ASSESSING
Collect data
Organize data
Validate data
Document data
ASSESSING
DIAGNOSIN
G
DIAGNOSING
Analyze data
Identify
ASSESSIN
G
health
problems,
risk, and strengths
Formulate diagnostic
statements
PLANNING
IMPLEMENTIN
G
EVALUATING
PLANNING
Prioritize problems/diagnoses
Formulate goals/desired outcomes
Select nursing interventions
Write nursing orders
IMPLEMENTING
Reassess the client
Determine the nurses need for
assistance
Implement the nursing interventions
Supervise delegated cases
Document nursing activities
EVALUATING
Collect data related to outcome
Compare data with outcomes
Relate nursing actions to client
goals/outcomes
Draw conclusions about problem status
Continue, modify, or terminate the
clients care plan
2
The nursing process in Action.
Purpose
Diagnosing
Analyzing and synthesizing To identify client strengths
data
and health problems that can
be prevented or resolved by
collaborative and independent
nursing interventions
To develop a list of nursing
and collaborative problems
Planning
Determining how to prevent,
reduce, or resolve the
identified client problems;
how to support client
strengths; and how to
implement
nursing
interventions
in
an
organized, individualized,
and goal-directed manner
Activities
To develop an individualized
care plan that specifies client
goals/desired outcomes, and
related nursing interventions
Evaluating
Measuring the degree to To determine whether to
which goals/outcomes have continue, modify, or terminate
been
achieved
and the plan of care
identifying factors that
positively or negatively
influence goal achievement
Activities
Reassess the client to update
the database.
Determine need for nursing
assistance
Perform planned nursing
interventions
Communicate what nursing
actions were implemented
Document care and
client responses to care
Give verbal reports as
necessary
Collaborate with client and
collect data related to
desired outcomes
Judge
whether
goals/outcomes have been
achieved
Relate nursing actions to
client outcomes
Make
decisions
about
problem status
Review and modify the care
plan
as
indicated
or
terminate nursing care
Document achievement of
outcomes and modification
of the care plan.
5
9. Sexuality/reproductive pattern. Describes the clients pattern of
satisfaction and dissatisfaction with sexuality pattern; describes
reproductive patterns.
10. Coping/stress tolerance pattern. Describes the clients general coping
pattern and the effectiveness of the pattern in terms of stress tolerance.
11. Value/belief pattern. Describes the patterns of values, beliefs (including
spiritual), and goals that guide the clients choices or decisions.
2.2.2 Orems Self-Care model
Universal Self-Care Requisites
1. The maintenance of a sufficient intake of air
2. The maintenance of a sufficient intake of water.
3. The maintenance of a sufficient intake of food.
4. The provision of care associated with elimination processes and
excrement
5. The maintenance of a balance between activity and rest.
6. The maintenance of a balance between solitude and social interaction.
7. The prevention of hazards to human life, human functioning, and human
well-being.
8. The promotion of human functioning and development within the social
groups in accord with human potential, known human limitations, and
human desire to be normal. (Normalcy is used in the sense of that which
is essentially human and that which is in accord with the generic and
constitutional characteristics and the talents of individuals.)
2.2.3 Roys Adaptation Model
Adaptation Modes
1. Physiologic needs
Activity and rest
Nutrition
Elimination
Fluid and Electrolytes
Oxygenation
Protection
Regulation: Temperature
Regulation: the senses
Regulation: endocrine system
2. Self-concept
Physical self
Personal self
3. Role function
4. Interdependence
2.2.4
6
Nauseated
Oral temp 39.4 C (103 F)
Decreased skin turgor
3. Elimination
Usually no problem
Decreased urinary frequency and amount x 2 days
Last bowel movement yesterday, formed, states was normal
4. Activity/Exercise
No musculoskeletal impairment
Difficulty sleeping because of cough
Cant breathe lying down
States I feel weak
Short of breath on exertion
Exercises daily
5. Cognitive/Perceptual
No sensory deficits
Pupils 3 mm, equal, brisk reaction
Oriented to time, place, and person
Responsive but fatigued
Responds appropriately to verbal and physical stimuli
Recent and remote memory intact
States short of breath on exertion
Reports pain in lungs, especially when coughing
Experiencing chills
Reports nausea
6. Roles/Relationships
Lives with husband and 3-year-old daughter
Husband out of town; will be back tomorrow afternoon
Child with neighbor until husband returns
States good relationships with friends and coworkers
Working mother, attorney
7. Self-Perception/Self-Concept
Expresses concern and worry over leaving daughter with
neighbors until husband returns
Well-groomed, says, Too tired to put on makeup.
8. Coping/Stress
Anxious: I cant breathe
Facial muscles tense; trembling
Expresses concerns about work: Ill never get caught up
9. Value/Belief
Catholic
No special practices desired except anointing of the sick
Middle-class, professional orientation
No wish to see chaplain or priest at present
10. Medication/History
Synthroid .1 mg per day
Client has history of appendectomy, partial thyroidectomy
11. Nursing Physical Assessment
28 years old
Height 158 cm (5 ft., 2 in); weight 56 kg (125 lb)
TPR 39.4C, 92,28
Radial pulses weak, regular
Blood pressure 122/80 sitting
Skin hot and pale, cheeks flushed
Mucous membranes dry and pale
Respirations shallow; chest expansion < 3 cm
Cough productive of small amounts of pale pink sputum
7
Inspiratory crackles auscultated throughout right upper and lower
chest
Diminished breath sounds on right side
Abdomen soft, not distended
Old surgical scars; anterior, RLQ abdomen
Diaphoretic
2.2.5 Wellness Models
Nurses use wellness models to assist clients to identify health risks and to
explore lifestyle habits and health behaviors, beliefs, values, and attitudes
that influence levels of wellness. Such models generally include the
following:
1. Health history
2. Physical fitness evaluation
3. Nutritional assessment
4. Life-stress analysis
5. Lifestyle and health habits
6. Health beliefs
7. Sexual health
8. Spiritual health
9. Relationships
10. Health risk appraisal
2.2.6 Nonnursing Models
Frameworks and models from other disciplines may also be helpful for
organizing data. These frameworks are narrower than the model required in
nursing; therefore, the nurse usually needs to combine these with other
approaches to obtain a complete history.
1. Body System Model. The body system model focuses on abnormalities
of the following anatomic systems:
Integumentary system
Respiratory system
Cardiovascular system
Nervous system
Musculoskeletal system
Gastrointestinal system
Genitourinary system
Reproductive system
Immune system
2. Maslows Hierarchy of Needs. Maslows hierarchy of needs clusters
data pertaining to the following:
Physiologic needs (survival needs)
Safety and security needs
Love and belonging needs
Self-esteem needs
Self-actualization needs
3. Developmental Theories. Several physical, psychosocial, cognitive, and
moral developmental theories may be used by the nurse in specific
situations.
Examples include the following:
Havighursts age periods and developmental tasks
Freuds five stages of development
Eriksons eight stages of development
Piagets phases of cognitive development
Kohlbergs stages of moral development
Related to
Related to
Etiology
Prolonged laxative use
10
Ineffective Breastfeeding
3.4.2
Related to
breast engorgement
Problem
Constipation
Related to
related to(r/t)
Etiology
rejection
husband
by
As manifested
as
manifested
(a.m.b)
by
11
1
2
Values
N = 99
N=4
3
4
5
6
Unit of care
Age
Health status
Descriptor
N=4
N = 12
N=3
N = 26
Topology
N = 17 body
parts/region
Examples
Anxiety, falls, nutrition, walking
Acute, chronic, intermittent,
continuous
Individual, family, group, community
Infant, adolescent, young old adult
Wellness, sick, actual
Anticipatory, deficient, imbalanced,
perceived
Cerebral, gustatory, renal, visual
4. Planning
4.1 Definition
Planning is a deliberate, systematic phase of the nursing process that involves
decision making and problem solving. In planning, the nurse refers to the clients
assessment data and diagnostic statements for direction in formulating client goals
and designing the nursing interventions required to prevent, reduce, or eliminate the
clients health problems.
4.2 Types of Planning
4.2.1 Initial Planning
The nurse who performs the admission assessment usually develops the initial
comprehensive plan of care. Planning should be initiated as soon as possible
after the initial assessment, especially because of the trend toward shorter
hospital stays.
4.2.2 Ongoing Planning
Ongoing planning is done by all nurses who work with the client. As nurses
obtain new information and evaluate the clients responses to care, they can
individualize the initial care plan further. Ongoing planning also occurs at the
beginning of a shift as the nurse plans the care to be given that day.
4.2.3 Discharge Planning
Discharge planning, the process of anticipating and planning for needs after
discharge, is a crucial part of a comprehensive health care and should be
addressed in each clients care plan.
4.3 Developing nursing Care Plan
4.3.1 An Informal nursing care plan is a strategy for action that exists in the nurses
mind. For example, the nurse may think, Mrs. Phan is very tired. I will need to
reinforce her teaching after she is rested.
4.3.2 A formal nursing care plan is a written or computerized guide that organizes
information about the clients care.
4.3.3 A standardized care plan is a formal plan that specifies the nursing care for
groups of clients with common needs (e.g., all clients with myocardial
infarction)
4.3.4 An individualized care plan is tailored to meet the unique needs of a specific
client needs that are not addressed by the standardized plan.
12
13
goal/desired outcome are used interchangeably. Some references also use the
terms expected outcome, predicted outcome, outcome criterion, and objective.
Some nursing literature differentiates the terms by defining goals as broad
statements about the clients status and desired outcomes as the more
specific, observable criteria used to evaluate whether the goals have been
met. For example:
Goal (broad)
Improved nutritional status
Desired outcome (specific) Gain 5 lb. by April 25
1. The Nursing Outcomes Classification
Standardized nursing language is required in all phases of the nursing
process if nursing data are to be included in computerized databases that
are analyzed and used in nursing practice. Working toward this end,
researchers have developed a taxonomy, the Nursing Outcomes
Classification (NOC), for describing client outcomes that respond to
nursing interventions (Johnson, Maas, & Moorhead, 2002). In the
taxonomy, outcomes belong to one of seven domains.
A NOC outcome is similar to a goal in traditional language. It is a
measurable patient or family caregiver state, behavior, or perception that
is conceptualized as a variable and is largely influenced by and sensitive
to nursing interventions. The NOC outcomes are broadly stated and
conceptual. To be measured an outcome must be made more specific by
identifying the specific indicators that apply to a client. An indicator is
concrete, an observable patient state, behavior, or self-reported
perception or evaluation and is similar to desired outcomes in
traditional language. Indicators are also stated in neutral terms, but each
outcome includes a five-point scale ( a measure) that is used to rate the
clients status on each indicator.
2. Purpose of Desired Outcomes/Goals
Desired outcomes/goals serve the following purposes:
Provide direction for planning nursing interventions. Ideas for
interventions come more easily if the desired outcomes state clearly
and specifically what the nurse hopes to achieve.
Serve as criteria for evaluating client progress. Although developed in
the planning step of the nursing process, desired outcomes serve as
the criteria for judging the effectiveness of nursing interventions and
client progress in the evaluation step.
Enable the client and nurse to determine when the problem has been
resolved.
Help motivate the client and nurse by providing a sense of
achievement. As goals are met, both client and nurse can see that their
efforts have been worthwhile. This provides motivation to continue
following the plan, especially when difficult lifestyle changes need to
be made.
3. Long-Term and Short-Term Goals
Short-term goal are useful for:
clients who require health care for a short time
those who are frustrated by long-term goals that seem difficult to
attain and who need the satisfaction of achieving a short-term goal.
Long - term goal are often used for clients who live at home and have
chronic health problems and for clients in nursing homes, extended
14
care facilities, and rehabilitation centers.
4. Components of Goal(Desired Outcome Statements)
Subject. The subject, a noun, is the client, any part of the client, or
some attribute of the client, such as the clients pulse or urinary
output. The subject is often omitted in goals; it is assumed that the
subject is the client unless indicated otherwise.
Verb. The verb specifies an action the client is to perform , for
example, what the client is to do, learn, or experience. Verbs that
denote directly observable behaviors, such as administer, show,
walk, must be used.
Conditions or modifiers. Conditions or modifiers may be added to
the verb to explain the circumstances under which the behavior is to
be performed. They explain what, where, when, or how. For
example:
Walks with the help of a cane (how)
Criterion of desired performance. The criterion indicates the
standard by which a performance is evaluated or the level at which
the client will perform the specified behaviors. Examples are:
Weighs 75 kg by April (time).
Lists five out of six signs of diabetes (accuracy)
Walks one block per day ( time and distance)
Administers insulin using aseptic technique (quality)
5. Guidelines for Writing Goals / Desired Outcomes
Write goals and outcomes in terms of client responses, not nurse
activities. Beginning each goal statement with the client will may
help focus the goal on client behaviors and responses.
Correct: Client will drink 100 cc of water per hour (client
behavior)
Incorrect: Maintain client hydration (nursing action)
Be sure that desired outcomes are realistic for the clients
capabilities, limitations, and designated time span, if it is indicated.
Ensure that the goals and the desired outcomes are compatible with
the therapies of other professionals.
Make sure that each goal is derived from only one nursing
diagnosis.
Use observable, measurable, terms for outcomes.
Make sure the client considers the goals/desired outcomes
important and values them.
4.6.3 Selecting Nursing Interventions and Activities
Nursing interventions and activities are the actions that a nurse performs to
achieve client goals.
Types of Nursing Interventions
1. Independent Interventions are those activities that nurses are licensed to
initiate on the basis of their knowledge and skills. They include physical
care, ongoing assessment, emotional support and comfort, teaching,
counseling, environmental management, and making referrals to other
health care professionals. McCloskey and Bulechek (2000) refer to these
as nurse-initiated treatment
15
16
Discuss the importance of daily exercises and Explore infantstimulation techniques.
4.6.5 Delegating Implementation
The American Nurses Association defines delegation as the transfer of
responsibility for the performance of an activity from one person to another
while retaining accountability for the outcome. This differs from assignment
which is a downward or lateral transfer of both the responsibility and
accountability of an activity from one individual to another.
The nurse has two responsibilities in delegating and assigning:
1. appropriate delegation of duties (that is, giving people duties within their
scope of practice)
2. adequate supervision of personnel to whom work is delegated or assigned.
4.7 The Nursing Interventions Classifications it describes the efforts of the North
American Nursing Diagnosis Association (NANDA) to standardize the language for
describing problems that require nursing care and to create a taxonomy of standardized
client outcome labels. A group of nurse researchers also recognized the need for
standardized language to describe the interventions that nurses perform. A taxonomy
of nursing interventions referred to as the Nursing Interventions Classification
(NIC) taxonomy has been developed by the Iowa Intervention Project (McCloskey &
Bulechek, 2000). This taxonomy consists of three levels:
4.7.1 Level I, domains
4.7.2 Level 2, classes
4.7.3 Level 3, interventions
NIC Taxonomy
Level I: Domains
Domain 1
Physiological: Basic
Care that supports physical
functioning
17
M. Thermoregulation: Interventions to maintain body temperature
within a normal range
N. Tissue Perfusion Management: Interventions to optimize
circulation of blood and fluids to the tissue
Level I: Domains
Level 2: Classes (lettered for cross-referencing)
Domain 3
O. Behavior Therapy: Interventions to reinforce or promote
Behavioral
desirable behaviors or alter undesirable behaviors
Care that supports psychoP. Cognitive Theory: Interventions to reinforce or promote desirable
Social functioning and
cognitive functioning or alter undesirable cognitive functioning
facilities lifestyle changes
Q. Communication Enhancement: Interventions to facilitate
delivering and receiving verbal and non verbal messages
R. Coping Assistance: Interventions to assist another to build on own
strength, to adapt to a change in function, or to achieve a higher
level of function
S. Patient Education: Interventions to facilitate learning
T. Psychological Comfort Promotion: Interventions to promote
comforts using psychological techniques
Domain 4
U. Crisis Management: Interventions to provide immediate shortSafety
term help in both psychological and physiological crisis
Care
that
supports V. Risk Management: Intervention s to initiate risk-reduction
protection against harm
activities and continue monitoring risk over time
Domain 5
W. Childbearing Care: Interventions to assist in understanding
Family
and coping with the psychological and physiological changes
Care that supports the
during the childbearing period
family unit
Z. Childbearing Care: Interventions to assist in child rearing
X. Lifespan Care: Interventions to facilitate family unit functioning
and promote the health and welfare of family members through
out the lifespan
Domain 6
Y. Health System Medication: Interventions to facilitate the inter Health System
Face between patient/family and the health care system
Care that supports effective a. Health System Management: Interventions to provide and
use of the health care
enhance support services for the delivery of care
delivery system
b. Information Management: Interventions to facilitate communi cation among health care providers
Domain 7
c. Community Health Promotion: Interventions that promote the
Community
health of the whole community
Care that supports the d. Community Risk Management: Interventions that assist in
health of the community
detecting or preventing health risks to the whole community
18
5.3.3 Implementing the nursing interventions
5.3.4 Supervising the delegated care
5.3.5 Documenting nursing activities
5.4. Definition of Evaluation
Evaluating is a planned, ongoing, purposeful activity in which clients and health
care professionals determine:
5.4.1 the clients progress toward achievement of goals/outcomes
5.4.2 the effectiveness of the nursing process because conclusions drawn from the
evaluation determine whether the nursing interventions should be terminated,
continued, or changed.
5.5 Five Components of the Evaluation Process
5.5.1 Collecting data related to the desired outcomes (NOC indicators)
5.5.2 Comparing the data with outcomes
5.5.3 Relating nursing activities to outcomes
5.5.4 Drawing conclusions about problem status
5.5.5 Continuing, modifying, or terminating the nursing care plan
5.6 Evaluating the Quality of Nursing Care
5.6.1 Quality Assurance
A quality assurance (QA) program is an ongoing, systematic process
designed to evaluate and promote excellence in the health care provided to
clients. Quality assurance frequently refers to evaluation of the level of care
provided in a health care agency, but it may limited to the evaluation of the
performance of one nurse or more broadly involve the evaluation of the
quality of the care in an agency, or even in a country.
Quality assurance requires evaluation of three components of care:
1. Structure evaluation focuses on the setting in which care is given. It
answers this question: What affects does the setting have on the quality of
care? Structural
standards describe desirable environmental and
organizational characteristics that influence care, such as equipment and
staffing.
2. Process evaluation focuses on how the care was given. It answers
questions such as these: Is the care relevant to the clients needs? Is the
care appropriate, complete, and timely? Process standards focus on the
manner in which the nurse uses the nursing process.
3. Outcome evaluation focuses on demonstrable changes in the clients
health status as a result of nursing care. Outcome criteria are written in
terms of client responses or health status, just as they are for evaluation
within the nursing process. For example, How many clients undergoing
hip repairs develop pneumonia? or How many clients who have a
colostomy experience an infection that delays discharge?
5.6.2 Quality Improvement
Quality improvement (QI) is also known as continuous quality
improvement (CQI), total quality management (TQM), performance
improvement (PI), or persistent quality improvement (PQI). According to
Schroeder , QI is the commitment and approach used to continuously
improve every process in every part of an organization, with the intent of
meeting and exceeding customer expectations and outcomes.
Unlike quality assurance, QI follows client care rather than organizational
structure, focuses on process rather than individuals, and uses a systematic
approach with the intention of improving the quality of care rather than
ensuring the quality of care. QI studies often focus on identifying and
19
correcting a systems problems, such as duplication of services in a hospital
or improving services.
5.6.3 Nursing Audit
An audit means the examination or review of record. A retrospective audit is
the evaluation of a clients record after discharge from agency. Retrospective
means relating to past events. A concurrent audit is the evaluation of a
clients health care while the client is still receiving care from the agency.
These evaluation use interviewing, direct observation of nursing care, and
review of clinical records to determine whether specific evaluative criteria
have been met.
Another type of evaluation of care is the peer review. In nurse peer review,
nurses functioning in the same capacity, that is, peers, appraise the quality of
care or practice performed by other equally qualified nurses. The peer
review is based on preestablished standards or criteria.
There are two types of peer reviews: individual and nursing audits. The
individual peer review focuses on the performance of an individual nurse.
The nursing audit focuses on evaluating nursing care through the review of
records. The success of these audits depends on accurate documentation;
auditors assume that if the data have been recorded, the care has not been
given.
20
21
O - Objective data consist of information that is measured or
observed by use of the senses (e.g., vital signs, laboratory and xray results)
A - Assessment is the interpretation or conclusions drawn about
the subjective and objective data.
P - The plan is the plan of care designed to resolve the stated
problem.
Over the years, the SOAP format has been modified. The acronyms
SOAPIE and SOAPIER refer to formats that add interventions,
evaluation and revision.
I
22
2. Standards of nursing care. An agency using CBE must develop its own
specific standards of nursing practice that identify the minimum criteria
for client care regardless of clinical area.
3. Bedside access to chart forms. In the CBE system, all flow sheets are
kept at the clients bedside to allow immediate recording and to
eliminate the need to transcribe data from the nurses worksheet to the
permanent record.
23
6.4.4 Care Plan Conference
A care plan conference is a meeting of a group of nurses to discuss possible
solutions to certain problems of a client, such as inability to cope with an
event or lack of progress toward goal attainment.
6.4.5 Nursing Rounds
During round, the nurse assigned to the client provides a brief summary of
the clients nursing needs and the interventions being implemented.
2. Communication
2.1 Definitions
2.1.1 The basic element of human interactions that allows people to establish,
maintain and improve contacts with others
2.1.2 A complex, multifaceted , dynamic series of events involving behaviors and
relationships and allows individuals to associate with others through meanings
which are generated and transmitted
2.1.3 Verbal and nonverbal behavior with a social context and includes all symbols
and clues used by persons in giving and receiving meaning
2.1.4 Do not only refers to content but also to feelings and emotions that people may
convey in relationship
2.1.5 An act of sharing because it influences a relationship
2.1.6 An active process between sender and receiver
2.2 Levels of Communication
2.2.1 Intrapersonal occurs within the individual. It is self-talk or an internal
dialogue that occurs constantly and consciously. The goal is self-awareness,
which is influenced by self-concept and feelings of self worth.
2.2.2 Interpersonal interaction that occurs between 2 people or in a small group. It
is often face-to-face and is the most frequently used type in nursing situations.
It allow problem-solving, sharing of ideas, decision-making and personal
growth
2.2.3 Public Communication interaction with large groups of people, e.g. giving a
lecture to a class of reviewees
2.3 Elements
2.3.1 Referent a stimulus which motivates a person to communicate with another.
May be an object, experience, emotion, idea or act.
2.3.2 Sender or encoder the person who initiates the interpersonal communication
or message
2.3.3 Message the information sent or expressed by the sender
2.3.4 Channels means of conveying messages, e.g., visual (facial expression),
auditory (spoken word) or tactile (touching) senses
2.3.5 Receiver or decoder person to whom the message is sent. To be effective, the
receiver must perceive or become aware of he message.
2.3.6 Feedback verbal and nonverbal response to the message. To be effective, the
sender and the receiver must be sensitive and open to each others message,
clarify the message and modify behavior accordingly
2.4 Modes
2.4.1 Verbal Communication involves spoken or written words
A. Language the words, their pronunciation and method or combining them
that is used and understood by a community
B. Effective verbal communication is simple, short and direct. Clarity is
achieved by speaking slowly and enunciating clearly
24
C. A message spoken in terms the client understands makes communication
more effective. Do not use medical terms when giving health teachings to
clients; if you must translate them to laymans terms
D. Denotative meaning one shared by individuals who use a common
language. A word that means the same to everyone.
E. Connotative meaning thoughts, feelings or ideas that people have about a
word. They are shades or interpretations of a words meaning rather its
definite definition
25
2.6 Factors Influencing Communication
2.6.1 Development the environment provided by parents affects the ability to
communicate
2.6.2 Perception a personal view of events
2.6.3 Values standards that influence behavior, what a person considers important
in life and, therefore, influence expression of thoughts and ideas
2.6.4 Emotions a persons subjective feelings about events. They influence the
ability to successfully receive a message
26
2.8.2 Convey acceptance do not judge another person and demonstrate
willingness to listen to the clients beliefs, values and practices
2.8.3 Ask related questions
2.8.4 Paraphrase restate clients messages in order to convey to the client that you
understood his message
2.8.5 Clarify repeat the message or admit you did not understand and then let the
client repeat his message
2.8.6 Focus eliminates vagueness in communication y limiting the area of
discussion
2.8.7 State conversation share with the client observations regarding their
behavior
2.8.8 Offer information as a means to provide additional data or insight
2.8.9 Maintain silence allows the nurse and client to organize thoughts as well as
observe each others behavior
2.8.10Be assertive express feelings and emotions confidently, spontaneously and
honesty
2.8.11Summarize a concise review of main ideas that have been discussed, it sets
the tone for further interactions
2.9 Barriers Effective Communication
2.9.1 Giving an opinion takes decision-making away from the client, inhibits
spontaneity, stalls problem-solving and creates doubt
2.9.2 Giving false reassurance can discourage open communication. Genuine
truthful reassurance is what is important is validating a clients self-worth and
sense of hope
2.9.3 Being defensive when a nurse becomes defensive, the clients concerns are
often ignored
2.9.4 Showing approval or disapproval offering excessive praise implies that the
behavior is the only acceptable one. But disapproval also implies that the
client must meet the nurses expectations or standards
2.9.5 Stereotyping inhibits communication and threatens
a client-nurse
relationship. e.g., People from depressed areas have very poor hygiene.
2.9.6 Asking why can cause resentment, insecurity and mistrust
2.9.7 Changing the topic inappropriately definitely rude and shows a lack of
empathy
3. Client Education
3.1 Purposes of Client Education the goal of client education is to assist individuals,
families, or communities in achieving optimal levels of health (Edelman and Mandle,
1998)
3.2 Domains of Learning
3.2.1 Cognitive Learning includes all intellectual behaviors such as the acquisition
of knowledge, comprehension (ability to understand), application (using
abstract ideas in concrete situations) analysis (relating ideas in an organized
way), synthesis (recognizing parts of information as a whole), and evaluation
(judging the worth of a body of information)
3.2.2 Affective learning deals with the expression of feelings related to attitudes,
opinions, or values.
3.2.3 Psychomotor learning involves acquiring skills that require the integration
of mental and motor activity such as the ability to walk, to use an eating
utensil, or to give an insulin injection
3.3 Teaching Methods Based on clients Developmental Capacity
3.3.1 Infant
Keep routines 9e.g., feeding, bathing) consistent
27
Hold infant firmly while smiling and speaking softly to convey sense of
trust
Have infant touch different textures (e.g., soft fabric, hard plastic)
3.3.2 Toddler
Use play to teach procedure or activity (e.g., handling, examination
equipment, applying bandage to doll)
Offer picture books that describes story of children in hospital r clinic
Use simple words such as cut instead of laceration to promote
understanding
3.3.3 Preschooler
Use role playing, imitation, and play to make it fun for preschoolers to
learn
Encourage questions and offer explanations. Use simple explanations and
demonstrations
Encourage children to learn together through pictures and short stories about
how to perform hygiene
3.3.4 School-Age Child
Teach psychomotor skills needed to maintain health. (Complicated skills
such as learning to use syringe, may take considerable practice)
Offer opportunities to discuss health problems and answer questions
3.3.5 Adolescent
Help adolescent learn about feelings and need for self-expression
Use teaching as collaborative activity
Allow adolescents to make decisions about health and health promotion
(safety, sex education, substance abuse)
Use problem solving to help adolescents make choices
3.3.6 Young or Middle Adult
Encourage participation in teaching plan by setting mutual goals
Encourage independent learning
Offer information so that adult can understand effects of health problem
3.3.7 Older Adult
Teach when client is alert and rested
Involve the adult in discussion or activity
Focus on wellness and the persons strength
Use approaches that enhance sensorially impaired clients reception stimuli
Keep teaching session short
3.4 Teaching Methods Based on Clients Learning Needs
3.4.1 Cognitive
Discussion (One-on-One or Group)
May involve nurse and client or nurse with several clients
Promotes active participation and focuses on topics of interest o client
Allows peer support
Enhances application and analysis for new information
Lecture
Is more formal method of instruction because it is controlled by teacher
Helps learner acquire new knowledge and gain comprehension
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Question-and-Answer Session
Is designed specifically to address clients concerns
Assists client in applying knowledge
Role Play, Discovery
Allows client to actively apply knowledge in controlled situation
Promotes synthesis of information and problem solving
Independent Project (Computer-Assisted Instruction), Field Experience
Allows client to assume responsibility for completing learning activities at
own pace
Promotes analysis, synthesis, and evaluation of new information and skills
3.4.2 Affective
Role Play
Allows expression of values, feelings, and attitudes
Discussion (Group)
Allows client to acquire support from others in group
Permits client to learn from others experiences
Promotes responding, valuing, and organization
Discussion (One-on-One)
Allows discussion of personal, sensitive, topics of interest or concern
3.4.3 Psychomotor
Demonstration
Provides presentation of procedures or skills by nurse
Permits client to incorporate modeling of nurses behavior
Allows nurse to control questioning during demonstration
Practice
Gives client opportunity to perform skills using equipment
Provides repetition
Return Demonstration
Permits client to perform skills as nurse observes
Is excellent source of feedback and reinforcement
Independent Project, Game
Requires teaching method that promotes adaptation and origination of
psychomotor learning
Permits learner to use new skills
UNIT III - Principles for Nursing Practice
1. Vital Signs
1.1 Temperature
1.1.1 Sites and normal values
Oral = 37 C = 98. F
1. The nurse should wait for 20-30 minutes before taking the temperature of
a client who has taken hot or cold drinks or food, has been smoking or
has been through strenuous exercise
2. Approximately 1F higher than the bodys core temperature (temperature
of deep tissues)
Rectal = 37.5C = 99.6 F
1. Considered to be the most reliable because few factors can alter the
result
2. Should not be taken in newborns because the thermometer can cause
rectal trauma
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3. Usually a few tenths higher than the oral temperature
Axilla = 36.4C (97.6F). Safest site for temperature measurement,
especially with newborns but is less convenient and accurate and requires
longer time (5 minutes)
Tympanic membrane
1. Excellent site because of its highly vascular nature and easy accessibility
2. Directly reflects core temperature
1.1.2 Factors affecting body temperature
Age
1. An infants temperature may change drastically with changes in the
environment because temperature-control mechanisms are not yet fully
developed
1.1 Clothing must be adequate and exposure to extreme temperatures
must be avoided
1.2 30% of body heat of newborns is lost through the head, that is why
a cap is to be worn to prevent heat loss
2. Temperature regulation stabilizes during puberty
3. The elderly are sensitive to extremes in temperature because of:
3.1 Deterioration in thermoregulation
3.2 Poor vasomotor control
3.3 Reduced amount of subcutaneous tissues
3.4 Reduce sweat gland activity
3.5 Reduced metabolism
Exercise muscle activity requires increased body supply increase in
carbohydrate and fat breakdown for more energy increased metabolism
increased heat production increased temperature
Hormone level
1. Progesterone increases body temperature. When progesterone levels are
low, just before ovulation, the temperature falls a few tenths of a degree
below the baseline; during ovulation, greater amounts of progesterone
raises the body temperature to previous baseline or higher.
2. Menopausal women may experience periods of intense body heat and
sweating lasting from 30 seconds to 5 minutes due to the instability of
the vasomotor control
3. The amount of thyroxine, epinephrine and norepinephrine in the body
can also affect temperature
Circadian rhythms body temperature changes 0.5 C to 1C during a 24
hour period
1. Temperature is usually lowest between 1:00 and 4:00 a.m.
2. During the day, body temperature rises, steadily until 6:00 p.m. then
declines to early morning levels
Stress physical and emotional stress increase body temperature through
hormonal and neural stimulation
Environment
1.1.3 Fever rectal temperature above 38C (100.4F) that is measured under resting
conditions. Common fever patterns:
Sustained little fluctuation, e.g., pneumococcal pneumonia
Intermittent wide temperature variations with return to normal at least
once daily, e.g., malaria, bacterial or viral infections
Remittent fluctuations less than intermittent, with no return to normal;
e.g., measles, Dengue fever
Recurrent duration of few days, returns to normal for 1 day or more, then
recurs; e.g., Hodgkins disease, leptospirosis
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Night e.g. , tuberculosis
1.1.4 Body temperature disorders
Heat exhaustion occurs when a person loses excessive amounts of water
and sodium because of profuse diaphoresis
Heat Stroke very high temperatures of 105F or more produces tissue
damage to the cells of all body organs; has a high fatality rate
1. Suddenly becomes giddy, confused or delirious
2. Extreme thirst, nausea, muscle cramps and visual disturbances
3. Hot, dry skin most important sign
4. Does not sweat because of severe electrolyte loss and impaired
hypothalamic function
5. Tachycardia and hypotension
6. Becomes unconscious incontinent, with blotchy redness of the skin and
fixed, unreactive pupils
Hypothermia
1. Skin temperature drops to 35C (95F) and uncontrolled shivering begins
2. Loss of memory, depression and signs of poor judgment
3. If temperature falls below 34.4 C (94 F), heat and respiratory rates and
blood pressure fall an skin becomes cyanotic
4. May have cardiac dysrhythmias, lose consciousness and becomes
unresponsive to painful stimuli
5. Frostbites are frozen surface areas of the skin, e.g, earlobes, fingers, toes
6. Formula
6.1 to convert Fahrenheit to centigrade, subtract 32 from the Fahrenheit
reading and multiple the result by 5/9
Example : (104 F - 32 F) x 5/9 = 40 C
6.2 To convert centigrade to Fahrenheit, multiple the centigrade reading
by 9/5 and add 32 to the product
Example: (9/5 x 40 C) + 32 = 104 F
1.2. Pulse The pulse is the palpable bounding of the blood flow in a peripheral artery.
1.2.1 Pulse Sites
Site
Location
Assessment
Temporal
Carotid
Apical
Brachial
Radial
Ulnar
Femoral
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superior iliac spine
Popliteal
Posterior tibial
Dorsalis pedis
1.2.2
1.3. Respiration
1.3.1 Definition
Respiration is the mechanism the body uses to exchange gases between the atmosphere
and the blood and the cells.
1.3.2 Processes
ventilation - the mechanical movement of gases into and out of the lungs
diffusion the movement of oxygen (0 2) and carbon dioxide (CO2)between the
alveoli and the red blood cells
perfusion the distribution of red blood cells to and from the pulmonary
capillaries
1.3.3. Factors Influencing Character of Respirations
a. Exercise
Exercise increases respiration rate and depth to meet the bodys need for
additional oxygen and to rid the body of CO2
b. Acute Pain
Pain alters rate and rhythm of respirations, breathing becomes shallow.
Client may inhibit or splint chest wall movement when pain is in ara of chest or
abdomen
c. Anxiety
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Anxiety increases respiration rate and depth as a result of sympathetic
stimulation
d. Smoking
Chronic smoking changes the lungs airways, resulting in increased rate of
respiration at rest when not smoking
e. Body Position
A straight, erect posture promotes full chest expansion
A stooped or slumped position impairs ventilatory movement
Lying flat prevents full chest expansion
f. Medications
Narcotic analgesic, general anesthetics, and sedative hypnotics depress
respiration rate and depth
Amphetamines and cocaine may increase rate and depth
Bronchodilators slow rate by causing airway dilation
g. Neurological Injury
Injury to the brainstem impairs the respiratory center and inhibits respiratory rate
and rhythm
h. Hemoglobin Function
Decreased hemoglobin levels (anemia) reduce oxygen-carrying capacity of the
blood, which increases respiratory rate
Increased altitude lowers the amount of saturated hemoglobin, which increases
respiratory rate and depth
Abnormal blood cell function (e.g., sickle cell disease) reduces ability of
hemoglobin to carry oxygen, which increases respiratory rate and depth
4. Acceptable Range of Respiratory Rates for Age
Age
Newborn
Infant (6 months)
Toddler (2 years)
Child
Adolescent
Adult
Rate (breaths/min)
35 40
30 50
25 32
20 30
16 19
12 - 6
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1 month
1 year
6 years
10-13 years
14-17 years
Middle-age adult
Older adult
85/54
95/65
105/65
110/65
120/75
120/80
140-160/80-90