
MIDTERMS The ability to promote health measures that
MODULE 1: WELLNESS AND WELL-BEING
 WELLNESS is well being. It involves engaging in
attitudes and behaviors that enhance quality of life
and maximize personal potential.
 WELL-BEING is a subjective perception of balance,
harmony and vitality.
 Wellness is a choice; way of life; the integration of
body, mind and spirit and the loving acceptance of
one’s self.
DIMENSIONS OF WELLNESS
Physical Dimension
- Genetic make-up, age, developmental level, race
and sex that strongly influence health status and
health practices.
 The ability to carry out daily tasks, achieve fitness
(e.g. pulmonary, cardiovascular, gastrointestinal),
maintain adequate nutrition and proper body fat, avoid
abusing drugs and alcohol or using tobacco products,
and generally to practice positive lifestyle habits.
Example: The toddler just learning to walk is prone to
tall and injure himself.
Emotional Dimension
 Ability to express feelings & develop/sustain
relationship; long term stress affects body condition
→ health habits
 The ability to manage stress and to express emotions
appropriately, Emotional wellness involves the ability to
recognize, accept, and express feelings.
Mental Dimension
Positive sense of purpose & underlying belief in one’s
own worth
 Feeling Good
Socio-cultural Dimension
 Health practices & beliefs are strongly influenced by
a person’s economic level, life style, family and
culture.
 Family & culture to which the person belongs
determine patterns of living & values about health
& illness are often unalterable
Intellectual Dimension
 Cognitive abilities, educational background and past
experiences.
 Influence a client’s responses to teaching about
health and reactions to health care during illness &
play a major role in health behaviors.
 The ability to learn and use information effectively
for personal, family, and career development
Environmental Dimension
 Housing, sanitation, climate and pollution of air,
food and water.
improve the standard of living and quality of life in
the community
Spiritual Dimension
 Spiritual and religious beliefs and values are
important components of the way the person
behaves in health and illness.
 Recognition & ability to put into practice moral &
religious principles & belief
Occupational Dimension
 Ability to achieve a balance between work &
leisure time.
HEALTH – ILLNESS CONTINUUM
 The health illness continuum is a graphic illustration
of a well being ,concept first proposed by John.W.Travis
in 1972.
 It describes how wellbeing is more than simply an
absence of illness, but also incorporates the individuals
mental and emotional health.
 Travis believed that the standard approach to
medicines, which assumes a person is well when there
are no signs or symptoms of disease, was insufficient
 Composed of two arrows pointing in opposite
direction and joined at a neutral point.
 Movement to the right to the arrows (toward the
high level of wellness) equals an increase in level of
health and wellbeing Achieved in three steps:
awareness, education & growth.
 Movement to the left to the arrows (towards
premature death) equates a progressively decreasing
state of health. Achieved in three steps: signs,
symptoms & disability
Other Models of Health & Illness
 The Health & Illness Continuum (Dunn)
 Health Belief Model (HBM)
 Smith’s Models of Health
 Leavell & Clark’s Agent-Host- Environment Model
 Health Promotion Model
ILLNESS AND DISEASE
ILLNESS
 Is a personal state in which the person feels unhealthy.
 A state in which a person’s physical, emotional, social,
intellectual, developmental or spiritual functioning is
diminished or impaired compared with previous
experience.
Classification of Illness:
a) Acute – severe symptoms, short duration
b) Chronic – lasts for 6 months or longer
Stages of Illness:
1) Symptom experience
2) Assumption of sick role
3) Medical care contact
4) Dependent patient role
5) Recovery / rehabilitation

DISEASE
 An alteration in body functions resulting in reduction
of capacities or a shortening of the normal life span.
Common Causes of Disease:
1) Biologic agents
2) Inherited genetic defects
3) Development defects
4) Physical agents
5) Chemical agents
6) Tissue response to irritation / injury
7) Faulty chemical / metabolic process
8) Emotional/ physical reaction to stress
HEALTH CARE SYSTEM
 Totality of services offered by all health disciplines.
 It is changing with increasing awareness in health
promotion, illness of prevention & level of wellness, so
with the roles of nurses.
TYPES OF HEALTH CARE SERVICES
1) Health Promotion and Illness Prevention (Primary
prevention)
 Primary prevention programs: adequate & proper
nutrition, weight control & exercise & stress reduction.
 Health promotion activities emphasize the important
role clients play in maintaining their own health &
encourage them to maintain the highest level of wellness
they can achieve.
 Illness prevention: immunizations, identifying risk
factors for illness, help in taking measures to prevent
illness (e.g stop smoking campaign); environmental
protective measures
2) Diagnosis and Treatment (Secondary prevention)
 Offered by hospitals & physicians’ offices.
 Hospitals – provides emergency, intensive & around
the clock acute care.
 Evolving freestanding diagnostic & treatment facilities.
 Walk-in clinics
3) Rehabilitation, Health Restoration & Palliative Care
(Tertiary prevention)
Goal of tertiary prevention: To help people move to their
previous level of health or to the highest they are capable
of.
 Rehabilitative Care – assisting clients to function
adequately in the physical, mental, social,
economic, & vocational areas of their lives.
 Palliative Care – people cannot return to health,
hence we provide comfort & treatment of
symptoms. End-of-life care
TYPES OF HEALTH CARE AGENCIES & SERVICES
1) Public Health
2) Physician’s office
3) Ambulatory Care Centers – diagnostics & treatments
facilities
4) Occupational Health Clinics
5) Hospitals
6) Sub-acute care facilities
7) Extended (Long Term) Care facilities
8) Retirement & Assisted Living Centers
9) Rehabilitation Centers
10) Home Health Care Agencies
11) Day Care Centers
12) Rural Care
13) Hospices Services
14) Crisis Centers
15) Mutual Support & Self-Help Groups
MEMBERS OF THE HEALTH CARE TEAM
FACTORS AFFECTING HEALTH CARE DELIVERY
1) Increasing number of older adults
 Long-term illness will be prevalent
 Home management & nursing support services are
required to assist those living in homes &
communities
 Need to feel that they are still part of the community
– the feeling of being useful, wanted & productive.
2) Advances in Technology
 Improved diagnostic procedures
 Sophisticated equipment
 New medications being manufactured
 Surgical procedures are more common today
 Laser & microscopic procedures
 Computers, internet access
3) Economics
 Health care cost is becoming a greater problem.
 Major reasons for cost increases: New equipment
costs more, inflation increase, growing population
especially the older adults, hospital costs were
billed to medicare or healtcare aids, more people
seek medical assistance, relative number of people
who provide health care services increased,
number of uninsured individuals are changing, cost
of drugs is increasing
4) Women’s Health
5) Uneven distribution of Services
6) Access to Health Insurance
 Birthing centers, concerns for reproductive aspects
of health
 Insufficient number of healthcare professionals &
services available to meet the healthcare needs in
remote & rural areas.
 Problems of individuals to access to health
insurance: low income; receive less preventive
care, delay & avoid care & meds; eligibility for
government insurance programs
7) The Homeless & the Poor
 The conditions where homeless people live their
health problems increases & becomes chronic
8) Health Insurance & Portability & Accountability Act
 This is instituted to protect the privacy of
individuals by safeguarding individually
identifiable healthcare records
9) Demographic Changes
 Single-parent families & alternative family
structures.
 Culture & ethnic diversity
CONCEPT OF MAN, HEALTH & ILLNESS
Man is an integrated BIO-PSYCHOSOCIO-CULTURAL &
SPIRITUAL BEING:
CONCEPT OF MAN:
1. Biological being, man is like all other men.
 Because all men have the same basic human
needs.
2. Psychological being, man is like no other man.
 Because man is a unique, irreplaceable, one-time
being. No two persons are exactly alike
 Capable of rational, logical thinking but become
irrational and illogical when provoked.
3. Social being, man is like some other men.
 Capable of relating with others
 Has the capacity to cope with stressful stimuli
 A group of people have common attributes that
make them different from other groups.
 Some factors that characterized a particular
groups of people are culture, age groups, social
status, and educational status.
4. Spiritual being, man is like all other men.
 All men are spiritual in nature, because they have
intellect & will; endowed with virtues of faith,
hope & charity.
 All men believe in the existence of a Supreme
Power who guides our fate & destiny; the source
of meaning & purpose of life; to whom we seek
console in case of difficulties in life.
Man is an OPEN SYSTEM ….
 It allows input & output to and from its
boundaries; one that allows exchange of, or is
constantly affected by matter, energy &
information.
a) Matter – foods, medicines, microorganisms
b) Energy – pain, fever, inflammation
c) Information – diagnosis of an illness, pregnancy,
undergoing surgery or other treatments, death of a
loved one
 Man is a UNIFIED WHOLE composed of parts which
are interdependent and interrelated with each
other.
 The different organs and organ systems function
together to achieve a particular purpose.
 Man is composed of parts which are greater that and
different from the sum of all his parts.
 “Greater than the sum of all his parts”…. because
he is not simply a composite of physiologic body
parts but also endowed with intellect, will,
judgment, decision-making abilities, talents,
strengths & other numerous enabling powers.
 “ Different from the sum of all his parts” … because
at times his responses are predictable, but at times
unpredictable. He is a creature with
contradictions.
 Man is composed of subsystems and suprasystems.
 Subsystems – cells, tissues, organs, organ systems.
 Suprasystems – family, community and the
society.
 Man is an individual with vital reparative processes
to deal with disease & desirous of health but passive
in terms of influencing the environment or nurse.
 Man is a whole, complete and independent being
who has 14 fundamental needs to: breath, eat &
drink, eliminate, move & maintain body posture,
sleep & rest, dress & undress, maintain body
temperature, keep clean, avoid danger,
communicate, worship, work, play, and learn.
 Man is a unity who can be viewed as functioning
biologically, symbolically & socially & who initiates
& performs self-care activities on own behalf in
maintaining life, health & well-being
CONCEPT OF HEALTH:
 (WHO) “A state of complete physical, mental, and
social well being, not merely the absence of disease
or infirmity”.
 (Claude Bernard) Health is the ability to maintain
internal milieu, homeostasis or dynamic
equilibrium.
Nightingale…
 Health is being well and using one’s power to the
fullest extent.
 Health is maintained through prevention of disease
via environmental health factors
Henderson …
 Health is viewed in terms of the individual’s ability
to perform 14 components of nursing care unaided.
Roy …
 Health is a state and a process of being and
becoming an integrated and whole person.
Orem …
 A state that is characterized by soundness or
wholeness of developed human structures and of
bodily and mental functioning.
King …  Behaviors are learned from parents, members of

 Health is a dynamic state in the life cycle; illness is

an interference in the life cycle

Neuman …

 Wellness are in harmony in which all parts and

subparts of an individual are in harmony with the
whole system.

Johnson …

 Health is an elusive, dynamic state influenced by

biologic, psychologic, and social factors.

 Health is reflected by the organization,

interaction, interdependence and integration of the
subsystems of the behavioral systems

Rogers …

 Positive health symbolizes wellness. It is a value

term defined by the culture or individual

HEALTH PROMOTION PROGRAMS

 Information dissemination
 Health Appraisal & Wellness Assessment Programs
 Lifestyle & Behavior Change Programs
 Worksite Wellness Programs
 Environmental Control Programs

MULTIPLE FACTORS AFFECTING HEALTH & ILLNESS

 Several models have been designed to define health.

One of these define health as a multifactorial
phenomenon. According to this model, there are
several factors within and outside the person that
influence health. These factors may or may not be
under the conscious control by the person or others in
the environment. However, one thing is certain it is the
interaction of these factors that constitutes health.
(Leddy & Pepper 1993)

BIOLOGICAL FACTORS

 Include genetic inheritance, sex, age,

developmental level, nutrition, cognitive structures
intelligence, & race.

BEHAVIORAL FACTORS

extended family, church, school, mass media &

others in the environment.

SOCIO-ECONOMIC FACTORS

Economic status, standard of living, occupational roles

& memberships in social groups influence health beliefs
& practices.

POLITICAL FACTORS

 Political structure, leadership, people’s

empowerment & will, policies & laws.
 The form of government, the style of leadership, the
extent & consistency in implementing laws, policies
& ordinances.
ENVIRONMENTAL FACTORS
 Rapidly accelerating changes in the ecosystem. 1. Promoting health & wellness - engaging in attitudes &
 Increasing mobility of people creates megacities. behaviors that enhance the quality of life & maximize
 Psychosocial environment – information technology personal potential. Promotes wellness in clients both
which has increased people’s access to information healthy & ill.
2. Preventing illness – goal is to maintain optimal health
MODULE 2: TEACHING by disease.
3. Restoring health – focuses on ill clients & it extends
TEACHING from early detection of disease through helping the
 A system of activities intended to produce client during recovery period.
learning. The teaching-learning process involves 4. Care of the dying – involves comforting & caring
dynamic interaction between teacher and learner. people of all ages who are dying.
 Nurses teach a variety of learners in various
settings – clients & their families, community, NURSING AS A PROFESSION
health personnel
PROFESSION
AREAS OF CLIENT EDUCATION An occupation that requires extensive / advanced
1) Promotion of Health knowledge & skills & is an outgrowth of society’s
2) Prevention of Illness / Injury needs for special services.
3) Restoration of Health An occupation that requires extensive education or
4) Adapting to altered health & function calling that requires special knowledge, skills &
preparation.
LEARNING Professional – a person who is conscientious in
 A change in human disposition or capability that actions, knowledgeable about the subject, &
persists and that cannot be solely accounted for by responsible to self & others
growth.
 It is represented by a change in behavior. CRITERIA OF A PROFESSION
 LEARNING NEED – is a desire or a requirement to 1. Specialized Education
know something that is presently unknown to the 2. Body of Knowledge
learner. It could include a new knowledge or 3. Service Orientation
information or a new or different skill or physical 4. Ongoing Research
ability or a new behavior or a need to change an old 5. Code Ethics
behavior. 6. Autonomy
 Compliance 7. Professional Organization
 Adherence
COMPONENTS OF GOOD PERSONALITY
LEARNING DOMAINS 1) Personal appearance – includes posture,
Bloom (1956) identified three (3) domains or areas of grooming, dress and uniform.
learning: 2) Character – the moral values and beliefs that are
used as guide to personal behavior and actions.
1) COGNITIVE DOMAIN (“thinking”) – includes 6 3) Attitude – a manner of acting, thinking or feeling
intellectual abilities & thinking processes - knowing, that is indicated by one’s response toward another
comprehending, applying, analysis, synthesis & person, situation or experience.
evaluation. 4) Charm – influence the senses or the mind by some
2) PSYCHOMOTOR DOMAIN (“skill) – includes fine & quality or attraction.
gross motor abilities such giving an injection.
3) AFFECTIVE DOMAIN (“feeling”) – deals with personal ROLES & FUNCTIONS OF THE NURSE
issues such as “attitudes, beliefs, behaviors & emotions” 1. Caregiver
2. Communicator
SMART – specific, measurable, attainable or achievable, 3. Teacher
realistic, time-bound 4. Client Advocate
5. Counselor
6. Change Agent
CONCEPT OF NURSING 7. Leader
8. Manager
Common themes in the definition of NURSING: 9. Case Manager
• Nursing is caring. 10. Research Consumer
• Nursing is an art.
• Nursing is a science.
• Nursing is client centered.
• Nursing is holistic.
• Nursing is adaptive.
• Nursing is concerned with health promotion, health
maintenance and health restoration.
• Nursing is a helping profession.

NURSING PRACTICE INVOLVES 4 AREAS RELATED TO

HEALTH:
FIELDS OF NURSING
THE 6 C’S OF CARING
CARING FOR SELF AND OTHERS
 Caring for Self – helping oneself grow and actualize
one’s possibilities.
 Self Care – responding to one’s own needs to grow,
EXPANDED CAREER ROLES OF NURSES: is the opposite of self-complacency that often
accompanies egocentricity.
1. Nurse Practitioner
2. Clinical Nurse Specialist COMMUNICATION
3. Nurse Anesthetist
4. Nurse Midwife  Any means of exchanging information or feelings
5. Nurse Research between two or more people.
6. Nurse Administrator  It is a basic component of human relationships,
7. Nurse Educator including nursing.
8. Nurse Entrepreneur  In nursing it is a dynamic process used to gather
9. Forensic Nurse assessment data, to teach & persuade & to express
caring & comfort.

MODULE 2: NURSING AS AN ART Two purposes:

1) to influence others
CARING 2) to obtain information
 People, relationship and things matter
 It is central to all & enables people to create FACTORS INFLUENCING THE COMMUNICATION
meaning in their lives PROCESS
 Sharing deep & genuine concern about the welfare 1. Development
of another person. 2. Gender
3. Values & Perceptions
Caring Practice 4. Personal space
 Involves connection, mutual recognition and 5. Territoriality
involvement between the nurse & client. 6. Roles & Relationships
7. Environment
NURSING THEORIES ON CARING 8. Congruence
9. Interpersonal attitudes
THEORY OF BUREAUCRATIC CARING (RAY)
 Caring in organizations as cultures. Caring in THERAPEUTIC COMMUNICATION TECHNIQUES
nursing is contextual and is influenced by the 1. Silence
organizational structure. 2. Providing general leads
3. Being specific & tentative
CARING, THE HUMAN MODE OF BEING (ROACH) 4. Touch
5. Restating & rephrasing
 Caring as a philosophical concept and proposes
6. Seeking clarification
that caring is the human mode of being, of the
7. Using open-ended question
“most common, authentic criterion of humanness.”
8. Perception checking & seeking consensual words
 All persons are caring, and develop their caring
9. Offering self
abilities by being true to self, being real and being
10.Giving information
who they truly are
11.Clarifying time & sequence
12.Presenting reality
THEORY OF CARING (SWANSON)
13.Focusing
 Caring as nurturing way of relating to a valued other,
14.Reflecting
toward whom one feels a personal sense of
15.Acknowledging
commitment and responsibility.
16.Summarizing & planning
 Described the caring processes which provided
guidance for nurses when caring for pregnant &
postpartum women. These are knowing, being with, HELPING RELATIONSHIP
doing for, enabling & maintaining belief  Nurse-client relationship or interpersonal
relationships or therapeutic relationships.
IN NURSING PRACTICE CARING INVOLVES:
1. Providing presence GOALS:
2. Comforting 1. Help clients manage their problems effectively.
3. Listening 2. Help clients become better in helping themselves
4. Knowing the client in their everyday lives.
5. Spiritual caring 3. Help clients develop an action-oriented
6. Family care prevention mentally in their lives.

KEYS:
1. Trust & acceptance can be developed
2. The belief that the nurse cares & wants to help
the client.

CHARACTERISTICS:
1. Is an intellectual & emotional bond between the
nurse & the client & is focused on the CLIENT.
2. Respects the client including:
 Maximizing their ability to participate in decision
making & treatments
 Consider the culture & ethnic aspects
 Consider family relationships & values
3. Respect client confidentiality.
4. Focus on client’s well-being.
5. Is based on mutual trust, respect & acceptance.
PHASES OF THE HELPING RELATIONSHIP
1. Pre-interaction phase
2. Introductory phase
3. Working phase
4. Termination phase
MODULE 3: NURSING AS A SCIENCE
CRITICAL THINKING & the NURSING PROCESS
Critical thinking
 An intentional higher level reasoning process
Clinical reasoning
 Cognitive process that uses thinking strategies
Purpose of Critical Thinking
o Essential component of professional
accountability and quality nursing care
o Generated from a triad of professional,
socioeconomic, and ethical/moral needs
o Alfaro-LeFevre's 4-Circle Critical Thinking Model
(2017)
 Visual representation of critical thinking abilities
 Promotes making meaningful connections between
nursing research and critical thinking and practice
o Nurses use critical thinking skills in a variety of
ways.
 Knowledge from other subjects and fields
 Deal with change in stressful environments
 Make important decisions
o Creativity
 Thinking that results in the development of new ideas
and products
 Allows nurse to:
 Generate many ideas rapidly
 Be generally flexible and natural
 Create original solutions to problems
 Be independent and self-confident, even when
under pressure
 Demonstrate individuality
Techniques in Critical Thinking
 Critical analysis
 Application of a set of questions to a particular
situation to discard unimportant ideas
 Socratic questioning
 Technique to search for inconsistencies,
examine multiple points of view, separate the known
from beliefs
 Inductive reasoning
 Generalizations formed from a set of facts,
observations
 Deductive reasoning
 Reasoning from general premise to specific
conclusion
Techniques in Critical Thinking
 Making valid inferences
 Differentiating facts from opinions
 Evaluating the credibility of information
sources
 Clarifying concepts
 Recognizing assumptions
Problem Solving
 Mental activity in which a problem is
identified that represents an unsteady state
 Clarify the nature of a problem and suggest
possible solutions
 Problem solving for one situation contributes
to the nurse's body of knowledge for problem
solving in similar situations
 Trial and error
 A number of approaches are tried until a
solution is found.
 Can be dangerous because client might
suffer harm if approach is inappropriate
 Intuition
 Relies on a nurse's inner sense
 Understanding or learning of things without
conscious reasoning
 Clinical judgment o Process to ascertain the
right nursing action to be implemented at the
appropriate time in the client's care
 Experience important
 Research process
 Formalized, logical, systematic approach to
problem solving
Attributes of a critical thinker
Components of Clinical Reasoning
 Analysis of a clinical situation as it unfolds or
develops
 Cognitive processes
 Thinking processes based on the knowledge of
aspects of client care  Metacognitive processes
 Reflective thinking and awareness of skills learned
by the nurse in caring for the client
 Setting priorities
 Needs to be dynamic, flexible
 Difficult for beginning nursing students to
determine which data are most relevant
- Preclinical preparation
  Priorities may change based on current client
situation
 Developing rationales
 Justifying the clinical plan
 Explaining the "why" of priority setting and
subsequent interventions
 Learning how to act
 How and when to respond in a clinical situation
 Thinking about potential complications given the
client's current problems
 Clinical reasoning-in-transition
 Ability to recognize subtle changes in client's
condition over time
 Responding to changes in the client's condition
 Nurse will notice change in priorities, adjust
nursing care, and alert primary care provider when
appropriate.
 Reflection
 Nurse identifies factors that improved client care
and those that required changing or elimination.
Integration of Clinical Thinking & Clinical Reasoning
o Decision-making process

Prioritizing care when providing care to many
clients
 Deciding whether client's condition can be
managed in the home or requires hospitalization
o Consider client's cultural, religious background 
Logical reasoning skills
o Commitment to lifelong learning
 Choosing or selecting nursing interventions that
are most likely to yield the desired outcomes
 Using critical thinking to solve problems creatively
2) Technical Skills.
 The use of technical equipment with sufficient
competence & ease to achieve goals with minimal
distress to participants involved.
 Creatively adapt equipment & technical
procedures to the needs of particular clients.
3) Interpersonal Skills
 Interacting with patients, their significant others
& colleagues to affirm their worth.
 Elicit personal strengths & abilities of patients to
achieve valued health goals.
 Provide the HCT with knowledge about the
patient’s valued goals & expectations.
 Work collaboratively with the HCT
4) Ethical & Legal Skill
 Trusted to act in ways that advance the interests
of patients
 Accountable for their practice to themselves, the
patients they serve, the team & the society.
 Act as effective patient advocates.
 Practice nursing faithfully to the tenets of
professional code of ethics & appropriate
standards of practice

Concept Mapping (Continuation of Nursing Process: Next Page)

 Graphic depiction of connections
 Linear and nonlinear relationships  Visual aid to
critical thinking process
 Concept Mapping and Enhancing Critical Thinking
and Clinical Reasoning
 Link between existing nursing knowledge and new
information
 Foster demonstration that nurses have acquired
body of knowledge, understanding of concepts
pertinent to delivery of safe and effective care
- Interrelationships among client's problems
- Care based on complexity

NURSING PROCESS
 A systematic and rational method of providing
nursing care.

Purpose or Goals of the Nursing Process

1) Identify client’s health care status & actual or
potential health problems.
2) Establish plans to meet the identified needs.
3) Deliver the specific nursing interventions to meet
those needs

Skills Needed to Successfully use the Nursing Process:

1) Cognitive Skills.

 It offers a scientific rational for a patient’s plan of

care
 MODULE 3: NURSING PROCESS 5 STEPS (ADPIE)

A. TEACHING
 A system of activities intended to produce learning. The teaching-learning process involves dynamic interaction
between teacher and learner.
 Areas of Client Education: Promotion of Health; Prevention of Illness / Injury / Restoration of Health /
Rehabilitative
I. Promotion of Health
 Increasing a person’s level of wellness
 Growth and development topics
 Fertility control
 Hygiene
 Nutrition
 Exercise
 Stress management
 Lifestyle modification
 Resources with the community
II. Prevention of Illness / Injury
 Health screening (e.g., blood glucose level, blood pressure, blood cholesterol, Pap test, mammogram,
vision, hearing, routine physical examinations)
 Reducing health risk factors (e.g., lowering cholesterol level)
 Specific protective health measures ( e.g., immunizations, use of condoms, use of sunscreen, use of
medication, umbilical cord care)
 First aid
 Safety (e.g., using seat belts, helmets, walkers)
III. Restoration of Health
 Information about tests, diagnosis, treatment, medications
 Self-care skills or skills needed to care for family members
 Resources within health care setting and community
IV. Adaptation of Altered Health & Function
 Adaptations in lifestyle
 Problem-solving skills
 Adaptation to changing health status
 Strategies to deal with current problems
 Information about treatments & likely outcomes
 Referrals to other healthcare facility or service
 Facilitation of strong self-image
 Grief & bereavement counseling
 Setting Learning Outcomes (Objectives)
 State the client behavior or performance, not nurse behavior.
 Reflect an observable, measurable activity. Avoid using words such as knows, understands, believes and
appreciates because they are neither observable nor measurable.
 May add conditions or modifiers as required to clarify what, where, when or how the behavior will be
performed.
 Include criteria specifying the time by which learning should have occurred.
 OR – S M A R T (S = specific; M = measurable; A = attainable; R = realistic; T = time-bound)
 Domains: Cognitive = Knowledge; Psychomotor = Skills; Affective = Attitude  Example:
Gen. Objective: After 1 day of RLE, the Level I Nursing students will be able to learn the
proper giving of hygiene to their respective clients.
Specific Objectives: Within 5 hours of RLE, the Level I nursing students will be able to:

COGNITIVE:
1. Explain the importance of proper hygiene in taking care of the client.

AFFECTIVE:
1. Participate in the demonstration of the different procedures in providing proper hygiene to a client.

PSYCHOMOTOR:
1. Demonstrate the different procedures in providing proper hygiene to a client such as hair care, bed
shampoo, oral hygiene, complete bed bath and back rub/ massage.
B. NURSING AS A SCIENCE
I. Nursing Process – a systematic and rational method of providing nursing care.
II. Definition of Terms:
a) Assessment – first step of the nursing process in which data are gathered to identify actual or potential health
problems.
b) Nursing Diagnosis – second step of the nursing process & includes clinical judgements made about wellness
states, illness states & syndromes, & the readiness to enhance current states of wellness experienced by
individuals, families & communities.
c) Planning – third step of the nursing process. Includes the formulation of guidelines that establish the proposed
course of nursing action in the resolution of nursing diagnoses and the development of the client’s plan of
care.
d) Nursing Care Plan (NCP) – written summary of the care that the client is to receive.
e) Implementation – the fourth step of the nursing process which involves the execution of the nursing care plan
derived during the planning phase.
f) Nursing Intervention – is an action performed by the nurse that helps the client to achieve the results specified
by the goals & expected outcomes.
g) Evaluation – last step of the nursing process which determines the efficacy of nursing care and ensures the
delivery of quality care.
h) Priority setting – a decision-making process that ranks the order of nursing diagnosis in terms of importance
to the client.
i) Accountability – the condition of being answerable and responsible to someone for specific behaviours that
are part of the nurse’s professional role.

III. Steps of the Nursing Process:

1. Assessment; 2. Nursing Diagnosis; 3. Planning; 4. Implementation; 5. Evaluation
IV. Goals of the Nursing Process:
1. Identify client’s health status and health care problems.
2. Establish plans to meet the identified needs.
3. Deliver the specific nursing interventions to meet those needs.
V. Skills needed to Successfully Use the Nursing Process:
1. Cognitive Skills, it offers a scientific rationale for a patient’s plan of care – select those nursing interventions
that are most likely to yield the desired outcomes; use critical thinking to solve problems creatively.
2. Technical Skills – use technical equipment with sufficient competence & ease to achieve goals with minimal
distress to participants’ involved. Creatively adapt equipment and technical procedures to the needs of
particular clients.
3. Interpersonal Skills – use interactions with patients, their significant others & colleagues to affirm their worth.
Elicit personal strengths & abilities of patients to achieve valued health goals. Provide health care team with
knowledge about the patient’s valued goals & expectations. Work collaboratively with the health care team.
4. Ethical & Legal Skills – be trusted to act in ways that advance the interest of the patients. Be accountable for
their practice to themselves, the patient they serve, the team & the society. Act as effective patient advocates.
Practice nursing faithful to the tenets of professional code of ethics & appropriate standards of practice.
VI. Characteristics of the Nursing Process
1. The system is open & flexible.
2. It is planned.
3. It is goal-oriented.
4. It is client-centered.
5. It permits creativity for the nurse & client to solve health problems.
6. It is interpersonal & collaborative.
7. It is cyclic & dynamic.
8. It emphasizes feedback.
9. It is universally applicable.
VII. Benefits of the Nursing Process
A. For the Client
 Quality client care
 Continuity of care
 Participation by the clients in their health care
B. For the Nurse
 Consistent & systematic nursing education
 Job satisfaction
 Professional growth
 Avoidance of legal action
 Meeting professional nursing standards.
VIII. NURSING PROCESS STEP 1: ASSESSMENT
• PURPOSE: To establish a database concerning a client’s physical, psychosocial & emotional health in order
to identify health promoting behaviors as well as actual & potential health problems.
• Four Different Types of Assessment:
a) Initial – establish complete data base.
b) Focused – to determine status of a specific problem identified in an earlier assessment.
c) Emergency – to identify life threatening problems.
d) Time-lapsed – to compare current status from previous baseline data.
• 4 Closely Related Activities Involved:
a) Collecting Data
b) Organizing Data – nurse writes data gathered in different database forms
c) Validating Data – act of double checking or verifying data to confirm that it is factual. Benefits: (1)
ensure that assessment information is complete; (2) ensured that objective and related subjective data
agree; (3) obtain additional information that may have been overlooked; and (d) differentiate between
cues & inferences.
d) Recording data – accurate documentation is essential & should include all data collected about the
client’s health status.
• Methods of Collecting Data:
a) Observation – gathering of data by using the five senses. Includes looking, watching, surveying,
scanning & appraising. There are 2 aspects: (1) noticing the data & (2) selecting, organizing &
interpreting the data.
b) Interview – planned communication or a conversation with purpose. Purpose: (1) gather & give
information; (2) identify problems; (3) evaluate change; (4) teach; (5) provide support; (6) provide
counselling or therapy. Approaches: (1) directive – highly structured; (2) non-directive – client controls
the purpose, subject matter & pacing (rapport-building).
 Kinds of Interview Questions: (1) Open-ended – it is broad, specifies only the topic to be
discussed & invites ansers longer that 1-2 words; (2) Closed – restrictive, generally requires
only specific answers or information; (3) neural questions – client can answer without direction
or pressure from the nurse; (4) leading questions – usually closed & thus directs the client’s
answer.
 Factors that Influence Interview: time, place, seating arrangement, distance, language
 Stages of Interview: (1) opening or introduction – establishing rapport & orienting the
interviewee; (2) body or development – uses communication techniques that makes both
parties feel comfortable& serve the purpose of the interview. The client communicates what
he feels, thinks, knows & perceives in response to questions.
 Closing – when needed information is obtained, the nurse terminates the activity or the client
otherwise.
c) Examining: Purpose – obtain baseline data, supplements, confirm data obtained in nursing history,
obtain data that will help the nurse establish nursing diagnosis & plan client’s care, evaluate the
physiologic outcomes of health care. Approaches: cephalocaudal or body system. Methods of
examining: IPPA
• Types of Data: (a) subjective – symptoms, covert cues & (b) objective – signs, overt cues, measurable
• Sources of Data: (1) primary data; (2) secondary data; (3) health care professionals; (4) literature
IX. NURSING PROCESS STEP 2: DIAGNOSIS
• PURPOSE: To effectively communicate the healthcare needs of the individuals & aggregates among
members of the health care team and with the health care delivery system. Quality client care is
enhanced. Diagnosis – science & art of identifying problems or conditions.
• Nursing Diagnosis – a clinical judgement about the individual, family or community responses to actual
health problems / life processes. Nursing Diagnosis provides the basis for selection of nursing
interventions to achieve outcomes for which the nurse is accountable.
Nursing Diagnosis VS Medical Diagnosis
a) Medical Diagnosis – terminology used for a clinical judgement by the physician that identifies or
determines a specific disease, condition or pathologic state.
b) Nursing Diagnosis – terminology used for a clinical judgement by the professional nurse that
identifies client’s actual, risk, wellness or syndrome responses to a health state, problem or condition.
Activities involved in Diagnosing: Analyze data; Identify health problems, risks, and strengths;
Formulate diagnostic statements

Types of Nursing Diagnoses (according to Status)

 “Status of the nursing diagnosis refers to the actuality or potentiality of the problem/syndrome
or the categorization of the diagnosis as a health promotion diagnosis” (Herdman & Kamitsuru, 2014,
p. 100).
 The kinds of nursing diagnoses according to status are actual, health promotion, risk, and
syndrome.
 a) Actual diagnosis – 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.
b) Health promotion diagnosis – relates to clients’ preparedness to implement behaviors to improve
their health condition. These diagnosis labels begin with the phrase Readiness for Enhanced, as in
Readiness for Enhanced Nutrition.
c) Risk nursing diagnosis – 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, Risk for
Infection to describe the client’s health status.

d) Syndrome diagnosis is assigned by a nurse’s clinical judgment to describe a cluster of nursing

diagnoses that have similar interventions (Herdman & Kamitsuru, 2014, p. 23). It is associated with a
cluster of other diagnosis. For example: Risk for Disuse Syndrome
3 Kinds of Problems That Can Lead to Errors in Identifying the Nursing Diagnosis:
1) Inaccurate collection of data
2) Inaccurate interpretation of data
3) lack of knowledge or practice
FORMULATING DIAGNOSTIC STATEMENTS
 3 Essential Components of a Nursing Diagnosis o (P) Problem – statement of
the client’s response o (E) Etiology – factors contributing to or a probable cause
of the response o (S) Signs and Symptoms – defining characteristics manifested
by the client.
Variations in the Basic Format

1) Writing UNKNOWN ETIOLOGY – when the defining characteristic are present but the nurse does
not know the cause or contributing factors.
o Altered Nutrition, less than body requirement related to unknown etiology
2) Using the phrase COMPLEX FACTORS – when there are too many etiologic factors or when they
are too complex to state in a brief phrase.
o Risk for suicide related to complex factor
3) Using the word POSSIBLE – when more data are needed about the client’s problem or the
etiology
o Possible risk for suicide R/T loss of loved ones and rejection of friends
4) Using SECONDARY TO – to divide the etiology into two parts thereby making the statement more
useful and descriptive
o Altered body temperature, Hyperthermia R/T presence of infection secondary to
SARS. 5) Adding a second part to the general response or NANDA label to make it more
precise o Impaired skin integrity (left lateral ankle) R/T decreased peripheral
circulation
NURSING PROCESS STEP 3: PLANNING
• Purpose: Serves as a framework to base scientific nursing practice in order to provide quality nursing care. It
improves staff communication and provides continuity of care.
• Activities involved in Planning: prioritize problem / diagnoses; formulate goals / desired outcomes; select
nursing intervention; write nursing interventions
• Nursing Intervention: Is any treatment based upon clinical judgement and knowledge, that a nurse performs
to enhance client outcomes. The product of the planning phase is a client CARE PLAN. Planning begins with the
first client contact and continues until the nurse-client relationship ends.
Types of Planning:
1. INITIAL – involves development of beginning of care by the nurse who performs the admission
assessment and gathers the comprehensive admission assessment data.
2. ONGOING – new information about the client is gathered and evaluated, and revisions may be
formulated and the initial plan becomes further individualized to the client. Purpose: to determine
whether the client health status has changed; to set priorities for the client’s care during the shift; to
decide which problems to focus on during the shift; to coordinate the nurses’ activities so that more than
one problem can be addressed at each client contact.
3. Discharge Planning – the process of anticipating and planning for needs after discharge. Setting
Priorities:
1. HIGH – life threatening problems such as loss of respiratory or cardiac function.
2. MEDIUM – health threatening problems such as acute illness and decreased coping ability.
3. LOW – arises from normal developmental needs or that requires only minimal nursing support.
Goal: A broad or globally written statement describing the intended or desired change in the client’s behavior,
response or outcome. Two Types of Goal: (a) Short term goal – usually few hours or days; (b) Long term goal –
over weeks or months
Component of Goal / Expected Outcome Statement
1. Subject – noun, is the client, any part of the client or some attribute of the client.
2. Verb – specify an action that the client is to perform (demonstrate, explain, show, walk)
3. Conditions or modifiers – it maybe added to the verb to explain the circumstance under which the
behavior is to be performed (walks with a cane, when at home . . , )
4. Criteria of desired performance – standard at which the client may perform the the specified behavior.
(weighs 75 kg by April, Lists five out of six signs of diabetes, administer insulin using aseptic technique).

Subject Verb Cond. / Mod. Criteria

Client Drinks 2500 ml of fluids daily

Client Administers Correct insulin dose Using aseptic

techinique
Criteria for choosing Nursing Strategies:
1. Safe and appropriate for individual’s age, health, etc.
2. Achievable with the resources available
3. Congruent with the client’s values and beliefs
4. Congruent with other therapies
5. Based on nursing knowledge and experience
6. Within established standard of care
Types of Nursing Interventions:
1. Independent – 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, teaching etc.
2. Dependent – are activities carried out under the physician’s order or supervision, or according to
specified routines
3. Interdependent/Collaborative – are actions the nurse carries out in collaboration with other health
team members.
Purpose of a written care plan:
1. Provide directions for individualized plan of care
2. Provide for continuity of care
3. Provide direction about what needs to be documented on the client’s progress notes
4. Serve as a guide for reimbursement from medical insurance companies
5. Serve as a guide for assigning staff to care for the client

Guidelines for writing a Nursing Care Plan

1. Date and sign the plan
2. Use category headings
3. Use standardized medical or English symbols and keywords rather than the complete sentence 4. Be
specific
5. Refer to procedure book and other sources of information rather than including all the steps on a written
care plan

6. Tailor the plan to the unique characteristics of the client by ensuring that the client’s choices are included.
7. Ensure that nursing plan incorporates preventive and health maintenance aspects as well as restorative
ones.
8. Ensure that the plan contains interventions for ongoing assessment of the client
9. Include collaborative and coordination activities in the plan.
10. Include plans for the client’s discharge and homecare needs Format for the NCP:
Nursing Objectives Intervention Rationale Evaluation
Diagnosis
• Must be • Independent
smart • Dependent
Interdendent /
Collaborative

NURSING PROCESS STEP 4: IMPLEMENTATION

• The 4th phase of the nursing process which consists of doing and documenting the activities that are specific
nursing actions needed to carry out the intervention (or nursing order).
• Process of Implementation: reassessing the client; determining the need for nursing assistance; implementing
the nursing strategies; supervising the delegated care; documenting nursing activities.
• 6 Important Considerations in Implementing Nursing Strategies:
1. Client’s individuality
 2. Client’s need for involvement
3. Prevention of complications
4. Preservation of the body defenses
5. Provision of comfort and support to the client
6. Accurate and careful implementation of all nursing activities
• Guidelines for Implementing Nursing Strategies
1. Base nursing interventions on scientific knowledge, nursing research and professional standards of care
(evidence based practice) whenever possible
2. Clearly understand the orders to be implemented and question any that are not understood
3. Adapt activities to the individual client, their beliefs, values, age, health status and environment are factors
that can affect the success of a nursing action
4. Implement safe care
5. Provide teaching, support and comfort
6. Be holistic
7. Respect the dignity of the client and enhance the client’s self esteem
8. Encourage client to participate actively in implementing the nursing intervention

NURSING PROCESS STEP 5: EVALUATION

• Final phase of the nursing process in which the nurse determines the client’s progress toward goal achievement
and the effectiveness of the nursing care plan.
• The plan maybe continued, modified or terminated.
• Components of Evaluation: Collecting data related to the desired outcomes; comparing the data with desired
outcomes; relating nursing activities to outcomes; drawing conclusions about problem status; continuing,
modifying, or terminating the nursing care plan.
• Evaluation Statement: When determining whether a goal has been achieved, the nurse can draw one of three
possible conclusions:
o The goal was met; that is, the client response is the same as the desired outcome.
o The goal was partially met; that is, either a short-term outcome was achieved but the long-term goal was
not, or the desired goal was incompletely attained.
o The goal was not met. After determining whether or not a goal has been met.
• An evaluation statement consists of two parts: a conclusion and supporting data. The conclusion is a statement
that the goal/desired outcome was met, partially met, or not met. The supporting data are the list of client
responses that support the conclusion, for example: Goal met: Oral intake 300 mL more than
output; skin turgor resilient; mucous membranes moist.
 FINALS Components Of Self Concept

1. Personal Identity sense of individuality and

MODULE 4
NURSING INTERVENTIONS TO
PROMOTE HEALTHY
PSYCHOSOCIAL RESPONSES
What Is Self Concept?

 One’s image of oneself

 Individuals with positive self-concept are better
able to develop and maintain interpersonal uniqueness
relationships and resist psychologic and physical 2. Body Image- image of physical self
illness. 3. Role Performance role mastery, role
development, role ambiguity, role strain, role
conflicts
4. Self- Esteem- One’s judgment of one’s own
Self- concept influences the following:
worth; Global Self-esteem and Specific Self-
1. How one thinks, talks, and acts esteem,
2. How one sees and treats another person
3. Choices one makes Factors That Affect Self- Concept
4. Ability to give and receive love 1. Stages of development
5. Ability to take action and to change things 2. Family and culture
3. Stressors
4. Resources
Four Dimensions 5. History of success and failure
1. Self- knowledge 6. Illness
2. Self- expectation
3. Social self
4. Social evaluation

Self- Awareness

 Refers to the relationship between one’s

perception of himself or herself and other’s
perceptions of him or her.
Nursing
Formation Of Self Concept

 A person is not born with a self- concept;

rather, it develops as a result of social
interactions with others.

Management: ASSESSING

1. Personal Identity
  The information that the nurse needs to access • originate outside the individual, for example, a
is the client’s personal identity. This involves move to another city, a death in the family, or
who the client believes he or she is. pressure from peers.

2. Body Image c. Developmental stressors

 If there are indications of a body image • occur at predictable times throughout an

disturbance, the nurse should assess the client individual’s life
carefully for possible functional or physical
d. Situational stressors
problems.
 are unpredictable and may occur at any time
3. Role Performance
during life. Situational stress may be positive or
 The nurse assesses the client’s satisfactions and negative.
dissatisfactions associated with role
responsibilities and relationships: family roles,
work roles, student roles, and social roles. Models of Stress

4. Self-Esteem 1. Stimulus-Based Models

• Are you satisfied with your life?  Stress is defined as a stimulus or a set of
• How do you feel about yourself? circumstances that arouses physiological and/or
• Are you accomplishing what you want? psychological reactions that may increase the
• What goals in life are important to you? individual’s vulnerability to illness

2. Response-Based Models the nonspecific response of

the body to any kind of demand made upon it.

General adaptation syndrome (GAS)

STRESS AND ADAPTATION  is a multisystem response to stress and involves

three steps: alarm reaction, stage of resis-
Stress tance, and stage of exhaustion.
 is a condition in which an individual experiences
changes in the normal balanced state
Local adaptation syndrome (LAS)
Stressor
 is a localized physiological response that also
 is any event or stimulus that causes an expresses the three stages of GAS
individual to experience stress
Three Stages

Sources of Stress

a. Internal stressors
• originate within a person, for example,
infection or feelings of depression.

b. External stressors
1) Alarm Reaction - Initial reaction of the body which
alerts the body’s defenses.
2 Phases of the Alarm Reaction
• Shock phase - the stressor may be perceived by
the person.
• Counter-shock phase - The changes produced in
the body during the shock phase are reversed.
2) Stage of resistance - is when the body’s adaptation
takes place.
3) Stage of exhaustion - the adaptation that the body
made during the second stage can’t be maintained.
Transaction-Based Models
 encompasses a set of cognitive, affective, and
adaptive responses that arise out of person
environment transactions.
Indicators of Stress
1. Physiological Indicators
 The physiological signs and symptoms of stress
result from activation of the sympathetic and
neuroendocrine systems of the body.
a) Anxiety
 a state of mental uneasiness, apprehension,
dread, or a feeling of helplessness
b) Fear
 an emotion or feeling of apprehension aroused
by impending or seeming danger, pain, or
another perceived threat
c) Anger
 an emotional state consisting of a subjective
feeling of animosity or strong displeasure.
d) Depression
 an extreme feeling of sadness, despair,
dejection, lack of worth, or emptiness.
e) Ego defense mechanisms
 mental mechanisms that develop as the
personality attempts to defend itself and calm
inner tensions.
2. Cognitive Indicators
a) Problem solving
 involves thinking through the threatening
situation, using specific steps to arrive at a
solution.
b) Structuring
 the arrangement or manipulation of a situation
so threatening events do not occur.
c) Self-control
 assuming a manner and facial expression that
convey a sense of being in control
d) Suppression
 is consciously and willfully putting a thought or
feeling out of mind.
e) Fantasy / Daydreaming
 unfulfilled wishes and desires are imagined as
fulfilled, or a threatening experience is
reworked or replayed so it ends differently from
reality
f) Coping
 may be described as dealing with change—
successfully or unsuccessfully.
Factors that Influence Coping
 The number, duration, and intensity of the
stressors
 Past experiences of the individual
 Support systems available to the individual
Personal qualities of the person.
Two Types Of Coping
1. Adaptive coping
 helps the person to deal effectively with
stressful events and minimizes distress
associated with them.
2. Maladaptive coping
 can cause unnecessary distress for the person
and others associated.
Coping strategy - is a natural or learned way of
responding to a changing environment or problem
 LOSS, GRIEF AND DYING - CONCEPT OF
DEATH AND DYING / POST-MORTEM
CARE
Loss
 An actual or potential situation in which
something that is valued is changed or no
longer available.
Death
 A loss both for the dying and for those who
survive.
Types of Loss
1. Actual Loss - can be recognized by others
2. Perceived Loss - experienced by one person but
cannot be verified by others
3. Anticipatory Loss - experienced before the loss
actually occurs
Sources of Loss
1. Aspect of Self - losing an aspect of self-changes a
person's body image, even though the loss may not be
obvious.
2. External Objects - include
1) loss of inanimate objects that have
importance to the person;
2) loss of animate (live)objects such as
pets.
3. Familiar Environment
 separation from an environment and people
who provided security can cause a sense of loss.
4. Loved Ones
 losing a loved one or valued person through
illness, divorce, separation, or death can be very
disturbing.
Grief
 The total response to the emotional experience
related to loss.
 Manifested in thoughts, feelings and behaviors
associated with overwhelming distress or
sorrow.
Bereavement
 the subjective response experienced by the
surviving loved ones.
Mourning
 The behavioral process through which grief is
eventually resolved or altered; it is often
influenced by culture, spiritual beliefs and
custom.
Types of Grief Responses
1. Abbreviated grief
 occurs when the lost object is not significantly
important to the grieving person or may have
been replaced immediately by another, equally
esteemed object.
2. Anticipating grief
 experienced in advance of the event such as the
wife who grieves before her ailing husband dies.
3. Disenfranchised grief
 occurs when a person is unable to acknowledge
the loss to other people.
4. Unhealthy grief (pathologic or complicated grief)
 exists when the strategies to cope with the loss
are maladaptive and out of proportion or
inconsistent with cultural, religious or
ageappropriate norms.
Several Forms of Complicated Grief
1. Unresolved or Chronic Grief
 extended in length and severity. Having
difficulty expressing the grief, may deny the loss
or may grieve beyond the expected time.
2. Delayed Grief
  occurs when feelings are purposely or
subconsciously suppressed until a much later
time.
3. Inhibited Grief
 many of the normal symptoms of grief are
suppressed and other effects, including somatic
are experienced instead.
4. Exaggerated Grief
 using dangerous activities as a method to lessen
the pain of grieving.
Kübler-Ross's Stages of Grieving
1. Denial
 Refuses to believe that loss is happening.
 Is unready to deal with practical problems.
 Verbally support client but do not reinforce
denial.
2. Anger
 Client or family may direct anger at nurse or
staff about matters that normally would not
bother them.
 Help client understand that anger is a normal
response to feelings of loss.
3. Bargaining
 Seeks to bargain to avoid loss
 Listen attentively, and encourage client to talk
to relieve guilt and irrational fear. If
appropriate, offer spiritual support.
4. Depression
 Grieves over what has happened and what
cannot be.
 May talk freely or may withdraw.
 Allow client to express sadness.
 Communicate nonverbally.
5. Acceptance
 Comes to terms with loss.
 May have decreased interest in surroundings
and support people.
 Help family and friends understand client's
decreased need to socialize.
Engel's Stages of Grieving
1. Shock and disbelief
 Refuses to accept loss.
 Has stunned feelings.
 Accepts the situation intellectually, but denies it
emotionally.
2. Developing awareness
 Reality of loss begins to penetrate
consciousness.
 Anger may be directed at agency, nurses, or
others.
3. Restitution
 Conducts rituals of mourning (e.g., funeral).
4. Resolving the loss
 Attempts to deal with painful void.
 Still unable to accept new love object to replace
lost person or object
5. Idealization
 Produces image of lost object that is almost
devoid of undesirable features.
 May feel guilty and remorseful about past
inconsiderate or unkind acts to lost person.
6. Outcome
 Behavior influenced by several factors:
importance of lost object as source of support,
degree of dependence on relationship.
Sander’s Phases of Bereavement
1. Shock
 Survivors are left with feelings of confusion,
unreality, and disbelief that the loss has
 occurred. They are often unable to process
normal thought sequences.
2. Awareness of loss
 Friends and family resume normal activities.
The bereaved experience the full significance of
their loss
3. Conservation/withdrawal
 Survivors feel a need to be alone to conserve
and replenish both physical and emotional
energy. The social support available to the
bereaved has decreased, may experience
despair and helplessness.
4. Healing: the turning point
 During this phase, the bereaved move from
distress about living without their loved one to
learning to live more independently.
5. Renewal
 In this phase, survivors move on to a new
selfawareness, an acceptance of responsibility
for self, and learning to live without the loved
one.
Factors Influencing the Loss and Grief Responses
•Age
•Significance of the Loss
•Culture
•Spiritual Beliefs
•Gender
• Socioeconomic Status
• Support System
• Cause of Loss or Death
DEVELOPMENT OF THE CONCEPT OF DEATH
Infancy–5 years
 Does not understand concept of death.
 Infant’s sense of separation forms basis for later
understanding of loss and death.
 Believes death is reversible, a temporary
departure, or sleep.
5–9 years
 Understands that death is final.
 Believes own death can be avoided.
 Associates death with aggression or violence.
9–12 years
 Understands death as the inevitable end of life.
 Begins to understand own mortality, expressed
as interest in afterlife or as fear of death.
12–18 years
 May fantasize that death can be defied, acting
out defiance through reckless behaviors.
 Seldom thinks about death, but views it in
religious and philosophic terms.
18–45 years
 Has attitude toward death influenced by
religious and cultural beliefs.
45–65 years
 Accepts own mortality.
 Encounters death of parents and some peers.
 Experiences peaks of death anxiety.
65+ years
 Fears prolonged illness.
 Encounters death of family members and peers.
 Sees death as having multiple meanings.
Definitions and Signs of Death
Heart-lung death
 traditional clinical signs of death were cessation
of the apical pulse, respirations, and blood
pressure.
Cerebral death or higher brain death
  occurs when the higher brain center, the
cerebral cortex, is irreversibly destroyed.
SIGNS OF IMPENDING CLINICAL DEATH
Loss Of Muscle Tone
 Relaxation of the facial muscles
 Difficulty speaking
 Difficulty swallowing and gradual loss of the gag
reflex
 Diminished body movement
Slowing of the Circulation
 Diminished sensation
 Mottling and cyanosis of the extremities
 Cold skin, first in the feet and later in the hands,
ears, and nose
 Slower and weaker pulse
Changes In Respirations
 Rapid, shallow, irregular, or abnormally slow
respirations
 Noisy breathing, referred to as the death rattle,
due to collecting of mucus in the throat
Sensory Impairment
 Blurred vision
 Impaired senses of taste and smell
Postmortem Care
Rigor mortis
 the stiffening of the body that occurs about 2 to
4 hours after death.
 starts in the involuntary muscles then
progresses to the head, neck, and trunk, and
finally reaches the extremities.
Algor mortis
 the gradual decrease of the body’s temperature
after death.
 body temperature falls about 1°C (1.8°F) per
hour until it reaches room temperature.
Livor mortis
 after blood circulation has ceased, the red
blood cells break down, releasing hemoglobin,
which discolors the surrounding tissues.
SENSORY PERCEPTION
Introduction
 An individuals senses are essential for growth,
development and survival. Any alteration in
people’s sensory functions can affect their
ability to function within the environment.
Components of the Sensory Experience
1. Sensory reception
 The process of receiving stimuli or data.Either
external ( visual,auditory,olfactory,tactile, and
gustatory)Gustatory can be internal as well.
2. Kinesthetic
 awareness of the position and movement of
body parts.
3. Stereognosis
 ability to perceive and understand.An object
through touch by is size,shape,texture.
4. Visceral
 any large organ within the body. stimuli that
make a person aware of them.
5.Sensory Perception
 Conscious organization and translation of the
data or stimuli into meaningful information.
Four Aspects of the sensory Process
1. Stimulus
 An agent or act that stimulates a nerve
receptor.
2. Receptor
 A nerve cells act as a receptor by converting
stimulus to a nerve impulse. Sensitive to visual,
auditory, or touch.
3. Impulse conduction
 Impulse travels along nerve pathways either
spinal cord or direct to brain.
4. Perception
 or awareness and interpretation of stimuli takes
place in the brain.
Arousal Mechanism
 The reticular activating system (RAS) in
Brainstem thought to meditate the arousal
mechanism.
Two components of RAS -REA Reticular excitatory area
responsible for arousal mechanism.
- RIA Reticular inhibitory area.
- Sensoristasis state which a person in optimal arousal.
- Awareness ability to perceive internal and external
stimuli to respond through thought and action.
States of Awareness
• Full consciousness
• disoriented
• confused
• somnolent
• semi comatose
• coma.
Factors affecting sensory function
Developmental Stage
 critical to the intellectual, social and physical
development of infants and children
Culture
 an individual’s culture determines amount of
stimulation that a person considers usual
“normal”
Cultural deprivation
 lack of supportive acts
Stress
 people find their senses already overloaded
thus seek to decrease sensory stimulation.
Medications and Illness alter individual’s
awareness of environmental stimuli
Sensory Alterations
Lifestyle and Personality
 Quality and quantity of stimulation.
 People accustomed to certain sensory stimuli,
changes markedly an individual may experience
discomfort.
Factors that contribute alterations in behaviors
Sensory Deprivation
 thought of as a decrease in or lack of
meaningful stimuli.
Sensory Overload
 person is Unable to process or manage the
amount or intensity of sensory stimuli.
Sensory Deficient
 impaired reception, perception or both of one
or more of the senses.
INTRODUCTION
 All humans are beings. Regardless of gender,
age, race, socioeconomic status, religious
beliefs, physical, and mental health, or other
demographic factors, we express our sexuality
in a variety of ways throughout our lives.
Human sexuality is difficult to define.
Development Of Sexuality  Transgender
 Queer
The development of sexuality begins with conception
and continues throughout the life span.  Questioning

 ADOLESCENCE
 YOUNG AND MIDDLE ADULTHOOD Gender Identity
 OLDER ALDULTHOOD
One’s self-image as a female or male. More than just
the biologic component, it also includes social and
cultural norms.
Dysmenorrhea (Painful Menstruation)
 INTERSEX
 Prevalent among adolescent females. Cramping,
 TRANSGENDERISM
lower abdominal pain radiating to the back and
 CROSS-DRESSER
upper thighs, nausea, vomiting, diarrhea and
headache may occur for a few hours up to 3
days.
EROTIC PREFERENCES
Sexual Health
 Over a lifetime, sexual fantasies and single
 An individual and constantly changing partner sex are the most common sexual
phenomenon falling within the wide range of outlets for women and men, single and coupled
human sexual thoughts, feelings, needs, and individuals, and heterosexual and LGBTQQ
desires. For most people, sexual health is not a individuals.
concern until its absence or impairment is
noticed.

Factors Influencing Sexuality

COMPONENTS OF SEXUAL HEALTH
 Many factors influence a person’s sexuality.
 SEXUAL SELF-CONCEPT
Discussed here are family, culture, religion, and
 BODY IMAGE
personal expectations and ethics.
 GENDER –ROLE BEHAVIOR
 ANDROGYNY (FLEXIBILITY IN GENDER ROLES)

SEXUAL ORIENTATION

• One’s attraction to people of the same sex, other sex,

or both sexes is referred to as sexual orientation.

• This is one reason why the number of terms used to

describe sexuality is increasing. The term LGBTQQ is
frequently used.

In general, same-sex attraction has been called

homosexuality
The following are common sexual messages children get
 Lesbian
from their families
 Gay
 Bisexual  Sex is dirty
  Premarital sex is sinful
 Good girls don’t do it
 Masturbation is disgusting
 Men should be the sexual expert
 Sex is mainly for procreating
 Sex should be fun for both women and men
 Sexual thoughts and feelings are natural
 Masturbation is common, pleasurable activity
 There is great variety in sexual behaviors.
 Bodies, including genitals, are beautiful
Female Circumcision
 Also known as female genital mutilation, female
ritual cutting (FRC), or female genital cutting
(FGC), is a practice in parts of africa, the middle
east, and parts of asia.
Male Circumcision
 is controversial.
 Sociocultural factors interfering in sexual
function include a very strict upbringing
accompanied by inadequate sex education.
Sexual Desire Disorders
 For most people, sexual desire varies from day
to day and over the years.
 Some people, however, report a deficiency in or
absence of sexual fantasies and persistently low
interest or a total lack of interest in sexual
activity; these clients suffer from hypoactive
sexual desire disorder.
Sexual Desire Disorders
 SEXUAL AVERSION DISORDER
 SEXUAL AROUSAL DISORDERS

-Female sexual arousal disorder

PERSONAL EXPECTATIONS AND ETHICS
- Male erectile disorder
 Although ethics is integral to religion, ethics
thought and ethical approaches to sexuality can
be viewed separately from religion.
Orgasmic Disorders
Sexual Response Cycle  Female orgasmic
 Common occurring phases of the human sexual  Male orgasmic disorder
response follow a similar sequence in both
females and males regardless of sexual
orientation. Sexual Pain Disorders
 Desire phase
 Dyspanreunia
 Excitement phase - Vasocongestion
 Pelvic disorders
 Orgasmic phase
 Vaginismus
 Resolution phase
 Vulvodynia
 Vestibulitis

Altered Sexual Function

 The ability to engage in sexual behavior is of Problem With Satisfaction

great importance to most people
 Some people experience sexual desire, arousal,
and orgasm and yet feel dissatisfied with their
sexual relationship . Satisfaction problems may
Past And Current Factors
be situation .

Spirituality
  Spirituality and Religion are often used by
clients and professionals.
Religious Practices:
 Spirituality- human tendency to seek meaning
and purpose in life.  Holy days
 Religion- applied to ritualistic practices and  Sacred Texts
organized beliefs.  Sacred symbol
 Koenig a nurse-turned-physician views  Prayer and meditation
spirituality as connected with religion.

 Beliefs affecting diet

There are people who do not believe that there is an  Beliefs about illness and healing
spiritual reality:  Beliefs about dress and modesty
* Agnostic  Beliefs related to birth
 Beliefs related to death
*Atheist

Four levels of being present in clients:

Spiritual Care- following set of guidelines for
intervening to resolve a client’s spiritual problem. 1. Presence
2. Partial presence
Spiritual Nursing Care- intuitive, interpersonal,
3. Full presence
altruistic, and integrative expression but reflects client’s
4. Transcendent presence
reality

Spiritual needs- better understood as inner

movements, yearnings, or experiences.
Spiritual distress- disturbance in the belief that provides
meaning to life.
Spiritual health- is thought to not occur by chance, but
by choice.
Religious coping- ways of thinking that help people
cope with their challenges.
 Conversing about spirituality
 Supporting religious practices
 Assisting clients with prayer
 Referring clients to spiritual care experts
Strategies for nurses to increase their spiritual
awareness:
*Write a self-epitaph,

*Explore personal end-of-life issues,

*Create a personal loss history,

*List significant values,

Religious Practices that nurses should know: *Conduct a spiritual self assessment
 Seek a basic understanding of client’s spiritual
needs.
Comfort, Rest and Sleep
 Follow the client’s expressed wishes regarding Pain
spiritual care.
 a sensation of physical or mental hurt or
 Do not urge clients to adopt certain spiritual
suffering that causes distress or agony to the
beliefs or practices.
one experiencing it.
 Provide spiritual care in a way that is consistent
with personal beliefs. Factors Affecting the Pain Experience
1. Age REST and SLEEP
2. Previous experience with Pain Rest
3. Cultural norms and attitudes
 a state of relaxation and calmness, both mental
Pain Assessment Questions and physical.

Characteristics Question Sleep

Quality How do you feel?
Intensity “Which picture best  a state of altered consciousness during which an
describes your pain?” individual experiences minimal physical activity
Location Where does it hurt? and a great slowing of the body’s physiological
Duration Is the pain constant? process.
Triggers What makes the pain
worse?
Effects How has the pain Stages of Sleep
affected your life?
1. NREM (Non-Rapid Eye Movement) Stage
Knowledge Level Have you taken any
medicine for pain? a. Stage 1 – readily awakened, drowsy relaxed
b. Stage 2 – light sleep
c. Stage 3 – difficult to arouse
d. Stage 4 – deep sleep

2. REM (Rapid Eye Movement) stage

a. Dream state of sleep, close to wakefulness but

Nonpharmacologic Therapies
difficult to arouse
 Relaxation, imagery, reframing
 Patient education
 Psychotherapy Common Sleep Disorders
 cutaneous stimulation
1. Insomnia – difficulty falling asleep
 transcutaneous electrical nerve stimulation
2. Hyperinsomnia – excessive sleep
Techniques that distract attention
3. Narcolepsy – overwhelming sleepiness during
a. Listen to music daytime
b. Conversation
4. Sleep Apnea – cessation of breathing during sleep
c. Read/play games
5. Parasomnia
Techniques that promote relaxation
• Somnambulism – sleep walking
a. Conventional methods
• Nocturnal enuresis –bedwetting
• Listen to music • Soliloquy – sleep talking
• Guided imagery • Nocturnal erections – wet dreams
• Meditation • Bruxism – clenching and grinding of teeth
during sleep
b. Analgesics
Nursing Interventions to Promote Sleep
c. Placebo
• promote comfort and relaxation
• create restful environment
 • attend to bedtime rituals
• high protein food
• avoid caffeine and alcohol in the evening
• use the bed mainly for sleep

Oxygenation Fluid and Electrolyte

Acid Base Balance
Oxygenation

 delivery of O2 to body tissues & cells

O2

 Sustain life

Respiration

 process of gaseous exchange between

individual & environment
 exchange of O2 & carbon dioxide

Physiology of Oxygenation

Processes involved:

1. Ventilation

2. Alveolar gas exchange

3. Oxygen transport & delivery

4. Cellular respiration Overview of anatomy & physiology of the respiratory

Process of Oxegenation system

1.) Ventilation – movement of air into & out of lungs A. Upper

delivers fresh air into alveoli
Transport gases to the lower airways
( controlled by respiratory centers: pons & medulla
Protection of the organs from the foreign matter
oblongata)
Warms filtrates and humidifies inspired air.
2.) Alveolar gas exchange:
Nasal Cavity
Oxygen uptake ( external respiration) – exchange of O2
from alveolar space into the pulmonary capillary blood Pharynx

3. Oxygen Transport & delivery Larynx

Respiratory System Oxygen Transport from Lungs to

Cells

A. Lower Airways
Clearance mechanism 3. Hypoventilation – lungs is unable to meet the body’s
oxygen demand that causes carbon dioxide retention
Protection from injury
4. Tachypnea – rapid respiratory rate.
Immunologic responses
5. Bradypnea – slow respiratory rate
o Trachea
6. Apnea – cessation of breathing
o Right and left main stem bronchi
7. Dyspnea – labored or difficulty in breathing
o Segmental bronchi
8. Orthopnea – inability to breathe except in upright or
o Terminal bronchi sitting position.

Respiratory Control

Medulla oblongata

Pons

Nursing Diagnosis

1. Ineffective airway clearance related to

• Tracheobronchial infection, obstruction, secretions

Measures that Promote adequate Respiratory Function • Decreased energy and fatigue
•Adequate oxygen supply from the environment. • Trauma
• Deep breathing and coughing exercises. • Dehydration
• Positioning

• Patent airway 2. Ineffective breathing pattern related to:

• Adequate hydration a. Neuromuscular/musculoskeletal impairment
• Avoid environmental pollutants and unhealthy b. Pain
lifestyle
c. Anxiety
• Chest physiotherapy
d. Decreased energy and fatigue

e. Inflammatory process
Alterations in Respiratory Function
f. Decreased lung expansion
1. Hypoxia – this results from a deficiency in oxygen
delivery or oxygen utilization at the circular level.

Causes: 3. Impaired gas exchange related to:

a. Low oxygen level in the blood a. Alteration oxygen supply

b. Low concentration of oxygen usually at high altitudes b. Alveolar-capillary membrane changes

2. Hyperventilation – excessive amount of air in the c. Altered oxygen-carrying capacity of the blood
lungs d. Altered blood flow
4. Activity * Water loss has a negative effect on the body’s ability
to function. (Lust & Tierra, 2003).
5. Anxiety

6. Ineffective individual coping

Physiological functions of the Electrolytes:
7. Fear
• Promote neuro muscular irritability – transfer of
Fluids and Electrolytes
information from nerve to the muscle
Body fluid – denote both water and electrolytes
• Maintain body fluid osmolarity – fluid moves through
Body water – refers to water alone out cellular environment by passively crossing semi
permeable membranes
Homeostasis- refers to the state of balance of body
fluid.
• Regulate acid-base balance – homeostatic regulation
of the pH of the body’s extracellular fluid. The proper
Fluid Compartment balance between the acids and bases in the ECF is
3 Compartments crucial for the normal physiology of the body and
cellular metabolism
1. Cells
METABOLISM - the chemical processes that occur with
2. Blood vessels in a living organism in order to maintain life
3. Tissue space • Distribute body fluids between the fluid
compartments.

2 types of body fluid

1. Intracellular fluid (ICF) ELECTROLYTES

2. Extracellular fluid (ECF)

Body Water Distribution

• 45-75% body's total weight

• 2/3- Intracellular

• 1/3 –Extracellular

= ¼ - intravascular

=3/4 – interstitial – thin layer of fluid which surrounds

the body’s cell

2 Main functions of H2O

1. Act as a solvent for the essential nutrients

2. Transport nutrients and oxygen from the blood to the

cells and to remove waste material and other
substances from the cells back to the blood so they can
be excreted by the body.
 Hyponatremia- deficit in the extracellular level of
sodium.

Edema- excess fluid in the interstitial space

Hypernatremia- excess in the extracellular level of

sodium

Disturbances in Electrolyte and Acid-Base Balance

• Potassium

Hypokalemia- decrease in the extracellular level of

potassium.

eg. Use of Laxatives, antibiotics

Hyperkalemia- increase in the extracellular level of

potassium.

eg. Potassium-sparing diuretics

Disturbances in Electrolyte and Acid-Base Balance

Hypokalemia can cause a CARDIAC ARREST when:

 the potassium level is less than 2.5 mEq/L

Factors Affecting Fluid and Electrolyte Balance

Calcium
1. Age. The smaller the body, the larger the fluid
content Hypocalcemia – decrease calcium level

Adult= 60% Hypercalcemia – increase calcium level

Child 60-77%

Infant = 77% MAGNESIUM

2. Lifestyle – diet, exercise, stress, and alcohol Hypomagnesemia – decrease magnesium level
consumption
- usually occurs with hypokalemia and hypocalcemia
3. Environmental temperature – -people in strenuous
Hypermagnesemia – increase magnesium level
activity – increased risk for fluid and electrolyte
imbalance when temp. is high. Fluid loss thru sweating. eg. Use of Antacids, laxatives
4. Sex and Body size – Female - Higher body fat – less
body water Male -Higher lean muscle - more body
Nursing Interventions for clients with problems in fluid
water
and electrolyte balance
• Women – more body fat than man
1. Encourage to drink adequate fluids.

2. Enteral (GIT) and Intravenous (into a vein) fluid and

Disturbances in Electrolyte and Acid-Base Balance electrolytes replacement

• Sodium
3. Fluid intake modifications – increased fluid intake or Hygienic Care
fluid restrictions.
• Involves the care of:
4. Dietary changes – some clients with electrolyte
Skin
problems need to avoid specific food groups.
Hair

Nails
NURSING INTERVENTIONS to
Teeth
PROMOTE HEALTHY PHYSIOLOGIC
RESPONSES Oral & Nasal Cavities

Eyes
1. Hygiene
Ears
2. Skin Integrity

3. Mobility / Activity Perineal-genital area

4. Rest & Sleep

Types of Hygienic Care
5. Comfort & Pain Management
A. Early Morning – offer urinal/bedpan, wash face &
6. Nutrition
hands, and give oral care.
7. Urinary Elimination
B. Morning – after breakfast, bedpan/urinal,
8. Bowel Elimination bath/shower, perineal care, back massage & oral, nail &
hair care.
9. Oxygenation & Perfusion
C. Hours of Sleep (HS) or PM – bedpan/urinal, washing
10.Fluid, Electrolytes & Acid-Base Balance
hands & face, oral care & backrub.

D. As needed (PRN) – care as needed.

HYGIENE

Hygiene – the science of health & maintenance.

Common Problems of the Skin
• Client hygiene is an extension of providing client
1. Abrasion – superficial layers of the skin are scraped or
safety and protecting the client’s defense mechanism.
rubbed away with localized bleeding.
• Personal hygiene – is a self-care by which people
a. Nursing Interventions
attend to such functions as bathing, toileting, general
body hygiene and grooming.  Keep the wound clean and dry

2. Excessive dryness – skin is scaly and rough

Factors Influencing Hygienic Practice a. Nursing Interventions
1. Body Image  Increase fluid intake
2. Social and Cultural Practices  Apply cream or lotion to moisturize the skin
3. Personal Preferences  Avoid use of alcohol
4. Socioeconomic Status  Bathe the client less frequently
5. Knowledge
 Perineal-Genital Care – to remove normal perineal
secretions and odor, to muscle quickly done.

3. Acne – an inflammatory condition of the skin which

occurs in the sebaceous glands Foot Care
a. Nursing Interventions •Wash your feet daily and dry them well especially the
interdigital spaces
Encourage daily bath
• Use warm water to soften the nails and the debris
Keep the skin clean and dry
around them
Adequate rest, sleep and exercise
• Use cream or lotion to moisten the skin and soften
Have exposure to natural sunlight calluses

Avoid foods with high carbohydrates and fat content • For toe nails, cut straight across

Reduce stress and anxiety

Avoid pickling and squeezing of pimples Causes of foot problems

4. Erythema – redness of the skin which may be 1. Callus – painless, flat, thickened epidermis.
associated with rashes, exposure to sun, elevated body 2. Corn – keratosis caused by friction and pressure from
temperature. a shoe.
a. Nursing Interventions 3. Unpleasant odors – this results from perspirations
Shave excessive hair growth and its interaction with microorganisms.

5. Hyperhidrosis – excessive perspiration 4. Plantar warts – caused by virus papova-virus hominis.

6. Bromhidrosis – foul-smelling perspiration 5. Fissures – caused by dryness and cracking of the skin
between the toes.
7. Vitiligo – patches of hypopigmented skin
6. Ingrown toenail – inward growth of the nail causing
into soft tissues.
Bed Bath – to remove microorganisms, body
secretions and excretions and dead skin cells. It
stimulates circulation, produces sense of well-being, Nail Care
promotes relaxation & comfort as well as prevents & • Trim nails straight across
eliminates unpleasant body odors.
• Do not trim nails at the lateral corners to prevent
ingrown
Back Rub – massage the back with two chief
objectives; to relax and relieve muscle tension and to
stimulate blood circulation to the tissues and muscles. Abnormal Findings of the Nails

Types • Spoon nails

•Effleurage – smooth, long stoke, moving the hands up • Excessing thickness or clubbing
and down the back. • Grooves or furrows
• Tapotement – sharp hacking movement on the back • Beau’s lines
• Petrissage – a large pinch on the skin, subcutaneous • Discolored or detached
tissue and muscle quickly done.
• Bluish or purplish tint or pallor Pediculosis capitic – head

• Hangnails or paronychia Pediculosis curporis – body

• Delayed capillary refilling time Pediculosis pubis – pubic hair

• Scabies – contagious skin infestation by the itch mite

Mouth Care • Hirsutism – excessive growth of baby hair
• Brush teeth thoroughly after meals and at bedtime

• Floss the teeth daily Ear Care

• Adequate intake of food rich in calcium • Clean the pinna with moist cloth
• Have dental check up every 6 months • Remove the cerumen by retracting the ears
downward

• Do not use pins, toothpicks, or cotton tip applicator

Common Mouth Problems

•Plaque – bacteria that adhere to the enamel surface of

the teeth Abnormal Findings of the Ears
• Tartar – a visible, hard deposit of plaque and bacteria • Asymmetrical, excessively red or tender auricles
that forms at the gum lines
• Lesions, flaky, scaly skin over auricles
• Halitosis – bad breath
• Normal voice tones not hear
• Gingivitis – inflammation of the gums
• Discharge
• Glossitis – inflammation of the tongue

• Stomatitis – inflammation and dryness of the oral

mucosa Abnormal Findings of the Eyes

• Parotitis – inflammation of the parotid salivary glands • Loss of hair, scaling, flaky eyebrows

• Sordes – accumulation of foul matter on the gums and • Redness, swelling, flaking, crusting, discharge,
teeth asymmetrical closing, ptosis of eyelids

• Cheilosi – cracking of the lips • Jaundiced sclera

• Dental carries – teeth have darkened area • Unequal pupils

• Pupils fail to dilate or constrict

Hair Care • Inability to see

• To stimulate the circulation of blood in the scalp and

to clean the hair. Nursing Process: Assessment
Common Hair & Scalp Problems • Nursing history to determine:
• Dandruff – a chronic diffuse scalling of the scalp with – Self-care practices
pruritus
– Self-care abilities
• Alopecia – hair loss
– Past or current problems
• Pediculosis – infestation with lice
 – Identification of clients at risk for developing Impaired skin integrity is a threat to older people;
impairment clients with restricted mobility; chronic illnesses or
trauma & those undergoing invasive healthcare
• Physical Assessment
procedures

Skin Integrity…
Nursing Process: Nursing Diagnoses
• Intact skin refers to the presence of normal skin & skin
• Deficient knowledge layers uninterrupted by wounds.

• Situational low self-esteem • Internal factors that influences the appearance of skin
& its integrity: genetics, age, underlying health of the
• Risk for impaired skin integrity individual & external factors (e.g. activity).
• Impaired skin integrity

• Self-care deficit TYPES OF WOUNDS

• Risk for infection
• Body wounds can either be:
• Impaired oral mucous membrane
a) Intentional – trauma occur during therapy
• Disturbed body image (operations or venipuncture).

• Risk for injury b) Unintentional – accidental (vehicular accident)

c) Closed – tissue are traumatized without a break in the

skin
Nursing Process: Planning
d) Open – skin or mucous membrane surface is broken.
• Nurse, and if appropriate, the client and/or family set
goals/desired outcomes

• Nurse identifies interventions to assist the client to Types of Wounds – how they are acquired:
achieve the designated outcomes 1. Incision – caused by a sharp instrument (knife or
scalpel); open wound

Nursing Process: Interventions 2. Contusion – blow from a blunt instrument; closed

wound
1. Assisting dependent clients with hygienic activities.
3. Abrasion – surface scrape
2. Educating clients and/or family about appropriate
hygienic practices. 4. Puncture – penetration of the skin by a sharp
instrument.
3. Demonstrating use of assistive equipment and
adaptive activities. 5. Laceration – tissues torn apart, often from accidents.

4. Assessing and monitoring physical and psychological 6. Penetrating wound – penetration of the skin & the
responses. underlying tissues, usually unintentional.

SKIN INTEGRITY Types of Wounds – degree of contamination:

• SKIN 1. Clean wounds – uninfected wound in which minimal

inflammation is encountered & the respiratory,
Largest organ of the body alimentary, genital & urinary tracts are not entered.
Maintains health & protects the body from injury They are primarily closed wounds.
2. Clean-contaminated wounds – surgical wounds in 2. Immobility
which the respiratory, alimentary, genital & urinary
3. Inadequate Nutrition
tracts has been entered. There is no evidence of
infection 4. Fecal & urinary incontinence
3. Contaminated wounds – open, fresh, accidental 5. Decreased mental status
wounds & surgical wounds involving a major break in
sterile technique or a large amount of spillage from the 6. Diminished sensation
GI tract. They show evidence of inflammation. 7. Excessive body heat
4. Dirty or infected wounds – wounds containing dead 8. Advanced age
tissue & wounds with evidence of a clinical infection,
such as purulent drainage. 9. Chronic medical conditions

10.Others – poor lifting techniques, incorrect

positioning, repeated injections in the same area, hard
Types of Wounds – by depth: support surfaces, incorrect application of
1. Partial thickness – confined to the skin (dermis & pressurerelieving devices
epidermis); heal by regeneration. Stages of Pressure Ulcers
2. Full thickness – involves the dermis, epidermis,
subcutaneous tissue, & possibly muscle & bone; require
connective tissue repair.

PRESSURE ULCERS

• Previously called – decubitus ulcer, pressure sores or

bedsores.

• Consists of injury to the skin and/or underlying tissue,

usually over a bony prominence, as a result of force
alone or in combination with movement.

• Most common problem of both acute care settings & WOUND HEALING
long-term settings, including homes. • Healing is a quality of living tissue, it is also referred to
as regeneration (renewal) of tissues.

Types of Wound Healing:

1. Primary intention healing

 Tissue surfaces have been approximated & there is

minimal or no tissue loss.

 Characterized by formation of minimal granulation

tissue & scarring

 Also called – primary union or first intention healing

Risk Factors (Pressure ulcers)
 Example: closed surgical incision or use of tissue
1. Friction & shearing force adhesive

2. Secondary intention healing
 Wound that is extensive & involves considerable
tissue loss & in which edges cannot or should not be
approximated.
 Example: pressure ulcers
 It differs with primary intention healing in 3 ways: (a)
repair time is longer; (b) scarring is greater; (c)
susceptibility to infection is greater.
Phases of Wound Healing:
1. Inflammatory Phase
 Lasts 3 to 6 days
 Hemostasis & phagocytosis occurs
2. Proliferative Phase
 Extends from day 3 or 4 to about day 21 post injury
 Fribroblasts (connective tissue cells) begins to
synthesize collagen
3. Maturation Phase
 Day 21 & can extend 1 or 2 years after injury
 Wound is remodeled & contracted
ACTIVITY, MOBILITY & EXERCISE
• Body Mechanics – efficient, coordinated and safe use
of the body to produce motion and maintain balance
during the activity.
Principles of Body Mechanics
1. Balance is maintained and muscle strained is avoided
as long as the line of gravity passes through the base of
support.
2. Wider based of support and lower center of gravity,
the greater the stability.
3. Balanced is maintained with minimal effort when the
base of support is enlarged in the direction in which the
movement will occur.
4. Objects that are close to the center of gravity are
moved with least effort.
5. Before moving objects, contract your gluteal,
abdominal, leg and arm muscles to prepare them for
action.
6. The synchronized use of as many large muscle groups
as possible during an activity increases overall strength
and prevents muscle fatigue and injury.
7. The closer line of gravity to the center of the base of
support of the greater its stability.
8. The greater the friction against the surface beneath
an object, the greater the force required to move the
object.
9. Pulling creates less friction than pushing.
10.The heavier the object, the greater the force needed
to move an object.
11.Moving an object along a level surface requires less
energy than moving an object up an inclined surface or
lifting it against the force of gravity.
12.Continuous muscle exertion can results in muscle
strain and injury.
Nursing Intervention to Promote Activity & Exercise
1. ADL (activities of daily living) – basic activities of
eating, grooming, dressing, elimination and locomotion.
2. Protective positions
a. Supine – back lying position
b. Fowler’s
 Low/semi-fowler’s – head of bed is elevated (15-45
degrees)
 High fowler’s – head of bed is elevated (80-90
degrees)
Protective positions ….
c. Lateral / side-lying / sim –body is turned to the sides.
d. Dorsal recumbent – supine with the knee flexed
e. Prone – lies on abdomen with head turned to sides. • The study of nutrients and the processes in which they
are used by the body.
f. Knee-chest / genupectoral – trunk is perpendicular to
the legs. • All interactions between the organism and the food it
consumes
f. Trendelenburg position – bed is tilted with the head
downward

g. Modified trendelenburg – supine with the lower The nutrients needed for body functioning:
extremities elevated at 45 degrees.
• Water
h. Reverse Trendelenburg – entire bed is tilted with feet
• Carbohydrates
downward
• Proteins

• Fats
Types of Exercises
• Vitamins
1. Active ROM – range of motion exercises done by the
client. • Minerals
2. Passive ROM –range of motion exercises done for the
client by a nurse.
Variables affecting an individual’s calorie needs
3. Active – Resistive ROM– done by the clients against a
weight or force. 1. Age and Growth

4. Active – Assistive ROM – done by the stronger arm 2. Gender

and leg to the weaker arm and leg. a. Men require more calories because they have higher
5. Isotonic – involves change in muscle length and BMR
tension. 3. Ethnicity and culture
6. Isometric - involves muscle exercise. 4. Beliefs about food

5. Personal Preferences
When Transporting a Client 6. Religious practices
1. From bed to wheelchair 7. Lifestyle
• Position the wheelchair parallel to bed 8. Economics
• Lock the wheels of the chair 9. Medications and Therapy
2. From bed to stretcher 10. Health
• Position the stretcher parallel to the bed 11. Alcohol Consumption
• Lock the wheels of the stretcher and the bed 12. Advertising
• Push from the head of the stretcher 13. Psychological Factors
• When entering the rooms/elevator, the head of the Food and fluid intake regulating mechanisms
stretcher should go in first.
• Thirst

• Hunger
NUTRITION • Appetite
• Satiety FAT SOLUBLE VITAMINS

1. Vit A (Retinol) Food source: milk and dairy products,

dark green and yellow vegetables
VITAMINS
Prolonged deficiency: night blindness, opacity of the
Water soluble Vitamins
lens, xeropthalmia
1. Vitamin C (Ascorbic acid) Common food sources:
2. Vit D (Cholecalciferol, Ergosterol) Food sources:
Guava, Citrus fruits, broccoli, potatoes, tomatoes,
fortified milk, breakfast cereals, butter, egg yolk
strawberries, cabbage, and green vegetables
Prolonged deficiency: Rickets, delayed dentition,
Prolonged deficiency: Scurvy, poor wound healing
Osteomalacia
2. B1 (Thiamine) Common food sources: pork liver,
3. Vit E(Tocopherol) Food sources: Vegetable oils, corn,
organ meats, whole and enriched grains, nuts, legumes,
peanuts, margarine
potatoes, eggs, milk
Prolonged deficiency: Anemia, skin lesions
Prolonged deficiency: Beriberi (hypochlorhydria)
4. Vit K (Menadione) Food sources: green leafy
3. B2 (Riboflavin) Common food sources: milk and dairy
vegetables, cabbage, cheese, egg yolk
products, organ meats, eggs, enriched grains, green
leafy vegetables Prolonged deficiency: Bleeding, Osteoporosis

Prolonged deficiency: skin lesions, cataracts,

forgetfulness
MINERALS
4. B3 (Niacin/Nicotinic acid) Common food sources:
Macrominerals
Kidney, liver, poultry lean meat, fish, peanut butter,
enriched and whole grain cereals, dried peas and 1. Calcium
greens, nuts
a. For bone and teeth formation
Prolonged deficiency: dermatitis, muscular weakness,GI
hemorrhage (Pellagra) b. Promotes blood coagulation

5. B6 (Plyridoxine) Food sources: Chicken peanuts, oats, Sources:

fish, pork, bananas, corn, egg yolk, potatoes ➢Milk and dairy products
Prolonged deficiency: Convulsions, anemia, flaky skin ➢Green and leafy vegetables
6. B12 (Cobalamin) Food sources: Liver, shrimp, oyster,
➢Whole grains
milk, meat, eggs, cheese
➢Carrots
Prolonged deficiency: loss of peripheral sensation and
paralysis ➢Tofu
7. Panthotenic Acid Food sources: meat, whole grain
cereals, legumes, milk, vegetables, fruits
2. Potasium
Prolonged deficiency: fatigue, sleep disturbances,
nausea, poor coordination a. Promotes electrolyte balance

b. Controls the activity of cardiac muscles

Sources:
8. Biotin Food sources: egg yolk, organ meats, milk

Prolonged deficiency: seborrheic Dermatitis(cradle cap) ➢Banana

➢Avocado
➢Oranges 1. Food must be pleasing to the eyes

➢Strawberries 2. Patient must be in comfortable position

➢Tomatoes 3. Provide oral hygiene

➢Raisins 4. Promote comfort

3. Sodium 5. Engage patient in pleasant conversation

a. Responsible for maintaining acid base balance and

muscle excitability Nursing Diagnosis for Clients with Nutritional Problems
4. Iron 1. Altered Nutrition
a. Necessary for hemoglobin formation a. Less than body requirement
Sources: b. More than body requirements
➢Pork Liver 2. Activity intolerance
➢Lean meat 3. Alteration in Elimination
5. Iodine 4. Knowledge deficit
a. Synthesis of thyroxine Bowel and Bladder Elimination Elimination of waste
Sources: products of digestion from the body is essential to
health.
➢Iodized salt
Defecation – is the expulsion of feces from the anus and
➢Seafood rectum

➢Milk Feces/stool – the excreted waste product.

Flatus – air-by-product of the digestion of

carbohydrates

Peristalsis – wavelike movement produced by the

Common Problems of Nutrition circular and longitudinal muscle fibers of the intestines.
1. Anorexia – loss of appetite

2. Nausea and vomiting Normal Characteristics of the Stool

3. Malnutrition • Color – yellow or golden brown
a. Overnutrition • Odor – aromatic
1. Overweight • Amount – depends on the food intake
2. Obesity • Consistency – soft, formed
b Undernutrition • Shape – cylindrical
1. Kwashiorkor • -caused by protein deficiency • Frequency – varies
2. Marasmus- severe malnutrition

Alterations on Characteristic of Stool

How to stimulate your appetite? 1. Alcoholic stool – gray, pale or clay colored.
2. Hematochezia –with bright red blood.

3. Melena –black, tarry stool.

4. Steatorrhea – greasy, bulky, foul smelling o Diarrhea – passage of liquid feces and an increase
frequency of defecation

a. Causes:
Common Fecal Elimination Problems
i. Psychologic stress (anxiety)
oConstipation – passage of dry, hard or the passage of
no stool ii. Medications

a. Causes iii. Allergy to foods

i. Insufficient fiber intake iv. Intolerance to food/fluid

ii. Insufficient fluid intake v. Diseases of the colon

iii. Immobility

iv. Irregular defecation habits Nursing Interventions

v. Change in daily routine •Replace fluid loss

vi. Lack of privacy • Promote rest

• Diet (low fiber diet, BRAT diet, high potassium diet)

Nursing Interventions BRAT – banana, rice, apple sauce, toast

• Adequate fluid intake (1.5L to 2 L) • Antidiarrheal medications

• High fiber diet

• Establish regular pattern of defecation o Flatulence – presence of excessive flatus in the

intestines that leads to distention of the abdomen.
• Respond immediately to the urge of defecation
a. Causes:

i. Constipation
o Fecal Impaction – mass or collection of hardened
feces in the folds of the rectum. ii. Medications that cause decreased intestinal motility.

a. Causes: iii. Anxiety

i. Prolonged retention of the fecal material iv. Eating gas forming foods

ii. Poor defecation habits v. Rapid food ingestion

iii. Constipation vi. Improper use of straw

vii. Excessive soda intake

Nursing Interventions viii.Gum chewing, smoking

• Manual extraction Interventions:

• Increase fluid intake – Avoid gas forming foods

• Sufficient bulk/fiber in diet – Provide warm fluids

• Activity and exercise – Ambulation

– Activity and exercise o Reservoir of urine

– Limit sodas, smoking and chewing of gums

• Urethra

o Fecal incontinence – loss of voluntary ability to control o Passageway of urine

fecal urges through the anal sphincter

Nursing Diagnosis for Clients with Fecal Elimination

Normal characteristic of Urine
Problems
• Color – amber/straw
• Constipation related to:
• Odor – Aromatic
oInadequate fiber in diet
• Transparency – clear
oImmobility oInadequate fluid intake
• pH – slightly acidic
oPain upon defecation
• Specific gravity – 1.010 – 1.025
• Perceived Constipation related to:

o Altered thought process

Problems in Urinary Elimination
o Family health beliefs
o Polyuria – production of abnormally large amount of
o Knowledge deficit about normal processes
urine (more than 2500 ml/day)
• Diarrhea related to:
o Oliguria – low urine output (less than 500 ml/day)
oDietary alteration
o Anuria – the absence of urine production
oStress/anxiety
o Nocturia – increased urinary frequency at night
• Potential fluid volume deficit related to:
o Dysuria – difficulty/pain upon urination o Hesitancy –
oDiarrhea difficulty in initiating voiding

• Potential impaired skin integrity o Pollakuria – frequent, scanty urination

o Urinary retention – accumulations of urine in the

bladder with associated inability to empty itself

Urinary Elimination
Nursing Diagnoses for Clients with Urinary Elimination
Four Urinary Tract Organs
Problems
o Bean shaped situated on either side of the spinal
• Incontinence related to:
column
oAltered environment
o Regulators of acid-base balance in the body
oSensory or cognitive deficit

oMobility deficit
• Ureters

o Transport urine to the urinary bladder

• Urinary retention related to:

oUrethral blockage
• Urinary Bladder
oMedication

• Altered patterns of Elimination related to:

oBladder infection and Renal calculi

MODULE 5
Evidence- Based Practice In Nursing
 It is the integration of best research evidence
with expertise and patient values for delivery of
optimal health care.
 It involves the incorporation of three
components to improve outcomes and quality
of life.
Three Components
1. External Evidence
 includes systematic reviews, and clinical
practice guidelines that support a change in
clinical practice.
2. Internal Evidence
 includes health care institution based quality
improvement projects, outcome management
initiatives and clinical expertise.
3. Patient References and Values
 RESEARCH ₊ CLINICAL EXPERTISE ₊ PATIENT
REFERENCES =EVIDENCED BASED PRACTICE
 The key elements of EBP are clinically relevant
research that is patient- centered and clinical
judgment that includes clinical expertise and
incorporates the patient specific characteristics
and preferences.
Characteristics
Research problem
 Significant, not trivial.
 Addresses an issue that is important to nursing.
 Addresses a researchable problem.
 Is feasible to address in study setting.
Research Purpose
 Is clearly stated.
 Will generate and refine knowledge.
 Consistent with current knowledge about
problem.
Research Subproblem
 Clear, flow logically from purpose.
Review Of Literature
 Relevant, thorough, current, authoritative.
Study Framework
 Appropriate, clearly informs and enhances
study.
Research Approach
 Research approach Appropriate for problem
and purpose. Consistent with nature of
subproblems.
Study Design
 Appropriate for study purpose.
 Incorporates appropriate control strategies
Sample
 Representative of target population or able to
represent phenomenon of interest.
 Sufficient size.
 Ethical recruitment strategies
Ethical Recruitment Strategies
 Appropriate for variables and sample.
 Yields appropriate level of measure.
 Reliable and valid. Safe and humane.
Ethical Considerations
 Protection of human rights.
 Ethical standards of beneficence, respect for
human dignity, and fair treatment upheld.
 Approved by Institutional Review Board (IRB).
Goals
 The ultimate goal is to standardized and
improved access and quality of care across the
health care system
And with integration of:
 clinical expertise/expert opinion
 external scientific evidence
  client/patient/caregiver values to provide high-
quality services reflecting the interests, values,
needs, and choices of the individuals we serve.
Evidence Based Paractice interest;
o Organized in a format known as PICO
(T)
P - patient, population or problem of

 EBP is client/patient/family centered. I - intervention being considered;

 a clinician's task is to interpret best current C - comparison or intervention;
evidence from systematic research in relation to
client/patient, O - outcome measured;
 is a continuing process, it is a dynamic T - time period.
integration of ever-evolving clinical expertise
and external evidence in day-to-day practice.
 including that individual's preferences,  Search for the Best Evidence
environment, culture, and values regarding o Select the information databases or
health and well-being. resources most likely to answer the
type of question being asked; utilize
keywords and concepts; combine
multiple search terms.
 Critically Appraise the Evidence
o Determine a study’s reliability,
validity, and applicability to
the client in
question.
o Assess
and evaluate
the strengths
and
weaknesses of
the evidence.
 Integrate The
Evidence With One’s
Clinical Expertise And
Client Preference
o To
make the best
clinical
decision.
Before
integration,
other considerations beyond
applicability must be considered, such
as biologic, socioeconomic, and
Steps of the Evidence-Based Practice epidemiologic
Process issues.
 Ask a Clinical Guiding Question  Evaluate the Outcomes
 oWas the expected outcome achieved? If
not, why not
o Was it due to non-adherence to
treatment plan, different client
prognostic factors, and/or providers not
ready for the practice change?
o Was it because of skills, evidence
interpretation, or in implementing the
intervention?
 Disseminate the Outcome
o Disseminate evidence to colleagues
within your organization, and beyond.
o Outcome dissemination can be done
through intra and inter-departmental
in-services, journal clubs, online media,
lectures, conferences, posters, and
manuscripts.
Techniques
 Strategy to reframe nurses' understanding of
the types of information used for clinical
decision making is to categorize information
garnered from empirical, ethical, personal, and
aesthetic sources of professional nursing
practice
Empirical evidence
 is information acquired by observation or
experimentation.
 is found in published documents that provide
background information, methods used to
conduct the study, study findings, and a
discussion of how the results may be used in
practice.
Ethical evidence
 based on nurses' knowledge of, and respect for,
patients' unique values and preferences, is
practiced as the ethics of nursing.
 Nurses have the ability to influence patient-care
outcomes by using their nursing knowledge and
skills, their individual understanding of ethical
principles, the nurse-patient relationships they
establish, and good communication skills
Personal evidence
 evolves from nurses' individual experiences
while caring for particular patients and is based
on the interpersonal relationships of nursing.
 Nurses must be able to respect another
person's beliefs and be non-judgmental even
when a patient's beliefs differ from their own
world views.
Aesthetic evidence
 is based on the nurse's intuition, interpretation,
understanding, and values.
 The nurse can use this information to
individualize the care plan so that proposed
interventions can be successful.
Documentation and Reporting
DEFINITION OF TERMS
1) Documentation
2) Record or chart or client record
3) Report
4) Recording or charting or documenting
Documentation
 is a nursing action that produces a written
account of pertinent patient data, nursing
clinical decisions and interventions, & patient
responses in health record (O’Toole, 2013).
 Is any written or electronically generated
information about a patient that describes the
patient, the patient’s health & the care &
services provided, including the dates of care.
 Is anything written or printed on which you rely
as record or proof of patient actions &
activities.
Record or chart or client record
 is a formal, legal document that provides
evidence of a client’s care and can be written or
computer-based.
Purpose of client record
1) Communication diagnosis and reveal that the appropriate care
has been given.
 The record serves as the vehicle by which
different health professionals who interact with 7) Legal Documentation
a client communicate with each other.
 The client’s record is a legal document and is
 This prevents fragmentation, repetition, and
usually admissible in court as evidence.
delays in client care.
8) Health Care Analysis
2) Planning Client Care
 Information from records may assist health care
 Each health professional uses data from the
planners to identify agency needs, such as over
client’s record to plan care for that client.
utilized and underutilized hospital services.
 Nurses use baseline and ongoing data to
 Records can be used to establish the costs of
evaluate the effectiveness of the nursing care
various services and to identify those services
plan.
that cost the agency money and those that
 The physicians plans treatment after seeing the
generate revenue
laboratory reports of patient.
Report
3) Auditing Health Agencies
 is an oral, written, or computer-based
 An audit is a review of client records for quality
communication intended to convey information
assurance purposes .
to others.
 Accrediting agencies such as The Joint
Commission may review client records to Recording, charting or documenting
determine if a particular health agency is
meeting its stated standards.  is the process of making an entry on a client
record .
4) Research

 The information contained in a record can be a

valuable source of data for research.
 The treatment plans for a number of clients
with the same health problems can yield
information helpful in treating other clients.
5) Education
 Students in health disciplines often use client
records as educational tools.
 A record can frequently provide a
comprehensive view of the client, the illness
and effective treatment strategies and factors
that affect the outcome of the illness.
6) Reimbursement
 Documentation also helps a facility receive
reimbursement from the government.
 For a patient to obtain payment through
Medicare or insurance agencies the client’s
clinical record must contain the correct
The Shift to Electronic Documentation
Computerized documentation
 Traditionally, healthcare professionals
documented on paper medical records. Paper
records are episode oriented, with a separate
records for each patient visit to a health care
agency.
 Key information such as patient allergies,
current medications, and complications from
treatment are sometimes lost from one episode
of care to the next, jeopardizing a patient’s
safety.
 Electronic Health Records (EHRs) – are used to
manage the huge volume of information
required in contemporary health care. It can
integrate all pertinent client information into
one record.
  Nurses use computers to store the client’s
database, add new data, create and revise care
plans and document client progress. Some
institutions have a computer terminal at each
client bedside, or carry a small handheld
terminally to document care immediately once
given.
 Hence, it makes care planning and
documentation easy.
Communication with in the health care team
 The quality of patient care depends on your
ability to communicate with other members of
the healthcare team.
 Whether the documentation is done
electronically or on paper, each member of the
HCT needs to document patient information in
an accurate, timely, concise and effective
manner to develop and maintain an effective,
organized and comprehensive plan of care.
 When a plan is not communicated to all
members of the HCT, care becomes fragmented
, tasks are repeated, delays & omissions in care
occur.
Confidentiality, privacy & security mechanisms
 Confidentiality - the ethical principle or legal
right that a physician or other health
professional will hold secret all information
relating to a patient, unless the patient gives
consent permitting disclosure.
 Privacy - is the right of an individual to have
some control over how his or her personal
information (or personal health information) is
collected, used, and/or disclosed.
 Security – data protection.
Guidelines for Quality Documentation
1) Fact – information about clients and their care
must be factual. A record should contain
descriptive, objective information about what a
nurse sees, hears, feels and smells
2) Accuracy – information must be accurate so
that health team members have confidence in it
3) Completeness – the information within a record
or a report should be complete, containing
concise and thorough information about a
client’s care. Concise data are easy to
understand
4) Currentness – ongoing decisions about care
must be based on currently reported
information. At the time of occurrence include
the following:
a. Vital signs
b. Administration of medications
and treatments
c. Preparation of diagnostic tests
or surgery
d. Change in status
e. Admission, transfer, discharge
or death of a client
f. Treatment for a sudden change
in status
5) Organization – the nurse communicate in a
logical format or order
6) Confidentiality – a confidential communication
is information given by one person to another
with trust and confidence that such information
will not be disclosed
DOCUMENTATION SYSTEMS
1) Source –Oriented Record
 The traditional client record
 Each person or department makes notations in
a separate section or sections of the client’s
chart
 It is convenient because care providers from
each discipline can easily locate the forms on
which to record data and it is easy to trace the
information
o Example: the admissions
department has an admission
 sheet; the physician has a continually updated as new problems are
physician’s order sheet, a identified & others resolved
physician’s history sheet & 3. Plan of Care – care plans are generated by the
progress notes person who lists the problems. Physician’s write
 NARRATIVE CHARTING is a traditional part of physician’s orders or medical care plans; nurses
the source-oriented record. It consists of write nursing orders or nursing care plans
written notes that include routine care, normal 4. Progress Notes – chart entry made by all health
professionals
involved in a
client’s care;
they all use
the same type
of sheet for
notes.
Numbered to
correspond to
the problems
on the
problem list
and may be
lettered for
the type of
data

findings & client problems, often in

chronological order.

2) Problem-Oriented Medical Records (Pomr)

Established by Lawrence Weed

The data are arranged according to the problems the

client has rather than the source of the information.

The four (4) basic components:

1. Database – consists of all information known
about the client when the client first enters the
health care agency. It includes the nursing
assessment, the physician’s history, social &
family data
2. Problem List – derived from the database.
Usually kept at the front of the chart & serves
as an index to the numbered entries in the
progress notes. Problems are listed in the order
in which they are identified & the list is
Example: SOAP Format or SOAPIE and SOAPIER

S – Subjective data
O – Objective data
A – Assessment
P – Plan
I – Intervention
E – Evaluation
R– Revision

4)
Focus

Charting (Fdar)
3) Pie (Problems, Interventions & Evaluation
 Intended to make the client & client concerns &
 Groups information in to three (3) categories
strengths the focus of care
 This system consists of a client care assessment
 Three (3) columns for recording are usually
floe sheet & progress notes
used: date & time, focus & progress notes
 FLOW SHEET – uses specific assessment criteria
 Focus charting describes the patient’s
in a particular format, such as human needs or
perspective and focuses on documenting the
functional health patterns
patient’s current status, progress towards goals
 Eliminate the traditional care plan &
and response to interventions.
 PURPOSE: It
brings the focus of
care back to the
patient and the
patient’s concern.
 The narrative
portion of focus
charting includes
DATA, ACTION and
RESPONSE (DAR).

The principal
advantage of focus
charting is in the
holistic emphasis on
the patient and
his/her priorities including ease in charting.
incorporate an ongoing care plan into the
progress notes 4 elements of Focus charting:

1. Focus – identifies the content or purpose of the

narrative entry and is separated from the body
 of the notes in order to promote easy data
retrieval and communication.
2. Data – the subjective/objective information
supporting the stated focus or describing the
observation at the time of a significant event.
3. Action – describes the nursing interventions
(independent, basic & perspective) past,
present, future.
4. Response – describes the patient
outcomes/response to interventions or
describes how the care plan goals have been
attained.
DATE/TIME FOCUS DATA,
ACTION,
RESPONSE
3. Bedside access to chart forms
6) Computerized Documentation
 Developed as a way to manage the huge
volume of information required in
contemporary health care
 Nurses use computers to store the client’s
database, add new data, create & revise care
plans & document client progress.
7) Case Management
 Emphasizes quality, cost-effective care
delivered within an established length of stay
 Uses a multidisciplinary approach to planning &
documenting client care, using critical
pathways.

04/22/21 Chest D: “Masakit DOCUMENTING NURSING ACTIVITIES

10 am Pain ang akon
Forms in the Client Record used to Document the
dughan.”
Nursing Process: The client record should describe the
Midclavicular
client’s ongoing status and reflect the full range of the
line pain of 4
nursing process:
on scale of 5
A: All steps of the nursing process are recorded on
Medicated discharge and referral documents.
with Isordil 5
mg, SL.
M. Sanchez, DOCUMENTATION DO’S and DON’T’S
RN
DO’S in Documentation
12:00 pm Chest R: Resting in 1. DO read what other providers have written
Pain bed. before providing care and before charting.
“Naghagan- 2. DO time and date entries.
hagan ang 3. DO use flow sheets / checklists. Keep
sakit sg akon information on flow sheet/checklist current. DO
dughan.
chart as you make observations.
Rating of 2.”
4. DO write your own observations and sign over
M. Sanchez,
printed name. Sign and initial every entry.
RN
5. DO describe patient’s behavior. DO use direct
5) Charting By Exception patient quotes when appropriate.
6. DO be factual and complete. Record exactly
 Documentation system in which only abnormal what happens to patient and care given.
or significant findings or exceptions to norms 7. DO draw a single line thru an error mark this
are recorded entry as “Mistaken” or “Error” and sign your
 Incorporates three (3) key elements: name.
1. Flow sheets 8. DO use next available line to chart.
2. Standards of nursing care
 9. DO document patient’s current status and
response to medical care and treatment.
10. DO write legibly. DO use standard chart forms.
11. DO use only approved abbreviations.

DONT’S in Documentation

1. DON’T begin charting until you check the name

and identifying number on the patient’s chart
on each page.
2. DON’T chart procedures or chart in advance.
3. DON’T clutter notes with repetitive and
frequently changing data already charted on
the flow sheet/checklist.
4. DON’T make or sign an entry for someone else.
DON’T change an entry because someone tell
you to.
5. DON’T label a patient or show bias.
6. DON’T try to cover up a mistake or accident by
inaccuracy or omission.
7. DON’T “white out” or erase an error.
8. DON’T throw away notes with an error on them.
9. DON’T squeeze in a missed entry or “leave
space” for someone else who forgot to chart.
DON’T write in the margin.
10. DON’T use meaningless words and phrases,
such as “good day” or “no complaints”.
11. DON’T use notebook, paper or pencil.
 Steps of Documentation Forms  Permanence
Nursing Process  Accepted Terminology
 Correct spelling
Assessment Assessment forms, various flow  Signature
sheets & progress notes (nurses’  Accuracy
notes)  Sequence

Nursing Care plans, critical pathways,

Diagnoses progress notes, problem lists

Planning NCPs, critical pathways, &

Kardexes

Implementation Progress notes & flow sheets

Evaluation Progress notes

REPORTING & its GENERAL GUIDELINES

• Reports are oral, written, or audio taped

exchanges of information among caregivers.

• Common reports given by nurses include  Appropriateness

change-of- shift reports, telephone reports,
 Completeness
hand-off reports, and incident reports.
 Conciseness
• A health care provider calls a nursing unit to  Legal Prudence
receive a verbal report on a patient’s condition.
REPORTS BY NURSES:
The laboratory submits a written report
providing the results of diagnostic tests and  A change-of-shift report is a meeting between
often notifies the nurse by telephone if results healthcare providers at the change of shift in
are critical. which vital information about and responsibility
for the patient is provided from the off-going
• Team members communicate information provider to the on-coming provider (Groves,
through discussions or conferences. For Manges, Scott-Cawiezell, 2016).
example, a discharge planning conference
involves members of all disciplines (e.g.,
nursing, social work, dietary, medicine, and
physical therapy) who meet to discuss the
patient’s progress toward established discharge
goals.

GENERAL GUIDELINES IN REPORTING

 Date & Time

 Timing
 Legibility
  Other names for change-of-shift report include  Guidelines/Protocols/Tools in Reporting Related
handoff, shift report, handover, or sign-out to Client Care
 Health Care Electronic Databases

A.

Other Reports: Guidelines/Protocols/Tools in documentation Related

to Client Care
1. Telephone Reports / Telephone Orders
2. Care Plan Conference – a meeting of a group of 1. Subjective Information, Objective Information,
nurses to discuss possible solutions to certain Assessment, Plan, Implement, Evaluation
problems of a client. (SOAPIE)
3. Nursing Rounds
2. Focus, Data, Action, Response (FDAR)
4. Incident Reports - also called Unusual
Occurrence Report. An agency record of an 3. Electronic Health Record (EHR)
accident or unusual occurrence.
5. Referral System - a process in which a health 4. Problem Oriented Medical Record (POMR)
worker at a one level of the health system,
1. Subjective Information, Objective Information,
having insufficient resources (drugs, equipment,
Assessment, Plan, Implement, Evaluation (SOAPIE)
skills) to manage a clinical condition; seeks the
The goals of the scope and standards are to:
assistance of a better or differently resourced
facility at the same or higher level to assist in, or  inform nurses and others about correctional
take over the management of, the client’s case. nursing practice
 guide nurse’s day-to-day practice and resolve
conflicts
Contents  develop policy and procedure and other
governance of professional practice
 Guidelines/Protocols/Tools in Documentation
 reflect on professional practice and plan
Related to Client Care
improvement.
Subjective
 Information provided by client, family (what
the patient says)
Objective
 Data obtained through observation e.g. vital
signs
Assessment
 conclusions based on the collected subjective
and objective data and formulated as patient
problem or nursing diagnosis
Plan
 Plan for treatment, education, or referrals.
Implementation
 records how those actions were carried out
Evaluation
 reports the actual patient response and
outcome
 This systematic approach to detailing patient
care keeps us goal orientated and focused on
how the patient is progressing in the treatment
plan.
 With an eye toward always evaluating or
“continuing” to evaluate a patient’s response
to treatment, the nurse is ready to intervene to
prevent an exacerbation of illness or
unexpected response to treatment.
 Instead of a problem list or list of nursing and
medical diagnosis, a focus column is used that
incorporates many aspects of patient and
patient care.
 The narrative portion of focus charting includes
DATA, ACTION and RESPONSE (DAR).
 The principal advantage of focus charting is in
the holistic emphasis on the patient and his/her
priorities including ease in charting.
 Establish a focus of care, to be addressed in the
Progress Notes.
Document the four elements of focus charting, as
necessary, wherein:
 Focus identifies the content or purposes of the
narrative entry; and is separated from the body
of the notes in order to promote easy data
retrieval and communication
 Data is the subjective and /or objective
information supporting the stated focus or
describing the observation at the time of a
significant event.
 Action describes the nursing interventions
(independent, basic and perspective) past,
present or future.
 Response describes the patient
outcome/response to the interventions or
describes how the care of plan goals have been
attained.

2. Focus, Data, Action, Response (FDAR)

Focus charting

 Focus charting describes the patient’s

perspective and focuses on documenting the
patient’s current status, progress towards goals
and response to interventions.

Purpose:

 Focus charting brings the focus of care back to Example Of Focus Charting:
the patient and the patient’s concern.
 Date/Tim Focu Data, Action  DO be factual and complete. Record exactly
e s and what happens to patient and care given.
Response  DO draw a single line thru an error, mark this
entry as “ERROR” and sign your name.
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 DON’T throw away notes with an error on them.
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S: Daisy space” for someone else who forgot to chart.
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 DON’T use meaningless words and phrases,
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Documentation DO’s and DONT’s  DON’T Use Notebook, Paper Or Pencil.

DO’s 3. ELECTRONIC HEALTH RECORD

 DO read what other providers have written
before providing care and before charting
 DO time and date all entries.
 DO use flow sheet/ checklist. Keep information
on flow sheet/checklist current. DO chart as you
make observations.
 DO write your own observations and sign over
printed name. Sign and initial every entry.
 DO describe patient’s behavior.
 DO use direct patient quotes when appropriate.
 An Electronic Health Record (EHR) is an
electronic version of a patients medical history,
that is maintained by the provider over time,
and may include all of the key administrative
clinical data relevant to that persons care under
a particular provider;
 including demographics, progress notes,
problems, medications, vital signs, past medical
history, immunizations, laboratory data and
radiology reports.
  The EHR automates access to information and
has the potential to streamline the clinician's
workflow.
 The EHR also has the ability to support other
care-related activities directly or indirectly
through various interfaces.
 For example, the EHR can improve patient care
by:
 Reducing the incidence of medical error by
improving the accuracy and clarity of medical
records.
 Making the health information available,
reducing duplication of tests, reducing delays in
treatment, and patients well informed to take
better decisions.
 Reducing medical error by improving the
accuracy and clarity of medical records.
4. Problem Oriented Medical Record (POMR)
 A method of recording data about the health
status of a patient in a problem-solving system.
 The POMR preserves the data in an easily
accessible way that encourages ongoing
assessment and revision of the health care plan
by all members of the health care team.
 The particular format of the system used varies
from setting to setting, but the components of
the method are similar.
 A data base is collected before beginning the
process of identifying the patient's problems.
The basic components of the POMR are:
1. Data Base
 History, Physical Exam and Laboratory Data
 The importance of the Data Base is obvious and
must include a complete history and physical
exam. Many hospitals include certain routine
laboratory studies (CBC, ECG, chest x-ray,
urinalysis, etc.) for each patient admitted.
 If these are available to the admitting
physician, they are to be included in the initial
Data Base along with a history and physical. As
additional information is collected it is added
to the Data Base.
2. Complete Problem List
 2. Complete Problem List: After the admitting
physician performs the history and physical,
reviews the basic laboratory data and records
the data base, the Problem List is constructed
and recorded.
 That is, once they have seen the patient,
physicians think about and define "what is
wrong with the patient" or "what are this
patient's problems.
 Problems are either active or inactive (inactive
problems are usually prior, resolved medical or
surgical illnesses that are still important to be
remembered).
 Dr. Weed had defined an active problem as
“anything that requires management or further
diagnostic workup.”
3. Initial Plans
 The next process that a physician undertakes
after deciding "what is wrong" is "what to do
about what is wrong." This is the initial plan and
must be written by the admitting physician after
the Problem List is constructed.
 For each problem defined, a SOAP note must be
recorded.
 The Subjective and the Objective are each a
brief review of the abnormalities identified in
the history, physical, and initial lab data, which
pertain to that particular problem.
 These need not be lengthy, but simply one or
two lines reviewing the pertinent data.
 The Assessment is a brief but pertinent
paragraph describing what the physician thinks
about that particular problem.
 If the problem is a known diagnosis (example -
asthma), the physician must include in the
Assessment a statement that describes the
severity and why the problem has worsened
requiring admission to the hospital.
 The Plan must include three distinct groupings:
o A. Diagnostic Plan: The diagnostic plan includes all
the diagnostic workup which the admitting
physician feels will be necessary. If the Assessment
 includes the differential diagnosis, then each must
be ruled in or ruled out in the diagnostic plan.
o B. Therapeutic Plan: Must detail all initial therapies
started and their rational.
o C. Patient Education Plan: Details the initiation of
plans to educate the patient of what the problem is
and how the patient will deal with it in the future.
4. Daily Progress Note
 Many physicians object to the POMR because
its use results in lengthy, redundant progress
notes. However, when used properly, the POMR
does just the opposite and results in notes that
are clear, direct, brief and complete.
5. Final Progress Note or Discharge Summary
 The final progress note should include all active
problems, each defined as to its furthest
resolution on the Problem List. The Subjective
should include a brief review of the course of
symptoms.
 The Objective should review the course of
objective parameters. The Assessment and Plan
should include the probable course to follow
and define end-points as a guide for further
therapy.
 The emphasis on the final progress note should
be the unresolved problems. Problems which
are resolved can be written up briefly.
B. Guidelines/Protocols/Tools in reporting Related to
Client Care
1. Identify, Situation, Background, Assessment,
Recommendation, Read Back (ISBARR)
 Identify
o identify yourself, name, position,
location. Identify the person you are
talking to if not already done.
o Identify the patient and unique ID
number
 Situation- explanation why you are calling
o Background- tell the story
-“ I’ll tell you the story”
- “I’ll give you the background
information”
 Assessment
o state what you think is going on. Give
your interpretation of the situation.
o This is not about providing your
diagnosis of the patient-only a qualified
medical practitioner can do this.
 Recommendation- state what you want from
the receiver
o -“we would be grateful for your opinion
regarding the need for surgery”
o -“I need help urgently, are you able to
come now?.. if not who would I call?
ISBAR (Identify, Situation, Background, Assessment
and Recommendation)
 is a mnemonic created to improve safety in the
transfer of critical information. It originates
from SBAR, the most frequently used mnemonic
in health and other high risk environments such
as the military.
 The “I” in ISBAR is to ensure that accurate
identification of those participating in handover
and of the patient is established.
SBAR helps clinical staff to:
• Further develop their communication skills
• Utilize these skills when making a telephone
referral
• SBAR helps clinical staff to:
• Further develop their communication skills
• Utilize these skills when making a telephone
referral
2. Change of Shift Report
 is a meeting between healthcare providers at
the change of shift in which vital information
about and responsibility for the patient is
provided from the off-going provider to the on-
coming provider).
 The purpose is not to cover all details recorded
in the patient's medical record, but to
summarize individual patient progress. The
communication during this process is intended
 to insure continuity of care giving and patient
safety.
The Process Of Report
 Nurses in many places are legally not permitted
to leave the facility until the provider has given
report to the next shift.
 Change-of-shift report may be verbal or written
and given in a group or individualized format.
 In a group format, report on all patients is
shared with the nurses of next shift, often by
the previous charge nurse.
 The report from the previous shift may be
audio- taped and available for listening.
 Typically, change-of-shift report occurs at the
nurses' station, in a conference room, or the
hallway, away from patients and families.
 Certainly, the process has not traditionally
included patients and families and, in fact,
"visiting" hours may be restricted during change
of shift.
 While privacy laws require report to be given in
a location where unauthorized people cannot
hear the report , some facilities prohibit family
members from visiting patients during report
times.
Guidelines in Reporting
 Communicate clearly. Effective communication
is a dynamic process in which questions are
asked and concerns are voiced.
 Focus and avoid distractions. When nurses give
report, their fatigue and stress can lead to
information being omitted. Unfortunately,
many handoffs take place under tight time
constraints and with distractions such as phone
calls, patient call lights, and family questions.
 Make drug information a priority. Information
about the medications prescribed,
administered, and not administered is vitally
important during handoff. Knowing why a
patient has been prescribed certain medications
goes a long way to understanding the patient's
clinical status and providing a safe environment
 Report at the bedside. Bedside report is a good
time to conduct an initial shift assessment and
include the patient and family (if available and if
the patient has given permission). Enhance
patient safety by confirming identification and
medication administration record right at the
bedside.
 Respect and dignity. Respect and dignity
requires that nurses honor patient and family
perspectives and choices.
 Consider a checklist. With all the information to
cover during handoff and tasks to be completed
during assessments, nurses can become
overwhelmed with heavy patient assignments.
3. Incident Report
 Also called Unusual Occurrence Report
 An agency record of an accident or unusual
occurrence.
 Used to make all facts available to agency
personnel, to contribute to statistical data
about accidents or incident and to help health
personnel prevent future incidents or accidents.
The nurse completes the following tasks when
completing an incident report:
 Identify the client by name, initials and hospital
or identification number.
 Give the date, time, and place of the incident.
 Describe the facts of incident. Avoid any
conclusions or blame.
 Describe the facts of incident. Avoid any
conclusions or blame.
 Describe the incident as you saw it even if your
impressions differ from those of others.
 Incorporate the client’s account of the incident.
 Identify all witnesses to the incident.
 Identify any equipment by number and any
medication by name and dosage.
 The report should be completed as soon as
possible and filed according to agency policy
 The purpose of the report form is to alert the
risk manager to the event.
 Incident reports are often reviewed by an
agency risk management committee, which
decides whether to investigate the incident
further.
  When an accident occurs, the nurse should first Health System
assess the client and intervene to prevent
 Service providers (public and private sector) and
injury.
quality of care
4. Referral System  Strengthened primary health care services
 Clarity of level and role of each facility
 A referral can be defined as a process in which a
 Availability of protocols of care for conditions
health worker at a one level of the health
for each level of facility
system, having insufficient resources (drugs,
 Availability of communication and transport
equipment, skills) to manage a clinical
condition; Performance expectations
 seeks the assistance of a better or differently
 Expectation to refer appropriately and follow
resourced facility at the same or higher level to
protocols of care
assist in, or take over the management of, the
 Expectations that health workers and clients
client’s case.
adhere to the referral discipline
 Key reasons for deciding to refer either an
 Regular supervision and capacity building
emergency or routine case include:
 to seek expert opinion regarding the Involvement of organizations
client
 to seek additional or different services  Ministry of Health
for the client  Medical and nursing schools
 to seek admission and management of  Medical and nursing professional associations
the client
Initiating facility
 to seek use of diagnostic and

therapeutic tools  The client and their condition

  Protocol of care for that condition at that level Benefits/Usefulness:
of service
1. The use of routinely collected data such as data
 Treat and stabilize client – document treatment
from EHRs, allows assessment of the benefits
provided
and risks of different medical treatments, as
 Decision to refer well as relative effectiveness of medicines in the
Referral practicalities real world.
2. Studies can be carried out quickly, studies based
 Outward referral form on real-world data (RWD) are faster to conduct
 Communication with receiving facility (make than randomized controlled trials.
arrangements as appropriate)
 Information to the client and their Limitations:
family/support network 1. Data is not collected for research purposes.
 Reasons and importance of referral, risks of 2. Invalid, inaccurate or incomplete data.
non-referral 3. Quality and completeness of data varies within
 How to get to the receiving facility – location and among data bases.
and transport 4. Variable quality and completeness
 Who to see and what is likely to happen
 Follow-up on return

Empathy - understanding of implications for client and

family/support network

 Overall fear
 Cost of transport, treatment and family
accommodation

Receiving Facility

 Anticipate arrival and receive client and referral

form
 Provide care – document treatment provided
 Plan rehabilitation or follow-up with client and
family/support network
 Feedback to initiating facility on
appropriateness of referral
 Referral register to monitor follow-up and
gather statistics

C. Health Care Electronic Databases

 Healthcare electronic databases are systems

into which healthcare providers routinely enter
clinical and laboratory data.
 Practitioners enter routine clinical and
laboratory data as a record of the patient’s care.
 Healthcare databases can be used as data
sources for the generation of real-world
evidence (RWE).
 MODULE 6
LEADERSHIP AND MANAGEMENT IN
NURSING
Leadership- Occurs whenever one person attempts to
influence the behavior of an individual or group—up,
down, or sideways in the organization—regardless of the
reason. It may be for personal goals or for the goals of
others, and these goals may or may not be congruent
with organizational goals. Leadership is influence
(Hersey & Campbell, 2004, p. 12)
In order to lead, one must develop three important
competencies: (1) ability to diagnose or understand the
situation you want to influence, (2) adaptation
in order to allow your behaviors and other resources to
close the gap between the current situation and what you
are hoping to achieve, and (3) communication. No matter
how much you diagnose or adapt, if you cannot
communicate effectively, you will probably not meet your
goal (Hersey &
Campbell, 2004).
Effective nurse leaders are those who engage others to
work together effectively in pursuit of a shared goal.
Examples of shared goals are providing excellent client
care, designing a costsaving procedure, and challenging
the ethics of a new policy.
Followership and leadership are separate but reciprocal
roles. Without followers, one cannot be a leader;
conversely, one cannot be a follower without a leader
(Lyons, 2002).
Being an effective follower is as important to the new
nurse as is being an effective leader. In fact, most of the
time most of us are followers: members of a team,
attendees at a meeting, staff of a nursing care unit, and so
forth.
Followership is not a passive role. On the contrary, the
most valuable follower is a skilled, self-directed
employee, one who participates actively in setting the
group’s direction, invests his or her time and energy in the
work of the group, thinks critically, and advocates for new
ideas (Grossman & Valiga,2000).
Leadership Theories
There are many different ideas about how a person
becomes a good leader. Despite years of research on
this subject, no one idea has emerged as the clear
winner. The reason for this may be that different
qualities and behaviors are most important in different
situations.
Trait Theory
• “Leaders are born, not made.”
• In other words, some people are natural
leaders, and others are not. In reality,
leadership may come more easily to some than
to others, but everyone can be a leader, given
the necessary knowledge and skill.
Behavioral Theories
The behavioral theories are concerned with what the
leader does. One of the most influential theories is
concerned with leadership style (White & Lippitt,
1960). The Three styles are:
a. Autocratic Leadership- Also called directive,
controlling, or authoritarian. The autocratic
leader gives orders and makes decisions for
the group. For example, when a decision needs
to be made, an autocratic leader says, “I’ve
decided that this is the way we’re going to
solve our problem.” Although this is an
efficient way to run things, it usually dampens
creativity and may inhibit motivation.
b. Democratic Leadership- Also called
participative. Democratic leaders share
leadership. Important plans and decisions are
made with the team (Chrispeels, 2004).
Although this is often a less efficient way to
run things, it is more flexible and usually
increases motivation and creativity.
Democratic leadership is characterized by
guidance from rather than control by the
leader.
c. Laisezz-faire Leadership- (also called
permissive or nondirective). The laissez-faire
(“let someone do”) leader does very little
planning or decision making and fails to
encourage others to do so. It is really a lack of
 leadership. For example, when a decision
needs to be made, a laissez-faire leader may
postpone making the decision or never make
the decision. In most instances, the laissez-
faire leader leaves people feeling confused and
frustrated because there is no goal, no
guidance, and no direction. Some very mature
individuals thrive under laissez-faire leadership
because they need little guidance. Most
people, however, flounder under this kind of
leadership.
Pavitt summed up the difference among these three
styles: a democratic leader tries to move the group
toward its goals; an autocratic leader tries to move the
group toward the leader’s goals; and a laissezfaire
leader makes no attempt to move the group
QUALITIES OF A GREAT LEADER
If leadership is seen as the ability to influence, what
qualities must the leader possess in order to be able to
do that? Integrity, courage, attitude, initiative, energy,
optimism, perseverance, balance, ability to handle
stress, and self-awareness are some of the qualities of
effective leaders in nursing
GREAT LEADER
Management
The essence of management is getting work done
through others. The classic definition of management
is Henri Fayol’s 1916 list of managerial tasks: planning,
organizing, commanding, coordinating, and controlling
the work of a group of employees (Wren, 1972).
But Mintzberg (1989) argued that managers really do
whatever is needed to make sure that employees do
their work and do it well.
Lombardi (2001) points out that two-thirds of a
manager’s time is spent on people problems. The rest
is taken up by budget work, going to meetings,
preparing reports, and other administrative tasks
There are two major but opposing schools of thought
in management: scientific management and the
human relations–based approach. As its name implies,
the human-relations approach emphasizes the
interpersonal aspects of managing people, whereas
scientific management emphasizes the task aspects.
Scientific Management
Almost 100 years ago, Frederick Taylor argued that
most jobs could be done more efficiently if they were
analyzed thoroughly (Lee, 1980; Locke, 1982). With a
well-designed task and enough incentive to get the
work done, workers could be more productive.
Nurse managers who use the principles of scientific
management will pay particular attention to the type
of assessments and treatments done on the unit, the
equipment needed to do this efficiently, and the
strategies that would facilitate efficient
accomplishment of these tasks. Typically, these nurse first.” So the manager sees himself or herself as being
managers keep careful records of the amount of work there for the employee.
accomplished and reward those who accomplish the
QUALITIES OF AN EFFECTIVE MANAGER
most.
The effective nurse manager possesses a combination
HUMAN RELATIONS–BASED MANAGEMENT
of qualities: leadership, clinical expertise, and business
McGregor’s theories X and Y provide a good example sense. None of these alone is enough; it is the
of the difference between scientific management and combination that prepares an individual for the
human relations–based management. Theory X, said complex task of managing a unit or team of healthcare
McGregor (1960), reflects a common attitude among providers.
managers that most people do not want to work very
Leadership. All of the people skills of the leader are
hard and that the manager’s job is to make sure that
essential to the effective manager. They are skills
they do work hard. To accomplish this, according to
needed to function as a manager.
Theory X, a manager needs to employ strict rules,
constant supervision, and the threat of punishment Clinical expertise. It is very difficult to help others
(reprimands, withheld raises, and threats of job loss) develop their skills and evaluate how well they have
to create industrious, conscientious workers. done so without possessing clinical expertise oneself.
It is probably not necessary (or even possible) to know
Theory Y, which McGregor preferred, is the opposite
everything all other professionals on the team know,
viewpoint. Theory Y managers believe that the work
but it is important to be able to assess the
itself can be motivating and that people will work hard
effectiveness of their work in terms of patient
if their managers provide a supportive environment. A
outcomes.
Theory Y manager emphasizes guidance rather than
control, development rather than close supervision, Business sense. This is a complex task that requires
and reward rather than punishment knowledge of budgeting, staffing, and measurement of
patient outcomes.
A Theory Y nurse manager is concerned with keeping
employee morale as high as possible, assuming that BEHAVIORS OF AN EFFECTIVE MANAGER
satisfied, motivated employees will do the best work.
Employees’ attitudes, opinions, hopes, and fears are
important to this type of nurse manager. Considerable
effort is expended to work out conflicts and promote
mutual understanding to provide an environment in
which people can do their best work.

Servant Leadership
Characteristics of an Effective Leader
The servant leader–style staff manager believes that
1) Use a leadership style that is natural to them.
people have value as people, not just as workers
2) Use a leadership style appropriate to the task
(Spears & Lawrence, 2004).The manager is committed
& the members.
to improving the way each employee is treated at
work. The attitude is “employee first,” not “manager
 3) Assess the effects of their behavior on others
& the effects of others’ behavior on
themselves.
4) Sensitive to forces acting for & against change,
express an optimistic view about human
nature & are energetic.
5) Open & encourage openness, so that real
issues are confronted .
6) Facilitate personal relationships
7) Plan & organize activities of the group.
8) Consistent in behavior toward group members.
9) Delegate tasks and responsibilities to develop
members’ abilities (not merely to get tasks
performed).
10) Involve members in all decisions.
11) Value and use group members’ contributions.
12) Encourage creativity.
13) Encourage feedback about their leadership
style.
14) Assess for & promote use of current
technology.
LEVELS OF MANAGEMENT
FUNCTIONS OF MANAGEMENT
COORDINATION
 It unites personnel and services towards a
common objective.
 It enhances collaborative efforts resulting in
efficient, smooth and harmonious flow of
work.
 Prevent overlapping of functions, promotes
good working relationship and work schedule
are accomplished as targeted.
 To whom do we coordinate: HCT, medical
services, administrative services, laboratory
services, radiology services, pharmacy services,
dietary services, medical social services,
medical records services, community services,
other institutions or civic organizations.
Roles & Functions of Nurse Managers
1) Reasons with logic, exploring assumptions,
alternatives & the consequences of actions.
2) Use both verbal & written communication.
Communicates assertively, expressing their
ideas clearly, accurately, & honestly.
3) Accountability for human, fiscal & material
resources.
4) Budgeting & determining variances between
the actual & budgeted expenses.
5) Ensures employees develop appropriate
learning opportunities as well as building &
managing the work team.
6) Manage conflict among individuals, groups or
teams.
7) Uses time effectively & assists others to do the
same.
Skills and Competencies of a Nurse Manager
1) Critical thinker
2) Communicates well
3) Manage resources effectively & efficiently
4) Enhance employee performance
5) Build and manage teams
6) Manage conflicts
7) Manage time
8) Initiate & manage change
Continuing Professional Development
The nursing profession is accountable to the public for
the quality of nursing care it provides. The nursing
practitioners assume a lifelong commitment to
learning in order to cope with rapid technological
advances, the changes in science and technology, the
delivery of healthcare services in the country, and the
expectations of the public.
-Venzon 2010-
Continuing Education
▪ Consists of planned learning experiences
beyond the basic education program.
▪ The inculcation, assimilation and acquisition of
knowledge, skills, proficiency and ethical and
moral values after the initial registration of a
professional.
▪ Raise and enhance the professional’s technical
skills and professional competence.
▪
Objectives of Continuing Education
1. To provide and ensure the continuous
education of a registered professional with the
latest trends in the profession brought about
by modernization and scientific and
technological advancement
2. To raise and maintain the highest standard
and quality of the practice of the profession
3. To make the professional globally competitive
4. To promote the general welfare and safety of
the public
Who offers CPD or Continuing Education Programs?
1. National professional nursing associations
such as the Philippine Nurses Association and
the National League of Philippine Government
Nurses and the Association of Nursing
Administrators of the Philippines
2. Professional organizations representing
various nursing specialties such as the Critical
Care Nurses Association of the Philippines, the
Psychiatric Nursing Specialists, Inc.,
Occupational Health Nurses Association of the
Philippines, the Operating Room Nurses
Association of the Philippines, and others
3. Health agencies with specialties such as the
Philippine Health Center, the Philippine
Children’s Medical Center, the Lung Center of
the Philippines, the National Kidney Institute,
and St. Luke’s Medical Center
4. Employing agencies in the form of in-service
training programs
Some other Forms of Continuing Education Programs
1. Seminars. These refer to the gathering of
professionals and include, among others,
workshops, technical lecturers or subject
matter meetings, non-degree training courses,
and scientific meetings.
2. Conventions: These refers to gatherings of
professionals and include, among others,
conferences , symposia or assemblies for
round table discussions.
3. Residency: This refers to apprenticeship
training at the graduate level, which is beyond
the basic preparation for health professionals.
This is conducted by duly accredited hospitals
and medical centers.
4. Distance Learning: This refers to
correspondence learning which uses course
manuals or accredited learning modules such
as cassette tapes, films, computerized assisted
learning (CAL), study kits, learning aids, etc.
5. On –the-Job-Training: This means externship
training or specialization at the post-graduate
level for a minimum period of four weeks.
Ethico-moral & legal considerations IN THE PRACTICE
OF NURSING
The Philippine Nursing Law of 2012 RA 9173
The Philippine Nursing Act of 2002: An Act for a more
Responsive Nursing Profession
THE PHILIPPINE NURSING LAW
 It defines, regulates and limits the practice of
the nursing profession.
 It provides for the organization of the Board of
Nursing.
 Sets regulations concerning schools and
colleges of nursing, sets requirements for
certification, its revocation or suspension.
Describes the scope of nursing practice, as well
as health human resources and penal
provisions.
SCOPE OF NURSING PRACTICE (Article 6, Section28)
  A person shall be deemed to be practicing
nursing within the meaning of this Act when
he/she singly or in collaboration with another,
initiates and performs nursing services to
individuals, families and communities in any
health care setting.
 It includes, but not limited to, nursing care
during conception, labor, delivery, infancy,
childhood, toddler, preschool, school age,
adolescence, adulthood, and old age.
 As independent practitioners, nurses are
primarily responsible for the promotion of
health and prevention of illness. As member of
the health team, nurses shall collaborate with
other health care providers for the curative,
preventive, and rehabilitative aspects of care,
restoration of health, alleviation of suffering,
and when recovery is not possible, towards a
peaceful death.
SCOPE OF NURSING PRACTICE (Article 6, Section28)
 It shall be the duty of the nurse to:
a) Provide nursing care through the
utilization of the nursing process.
Nursing care includes: traditional and
innovative approaches, therapeutic
use of self, executing health care
techniques and procedures, essential
primary health care, comfort
measures, health teachings, and
administration of written prescription
for treatment, therapies, oral topical
and parenteral medications, internal
examination during labor in the
absence of antenatal bleeding and
delivery. In case of suturing of perineal
laceration, special training shall be
provided according to protocol
established;
b) Establish linkages with community
resources and coordination with the
health team;
c) Provide health education to
individuals, families and communities;
d) Teach, guide and supervise students in
nursing education programs including
the administration of nursing services
in varied settings such as hospitals and
clinics; undertake consultation
services; engage in such activities that
require the utilization of knowledge
and decision making skills of a
registered nurse; and
e) Undertake nursing and health human
resource development training and
research, which shall include, but not
limited to, the development of
advance nursing practice;
 Provided, that this section shall not apply to
nursing students who perform nursing
functions under the direct supervision of a
qualified faculty. Provided further, that in the
practice of nursing in all settings, the nurse is
duty-bound to observe the Code of Ethics for
nurses and uphold the standards of safe
nursing practice.
 The nurse is required to maintain competence
by continual learning through continuing
professional education to be provided by the
accredited professional organization or any
recognized professional nursing organization:
Provided, That the program and activity for the
continuing professional education shall be
submitted to and approved by the Board.
2012 NATIONAL NURSING CORE COMPETENCY
STANDARDS
 Heightened by the escalating complexity of
globalization, dynamics of information
technology, demographic changes, health care
reforms and increasing demands for quality
nursing care from consumers, expectations for
contemporary nursing practice competencies
emerged. Thus, in 2005, as an output of a key
project, Board of Nursing Resolution no. 112
Series of 2005, adopted and promulgated the
Core Competency Standards of Nursing
Practice in the Philippines. As mandated, the
Board of Nursing ensured, through a
monitoring and evaluation scheme, that the
core competency standards are implemented
and utilized effectively in nursing education , in
the development of test questions for the
Nurse Licensure Examination (NLE),and in
 nursing service as a basis for orientation, 3. Standards of Professional Nursing
training and performance appraisal. Practice in various settings in the
 Through the years of implementation, global Philippines.
and local developments in health and likewise, 4. National Career Progression Program
professional nursing developments prompted (NCPP) for nursing practice in the
the Board of Nursing to conduct a “ revisiting “ Philippines.
of the Core Competency Standards of Nursing 5. Any or related evaluation tools in
Practice in the Philippines. In 2009, the Board various practice settings in the
of Nursing created the Task force on Nursing Philippines
Core Competencies Revisiting Project in
collaboration with the Commission on Higher CONCEPTUAL FRAMEWORK
Education Technical Committee on Nursing
Education with the primary goal of
determining the relevance of the current
nursing core competencies to expected roles of
the nurse and to its current and future work
setting.

LEGAL BASIS 2012 NATIONAL NURSING CORE COMPETENCY

 Article III, section 9 (c) of Republic Act No. 9173 STANDARDS (2012 NNCCS)
or the Philippine Nursing Act of 2002, which
states that:
 The Professional Regulatory Board of Nursing
is empowered to “monitor and enforce quality
standards of nursing practice in the Philippines
and exercise the powers 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 THE 2012 NATIONAL NURSING CORE

COMPETENCY STANDARDS (2012 NNCCS)
A. The 2012 National Nursing Core Competency
Standards (2012 NNCCS) will serve as a guide
for the development of the following:
1. Basic Nursing Education Program in the
Philippines through the Commission on
Higher Education (CHED).
2. Competency-based Test Framework as
the basis for the development of
course syllabi and test questions for
“entry level” nursing practice in the
Philippine Nurse Licensure
Examination.
FILIPINO PATIENT’S BILL OF RIGHTS
  PATIENT’S RIGHT – means the moral and
inviolable power vested in him as a person to
do, hold, or demand something as his own.
 Every right in one individual involves a
corresponding duty in others to
respect this right and not to violate it.
Filipino Patient’s Bill of Rights
1) The patient has the right to considerate and
respectful care.
2) The patient has the right to and is encouraged
to obtain from physicians and other direct
caregivers relevant, current, and
understandable information concerning
diagnosis, treatment and prognosis.
 Except in emergencies when the
patient lacks decision-making capacity
and the need for treatment is urgent,
the patient is entitled to the
opportunity to discuss and request
information related to the specific
procedures and/or treatments, the
crisis involved, the possible length of
recuperation, and the medically
reasonable alternatives and their
accompanying risks and benefits.
 The patient has the right to know the
identity of physicians, nurses, and
others involved in his/her care, as well
as when those involved are students,
residents, or trainees. The patient also
has the right to know the immediate
and long-term financial implications of
treatment choices, in so far as they are
known.
 The patient has the right to make
decisions about the plan of care prior
to and during the course of treatment
and to refuse a recommended
treatment or plan of care to the extent
permitted by law and hospital policy
and to be informed of the medical
consequences of this action. In case of
such refusal, the patient is entitled to
other appropriate care and services the
hospital provides or transfer to
another hospital. The hospital should
notify patients of any policy that might
affect patient choice within the
institution.
 The patient has the right to have an
advance directive (such as a living will,
health care) concerning treatment or
designating a surrogate decision maker
with the expectation that the hospital
will honor the intent of that directive
to the extent permitted by law and
hospital policy.
5) The patient has the right to every
consideration of his privacy. Case discussion,
consultation, examination, and treatment
should be conducted so as to protect each
patient’s privacy.
6) The patient has the right to expect that all
communications and records pertaining to
his/her care should be treated as confidential
by the hospital, except in cases such as
suspected public health hazards where
reporting is permitted or required by law.
7) The patient has the right to review the records
pertaining to his/her medical care and to have
the information explained or interpreted as
necessary except when restricted by law.
8) The patient has the right to expect that, within
its capacity and policies, a hospital will make
reasonable response to the request of a
patient for appropriate and medically
indicated care and services.
9) The patient has the right to ask and be
informed of the existence of business
relationships among the hospital, educational
institutions, other health care providers, or
players that may influence the patient’s
treatment and care.
10) The patient has the right to consent to or
decline to participate in proposed research
studies or human experimentation affecting
his care and treatment or requiring direct
patient involvement, and to have those studies
fully explained prior to consent.
11) The patient has the right to expect reasonable
continuity of care when appropriate and to be
 informed by physicians and other caregivers
available and realistic patient care options
when hospital care is no longer appropriate.
12) The patient has the right to be informed of
hospital policies and practices that relate to
patient care, treatment, and responsibilities.
INFORMED CONSENT
• Every person is primarily responsible for his
own body – to protect patient’s personal
integrity and enhance his active role in his own
care.
• Main Functions:
a) Protective
b) Participative
 ELEMENTS
1) Knowledge
2) Information disclosure by
healthcare giver.
3) Comprehension by the subject
4) Consent
5) Subject competence
6) Subject freedom
PROXY CONSENT
 The field of Bioethics as promoted by the
Institute of Ethics and Human Rights in
Houston, Texas (1993) specifies the following:
1. When the patient is in a coma,
unconscious or incapable of making a
decision - those closest to him or her
such as the family or relatives may
decide for the best benefit of the
patient.
2. In instances when there is no close
relatives and decisions must be made -
the health professionals with honest
desires and intentions to give the best
strategy or intervention to the patient
may decide for the patient. They are
expected to execute their ADVOCACY
ROLE to the best outcome of the
patient.
3. In case of minors – parents and the
family of the patient will assume the
patient’s autonomy and make the
decision which should always be the
best for the patient.
SCENARIOS:
1. A bystander seen a person on the street with
multiple gunshot wound, and he was brought
to the ER. Upon assessment by the medical
doctor, he needs an immediate surgery
because of blood loss. There is no significant
others with him to sign consent. Patient needs
a STAT surgery.
2. A patient is scheduled for TAHBSO. During the
operation, doctor has seen the appendix and it
needs to be taken because its about to
rupture. Consent that was signed was only for
TAHBSO procedure, what will be done?
DATA PRIVACY LAW
RA 10173 – Data Privacy act 2012
 AN ACT PROTECTING INDIVIDUAL PERSONAL
INFORMATION IN INFORMATION AND
COMMUNICATIONS SYSTEMS IN THE
GOVERNMENT AND THE PRIVATE SECTOR,
CREATING FOR THIS PURPOSE A NATIONAL
PRIVACY COMMISSION, AND FOR OTHER
PURPOSES.
 It is a 21st century law to address 21st century
crimes and concerns. It
1) protects the privacy of individuals
while ensuring free flow of information
to promote innovation and growth;
2) regulates the collection, recording,
organization, storage, updating or
modification, retrieval, consultation,
use, consolidation, blocking, erasure or
destruction of personal data; and
3) ensures that the Philippines complies
with international standards set for
data protection through National
Privacy Commission (NPC).
Who Administers the Provision of this Act?
 The National Privacy Commission
(NPC) protects individual personal information
and upholds the right to privacy by regulating
the processing of personal information.
 Purpose of Ethical Codes
1) A basis for it regulates the relationship
between the nurse, client, co-workers, society
& profession.
2) Provides a standard basis for excluding
unscrupulous nursing practitioner & for
defending a practitioner who is unjustly
accused.
3) Serving as a basis for professional curricula and
for orienting the new graduate to professional
nursing practice.
4) Assisting public in understanding professional
nursing conduct.

PHILIPPINE PROFESSIONAL NURSING ROADMAP

RIGHTS OF THE DATA SUBJECT
CODE OF ETHICS FOR NURSES
 Means by which professional standards of
practice are established, maintained &
improved.
 Formal guidelines for professional actions.
 Gives members of the profession a frame of
reference for judgements in complex
situations.
CODE OF NURSING ETHICS
a) A four-fold responsibility of nurses
b) Nursing universality
c) Scope of services rendered by the
nurses
d) Responsibilities to the people, their
practice, to society, their co-workers
and profession
 The BOARD OF NURSING has mandated itself
to pursue the challenge in the nursing
profession. Adopted the "The Philippine
Professional Nursing Roadmap 2030: A
Program of Good Governance of the Nursing
Profession.
 VISION: Philippine Professional Nursing Care:
The BEST for the Filipino and the Choice of the
World by 2030
 MISSION: We, the Filipino nurses, responding
to the needs of society, are engaged in
providing humane and globally competent
nursing care.
 CORE VALUES: Love of God; Caring; Integrity;
Excellence; Nationalism
Strategic Objectives:
1) Develop dynamic leaders and provide
opportunities for innovative management in
education, training and research.
2) Ensure adherence to professional, ethical and
legal standards for the health and safety of the
public.
3) Practice good governance to sustain
participative efforts among nurses and nursing
organizations.
4) Maintain linkages with domestic and
international stakeholders.
5) Sustain growth and productivity that improve
the quality of life of nurses, the Filipino and
the people of world.
 AREAS & their SPECIFIC OBJECTIVES:
1) The Filipino Nurse
a) To live the core values and to manifest the
desired qualities of a Filipino Nurse.
b) Foster sense of accountability among all
nurses.
2. Collaborative and Partnership
a) To advocate collegiality and mutual
respect that cut across all health
disciplines.
b) To engage stakeholders and make them
co-owners of nursing issues and concerns.
c) To actively participate in the socio-
economic and political arena of the
country.
3. Service Excellence
a) To put into committed practice the quality
standards in education and nursing service.
b) To institutionalize sustainable
organizational support for nursing
positions.
4. Competency Enhancement
a) To promote functional integration
between education and service.
b) To institutionalize a sustainable and
effective continuing professional education
and development for individual nurses and
institutions.
5. Linkages / Networking
a) To institutionalize best practice resource
generation.
b) To adopt local and global best practices in the
management of resources.
c) To forge linkages to generate funds from
governments and NGOs.
6. Social Impact
a) Empowered clients to maintain the highest
level of wellness and well-being.
b) Nursing Profession as a recognized leader in
primary health care.
c) Ensure "positive practice environments" for
nurses.