Download - 55354481 Acute Biologic Crisis

UNIVERSITY OF THE ASSUMPTIONCity of San Fernando, Pampanga

College of Nursing

NCM 106

CARE OF THE CLIENTS WITH PROBLEMS IN ACUTE BIOLOGIC CRISIS

Course Description:

It deals with the principles and techniques of nursing care management of sick clients across the lifespan with the emphasis on the adult and older person with alteration/problems in acute biologic crisis.

Objectives:

At the end of the course, and given actual clients with problems in acute biologic crisis, the student should be able:

1. Scientia (Academic Excellence)a. Utilize the nursing process in the care of individuals, families, in community and hospital

settings.i. Assess with the client his/her condition/health status through interview, physical

examination, interpretation of laboratory findingsii. Identify actual and potential diagnosisiii. Plan appropriate nursing interventions with client and family for identified nursing

diagnosisiv. Implement plan of care with client and familyv. Evaluate the progress of the client’s condition and outcomes of care

b. Ensure a well-organized and accurate documentation system

2. Virtus (Christian Formation)a. Observe bioethical principles and the core values (love of God, caring, love security and

of people)b. Utilize the bioethical principle and core values and nursing standards in the care of

clients.c. Integrate the various principles, concept and application of bioethics in the care of the

client.

3. Communitas (Community Service)a. Determine the different principles and techniques of nursing care management in

promoting the health of the community.b. Take part in the community projects that would require the utilization of appropriate

health promotion and disease prevention.c. Relate with client and their family and the health team appropriately.d. Promote personal and professional growth of self and others.

Acute Biologic Crisis By: Raidis L. Dela Cruz,RN,MAN

Cardiac Failure

Description - Is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygenation and nutrients

- CHF is most commonly used when referring to left-sided and right- sided failure

- Formerly called Congestive Heart Failure

Etiologic Factors : - Increased metabolic rate (eg. fever, thyrotoxicosis)

- Hypoxia

- AnemiaPathophysiology: - Cardiac failure most commonly occurs with disorders of cardiac

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

Left-Sided Cardiac Failure

- Pulmonary congestion occurs when the left ventricle cannot pump the blood out of the chamber. This increases pressure in the left ventricle and decreases the blood flow from the left atrium. The pressure in the left atrium increases, which decreases the blood flow coming from the pulmonary vessels. The resultant increase in pressure in the pulmonary circulation forces fluid into the pulmonary tissues and alveoli; which impairs gas exchange.

Clinical Manifestations

- Dyspnea on exertion- Cough- Adventitious breath sounds- Restless and anxious- Skin appears pale and ashen and feels cool and clammy- Tachycardia and palpitations- Weak, thready pulse- Easy fatigability and decreased activity tolerance

Right-Sided Cardiac Failure

- When the right ventricle fails, congestion of the viscera and the peripheral tissues predominates. This occurs because the right side of the heart cannot eject blood and thus cannot accommodate all the blood that normally returns to it from the venous circulation.



- Edema of the lower extremities (dependent edema)- Weight gain- Hepatomegaly (enlargement of the liver)- Distended neck veins- Ascites (accumulation of fluid in the peritoneal cavity)- Anorexia and nausea- Nocturia (need to urinate at night)- Weakness

Diagnostics - Chest Xray (may show cardiomegaly or vascular congestion)

- Echocardiogram (shows decreased ventricular function and decreased ejection fraction)

- CVP (elevated in right-sided failure)

*pulmonary artery pressure monitoring may be used as guide treatment in serious case of pulmonary edema

Nursing Diagnoses - Activity intolerance r/t imbalance between oxygen supply and demand secondary to decreased CO

- Excess fluid volume r/t excess fluid/sodium intake or retention secondary to CHF and its medical therapy

- Anxiety r/t breathlessness and restlessness secondary to inadequate oxygenation

- Non-compliance r/t to lack of knowledge

- Powerlessness r/t inability to perform role responsibilities secondary to chronic illness and hospitalization

Nursing Management

a. Acute phase

- monitor and record BP, pulse, respirations, ECG and CVP to detect changes in cardiac output

- maintain client in sitting position to decrease pulmonary congestion and facilitate improved gas exchange

- auscultate heart and lung sounds frequently: increasing crackles, increasing dyspnea, decreasing lung sounds indicate worsening failure

- administer O2 as ordered to improve gas exchange and increase oxygenation of blood; monitor arterial blood gases (ABG) as ordered to assess oxygenation

- administer prescribed medications on accurate schedule

- Monitor serum electrolytes to detect hypokalemia secondary to diuretic therapy

- monitor accurate input and output ( may require Foley cathether to allow accurate measurement of urine output) to evaluate fluid status

- if fluid restriction is prescribed, spread the fluid throughout the day to reduce thirst


- encourage physical rest and organized activities with frequent rest periods to reduce the work of the heart

- provide a calm reassuring environment to decrease anxiety; this decreases oxygen consumption and demands on the heart

b. Chronic heart failure

- educate client and family about the rationale for the regimen

- establish baseline assessment for fluid status and functional abilities

- monitor daily weights to evaluate changes in fluid status

- assess at regular intervals for changes in fluid status or functional activity level

Pharmacologic Therapy

- ACE Inhibitors (promotes vasodilation and diuresis by decreasing afterload and preload eventually decreasing the workload of the heart.)

- Diuretic Therapy. A diuretic is one of the first medications prescribed to a patient with CHF. Diuretics promote the excretion of sodium and water through the kidneys

- Digitalis (increases the force of myocardial contraction and slows conduction through the AV node. It improves contractility thus, increasing left ventricular output.)

- Dobutamine.(Dobutrex) is an intravenous medication given to patients with significant left ventricular dysfunction. A catecholamine, it stimulates the beta1-adrenergic receptors. Its major action is to increase cardiac contractility.

- Milrinone (Primacor). A phosphodiesterase inhibitor that prolongs the release and prevents the uptake of calcium. This in turn, promotes vasodilation, causing a decrease in preload and afterload and decreasing the workload of the heart.

- Nitroglycerine ( a vasodilator reduces preload)

- Morphine to sedate and vasodilate,decreasing the work of the heart

- Anticoagulants may be prescribed. Beta-adrenergic blockers maybe indicated in patients with mild or moderate failure

Client Education - Include family member or others in teaching as appropriate

- Weight monitoring: teach client the importance of measuring and recording daily weights and report unexplained increase of 3-5 pounds

- Diet: sodium restriction to decrease fluid overload and potassium rich foods to replenish loss from medications; do not restrict water intake unless directed

- Medication regime: explain the importance of following all medication instructions


- Activity: help client plan paced activity to maximize available cardiac output

- Symptoms: report to MD promptly any of the following: chest pain, new onset of dyspnea on exertion, paroxysmal and nocturnal dyspnea

- Report even minor changes to MD as they may be an early sign of decompensation

Acute Myocardial Infarction

Description - Occurs when the heart muscle is deprived of oxygen and nutrient-rich blood. However, in the case of MI, this deprivation occurs over a sustained period to the point at which irreversible cell death and necrosis take place. Infarction results from sustained ischemia and is irreversible causing cellular death and necrosis.

Etiologic factors - Physical exertion

- Emotional stress

- Weather extremes

- Digestion after a heavy meal - Valsalva maneuver - Hot baths or showers

- Sexual excitation - Pathophysiologic characteristic (Coronary artery disease)

Pathophysiology - Coronary artery blood flow is blocked by atherosclerotic narrowing, thrombus formation or persistent vasospasm; myocardium supplied by the arteries is deprived of oxygen; persistent ischemia may rapidly lead to tissue death


- Chest pain or discomfort ( described as aching or squeezing pain, most common location is substernal, radiating to neck, jaw, back, shoulders, left arm or occasionally the right arm)

- complain of heartburn or indigestion

- pallor, diaphoresis, cold skin, shortness of breath, weakness, dizziness, anxiety, and feelings of impending doom

Diagnostics

Laboratory Tests

- Electrocardiogram (12-lead) – capable of diagnosing MI in 80% of patients, making it an indispensable, noninvasive, and cost-effective tool. Reading shows ST elevation, accompanied by T-wave inversion; and later new pathologic Q wave

- Cardiac Enzymes – elevated CK with MB isoenzymes >5percent (early diagnosis); elevated Troponin (early to late diagnosis); or elevated LDH with “flipped” isoenzymes (late diagnosis)

- WBC count – leukocytosis (10,000/mm3 to 20,000/mm3) appears on thesecond day after AMI and dis appears after 1 week


Imaging Studies - Positron Emission Tomography (PET) is used to evaluate cardiac metabolism and to assess tissue perfusion

- Magnetic Resonance Imaging helps identify the site and extent of an MI

- Tranesophageal Echocrdiography (TEE) is an imaging technique in which transducer is placed against the wall of the esophagus; the image of the myocardium is clearer when the esophageal site is used.

Nursing Diagnoses - Acute Pain related to myocardial ischemia resulting from coronary artery occlusion

- Ineffective Tissue Perfusion related to thrombus in coronary artery

- Decreased Cardiac Output related to negative inotropic changes in the heart secondary to myocardial ischemia

- Impaired Gas Exchange related to decreased cardiac output

- Anxiety and Fear related to hospital admission and fear of death

Nursing Management

- Assess pain status frequently with pain scale

- Assess hemodynamic status including BP, HR, LOC, skin color, and temperature (every 5 minutes during with pain;every 15 minutes)

- Monitor continuous ECG to detect dysrhytmias

- Perform 12-lead ECG immediately with new pain or changes in level of pain

- Monitor respirations, breath sounds, and input and output to dtect early signs of heart failure

- Monitor O2 saturation and administer O2 as prescribed

- Provide for physiological rest to decrease oxygen demands on heart

- Keep client NPO or progress to liquid diet as ordered; maintain IV access for medication as needed

- Provide a calm environment and reassure client and family to decrease stress, fear and anxiety

- Report significant changes immediately to physician to ensure rapid treatment of complications

- Maintain bed rest for 24 to 36 hours and gradually increase activity as ordered while closely monitoring CO,ECG and pain status


- Nitroglycerine (to dilate coronary vessels and increase blood flow)

- Morphine Sulfate (to relieve chest pain)

- Anticoagulant (heparin) and Antiplatelet (aspirin) - to prevent additional clot formation

- Streptokinase (to dissolve clot)

- Beta blockers (to decrease cardiac work)

- Anti-dysrhytmic drugs


Surgical Interventions

- Percutaneous transluminal coronary angioplasty (PTCA) – involves the passage of an inflatable balloon catheter into the stenonic coronary vessel, which is then dilated, resulting in compression of the atherosclerotic plaque and widening of the vessel

- Coronary artery bypass grafting (CABG) – done by harvesting either a saphenous vein from the leg or the left internal mammaryartery and then used to bypass areas of obstruction in the heart

Client Education - Include appropriate family members whenever possible

- Explain cardiac rehabilitation program if ordered

- Explain modifiable risk factors and develop a plan with client including supportive resources to change lifestyle to decrease these factors

- Explain medication regime as prescribed; identify side effects to report (provide written instructions for later reference)

- Stress the importance of immediate reporting of chest pain or signs of decreased CO2

- Instruct about bleeding precautions if client is on anticoagulant therapy: use soft toothbrush, electric razor, avoid trauma or injury; wear or carry medical alert identification

Acute Pulmonary failure

Description - Defined as a fall in arterial oxygen tension and a rise in arterial carbon dioxide tension.

- The ventilation and/or perfusion mechanisms in the lung are impaired.

Etiologic factors - Alveolar hypoventilation

- Diffusion abnormalities

- Ventilation-perfusion mismatching

- Shunting

Pathophysiology - progression of pulmonary edema occurs when capillary hydrostatic pressure is increased, promoying movement of fluid into the interstitial space of the alveolar-capillary membrane. Initially, increased lymphatic flow removes the excess fluids, but continued leakage eventually overwhelms this mechanism. Gas exchange becomes impaired by the thick membrane. Increasing interstitial fluid pressure ultimately causes leaks into the alveolar sacs, impairing ventilation and gas exchange

Clinical - Tachypnea


Manifestations- Tachycardia

- Cold, clammy skin and frank diaphoresis are apparent especially

around the forehead and face

- Percussion reveals hyperresonance in patients with COPD; dull or

flat on patients with atelectasis or pneumonia

- Diminished breath sounds; absence of breath sounds of the

affected lung in patients with pneumothorax; wheezes on patients

with asthma; ronchi on patients with bronchitis and crackles may

reveal suspicion of pulmonary edema

Diagnostics - ABG analysis indicates respiratory failure when PaO2 is low and PaCO2 is high and the HCO3 level is normal

- Chest Xray is used to identify pulmonary diseases such as emphysema, atelectasis, pneumothorax, infiltrates and effusions

- Electrocardiogram (ECG) can demonstrate arrhytmias, commonly found with cor pulmonale and myocardial hypoxia

- Pulse oximetry reveals a decreasing SpO2 level

- WBC count aids detection of an underlying infection;abnormally low hemoglobin and hematocrit levels signal blood loss,indicating decrease oxygen carrying capacity

- PA catheterization is used to distinguish pulmonary causes from cardiovascular causes of acute respiratory failure

Nursing Diagnoses - Impaired Gas Exchange related to capillary membrane obstruction from fluid

- Excess Fluid Volume related to excess preload

Nursing Management

- Assess the patient’s respiratory status at least every 2 hours or more as indicated

- Position the patient for optimal breathing effort when he isn’t intubated. Put the call bell within easy reach to reassure the patient and prevent necessary exertion

- Maintain the normothermic environment to reduce patient’s oxygen demand

- Monitor vital signs, heart rhythm, and fluid intake and output, including daily weights, to identify fluid overload or impending dehydration

- After intubation, auscultate the lungs to check for accidental intubation of the esophagus or mainstem bronchus.

- Don’t suction too often without identifying the underlying cause of an equipment alarm.

- Watch oximetry and capnography values because these may indicate changes in patient’s condition

- Note the amount and quality of lung secretions and look for


changes in the patient’s status

- Check cuff pressure on the ET tube to prevent erosion from an overinflated cuff

- Implement measures to prevent nasal tissue necrosis

- Be alert of GI bleeding

- Provide a means of communication for patients who are intubated and alert


- Reversal agents such as Naloxone (Narcan) are given if drug overdose is suspected

- Bronchodilators are given to open airways

- Antibiotics are given to combat infection

- Corticosteroids may be given to reduce inflammation

- Continuous IV solutions of positive inotropic agents may be given to increase cardiac output, and vasopressors may be given to induce vasoconstrictions to improve or maintain blood pressure

- Diuretics may be given to reduce fluid overload and edema

Client Education - Include family member or others in teaching as appropriate

- Weight monitoring: teach client the importance of measuring and recording daily weights and report unexplained increase of 3-5 pounds

- Diet: sodium restriction to decrease fluid overload and potassium rich foods to replenish loss from medications; do not restrict water intake unless directed

- Medication regime: explain the importance of following all medication instructions

- Instruct client and family to maintain elevation of the head of the client at least 45 degrees ; position increases chest expansion and mobilizes fluid from the chest into more dependent areas

Acute Renal Failure

Description - a sudden loss of kidney function caused by failure of renal circulation or damage to the tubules or glomeruli

Etiologic factor a. Prerenal - caused by decrease blood flow to kidneys like severe dehydration,diuretic therapy,circulatory collapse,hypovolemia or shock;readily reversible when recognized and treated

b. Intrarenal – caused by disease process, ischemia, or toxic conditions such as acute glomerulonephritis,vascular disorders,toxic agents, or severe infection

c. Postrenal – caused by any condition that obstructs urine flow such as benign prostatic hyperplasia,renal or urinary tract calculi, or tumors

Pathophysiology - Acute renal failure is classified as prerenal, intrarenal or


postrenal. All conditions that lead to prerenal failure impair blood flow to the kidneys (renal perfusion), resulting in a decreased glomerular filtration rate and increased tubular resorption of sodium and water. Intrarenal failure results from damage to the kidneys. Postrenal failure results from obstructed urine flow.


*A change in blood pressure and volume signals pre renal failure, the patient may have the following:

- Oliguria

- Tachycardia

- Hypotension

- Dry mucous membranes

- Flat jugular veins

- Lethargy progressing to coma

- Decreased cardiac output and cool, clammy skin in patient with heart failure

*As renal failure progresses, the patient may manifest the following signs and symptom:

- uremia

- confusion

- GI complaints

- fluid in the lungs

- infection

Diagnostics - Blood studies reveal elevated BUN, serum creatinine, and potassium levels and decreased blood pH, bicarbonate, HCT, and Hb levels

- Urine studies show cats, cellular debris, decreased specific gravity and, in glomerular diseases, proteinuria and urine osmolality close to serum osmolality.

- Creatinine clearance testing is used to measure the GFR and estimate the number of remaining functioning nephrons

- Electrocardiogram (ECG) shows tall, peaked T waves, a widening QRS complex, and disappearing P waves if increased potassium is present

*other studies used to determine the cause of renal failure:

- kidney ultrasonography

- plain films of the abdomen

- KUB radiography

- excretory urography

- renal scan

- retrograde pyelography


- computed tomography scan and nephrotomography

Nursing Diagnoses - Excess Fluid Volume

- Imbalanced Nutrition: Less than Body Requirements

- Deficient Knowledge

- Risk for Infection

Nursing Management

- Monitor intake and output

- Observe for oliguria followed by polyuria

- Weigh daily and observe for edema

- Monitoring of complications of electrolyte imbalances, such as acidosis and hyperkalemia

- Allow client to verbalize concerns regarding disorder

- Encourage prescribed diet: moderate protein restriction, high in carbohydrates, restricted potassium

- Once diuresis phase begins, evaluate slow return of BUN, creatinine, phosphorus, and potassium to normal


- use volume expanders are prescribed to restore renal perfusion in hypotensive clients and Dopamine IV to increase renal blood flow

- Loop diuretics to reduce toxic concentration in nephrons and establish urine flow

- ACE inhibitors to control hypertension

- Antacids or H2 receptor antagonists to prevent gastric ulcers

- Kayexelate to reduce serum potassium levels and sodium bicarbonate to treat acidosis

* avoid nephrotoxic drugs

Client Education - Dietary and fluid restrictions, including those that may be continued after discharge

- Signs of complications such as fluid volume excess, CHF, and hyperkalemia

- Monitor weight, blood pressure, pulse, and urine output

- Avoid neprotoxic drugs and substances: NSAIDs, some antibiotics, radiologic contrast media, and heavy metals; consult care provider prior to taking any OTC drugs

- Recovery of renal function requires up to 1 year; during this period, nephrons are vulnerable to damage from nephrotoxins


Stroke/Cerebrovascular accident

Description - is a condition where neurological deficits occur as a result of decreased blood flow to a localized area of the brain

- thrombosis of the cerebral arteries supplying the brain or of the intracranial vessels occluding blood flow

- embolism from a thrombus outside the brain, such as in the heart, aorta, or common carotid artery

- hemorrhage from an intracranial artery or vein, such as from hypertension, ruptured aneurysm, AVM, trauma, hemorrhagic disorder, or septic embolism

Pathophysiology - the underlying event leading to stroke is oxygen and nutrient deprivation; if the arteries become blocked, auto regulatory mechanisms maintain cerebral circulation until collateral circulation develops to deliver blood to the affected area; if the compensatory mechanisms become overworked or cerebral blood flow remains impaired for more than a few minutes, oxygen deprivation leads to infarction of brain tissue

Risk factors - hypertension

- family history of stroke

- history of TIA

- cardiac disease, including arrhythmias, coronary artery disease, acute myocardial infarction, dilated myopathy, and valvular disease

- diabetes mellitus

- familial hyperlipidemia

- cigarette smoking

- increased alcohol intake

- obesity, sedentary lifestyle

- use of hormonal contraceptives


- hemiparesis on the affected side ( may be more severe in the face and arm than in leg)

- unilateral sensory defect (such as numbness, or tingling) generally on the same side as the hemiparesis

- slurred or indistinct speech or the inability to understand speech

- blurred or indistinct vision, double vision, or vision loss in one eye (usually described as a curtain coming down or gray-out of vision)

- mental status changes or loss of consciousness (particularly if associated with one of the above symptoms)

- very severe headache (with hemorrhagic)

*A stroke in the left hemisphere produces symptoms on the right side of the body; in the right hemisphere, symptoms on the left side

Diagnostics - CT scan discloses structural abnormalities, edema, and lesions,


such as nonhemorrhagic infarction and aneurysms

- MRI is used to identify areas of ischemia, infarction and cerebral swelling

- DSA is used to evaluate patency of the cerebral vessels and shows evidence of occlusion of the cerebral vessels, a lesion or vascular abnormalities

- Cerebral angiography shows details of disruption or displacement of the cerebral circulation by occlusion or hemorrhage

- Carotid Duplex scan is a high frequency ultrasound that shows blood flow through the carotid arteries and reveals stenosis due to atherosclerotic plaque and blood clots

- Transcranial Doppler studies are used to evaluate the velocity of blood flow through major intracranial vessels, which can indicate vessel diameter

- Brain scan shows ischemic areas but may not be conclusive for up to 2 weeks after stroke

- Single photon emission CT scanning and PET scan show areas of altered metabolism surrounding lesions that aren’t revealed by other diagnostic tests

- Lumbar puncture reveals bloody CSF when stroke is hemorrhagic

- EEG is used to identify damaged areas of the brain and to differentiate seizure activity from stroke

- A blood glucose test shows whether the patient’s symptoms are related to hypoglycemia

- Hemoglobin and hematocrit level may be elevated in severe occlusion

- Baseline CBC, platelet count, PTT, PT, fibrinogen level and chemistry panel are obtained before thrombolytic therapy

Nursing Diagnoses - Ineffective Tissue Perfusion related to decreased cerebral blood flow

- Risk for Prolonged Bleeding related to use of thrombolytic agents

- Increased Risk for Aspiration related to depressed gag reflex, Impaired swallowing

- Impaired Physical Mobility related to loss of muscle tone

Nursing Management

- Encourage active range of motion on unaffected side and passive range of motion on the affected side

- Turn client every 2 hours

- Monitor lower extremities for thrombophlebitis

- Encourage use of unaffected arm for ADLs


- Teach client to put clothing on affected side first

- Resume diet orally only after successfully completing a swallowing evaluation

- Collaborate with occupational and physical therapists

- Try alternate methods of communication with aphasia patients

- Accept client’s frustration and anger as normal to loss of function

- Teach client with homonymous hemianopsia to overcome the deficit by turning the head side to side to be able to fully scan the visual field


- Thrombolytics for emergency treatment of ischemic stroke

- Aspirin or Ticlopidine (Ticlid) as an antiplatelet agent to prevent recurrent stroke

- Benzodiazepines to treat patients with seizure activity

- Anticonvulsants to treat seizures or to prevent them after the patient’s condition has stabilized

- Stool softeners to avoid straining, which increase ICP

- Antihypertensives and antiarrhythmics to treat patients with risk factors for recurrent stroke

- Corticosteroids to minimize associated cerebral edema

- Hyperosmolar solutions (Mannitol) or diuretics are given to clients with cerebral edema

- Analgesics to relieve the headaches that may follow a hemorrhagic stroke

Surgical Intervention - Craniotomy to remove hematoma

- Carotid endarterectomy to remove atherosclerotic plaques from the inner arterial wall

- Extracranial bypass to circumvent an artery that’s blocked by occlusion or stenosis

Client Education - Educate client and family about CVA and CVA prevention

- Educate client and family about community resources

- Educate client and family about physical care and need for psychosocial support

- Educate client and family about medication

Increased Intracranial Pressure

Description - prolonged pressure greater than 15mmHg or 180mmH2O measured in the lateral ventricles

Etiology - Cerebral Edema is an increase in volume of brain tissue due to alterations in capillary permeability, changes in functional or the structural integrity of the cell membrane or an increase in the


interstitial fluids

- Hydrocephalus is an increase in the volume of CSF within the ventricular system; it may be noncommunicating hydrocephalus where the drainage from the ventricular system is impaired

Pathophysiology - Blood flow exerts pressure against a weak arterial wall, stretching it like an overblown balloon and making it to rupture; rupture is followed by a subarachnoid hemorrhage, in which blood spills into space normally occupied by CSF. Sometimes, blood spills into brain tissue, where a clot can cause potentially fatal increased ICP and brain tissue damage

Clinical manifestations

- blurring of vision, decreased visual acuity and diplopia are the earliest signs of increased ICP

- headache, papilledema or the swelling of optic disk and vomiting

- change of LOC

Diagnostics - skull radiography

- CT scan

- MRI

* Lumbar puncture is not performed because of brain herniation caused by sudden release of pressure

*Laboratory tests are performed to augment and monitor treatment approaches; serum osmolarity monitors hydration status and ABGs measure pH, oxygen and carbon dioxide

Nursing Diagnoses - Ineffective Cerebral Tissue Perfusion related to Increased ICP


- Impaired Physical Mobility

- Risk for Ineffective Airway Clearance

Nursing Management

- Assess neurological status every 1 to 2 hours and report any deterioration; include LOC, behavior, motor/sensory function, pupil size and response, vital signs with temperature

- Maintain airway; elevate head of 30 degree or keep flat as prescribed; maintain head and neck in neutral position to promote venous drainage

- Assess for bladder distention and bowel constipation; assist client when necessary to prevent Valsava maneuver

- Plan nursing care so it is not clustered because prolonged activity may increase ICP; provide quiet environment and limit noxious stimuli; limit stimulants such as radio, TV and newspaper; avoid ingesting stimulants such as coffee, tea, cola drinks and cigarette smoke

- Maintain fluid restriction as prescribed

- Keep dressings over catheter dry and change dressings as prescribed; monitor insertion site for CSF leakage or infection; monitor clients for signs and symptoms of infection; use aseptic


technique when in contact with ICP monitor

Pharmacologic therapy

- Osmotic diuretics such as Mannitol and loop diuretics such as Furosemide ( Lasix) are mainstays used to decrease ICP

- Corticosteroids are effective in decreasing ICP especially with tumors

Surgical Intervention - A drainage catheter, inserted via ventriculostomy into lateral ventricle, can be done to monitor ICP and to drain CSF to maintain normal pressure; if used the system is calibrated with transducer is leveled 1 inch above the ear; sterile is of utmost importance

Client Education - Teach the client at risk for increased ICP to avoid coughing, blowing the nose, straining for bowel movements, pushing against the bed side rails, or performing isometric exercises

- Advice the client to maintain neutral head and neck alignment

- Encourage the family to maintain a quiet environment and minimize stimuli

- Educate the family that upsetting the client may increase ICP

METABOLIC EMERGENCIES

DKA

Description - Life threatening metabolic acidosis resulting from persistent hyperglycemia and breakdown of fats into glucose, leading to presence of ketones in blood; can be triggered by emotional stress, uncompensated exercise,infection, trauma, or insufficient or delayed insulin administration

Etiology- Decreased or missed dose of insulin- Illness or infection

- Undiagnosed and untreated diabetes

Pathophysiology - In the absence of endogenous insulin, the body breaks down fats for energy. In the process, fatty acids develop too rapidly and are converted to ketones, resulting to severe metabolic acidosis. As acidosis worsens, blood glucose levels increase and hyperkalemia worsens. The cycle continues until coma and death occur

Clinical manifestations

- Acetone breath

- Poor appetite or anorexia

- Nausea and vomiting

- Abdominal pain

- Blurred vision

- Weakness

- Headache

- Dehydration


- Thirst or polydipsia

- Orthostatic hypotension

- Hyperventilation (Kussmaul respirations)

- Mental status changes in DKA vary from patient to patient

- weight loss

- muscle wasting

- leg cramps

- recurrent infections

Diagnostics- Serum glucose is elevated (200 to 800 mg/dl)

- Serum Ketone Level is increased

- Urine acetone test is positive

- Arterial Blood Gas analysis reveals metabolic acidosis

- ECG findings shows tall tented T waves and widened QRS complex changes related to hyperkalemia; later with hypokalemia, shows flattened T wave and the presence of U wave

- Serum osmolality is elevated

Nursing Diagnoses - Deficient Fluid Volume

- Risk for Injury

- Risk for Skin Impaired Integrity

- Ineffective Breathing Pattern

- Disturbed Sensory Perception

- Knowledge Deficit

- Anxiety

Nursing Management - Restore fluid, electrolyte and glucose balance with IV infusions and medications, analyze intake and out, blood glucose, urine ketones, vital signs, oxygenation and breathing pattern

- Maintain skin integrity; promote healing of impaired skin; prevent infection by turning and positioning client every 2 hours; provide pressure relief as indicated; manage incontinence and perspiration with skin protective barriers and cleansing; provide appropriate nutrition and oxygen support

- Promote safety by analyzing vital signs, client communication, LOC and emotional response, and activity tolerance; implement falls prevention measures

- Assist client to verbalize concerns and cope effectively with illness and fears

- Assist client to update Medic-Alert bracelet information as appropriate


Pharmacotherapy - Administer IV Insulin and fluid and electrolyte replacements based on laboratory test results

Client Education - Instruct client about the nature and causes of DKA (such as excess glucose intake, insufficient medications or physiological and/or psychological stressors) any new medications

HYPEROSMOLAR HYPERGLYCEMIC NONKETOTIC COMA Description - Life threatening metabolic disorder of hyperglycemia usually

recurring with DM type 2 medications, infections, acute illness, invasive procedure, or a chronic illness

Etiology - Medications

- Infections

- acute illness

- invasive procedure

- chronic illness

Pathophysiology - glucose production and release into the blood is increased or glucose uptake by the cells is decreased; when the cells don’t receive glucose, the liver responds by converting glycogen to glucose for release into the bloodstream; when all excess glucose molecules remain in the serum, osmosis cause fluid shifts.; the cycle continues until fluid shifts in the brain cause coma and death


- severe dehydration

- hypotension and tachycardia

- diaphoresis

- tachypnea

- polyuria, polydipsia and polypahgia

- lethargy and fatigue

- vision changes

- rapid onset of lethargy

- stupor and coma

- neurologic changes

Diagnostics - Serum glucose is elevated, sometimes 800 to 2,000 mg/dl

- Ketones are absent, urine and serum ketones are absent

- Urine glucose levels are positive

- Serum osmolality is increased

- Serum Sodium levels are elevated and the serum potassium level is usually normal

- ABG results are usually normal, without evidence of acidosis

Nursing Diagnoses - Decreased Cardiac Output


- Deficient Fluid Volume

- Hyperthermia

- Disturbed Sensory Perception

- Risk for Impaired Skin Integrity

- Risk for Aspiration

- Deficient Knowledge

Nursing Management - Assess the patient’s LOC, respiratory status and oxygenation

- Monitor the patient’s VS; changes may reflect the patient’s hydration status

- Monitor patient’s blood glucose and serum electrolytes

- Administer regular insulin IV as ordered, by continuous infusion and titrate dosage based on the patient’s blood glucose levels

- Maintain intact skin integrity by turning every 2 hours, use of pressure relief aids, nutritional support, use of skin moisturizers and barriers, and management of incontinence

- Prevent aspiration by using appropriate feeding precautions, elevate head of bed 15 to 30 degrees during and after feeding for 1 hour; if BP is too unstable to elevate head of bed with feeding, then withhold oral feedings

Pharmacotherapy - IV infusion of NS to replace fluids and sodium, regular insulin IV to manage the hyperglycemia, and potassium to replace losses and shifts

Client Education - Instruct client and family about HHNK, symptoms to report, and administration of new medications

- Provide patient and family education to foster prevention of future episodes

Massive Bleeding

Description - Uncontrolled bleeding

Etiology - Result of blunt or penetrating trauma

- Gastrointestinal or genitourinary bleeding

- Hemoptysis

Pathophysiology - Due to the lack of adequate circulating blood volume causing dcreased tissue perfusion and metabolism resulting in hypoxia, vasoconstriction and shunting of the available circulating blood volume to the vital organs(heart and brain);Symphathetic nervous system stimulation, hormonal release of antidiuretic hormone and the angiotensin-renin mechanisms and neural responses attempt to compensate for the loss of circulating volume but eventually metabolic acidosis, multi organ system failure occurs


- cool, clammy, pale skin (esp. distal extremities)


- delayed capillary refill (>3 seconds)

- weak, rapid pulses

- decreased blood pressure (systolic pressure <90mmHg)

- rapid shallow respirations(>28/ min)

- restless, anxious, decreased LOC

- cardiac dysrhtymias (abnormalities of cardiac rhythm)

- decreased urinary output

Diagnostics - evidence of bleeding from thorocostomy that indicates bleeding from chest area

- abdominal or pelvic CT scan, abdominal ultrasound or peritoneal lavage indicate intra abdominal bleeding

- Endoscopy indicates upper or lower GI bleeding

- Angiography procedures diagnose severe vascular damage

- Extremity radiographs show long bone fractures

- Hemoglobin and hematocrit from the CBC are decreased due to blood loss

- Elevated serum lactate if bleeding continues and client becomes acidotic

- ABGs show metabolic acidosis as blood loss continues

- Baseline coagulation studies should be reviewed; initial PT/PTT and platelet counts will be within normal limits but as coagulation factors become depleted, clotting times will increase and platelet counts will decrease

- Serum electrolytes to assess renal function

Nursing Diagnoses - Impaired Tissue Perfusion

- Deficient Fluid volume

- Decreased cardiac Output

Nursing Management - Establish an adequate airway, breathing pattern, and applying supplemental oxygen

- Give priority interventions to control bleeding such as direct pressure to wound site, or assisting with surgical interventions

- Establish IV access and begin with fluid replacement

- Draw blood specimens as ordered to assist in evaluation of hemoglobin, hematocrit, electrolyte, oxygenation andhydration status

- Insert an indwelling catheter and NG tube to assist in accurate recording of fluid balance status

- Perform and document continuous serial assessments of hemodynamic parameters such as VS, capillary refill, CVP, cardiac rhythm, LOC, urinary output and laboaratory findings

Pharmacotherapy - Crystalloids and blood products to maintain adequate circulating


volume status

- Sodium Bicarbonate to correct acidosis state

- Vasopressor such as Dopamine

Client Education - Explain procedures to the client

- Support the family by explaining emergency measures and interventions

Burns

Description - An alteration in skin integrity resulting in tissue loss or injury caused by heat, chemicals, electricity or radiation

Etiology Types of burn injury

a. Thermal: results from dry heat (flames) or moist heat (steam or hot liquids); it is the most common type; it causes cellular destruction that results in vascular, bony, muscle, or nerve complications; thermal burns can also lead to inhalation injury if the head and neck area is affected

b. Chemical burns are caused by direct contact with either acidic or alkaline agents; they alter tissue perfusion leading to necrosis

c. Electrical burns; severity depends on type and duration of current and amount of voltage; it follows the path of least resistance(muscles, bone, blood vessels and nerves); sources of electrical injury include direct current, alternating current and lightning

d. Radiation burns: are usually associated with sunburn or radiation treatment for cancer; are usually superficial; extensive exposure to radiation may lead to tissue damage

Pathophysiology - It depends on the cause and classification of the burn; the injuring agents denatures cellular proteins; some cells die because of traumatic or ischemic necrosis; loss of collagen cross-linking also occurs with denaturation, creating abnormal osmotic and hydrostatic pressure gradients that cause intravascular fluid to move into interstitial spaces; Cellular injury triggers the release of mediators of inflammation, contributing to local and in the case of major burns , systemic increases in capillary permeability


- Localized pain and erythema, usually without blisters in the first 24 hours (first degree burn)

- Chills, headache, localized edema, nausea and vomiting (most severe first degree burn)

- Thin-walled, fluid filled blisters appearing within minutes of the injury, with mild to moderate edema and pain (second degree superficial partial thickness burn)

- White, waxy appearance to damaged area(second degree partial-thickness burn)

- White, brown or black leathery tissue and visible thrombosed vessels due to destruction of skin elasticity(dorsum of hand,


most common site of thrombosed veins), without blisters (third-degree burn)

- Silver-colored, raised or charred area, usually at the site of electrical contact

Diagnostics *Rule of Nines chart determines the percentage of body surface area (BSA)covered by the burn

- ABG levels may be normal in the early stages but may reveal hypoxemia and metabolic acidosis

- Carboxyhemoglobin level may reveal the extent of smoke inhalation due to the presence of carbon monoxide

- Complete blood count may reveal a decrease hemoglobin due to hemolysis, increased hematocrit and leukocytosis

- Electrolyte levels show hyponatremia and hyperkalemia,other laboratory tests reveals elevated BUN,decreased total protein and albumin

- Creatinine kinase (CK) and myoglobin levels may be elevated

- Presence of myoglobin in urine may lead to acute tubular necrosis

Nursing Diagnoses - Risk for Deficient Fluid Volume


- Impaired Physical Mobility

- Imbalanced Nutrition: Less than Body Requirements


- Impaired Tissue Perfusion

- Risk for Impaired Gas Exchange

- Anxiety

- Risk for Ineffective Thermoregulation

- Pain

- Impaired Skin Integrity

Nursing Management - Assess patient’s ABCs; monitor arterial oxygen saturation and serial ABG values and anticipate the need for ET intubation and mechanical ventilation

- Auscultate breath sounds

- Administered supplemental humidified oxygen as ordered

- Perform oropharyngeal or tracheal suctioning as indicated by the patient’s inability to clear his airway

- Monitor the patient’s cardiac and respiratory status

- Assess LOC for changes such as confusion, restlessness or decreased responsiveness

- Irrigate the wound with amounts of water or normal saline


solution for chemical burns

- Place the patient in semi-Fowler’s position to maximize chest expansion; keep patient as quiet and comfortable to minimize

oxygen demand

- Prepare the patient for an emergency escharotomy of the chest and neck for deep burns

- Administer rapid fluid replacement therapy as ordered

*For burn patient in shock

- Monitor VS and hemodynamic parameters

- Assess patient’s intake and output every hour, insert an indwelling cathether

- Assess the patient’s level of pain, including nonverbal indicators and administer analgesics such as Morphine Sulfate IV as ordered

- Keep the patient calm, provide periods of uninterrupted rest between procedures and use nonpharmacologic pain relief measures as appropriate

- Obtain daily weights and monitor intake, including daily calorie counts; provide high calorie, high protein diet

- Administer histamine 2 receptor antagonists as ordered to reduce risk of ulcer formation

- Assess the patient’s sign and symptoms of infection; may obtain wound culture and administer antimicrobials an antipyretics as ordered

- Administer tetanus prophylaxis if indicated

- Perform burn wound care as ordered; prepare patient for grafting as indicated

- Assess the neurovascular status of the injured area, including pulses, reflexes, paresthesia, color and temperature of the injured area at least 2 to 4 hours or more frequently as indicated

- Assist with splinting, positioning, compression therapy and exercise to the burned area as indicated; maintain the burned area in a neutral position to prevent contractures and minimize deformity

- Explain all procedures to the patient before performing them

Pharmacotherapy - Antibiotic prophylaxis will eradicate bacterial component

- Pain therapy

- Tetanus prophylaxis

- Topical antimicrobial

- Enzymatic debriding agents such as collagenase, fibrinolysin-desoxyribonuclease, papin or sutilins are used with a moisture barrier to protect surrounding tissue

- Recommended dressings include polyurethane films(Op-site, Tegaderm), absorbent hydrocolloid dressings (Duoderm)


Client Education - Environmental safety: use low temperature setting for hot water heater, ensure access to and adequate number of electrical cords/outlets, isolate household chemicals, avoid smoking inbed

- Use of household smoke detectors with emphasis on maintenance

- Proper storage and use of flammable substances

- Evacuation plan for family

- Care of burn at home

- Signs and symptoms of infection

- How to identify risk of skin changes

- Use of sunscreen to protect healing tissue and other protective skin care

Poisoning

Description - Substances that are harmful to humans that are inhaled, ingested (food, drug overdose) or acquired by contact

Etiology - Carbon monoxide inhalation

- Food poisoning

- Drug overdose

- Insecticide surface absorption

Pathophysiology - The pathophysiology of poisons depends on the substance that’s inhaled or ingested. The extent of damage depends on the pH of the substance, the amount ingested, its form and the length of exposure to it. Substances with an alkaline pH cause tissue damage by liquefaction necrosis, which softens the tissue. Acids produce coagulation necrosis. Coagulation necrosis denatures proteins when substance contacts tissue. This limits the extent of the injury by preventing penetration of the acid into the tissue.

- *The mechanism of action for inhalants is unknown, but they’re believed to act on the CNS similarly to a very potent anesthetic. Hydrocarbons sensitize the myocardial tissue and allow it to be sensitize to cathecolamines, resulting in arrhythmias


a. Carbon monoxide inhalation: mild exposure – nausea, vomiting, mild throbbing headache, flu-like symptoms; moderate exposure – dyspnea, dizziness, confusion, increased severity of mild symptoms; severe/prolonged exposure – seizures, coma, respiraotory arrest, hypotension and dysrhytmias

b. Food poisonings: nausea, vomiting, diarrhea, abdominal cramps, fever , chills, dehydration, headache

c. Drug overdose: depends upon the substance ingested; symptoms may include nausea, vomiting, CNS depression or agitation, altered pupil response, respiratory changes such as tachypnea or bradypnea, alterations in temperature control, seizures or cardiac arrest


d. Surface absorption of insecticides( organophosphates or carbamates): nausea, vomiting, diarrhea, headache, dizziness, weakness or tremors, mild to severe respiratory distress, slurred speech, seizures, and cardio-pulmonary arrest

Diagnostics *The diagnosis of many poisonings is based on a thorough client history and clinical manifestations

- laboratory toxicology screens (serum,vomitus, stool and urine) determine the extent of the absorption

- baseline blood work such as CBC, electrolytes, renal and hepatic studies enable future determination of organ and tissue damage

- Chest Xray may show aspiration pneumonia in inhalation poisoning

- Abdominal Xrays may reveal iron pills or other radiopaque substances

- ABG analysis used to evaluate oxygenation

Nursing Diagnoses - Risk for Ineffective Airway Clearance

- Risk For Decreased Cardiac Output




- Risk for Injury

- Anxiety

- Risk for Self-directed Violence

- Hopelessness

Nursing Management - Assist with the management of an effective airway, breathing pattern and circulatory status

- Give treatment of life-threatening dysrhythmias and conditions as ordered; continual monitoring of vital signs, cardiac rhythm and neurological status and supportive care is essential

- Assist in the hastening in the elimination of the medication or poison, decrease the amount of absorption and administer antidotes as ordered

- for specific treatment contact the poison center

Pharmacotherapy *antidotes will vary with medication ingested

- Ipecac syrup 30ml PO followed by 240ml water is used for adults

- Activated charcoal powder slurry 30 to 100g PO or per NG tube

- Magnesium Citrate will be used for GI evacuation

- Naloxone (Narcan) for respiratory depression caused by narcotic overdose

- Flumazanil (Romazicon) for benzodiazepine ingestions Client Education - Assist the client and family in seeking the appropriate referrals


and provide client education to further complications or incidence of overdose

- Ensure that the client and family understand discharge instruction for follow up care or reason for admission

Multiple Injuries

Description - Is a physical injury or wound that’s inflicted by an external or violent act; it may be intentional or unintentional; involve injuries to more than one body area or organ

Etiology - Weapons

- Automobile collision

- Physical confrontation

- Falls

- Unnatural occurrence to the body

*Type of trauma which determines the extent of injury

- Blunt trauma – leaves the body intact

- Penetrating trauma – disrupts the body surface

- Perforating trauma – leaves entrance and exit

Pathophysiology - A physical injury can create tissue damage caused by stress and strain on surrounding tissue which results to infection, pain , swelling and potential compartment syndrome or it can be life threatening if it affects a highly vascular or vital organ

Diagnostics - Chest Xray – detect rib and sterna fractures, pneumothorax, flail chest, pulmonary contusion and lacerated or ruptured aorta

- Angiography studies – performed with suspected aortic laceration or rupture

- Ct scan, cervical spine Xrays, skull Xrays, Angiogram – test for a patient with head trauma

- ABG analysis to evaluate respiratory status and determine acidotic and alkalotic states

- CBC to indicate the amount of blood loss

- Coagulation studies to evaluate clotting ability

- Serum electrolyte levels to indicate the presence of electrolyte imbalances

Nursing Diagnoses - Ineffective Airway Clearance


- Impaired Gas Exchange


- Decreased Cardiac Output



- Impaired Skin Integrity

- Risk for infection

- Anxiety

- Pain

- Disturbed Body Image

Nursing Management - Assess the patient’s ABCs and initiate emergency measures

- Administer supplemental oxygen as ordered

- Immobilize the patient’s head and neck with an immobilization device, sandbags, backboard and tape

- Assist with cervical Xrays

- Monitor VS and note significant changes

- Immobilize fractures

- Monitor the patient’s oxygen saturation and cardiac rhythm for arrhythmias

- Assess the patient’s neurologic status, including LOC and papillary and motor response

- Obtain blood studies, including type and crossmatch

- Insert large bore IV catheter and infuse normal saline or lactated Ringer’s solution

- Assess the patient for multiple injuries

- Assess the patient’s wounds and provide wound care as appropriate; cover open wounds and control bleeding by applying pressure and elevating extremities

- Assess for increased abdominal distention and increased diameter of extremities

- Administer blood products as appropriate

- Monitor the patient for signs of hypovolemic shock

- Provide pain medication as appropriate

- Provide reassurance to the patient and his family

Pharmacotherapy - Tetanus immunization

- Antibiotics for infection control

- Analgesics for pain

Client Education - Provide explanations of all procedures done

- Families usually require emotional support and honest discussions about therapeutic interventions and plans


Glossary of terms

1. Appropriate: Matching the circumstances of a situation or meeting the needs of the individual or group.

2. Assessment: A systematic procedure for collecting qualitative and quantitative data to describe progress and ascertain deviations from expected outcomes and achievements.

3. Attributes: Characteristics that underpin competent performance.

4. Benchmark: Essential standard

5. Client: An individual, family, group or community that is a consumer of nursing service.

6. Competence: The combination of skills, knowledge, attitudes, values and abilities that underpin effective performance as a nurse.

7. Competent: The person has competence across all domains of competencies applicable to the registered nurse, at a standard that is judged to appropriate for the level of nurse being assessed.

8. Competency: A defined area of skilled performance.

9. Context: The setting/environment where competence can be demonstrated or applied.

10. Domain: An organized cluster of competencies in nursing practice.

11. Effective: Having the intended outcome.

12. Enrolled nurse: A nurse registered under the enrolled nurse scope of practice.

13. Indicator: Key generic examples of competent performance. They are neither comprehensive nor exhaustive. They assist the assessor when using their professional judgment in assessing nursing practice. They further assist curriculum development.

14. Performance criteria: Descriptive statements that can be assessed and that reflect the intent of a competency in terms of performance, behaviour and circumstance.

15. Registered nurse: A nurse registered under the registered nurse scope of practice

16. Reliability: The extent to which a tool will function consistently in the same way with repeated use.

17. Validity: The extent to which a measurement tool measures what it purports to measure.


Pre – Test

CLINICAL COMPETENCE

DIRECTION: Circle the one best answer for each test question. Write your rationale for selecting the answer. To enhance your learning and test taking skill, discuss your answer and rationale with a partner.

A: Physical Examination 5 pts each (15 items)

1. The nurse is using a digital thermometer to take an oral temperature. After taking the oral temperature, the nurse obtains a reading of 94.2 degree F. Which of the follow-up actions is most appropriate for the nurse to do?

a. Use another digital thermometer to retake the temperature

b. Feel the client’s skin temperature

c. Take a rectal temperature

d. Document the findings

Rationale for your selection:____________________________________________________________________________________________________________________

2. The nurse obtains an axillary temperature of 97.4 degree F on a client. In graphing the temperature, it is most appropriate for the nurse to:

a. Write “see nurse’s notes” above the temperature reading

b. Identify the temperature reading with an “Ax”

c. Graph the oral equivalent temperature of 98.4 degree F

d. Just graph 97.4 degree F on the form

Rationale for your selection:_________________________________________________________________________________________________________________________

3. The nurse is caring for a client who has an oral temperature of 99.6 degree F at 8:00AM, the start of the day shift. The client’s RAND indicates that the vital signs sould be taken once a shift. In planning care for the client, which action is most appropriate?

a. Ensure that the temperature is taken promptly at 4:00PM

b. Call the doctor for a more frequent order.

c. Take the temperature as necessary

d. Begin cooling measures

Rationale for your selection______________________________________________________________________________


KEY ANSWER:

1. The nurse is using a digital thermometer to take an oral temperature. After taking the oral temperature, the nurse obtains a reading of 94.2 degree F. Which of the follow-up actions is most appropriate for the nurse to do?

a. Use another digital thermometer to retake the temperature

b. Feel the client’s skin temperature

c. Take a rectal temperature

d. Document the findings

Rationale : A is the answer. Since the nurse is using a digital thermometer, it is important for the nurse to ensure that the equipment is functioning. The temperature recording should be low and should be taken again. Option B & C are not appropriate: option D should be done after verifying the temperature.

2. The nurse obtains an axillary temperature of 97.4 degree F on a client. In graphing the temperature, it is most appropriate for the nurse to:

a. Write “see nurse’s notes” above the temperature reading

b. Identify the temperature reading with an “Ax”

c. Graph the oral equivalent temperature of 98.4 degree F

d. Just graph 97.4 degree F on the form

Rationale: B is the answer. It is important for the nurse to identify the appropriate information on where the temperature was taken. Option A,C,& D do not accurately document the temperature information.

3. The nurse is caring for a client who has an oral temperature of 99.6 degree F at 8:00AM, the start of the day shift. The client’s RAND indicates that the vital signs sould be taken once a shift. In planning care for the client, which action is most appropriate?

a. Ensure that the temperature is taken promptly at 4:00PM

b. Call the doctor for a more frequent order.

c. Take the temperature as necessary

d. Begin cooling measures

Rationale: C is the answer. The nurse can make an independent decision to take the temperature more frequently to ensure safe nursing care. Option A does not allow for through ongoing assessment. Option B & D are not necessary at this time.


Lesson A.1

CORE COMPETENCIES

“Tell me, I might forget;

Teach me and I might remember;

Involve me and I learn!”

-Benjamin Franklin

Definition:

A competency appraisal is a process in which an individual is assessed for his or her competence in a particular area of employment. The main objective of the competency appraisal is to ascertain whether an employee is able to carry out his or her duties in a professional role. A typical scenario would involve an employee — the person being assessed for competence — and one or more of his or her seniors. It normally would take place in a private location, such as an unused office. The duration of a competency appraisal depends on the nature of the appraisal; the actual meeting between the senior professional and the employee typically lasts one to two hours.

Legal Basis:

Article 3 Sec.9 (c) of R.A. 9173/ “Philippine Nursing Act 2002"

Board shall monitor & enforce quality standards of nursing practice necessary to ensure the maintenance of efficient, ethical and technical, moral and professional standards in the practice of nursing taking into account the health needs of the nation.

SIGNIFICANCE OF CORE COMPETENCY STANDARDS

There are certain professions in which a competency appraisal is of critical importance, such as medical professions in which human safety is an essential priority. If patients are exposed to incompetent medical practitioners, this could be a potential threat to the patient's health and safety. In developed nations, competency appraisal in the medical professional is highly prevalent as it is considered to be absolutely necessary; medical practitioners, particularly in their first years of practice, are monitored closely by senior medical professionals.

Unifying framework for nursing practice, education, regulation

Guide in nursing curriculum development

Framework in developing test syllabus for nursing profession entrants

Tool for nurses’ performance evaluation

Basis for advanced nursing practice, specialization

Framework for developing nursing training curriculum

Public protection from incompetent practitioners

Yardstick for unethical, unprofessional nursing practice


Phases of developing competency standards

○ 1st Phase

Competency identification through Developing a Curriculum (DACUM) workshop and series of focus group discussions with the participation of nurse experts and consumers of nursing practice such as administrators, doctors and clients

○ 2nd PhaseVerification of identified competencies among nursing experts from the different regions of the country

○ 3rd PhasePilot testing ( senior student in 8 nursing colleges)

○ 4th PhaseBenchmarking with exiting standards from 3 countries as well as International Council for Nurses (ICN)

FOUR DOMAINS OF COMPETENCIES

There are four domains of competence for the registered nurse scope of practice. Evidence of safety to practise as a registered nurse is demonstrated when the applicant meets the competencies within the following domains:

Domain one: Professional responsibility

This domain contains competencies that relate to professional, legal and ethical responsibilities and cultural safety.

These include being able to demonstrate knowledge and judgment and being accountable for own actions and decisions, while promoting an environment that maximizes clients’ safety, independence, quality of life and health.

Domain two: Management of nursing care

This domain contains competencies related to client assessment and managing client care, which is responsive to clients’ needs, and which is supported by nursing knowledge and evidence based research.

Domain three: Interpersonal relationships

This domain contains competencies related to interpersonal and therapeutic communication with clients, other nursing staff and interprofessional communication and documentation.

Domain four: Interprofessional health care & quality improvement

This domain contains competencies to demonstrate that, as a member of the health care team, the nurse evaluates the effectiveness of care and of the team.

Competencies and Indicators

The competencies in each domain have a number of key generic examples of competence performance called indicators.

These are neither comprehensive nor exhaustive; rather they provide examples of evidence of competence.


The indicators are designed to assist the assessor when using his/her professional judgment in assessing the attainment of the competencies.

The indicators further assist curriculum development for bachelors’ degrees in nursing or first year of practice programmes.

Registered nurses are required to demonstrate competence. They are accountable for their actions and take responsibility for the direction of nurse assistants, enrolled nurses and others. The competencies have been designed to be applied to registered nurse practice in a variety of clinical contexts. They take into account the contemporary role of the registered nurse, who utilizes nursing knowledge and complex nursing judgment to assess health needs, provide care, and advise and support people to manage their health. The registered nurse practices independently and in collaboration with other health professionals. The registered nurse performs general nursing functions, and delegates to, and directs enrolled nurses and nurse assistants.

The registered nurse also provides comprehensive nursing assessments to develop, implement, and evaluate an integrated plan of health care, and provides nursing interventions that require substantial scientific and professional knowledge and skills. This occurs in a range of settings in partnership with individuals, families, and communities.

Nursing students are supervised in practice by a registered nurse. Nursing students are assessed against all competencies on an ongoing basis, and will be assessed for entry to the registered nurse scope of practice at the completion of their program.

Nurses involved in management, education, policy and research

The competencies also reflect the scope statement that some registered nurses use their nursing expertise to manage, teach, evaluate and research nursing practice. Registered nurses, who are not practicing in direct client care, are exempt from those competencies in domain two (management of nursing care) and domain three (interpersonal relationships) that only apply to clinical practice. There are specific competencies in these domains for nurses working in management, education, policy and/or research. These are included at the end of domains two and three. Nurses who are assessed against these specific competencies are required to demonstrate how they contribute to practice.

Those practicing in direct client care and in management, education, policy and/or research must meet both sets of competencies.

Concepts and Definitions of 11 Key areas of Responsibility

I. SAFE AND QUALITY NURSING CARE

CORE COMPETENCY 1:Demonstrate knowledge based on health/illness status of individual/ groups

Indicators :○ Identifies health needs of patients/groups○ Explains patient/group status

CORE COMPETENCY 2:Provides sound decision making in care of individual/groups considering their beliefs, values

Indicators :○ Problem identification○ Data gathering related to problem○ Data analysis○ Selection appropriate action○ Monitor progress of action taken


CORE COMPETENCY 3:Promotes patient safety and comfort

Indicators :○ Performs age-specific safety measures and comfort measure in all aspects of patient care

CORE COMPETENCY 4:Priority setting in nursing care based on patients’ needs

Indicators :○ Identifies priority needs of patients○ Analysis of patients’ needs○ Determine appropriate nursing care to be provided

CORE COMPETENCY 5:Ensures continuity of care

Indicators :○ Refers identified problems to appropriate individuals/ agencies○ Establish means of providing continuous patient care

CORE COMPETENCY 6:Administers medications and other health therapeutics

Indicators :○ Conforms to the 10 golden rules in medication administration and health therapeutics

CORE COMPETENCY 7:Utilizes nursing process as framework for nursing. Performs comprehensive, systematic nursing assessment

Indicators :○ Obtains consent○ Complete appropriate assessment forms○ Performs effective assessment techniques○ Obtains comprehensive client information○ Maintains privacy and confidentiality○ Identifies health needs

CORE COMPETENCY 8:Formulates care plan in collaboration with patients, other health team members

Indicators :○ Includes patients, family in care planning○ States expected outcomes in nursing interventions○ Develops comprehensive patient care plan○ Accomplishes patient centered discharge plan

CORE COMPETENCY 9:Implements NCP to achieve identified outcomes

Indicators :○ Explain interventions to patient, family before carrying them out○ Implement safe, comfortable nursing interventions○ Acts according to client’s health conditions, needs○ Performs nursing interventions effectively and in timely manner

CORE COMPETENCY 10:


Implements NCP progress toward expected outcomes

Indicators :○ Monitors effectiveness of nursing interventions○ Revises care plan PRN

CORE COMPETENCY 11:Responds to urgency of patient’s condition

Indicators :○ Identifies sudden changes in patient’s health conditions○ Implements immediate, appropriate interventions

II. MANAGEMENT OF RESOURCES AND ENVIRONMENT

CORE COMPETENCY 1:Organizes workload to facilitate patient care

Indicators:○ Identifies task or activities that need to be accomplished○ Plans the performance of task or activities based on priority○ Finishes work assignment on time

CORE COMPETENCY 2:Utilizes resources to support patient care

Indicators:○ Determines the resources needed to deliver patient care○ Control the use of equipment

CORE COMPETENCY 3:Ensures the functioning of resources

Indicators:○ Check proper functioning of the equipment○ Refers Malfunctioning equipment to appropriate unit

CORE COMPETENCY 4:Check the Proper functioning of the Equipment

Indicators:○ Determines the task and procedures that can be safely assigned to the other members of the team○ Verifies the competence of the staff prior to delegating tasks

CORE COMPETENCY 5:Maintains safe Environment

Indicators:○ Observe proper disposal of waste○ Adheres to policies, procedures and protocols on prevention and control of infection○ Defines steps to follow incase of fire , earthquake and other emergency situation

III. HEALTH EDUCATION


CORE COMPETENCY 1:Assesses the learning needs of the patient and the family

Indicators:○ Obtains learning information through interview, observation and validation○ Defines relevant information○ Completes assessment records appropriately○ Identify priority needs

CORE COMPETENCY 2:Develops Health Education plan based on assessed and anticipated needs.

Indicators:○ Considers nature of the learner in relation to social, cultural, political, economic, educational, and religious factor

CORE COMPETENCY 3:Develops learning material for health education

Indicators:○ Involves the patient, family and significant others and other resources○ Formulates a comprehensive health educational plan with the following components , objectives, content and time allotment○ Teaching-learning resources and evaluation parameters○ Provides for feedback to finalize plan

CORE COMPETENCY 4:Implements the health Education Plan

Indicators:○ Provides for conducive learning situation in terms of timer and place ○ Considers client and family preparedness○ Utilize appropriate strategies○ Provides reassuring presence through active listening, touch and facial expression and gestures○ Monitors client and family’s responses to health education

CORE COMPETENCY 5:Evaluates the outcome of health Education

Indicators:○ Utilizes evaluation parameters○ Documents outcome of care○ Revises health education plan when necessary

IV. ETHICO-MORAL RESPONSIBILITY

CORE COMPETENCY 1:Respects the rights of individual/ groups

Indicator:○ Renders nursing care consistent with the patient’s bill of rights (ie. confidentiality of information, privacy, etc.)

CORE COMPETENCY 2Accepts responsibility & accountability for own decisions and actions

Indicators:


○ Meets nursing accountability requirements as embodied in the job description○ Justifies basis for nursing actions and judgment○ Protects a positive image of the profession

CORE COMPETENCY 3Adheres to the national and international code of ethics for nurses

Indicators:○ Adheres to the Code of Ethics for Nurses and abides by its provisions○ Reports unethical and immoral incidents to proper authorities

V. LEGAL RESPONSIBILITY

CORE COMPETENCY 1:Adheres to practices in accordance with the nursing law and other relevant legislation including contract and informed consent.

Indicators:○ Fulfill legal requirements in Nursing Practice ○ Holds current professional license○ Acts in accordance with the terms of contract of employment and other rules and regulation○ Complies with the required CPE○ Confirms information given by the doctor for informed consent ○ Secures waiver of responsibility for refusal to undergo treatment or procedures○ Check the completeness of informed consent and other legal forms

CORE COMPETENCY 2:Adheres to organizational policies and procedures, local and national

Indicators:○ Articulates the vision and mission of the institution where one belongs○ Acts in accordance with the established norms and conduct of the institution/ organization

CORE COMPETENCY 3:Document care rendered to patients.

Indicators:○ Utilizes appropriate patient care records and reports○ Accomplish accurate documentation in all matters concerning patient care in accordance with the standard of nursing practice.

VI. PERSONAL & PROFESSIONAL DEVELOPMENT

CORE COMPETENCY 1Identifies own learning needs

Indicators:○ Verbalizes strengths, weaknesses, limitations.○ Determines personal and professional goals and aspirations.

CORE COMPETENCY 2Pursues continuing education

Indicators:○ Participates in formal and non-formal education.○ Applies learned information for the improvement of care.


CORE COMPETENCY 3Gets involved in professional organizations and civic activities

Indicators:○ Participates actively in professional, social, civic and religious activities○ Maintain membership to professional organizations○ Support activities related to nursing and health issues

CORE COMPETENCY 4Projects a professional image of nurse

Indicators:○ Demonstrate good manners and right conduct at all times.○ Dresses appropriately.○ Demonstrates congruence of words and actions.○ Behaves appropriately at all times.

CORE COMPETENCY 5Possesses positive attitude towards change and criticism Indicators:○ Listens to suggestions and recommendations.○ Tries new strategies or approaches.○ Adapts to changes willingly.

CORE COMPETENCY 6Performs function according to professional standards

Indicators:○ Assesses own performance against standards of practice.○ Sets attainable objectives to enhance nursing knowledge and skills.○ Explains current nursing practices, when situations call for it.

VII. RESEARCH

CORE COMPETENCY 1:

Gathers data using different methodologies

Indicators:Identifies researchable problems regarding patient care and community healthIdentifies appropriate methods of research for a particular patient/community problemCombines quantitative and qualitative nursing design thru simple explanation on the phenomena observedAnalyzes data gathered

CORE COMPETENCY 2:Recommends actions for implementation

Indicator:Based on the analysis of data gathered, recommends practical solutions appropriate for the problem

CORE COMPETENCY 3:Disseminates results of research findings

Indicators:Communicates results of findings to colleagues/patients/family and to others


Endeavors to publish researchSubmits research findings to own agencies and others as appropriate

CORE COMPETENCY 4:Applies research findings in nursing practice

Indicators:Utilizes and findings in research in the provision of nursing care to individuals/groups/communitiesMakes use of evidence-based nursing to ameliorate nursing practice

VIII. RECORDS MANAGEMENT

CORE COMPETENCY 1:Maintains accurate and updated documentation of patient care

Indicator:Completes updated documentation of patient care

CORE COMPETENCY 2:Records outcome of patient care

Indicator:Utilizes a record system

CORE COMPETENCY 3:Observes legal imperatives in recording keeping

Indicators:Observes confidentially and privacy of patient’s recordsMaintains an organized system of filing and keeping patient’s records in a designated areaRefrains from releasing records and other information without proper authority

IX. COMMUNICATION

CORE COMPETENCY 1:Establishes rapport with patients, significant others and members of the health team.

Indicators:○ Creates trust and confidence○ Listens attentively to client’s queries and requests○ Spends time with the client to facilitate conversation that allows client to express concern.

CORE COMPETENCY 2:Identifies verbal and non-verbal cues

Indicator:○ Interprets and validates client’s body language and facial expression

CORE COMPETENCY 3:Utilizes formal and informal channels

Indicator:○ Makes use of available visual aids

CORE COMPETENCY 4:


Responds to needs of individuals, family, group and community

Indicator:○ Provides reassurance through therapeutic, touch, warmth and comforting words of encouragement○ Readily smiles

CORE COMPETENCY 5:Uses appropriate information technology to facilitate communication

Indicator:○ Utilizes telephone, mobile phone, email and internet, and informatics○ Identifies a significant other so that follow up care can be obtained○ Provides “holding” or emergency numbers of services

X. COLLABORATION and TEAMWORK

CORE COMPETENCY 1:Establishes collaborative relationship with colleagues and other members of the health team

Indicators:○ Contributes to decision making regarding patients” needs and concerns○ Participates actively in patients care management including audit○ Recommends appropriate intervention to improve patient care○ Respects the role of the other members of the health team○ Maintains good interpersonal relationships with patients, colleagues and other members of the health team

CORE COMPETENCY 2:Collaborates plan of care with other members of the health team

Indicator: ○ Refers patients to allied health team partners○ Acts liaison / advocate of the patients○ Prepares accurate documentation of efficient communication of services

XI. QUALITY IMPROVEMENT

CORE COMPETENCY 1:Gathers data for quality improvement

Indicators:Demonstrates knowledge of method appropriate for the clinical problems identifiedDetects variation in the vital signs of the patient from day to dayReports necessary elements at the bedside to improve patient stay at hospitalSolicits feedback from patient and significant others regarding care rendered

CORE COMPETENCY 2:Participates in nursing audits and rounds

Indicators:Contributes relevant information about patient condition as well as unit condition and patient current reactionsShares with the team current information regarding particular patients conditionEncourages the patient to speak about what is relevant to his conditionDocuments and records all nursing care and actionsPerforms daily check of patient records/conditionCompletes patients recordsActively contributes relevant information of patients during rounds thru readings and sharing


with others

CORE COMPETENCY 3:Identifies and reports variances

Indicators:Documents observed variance regarding patient care and submits to appropriate group within 24 hoursIdentifies actual and potential variance to patient careReports actual and potential variance to patient careSubmits report to appropriate groups within 24 hours

CORE COMPETENCY 4:Recommends solutions to identified problems

Indicators:Gives appropriate suggestions on corrective and preventive measuresCommunicates and discusses with appropriate groupsGives and objective and accurate report on what was observed rather than an interpretation of the event.


LesssonB.1

APPLICATION OF CORE COMPETENCY IN NURSING PRACTICE

PRE TEST 2

ASSESSMENT OF INDIVIDUAL PATIENT NEEDS FOR NURSING

INSTRUCTIONS: Circle the one best answer for each test question. Write your rationale for selecting the answer. To enhance your learning and test taking skill, discuss your answer and rationale with a partner.

1. The nurse is preparing to assess neuro status of an adult client who had hip fracture 5 days ago and was reported to have experienced confusion the previous shift. Which statement will provide the nurse with the most appropriate information?

a. “Can you tell me today’s date?”

b. “Do you know that you are in the hospital?”

c. “When did you have hip surgery?”

d. “What is your name?”

Rationale:_________________________________________________

2. The nurse is informed that the newly admitted client is complaining of itching and has a rash all over the body. The most appropriate nursing intervention initially is to:

a. Inform the doctor of the objective and subjective complaints

b. Inspect the client and describe the rash

c. Ask the client to try not to scratch the areas

d. Check the medication record for anti-itch medication

Rationale:____________________________________________________

3. The nurse is assigned to a client who was admitted for a blood clot in the right leg. Which of the following describes the appropriate assessment technique initially?

a. Inspection of the right leg

b. Light palpation of the right leg

c. Inspection followed by deep palpation of edematous areas

d. Light palpation followed by inspection of any reddened areas.

Rationale:____________________________________________________


Key answers

1. The nurse is preparing to assess neuro status of an adult client who had hip fracture 5 days ago and was reported to have experienced confusion the previous shift. Which statement will provide the nurse with the most appropriate information?

a. “Can you tell me today’s date?”

b. “Do you know that you are in the hospital?”

c. “When did you have hip surgery?”

d. “What is your name?”

Rationale: Eliciting orientation to person is part of assessing client orientation. Options A & B encourages yes or no response, and option c may not give accurate data if the client does not remember the date.

2. The nurse is informed that the newly admitted client is complaining of itching and has a rash all over the body. The most appropriate nursing intervention initially is to:

a. Inform the doctor of the objective and subjective complaints

b. Inspect the client and describe the rash

c. Ask the client to try not to scratch the areas

d. Check the medication record for anti-itch medication

Rationale:it is most appropriate for the nurse to initially gather data by using the assessment skill of inspection and then to further describe the observations. Options A,C, & D are follw-up nursing interventions.

3. The nurse is assigned to a client who was admitted for a blood clot in the right leg. Which of the following describes the appropriate assessment technique initially?

a. Inspection of the right leg

b. Light palpation of the right leg

c. Inspection followed by deep palpation of edematous areas

d. Light palpation followed by inspection of any reddened areas.

Rationale: Inspection is the initial step in the assessment process that provides information on color, size, shape and movement of the extremity. Options B and D are not appropriate initially and option C should not be done in this situation.


Lesson B.1

APPLICATION OF CORE COMPETENCY IN NURSING PRACTICE INTEGRATING NURSING PROCESS

INTRODUCTION:

Stressing the point that the entire plan of care depends on the accuracy and completeness of Assessment, this section examines how to do an assessment in a way that facilitates the next step, Diagnosis. It addresses characteristics of an assessment that promotes critical thinking and competency indicators that relate to assessment. Finally it gives the tips for interviewing and examining patients and explains the how to’s and the why’s of the six phases of assessment.

EXPECTED LEARNING OUTCOMES

After studying the content of this section, the students should be able to:

1. Describe the five characteristics of an assessment that promotes competency, and explain how the phases of Assessment described in this section promote critical thinking.

2. Explain how the interview and physical assessment complement and clarify each other.

3. Give an example of an open-ended question, a closed ended question, a leading question and an exploratory statement.

4. Differentiate between cues and inferences

5. Explain why organizing data more than one way promotes competence and critical thinking.

ASSESSMENT OF INDIVIDUAL PATIENT NEEDS FOR NURSING

ANA STANDARD

The nurse collects comprehensive data pertinent to the patient’s health situation (ANA, 2004)

SIX PHASES OF ASSESSMENT

1. Collecting of data- gathering data (information) about health status

2. Identifying cues and making inferences- recognizing significant data and drawing some beginning conclusions about what the data may indicate.

3. Validating the data- double checking to make sure that your data are accurate and complete.

4. Clustering the data- organizing or grouping related pieces of information to help you identify patterns of health or illness (eg, Clustering data about nutrition together, the data about rest together and so forth)

5. Identifying patterns/ testing first impressions- looking for the patterns and focusing your assessment to gain more information to better understand the situations at hand. For example, you suspect that someone’s data shows a pattern of poor nutrition and decide to find out what’s contributing to this pattern( does the person have poor eating habits or could it be something else, such as not having enough money to eat well?)

6. Reporting and recording data- Reporting significant data (eg. High fever) and charting on the patient’s record.


CHARACTERISTICS OF AN ASSESSMENT THAT PROMOTES COMPETENCY

1. PURPOSEFUL

To promote Critical thinking, your approach to assessment must change, depending on your purpose and the circumstances(c0ntext) of your patient situation.

For example:

Are you aiming to assess all aspects of care, or are you monitoring one specific problem?

Are your assessing a hospitalized patient or someone in the home?

Is the person an adult or a child?

NOTE: Your aim is to gain all the information needed to ensure that your patients have individualized plans that are designed to help them achieve outcomes in the best way possible, in context of their particular situation (eg, their age, culture, and level of independence)

2. FOCUSED AND RELEVANT

Your assessment must be focused to gain relevant information, depending on purpose and context as above.

For example:

Physician’s Data: (Disease focus)

“ Mrs. Garcia has pain and swelling in all joints. Diagnostic studies indicates that she has rheumatoid arthritis. We will start her on a course of anti inflammatory drugs to treat the rheumatoid arthritis.” (focus on the treatment modalities)

Nurse’s Data: (holistic focus, considering both problems and their effect on the person’s ability to function independently)

“Mrs. Garcia has pain and swelling in all joints, making it difficult to feed and dress herself. She has voiced that it’s difficult to feel worthwhile when she can’t feed herself. She states that she is depressed because she misses seeing her two small grandchildren. We need to to develop a plan to help her with her pain, to assist her with feeding and dressing, to work through feelings of self-esteem, and for special visitations with the grandchildren.” ( Focus is on Mrs. Garcia)

3. SYSTEMATIC

Developing a systematic approach to assessment helps you pay attention to what is important, learn how to prioritize, be comprehensive, and avoid omission errors.

For example:

What are your symptoms?

Can you point out with one finger to the areas that are bothering you?

When did they start?

What makes them better?

What makes them worse?

Are you taking any medications- prescribed, over-the-counter, or herbal remedies- that may be causing some of these symptoms?

Can you think of anything else that might be contributing to your symptoms?

4. COMPREHENSIVE AND ACCURATE


The most common error that happens in critical thinking is identifying problems or making judgments based on sufficient or incorrect information. Your information must be factual, and as complete as is warranted by your purpose.

For example:

An assessment aims to get information about one specific problem is shorter than one that aims to get comprehensive data about all aspects of care.

DISPLAY B.1.1:

How to ensure Comprehensive Data Collection

Comprehensive data collection often occurs in three phases:

1. Before you see the person: You find what you can. This information may be limited( only name and age) or extensive ( medical records may be available for you to read)

2. When you see the person: You interview the person and do Physical Examination (PE).

3. After you see the person: You review the resources(consumer like patient, family and community, significant others, nursing and medical records, verbal and written consultations, diagnostic and laboratory results) you used and determines what other resources may offer additional information (e.g. You may consult a pharmacist to gain more information about a medication regimen)

Comprehensive Data Collection have several factors:

1. The purpose of the assessment- example is when you do data base(start of care) assessment or a focus assessment

Data base assessment- Comprehensive information gathered on initial contact with the person to assess all aspect of health status

Focus Assessment- Data gathered to determine the status of a specific condition like someone’s bowel habits

2. The needs and problems commonly encountered in a particular clinical setting.

For example: An adult assessment tool is different from a newborn assessment tool.

3. Standards of care for the assessment as defined by regulatory agencies and professional associations

For example: Maternal and Child Nursing Association of the Philippines/ MCNAP, Operating Room Nurses association of the Philippines/ORNAP, Philippine Nurses Association/PNA etc.

4. The nursing model or theory adopted by the school or facilities

For example: Gordon’s Functional Health Patterns or Orem’s Self Care theory.

5. RECORDED IN A STANDARDIZED WAY

Like pilots who follow computerized or pre-printed checklists (instead of relying on memory), you must value the importance of completing a standardized tool that is designed to promote an assessment that is purposeful, relevant, systematic, and complete.

NOTE: You cannot rely your brain to do it all, even if you have years of experience


DISPLAY B.1.2:

Major Intellectual Skills & Critical Thinking Skills R/T Assessment (Behavior Evidence Suggesting Competence in Nursing Practice)

The competent nurse:

Applies standard and principles

Assesses systematically and comprehensively; uses a nursing framework to identify nursing concerns; uses a body systems framework to identify medical concerns

Detects bias; determines credibility of information sources

Distinguishes normal from abnormal; identifies risks for abnormal

Determines significance of data; distinguishes relevant from irrelevant clusters relevant data together

Identifies assumptions and inconsistencies; checks accuracy and reliability ; recognizes missing information; focuses assessment as indicated

Communicates effectively orally and in writing

Establishes empowered partnerships with patients, families, peers, and co workers

Sets priorities and make decisions in a timely way; includes key stakeholders in making decisions

Weigh risks and benefits

Identifies ethical issues and take appropriate action

Identifies and uses technologic, information, and human resources

Address conflicts fairly, fosters positive interpersonal relationships

Facilitates and navigates change

Organize and manages time and environment

Facilitates teamwork ( focuses on common goals; helps and encourages others to contribute in their own way)

Demonstrates systems thinking (shows awareness of the interrelationships existing within and across health care systems)

IDENTIFYING CUES AND MAKING INFERENCES


Who guards the patient?

“Safety lies at the crux of the care we deliver. And yet we all know that there are so many factors that affect patient safety- from communication snafus through systems design problems and through inadequate staffing- at the minimum. Nurses are in pivotal roles within health care settings because they coordinate, implement and evaluate the patient care that is administered by the entire team on an ongoing basis”

- Rebecca B. Rice, RN, EdD, MPH

-

Identifying subjective and objective data both aids in critical thinking and competence because each complements and clarifies the other.

For example:

Subjective data: States, “ I feel like my heart is racing.”

Objective data: Right radial pulse 150 beats per minute, regular, and strong.

The preceding objective data support the subjective data- what you observe confirms what the person is stating.

Sometimes, what you observe and what the person states are different.

For example:

Subjective data: States, “I feel fine.”

Objective data: Color pale, becomes easily short of breath.

Above, what the person states isn’t supported by what you observe. You need to investigate then further to understand fully the scope of the problems.

The subjective and objective data you identified acts as cues. Cues are data that prompt you to get a beginning impression of patterns of health or illness.

For example:

Subjective data: “I started taking penicillin for a tooth abscess.

Objective data: Fine rash over the trunk.

The above gives you cues that may lead you to infer (suspect) that there is an allergic reaction to penicillin. How you interpret or perceive a cue- the conclusion you draw about the rash: you decide that rash may indicate a penicillin allergy.

Your ability to identify cues and make correct inferences is influenced by your observational skills, your nursing knowledge, and your clinical expertise. Your values and beliefs also affect how you interpret some cues, so make an effort to avoid making value judgments ( for example, inferring that a person who bathes only once a week needs to be taught better hygiene when the practice may be a part of his culture.

GENERAL RULE:


Display B.1.3

Examples of cues and inferences

CUES INFERENCES

“I have trouble moving my bowels.” May be constipated

“I don’t want to talk” May be depressed or angry

BP 60/50 The person is in shock

“I cannot stand this pain anymore” The person is experiencing unbearable pain.

* ** Factual, relevant, and comprehensive assessment is the key to accurate diagnosis (problem and risk identification) and to developing a plan that is safe, effective, efficient, and individualized.

1. Establishes rapport and trust with the patient, family and significant others.

Quality Indicators:

a. Welcomes the patient, family and significant others upon admission.

b. Greets patient by name, introduces self and co- staff

c. Encourages verbalization of needs and feelings through attentive listening.

d. Conveys availability and willingness to help by attending to needs at the soonest time possible.

2. Obtain a nursing history and document an initial physical examination through application of the general principles of and follows a logical sequence in history taking and physical examination.

3. Recognizes normal and abnormal findings from common laboratory and diagnostic examination results. As indicated by comparing results from standard listing of normal values/ results of common laboratory and diagnostic examination.

4. Defines health needs and problems from data gathered by identifying the significant findings from the accurate nursing history, PE and laboratory/diagnostic results.


CLASSROOM ACTIVITY 1

The Nursing Interview and Physical Assessment

Instructions:

Divide the class into 4 groups. Each group is entitled to answer task Part 1 and Part 2. Presentation should be in a clinical setting and is limited to 15 minutes only.

Part 1: Interviewing

1. Practice asking open-ended questions. Restate each question below so it’s an open ended question.

a. Are you feeling better?

b. Did you like dinner?

c. Are your happy here?

d. Are you having pain?

2. Practice clarifying ideas by using reflection(restating what you hear) and making an open-ended questions. For each statement below, write a reflective statement and an open-ended question that would help you to clarify what has been said.

a. “I’ve been sick off and on for a month.”

b. “Nothing ever goes right for me.”

c. “I seem to have a pain in my side that comes and goes.”

d. “I’ve had this funny feeling for a week.”

Part 2: Physical Assessment

1. Because physical assessment and interviewing go hand in hand, use the following situations to practice focusing you interview questions on areas of concern noted during the PE

a. You examine and find: The patient’s hands and fingernails are filthy with ground-in dirt, although the rest of him is clean. What will you say next?

b. You examine and find: The patient has a lump on the back of his head. What will you say next?

c. You examine and find: The patient’s RR is 40. What will you say next?

d. You examine and find: The patient’s right eye is red, teary, and inflamed. What will you say next?

2. Now practice focusing your PE on areas of concern voiced by the patient

a. Patient states: “I have had a rash that comes and goes.” What will you reply and examine?

b. Patient states:”My stomach has been hurting me,” What will you reply and examine?

c. Patient states:” I find it burns when I urinate,” What will you reply and examine?

d. Patient states: “I feel like I’m heavier than usual, like I’m bloated with fluid,” What will reply and examine?

Example Responses to Activity 1 Acute Biologic Crisis By: Raidis L. Dela Cruz,RN,MAN

Part 1: Interviewing

1. Practice asking open-ended questions. Restate each question below so it’s an open ended question.

a. Are you feeling better? Tell me how you’re feeling

b. Did you like dinner? How was your dinner?

c. Are your happy here? How do you feel about being here?

d. Are you having pain? Describe what you are feeling; tell me how you’re feeling.

2. Practice clarifying ideas by using reflection(restating what you hear) and making an open-ended questions. For each statement below, write a reflective statement and an open-ended question that would help you to clarify what has been said.

a. “I’ve been sick off and on for a month.”So, you’ve been sick off and for a month. What do you mean by sick off and on?

b. “Nothing ever goes right for me.”You feel like nothing ever goes right for you. What is been happening?

c. “I seem to have a pain in my side that comes and goes.” You have pain in your side that comes and goes- can you explain more?

d. “I’ve had this funny feeling for a week.” You’ve had a funny feeling for a week. What do you mean by funny?

Part 2: Physical Assessment

1. Because physical assessment and interviewing go hand in hand, use the following situations to practice focusing you interview questions on areas of concern noted during the PE

a. You examine and find: The patient’s hands and fingernails are filthy with ground-in dirt, although the rest of him is clean. What will you say next?

You have a lot of ground- in dirt here. What is it from?

b. You examine and find: The patient has a lump on the back of his head. What will you say next?

I feel a lump on the back of your head. How did it happen? Does it hurt when I touch it?

c. You examine and find: The patient’s RR is 40. What will you say next?

Your breathing is a little fast. How do you feel?

d. You examine and find: The patient’s right eye is red, teary, and inflamed. What will you say next?

Your eyes seem inflamed. How does it feel?

2. Now practice focusing your PE on areas of concern voiced by the patient

a. Patient states: “I have had a rash that comes and goes.” What will you reply and examine?

Show me where (and examine that area). Is there anything you think causes it?


b. Patient states:”My stomach has been hurting me,” What will you reply and examine?

Show me where (and examine that area). Tell me more how it feels.

c. Patient states:” I find it burns when I urinate,” What will you reply and examine?

That is a common symptom of infection. Let us get a urine sample( and examine it)

d. Patient states: “I feel like I’m heavier than usual, like I’m bloated with fluid,” What will reply and examine?

Where do you feel this bloating? Your stomach? Ankles? Where? Examine the areas


Lesson B.2

Health Promotion: Screening for Prevention and Early Diagnosis

Depending on where you work, your assessments may include helping with screening for prevention and early diagnosis of common health problems.

Usually screening is done at significant points during the life cycle.

For example:

Assessing infant development using standardized scales

Measuring height, weight, and vision in school aged children

Assessing for problem drinking and depression beginning in adolescence.

Measuring cholesterol and fecal occult blood in adults

To meet the goals of healthy people. Which aims to increase the length and quality of life of all people, all health care providers are encouraged to record health promotion counseling that occurs during all important interactions.

A key part of assessment is helping patients make informed and joint decisions about what screening and prevention measures they should follow.

The length of discussions about screening for health problems and use of medication to prevent diseases varies according to:

a. The scientific evidence addressing how useful the service is.

b. The health, preference, and concerns of each patient

c. The decision making style of each clinician

d. Practical constraints, such as the amount of time available

NOTE:

A decision can be considered informed and mutually decided only if patients:

1. Understand the risk or seriousness of the disease or condition to be prevented.

2. Comprehend what the preventive service involves( including the risks, benefits, alternatives and uncertainties)

3. Have weighed their values regarding the potential harms and benefits associated with the service.

4. Have engaged in decision-making at level at which they want and feel comfortable (US Preventive Task Force 2004)

Display B.2.1

Recommended Screening for Health Promotion

The Department of Health must rigorously evaluate clinical research to assess the merits of preventive measures, including screening tests, counseling immunization and preventive medications.

Lesson C.1


Communication

Your ability to establish rapport, ask questions, listen, and observe is the key to establishing the positive nurse- patient relationship needed to build a therapeutic relationship. People seeking health care are in a very vulnerable position. They need to know that they’re in good hands and that their main concerns will be addressed. This is where you come in as nurses. Consider the following guidelines that can help you establish trust, positive attitude, and reduce anxiety.

Display C.1.1

Guidelines in Promoting a Caring Interaction/Communication

How to establish rapport

Before you go into the interview:

Get organized: When you know what you’re going to do, you’re more confident and able to focus on the person

Don’t rely on memory: Have a written or printed plan to guide the questions you’ll be asking. Some nurses use the nursing data base as a guide.

Plan enough time: The admission interview usually takes 30 minutes to 1 hour.

Ensure privacy: Make sure you have a quiet, private setting, free from interruptions or distractions.

Get focused: Take a minute to clear your mind of other concerns( other duties, worries about yourself). Say to yourself, Getting to know this person is most important thing I have to do right now.

Visualize yourself as being confident, warm and helpful: Seeing yourself in this light helps you to be confident, warm and helpful- your genuine interest comes through.

When you begin interview:

Give your name and position: (if the person can read, give it in writing). This sends the message that you accept responsibility and are willing to be accountable of your actions.

Verify the person’s name and ask what he or she would like to be called (eg. I have your name listed here as Michael Riles. Is that correct? What would you like us to call you?”). Using the preferred name helps the person to feel more relaxed and sends the message that you recognize that this person is an individual who has likes and dislikes. Most facilities require that you use two unique identifiers to identify the patient (eg, asking the person his name and also checking ID bracelets)

Briefly explain your purpose(eg, I’m here to do the admission interview to help us plan your nursing care.”).

During the interview:

Give the person your full attention. Avoid the impulse to become engrossed in your notes or in reading the assessment tool.


Don’t hurry: Rushing sends the message that you’re not interested in what the person has to say.

Sit down: This communicates that you’re willing to take your time.

How to listen

Be an empathetic listener

To listen empathetically

1. Eliminates thoughts about how you, yourself, see the situation.

2. Listen carefully for feelings, trying to identify with how the other person perceives his situation. Don’t allow yourself to think about how you feel or how you’re going to respond; think only about the content of what you’re hearing

3. Reflect on what you’ve been told, then rephrase the feelings you have heard.

4. Seek validation that you understood the message, content, and emotion correctly. Keep trying until you’re sure you understand.

5. Detach, come back to your own frame of reference, and separate yourself from the emotions involved.

DISPLAY C.1.2

TEN CARING BEHAVIORS

1. Monitoring patients closely and telling them you know you’re doing it.

Example: “I will be checking on you every 15 minutes”

2. Inspiring someone, or instilling hope and faith ( creating a vision of “can be”)

3. Showing patience, compassion, and willingness to persevere

4. Taking time, rather than hurrying through just to get things done.

5. 2

6. Offering companionship or presence

7. Helping someone stay in touch with positive aspects of his life.

8. Demonstrating thoughtfulness

9. Bending the rules when it really counts


Think about this

Caring means little to patients unless it is bundled with knowledge, skills and competence. Patients look for nurses who are knowledgeable, clinically competent, and willing to be vigilant in monitoring key aspects of their care. You can smile and be as kind as you’d like, but if you don’t commit yourself to gaining key skills and monitoring your patients closely, your patients see you as being uncaring.

10. Showing your human side by sharing humor or stories of daily life.

NOTE:

Simply Being Nice and Making Work Fun Can Improve Patient Outcomes

“(Studies show that) patients who come away from a positive encounter with a nurse are more likely to follow prescribed directions, take medications, and seek follow-up care… (however if) a patient encounters a health care worker who’s in a negative emotional state, it becomes a springboard into other negative behaviors. Down the road, their own outcomes to suffer, and they just don’t fare well..try to make the work environment as fun as possible> If you see a staff member in a bad mood, jump in and try to derail it before itr becomes contagious.”- Howared Weiss (Farella, 2009)

CLINICAL SCENARIO


Listening Empathetically Promotes Understanding of the Real Issues, Fostering Caring Human Responses

Today Patricia/Pat is caring for Sharon, who’s just given birth to her fifth child, a healthy baby girl. Pat never has been able to conceive, has always wanted children, and feels a little envious of Sharon’s family of two boys and (now) of three girls.

Pat notes that Sharon seems very quiet. Recognizing the importance of being empathetic listener, Pat has the following conversation with Sharon.

Pat: “You’ve been pretty quiet since I came on.”

Sharon: “I can’t help it. I’m supposed to be happy, but I’m really disappointed- I was so sure I’d had a baby boy.”

Pat: (making a conscious effort to eliminate thoughts about the fact that she’d be happy with any child, and rephrasing what Sharon seems to be feeling): “ you feel like you’re supposed to be happy, but you really feel sort of sad?”

Sharon: “yes”,

Pat pauses to reflect on the feeling of sadness and encourages Sharon to continue.

Sharon: “I was going to name this baby after my father. He died 2 months ago.”

Pat (connecting to what Sharon must be feeling): “I’m sorry. That would be a disappointment. Being able to name the baby after him would have been a lovely thing to do.”

Sharon (crying): “Yes, I had it all pictured in my mind.”

Pat conveying acceptance and understanding, sits quietly, allowing Sharon to cry.

Pat (detaching and coming back to her own frame of reference):

“Sharon, I think you needed to cry and you may need to cry again. But right now you’ve got a very beautiful baby girl, with the longest hair I’ve ever seen, waiting to meet her mother. How would you feel if I brought her into you?”

Sharon: (smiling) “Yes, I really haven’t seen her for more than 5 minutes. I’ve got to admit, I’ve always gotten along better with my girls than my boys.”


CLASSROOM ACTIVITY 2

CRITICAL THINKING ABILITY AND WILLINGNESS AND ABILITY TO CARE

1. List five critical thinking indicators you’d like to acquire or improve.

2. Complete the following sentence, using as many words as you choose: If I were to tell someone how I think, I would say that I………..

3. In five sentences or less, describe what critical thinking means to you.

4. Give three examples of caring behaviors

5. Explain how the statements relates to willingness and ability to care:

a. Health and Illness are human experiences

b. The presence of illness does not preclude health nor does optimal health preclude illness.

c. An essential feature of contemporary nursing practice is the provision of a caring relationship that facilitates healing.

ASSIGNMENT


1. Improve your interpersonal skills by learning about your innate personality and how to get along well with “difficult” people.

Read: “Don’t Worry Be Happy! Harmonize Diversity Through Personality Sensitivity,” at http:nsweb.nursingspectrum.com/ce/ce236.htm

2. Are you stressed out? Managing stress is an important part of staying healthy. Take the Life Stress Test at http://www.cliving.org/lifstrstst.htm. Think of some things that you can do to reduce your stress level.

3. Practice empathetic listening

Ask someone to tell you about an upsetting experience in his or her childhood and listen using the steps of empathetic listening taught.

Discuss in the class what can happen when you are too emotionally involved in patient situations.

Identify ways you can manage your emotions to remain empathetic, but also objective and logical.

Lesson C.3


http://www.cliving.org/lifstrstst.htm

Ethico-Moral /Legal Responsibilities

The success of nurse- patient interaction and examination is influenced by your awareness of ethical, cultural, and spiritual concerns. As a nurse you must:

1. Provide service with respect for human dignity and the uniqueness of the patient, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems (ANA, 2004)

2. Safeguard the client’s right to privacy by judiciously protecting information of a confidential nature.

3. Be honest. Tell the person the truth about how you’ll see the data (eg. “I have to write a paper examining someone’s eating patterns. Would you be willing to tell me about your eating habits?

4. Respect individual cultural and religious beliefs and be aware of physical tendencies related to culture. This include being aware of:

Biologic variations

For example:

Differences among racial and ethnic groups like skin color, texture, and susceptibility to diseases like hypertension and sickle cell anemia.

Comfortable communication patterns

For example:

How language and gestures are used, whether eye contact or touching is acceptable, and whether the person is threatened by being in close proximity to another.

Family organization and practices

We have diverse family units and practices. We must understand them to gain insight into factors that influence health status.

Beliefs about whether people are able to control nature and influence their ability to be healthy (eg, whether blood transfusions are allowed or whether rituals are required)

The person’s concept of God and beliefs about the relationship between spiritual beliefs and health status. (eg, God gives you what you deserve.).


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