week 1 (lec)

NURSING PROCESS ■​ Document the data

NURSING ○​ STANDARD2
●​ Is the diagnosis and treatment of human responses ■​ The registered nurse should analyze the data
to health and illness. ■​ Diagnosis
●​ Is both an art and a science; ■​ Validation of data to the client, their families, and
○​ Physical other medical workers
○​ Psychological ■​ Documentation of data
○​ Sociological NURSING PROCESS
○​ Cultural ●​ “Combines the arts of nursing with the elements
○​ Spiritual of the Systems theory using the scientific
●​ Protection of the client from stressors. method” -Shore
●​ Promotion of health. ●​ “It incorporates an interpersonal approach with a
●​ Optimization of health. problem solving and decision-making process”
●​ Alleviation of problems. -Peplau
○​ To the client, their families, the community, and the ●​ Circular process.
whole population. ●​ This is a systematic problem solving approach
●​ EVOLUTION that determines an individualized nursing care
○​ 1800-1900; no medical paraphernalia was available plan.
and only observation was used for health assessment. ●​ GOSH
○​ 1930-1949; community health nursing arose and ○​ Goal oriented
isolation of infected communities was implemented. ○​ Organized
○​ 1950-1969; health assessments for employment ○​ Systematic
became mandatory. ○​ Humanistic care
○​ 1970-1989; ICU equipments were further developed ●​ PURPOSE
○​ 1990-PRESENT; research advancements are in put ○​ Identification of health status
and advanced nurse practitioners are currently the ■​ actual=present
highest ranked nurses. ■​ potential=possible
●​ ESSENTIALS IN NURSING ○​ Establishing plan of care
○​ Full range of human experiences and responses ○​ Performing nursing interventions
without restrictions to a problem focused orientation of ○​ Giving individualized care to the client
the nurse; attention ●​ ADPIE (5 STEPS)
○​ Caring relationships ○​ ASSESSMENT
○​ Understanding and integration of objective data that is ■​ Is a critical process that involves the collection of
derived from the subjective experiences of the client. data which sets the tone for the whole nursing
○​ Knowledge for diagnosis and treatment. process and identifies the client’s strengths and
●​ FUNDAMENTAL PHILOSOPHICAL BELIEFS (7) limitations continuously.
○​ Worth; Human beings have worth and dignity. ■​ FRAMEWORK:
○​ Unity; Humans have unified minds, bodies, and spirits. ➧​ History of the present health concern.
○​ Needs; Basic human needs are to be met. ➧​ Family history.
○​ Problems; Problems arise when needs are not met. ➧​ Lifestyle and health practices.
○​ Culture; Human experiences are contextually and ■​ TYPES
culturally defined. ➧​ Initial comprehensive assessment; is the
○​ Care; Clients have the right to quality care assessment done during the first contact
○​ Therapeutic nurse client relationship with the patient.
●​ SCOPE ➧​ on-going/partial assessment; has the
○​ STANDARD1 potential to change due to new data.
■​ Collection of comprehensive data ➧​ focused/problem oriented assessment;
■​ Analyzation process of the collected data focuses on a specific problem.
 ➧​ Emergency assessment; is conducted ★​ Identify the abnormal data
during life threatening situations and ★​ Cluster data
happens at a rapid pace ★​ Draw inferences and identify the problem
■​ STEPS ★​ Check for defining characteristics of the
➧​ Collection of subjective data problem
➧​ Collection of objective data ★​ Confirm the problem and rule out the
➧​ Validation of data to the patient, their families, nursing diagnosis
and other medical professionals ★​ Document the conclusion made
➧​ Documentation of data ○​ PLANNING
○​ DIAGNOSIS ■​ Sets an individualized plan of care for the patient
■​ Medical diagnosis is the identification of diseases through appropriate interventions and desired
and can only be given by a medical doctor. outcomes after diagnosis.
■​ Nursing diagnosis is the clinical judgment where ■​ DUTY SHIFTS
data analysis is needed to identify a human ➧​ 6AM-2PM; morning shift
response to health conditions. ➧​ 2PM-10PM; afternoon shift
➧​ Actual nursing diagnosis identifies the ➧​ 10PM-6AM; graveyard shift
occuring/current health problem. ➧​ SHORT TERM PLANNING(2-4 hrs)
➧​ Potential nursing diagnosis identifies health ➧​ LONG TERM PLANNING (8-16 hrs)
problems that may occur without preventive ■​ Priority setting is the ordering of nursing
measures. diagnoses based on urgency and importance for
➧​ Possible nursing diagnosis needs more preferential order of nursing interventions.
data to support the actual diagnosis. ■​ Goals are the statements in desire to change the
➧​ COMPONENTS patient’s conditions.
★​ Problem is the diagnosis and contains ■​ SMART PLANNING
qualifiers (ex., impaired, imbalanced, etc.) ➧​ Specific
for further identification. ➧​ Measurable
★​ Etiology is the cause of the problem and ➧​ Attainable
uses the phrase “related to” when charted. ➧​ Realistic
★​ Signs and symptoms are the defining ➧​ Time-bound
characteristics of the problem which is ○​ INTERVENTION (implementation)
introduced as “as evidenced by” when ■​ Is any treatment based on diagnosis that a nurse
charting. performs to enhance patient outcomes.
➧​ TYPES ■​ The doing phase where the plan is put into action
★​ Problem focused contains the problem, to achieve goals.
it’s etiology, and signs and symptoms. ■​ All actions must have a rationale.
Ex. acute pain related to trauma of ■​ APPROACH
surgical incision as evidenced by facial ➧​ Direct care is interventions done through
grimace and guarding behaviour. interactions with the patient.
★​ Risk contains only the problem and ➧​ Indirect care is performed for the patient’s
etiology. benefit but away from the patient.
Ex. risk for infection related to the patient’s ■​ TYPES
surgical incision. ➧​ Independent nursing interventions are
★​ Health promotion concerns about performed without another health care
motivation and desire to increase well provider’s supervision or orders.
being and health potential. ➧​ Dependent nursing interventions are in need
★​ Syndrome has no identified illness but is of another health care provider’s approval or
a cluster of nursing diagnoses and is order.
solved in a long-term process.
➧​ STEPS FOR DATA ANALYSIS
 ➧​ Collaborative nursing interventions allow the
nurse to interact with other healthcare workers
for the patient’s treatment.
○​ EVALUATION
■​ Determines the patient’s improvements or
deteriorations after the interventions through
monitoring of their health progress to determine
the effectiveness of the plan of care based on set
goals.
week 1 (lab)
HOLISTIC HEALTH NURSING ASSESSMENT ➧​ Muscle activity increases metabolic rate and
GENERAL HEALTH STATUS the use of large muscles to make heat
●​ General survey is done during the first interaction of (shivering).
the nurse and the client which includes; ➧​ Thyroxine (T4) output is a hormone for the
○​ Physical development and body build regulation of metabolism and affects blood
○​ Gender and sexual development vessels to constrict or dilate depending on the
○​ Apparent age in comparison to reported age body temperature.
○​ Skin condition ★​ Can also affect the cell’s protein synthesis.
○​ Dress and hygiene ➧​ Epinephrine, norepinephrine, and
○​ Posture sympathetic stimulation affects the body’s
○​ Level of consciousness thermoregulation process involving the
○​ Behaviors sympathetic nervous system.
○​ Facial expressions ➧​ Fever/pyrexia/hyperthermia increases the
○​ Speech body’s temperature by increasing the cellular
○​ Vital signs metabolic rate and triggers muscle contraction
●​ Vital signs (cardinal signs) are the indicators of (shivering) for thermoregulation.
health and are the first step of physical assessment ★​ Intermittent fever alternates between
which provides data for the patient’s health status. regular and abnormal temperatures.
○​ TAKEN UPON; ★​ Remittent fever is a wide range of above
■​ Admission normal temperatures.
■​ Change in health status ★​ Relapsing fever is a recurred fever.
■​ Pre and post procedures ★​ Constant fever has a minimally
■​ Pre and post medicine administration fluctuating temperature.
■​ Pre and post nursing interventions ★​ CLINICAL ONSET OF FEVER
○​ TEMPERATURE ➛​ ONSET/CHILLS
■​ Body temperature reading can be done at various ✧​ Set points become higher than
anatomic sites but not completely accurate and are normal rates and body
only approximations of the client’s body temperature rises to compensate.
temperature. ✧​ Increased heart and respiratory
■​ Measured in degrees. rate
■​ Regulated by the hypothalamus. ✧​ Shivering with cold and pallid skin
■​ Lowest in the morning. paired with goosebumps and
■​ Highest in the evening. cyanotic nail beds.
■​ Core; 36.5 - 37.9 ✧​ Cessation of sweating
■​ Oral; 35.9 - 37.5 ➛​ COURSE/PLATEAU
■​ Axillary; 35.4 - 37 ✧​ Warm skin due to the absence of
■​ Temporal artery; 36.3 - 37.9 chills
■​ Rectal; 36.3 - 37.9 ✧​ Glassy eyed appearance due to
■​ Tympanic membrane; 36.7 - 38.3 photosensitivity
■​ FACTORS THAT AFFECT HEAT PRODUCTION ✧​ Dehydration
IN THE BODY ✧​ Drowsiness and restlessness
➧​ Basal metabolic rate is the utilization of ✧​ Loss of appetite
energy for essential activities in the body.
★​ When the body is in a cooler environment,
the body increases its metabolism to
produce body heat (increase core
temperature).
week 1 (ret dem)
PAIN ASSESSMENT MEDICAL HISTORY
HAND HYGIENE ●​ Assess the patient’s medical history
●​ When to wash hands: ●​ Assess the patient’s past pharmacological
○​ Before patient contact inventions and determine its effects for allergies.
○​ Before an aseptic/clean task.
○​ After bodily fluid exposure risk and removing gloves. PAIN IMPLEMENTATION
○​ After patient contact. COMFORT MEASURES
○​ After contact with the patient's surroundings. ●​ Hand hygiene.
●​ How to wash hands: ●​ Assessed and adjusted the patient's environment.
○​ Wet hands with running water. ●​ Taught the patient on how to use the pain scale.
○​ Apply soap. ●​ Set a pain-intensity goal with the patient.
○​ Palm to palm rubbing. ●​ Administer pain-relieving medications.
○​ Rub right palm over left dorsum. ●​ Reduced the patient’s pain stimuli.
○​ Rub left hand over right dorsum. ●​ Teach the patient how to splint using a pillow and/or
○​ Rub palm to palm with fingers interlaced. hands and explain their purpose.
○​ The backs of the fingers are rubbed against the opposing ○​ Placed the blanket/pillow over the site and placed the
palms by interlocking fingers. patient.
○​ Rub the thumb rotationally by clasping the palm over the ○​ Taught the patient to hold the site when coughing, deep
thumb. breathing, and turning.
○​ Clasp fingers together and rub in a rotational manner ●​ Reduced emotional factors that may increase pain.
over the opposing palm. ●​ Hand hygiene.
○​ Clasp palm over wrists and rub rotationally. EVALUATION
○​ Rinse hands with water. ●​ Asked the patient for the level of relief after 1 hour.
○​ Dry using a towel. ●​ Compared the level of relief to the pain-intensity
○​ Use the towel to turn off the faucet. goal.
SELF INTRODUCTION ●​ Assessed the patient’s ability to function.
●​ Greet the patient. ●​ Taught the patient to perform daily living activities
●​ Introduce yourself as a student nurse. after pain interventions.
PAIN ASSESSMENT ●​ Observed the patient’s behaviours.
●​ Ask if the patient is in pain. ●​ Evaluated the effects of the pain interventions.
●​ Examine the site of pain. ●​ Asked the patient to explain pain relieving
○​ Inspect the range of motion of joints and auscultate techniques.
the patient’s site of pain if necessary. ●​ Identified the unexpected outcomes.
●​ Asses physical, behavioral, and emotional signs and DOCUMENTATION
symptoms of pain. ●​ Recorded the characteristics of pain before
●​ Follow OPQRST pain assessment. interventions, therapies used, and patient
○​ On set; asking the patient when the pain started. responses.
○​ Provocative & Palliative; what actions or events makes ●​ Evaluate the level of the patient's learning.
the pain occur or worse and what actions or events ●​ Assess inadequate pain relief given, the reduction
soothes the pain. of the patient’s functional abilities, the side effects
○​ Quality; ask the patient to describe the pain (ex., of the pain interventions given, and the educational
throbbing, burning, radiating, sharp, etc.) level given to the patient and their guardians.
○​ Region & Radiation; ask the patient for the pain’s location
and if it spreads/occurs in other regions. VITAL SIGNS
○​ Severity; use the pain scale as a reference for the level
of pain the patient is experiencing.
○​ Timing; ask the patient how often and when the pain
occurs.
week 2 (lec)
ASSESSMENT ○​ Interviews are planned conversations to get and give
●​ First and most critical phase. information, identify problems, evaluate changes from the
●​ Ongoing and continuous. patient, teach, and provide support and counseling.
●​ Gathering information about the patient’s health ●​ PREPARATION
status. ○​ Review available medical records.
●​ Analyzing and synthesizing data. ○​ Know the client’s basic biographical data, activities of
NURSING ASSESSMENT daily living, and occupation.
●​ TYPES OF DATA ○​ Know the client’s previous and current health status.
○​ Subjective ○​ Refrain from premature judgement.
■​ Symptoms ○​ Educate yourself.
■​ Apparent to the person affected ○​ Reflect on one’s own feelings.
■​ Establishes rapport with the client ○​ Organize the materials needed for the assessment.
■​ Developmental, psychological, and physiological ●​ INTERVIEW
■​ Collection; ○​ PHASES
➧​ Nonverbal ■​ Please interview with sensitivity
★​ Appearance ■​ Pre-introductory
★​ Demeanor ■​ Introductory
★​ Facial expression ■​ Working
★​ Attitude ■​ Summary
★​ Silence ○​ TYPES
★​ Listening ■​ Directive interviews are highly structured and are
★​ Avoid excessive or insufficient eye contact controlled by the nurse to elicit specific information
★​ Avoid standing using directive questions.
➧​ Verbal ■​ Information gathering interview is a combination of
★​ Open and closed ended questions non-directive and directive interviews.
★​ Rephrasing ■​
★​ Inferring
★​ Laundry list
★​ Avoid biased or leading questions
★​ Avoid rushing the interview
★​ Avoid reading only the questions
○​ Objective
■​ Detectable by an observer
■​ Can be measured and tested
●​ SOURCES OF DATA
○​ The client is the best source of subjective data.
○​ The support people are important sources of data if the
client is young, unconscious, or confused.
○​ Client records are the documented information done by
other healthcare professionals.
○​ Healthcare professionals provide verbal reports.
○​ Literature refers to journals, reference texts, and
published stories to study the patient’s case.
●​ DATA COLLECTION METHODS
○​ Observing is gathering data using the senses and is a
conscious and deliberate skill in noticing, selecting,
organizing, and interpreting data.