Nursing ProcessUNIT II Processes in Nursing Care 1. Nursing Process 1.1 Overview of the Nursing Process ASSESSING Collect data © Organize data © Validate data © Document data DIAGNOSING ‘ASSESS © Analyze data « Identify h problems, risk, and strengths © Formulate diagnostic statements PLANNING Prioritize problems/diagnoses © Formulate goals/desired outcomes © Select nursing interventions © Write nursing orders IMPLEMENTING © Reassess the client * Determine the nurse’s need for assistance ¢ Implement the nursing interventions Supervise delegated cases Document nursing activities EVALUATING © Collect data related to outeome © Compare data with outcomes © Relate nursing actions to client goals/outcomes Draw conclusions about problem status © Continue, modify, or terminate the client’s care planThe main process in Acton Overview of the Nursing Process Phase and Description Purpose Activities ‘Assessing Collecting, onganizing, validating, and documenting client data To establish a database about the client’s response to health concerns or illness and the ability to manage health care needs Establish a database: > Obtain a nursing health history > Conduct a — physical assessment Review client records Review nursing literature Consult support persons Consult health professionals Update data as needed Onganize data Validate data Communicate/document data vv vv Diagnosing Analyzing and synthesizing data To identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions To develop a list of nursing and collaborative problems Interpret and analyze data. > Compare data against standards > Cluster or group data (generate tentative hypothesis) > Identify gaps and inconsistencies Determine client’s strengths, risk, diagnoses, and problems. Formulate nursing diagnoses and collaborative problem statements. Document nursing diagnoses on the care plan. Planning Determining how to prevent, reduce, or resolve the identified client problems; how to support client strengths; and how to implement nursing interventions in an organized, individualized, and goal-directed manner To develop an individualized care plan that specifies client goals/desired outcomes, and related nursing interventions Set priorities and goals/ outcomes in collaboration with client Write goals / desired outcomes Select nursing strategies / interventions Consult other health professionals Write nursing orders and nursing care plan Communicate care plan to relevant health care providersPhase and Description Purpose ‘Activities Implementing Carrying out the planned nursing interventions To assist the client to meet desired goals / outcomes, promote wellness; prevent illness and disease; restore health; and facilitate coping with related functioning Reassess the client to update the database. Determine need for nursing assistance Perform planned nursing interventions Communicate what nursing actions were implemented > Document care and client responses to care > Give verbal reports as necessary Evaluating Measuring the degree to which goalvouteomes have been achieved and identifying factors that positively or negatively influence goal achievement To determine whether to continue, modify, or terminate the plan of care Collaborate with client and collect data related to desired outcomes Judge whether goals/outcomes have been achieved Relate nursing actions to client outcomes Make — decisions about problem status Review and modify the care plan as indicated or terminate nursing care Document achievement of| outcomes and modification of the care plan. 2. Four (4) Related Activities of the Assessment Process 2.1 Collecting Data — data can be subjective or Objective. 2.1.1 Types of data 1. Subjective data - also referred to as symptoms or covert data, are apparent only to the person affected and can be described or verified only by that person. Subjective data include the client’s sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situation. 2. Objective data - also referred to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard, They can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination. 2.1.2 Sources of data The client is the primary source of data, Family members or other support persons, other professionals, record s and reports, laboratory and diagnostic analyses, analyses, and relevant literature are secondary or indirect sources. In fact, all sources other than the client are considered secondary sources.2.1.3 Methods of data collection 1. Observing To observe is to gather data by using the senses. Observation is a conscious, deliberate skill that is developed through effort and with organized approach. 2. Interviewing ‘An interview is a planned communication or a conversation with a purpose, for example, to get or give information, identify problems of mutual concern, evaluate change, teach, provide, support, or provide ‘counseling or theory. 3. Examining The physical examination or physical assessment is a systematic data- collection method that uses observation (i.e., the senses of sight, hearing, smell, and touch) to detect health problems. To conduct the examination the nurses uses techniques of inspection, auscultation, palpation, and percussion. The physical examination is carried out systematically. It may be organized according to the examiner's preference, in a head-to-toe approach or a body system approach. ‘The cephalocaudal or head-to-toe approach begins the examination at the head, progresses to the neck, thorax , abdomen, and extremities, and ends at the toes. The nurse using a body systems approach investigates each system individually, that is, the respiratory system, the circulatory system, the nervous system, and so on, Alternatively, the nurse may perform a. screening examination. A screening examination, also called a review of systems, is a brief review of essential functioning of various body parts or systems. An example of a screening examination is the nursing admission assessment form. 2.2 Organizing data 2.2.1 Gordon’s Typology of I Functional Health Patterns 1. Health-perception/health-management pattern, Describes the client’s perceived pattern of health and well-being and how health is managed. 2. Nutritional/Metabolic pattern. Describes the client's pattern of food and ‘fluid consumption relative to metabolic need and pattem indicators of local nutrient body. 3. Elimination pattern. Describes the patterns of excretory function (bowel, bladder, and skin) 4, Activity/exercise pattern. Describes the pattem of exercise, activity, leisure, and recreation. 5. Sleep-test pattern. Describes pattern of sleep, rest, and relaxation. 6. Cognitive/perceptual pattern. Describes sensory-perceptual and cognitive pattems. 7. Self-perception/self-concept pattern. Describes the client's self- concept pattern and perceptions of self (e.g., self conception/worth, comfort, body image, feeling state). 8. Role/relationship pattern. Describes the client's pattem of role participation and relationships.9. Sexuality/reproductive pattern. Describes the client's pattem of satisfaction and dissatisfaction with sexuality pattern; describes reproductive patterns, 10. Coping/stress tolerance pattern. Describes the client’s general coping pattern and the effectiveness of the pattem in terms of stress tolerance. 11, Value/belief pattern. Describes the patterns of values, beliefs (including spiritual), and goals that guide the client's choices or decisions. 2.2.2 Orem's Self-Care model Universal Self-Care Requisites 1. The maintenance of a sufficient intake of air 2. The maintenance of a sufficient intake of water. 3. The maintenance of sufficient intake of food. 4, The provision of care associated with elimination processes and excrement 5. The maintenance of a balance between activity and rest. 6. The maintenance ofa balance between solitude and social interaction. 7. The prevention of hazards to human life, human functioning, and human well-being. 8. The promotion of human functioning and development within the social ‘groups in accord with human potential, known human limitations, and human desire to be normal, (Normalcy is used in the sense of that which is essentially human and that which is in accord with the generic and constitutional characteristics and the talents of individuals.) 2.2.3. Roy’s Adaptation Model Adaptation Modes 1. Physiologic needs © Activity and rest © Nutrition Elimination © Fluid and Electrolytes © Oxygenation © Protection © Regulation: Temperature ‘© Regulation: the senses Regulation: endocrine system 2. Self-concept © Physical self Personal self 3. Role function 4. Interdependence 224 Data for Amanda Aquilini, Organized According to Functional Health Process 1. Health Perception/Health Management ‘© Avare/understands medical diagnosis © Gives thorough history of illnesses and surgeries ‘© Complies with Synthroid regimen # Relates progression of illness in detail ‘* Expects to have antibiotic therapy and “go home in a day or two” @ States usual eating pattern “3 meals a day” 2. Nutritional/Metabolie © 158 em 6 ft, 2 in) tall; weighs 56 kg (125 Ib) ‘© Usual eating pattern “3 meals a day” ‘© No appetite” since having “cold” @ Has not eaten today; last fluids at noon© Nauseated © Oral temp 39.4 C (103 F) © Decreased skin turgor 3. Elimination © Usually no problem © Decreased urinary frequency and amount x 2 days Last bowel movement yesterday, formed, states was “normal” 4, Activity/Exercise © No musculoskeletal impairment © Difficulty sleeping because of cough © “Can't breathe lying down” © States “I feel weak” © Short of breath on exertion # Exercises daily 5. Cognitive/Perceptual ‘No sensory deficits © Pupils 3 mm, equal, brisk reaction * Oriented to time, place, and person ‘© Responsive but fatigued ‘© Responds appropriately to verbal and physical stimuli Recent and remote memory intact © States “ short of breath” on exertion © Reports “pain in lungs”, especially when coughing © Experiencing chills © Reports nausea 6. Roles/Relationships © Lives with husband and 3-year-old daughter ‘© Husband out of town; will be back tomorrow afternoon Child with neighbor until husband retums © States “good” relationships with friends and coworkers ‘© Working mother, attorney Self-Perception/Self-Concept © Expresses “concern” and “worry” over leaving daughter with neighbors until husband returns © Well-groomed, says, “ Too tired to put on makeup.” Coping/Stress © Anxious: “I can’t breathe” Facial muscles tense; trembling ‘© Expresses concerns about work: I’ll never get caught up” Value/Belief © Catholic ‘© No special practices desired except anointing of the sick ‘® Middle-class, professional orientation ‘¢ No wish to see chaplain or priest at present 10. Medication/History © Synthroid .1 mg per day Client has history of appendectomy, partial thyroidectomy 11. Nursing Physical Assessment © 28 years old © Height 158 cm (5 ft., 2 in); weight 56 kg (125 Ib) # TPR 39.4C, 92,28 ‘© Radial pulses weak, regular # Blood pressure 122/80 sitting Skin hot and pale, cheeks flushed ‘© Mucous membranes dry and pale ‘© Respirations shallow; chest expansion <3 em ‘© Cough productive of small amounts of pale pink sputum 2¢ Inspiratory crackles auscultated throughout right upper and lower chest Diminished breath sounds on right side ‘¢ Abdomen soft, not distended © Old surgical scars; anterior, RLQ abdomen © Diaphoretic 2.2.5 Wellness Models Nurses use wellness models to assist clients to identify health risks and to explore lifestyle habits and health behaviors, beliefs, values, and attitudes that influence levels of wellness. Such models generally include the following: 1. Health history 2. Physical fitness evaluation 3. Nutritional assessment 4. Life-stress analysis 5. Lifestyle and health habits 6. 7 8 9. Health beliefs Sexual health Spiritual health Relationships 10. Health risk appraisal 2.2.6 Nonnursing Models Frameworks and models from other disciplines may also be helpful for organizing data. These frameworks are narrower than the model required in nursing; therefore, the nurse usually needs to combine these with other approaches to obtain a complete history. 1. Body System Model. The body system model focuses on abnormalities of the following anatomic systems: © Integumentary system © Respiratory system © Cardiovascular system © Nervous system © Musculoskeletal system © Gastrointestinal system © Genitourinary system © Reproductive system © Immune system 2. Maslow’s Hierarchy of Needs. Maslow’s hierarchy of needs clusters, data pertaining to the following: ‘Physiologie needs (survival needs) Safety and security needs Love and belonging needs # Self-esteem needs #Self-actualization needs 3. Developmental Theories. Several physical, psychosocial, cognitive, and ‘moral developmental theories may be used by the nurse in specific situations. Examples include the following: ¢ Havighurst’s age periods and developmental tasks Freud's five stages of development © Erikson’s eight stages of development Piaget's phases of cognitive development # Kohlberg’s stages of moral development23 Validating Data Definition of Toms: ‘Validation — is the act of “double-checking” or verifying data to confirm that itis accurate and factual. Validating data helps the nurse complete the tasks: ‘Cues — are subjective or objective data that can_be directly observed by the nurse ; that is, what the client says or what the murse can see, hear, feel, smell, or measure. Inferences ~ are the nurse’s interpretation or conclusions made based on the cues (e.g., a nurse observes the cues that an incision is red, hot, and swollen ; the nurse makes the inference that the incision in infected). 2.4 Documenting Data Accurate documentation is essential and should include all data collected about the client’shealth status. Data are recorded in a factual manner and not interpreted by the nurse. 3. Diagnosing 3.1 Definition The term diagnosis is a statement or conclusion regarding the nature of phenomenon. The standardized NANDA names for the diagnoses are called Gingnostic labels; and the client’s problem statement, consisting of the diagnostic label plus etiology (causal relationship between a problem and its related or risk factors), is called a nursing diagnosis. Nursing diagnosis — “ a clinical judgment about individual, family, or community responses to actual and potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable”. 3.2 Types of Nursing Diagnoses The five types of nursing diagnoses are actual, risk, wellness, possible, and syndrome: 3.2.1 An actual diagnosis is a client problem that is present at the time of the nursing assessment. Examples are Ineffective Breathing Pattern and Anxiety. ‘An actual nursing diagnosis is based on the presence of associated signs and symptoms. 3.2.2 A risk nursing diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. For example, all people admitted to a hospital have some possibility of acquiring an infection; however’ a client with diabetes or a compromised immune system is at high risk than others. Therefore, the nurse would appropriately use the label Risk for Infection to describe the client’s health status. 3.2.3 A wellness diagnosis “Describes human responses to levels of wellness in an individual, family or community that have a readiness for enhancement”. Example of wellness diagnosis would be Readiness for Enhanced Spiritual Well-Being or Readiness for Enhanced Family Coping.Dueck Fe pussie-nursuns-anagmasig 1s vine Inman y vimana aU aman problem is incomplete or unclear. A possible diagnosis requires more data either to support or to refute it. For example, an elderly widow who lives alone is admitted to the hospital. The nurse notices that she has no visitors and is pleased with attention and conversation from the nursing staff. Until more data are collected, the nurse may write a nursing diagnosis of Possible Social Isolation related to unknown etiology. 3.2.5 A syndrome diagnosis is a diagnosis that is associated with a cluster of other diagnoses. Currently six syndrome diagnoses are on the NANDA International list. Risk for Disuse Syndrome, for example, may be experienced by long-term bedridden clients. Clusters of diagnosis associated with this syndrome include Jmpaired Physical Mobility, Risk for Impaired Tissue Integrity, Risk for Activity Intolerance, Risk for Constipation, Risk for Infection, risk for Injury, Risk for Powerlessness, Impaired Gas Exchange, and so on, 3.3 Components of a NANDA Nursing Diagnosis ‘A nursing diagnosis has three components: 3.3.1 Problem (Diagnostic Label) and Definition The problem statement, or diagnostic label, describes the client's health problem or response for which nursing therapy is given. It describes the client's health status clearly and concisely in a few words. The purpose of the diagnostic label is to direct the formation of client goals and desired ‘outcomes, It may also suggest some nursing interventions. 3.3.2 Etiology (Related Factors and Risk Factors) The etiology component of a nursing diagnosis identifies one or more probable cause of the health problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client's care. 3.3.3 Defining Characteristics Defining Characteristics are the cluster of signs and symptoms that indicate the presence of a particular diagnostic label, For e actual nursing diagnoses, the defining characteristic are the client's signs and symptoms, For risk nursing diagnoses, no subjective and objective signs are present. Thus, the factors that cause the client to be more than “normally” vulnerable to the problem from the etiology of a risk nursing diagnosis. 3.4 Formulating Diagnostic Statements 3.4.1 Basic Two-Part Statements The basic two-part statement includes the following: 1. Problem (P) : statement of the client’s response (NANDA Label) 2. Ettology (E): factors contributing to or probable causes of the responses ‘The two parts are joined by the words related to rather than due fo. The phrase due to implies that one part causes or is responsible for the other part. By contrast, the phrase related to merely implies a relationship. Some examples of two-part nursing diagnoses are shown below: Basic Two-Part Diagnostic Statement Problem Related to Etiology Constipation Related to | Prolonged laxative use10 Ineffective Breastfeeding | Related to __| breast engorgement 3.4.2. Basic Three-Part Statements ‘The basic three-part nursing diagnosis statement is called the PES format and includes the following: 1. Problem (P); statement of the client's response (NANDA Label) 2. Etiology (E): factors contributing to or probable cause of the response 3. Signs and Symptoms (5): defining characteristics manifested by the client Actual nursing diagnoses can be documented by using the three-part statement because the signs and symptoms have been identified. This format cannot be used for risk diagnoses because the signs and symptoms of the diagnosis, Basic Three-Part Statement Problem Related | Btiolog ‘As manifested ‘Signs and Symptoms ‘Constipation | welated to(en) rejection by | as manifested by] hypersmsitivity to husband (amb) criticism; sts © T don't know if ean don’t know if ean manage by myself” and rejects positive feetback ‘The PES format is especially recommended for beginning diagnosticians because the signs and symptoms validate why the diagnosis was chosen and make the problem statement mores descriptive. The disadvantage of the EPS format is that it can create very long problem statements, thereby making the problem and etiology unclear. 3.43 One-Part Statements Some diagnostic statements, such as wellness diagnoses and syndrome nursing diagnoses, consist of a NANDA label only. As the diagnostic labels are refined they tend to become more specific, so that nursing interventions can be derived from the label itself. ‘Therefore, an etiology may not be needed. For example, adding an etiology to the label Rape-Trauma Syndrome does not make the label any more descriptive or useful. 3.5. Ongoing Development of Nursing Diagnoses, The diagnoses are no longer grouped by Gordon’s pattern but by seven axes: diagnostic concept, time, unit of care, age, health status, descriptor, and topology. In addition, diagnoses are now listed alphabetically by concept, not by first word. In 1997, NANDA changed the name of its official journal from Nursing Diagnosis to Nursing Diagnosis: The International Journal of Nursing Language and Classification./ The subtitle emphasizes that nursing diagnosis is part of a larger, developing system of standaniized nursing language. This system includes classifications of nursing interventions (NIC) and nursing outcomes (NOC) that are being developed by other research groups and linked to the NANDA diagnostic labels.11 ‘The Seven axes: Taxonomy It ‘Axis | Dimension of the Human Response Values Examples 1 Diagnostic Concept N=99 ‘Anxiety, falls, nutrition, walking 2 Time N=4 ‘Acute, chronic, intermittent, continuous, 3 Unit of care Individual, family, eroup, community 4 ‘Age Infant, adolescent, young old adult s Health status Wellness, sick, actual 6 Deseriptor “Anticipatory, deficient, imbalanced, perceived 7 ‘Topology N= 17 body | Cerebral, gustatory, renal, visual parts/region 34, Planning 4° 4.1 Definition Planning is a deliberate, systematic phase of the nursing process that involves decision making and problem solving. In planning, the nurse refers to the client's, assessment data and diagnostic statements for direction in formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client’s health problems. 4.2 Types of Planning 4.2.1 Initial Planning The nurse who performs the admission assessment usually develops the initial comprehensive plan of care. Planning should be initiated as soon as possible after the initial assessment, especially because of the trend toward shorter hospital stays. 4.2.2 Ongoing Planning Ongoing planning is done by all nurses who work with the client. As nurses obtain new information and evaluate the client’s responses to care, they can individualize the initial care plan further. Ongoing planning also occurs at the beginning of a shift as the nurse plans the care to be given that day. 4.23 Discharge Planning Discharge planning, the process of anticipating and planning for needs after discharge, is a crucial part of a comprehensive health care and should be addressed in each client’s eare plan. 43 Developing nursing Care Plan 43.1 An Informal nursing care plan is a strategy for action that exists in the nurse’s mind, For example, the nurse may think, “ Mrs. Phan is very tired. I will need to reinforce her teaching after she is rested”. 43.2 Aformal nursing care plan is a written or computerized guide that organizes information about the client's care. 4.3.3 A standardized care plan is a formal plan that specifies the nursing care for groups of clients with common needs (eg, all clients with myocar infarction) 4.3.4 An individualized care plan is tailored to meet the unique needs of a specific client — needs that are not addressed by the standardized plan.z= 44 Standardized Approaches to Care Planning 4.4.1 Standards of Care describe nursing actions for clients with similar medication conditions rather than individuals, and they describe achievable rather than ideal nursing care. They defines the interventions fore which nurse are held accountable, they do not contain medical interventions. Standards of care are usually agency records and not part of the client’s care plan, but they may be referred to in the plan (¢.g., a nurse might write “see unit standards of care for cardiac catheterization). 44.2 Standardized care plans are reprinted guides for the nursing care of the client who has a need that arises frequently in the agency (¢.g., specific nursing diagnosis or all nursing diagnoses associated with a particular medical condition). They are written from the perspective of what care the client can expect. They should not be confused with standards of care. Although the two have some similarities, they have important differences. 4.4.3 Protocols are reprinted to indicate the actions commonly required for a particular group of clients. For example, an agency may have a protocol for admitting a client to the intensive care unit, for administering magnesium sulfate to a client with preeclampsia, or for caring for a client receiving continuous epidural analgesia. Protocols may include both physician's onder and nursing interventions. 4.44 Policies and Procedures are developed to govern the handling of frequently occurting situations. For example, a hospital may have a policy specifying the number of visitors a client may have. 4.4.5 A standing Order is a written document about policies, rules, regulations, or orders regarding client care. Standing orders give nurses the authority to carry out specific actions under certain circumstances, often wen a physician is not immediately available 4.5. Formats for Nursing Care Plans ‘Although formats differ from agency to agency, the care plan is often organized into four columns or categories: 4.5.1 nursing diagnoses 45.2. goalsidesired outcomes 453° nursing orders 4.54 evaluation Some agencies use a three-column plan in which evaluation is done in the goals column or in the nurses’ notes; others have a five-column plan that adds a column for assessment data preceding the nursing diagnosis column, 4.6 The Planning Process ‘The nurse engages in the following activities: 4.6.1 Setting Priorities Priority setting is the process of establishing preferential sequence for addressing nursing diagnoses and interventions. Nurses frequently use Maslow’s hierarchy of needs when setting priorities. 4.6.2. Establishing Client Goals (Desired Outcomes) Goals/desired outcomes describe, in terms of observable client responses, what the nurse hopes to achieve by implementing the nursing interventions. The term13 goalidesired outcome are used interchangeably. Some references also use the terms expected outcome, predicted outcome, outcome criterion, and objective. Some nursing literature differentiates the terms by defining goals as broad statements about the client’s status and desired outcomes as the mor specific, observable criteria used to evaluate whether the goals have been met. For example: Goal (broad) Improved nutritional status Desired outcome (specific) Gain 5 tb. by April 25 1. The Nursing Outcomes Classification Standardized nursing language is required in all phases of the nursing process if nursing data are to be included in computerized databases that are analyzed and used in nursing practice. Working toward this end, researchers have developed a taxonomy, the Nursing Outcomes Classification (NOC), for describing client outcomes that respond to nursing interventions (Johnson, Mass, & Moorhead, 2002), In the taxonomy, outcomes belong to one of seven domains. A NOC outcome is similar to a goal in traditional language. It is “a ‘measurable patient or family caregiver state, behavior, or perception that is conceptualized as a variable and is largely influenced by and sensitive to nursing interventions”. The NOC outcomes are broadly stated and conceptual. To be measured an outcome must he made more specific by identifying the specific indicators that apply to a client. Anindicator is, conerete, an “observable patient state, behavior, or self-reported perception or evaluation” and is similar to desired outcomes in traditional language. Indicators are also stated in neutral terms, but each outcome includes a five-point scale ( a measure) that is used to rate the client’s status on each indicator. 2. Purpose of Desired Outcomes/Goals Desired outcomes/goals serve the following purposes: Provide direction for planning nursing interventions. Ideas for interventions come more easily if the desired outcomes state clearly and specifically what the nurse hopes to achieve # Serve as criteria for evaluating client progress. Although developed in the planning step of the nursing process, desired outcomes serve as the criteria for judging the effectiveness of nursing interventions and client progress in the evaluation step. ‘© Enable the client and nurse to determine when the problem has been resolved. ‘© Help motivate the client and nurse by providing a sense of achievement. As goals are met, both client and nurse can see that their efforts have been worthwhile. This provides motivation to continue following the plan, especially when difficult lifestyle changes need to be made. 3. Long-Term and Short-Term Goals ‘Short-term goal are useful for: © clients who require health care for a short time © those who are frustrated by long-term goals that seem difficult to attain and who need the satisfaction of achieving a short-term goal. Long = term goal are often used for clients who live at home and have chronic health problems and for clients in nursing homes, extended14 care facilities, and rehabilitation centers. 4. Components of Goal(Desired Outcome Statements) ‘© Subject. The subject, a noun, is the client, any part of the client, or some attribute of the client, such as the client’s pulse or urinary output. The subject is often omitted in goals; itis assumed that the subject is the client unless indicated otherwise. ‘* Verb. The verb specifies an action the client is to perform , for example, what the client is to do, learn, or experience, Verbs that denote directly observable behaviors, such as administer, show, walk, must be used. ‘© Conditions or modifiers. Conditions or modifiers may be added to the verb to explain the circumstances under which the behavior is to be performed. They explain what, where, when, or how. For example: Walks with the help ofa cane (how) ‘© Criterion of desired performance. The criterion indicates the standard by which a performance is evaluated or the level at which the client will perform the specified behaviors. Examples are: ‘Weighs 75 kg by April (time). Lists five out of six signs of diabetes (accuracy) Walks one block per day ( time and distance) Administers insulin using aseptic technique (quality) 5. Guidelines for Writing Goals / Desired Outcomes ‘© Write goals and outcomes in terms of client responses, not nurse activities. Beginning each goal statement with the client will may help focus the goal on client behaviors and responses. Correct: Client will drink 100 cc of water per hour (client behavior) Incorrect: Maintain client hydration (nursing action) ‘* Be sure that desired outcomes are realistic for the client's capabilities, limitations, and designated time span, if itis indicated. ‘© Ensure that the goals and the desired outcomes are compatible with the therapies of other professionals. Make swe that each goal is derived fom only one nursing diagnosis. © Use observable, measurable, terms for outcomes. © Make sure the client considers the gouls/desired outcomes important and values them. 4.6.3. Selecting Nursing Interventions and Activities Nursing interventions and activities are the actions that a nurse performs to achieve client goals. ‘Types of Nursing Interventions 1. Independent Interventions are those activities that nurses are licensed to initiate on the basis of their knowledge and skills. They include physical care, ongoing assessment, emotional support and comfort, teaching, counseling, environmental management, and making referrals to other health care professionals. McCloskey and Bulechek (2000) refer to these as nurse-initiated treatment15, 2. Dependent Intervention are activities carried out under the physician's orders or supervision, or according to specified routines. McCloskey and Bulechek (2000) call these physician-initiated treatmenss. Physician's orders commonly include orders for medications, intravenous therapy, diagnostic tests, treatments, diet, and activity. The nurse is responsible for explaining, assessing the need for, and administering the medical orders. 3. Collaborative Interventions are actions the nurse carries out in collaboration with other health team members, such as physical therapist, social workers, dietitians, and physicians. Collaborative nursing activities reflect the overlapping responsibilities of, and collegial relationship between health personnel. 4.64 Writing Nursing Orders Nursing orders are instructions for the specific individualized activities the nurse performs to help the client meet established health care goals. The term order connotes a sense of accountability for the nurse who gives the order and. for the nurse who carries it out Components of a nursing order are the following 1, Date, Nursing orders are dated when they are written and reviewed regularly at intervals that depend on the individual’s needs. 2. Action Verb. The action verb starts the order and must be precise. 3. Content Area, The content is the what and the where of the order. 4. Time Element. The time element answers when, how long, or how often the nursing action is to occur. 5. Signature. The signature of the nurse prescribing the order shows the nurse's accountability and has legal significance. 1. Observation orders include assessments made to determine whether a complication is developing, as well as observation of the client's responses to nursing and other therapies. Some examples are “Auscultate lungs qBh,” “Observe for redness over sacrum q2h.” and “Record intake and output hourly”, 2. Prevention orders prescribe the care needed to prevent complications or reduce risk factors. They are needed mainly for potential nursing diagnoses and collaborative problems. Examples of prevention orders are “Turn, cough, and deep breathe q2h”. 3. Treatment orders include teaching, referrals, physical care, and other care needed to treat an actual nursing diagnosis. Some orders accomplish either prevention or treatment functions, depending on the status of the problem. “If fundus is boggy, massage until firm” can also be intended to treat an actual postpartum hemorrhage. 4. Health promotion orders are appropriate when the client has no health problems or when the nurse makes a wellness nursing diagnosis.16 “Discuss the importance of daily exercises” and “Explore infant- stimulation techniques” 4.6.5 Delegating Implementation ‘The American Nurses Association defines delegation as “the transfer of responsibility for the performance of an activity from one person to another while retaining accountability for the outcome.” This differs from assignment which is a “downward or lateral transfer of both the responsibility and accountability of an activity from one individual to another”, The nurse has two responsibilities in delegating and assigning: 1. appropriate delegation of duties (that is, giving people duties within their scope of practice) 2. adequate supervision of personnel to whom work is delegated or assigned 4.7 The Nursing Interventions Classifications — it describes the efforts of the North American Nursing Diagnosis Association (NANDA) to standardize the language for describing problems that require nursing care and to create a taxonomy of standardized client outcome labels. A group of nurse researchers also recognized the need for standardized language to describe the interventions that nurses perform. A taxonomy of nursing interventions referred to as the Nursing Interventions Classification (NIC) taxonomy has been developed by the Iowa Intervention Project (McCloskey & Bulechek, 2000). This taxonomy consists of three levels: 4.7.1 Level, domains 4.72 Level2,classes 473 Level 3, interventions NIC Taxonomy Level I: Domains Level 2: Classes (lettered for eross-referencing) ‘Domain T ‘A. Activity and Exercise Management: Interventions to organize or Physiological: Rasic assist with physical activity and energy conservation and Care that supports physical | __ expenditure functioning, B. Elimination Management: Interventions to establish and maintain regular bowel and urinary el ‘complications due to altered patterns C. Immobility Management: Interventions to manage restricted body Movement and the sequelae D. Nutrition Support: Interventions to modify or maintain nutritional status E, Physical Comfort Promotion: Interventions to promote comfort using physical techniques F. Self-Care Facilitation: Interventions to provide or assist with routine activities of daily living Domain 2 G. Electrolyte and Acid-Base Management: Interventions to regulate Physiological: Complex electrolyte/acid-base balance and prevent complications Care ‘that supports | H. Drug Management: Interventions to facilitate desired effects of homeostatic regulation pharmacological agents 1 Neurologic Management; Interventions to optimize neurologic funetions J. Perioperative Care: Interventions to provide care before, during, and immediately after surgery K. Respiratory Management: Interventions to promote airway patency and gas exchange L. Skin/Wound Management: Interventions to maintain or restore tissue integrity tion patterns and manage5 7 'M. Thermoregulation: Interventions to maintain body temperature within a normal range N. Tissue Perfusion Management: Interventions to optimize circulation of blood and fluids to the tissue Level : Domains Level 2: Classes (lettered for cross-referencing) ‘Domain 3 (©. Behavior Therapy: Interventions to reinforce oF promote Behavioral desirable behaviors or alter undesirable behaviors Care that supports psycho- | P. Cognitive Theory: Interventions to reinforce or promote desirable Social functioning and | __ cognitive functioning or alter undesirable cognitive functioning facilites lifestyle changes | Q. Communication Enhancement: Interventions to facilitate Domain 4 U. Crisis Management: Interventions to provide immediate short- Safety term help in both psychological and physiological crisis Care that supports | V._ Risk Management: Intervention to initiate rsk-reduction protection against harm activities and continue monitoring risk over time Domain 5 W.Childbeating Care: Interventions to assist in understanding Family and coping with the psychological and physiological changes Care that supports the | during the childbearing period family unit Z. Childbearing Care: Interventions to assist in child rearing X. Lifespan Care: Interventions to facilitate family unit functioning delivering and receiving verbal and non verbal messages R. Coping Assistance: Interventions to assist another to build on own strength, to adapt to a change in function, or to achieve a higher level of function S. Patient Education: Interventions to facilitate learning TT. Psychological Comfort Promotion: Interventions to promote comforts using psychological techniques and promote the health and welfare of family members through ‘out the lifespan Domain 6 Y. Health System Medication: Interventions to facilitate the inter - Health System Face between patient/family and the health care system Care that supports effective | a. Health System Management: Interventions to provide and use of the health care] enhance support services forthe delivery of care delivery system b. Information Management: Interventions to facilitate communi - cation among health care providers Domain 7 ¢. Community Health Promotion: Interventions that promote the Community health of the whole community Care that supports the | d. Community Risk Management: Interventions that assist in health of the community detecting or preventing health risks to the whole community Implementing and Evaluating 5.1 Definition 5.2 a Implementing consists of doing and documenting the activities that are specific nursing actions needed to carry out the interventions (or nursing orders). Implementing Skills 5.2.1 The cognitive skills (intellectual skills) include problem solving, decision making, critical thinking, and creativity. They are crucial to safe intelligent nursing care, 5.2.2 Interpersonal skills are all of the activities, verbal and nonverbal, people uses when interacting directly with one another. 5.2.3 Technical skills are “hands-on” skills such as manipulating equipment, giving injections and bandaging, moving, lifting, and repositioning clients. These skills are also called tasks, procedures, or psychomotor skills. The term psychomotor includes the interpersonal component, for example, the need to communicate with the client. Process of Implementing 5.3.1 Reassessing the client 5.3.2 Determining the nurse's need for assistance18 5.33. Implementing the nursing interventions 5.3.4 Supervising the delegated care 5.35 Documenting nursing activities 5.4, Definition of Evaluation Evaluating is a planned, ongoing, purposeful activity in which clients and health care professionals determine: 5.4.1 the client’s progress toward achievement of goals/outcomes 5.4.2 the effectiveness of the nursing process because conclusions drawn from the evaluation determine whether the nursing interventions should be terminated, continued, or changed. 5.5 Five Components of the Evaluation Process 5.5.1 Collecting data related to the desired outcomes (NOC indicators) 5.5.2 Comparing the data with outcomes 5.5.3 Relating nursing activities to outcomes 5.5.4 Drawing conclusions about problem status 5.5.5 Continuing, modifying, or terminating the nursing care plan 5.6 Evaluating the Quality of Nursing Care 5.6.1 Quality Assurance ‘A quality assurance (QA) program is an ongoing, systematic process designed to evaluate and promote excellence in the health care provided to clients. Quality assurance frequently refers to evaluation of the level of care provided in a health care agency, but it may limited to the evaluation of the performance of one nurse or more broadly involve the evaluation of the quality of the care in an agency, or even in a country. Quality assurance requires evaluation of three components of care: 1. Structure evaluation focuses on the setting in which care is given. It answers this question: What affects does the setting have on the quality of care? Structural standards describe desirable environmental and organizational characteristics that influence care, such as equipment and staffing. 2. Process evaluation focuses on how the care was given. It answers questions such as these: Is the care relevant to the client’s needs? Is the care appropriate, complete, and timely? Process standards focus on the manner in which the nurse uses the nursing process. 3. Outcome evaluation focuses on demonstrable changes in the client's health status as a result of nursing care. Outcome eriteria are written in terms of client responses or health status, just as they are for evaluation within the nursing process. For example, “How many clients undergoing hip repairs develop pneumonia?” or “How many clients who have a colostomy experience an infection that delays discharge?” 5.6.2 Quality Improvement Quality improvement (QD) is also known as continuous quality improvement (CQI), total quality management (TQM), performance improvement (PI), or persistent quality improvement (PQI). According to Schroeder , QI is the commitment and approach used to continuously improve every process in every part of an organization, with the intent of meeting and exceeding customer expectations and outcomes. Unlike quality assurance, QI follows client care rather than organizational structure, focuses on process rather than individuals, and uses a systematic approach with the intention of improving the quality of care rather than ensuring the quality of care. QI studies often focus on identifying and19 correcting a system’s problems, such as duplication of services in a hospital or improving services. 5.6.3 Nursing Audit An audit means the examination or review of record. A retrospective audit is the evaluation of a client's record after discharge from agency. Retrospective means “relating to past events.” A concurrent audit is the evaluation of a client’s health care while the client is still receiving care from the agency. ‘These evaluation use interviewing, direct observation of nursing care, and review of clinical records to determine whether specific evaluative criteria have been met. Another type of evaluation of care is the peer review: In nurse peer review, nurses functioning in the same capacity, that is, peers, appraise the quality of care or practice performed by other equally qualified nurses. The peer review is based on preestablished standards or criteria. There are two types of peer reviews: individual and nursing audits. The individual peer review focuses on the performance of an individual nurse ‘The nursing audit focuses on evaluating nursing care through the review of records. ‘The success of these audits depends on accurate documentation; auditors assume that if the data have been recorded, the care has not been given. 6. Documenting and Reporting 5 6.1 Definition of Terms A report is oral, written, or computer-based communication intended to convey information to others. For instance, nurses always report on clients at the end of a hospital work shift. A record is written or computer-based. The process of making an entry on a client record is called recording, charting, or documenting. 6.2 Purposes of Client Reconls 6.2.1 Communication. ‘This prevents fragmentation, repetition, and delays in client care 6.2.2 Planning Client Care. Nurses use baseline and ongoing data to evaluate the effectiveness of the nursing care plan. 6.2.3. Auditing Health Agencies. An audit is a review of client reconis for quality assurance purposes. 6.24 Research The treatment plans for a number of clients with the same health problems can yield information helpful in treating other clients. 6.2.5 Education. A record can frequently provide a comprehensive view of the client, the illness, effective treatment strategies, and factors that affect the outeome of the illness. 6.2.6 Reimbursement. This is not only facilitates reimbursement from the federal government, but also from insurance companies and other third-party payers. 6.2.7 Legal Documentation, The client’s record is a legal document and is usually admissible in court as evidence. 628 Health Care Analysis. Records can be used to establish the costs of various services and to identify those services that cost the agency money and those that generate revenue.20 6.3. Documentation Systems 6.3.1 Source-Oriented Record The traditional client record is a source-oriented record. Each person or department makes notations in a separate section or sections of the client's chart. For example, the admission department has an admission sheet, the physician has a physician's order sheet, a physician’s history sheet, and progress notes; nurses use the nurse’s notes; and other departments or personnel have their own records. ‘Narrative charting is a traditional part of the source oriented record. It consists of written notes that include routine care, normal findings, and client problems. 6.3.2 Problem-Oriented Medical Record In the problem-oriented medical record (POMR), or problem-oriented record (POR), established by Lawrence Weed in the 1960s, the data are arranged according tot the problems the client has rather than the source of the information. 1 it encourages collaboration 2. the problem list in the front of the chart alerts caregivers to the client's needs and makes it easier (o tract the status of each problem The disadvantages are that: 1. caregivers differ in their ability to use the required charting format 2. it is somewhat inefficient because assessment s and interventions that apply 10 more than one problem must be repeated. 1. Database — it includes the nursing assessment, the physician’s history, social and family data, and the results of the physical examination and baseline diagnostic tests. Data are constantly updated as the client’s health status changes. 2. Problem list — problems are listed in the order in which they are identified, and the list is continually updated as new problems are identified and others resolved. 3. Plan of care — physician write physician's orders or medical care plans, nurses write nursing orders or nursing care plans. 4. Progress notes — is a chart entry made by all health professionals involved in a client's eare; they all use the same type of sheet for notes. Progress notes are numbered to correspond to the problems on the problem list and may be lettered for the type of data. For example, the SOAP format is frequently used. SOAP is acronym for subjective data, objective data, assessment, and planning. S - Subjective data consist of information obtained from what the client says. It describes the client's perceptions of and experience with the problem. Subjective data are included only when it is important and relevant to the problem.2 © = Objective data consist of information that is measured or observed by use of the senses (¢.g., vital signs, laboratory and x- ray results) A. ~ Assessment is the interpretation or conclusions drawn about the subjective and objective data. P - Theplan is the plan of care designed to resolve the stated problem. Over the years, the SOAP format has been modified. The acronyms SOAPIE ‘and SOAPIER refer to formats that add interventions, evaluation and revision. I~ Intervention refer to the specific interventions that have actually been performed by the caregiver. E - Evaluation includes the client responses to _ nursing interventions and medical treatments, This is primarily reassessment data, R - Revision reflects care plan modifications suggested by the Evaluation. Changes may e made in desired outcomes, interventions, or target dates. 633 PIE ‘The PTE documentation model groups information into three categories. PIE is an acronym for problems, interventions, and evaluation of nursing care. 634 Focus Charting Focus charting is intended to make the client and the client concerns and strengths the focus of care. Three columns for recording are usually used: date and time, focus, progress notes. The focus maybe a condition, a nursing diagnosis, a behavior, a sign or symptom, an acute change in the client’s condition, or a client strength. ‘The progress notes are organized into 1. @) Data Data category reflects the assessment phase of the nursing process and consist of observations of client status and behaviors including data flow sheets. 2. (A) Action ‘The action category reflects planning and implementation and includes, immediate and future nursing actions. It may also include any changes. to the plan of care. 3. (R) Response The response category reflects the evaluation phase of the nursing process and describes the client’s response to any nursing and medical care 6.3.5 Charting by Exception Charting by Exception (CEB) is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded, Flow sheet. Examples of flow sheets include a graphic record, fluid balance record, daily care record, client teaching record, client discharge record, and skin assessment record.22 2. Standards of nursing care, An agency using CBE must develop its own specific standards of nursing practice that identify the minimum criteria for client care regardless of clinical area 3. Bedside aecess io chart forms. In the CBE system, all flow sheets are kept at the client’s bedside to allow immediate recording and to eliminate the need to transcribe data from the nurse’s worksheet to the permanent record. 6.3.6 Computerized Documentation Computerized clinical record system are being developed as a way to ‘manage the huge volume of information required in contemporary health care, Computers make care planning and documentation relatively easy. 6.3.7 Case Management The case management model emphasizes quality, cost-effective care delivered within an established length of stay. This model uses a multidisciplinary approach to planning and documenting client care, using critical pathways. These forms identify the outcomes that certain groups of clients are expected to achieve on each day of care, along with the interventions necessary for each day. Along with critical pathways, the case management model incorporates graphics and flow sheets. Progress notes typically use some type of charting by exception. For example, if goals are met, no further charting is required. A goal that is not met is called a variance, Variations are deviations to what is planned on the critical pathway — unexpected occurrences that affeet the planned care or the client’s responses to care. 64 Reporting The purpose of reporting is to communicate specific information to a person or group of people. A report, whether oral or written, should be concise, including pertinent information but no extraneous detail CChange-of-Shift-Reports A change-of-shift-report is a report given to all nurses on the next shift 6.4.2 Telephone Report 643 ‘The nurse receiving a telephone repost should document the date and time, the name of the person giving the information, and the subject of the information received and signs the notation. Telephone reports usually include the client’s name and medical diagnosis, change in nursing assessment, vital signs related to baseline vital signs, significant laboratory data, and related nursing interventions. ‘Telephone Orders Physician often order a therapy (e.g., a medication) for a client by telephone. Most agencies have specific policies about telephone orders. Many agencies allow only registered nurses to take telephone orders. While the physician gives the order, write it down and repeat it back to the physician to ensure accuracy. Question the physician about any order that is ambiguous, unusual (e.g., an abnormally high dosage of a medication), or contraindicated by the client’s condition.23 6.44 Cate Plan Conference A care plan conference is a meeting of a group of nurses to discuss possible solutions to certain problems of a client, such as inability to cope with an event or lack of progress toward goal attainment. 64,5 Nursing Rounds During round, the nurse assigned to the client provides a brief summary of the client’s nursing needs and the interventions being implemented. 2. Communication 21 2.2 23 24 Definitions 2.1.1 The basic element of human interactions that allows people to establish, maintain and improve contacts with others 2.1.2 A complex, multifaceted , dynamic series of events involving behaviors and relationships and allows individuals to associate with others through meanings which are generated and transmitted 2.1.3 Verbal and nonverbal behavior with a social context and includes all symbols and clues used by persons in giving and receiving meaning 2.1.4 Do not only refers to content but also to feelings and emotions that people may convey in relationship 2.1.5 An act of sharing because it influences a relationship 2.1.6 An active process between sender and receiver Levels of Communication 2.2.1 Intrapersonal — occurs within the individual. It is self-talk or an internal dialogue that occurs constantly and consciously. The goal is self-awareness, which is influenced by self-concept and feelings of self worth. 2.2.2 Interpersonal — interaction that occurs between 2 people or in a small group. It is often face-to-face and is the most frequently used type in nursing situations. It allow problem-solving, sharing of ideas, decision-making and personal growth 2.2.3 Public Communication — interaction with large groups of people, e.g. giving a lecture to a class of reviewees Elements 2.3.1 Referent—a stimulus which motivates a person to communicate with another. May be an object, experience, emotion, idea or act. 2.3.2 Sender or encoder the person who initiates the interpersonal communication or message 2.3.3 Message — the information sent or expressed by the sender 2.3.4 Channels ~ means of conveying messages, e.¢., visual (facial expression), auditory (spoken word) or tactile (touching) senses 2.3.5 Receiver or decoder ~ person to whom the message is sent. Tobe effective, the receiver must perceive or become aware of he message. 2.3.6 Feedback —verbal and nonverbal response to the message. To be effective, the sender and the receiver must be sensitive and open to each other’s message, clarify the message and modify behavior accordingly Modes 2.4.1 Verbal Communication — involves spoken or written words ‘A. Language ~ the words, their pronunciation and method or combining them that is used and understood by a community B. Effective verbal communication is simple, short and direct. Clarity is achieved by speaking slowly and enunciating clearly24 C. A message spoken in terms the client understands makes communication more effective. Do not use medical terms when giving health teachings to clients; if you must translate them to layman’s terms D. Denotative meaning — one shared by individuals who use a common language. A word that means the same fo everyone. E. Connotative meaning — thoughts, feclings or ideas that people have about a word. They are shades or interpretations of a words meaning rather its definite definition 2.42 Nonverbal Communication — transmission of message without the use of words. “Actions speak louder than words.” One of the most powerful ways to convey messages to others ‘A. Metacommunication — a message within a message that conveys the sender’s attitude toward the self and the message, as well as the attitudes, feelings and intentions toward the listener. Maybe verbal or nonverbal B. Personal appearance — of the first things noticed during an intrapersonal encounter. People form an impression about another within 20 seconds to 4 minutes and 84% of this impression is based on appearance. Physical characteristies, dress, grooming as well as jewelry and other adornment provide clues to the person’s physical well-being, personality, social status, occupation, religion, culture and self concept. Physical characteristics, e.g., condition of hair, nails, skin or teeth, weight, energy level, etc, also communicate information about the level of health, in fact, even socioeconomic status C. Intonation — voice tone ean be a clue to a client's emotional tone or energy level D. Facial expression — the face and eyes send overt and subtle cues that assist in interpretation of messages. Studies show that the face reveals 6 primary emotions: surprise, fear, anger, disgust, happiness and sadness E. Posture and Gait ~ reflect attitudes , emotions, self-concept and physical wellness F. Gestures - a wave of a hand, a salute or shifting of feet are visual italics which may emphasize, punctuate or clarify the spoken word, Three functions of gestures: illustrate an idea; express an emotional state; or make a signal G. Touch — a personal form of nonverbal communication. Affection, emotional, support, encouragement, tenderness and personal attention can be conveyed through touch. Touch, however, must be used with caution because strong social norms govern its use. Who, when, why and where people touch are determined by unwritten sociocultural guidelines 2.5 Characteristics of Communication 2.5.1 Credibility —includes cognitive skills, interpersonal skills and right attitudes 2.5.2 Clarity — messages should b clear and direct, 2.5.3 Brevity — briefand direct use few words 2.5.4 Simplicity — use layman’s term. Avoid medical terms 2.5.5 Timing and Relevance - information to be given, to the client should be relevant to the client’s health condition 2.5.6 Adaptability and Flexibility — use various technique in communication with client to adjust to the age or educational attainment of the client 2.5.7 Intonation ~ the tone of voice may affect the interaction process. It provides information about the person's mood 2.5.8 Pacing — speak slow enough to convey the message clearly25 2.6 Factors Influencing Communication 2.6.1 Development — the environment provided by parents affects the ability to communicate 2.6.2. Perception — a personal view of events 2.6.3, Values — standards that influence behavior, what a person considers important in life and, therefore, influence expression of thoughts and ideas 2.64. Emotions ~ a person's subjective feelings about events. They influence the ability to successfully receive a message 2.6.5 Sociocultural background — communication style is highly dependent on cultural factors. e.g. a nurse can ask an American client directly without the latter feeling offended., “Are you gong to commit suicide?” With a Filipino suicidal patient, however, a nurse tends to diversional therapy rather than confront the client 2.6.6 Gender— men and women have different communication styles 2.6.7 Knowledge — a common language is important when communicating across different knowledge levels. 2.68 Roles and Relationships ~ ¢.g., students talk with friends in a different way than with teachers or parents. 2.6.9 Environment — people tend to communicate more effectively in a comfortable environment 2.6.10 Space and Territoriality A. Territoriality — the drive to gain, maintain and defend an exclusive right to an area or space. It provides people with a sense of identity, security and control B. Proxemics (Hall, 169) — use of space in interpersonal relationships or the distance between communicators. During social interactions, people consciously maintain a distance between themselves (personal space) When personal space is threatened, a defensive response occurs, thus preventing effective communication 2.7 Functions of Communication in Nursing 2.7.1 To gather information A. Collect assessment information on which to base diagnosis and decision- making B. Use methods to provide information that promotes client understanding, retention and comprehension 2.7.2 To expert influence — use communication techniques when helping clients to change altitudes, beliefs and actions 2.73 To provide comfort A. Interact with clients to provide reassurance, support and comfort B, Reduce a client’s uncertainty during stressful times to alleviate or moderate emotional distress 2.7.4 To promote relations ‘A. Interact to define control and modify the relationship between nurse and client B. Establish, maintain, repair and end relationships 2.7.5 Toestablish identity ‘A. Establish self-identities to present oneself in ways that build credibility and produce friendliness, respect and nurturing B. Present oneself in a way that reflects competency, 2.8 Methods of effective Nursing Communication 2.8.1 Listen attentively26 28.2 Convey acceptance — do not judge another person and demonstrate willingness to listen to the client's beliefs, values and practices 2.83 Ask related questions 2.8.4 Paraphrase — restate client's messages in order to convey to the client that you understood his message 2.8.5 Clarify — repeat the message or admit you did not understand and then let the client repeat his message 2.8.6 Focus — eliminates vagueness in communication y limiting the area of discussion 2.8.7 State conversation — share with the client observations regarding their behavior 2.8.8 Offer information — as a means to provide additional data or insight 2.8.9 Maintain silence ~ allows the nurse and client to organize thoughts as well as observe each other's behavior 2.8.10Be assertive — express feelings and emotions confidently, spontaneously and honesty 2.8.11 Summarize — a concise review of main ideas that have been discussed, it sets the tone for further interactions 2.9 Barriers Effective Communication 2.9.1 Giving an opinion — takes decision-making away from the client, inhibits spontaneity, stalls problem-solving and creates doubt 2.92 Giving false reassurance — can discourage open communication. Genuine truthful reassurance is what is important is validating a client's self-worth and sense of hope 2.9.3 Being defensive ~ when a nurse becomes defensive, the client’s concerns are often ignored 2.9.4 Showing approval or disapproval — offering excessive praise implies that the behavior is the only acceptable one. But disapproval also implies that the client must meet the nurse’s expectations or standards 2.95 Stereotyping — inhibits communication and threatens a client-nuse relationship. e.g., “People from depressed areas have very poor hygiene.” 2.9.6 Asking why — can cause resentment, insccurity and mistrust 2.9.7 Changing the topic inappropriately — definitely rude and shows a lack of empathy 3. Client Education 3.1 Purposes of Client Education — the goal of client education is to assist individuals, families, or communities in achieving optimal levels of health (Edelman and Mandle, 1998) 3.2. Domains of Leaming 3.2.1 Cognitive Learning — includes all intellectual behaviors such as the acquisition of knowledge, comprehension (ability to understand), application (using abstract ideas in concrete situations) analysis (relating ideas in an organized way), synthesis (recognizing parts of information as a whole), and evaluation (judging the worth of a body of information) 3.2.2 Affective learning — deals with the expression of feelings related to attitudes, opinions, or values. 3.2.3. Psychomotor learning — involves acquiring skills that require the integration of mental and motor activity such as the ability to walk, to use an eating utensil, or to give an insulin injection 3.3 Teaching Methods Based on client’s Developmental Capacity 3.3.1 Infant + Keep routines 9e.g,, feeding, bathing) consistent27 * Hold infant firmly while smiling and speaking softly to convey sense of trust * Have infant touch different textures (¢.g., soft fabric, hard plastic) 3.3.2 Toddler * Use ply to teach procedure or activity (eg. handling, exa equipment, applying bandage to doll) * Offer picture books that describes story of children in hospital r clinic * Use simple words such as cut instead of laceration to promote understanding ation 3.3.3 Preschooler * Use role playing, imitation, and play to make it fun for preschoolers to learn * Encourage questions and offer explanations. Use simple explanations and demonstrations * Encourage children to learn together through pictures and short stories about how to perform hygiene 3.3.4 School-dge Child * Teach psychomotor skills needed to maintain health. (Complicated skills such as learning to use syringe, may take considerable practice) * Offer opportunities to discuss health problems and answer questions 3.3.5 Adolescent * Help adolescent learn about feelings and need for self-expression * Use teaching as collaborative activity * Allow adolescents to make decisions about health and health promotion (safety, sex education, substance abuse) * Use problem solving to help adolescents make choices 3.3.6 Young or Middle Adult * Encourage participation in teaching plan by setting mutual goals + Encourage independent learning * Offer information so that adult can understand effects of health problem 3.3.7 Older Adult * Teach when client is alert and rested * Involve the adult in discussion or activity * Focus on wellness and the person’s strength * Use approaches that enhance sensorially impaired client’s reception stimuli * Keep teaching session short 3.4 Teaching Methods Based on Client’s Leaming Needs 3.4.1 Cognitive Discussion (One-on-One or Group) * May involve nurse and client or nurse with several clients * Promotes active participation and focuses on topics of interest o client * Allows peer support * Enhances application and analysis for new information Lecture * Is more formal method of instruction because it is controlled by teacher * Helps learner acquire new knowledge and gain comprehension28 Question-and-Answer Session * Is designed specifically to address client’s concerns ‘* Assists client in applying knowledge Role Play, Discovery ‘ Allows client to actively apply knowledge in controlled situation ‘* Promotes synthesis of information and problem solvin, Independent Project (Computer-Assisted Instruction), Field Experience * Allows client to assume responsibility for completing learning activities at own pace '* Promotes analysis, synthesis, and evaluation of new information and skills 3.4.2 Affective Role Play * Allows expression of values, feelings, and attitudes * Allows client to acquire support from others in group ‘* Permits client to learn from other’s experiences, ‘+ Promotes responding, valuing, and organization Discussion (One-on-One) * Allows discussion of personal, ser itive, topics of interest or concern 3.43 Psychomotor Demonstration ‘* Provides presentation of procedures or skills by nurse ‘+ Permits client to incorporate modeling of nurse’s behavior ‘+ Allows nurse to control questioning during demonstration Practice ‘Gives client opportunity to perform skills using equipment ‘+ Provides repetition Retum Demonsiration + Permits client to perform skills as nurse observes Is excellent source of feedback and reinforcement Independent Project, Game * Requires teaching method that promotes adaptation and origination of psychomotor learning ‘* Permits learner to use new skills UNIT IIL - Principles for Nursing Practice 1. Vital Signs 1.1 Temperature 1.1.1 Sites and normal values * Oral =37° C= 98°F 1. The nurse should wait for 20-30 minutes before taking the temperature of a client who has taken hot or cold drinks or food, has been smoking or hhas been through strenuous exercise 2. Approximately 1°F higher than the body’s core temperature (temperature of deep tissues) * Rectal = 375°C = 99.6 °F 1. Considered to be the most reliable because few factors can alter the result 2. Should not be taken in newboms because the thermometer can cause rectal trauma29 3. Usually a few tenths higher than the oral temperature Axilla = 36.4°C (97.°6F). Safest site for temperature measurement, especially with newboms but is less convenient and accurate and requires longer time (5 minutes) ‘Tympanic membrane 1. Excellent site because of its highly vascular nature and easy accessibility 2. Directly reflects core temperature 1.1.2 Factor affecting body temperature Age 1. An infant's temperature may change drastically with changes in the environment because temperature-control mechanisms are not yet fully developed 1.1 Clothing must be adequate and exposure to extreme temperatures must be avoided 1.2. 30% of body heat of newboms is lost through the head, that is why a cap is to be worn to prevent heat loss 2, Temperature regulation stabilizes during puberty The elderly are sensitive to extremes in temperature because of: 3.1 Deterioration in thermoregulation 3.2 Poorvasomotor control 3.3 Reduced amount of subcutaneous tissues 3.4 Reduce sweat gland activity 3.5 Reduced metabolism Exercise ~ muscle activity requires increased body supply — increase in carbohydrate and fat breakdown for more energy — increased metabolism — increased heat production — increased temperature Hormone level 1. Progesterone increases body temperature. When progesterone levels are low, just before ovulation, the temperature falls a few tenths of a degree below the baseline; during ovulation, greater amounts of progesterone raises the body temperature to previous baseline or higher. 2. Menopausal women may experience periods of intense body heat and sweating lasting from 30 seconds to 5 minutes due to the instability of the vasomotor control 3. The amount of thyroxine, epinephrine and norepinephrinein the body can also affect temperature Circadian rhythms ~ body temperature changes 0.5° C to 1°C during a 24 hour period 1, Temperature is usually lowest between 1:00 and 4:00 a.m. 2. During the day, body temperature rises, steadily until 6:00 p.m. then declines to early morning levels Stress — physical and emotional stress inerease body temperature through hormonal and neural stimulation Environment 1.1.3 Fever — rectal temperature above 38°C (100.4°F) that is measured under resting conditions. Common fever pattems: Sustained — little fluctuation, e.g., pneumococcal pneumonia Intermittent — wide temperature variations with return to normal at least once daily, e.g., malaria, bacterial or viral infections Remittent ~ fluctuations less than intermittent, with no return to normal; e.g, measles, Dengue fever Recurrent — duration of few days, returns to normal for | day or more, then recurs; €.g., Hodgkin’s disease, leptospirosis30 © Night — eg. , tuberculosis 1.1.4 Body temperature disorders ‘+ Heat exhaustion — occurs when a person loses excessive amounts of water and sodium because of profuse diaphoresis ‘* Heat Stroke — very high temperatures of 105°F or more produces tissue damage to the cells of all body organs; has a high fatality rate 1. Suddenly becomes giddy, confused or delirious 2. Extreme thirst, nausea, muscle cramps and visual disturbances 3. Hot, dry skin— most important sign 4. Does not sweat because of severe electrolyte loss and impaired hypothalamic function 5. Tachycardia and hypotension 6. Becomes unconscious incontinent, with blotchy redness of the skin and fixed, unreactive pupils * Hypothermia 1, Skin temperature drops to 35°C (95°F) and uncontrolled shivering begins 2. Loss of memory, depression and signs of poor judgment 3. If temperature falls below 34.4 °C (94 °F), heat and respiratory rates and bblood pressure fall an skin becomes cyanotic 4, May have cardiac dysthythmias, lose consciousness and becomes unresponsive to painful stimuli 5. Frostbites are frozen surface areas of the skin, e.g, earlobes, fingers, toes 6. Formula 6.1 to convert Fahrenheit to centigrade, subtract 32 from the Fahrenheit reading and multiple the result by 5/9 Example: (104° F - 32°F) x 5/9 = 40°C 6.2 To convert centigrade to Fahrenheit, multiple the centigrade reading by 9/5 and add 32 to the product Example: (9/5 x 40° C) + 32 = 104° F 1.2. Pulse—The pulse is the palpable bounding of the blood flow in a peripheral artery 1.2.1 Pulse Sites Site Location ‘Assessment “Temporal ‘Over temporil bone of head, above | Easily accessible site usal to assss and lateral to eye pulse in childzen Carotia Along medial edge of stemockido-| Easily accessible site used during mastoid musele in neck physiological shock or eardiae arrest ‘when other sites are not palpable Apical Fourth to fifth intercostal space at left | Site used to auscultate for heart sounds; mid clavieular line site used for infants and young children Brachial Groove between biceps and triceps | Site used to assess pulse rate; site used muscles at antecubital fossa {toauscultate blood pressure Radial Radial or thumb side of forcanm at | Common site used to assess character wrist of pulse peripherally and assess status of circulation to hand Ulnar ‘Ulnar side of forearm at wrist Site used to assess status of circulation tohand Femoral Below inguinal lignment, midway | Site used to assess character of pulse ‘between symphysis pubis and anterior | during physiological shock or cardiac