthquake and other emergency
situation
III. HEALTH EDUCATION
CORE COMPETENCY 1:Assesses the

learning needs of the patient and the family
Indicators:○ Obtains learning information
through interview, observation and validation○
Defines relevant information○ Completes
assessment records appropriately○ Identify
priority needs CORE COMPETENCY
2:Develops Health Education plan based on
assessed and anticipated needs. Indicators:○
Considers nature of the learner in relation to
social, cultural, political, economic, educational,
and religious factor CORE COMPETENCY
3:Develops learning material for health
education Indicators:○ Involves the patient,
family and significant others and other
resources○ Formulates a comprehensive
health educational plan with the following
components ,objectives, content and time
allotment○ Teaching-learning resources and
evaluation parameters○ Provides for feedback
to finalize plan CORE COMPETENCY
4:Implements the health Education Plan
Indicators:○ Provides for conducive learning
situation in terms of timer and place○
Considers client and family preparedness○
Utilize appropriate strategies○ Provides
reassuring presence through active listening,
touch and facial expression and gestures○
Monitors client and family’s responses to
health education CORE COMPETENCY
5:Evaluates the outcome of health Education
Indicators:○ Utilizes evaluation parameters○
Documents outcome of care○ Revises health
education plan when necessary
IV. ETHICO-MORAL RESPONSIBILITY
CORE COMPETENCY 1: Respects the rights
of individual/ groups Indicator: ○ Renders
nursing care consistent with the patient’s bill of
rights (i.e. confidentiality of information,
privacy, etc.)CORE COMPETENCY 2Accepts
responsibility & accountability for own
decisions and actions Indicators:
○ Meets nursing accountability requirements

as embodied in the job description○ Justifies
basis for nursing actions and judgment○
Protects a positive image of the profession
CORE COMPETENCY 3Adheres to the
national and international code of ethics for
nurses Indicators:○ Adheres to the Code of
Ethics for Nurses and abides by its provisions○
Reports unethical and immoral incidents to
proper authorities
V. LEGAL RESPONSIBILITY
CORE COMPETENCY 1:Adheres to practices
in accordance with the nursing law and other
relevant legislation including contract and
informed consent. Indicators:○ Fulfill
legal requirements in Nursing Practice○
Holds current professional license○ Acts in
accordance with the terms of contract of
employment and other rules and regulation○
Complies with the required CPE○ Confirms
information given by the doctor for informed
consent○ Secures waiver of responsibility for
refusal to undergo treatment or procedures○
Check the completeness of informed consent
and other legal forms CORE COMPETENCY
2:Adheres to organizational policies and
procedures, local and national Indicators:○
Articulates the vision and mission of the
institution where one belongs○ Acts in
accordance with the established norms and
conduct of the institution/ organization CORE
COMPETENCY 3:Document care rendered to
patients. Indicators: ○ Utilizes appropriate
patient care records and reports○
Accomplish accurate documentation in all
matters concerning patient care in accordance
with the standard of nursing practice.
VI. PERSONAL & PROFESSIONAL
DEVELOPMENT
CORE COMPETENCY 1Identifies own
learning needs Indicators:○ Verbalizes
strengths, weaknesses, limitations.○
Determines personal and professional goals
and aspirations. CORE COMPETENCY
2Pursues continuing education Indicators: ○
Participates in formal and non-formal
education.○ Applies learned information for the
improvement of care.
CORE COMPETENCY 3Gets involved in

professional organizations and civic activities
Indicators:○ Participates actively
in professional, social, civic and religious
activities○ Maintain membership to
professional organizations○ Support activities
related to nursing and health issues CORE
COMPETENCY 4Projects a professional
image of nurse Indicators:○ Demonstrate good
manners and right conduct at all times.○
Dresses appropriately.○ Demonstrates
congruence of words and actions.○ Behaves
appropriately at all times. CORE
COMPETENCY 5Possesses positive attitude
towards change and criticism Indicators:○
Listens to suggestions and
recommendations.○ Tries new strategies or
approaches.○ Adapts to changes willingly.
CORE COMPETENCY 6Performs function
according to professional standards
Indicators:○ Assesses own performance
against standards of practice.○ Sets attainable
objectives to enhance nursing knowledge and
skills.○ Explains current nursing practices,
when situations call for it.
VII. RESEARCH
CORE COMPETENCY 1:Gathers data using
different methodologiesIndicators:Identifies
researchable problems regarding patient care
and community healthIdentifies appropriate
methods of research for a particular
patient/community problemCombines
quantitative and qualitative nursing design thru
simple explanation on thephenomena
observedAnalyzes data gatheredCORE
COMPETENCY 2:Recommends actions for
implementationIndicator:Based on the analysis
of data gathered, recommends practical
solutions appropriate for theproblemCORE
COMPETENCY 3:Disseminates results of
research findingsIndicators:Communicates
results of findings to colleagues/patients/family
and to others
Endeavors to publish researchSubmits

research findings to own agencies and others
as appropriateCORE COMPETENCY
4:Applies research findings in nursing
practiceIndicators:Utilizes and findings in
research in the provision of nursing care
toindividuals/groups/communitiesMakes use of
evidence-based nursing to ameliorate nursing
practice
VIII. RECORDS MANAGEMENT
CORE COMPETENCY 1:Maintains accurate
and updated documentation of patient
careIndicator:Completes updated
documentation of patient careCORE
COMPETENCY 2:Records outcome of patient
careIndicator:Utilizes a record systemCORE
COMPETENCY 3:Observes legal imperatives
in recording keepingIndicators:Observes
confidentially and privacy of patient’s
recordsMaintains an organized system of filing
and keeping patient’s records in a designated
areaRefrains from releasing records and other
information without proper authority
IX. COMMUNICATION
CORE COMPETENCY 1:Establishes rapport
with patients, significant others and members
of the health team.Indicators:○ Creates trust
and confidence○ Listens attentively to client’s
queries and requests○ Spends time with the
client to facilitate conversation that allows client
to express concern.CORE COMPETENCY
2:Identifies verbal and non-verbal
cuesIndicator:○ Interprets and validates client’s
body language and facial expressionCORE
COMPETENCY 3:Utilizes formal and informal
channelsIndicator:○ Makes use of available
visual aidsCORE COMPETENCY 4:
Meets nursing accountability requirements as

embodied in the job description○ Justifies basis
for nursing actions and judgment○ Protects a
positive image of the professionCORE
COMPETENCY 3Adheres to the national and
international code of ethics for
nursesIndicators:○ Adheres to the Code of
Ethics for Nurses and abides by its provisions○
Reports unethical and immoral incidents to
proper authorities
V. LEGAL RESPONSIBILITY
CORE COMPETENCY 1:Adheres to practices
in accordance with the nursing law and other
relevant legislation includingcontract and
informed consent.Indicators:○ Fulfill
legal requirements in Nursing Practice○
Holds current professional license○ Acts in
accordance with the terms of contract of
employment and other rules and regulation○
Complies with the required CPE○ Confirms
information given by the doctor for informed
consent○ Secures waiver of responsibility for
refusal to undergo treatment or procedures○
Check the completeness of informed consent
and other legal formsCORE COMPETENCY
2:Adheres to organizational policies and
procedures, local and nationalIndicators:○
Articulates the vision and mission of the
institution where one belongs○ Acts in
accordance with the established norms and
conduct of the institution/ organizationCORE
COMPETENCY 3:Document care rendered to
patients.Indicators:○ Utilizes appropriate
patient care records and reports○
Accomplish accurate documentation in all
matters concerning patient care in accordance
withthe standard of nursing practice.
VI. PERSONAL & PROFESSIONAL
DEVELOPMENT
CORE COMPETENCY
1Identifies own learning needsIndicators:○
Verbalizes strengths, weaknesses,
limitations.○ Determines personal and
professional goals and aspirations.
CORE COMPETENCY
2 Pursues continuing educationIndicators:○
Participates in formal and non-formal
education.○ Applies learned information for the
improvement of care.
CORE COMPETENCY
3 Gets involved in professional organizations
and civic activitiesIndicators:○ Participates
actively in professional, social, civic and
religious activities○ Maintain membership to
professional organizations○ Support activities
related to nursing and health issues
CORE COMPETENCY
4 Projects a professional image of
nurseIndicators:○ Demonstrate good manners
and right conduct at all times.○ Dresses
appropriately.○ Demonstrates congruence of
words and actions.○ Behaves appropriately at
all times.
CORE COMPETENCY
5 Possesses positive attitude towards change
and criticismIndicators:○ Listens to suggestions
and recommendations.○ Tries new strategies
or approaches.○ Adapts to changes willingly.
CORE COMPETENCY
6 Performs function according to professional
standardsIndicators:○ Assesses own
performance against standards of practice.○
Sets attainable objectives to enhance nursing
knowledge and skills.○ Explains current
nursing practices, when situations call for it.
VII. RESEARCH
CORE COMPETENCY 1:
Gathers data using different
methodologiesIndicators:Identifies
researchable problems regarding patient care
and community health Identifies appropriate
methods of research for a particular
patient/community problem Combines
quantitative and qualitative nursing design thru
simple explanation on the phenomena
observed Analyzes data gathered
CORE COMPETENCY 2:
Recommends actions for
implementationIndicator:Based on the analysis
of data gathered, recommends practical
solutions appropriate for theproblemCORE
COMPETENCY 3:Disseminates results of
research findingsIndicators:Communicates
results of findings to colleagues/patients/family
and to others
Endeavors to publish research Submits

research findings to own agencies and others
as appropriate CORE COMPETENCY
4:Applies research findings in nursing
practiceIndicators:Utilizes and findings in
research in the provision of nursing care to
individuals/groups/communities Makes use of
evidence-based nursing to ameliorate nursing
practice
VIII. RECORDS MANAGEMENT
CORE COMPETENCY 1:Maintains accurate
and updated documentation of patient
careIndicator:Completes updated
documentation of patient care CORE
COMPETENCY 2:Records outcome of patient
careIndicator:Utilizes a record system CORE
COMPETENCY 3:Observes legal imperatives
in recording keepingIndicators:Observes
confidentially and privacy of patient’s records
Maintains an organized system of filing and
keeping patient’s records in a designated area
Refrains from releasing records and other
information without proper authority
IX. COMMUNICATION
CORE COMPETENCY 1:Establishes rapport
with patients, significant others and members
of the health team. Indicators: ○ Creates trust
and confidence○ Listens attentively to client’s
queries and requests○ Spends time with the
client to facilitate conversation that allows client
to express concern. CORE COMPETENCY 2:
Identifies verbal and non-verbal cues Indicator
: ○ Interprets and validates client’s body
language and facial expression CORE
COMPETENCY 3: Utilizes formal and informal
channels Indicator: ○ Makes use of available
visual aids CORE COMPETENCY 4:
Responds to needs of individuals, family,
group and community Indicator: ○ Provides re-
assurance through therapeutic, touch, warmth
and comforting words of encouragement○
Readily smiles CORE COMPETENCY 5: Uses
appropriate information technology to facilitate
communication Indicator: ○ Utilizes telephone,
mobile phone, email and internet, and
informatics○ Identifies a significant other so
that follow up care can be obtained○ Provides
“holding” or emergency numbers of services
X. COLLABORATION and TEAMWORK
CORE COMPETENCY 1:Establishes
collaborative relationship with colleagues and
other members of the health team Indicators:○
Contributes to decision making regarding
patients” needs and concerns○ Participates
actively in patients care management including
audit○ Recommends appropriate intervention
to improve patient care○ Respects the role of
the other members of the health team○
Maintains good interpersonal relationships with
patients, colleagues and other members of the
health team CORE COMPETENCY
2:Collaborates plan of care with other
members of the health team Indicator:○ Refers
patients to allied health team partners○ Acts
liaison / advocate of the patients○ Prepares
accurate documentation of efficient
communication of services
XI. QUALITY IMPROVEMENT
CORE COMPETENCY 1:Gathers data for
quality improvementIndicators:Demonstrates
knowledge of method appropriate for the
clinical problems identified Detects variation in
the vital signs of the patient from day to day
Reports necessary elements at the bedside to
improve patient stay at hospital Solicits
feedback from patient and significant others
regarding care rendered CORE
COMPETENCY 2:Participates in nursing
audits and roundsIndicators:Contributes
relevant information about patient condition as
well as unit condition and patient current
reactions Shares with the team current
information regarding particular patient’s
condition Encourages the patient to speak
about what is relevant to his condition
Documents and records all nursing care and
actions Performs daily check of patient
records/condition Completes patients records
Actively contributes relevant information of
patients during rounds thru readings and
sharing
Acute Biologic Crisis By: Raids L. Della Cru
z, RN,MAN Page
with others CORE COMPETENCY 3:Identifies

and reports variancesIndicators:Documents
observed variance regarding patient care and
submits to appropriate group within24 hours
Identifies actual and potential variance to
patient care Reports actual and potential
variance to patient care Submits report to
appropriate groups within 24 hours CORE
COMPETENCY 4:Recommends solutions to
identified problemsIndicators:Gives appropriate
suggestions on corrective and preventive
measures Communicates and discusses with
appropriate groups Gives and objective and
accurate report on what was observed rather
than an interpretation of the event.
LesssonB.1APPLICATION OF CORE
COMPETENCY IN NURSING
PRACTICEPRE TEST 2ASSESSMENT OF
INDIVIDUAL PATIENT NEEDS FOR
NURSINGINSTRUCTIONS: Circle the one
best answer for each test question. Write
your rationale for selecting the answer. To
enhance your learning and test taking skill,
discuss your answer and rationale with a
partner.
1.
The nurse is preparing to assess neuron status
of an adult client who had hip fracture 5days
ago and was reported to have experienced
confusion the previous shift. Which statement
will provide the nurse with the most appropriate
information? A. “Can you tell me today’s
you know that you are in
the hospital?”c.“When did you have hip
surgery?”d.“What is your
name?” Rationale:_____________________
____________________________ 2.The
nurse is informed that the newly admitted
client is complaining of itching and has
arash all over the body. The most appropriate
nursing intervention initially is to:a.Inform the
doctor of the objective and subjective
complaintsb.Inspect the client and
describe the rashc.Ask the client to try
not to scratch the areasd.Check the
medication record for anti-itch
medicationRationale:___________________
_________________________________ 3.T
he nurse is assigned to a client who
was admitted for a blood clot in the right
leg.Which of the following describes the
appropriate assessment technique initially?
a.Inspection of the right legb.Light
palpation of the right legc.Inspection
followed by deep palpation of edematous
areasd.Light palpation followed by
inspection of any reddened
areas.Rationale:_______________________
_____________________________
Key answers
1.
The nurse is preparing to assess neuro status
of an adult client who had hip fracture 5days
ago and was reported to have experienced
confusion the previous shift. Whichstatement
will provide the nurse with the most appropriate
information?a.“Can you tell me today’s
date?”b.“Do you know that you are in
the hospital?”c.“When did you have hip
surgery?”
d.
“What is your name?”Rationale: Eliciting
orientation to person is part of assessing client
orientation.Options A & B encourages yes or
no response, and option c may not give
accuratedata if the client does not remember
the date.2.The nurse is informed that
the newly admitted client is complaining of
itching and has arash all over the body. The
most appropriate nursing intervention initially is
to:a.Inform the doctor of the objective
and subjective
complaintsb.Inspect the client and
describe the rashc.Ask the client to try
not to scratch the areasd.Check the
medication record for anti-itch
medicationRationale:it is most appropriate for
the nurse to initially gather data by using
theassessment skill of inspection and then to
further describe the observations. OptionsA,C,
& D are follw-up nursing interventions.3.The
nurse is assigned to a client who
was admitted for a blood clot in the right
leg.Which of the following describes the
appropriate assessment technique initially?
a.Inspection of the right legb.Light
palpation of the right legc.Inspection
followed by deep palpation of edematous
areasd.Light palpation followed by
inspection of any reddened
areas.Rationale: Inspection is the initial step in
the assessment process that
providesinformation on color, size, shape and
movement of the extremity. Options B and
Dare not appropriate initially and
option C should not be done in this situation.
Lesson B.1APPLICATION OF CORE

COMPETENCY IN NURSING PRACTICE
INTEGRATINGNURSING
PROCESSINTRODUCTION:
Stressing the point that the entire plan of care
depends on the accuracy and completeness
of Assessment, this section examines how to
do an assessment in a way that facilitates the
next step, Diagnosis. It addresses
characteristics of an assessment that promotes
critical thinking and competency indicators that
relate to assessment. Finally it gives the tips for
interviewing and examining patients and
explains the how to’s and the why’s of the six
phases of assessment.
EXPECTED LEARNING OUTCOMES
After studying the content of this section, the
students should be able to:1.Describe the
five characteristics of an assessment that
promotes competency, and explain how the
phases of Assessment described in this
section promote criticalthinking.2.Explain how
the interview and physical
assessment complement and clarify each
other.3.Give an example of an open-ended
question, a closed ended question, a
leading question and an exploratory
statement.4.Differentiate between cues an
d inferences5.Explain why organizing data
more than one way promotes competence
and critical thinking.
ASSESSMENT OF INDIVIDUAL PATIENT
NEEDS FOR NURSINGANA STANDARD
The nurse collects comprehensive data
pertinent to the patient’s health situation (ANA,
2004)
SIX PHASES OF ASSESSMENT
1.
Collecting of data- gathering data (information)
about health status
2.
Identifying cues and making inferences-
recognizing significant data and drawing
somebeginning conclusions about what the
data may indicate.
3.
Validating the data- double checking to make
sure that your data are accurate andcomplete.
4.
Clustering the data- organizing or grouping
related pieces of information to help youidentify
patterns of health or illness (eg, Clustering data
about nutrition together, the dataabout rest
together and so forth)
5.
Identifying patterns/ testing first impressions-
looking for the patterns and focusing
your assessment to gain more information to
better understand the situations at hand.
For example, you suspect that someone’s data
shows a pattern of poor nutrition and decideto
find out what’s contributing to this pattern( does
the person have poor eating habits or could it
be something else, such as not having enough
money to eat well?)
6.
Reporting and recording data- Reporting
significant data (eg. High fever) and charting
onthe patient’s record.
CHARACTERISTICS OF AN ASSESSMENT
THAT PROMOTES
COMPETENCY1 . P U R P O S E F U L
To promote Critical thinking, your approach to
assessment must change, depending onyour
purpose and the circumstances(c0ntext) of
your patient situation.For example:Are you
aiming to assess all aspects of care, or are
you monitoring one specificproblem?Are your
assessing a hospitalized patient or someone in
the home?Is the person an adult or a child?
NOTE: Your aim is to gain all the information
needed to ensure that your patients
haveindividualized plans that are designed to
help them achieve outcomes in the best
waypossible, in context of their particular
situation (eg, their age, culture, and level
of independence)
2.FOCUSED AND RELEVANT
Your assessment must be focused to gain
relevant information, depending onpurpose
and context as above.For example:Physician’s
Data: (Disease focus)
“ Mrs. Garcia has pain and swelling in all
joints. Diagnostic studies indicates that she has
rheumatoid arthritis. We will start her on a
course of anti inflammatory drugsto treat the
rheumatoid arthritis.” (focus on the treatment
modalities)
Nurse’s Data: (holistic focus, considering both
problems and their effect on theperson’s ability
to function independently)“Mrs. Garcia has
pain and swelling in all joints, making it difficult
to feed and dressherself. She has voiced that
it’s difficult to feel worthwhile when she can’t
feedherself. She states that she is depressed
because she misses seeing her two
smallgrandchildren. We need to to develop a
plan to help her with her pain, to assist her with
feeding and dressing, to work through feelings
of self-esteem, and for specialvisitations with
the grandchildren.” ( Focus is on Mrs. Garcia)
3.SYSTEMATIC
Developing a systematic approach to
assessment helps you pay attention to what
isimportant, learn how to prioritize, be
comprehensive, and avoid omission errors.For
example:
•
What are your symptoms?
•
Can you point out with one finger to the areas
that are bothering you?
•
When did they start?
•
What makes them better?
•
What makes them worse?
•
Are you taking any medications- prescribed,
over-the-counter, or herbalremedies- that may
be causing some of these symptoms?
•
Can you think of anything else that might be
contributing to your symptoms?
4.COMPREHENSIVE AND
ACCURATE
The most common error that happens in critical
thinking is identifying problems or making
judgments based on sufficient or incorrect
information. Your information mustbe factual,
and as complete as is warranted by your
purpose.For example:An assessment aims to
get information about one specific problem is
shorter thanone that aims to get
comprehensive data about all aspects of care.
DISPLAY B
.
1.1
:How to ensure Comprehensive Data
CollectionComprehensive data collection often
occurs in three phases:1.Before you see the
person: You find what you can. This
information may belimited( only name and
age) or extensive ( medical records may be
available for you to read)2.When you see the
person: You interview the person and
do PhysicalExamination (PE).3.After you see
the person: You review
the resources(consumer like patient,
familyand community, significant others,
nursing and medical records, verbal andwritten
consultations, diagnostic and laboratory
results) you used and determineswhat other
resources may offer additional information (e.g.
You may consult apharmacist to gain more
information about a medication
regimen)Comprehensive Data Collection have
several factors:1.The purpose of the
assessment- example is when you do data
base(start of care) assessment or a focus
assessmentData base assessment-
Comprehensive information gathered on
initialcontact with the person to assess all
aspect of health statusFocus Assessment-
Data gathered to determine the status of a
specificcondition like someone’s bowel
habits2.The needs and problems commonly
encountered in a particular
clinicalsetting.For example: An adult
assessment tool is different from a
newbornassessment tool.3.Standards of care
for the assessment as defined by
regulatory agencies andprofessional
associationsFor example: Maternal and Child
Nursing Association of the
Philippines/MCNAP, Operating Room Nurses
association of the
Philippines/ORNAP,Philippine Nurses
Association/PNA etc.4.The nursing model
or theory adopted by the school or
facilitiesFor example: Gordon’s Functional
Health Patterns or Orem’s Self Caretheory.
5.RECORDED IN A STANDARDIZED
WAY
Like pilots who follow computerized or pre-
printed checklists (instead of relying
onmemory), you must value the importance of
completing a standardized tool that isdesigned
to promote an assessment that is purposeful,
relevant, systematic, andcomplete.
NOTE: You cannot rely your brain to do it all,
even if you have years of experience
DISPLAY B.1.2:
Major Intellectual Skills & Critical
Thinking Skills R/T Assessment
(Behavior Evidence Suggesting
Competence in Nursing

Practice)
The competent nurse:
•
Applies standard and principles
•
Assesses systematically and comprehensively;
uses a nursing framework toidentify nursing
concerns; uses a body systems framework to
identify medicalconcerns
•
Detects bias; determines credibility of
information sources
•
Distinguishes normal from abnormal; identifies
risks for abnormal
•
Determines significance of data; distinguishes
relevant from irrelevantclusters relevant data
together
•
Identifies assumptions and inconsistencies;
checks accuracy and reliability ;recognizes
missing information; focuses assessment as
indicated
•
Communicates effectively orally and in writing
•
Establishes empowered partnerships with
patients, families, peers, and coworkers
•
Sets priorities and make decisions in a timely
way; includes key stakeholdersin making
decisions
•
Weigh risks and benefits
•
Identifies ethical issues and take appropriate
action
•
Identifies and uses technologic, information,
and human resources
•
Address conflicts fairly, fosters positive
interpersonal relationships
•
Facilitates and navigates change
•
Organize and manages time and environment
•
Facilitates teamwork ( focuses on common
goals; helps and encouragesothers to
contribute in their own way)
•
Demonstrates systems thinking (shows
awareness of the interrelationshipsexisting
within and across health care systems)

IDENTIFYING CUES AND MAKING

INFERENCES
Identifying subjective and objective data both
aids in critical thinking and
competencebecause each complements and
clarifies the other.For example:
Subjective data:
States, “ I feel like my heart is racing.”
Objective data
: Right radial pulse 150 beats per minute,
regular, and strong.
The preceding objective data support the
subjective data
- what you observe confirmswhat the person is
stating.
Sometimes, what you observe and what the
person states are different
.For example:Subjective data: States, “I feel
fine.”Objective data: Color pale, becomes
easily short of breath.Above, what the person
states isn’t supported by what you observe.
You need toinvestigate then further to
understand fully the scope of the problems.The
subjective and objective data you identified
acts as
cues.
Cues are data that promptyou to get a
beginning impression of patterns of health or
illness.For example:Subjective data: “I started
taking penicillin for a tooth abscess.Objective
data: Fine rash over the trunk.The above gives
you cues that may lead you to
infer
(suspect) that there is an allergicreaction to
penicillin. How you interpret or perceive a cue-
the conclusion you draw aboutthe rash: you
decide that rash may indicate a penicillin
allergy.Your ability to identify cues and make
correct inferences is influenced by
your observational skills, your nursing
knowledge, and your clinical expertise. Your
valuesand beliefs also affect how you interpret
some cues, so make an effort to avoid
makingvalue judgments ( for example, inferring
that a person who bathes only once a
weekneeds to be taught better hygiene when
the practice may be a part of his culture.
GENERAL RULE

* ** Factual, relevant, and comprehensive

assessment is the
key to accurate
diagnosis(problem and risk identification) and
to developing a plan that is safe, effective,
efficient,and individualized.1. Establishes
rapport and trust with the patient, family and
significant others.Quality
Indicators:a.Welcomes
the patient, family and
significant others upon admission.b.Greets
patient by name, introduces self and co-
staff c.Encourages verbalization of needs
and feelings
through attentive listening.d.Conveys availa
bility and willingness to help by attending to
needs at the soonesttime possible.2. Obtain
a nursing history and document an initial
physical examination throughapplication of the
general principles of and follows a logical
sequence in history takingand physical
examination.3. Recognizes normal and
abnormal findings from common laboratory
and diagnosticexamination results. As
indicated by comparing results from standard
listing of normalvalues/ results of common
laboratory and diagnostic
examination.4.Defines health needs and
problems from data gathered by identifying
the significantfindings from the accurate
nursing history, PE and laboratory/diagnostic
results.
CLASSROOM ACTIVITY 1
The Nursing Interview and Physical
AssessmentInstructions:
Divide the class into 4 groups. Each group is
entitled to answer task Part 1 and Part2.
Presentation should be in a clinical setting and
is limited to 15 minutes only.Part 1:
Interviewing1.Practice asking open-ended
questions. Restate each question below so
it’s anopen ended
question.a.Are you feeling better?
Bodied you like dinner? Care you
happy here? Dare you having pain?
2.
D making open-ended questions. For

Statement below, write a reflective statement
and an open-ended question that would help
you to clarify what has been said. A.
“I’ve been sick off and on for a month.”B.
“Nothing ever goes right for mock. “I
seem to have a pain in my side that
comes and goes.”d. “I’ve had this funny
feeling for a week.” Part 2: Physical
Assessment1.Because physical
assessment and interviewing go hand
in hand, use the following situations to
practice focusing you interview questions on
areas of concern noted during the Pea. You
examine and find: The patient’s hands and
fingernails are filthy with ground-in dirt,
although the rest of him is clean. What will you
say next? Buyout examines and find: The
patient has a lump on the back of his head.
What will you say next? You examine and
find: The patient’s RR is 40. What will
you say next? You examine and find: The
patient’s right eye is red, teary, and
inflamed. What will you say next? 2. Now
practice focusing your PE on areas of
concern voiced by
the patienta.Patient states: “I have had a
rash that comes and goes.” What will
you reply and examine? Patient states:
“My stomach has been hurting me,” What
will you reply and examine? Patient states:”
I find it burns when I urinate,” What will
you reply and examine?
D.
Patient states: “I feel like I’m heavier than
usual, like I’m bloated with fluid, “What will
reply and examine?
Example Responses to Activity 1
Part 1: Interviewing
1. Practice asking open-ended questions.
Restate each question below so it’s an open
ended question.
A.
Are you feeling better? Tell me how you’re
feeling
B.
Did you like dinner?
How was your dinner?
C.
Are your happy here?
How do you feel about being here?
D.
Are you having pain?
Describe what you are feeling; tell me how
you’re feeling.
2.
Practice clarifying ideas by using reflection
(restating what you hear) and making open-
ended questions. For each statement below,
write a reflective statement and an open-ended
question that would help you to clarify what has
been said.
A.
“I’ve been sick off and on for a month.”
So, you’ve been sick off and for month. What
do you mean by sick off and on?
B.
“Nothing ever goes right for me.”
You feel like nothing ever goes right for you.
What is been happening?
c.
“I seem to have a pain in my side that comes
and goes.”
You have pain inyour side that comes and
goes- can you explain more?
d.
“I’ve had this funny feeling for a week.”
You’ve had a funny feeling for aweek. What do
you mean by funny?
Part 2: Physical
Assessment1.Because physical assessment
and interviewing go hand in hand, use
thefollowing situations to practice focusing you
interview questions on areas of concern noted
during the PEa.You examine and find: The
patient’s hands and fingernails are filthy
withground-in dirt, although the rest of him is
clean. What will you say next?You have a lot of
ground- in dirt here. What is it from?b.You
examine and find: The patient has a
lump on the back of his head. Whatwill you
say next?I feel a lump on the back of your
head. How did it happen? Does it hurt whenI
touch it?c.You examine and find: The
patient’s RR is 40. What will you say
next?Your breathing is a little fast. How do you
feel?d.You examine and find: The patient’s
right eye is red, teary, and inflamed.What
will you say next?Your eyes seem inflamed.
How does it feel?2.Now practice focusing
your PE on areas of concern voiced by
the patienta.Patient states: “I have had a
rash that comes and goes.” What will
you replyand examine?Show me where (and
examine that area). Is there anything you think
causesit?b.Patient states:”My stomach has
been hurting me,” What will you reply
andexamine?
Show me where (and examine that area). Tell
me more how it feels.c.Patient states:” I
find it burns when I urinate,” What will
you reply andexamine?That is a common
symptom of infection. Let us get a urine
sample( andexamine it)d.Patient states:
“I feel like I’m heavier than usual, like
I’m bloated with fluid,”What will reply and
examine?Where do you feel this bloating?
Your stomach? Ankles? Where? Examinethe
areas
Lesson B.2Health Promotion: Screening for
Prevention and Early Diagnosis
Depending on where you work, your
assessments may include helping
withscreening for prevention and early
diagnosis of common health problems.Usually
screening is done at significant points during
the life cycle.For example:
•
Assessing infant development using
standardized scales
•
Measuring height, weight, and vision in school
aged children
•
Assessing for problem drinking and depression
beginning in adolescence.
•
Measuring cholesterol and fecal occult blood in
adultsTo meet the goals of healthy people.
Which aims to increase the length and quality
of lifeof all people, all health care providers are
encouraged to record health
promotioncounseling that occurs during all
important interactions.A key part of
assessment is helping patients make informed
and jointdecisions about what screening and
prevention measures they should follow.The
length of discussions about screening for
health problems and use of medication to
prevent diseases varies according to:a.The
scientific evidence addressing how
useful the service is.b.The health,
preference, and concerns of each
patientc.The decision making style
of each cliniciand.Practical constraints,
such as the amount of time
availableNOTE:A decision can be considered
informed and mutually decided only if
patients:1.Understand the risk
or seriousness of the disease
or condition to
beprevented.2.Comprehend what the pr
eventive service involves( including th
e risks,benefits, alternatives and
uncertainties)3.Have weighed their value
s regarding the potential harms
and benefitsassociated with the service.
4.
Have engaged in decision-making at
level at which they want and
feelcomfortable (US Preventive Task Force
2004)
Display B.2.1Recommended Screening for
Health Promotion
The Department of Health must rigorously
evaluate clinical research
toassess the merits of preventive measur
es, including screening tests,counseling
immunization and preventive medications.
Lesson C.1Communication
Your ability to establish rapport, ask questions,
listen, and observe is thekey to establishing the
positive nurse- patient relationship needed to
builda therapeutic relationship. People seeking
health care are in a veryvulnerable position.
They need to know that they’re in good hands
andthat their main concerns will be addressed.
This is where you come in asnurses. Consider
the following guidelines that can help you
establishtrust, positive attitude, and reduce
anxiety.Display C.1.1Guidelines in Promoting
a Caring Interaction/CommunicationHow to
establish rapportBefore you go into the
interview:
Get organized
:
When you know what you’re going to do,
you’re moreconfident and able to focus on the
personDon’t rely on memory: Have a written
or printed plan to guide thequestions you’ll be
asking. Some nurses use the nursing data base
as aguide.Plan enough time: The admission
interview usually takes 30 minutes to
1hour.Ensure privacy: Make sure you have a
quiet, private setting, free frominterruptions or
distractions.Get focused: Take a minute to
clear your mind of other
concerns( other duties, worries about yourself).
Say to yourself, Getting to know this person is
most important thing I have to do right
now.Visualize yourself as being confident,
warm and helpful: Seeing yourself in this light
helps you to be confident, warm and helpful-
your genuineinterest comes through.When you
begin interview:Give your name and position:
(if the person can read, give it in writing).This
sends the message that you accept
responsibility and are willing tobe accountable
of your actions.Verify the person’s name and
ask what he or she would like to be called (eg. I
have your name listed here as Michael Riles. Is
that correct? What would you like us to call
you?”). Using the preferred name helps
the person to feel more relaxed and sends the
message that you recognizethat this person is
an individual who has likes and dislikes. Most
facilitiesrequire that you use two unique
identifiers to identify the patient (eg,asking the
person his name and also checking ID
bracelets)Briefly explain your purpose(eg, I’m
here to do the admission interview tohelp us
plan your nursing care.”).During the
interview:Give the person your full attention.
Avoid the impulse to becomeengrossed in your
notes or in reading the assessment tool.Don’t
hurry: Rushing sends the message that you’re
not interested inwhat the person has to say.
Sit down: This communicates that you’re

willing to take your time.How to listenBe an
empathetic listener
To listen empathetically
1.Eliminates thoughts about how you,
yourself, see the situation.
2.
Listen carefully for feelings, trying to identify
with how the other personperceives his
situation. Don’t allow yourself to think about
how you feel or how you’re going to respond;
think only about the content of what
you’rehearing3.Reflect on what you’ve been
told, then rephrase the feelings you have
heard.4.Seek validation that
you understood the message, content,
and emotioncorrectly. Keep trying until you’re
sure you understand.
5.
Detach, come back to your own frame of
reference, and separate yourself from the
emotions involved.DISPLAY C.1.2
TEN CARING BEHAVIORS
1.Monitoring patients closely and telling
them you know you’re doing it.Example: “I
will be checking on you every 15
minutes”2.Inspiring someone, or instilling
hope and faith ( creating a vision of
“canbe”)3.Showing patience, compassion,
and willingness to
persevere4.Taking time, rather than
hurrying through just to get things
done.5.26.Offering companionship or pre
sence7.Helping someone stay in touch
with positive aspects of his
life.8.Demonstrating thoughtfulness9.B
ending the rules when it really
counts10.Showing your human side by
sharing humor or stories of daily life.NOTE:
Simply Being Nice and Making Work Fun Can

Improve Patient Outcomes“(Studies show that)
patients who come away from a positive
encounter with a nurse are morelikely to follow
prescribed directions, take medications, and
seek follow-up care… (however if) apatient
encounters a health care worker who’s in a
negative emotional state, it becomes
aspringboard into other negative behaviors.
Down the road, their own outcomes to suffer,
andthey just don’t fare well..try to make the
work environment as fun as possible> If you
see a staff member in a bad mood, jump in
and try to derail it before itr becomes
contagious.”- HowaredWeiss (Farella, 2009)
CLINICAL SCENARIO
Listening Empathetically Promotes
Understanding of the Real Issues,Fostering
Caring Human Responses
Today Patricia/Pat is caring for Sharon, who’s
just given birth to her fifth child,a healthy baby
girl. Pat never has been able to conceive, has
always wanted children, and feels a little
envious of Sharon’s family of two boys and
(now) of three girls.Pat notes that Sharon
seems very quiet. Recognizing the importance
of beingempathetic listener, Pat has the
following conversation with Sharon.Pat:
“You’ve been pretty quiet since I came
on.”Sharon: “I can’t help it. I’m supposed to be
happy, but I’m really disappointed-I was so
sure I’d had a baby boy.”Pat: (making a
conscious effort to eliminate thoughts about the
fact that she’dbe happy with any child, and
rephrasing what Sharon seems to be feeling):
“you feel like you’re supposed to be happy, but
you really feel sort of sad?”Sharon: “yes”,Pat
pauses to reflect on the feeling of sadness and
encourages Sharon tocontinue.Sharon: “I was
going to name this baby after my father. He
died 2 monthsago.”Pat (connecting to what
Sharon must be feeling): “I’m sorry. That would
be adisappointment. Being able to name the
baby after him would have been alovely thing
to do.”Sharon (crying): “Yes, I had it all pictured
in my mind.”Pat conveying acceptance and
understanding, sits quietly, allowing Sharon
tocry.Pat (detaching and coming back to her
own frame of reference):“Sharon, I think you
needed to cry and you may need to cry again.
But right now you’ve got a very beautiful baby
girl; with the longest hair I’ve ever seen, waiting
to meet her mother. How would you feel if I
Brought her into you? “Sharon: (smiling) “Yes, I

really haven’t seen her for more than 5
minutes. I’ve got to admit, I’ve always gotten
along better with my girls than my boys.”
CLASSROOM ACTIVITY 2 CRITICAL

THINKING ABILITY AND WILLINGNESS
AND ABILITY TOCARE
1.List five critical thinking indicators
you’d like to acquire or improve.
2.Complete the following sentence,
using as many words as you choose: If I
were to tell someone how I think, I would say
that I………..
3.In five sentences or less, describe what
critical thinking means to you
4.Give three examples of
caring behaviors
5.Explain how the statements relates to
willingness and ability to care: a.Health
and Illness are human experiencesb.The
presence of illness does not preclude
health nor does optimal health
precludeillness.c.An essential feature
of contemporary nursing practice is the
provision of a caring relationship that
facilitates healing.
ASSIGNMENT
1. Improve your interpersonal skills by
learning about your innate personality and
how to get along well with “difficult” people.
Read: “Don’t Worry Be Happy! Harmonize
Diversity through Personality Sensitivity,” at
http:nsweb.nursingspectrum.com/ce/ce236.ht
m
2.Are you stressed out? Managing stress is an
important part of staying healthy. Take the Life
Stress Test
at http://www.cliving.org/lifstrstst.htm . Thin
k of something’s that you can do to reduce
your stress level.
3.Practice empathetic listening Ask
someone to tell you about an upsetting
experience in his or her childhood and listen
using the steps of empathetic listening taught.
Discuss in the class what can happen when
you are too emotionally involved inpatient
situations.

Identify ways you can manage your emotions

to remain empathetic, but also objective and
logical.
Lesson C.3Ethico-Moral /Legal
Responsibilities
His success of nurse- patient interaction and
examination is influenced by your awareness
of ethical, cultural, and spiritual concerns. As a
nurse you must:
1.Provide service with respect for human
dignity and the uniqueness of the patient,
unrestricted by considerations of social or
economic status, personal attributes, or the
nature of health problems (ANA, 2004)
2.Safeguard the client’s right to privacy by

judiciously protecting information of a
confidential nature.
3.Be honest. Tell the person the truth about
how you’ll see the data (egg. “I have to write
a paper examining someone’s eating patterns.
Would you be willing to tell me about your
eating habits?
4.Respect individual cultural and religious

beliefs and be aware of physical tendencies
related to culture. This include being aware of:
•Biologic variations for example: Differences
among racial and ethnic groups like skin color,
texture, and susceptibility to diseases like
hypertension and sickle cell anemia.
•Comfortable communication patterns For
example: How language and gestures are
used, whether eye contact or touching is
acceptable, and whether the person is
threatened by being in close proximity to
another.
•Family organization and practices we have
diverse family units and practices. We must
understand them to gain insight into factors
that influence health status.
•Beliefs about whether people are able to
control nature and influence their ability to be
healthy (egg, whether blood transfusions are
allowed or whether rituals are required)
•The person’s concept of God and beliefs
about the relationship between spiritual beliefs
and health status. (Egg, God gives you what
you deserve.).

NCM 106 Acute Biologic Crisis

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Catanduanes State Colleges

NCM 106 CARE OF THE CLIENTS WITH

It deals with the principles and techniques of

a. Utilize the nursing process in the care of

ii. Identify actual and potential diagnosis

iii. Plan appropriate nursing interventions

iv. Implement plan of care with client and family

v. Evaluate the progress of the client’s condition

3. Communities (Community Service)

.be taken part in the community projects

.correlate with client and their family and the

Promote personal and professional growth

-Increased metabolic rate (egg. fever,

Left-Sided Cardiac Failure-

Activity intolerance r/t imbalance bet

Myocardial Infarction Description- Occurs

-Cardiac Enzymes – elevated CK with MB is

-WBC count – leukocytosis (10,000/mm3 to

-Positron Emission Tomography (PET) is used

-Percussion reveals hyper resonance in

-Thrombosis of the cerebral arteries

Importance Client Education

METABOLIC EMERGENCIES DKA

HYPEROSMOLAR HYPERGLYCEMIC NONKETOTIC

b.Chemical burns are caused by direct contact with

C.Electrical burns; severity depends on type and duration

d.Radiation burns: are usually associated with

-Risk for Deficient Fluid Volume

*For burn patient in shock -

-Monitor VS and hemodynamic parameters

D.Surface absorption of insecticides (organophosphates

*antidotes will vary with medication

-Assess the patient’s ABCs and initiate emergency measures

-Assist with cervical X-rays

Pre – Test CLINICAL COMPETENCE

DIRECTION: Circle the one best answer for

KEY ANSWER: 1.The nurse is using

The indicators are designed to assist the

CORE COMPETENCY 3:Promotes patient

CORE COMPETENCY 1:Assesses the

○ Meets nursing accountability requirements

CORE COMPETENCY 3Gets involved in

Endeavors to publish researchSubmits

Meets nursing accountability requirements as

Endeavors to publish research Submits

with others CORE COMPETENCY 3:Identifies

Lesson B.1APPLICATION OF CORE

IDENTIFYING CUES AND MAKING

* ** Factual, relevant, and comprehensive

D making open-ended questions. For

Sit down: This communicates that you’re

Simply Being Nice and Making Work Fun Can

Brought her into you? “Sharon: (smiling) “Yes, I

CLASSROOM ACTIVITY 2 CRITICAL

Identify ways you can manage your emotions

2.Safeguard the client’s right to privacy by

4.Respect individual cultural and religious

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