THEORIES OF NURSINGTHEORIES OF NURSING

Florence NightingaleFlorence Nightingale

Florence Nightingale (1960/1969)Florence Nightingale (1960/1969)

Often considered the first nurse Often considered the first nurse theoristtheorist

Defined nursing as “the act of Defined nursing as “the act of utilizing the environment of the utilizing the environment of the patient to assist him in his recovery”. patient to assist him in his recovery”.

Nightingale’s theory remains an Nightingale’s theory remains an integral parts of nursing and integral parts of nursing and healthcare today.healthcare today.

5 Environmental Factors:5 Environmental Factors:Pure or fresh airPure or fresh airPure waterPure waterEfficient drainageEfficient drainageCleanlinessCleanlinessLight, especially direct sunlightLight, especially direct sunlight

Nightingale’s general concepts are:Nightingale’s general concepts are:1.Ventilation1.Ventilation 4.Warmth4.Warmth

2.Cleanliness2.Cleanliness 5.Diet5.Diet

3.Quiet3.Quiet

Dorothy JohnsonDorothy Johnson

Dorothy E. Johnson (1980)Dorothy E. Johnson (1980)The Behavioral System Model for The Behavioral System Model for

NursingNursingFocuses on how the client adapt to Focuses on how the client adapt to

illness; the goal of nursing is to reduce illness; the goal of nursing is to reduce stress so that the client can move easily stress so that the client can move easily through recovery.through recovery.

Viewed the patient’s behavior as a Viewed the patient’s behavior as a system that is a whole with interacting system that is a whole with interacting parts. The nursing process is viewed as parts. The nursing process is viewed as a major tool.a major tool.

Purpose:Purpose: To reduce stress so the client To reduce stress so the client can recover as quickly as possible.can recover as quickly as possible.

View of componentsView of components Person: A system of interdependent parts Person: A system of interdependent parts

with patterned, repetitive, and purposeful with patterned, repetitive, and purposeful ways of behaving.ways of behaving.

Environment: All forces that affect the Environment: All forces that affect the person and that influence the behavioral person and that influence the behavioral system.system.

Health: Focus on person, not illness. Health Health: Focus on person, not illness. Health is a dynamic state influenced by biologic, is a dynamic state influenced by biologic, psychological, and social factors.psychological, and social factors.

Nursing: Promotion of behavioral system, Nursing: Promotion of behavioral system, balance, and stability. An art and science balance, and stability. An art and science providing external assistance before and providing external assistance before and during system balance disturbances.during system balance disturbances.

Myra Estrin Levin(1973)Myra Estrin Levin(1973)

Conservation ModelConservation Model

Described the Four Conservation Described the Four Conservation Principles. She advocated that Principles. She advocated that nursing is a human interaction and nursing is a human interaction and proposed four conservation proposed four conservation principles of nursing which are principles of nursing which are concerned with the unity and concerned with the unity and integrity of the individual. The four integrity of the individual. The four principles are as follows:principles are as follows:

1. 1. Conservation of EnergyConservation of Energy – The human – The human body functions by utilizing energy. The body functions by utilizing energy. The

human body needs energy producing human body needs energy producing input (food, oxygen, fluids) to allow input (food, oxygen, fluids) to allow energy utilization as output.energy utilization as output.

2. 2. Conservation of Structural IntegrityConservation of Structural Integrity- - the human body has physical the human body has physical boundaries (skin, and mucous boundaries (skin, and mucous membranes) that must be maintained membranes) that must be maintained to facilitate health and prevent to facilitate health and prevent harmful agents from entering the harmful agents from entering the body. body.

3.3.Conservation of Personal IntegrityConservation of Personal Integrity- the - the nursing interventions are based on the nursing interventions are based on the conservation of the individuals conservation of the individuals personality. Every individual has a sense personality. Every individual has a sense of identity, self-worth and self-esteem, of identity, self-worth and self-esteem, which must be preserved and enhanced which must be preserved and enhanced by the nurses.by the nurses.

4.4.Conservation of Social IntegrityConservation of Social Integrity- the social - the social integrity of the clients reflects the family integrity of the clients reflects the family and the community in which the clients and the community in which the clients functions. Health care institutions may functions. Health care institutions may separate individuals form their family. It separate individuals form their family. It is important for nurses to consider the is important for nurses to consider the individual in the context of a family. individual in the context of a family.

Imogene KingImogene King

Imogene King (1971)Imogene King (1971)

Goal Attainment TheoryGoal Attainment TheoryHighlights the importance of the Highlights the importance of the

participation of all the individuals in participation of all the individuals in decision making & deals with the decision making & deals with the choices, alternatives, & outcomes of choices, alternatives, & outcomes of nursing carenursing care

This theory offers insights into This theory offers insights into nurses’ interactions with individuals nurses’ interactions with individuals & groups within the environment& groups within the environment

Defines Health as a dynamic state in Defines Health as a dynamic state in the life cycle; illness is an interference the life cycle; illness is an interference in the life cycle. Health implies a in the life cycle. Health implies a continuous adaptation to stresscontinuous adaptation to stress

Described nursing as a helping Described nursing as a helping profession that assists individuals and profession that assists individuals and groups in society to attain, maintain groups in society to attain, maintain and restore health. If this is not and restore health. If this is not possible, nurses help individuals to die possible, nurses help individuals to die with dignity. with dignity.

Viewed nursing as an interaction Viewed nursing as an interaction between the client and the nurse between the client and the nurse whereby perceiving, setting goals whereby perceiving, setting goals and acting on them, transaction and acting on them, transaction occurs and goals are achieved. occurs and goals are achieved.

Interpersonal System(Groups)

Social Systems (Society)

Imogene KingA conceptual framework for nursing:Dynamic interacting systems.

Nursing process is defined as dynamic interpersonal process between nurse, client and health care system.

Personal Systems (Individuals)

Faye Glenn AbdellahFaye Glenn Abdellah

Faye Glenn Abdellah (1960)Faye Glenn Abdellah (1960)

Patient-Centered Approaches to Patient-Centered Approaches to NursingNursing

Purpose:Purpose: To deliver nursing care for the To deliver nursing care for the whole individual.whole individual.

Abdellah described nursing as a service to Abdellah described nursing as a service to people, families and society. The nurse people, families and society. The nurse helps people, sick or well, to cope with helps people, sick or well, to cope with their health needs. In Abdellah’s model, their health needs. In Abdellah’s model, nursing care means providing information nursing care means providing information to the client or doing something to the to the client or doing something to the client with the goal of meeting needs or client with the goal of meeting needs or alleviating an impairment.alleviating an impairment.

View of componentsView of componentsPerson: The recipient of nursing care Person: The recipient of nursing care

having physical, emotional, and having physical, emotional, and sociologic sociologic

needs that may be overt or covert.needs that may be overt or covert.Environment: Not clearly defined. Some Environment: Not clearly defined. Some

discussion indicates that client interact discussion indicates that client interact with their environment, of which the with their environment, of which the

nurse is a part.nurse is a part.Health: Implicitly defined as a state Health: Implicitly defined as a state

when the individual has no unmet needs when the individual has no unmet needs and and

no anticipated or actual impairments.no anticipated or actual impairments. Nursing: Broadly grouped in “21 nursing Nursing: Broadly grouped in “21 nursing

problems.”problems.”1. To maintain good hygiene.1. To maintain good hygiene.2. To promote optimal activity: exercise, 2. To promote optimal activity: exercise,

rest, and sleep.rest, and sleep.3. To promote safety.3. To promote safety.4. To maintain good body mechanics.4. To maintain good body mechanics.5. To facilitate the maintenance of supply of 5. To facilitate the maintenance of supply of

oxygen.oxygen.6. To facilitate maintenance of nutrition.6. To facilitate maintenance of nutrition.7. To facilitate maintenance of elimination.7. To facilitate maintenance of elimination.

8. To facilitate the maintenance of fluid and 8. To facilitate the maintenance of fluid and electrolytes balance.electrolytes balance.

9. To recognize the physiologic response of 9. To recognize the physiologic response of the body to disease conditions.the body to disease conditions.

10. To facilitate the maintenance of 10. To facilitate the maintenance of regulatory mechanisms and functions.regulatory mechanisms and functions.

11. To facilitate the maintenance of sensory 11. To facilitate the maintenance of sensory function.function.

12. To identify and accept positive and 12. To identify and accept positive and negative expressions, feelings and negative expressions, feelings and reactions.reactions.

13. To identify and accept the 13. To identify and accept the interrelatedness of emotions and illness.interrelatedness of emotions and illness.

14. To facilitate the maintenance of effective 14. To facilitate the maintenance of effective verbal and non-verbal communication.verbal and non-verbal communication.

15. To promote the development of 15. To promote the development of productive interpersonal relationship.productive interpersonal relationship.

16. To facilitate progress toward 16. To facilitate progress toward achievement of personal spiritual goals.achievement of personal spiritual goals.

17. To create and maintain a therapeutic 17. To create and maintain a therapeutic environment.environment.

18. To facilitate awareness of self as an 18. To facilitate awareness of self as an individual with varying needs.individual with varying needs.

19. To accept the optimum possible goals.19. To accept the optimum possible goals.20. To use community resources as an aid in 20. To use community resources as an aid in

resolving problems arising from illness.resolving problems arising from illness.21. To understand the role of social 21. To understand the role of social

problems as influencing factors.problems as influencing factors.

Betty NeumanBetty Neuman

Betty Neuman (1972)Betty Neuman (1972)

Health Care Systems ModelHealth Care Systems Model

Views client as an open system Views client as an open system consisting of a basic structure or consisting of a basic structure or central core of energy resources central core of energy resources (physiologic, psychologic, (physiologic, psychologic, sociocultural, developmental, & sociocultural, developmental, & spiritual) surrounded by lines of spiritual) surrounded by lines of resistance that defends client against resistance that defends client against stressorsstressors

She asserted that nursing is a She asserted that nursing is a unique profession in that it is concerned unique profession in that it is concerned with all the variables affecting an with all the variables affecting an individual’s response to stresses which individual’s response to stresses which are intra (within), inter (between one or are intra (within), inter (between one or more people) and extra-personal more people) and extra-personal ( outside the individual) in nature.( outside the individual) in nature.

The concern of nursing is to The concern of nursing is to prevent stress invasion, to protect the prevent stress invasion, to protect the client’sclient’s

basic structure and obtain or basic structure and obtain or maintain maximum level of wellness. maintain maximum level of wellness.

The nurse helps the client, The nurse helps the client, through primary, secondary, and through primary, secondary, and tertiary prevention modes, to adjust tertiary prevention modes, to adjust to environmental stressors and to environmental stressors and maintain client system stability. maintain client system stability.

Sister Calista RoySister Calista Roy

Sister Callista Roy (1979)Sister Callista Roy (1979)

Adaptation ModelAdaptation ModelFocuses on the individual as a Focuses on the individual as a

biopsychosocial adaptive system. biopsychosocial adaptive system. Both the individual & the environment Both the individual & the environment are sources of stimuli that require are sources of stimuli that require modification to promote adaptation, modification to promote adaptation, an on-going purposive responsean on-going purposive response

The individual receives inputs or The individual receives inputs or stimuli from both the self & the stimuli from both the self & the environmentenvironment

She contended that the person is an She contended that the person is an adaptive system, function as a whole adaptive system, function as a whole through interdependence of its parts. through interdependence of its parts.

The system consist of input, control The system consist of input, control process, output and feedback. process, output and feedback.

In addition, she advocated that all In addition, she advocated that all people have certain needs which people have certain needs which they endeavor to meet in order to they endeavor to meet in order to maintain integritymaintain integrity

These needs are divided into four These needs are divided into four different modes, the physiological, different modes, the physiological, self concept, role function, and self concept, role function, and interdependence. interdependence.

Accordingly Roy believed that Accordingly Roy believed that adaptive human behavior is directed adaptive human behavior is directed toward an attempt to maintain toward an attempt to maintain homeostasis or integrity of the homeostasis or integrity of the individual by conserving energy and individual by conserving energy and promoting the survival, growth, promoting the survival, growth, reproduction and mastery of the reproduction and mastery of the human system. human system.

Ida Jean OrlandoIda Jean Orlando

Ida Jean Orlando (1961)Ida Jean Orlando (1961)

The Dynamic Nurse-Patient The Dynamic Nurse-Patient RelationshipRelationship

Three elements – Client behavior, Three elements – Client behavior, nurse reaction and nurse actions – nurse reaction and nurse actions – compose the nursing situation.compose the nursing situation.

Purpose:Purpose: To interact with clients to To interact with clients to meet immediate needs by identifying meet immediate needs by identifying client client

behaviors, nurse’s reactions, and behaviors, nurse’s reactions, and nursing actions to take.nursing actions to take.

Views of ComponentsViews of ComponentsPerson: Unique individual behaving Person: Unique individual behaving

verbally and nonverbally. Assumption verbally and nonverbally. Assumption is that is that

individuals are at times able to meet individuals are at times able to meet their own needs and at other times their own needs and at other times unable to do so.unable to do so.

Health: Not defined. Assumption is Health: Not defined. Assumption is that being without emotional or that being without emotional or physical physical

discomfort and having a sense of well-discomfort and having a sense of well-being contribute to a healthy state.being contribute to a healthy state.

Nursing: Professional nursing is Nursing: Professional nursing is conceptualized as finding out and conceptualized as finding out and meeting the meeting the

client’s immediate need for help. client’s immediate need for help. Medicine and nursing are viewed as Medicine and nursing are viewed as distinctly different.distinctly different.

The concept of need is central to The concept of need is central to Orlando’s theory, which focuses on Orlando’s theory, which focuses on clients and their unmet needs. clients and their unmet needs. Orlando believed that the purpose of Orlando believed that the purpose of nursing is to provide the assistance nursing is to provide the assistance that a client requires to meet his or that a client requires to meet his or her needs.her needs.

Virginia HendersonVirginia Henderson

Virginia Henderson (1955)Virginia Henderson (1955)

Definition of NursingDefinition of Nursing Nursing as a discipline separate from medicine.Nursing as a discipline separate from medicine. Described nursing in relation to the client and Described nursing in relation to the client and

the client’s environmentthe client’s environment Concerned with both healthy and ill individuals Concerned with both healthy and ill individuals

even when recovery may not be feasibleeven when recovery may not be feasible Teaching and advocacy roles of the nurseTeaching and advocacy roles of the nurse The unique function of the nurse is to assist the The unique function of the nurse is to assist the

individual sick or well to perform his/her individual sick or well to perform his/her activities contributing to health, its recovery, or activities contributing to health, its recovery, or to a peaceful death, the client would perform, to a peaceful death, the client would perform, if he had the necessary strength, will and if he had the necessary strength, will and knowledge.knowledge.

The 14 Fundamental NeedsThe 14 Fundamental Needs

Breathing normallyBreathing normallyEating and drinking adequatelyEating and drinking adequatelyEliminating body wasteEliminating body wasteMoving and maintaining a desirable Moving and maintaining a desirable

positionpositionSleeping and restingSleeping and restingSelecting suitable clothesSelecting suitable clothesMaintaining body temperature within Maintaining body temperature within

normal range by adjusting clothing normal range by adjusting clothing and modifying the environmentand modifying the environment

Keeping the body clean and well groomed Keeping the body clean and well groomed to protect the integument.to protect the integument.

Avoiding dangers in the environment and Avoiding dangers in the environment and avoiding injuring others.avoiding injuring others.

Communicating with others in expressing Communicating with others in expressing emotions, needs, fears, or opinionsemotions, needs, fears, or opinions

Worshipping according to one’s faithWorshipping according to one’s faith Working in a such way that one feels a Working in a such way that one feels a

sense of accomplishmentsense of accomplishment Playing or participating in various forms of Playing or participating in various forms of

recreationrecreation Learning, discovering, or satisfying the Learning, discovering, or satisfying the

curiosity that leads to normal development curiosity that leads to normal development and health, and using available health and health, and using available health facilitiesfacilities

Hildegard PeplauHildegard Peplau

Hildegard Peplau (1952)Hildegard Peplau (1952)Interpersonal Relations ModelInterpersonal Relations Model The use of a therapeutic relationship between the The use of a therapeutic relationship between the

nurse and the client.nurse and the client. Nursing as a therapeutic, interpersonal process Nursing as a therapeutic, interpersonal process

which strives to develop a nurse-patient which strives to develop a nurse-patient relationship in which the nurse serves as a relationship in which the nurse serves as a resource person, counselor and surrogate. resource person, counselor and surrogate.

The nurse-client relationship evolves four The nurse-client relationship evolves four phases:phases:

OrientationOrientation The client seeks helpThe client seeks help The nurse assist the client to understand the The nurse assist the client to understand the

problem and the extent of the need for help. problem and the extent of the need for help.

IdentificationIdentification The client assumes a posture of dependence, The client assumes a posture of dependence,

interdependence, or independence in relation to interdependence, or independence in relation to the nurse. the nurse.

The nurse’s focus is to assure the person that The nurse’s focus is to assure the person that the nurse understands the interpersonal the nurse understands the interpersonal meaning of the client’s situation.meaning of the client’s situation.

ExploitationExploitation The client derives full value from what the nurse The client derives full value from what the nurse

offers through the relationship.offers through the relationship. The client uses available services based on self-The client uses available services based on self-

interest and needs.interest and needs. Power shifts from the nurse to the client.Power shifts from the nurse to the client.Resolution Resolution Old needs and goals are put aside and new Old needs and goals are put aside and new

ones adopted. Once older needs are resolved, ones adopted. Once older needs are resolved, newer and more mature ones emerge.newer and more mature ones emerge.

Nurses’ Roles:Nurses’ Roles:StrangerStrangerTeacherTeacherResource PersonResource PersonSurrogateSurrogateLeaderLeaderCounselorCounselor

Martha RogersMartha Rogers

Martha Rogers (1970)Martha Rogers (1970)Science of Unitary Human BeingsScience of Unitary Human Beings Views person as an irreducible whole, the Views person as an irreducible whole, the

whole being greater than the sum of its whole being greater than the sum of its parts. Whole is differentiated from holistic.parts. Whole is differentiated from holistic.

States that the humans are dynamic States that the humans are dynamic energy fields in continuous exchange with energy fields in continuous exchange with environmental fields, both of which are environmental fields, both of which are infinite.infinite. Both human and environmental fields are Both human and environmental fields are

characterized by pattern, a universe of open characterized by pattern, a universe of open systems, and four dimensionality.systems, and four dimensionality.

Considers man as a unitary human being Considers man as a unitary human being co-existing within the universe, views co-existing within the universe, views nursing primarily as a science and is nursing primarily as a science and is committed to nursing research.committed to nursing research.

What is an unitary man? Unitary What is an unitary man? Unitary man :man :

Is an irreducible, four-dimensional Is an irreducible, four-dimensional energy field identified by patternenergy field identified by pattern

Manifests characteristics different Manifests characteristics different from the sum of partsfrom the sum of parts

Interacts continuously and creatively Interacts continuously and creatively with the environment with the environment

Behaves as a totalityBehaves as a totalityAs a sentient being, participates As a sentient being, participates

creatively in change.creatively in change.

Nurses applying Roger’s theory in Nurses applying Roger’s theory in practice:practice:

focus on the person’s wholenessfocus on the person’s wholenessseek to promote symphonic interaction seek to promote symphonic interaction

between the two energy fields to between the two energy fields to strengthen the coherence and integrity strengthen the coherence and integrity of the personof the person

coordinate the human field with the coordinate the human field with the rhythmicities of the environment fieldrhythmicities of the environment field

direct and redirect patterns of direct and redirect patterns of interaction between the two energy interaction between the two energy fields to promote maximum health fields to promote maximum health potential.potential.

Non-therapeutic touch:Non-therapeutic touch:based on human energy fieldsbased on human energy fieldsaffected by pain and illnessaffected by pain and illnesscan assess and feel the energy field can assess and feel the energy field

and manipulate it to enhance the and manipulate it to enhance the healing process of people who are ill healing process of people who are ill or injured.or injured.

Dorothea Orem (1971)Dorothea Orem (1971)General Theory of NursingGeneral Theory of NursingEmphasizes the client’s self-care Emphasizes the client’s self-care

needs, nursing care becomes needs, nursing care becomes necessary when client is unable to necessary when client is unable to fulfill biological, psychological, fulfill biological, psychological, developmental or social needs.developmental or social needs.

Three related conceptsThree related conceptsSelf-careSelf-careSelf-care deficitSelf-care deficitNursing systemsNursing systems

Self-care theory is based on four Self-care theory is based on four concepts:concepts:

Self-care – activities an individual Self-care – activities an individual performs independently to promote performs independently to promote and maintain personal well-being.and maintain personal well-being.

Self-care agency – individual’s ability Self-care agency – individual’s ability to perform self-care activities. to perform self-care activities. Consists of two agentsConsists of two agents

A self care agent – an individual who A self care agent – an individual who performs self-care independentlyperforms self-care independently

A dependent care agent – a person A dependent care agent – a person other than the individual who provides other than the individual who provides the carethe care

Self – care requisites (self-care needs) – Self – care requisites (self-care needs) – actions or measures taken to provide actions or measures taken to provide care. There are three categories:care. There are three categories:Universal requisites – includes: Intake and Universal requisites – includes: Intake and

elimination of air, water and food; balancing elimination of air, water and food; balancing rest, solitude, and social interaction; rest, solitude, and social interaction; preventing hazards to life and well-being; and preventing hazards to life and well-being; and promoting normal human functioning.promoting normal human functioning.

Developmental requisites – results from Developmental requisites – results from maturation or are associated with conditions maturation or are associated with conditions and events.and events.

Health deviation requisites – result from Health deviation requisites – result from illness, injury or disease or its treatment. (eg. illness, injury or disease or its treatment. (eg. Seeking health care assistance, carrying out Seeking health care assistance, carrying out prescribed therapies, and learning to live with prescribed therapies, and learning to live with the effects of illness or treatment)the effects of illness or treatment)

Therapeutic self- care demand – all self-care Therapeutic self- care demand – all self-care activities required to meet existing self-activities required to meet existing self-care requisites. ( Actions to maintain care requisites. ( Actions to maintain health and well-being Self-care deficit health and well-being Self-care deficit results when self-care agency is not results when self-care agency is not adequate to meet the known self-care adequate to meet the known self-care demand.)demand.)

5 Methods in helping:5 Methods in helping: a. Acting or doing fora. Acting or doing for b. Guiding b. Guiding c. Teaching c. Teaching d. Supportingd. Supporting e. Providing an environment that promotes e. Providing an environment that promotes

abilities to meet current demandsabilities to meet current demands

3 Types of Nursing Systems:3 Types of Nursing Systems: Wholly compensatory systems are Wholly compensatory systems are

required for individuals who are unable to required for individuals who are unable to control and monitor their environment and control and monitor their environment and process information.process information.

Partly compensatory systems are designed Partly compensatory systems are designed for individuals who are unable to perform for individuals who are unable to perform some, but not all, self-care activitiessome, but not all, self-care activities

Supportive-educative (developmental) Supportive-educative (developmental) systems are designed for persons who systems are designed for persons who need to learn to perform self-care need to learn to perform self-care measures and need assistance to do so.measures and need assistance to do so.

Basic Conditioning Factors for Self-care Basic Conditioning Factors for Self-care Agency and Therapeutic Self Care Agency and Therapeutic Self Care Demand:Demand:

AgeAge GenderGender Developmental stateDevelopmental state Sociocultural orientationSociocultural orientation Health StateHealth State Family system factorsFamily system factors Health care system factorsHealth care system factors Patterns of livingPatterns of living Environmental factorsEnvironmental factors Resource availability and adequacyResource availability and adequacy

Basic Conditioning Factors for Basic Conditioning Factors for Nursing AgencyNursing Agency

AgeAgeGender, raceGender, racePhysical and constitutional Physical and constitutional

characteristicscharacteristicsHealth stateHealth stateFamily/Community rolesFamily/Community rolesNursing educational preparation Nursing educational preparation Nursing experienceNursing experienceMaturity/Status as a personMaturity/Status as a person

Self-care

Self-careagency Self-care

demands

Nursing Agency

Deficit

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R

R

R

R

RContributing Factors

Contributing Factors

Contributing Factors

Jean Watson (1979)Jean Watson (1979)

Human Caring TheoryHuman Caring TheoryBelieves the practice of caring is central Believes the practice of caring is central

to nursing: it is the unifying focus for to nursing: it is the unifying focus for practicepractice

Carative factors – nursing intervention Carative factors – nursing intervention related to human care.related to human care.

Redefining nursing as a caring-healing Redefining nursing as a caring-healing health modelhealth model

10 Factors10 Factors Forming a humanistic-altruistic system of valuesForming a humanistic-altruistic system of values Instilling faith and hopeInstilling faith and hope Cultivating sensitivity to one’s self and othersCultivating sensitivity to one’s self and others Developing a helping-trust (human care) relationshipDeveloping a helping-trust (human care) relationship Promoting and accepting the expression of positive Promoting and accepting the expression of positive

and negative feelingsand negative feelings Systematically using the scientific problem-solving Systematically using the scientific problem-solving

method for decision making.method for decision making. Promoting interpersonal teaching-learningPromoting interpersonal teaching-learning Providing a supportive, protective, or corrective Providing a supportive, protective, or corrective

mental, physical, socio-cultural, and spiritual mental, physical, socio-cultural, and spiritual environmentenvironment

Assisting with the gratification of human needsAssisting with the gratification of human needs Allowing for existential-phenomenologic forcesAllowing for existential-phenomenologic forces

Watson’s Assumptions of CaringWatson’s Assumptions of Caring Human caring is not just an emotion, concern, Human caring is not just an emotion, concern,

attitude or benevolent desire. Caring connotes attitude or benevolent desire. Caring connotes a personal response.a personal response.

Caring is an intersubjective human process and Caring is an intersubjective human process and is the moral ideal of nursing.is the moral ideal of nursing.

Caring can be effectively demonstrated only Caring can be effectively demonstrated only interpersonally.interpersonally.

Effective caring promotes health and individual Effective caring promotes health and individual or family growth.or family growth.

Caring promotes health more than does curing.Caring promotes health more than does curing. Caring responses accept a person not only as Caring responses accept a person not only as

they are now, but also for what the person may they are now, but also for what the person may become.become.

A caring environment offers the development A caring environment offers the development of potential while allowing the person to of potential while allowing the person to choose the best action for the self at a given choose the best action for the self at a given point in time.point in time.

Caring occasions involve action and choice by Caring occasions involve action and choice by nurse and client. If the caring occasion is nurse and client. If the caring occasion is transpersonal, the limits of openness expand, as transpersonal, the limits of openness expand, as do human capacities.do human capacities.

The most abstract characteristic of a caring The most abstract characteristic of a caring person is that the person is somehow responsive person is that the person is somehow responsive to another person as a unique individual, to another person as a unique individual, perceives the other’s feelings, and sets one perceives the other’s feelings, and sets one person apart from another.person apart from another.

Human caring involves values, a will and a Human caring involves values, a will and a commitment to care, knowledge, caring actions, commitment to care, knowledge, caring actions, and consequences.and consequences.

The ideal and value of caring is a starting point, The ideal and value of caring is a starting point, a stance, and an attitude that has to become a a stance, and an attitude that has to become a will, an intention, a commitment, and a will, an intention, a commitment, and a conscious judgment that manifests itself in conscious judgment that manifests itself in concrete acts.concrete acts.

THE NURSING PROCESS

Systematic problem - Systematic problem - solving approach toward solving approach toward giving individualized nursing care.giving individualized nursing care.

STEPS:AssessmentAssessmentNursing DiagnosisNursing DiagnosisPlanningPlanning InterventionInterventionEvaluationEvaluation

ASSESSING PATIENT’S HEALTH STATUS

AssessmentA systematic collection of subjective A systematic collection of subjective

and objective data with the goal of and objective data with the goal of making a clinical nursing judgment making a clinical nursing judgment about an individual, family or about an individual, family or community.community.

1st phase of nursing process which 1st phase of nursing process which involves data collection , involves data collection , organization and validation.organization and validation.

Purpose of Nursing Assessment

To establish the client-nurse relationship.To establish the client-nurse relationship.To obtain information about the client’s To obtain information about the client’s

health, including physiologic, socio-health, including physiologic, socio-cultural, cognitive, developmental & cultural, cognitive, developmental & spiritual aspects.spiritual aspects.

To identify the client’s strength.To identify the client’s strength.To identify actual & potential problems.To identify actual & potential problems.To establish a data base from w/c the To establish a data base from w/c the

subsequent phases of the nursing subsequent phases of the nursing process evolve.process evolve.

Methods used in Nursing Assessment

ObservationObservationInterviewInterviewPhysical ExaminationPhysical Examination

OBSERVATION

To gather data by using the 5 sensesTo gather data by using the 5 senses Is a conscious deliberate skill that is Is a conscious deliberate skill that is

developed only through effort and developed only through effort and with organized approachwith organized approach

Observational Skills

VisionVision Overall appearance (body size, weight, Overall appearance (body size, weight,

posture); signs of distress or discomfort; facial posture); signs of distress or discomfort; facial & body gestures; skin color & lesions; & body gestures; skin color & lesions; abnormalities of movement; non-verbal abnormalities of movement; non-verbal demeanordemeanor

Smell - Body or breath odorsSmell - Body or breath odors Hearing - Breath & heart sounds, bowel Hearing - Breath & heart sounds, bowel

sounds, ability to communicate, language sounds, ability to communicate, language spoken, orientation to time person & placespoken, orientation to time person & place

Touch - Skin temp, pulse rate, rhythm; muscle Touch - Skin temp, pulse rate, rhythm; muscle strength; strength;

INTERVIEWINTERVIEW

Planned communication or Planned communication or conversation wherein its primary conversation wherein its primary purpose is to gather data. purpose is to gather data.

This will give information, identify This will give information, identify problems of mutual concern, problems of mutual concern, evaluate change, teach, provide evaluate change, teach, provide support, counseling & therapysupport, counseling & therapy

APPROACHES FOR INTERVIEW

Directive InterviewDirective InterviewNondirective InterviewNondirective Interview

Directive Interview Is a highly structured and elicits Is a highly structured and elicits

specific information.specific information.The nurse establishes the purpose of The nurse establishes the purpose of

the interview & controls the interview the interview & controls the interview by asking closed type of questionsby asking closed type of questions

Nondirective InterviewThis is a rapport-building interview w/c This is a rapport-building interview w/c

allows the client to control the allows the client to control the purpose, subject matter, and pacing of purpose, subject matter, and pacing of the interview.the interview.

The nurse usually used an open-ended The nurse usually used an open-ended questionsquestions

KINDS OF INTERVIEW QUESTIONS

Closed questionsClosed questions Used in directive interview, usually Used in directive interview, usually

restrictive & generally require only short restrictive & generally require only short answers giving specific information. Thus, answers giving specific information. Thus, the amount of the information gained is the amount of the information gained is limited.limited.

Often begins with 4WH. Often begins with 4WH.

Open-ended questionsOpen-ended questions Associated in nondirective interview.Associated in nondirective interview. Allow the clients to elaborate, clarify & Allow the clients to elaborate, clarify &

illustrate their thoughts & feelings. (e.g. illustrate their thoughts & feelings. (e.g. Why did you come to the hospital tonight?; Why did you come to the hospital tonight?; How did you feel in that situation?How did you feel in that situation?

Neutral question It is a question the client can answer without It is a question the client can answer without

direction or pressure from the nurse.direction or pressure from the nurse.

(e.g., How do you feel about that?; (e.g., How do you feel about that?; Why do Why do you think you had an operation?)you think you had an operation?)

Leading question Directs the client’s answer. The phrasing of the Directs the client’s answer. The phrasing of the

question suggests what answer is expected.question suggests what answer is expected.

e. g. You are stressed about the surgery e. g. You are stressed about the surgery tomorrow, aren’t you?; You will take your tomorrow, aren’t you?; You will take your medicine, won’t you?medicine, won’t you?

POINTS TO REMENBER IN AN INTERVIEW

Select a quiet private setting (time, Select a quiet private setting (time, place, seating arrangement, distance).place, seating arrangement, distance).

Choose terms carefully and avoid Choose terms carefully and avoid using jargon.using jargon.

Use appropriate body language.Use appropriate body language.Confirm patient statements to avoid Confirm patient statements to avoid

misunderstanding.misunderstanding.Use open-ended question.Use open-ended question.

COMMUNICATION COMMUNICATION STRATEGIESSTRATEGIES a.a. SilenceSilence

- Moments of silence during the interview encourage - Moments of silence during the interview encourage the pt. to continue talking & give a nurse a chance the pt. to continue talking & give a nurse a chance to assess the clients ability to organize thoughts.to assess the clients ability to organize thoughts.

b.b. Facilitation Facilitation -Facilitation encourages the pt. to continue with his -Facilitation encourages the pt. to continue with his

story. (e.g. “please continue”, “go on” and “uh-huh)story. (e.g. “please continue”, “go on” and “uh-huh)c.c. Confirmation Confirmation - Ensures that both the nurses & the pt. are on the - Ensures that both the nurses & the pt. are on the

same track. same track. (e.g. If I understand you correctly, you said…..)(e.g. If I understand you correctly, you said…..)d.d. Reflection Reflection - Repeating something the pt. has just said can help - Repeating something the pt. has just said can help

you obtain more specific information.you obtain more specific information.

e.e. ClarificationClarification is used when an information given is vague.is used when an information given is vague. e.g. client: I can’t stand this!e.g. client: I can’t stand this! Nurse : What do you mean by I cant stand Nurse : What do you mean by I cant stand

this?this?f.f. Summarization Summarization -restating the information that the pt. gave you. It -restating the information that the pt. gave you. It

ensures that the data collected is accurate & ensures that the data collected is accurate & complete.complete.

g.g. Conclusion Conclusion Signals the pt. that the nurse is ready to conclude Signals the pt. that the nurse is ready to conclude

the interview. It provides the pt. the opportunity the interview. It provides the pt. the opportunity to gather his thoughts and make any pertinent to gather his thoughts and make any pertinent final statements.final statements.

e.g. nurse: I think I have all the information I need e.g. nurse: I think I have all the information I need now. Is there anything you would like to add.now. Is there anything you would like to add.

NURSING HEALTH HISTORYNURSING HEALTH HISTORY

One example of an interview.One example of an interview.1st part of the assessment of the 1st part of the assessment of the

client’s health status.client’s health status.Used to gather subjective data about Used to gather subjective data about

the pt. & explore the past & the the pt. & explore the past & the present health problems.present health problems.

It is the uniqueness of the client in his or her situation that brings a Nursing Care Plan to life. Be sure to match your assessment, priority diagnoses, goals and evaluative measures to the personality, life style and needs of your client.

COMPONENTS OF THE NURSING

HISTORY

Biographic data Biographic data Includes the client’s name, address, age, Includes the client’s name, address, age,

sex, telephone no., race, marital status, sex, telephone no., race, marital status, b-day, occupation, religion, nationality.b-day, occupation, religion, nationality.

Chief complaint or reason for visitChief complaint or reason for visitThe c/c should be recorded in the client’s The c/c should be recorded in the client’s

own words. (‘What is troubling you?”)own words. (‘What is troubling you?”)

History of present illness

P-rovocative/Palliative P-rovocative/Palliative ask the patient: what triggers & relieves the ask the patient: what triggers & relieves the

symptom?symptom?

Q-uality or QuantityQ-uality or Quantity What the symptom feels like, look like?What the symptom feels like, look like? Are you having the symptom right now? If so , is Are you having the symptom right now? If so , is

it more or less severe than usual?it more or less severe than usual?

R-egion or Radiation Where in the body does the symptom occur?Where in the body does the symptom occur? - Does the symptom appear in other regions? If - Does the symptom appear in other regions? If

so, where?so, where?

S-everity How severe is the symptom? How would How severe is the symptom? How would

you rate it on a scale of 1-10, with 10 you rate it on a scale of 1-10, with 10 being the most severe.being the most severe.

Does the symptom seem to diminishing, Does the symptom seem to diminishing, intensifying, or staying about the same?intensifying, or staying about the same?

T-iming When did the symptom begin?When did the symptom begin? Was the onset sudden or gradual?Was the onset sudden or gradual? How often does the symptom occur?How often does the symptom occur? How long does the symptom last?How long does the symptom last?

Family History The family nursing history reveals risk factors for The family nursing history reveals risk factors for

certain diseasescertain diseases This information should include the ages of This information should include the ages of

siblings, parents & grandparents & their current siblings, parents & grandparents & their current state of health or cause of death.state of health or cause of death.

Particular attention should be given to disorders Particular attention should be given to disorders such as heart disease, cancer, diabetes, such as heart disease, cancer, diabetes, hypertension, obesity, allergies, arthritis , TB, hypertension, obesity, allergies, arthritis , TB, jaundice, bleeding, ulcers, migraine & alcoholism.jaundice, bleeding, ulcers, migraine & alcoholism.

Review of systems (ROS) It’s a review of all health problems by body It’s a review of all health problems by body

system to prevent omission of data related to the system to prevent omission of data related to the present illness and to discover any other present illness and to discover any other problems that might have been blessed.problems that might have been blessed.

Head to Toe approach is used and often an Head to Toe approach is used and often an agency checklist is available.agency checklist is available.

Medical HistoryMedical HistoryPast and current medical problems such Past and current medical problems such

as hypertension, diabetes, and back as hypertension, diabetes, and back pain.pain.

Typical question:Typical question:Have you ever been hospitalized? When Have you ever been hospitalized? When

& Why?& Why?What childhood illnesses did you have?What childhood illnesses did you have?Have you ever had a surgery? When & Have you ever had a surgery? When &

Why?Why?

Lifestyle Personal Habits – the frequency of substance used such as, Personal Habits – the frequency of substance used such as,

alcohol, coffee, cola, tobacco, illicit or recreational drugs.alcohol, coffee, cola, tobacco, illicit or recreational drugs. Diet & elimination– food allergies, special food preparation, Diet & elimination– food allergies, special food preparation,

prescribed diet. Frequency of bowel movement.prescribed diet. Frequency of bowel movement. Sleep/rest & exercise pattern Sleep/rest & exercise pattern Work & leisure – what he does for a living & leisure time; Work & leisure – what he does for a living & leisure time;

hobbies.hobbies. Religious observancesReligious observancesPsychosocial Find out how the pt. feels about himself, his place in society Find out how the pt. feels about himself, his place in society

& his relationship to others, occupation, educational status & his relationship to others, occupation, educational status & responsibilities.& responsibilities.

e.g. how have you coped w/ medical or emotional crises in e.g. how have you coped w/ medical or emotional crises in the past?the past?

how adequate is the emotional support?how adequate is the emotional support? do you have a health insurance?do you have a health insurance? do you have a fixed income, extra money for health care?do you have a fixed income, extra money for health care?

Gordon (1987)Gordon (1987) devised a theoretical devised a theoretical framework for assessment of a nursing client framework for assessment of a nursing client that allows nurses to identify obvious as well that allows nurses to identify obvious as well as emerging patterns of functioning. Using as emerging patterns of functioning. Using this framework nurses screen their client for this framework nurses screen their client for functional functional as well as as well as dysfunctional dysfunctional patternspatterns . .

An early step in the development of nursing An early step in the development of nursing diagnoses for a client is to do a general diagnoses for a client is to do a general assessment using some selected framework. assessment using some selected framework. There are many nursing frameworks from There are many nursing frameworks from which to choose. which to choose. Gordon's 11 Functional Gordon's 11 Functional Health PatternsHealth Patterns is one that is useful for a is one that is useful for a screening assessment.screening assessment.

Gordon’s Typology of 11 Gordon’s Typology of 11 Functional Health PatternsFunctional Health Patterns

Health Perception and Health Management.Health Perception and Health Management. Data collection is focused on the person's perceived Data collection is focused on the person's perceived level of health and well-being, and on practices for level of health and well-being, and on practices for maintaining health. Habits that may be detrimental maintaining health. Habits that may be detrimental to health are also evaluated, including smoking and to health are also evaluated, including smoking and alcohol or drug use. Actual or potential problems alcohol or drug use. Actual or potential problems related to safety and health management may be related to safety and health management may be identified as well as needs for modifications in the identified as well as needs for modifications in the home or needs for continued care in the home. home or needs for continued care in the home.

Nutrition and MetabolismNutrition and Metabolism Assessment is focused Assessment is focused on the pattern of food and fluid consumption relative on the pattern of food and fluid consumption relative to metabolic need. The adequacy of local nutrient to metabolic need. The adequacy of local nutrient supplies is evaluated. Actual or potential problems supplies is evaluated. Actual or potential problems related to fluid balance, tissue integrity, and host related to fluid balance, tissue integrity, and host defenses may be identified as well as problems with defenses may be identified as well as problems with the gastrointestinal system. the gastrointestinal system.

Elimination.Elimination. Data collection is focused Data collection is focused on excretory patterns (bowel, bladder, on excretory patterns (bowel, bladder, skin). Excretory problems such as skin). Excretory problems such as incontinence, constipation, diarrhea, and incontinence, constipation, diarrhea, and urinary retention may be identified. urinary retention may be identified.

Activity and Exercise.Activity and Exercise. Assessment is Assessment is focused on the activities of daily living focused on the activities of daily living requiring energy expenditure, including requiring energy expenditure, including self-care activities, exercise, and leisure self-care activities, exercise, and leisure activities. The status of major body activities. The status of major body systems involved with activity and systems involved with activity and exercise is evaluated, including the exercise is evaluated, including the respiratory, cardiovascular, and respiratory, cardiovascular, and musculoskeletal systems.musculoskeletal systems.

Cognition and PerceptionCognition and Perception. Assessment is . Assessment is focused on the ability to comprehend and use focused on the ability to comprehend and use information and on the sensory functions. Data information and on the sensory functions. Data pertaining to neurologic functions are collected pertaining to neurologic functions are collected to aid this process. Sensory experiences such as to aid this process. Sensory experiences such as pain and altered sensory input may be identified pain and altered sensory input may be identified and further evaluated. and further evaluated.

Sleep and Rest.Sleep and Rest. Assessment is focused on the Assessment is focused on the person's sleep, rest, and relaxation practices. person's sleep, rest, and relaxation practices. Dysfunctional sleep patterns, fatigue, and Dysfunctional sleep patterns, fatigue, and responses to sleep deprivation may be identified. responses to sleep deprivation may be identified.

Self-Perception and Self-Concept.Self-Perception and Self-Concept. Assessment is focused on the person's attitudes Assessment is focused on the person's attitudes toward self, including identity, body image, and toward self, including identity, body image, and sense of self-worth. The person's level of self-sense of self-worth. The person's level of self-esteem and response to threats to his or her self-esteem and response to threats to his or her self-concept may be identified. concept may be identified.

Roles and Relationships.Roles and Relationships. Assessment is focused on the person's Assessment is focused on the person's roles in the world and relationships with roles in the world and relationships with others. Satisfaction with roles, role others. Satisfaction with roles, role strain, or dysfunctional relationships strain, or dysfunctional relationships may be further evaluated. may be further evaluated.

Sexuality and Reproduction.Sexuality and Reproduction. Assessment is focused on the person's Assessment is focused on the person's satisfaction or dissatisfaction with satisfaction or dissatisfaction with sexuality patterns and reproductive sexuality patterns and reproductive functions. Concerns with sexuality may functions. Concerns with sexuality may he identified. he identified.

Coping and Stress ToleranceCoping and Stress Tolerance. . Assessment is focused on the person's Assessment is focused on the person's perception of stress and on his or her perception of stress and on his or her coping strategies Support systems are coping strategies Support systems are evaluated, and symptoms of stress are evaluated, and symptoms of stress are noted. The effectiveness of a person's noted. The effectiveness of a person's coping strategies in terms of stress coping strategies in terms of stress tolerance may be further evaluated. tolerance may be further evaluated.

Values and Belief.Values and Belief. Assessment is Assessment is focused on the person's values and beliefs focused on the person's values and beliefs (including spiritual beliefs), or on the goals (including spiritual beliefs), or on the goals that guide his or her choices or decisions. that guide his or her choices or decisions.

Types of dataTypes of dataSubjective data These can be gathered solely from the patient’s own These can be gathered solely from the patient’s own

account. Includes the pt. sensation, feelings, account. Includes the pt. sensation, feelings, values, beliefs, attitudes & perception towards values, beliefs, attitudes & perception towards health status & life situation.health status & life situation.

Referred to as symptoms or covert dataReferred to as symptoms or covert data e.g. “I feel weak all over when I exert myself”e.g. “I feel weak all over when I exert myself” “ “ I have a sharp pain on my chest”I have a sharp pain on my chest”Objective data Can be obtained through observation and verifiableCan be obtained through observation and verifiable Referred as signs or overt data, these can be seen , Referred as signs or overt data, these can be seen ,

heard, felt or smelledheard, felt or smelled Validates the subjective dataValidates the subjective data e.g. B.P. 90/50e.g. B.P. 90/50 Apical pulse 104, abdomen is distended, skin is pale Apical pulse 104, abdomen is distended, skin is pale

& diaphoretic.& diaphoretic.

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

It is a systematic data-collection It is a systematic data-collection method that uses observational skills method that uses observational skills to detect health problems. to detect health problems. (cephalocaudal or body system (cephalocaudal or body system approach)approach)

Uses the following techniques:Uses the following techniques:

Inspection, Palpation, Percussion, Inspection, Palpation, Percussion, Auscultation (IPPA)Auscultation (IPPA)

PURPOSE OF PHYSICAL ASSESMENT

To obtain baseline data about the To obtain baseline data about the client’s functional abilities.client’s functional abilities.

To supplement, confirm or refute the To supplement, confirm or refute the data obtained in nursing history.data obtained in nursing history.

To obtain data that will help the nurse To obtain data that will help the nurse establish nursing dx. & plan the client’s establish nursing dx. & plan the client’s care.care.

To evaluate the physiologic outcomes To evaluate the physiologic outcomes of healthcare & the progress of the of healthcare & the progress of the client’s health problem.client’s health problem.

ASSESSMENT TOOLS

Sphygmomanometer Sphygmomanometer Cotton ballsCotton balls GlovesGloves Visual acuity chartsVisual acuity charts OphthalmoscopeOphthalmoscope OtoscopeOtoscope PenlightPenlight Percussion HammerPercussion Hammer Safety pinsSafety pins

Scale with height Scale with height measurementmeasurement

Skin calipersSkin calipers SpeculumSpeculum StethoscopeStethoscope Tape measureTape measure ThermometerThermometer Tuning forkTuning fork Tongue depressorTongue depressor

NURSING DIAGNOSIS NURSING DIAGNOSIS

A clinical judgment about an A clinical judgment about an individual, family or community individual, family or community responses to actual or potential responses to actual or potential health/life processes.health/life processes.

Provides the basis for selection of Provides the basis for selection of nursing intervention to achieve nursing intervention to achieve outcomes for which the nurse is outcomes for which the nurse is accountable. accountable.

Nursing DiagnosisNursing Diagnosis

Diagnosing is a process which results Diagnosing is a process which results to a diagnostic statement. to a diagnostic statement.

Nursing Diagnosis – is a statement of Nursing Diagnosis – is a statement of a client’s potential or actual a client’s potential or actual alteration of health status. It results alteration of health status. It results from analysis and synthesis. from analysis and synthesis.

Purpose: To identify the client’s Purpose: To identify the client’s health care needs and to prepare health care needs and to prepare diagnostic statements.diagnostic statements.

NURSING DIAGNOSISNURSING DIAGNOSIS

Medical diagnosisMedical diagnosis describes a disease or pathology of specific describes a disease or pathology of specific

organs or body systemorgans or body system Provide convenient means for Provide convenient means for

communicating treatment requirementscommunicating treatment requirements Nursing DiagnosisNursing Diagnosis

- describes an actual, risk or wellness human - describes an actual, risk or wellness human response to a health problem that nurses response to a health problem that nurses are responsible for treating independently. are responsible for treating independently.

Nursing Diagnosis Nursing Diagnosis

EXAMPLE:EXAMPLE:Medical Dx: Pneumonia Medical Dx: Pneumonia Nursing Dx: Ineffective airway Nursing Dx: Ineffective airway

clearance r/t tracheobronchial clearance r/t tracheobronchial secretions secretions

Medical Dx: TonsillitisMedical Dx: TonsillitisNursing Dx: Elevated body temperature Nursing Dx: Elevated body temperature

related to presence of pyrogens.related to presence of pyrogens.

NURSING DIAGNOSIS NURSING DIAGNOSIS TAXONOMYTAXONOMY

Taxonomy Taxonomy Method for ordering complex Method for ordering complex

information information Classification system to provide Classification system to provide

structure for nursing practice. structure for nursing practice. Purpose: to provide vocabulary for Purpose: to provide vocabulary for

classifying phenomena in a disciplineclassifying phenomena in a discipline

Components of Nursing DxComponents of Nursing Dx

Diagnostic Label/Problem - this describes Diagnostic Label/Problem - this describes the client’s health status clearly and the client’s health status clearly and concisely in a few words. - name of the concisely in a few words. - name of the nursing diagnosis as listed in the taxonomynursing diagnosis as listed in the taxonomy E.g. Impaired mobility; activity intoleranceE.g. Impaired mobility; activity intolerance

Descriptors – words used to give additional Descriptors – words used to give additional meaning to a nursing diagnosis. They meaning to a nursing diagnosis. They describe changes in condition, state of the describe changes in condition, state of the client or some qualificationclient or some qualification E.g. altered, impaired, decreased, ineffective, E.g. altered, impaired, decreased, ineffective,

acute, chronic, excessive, delayed acute, chronic, excessive, delayed

Components of Nursing DxComponents of Nursing Dx

Related factors/Etiology – describes the Related factors/Etiology – describes the conditions, circumstances that contribute to the conditions, circumstances that contribute to the problem. Terms used: associated with, related problem. Terms used: associated with, related to or contributing to. to or contributing to.

Defining characteristics/Signs and symptoms – Defining characteristics/Signs and symptoms – observable cues that cluster as manifestation of observable cues that cluster as manifestation of an actual or wellness nursing diagnosis. an actual or wellness nursing diagnosis.

Risk factors – describe clinical cues in risk Risk factors – describe clinical cues in risk nursing diagnosis. They are environmental, nursing diagnosis. They are environmental, physiological, psychological, genetic, or physiological, psychological, genetic, or chemical factors that increase the vulnerability chemical factors that increase the vulnerability of pt. leading to unhealthful event. of pt. leading to unhealthful event.

Formulating Nursing DiagnosisFormulating Nursing Diagnosis

A.A. Collect Valid and pertinent dataCollect Valid and pertinent data

B.B. Cluster the DataCluster the Data

C.C. Differentiate Nursing Dx from Differentiate Nursing Dx from Collaborative problemsCollaborative problems

D.D. Formulate Nursing Dx correctly Formulate Nursing Dx correctly select priority diagnosis.select priority diagnosis.

Use Nursing Diagnosis Decision TreeUse Nursing Diagnosis Decision TreeIs there a problem in a specific area?

Yes No

If no problem, is the person at risk for developing a problem?

Collect more focused data. Is a problem present?

YesYes No

Actual Nsg Dx Risk Nsg Dx Although there is no actual problem or risk factors to actual problem, does the person desire to improve

Well Nursing Diagnosis

Types of Nursing DiagnosisTypes of Nursing DiagnosisA. ActualA. Actual

Describes a clinical judgment that the nurse Describes a clinical judgment that the nurse has validated because of the presence of has validated because of the presence of major defining characteristics.major defining characteristics.Ex. Ineffective Airway Clearance related to Ex. Ineffective Airway Clearance related to excessive and tenacious secretions.excessive and tenacious secretions.

B. RiskB. RiskDescribes a clinical judgment that an Describes a clinical judgment that an individual/group is more vulnerable to individual/group is more vulnerable to develop the problem than others in the same develop the problem than others in the same or similar situationor similar situationEx. Risk for Impaired Skin Integrity related to Ex. Risk for Impaired Skin Integrity related to immobility secondary to fractured hip. immobility secondary to fractured hip.

C. PossibleC. PossibleAn option to indicate that some data are An option to indicate that some data are present to confirm a diagnosis but are present to confirm a diagnosis but are insufficient as of this time.insufficient as of this time.Ex. Possible Self Care Deficit related to Ex. Possible Self Care Deficit related to impaired ability to use left hand secondary impaired ability to use left hand secondary to presence of intravenous therapy. to presence of intravenous therapy.

D. WellnessD. WellnessDiagnostic statement that describes the Diagnostic statement that describes the human response to level of wellness.human response to level of wellness.From a specific level of wellness to a From a specific level of wellness to a higher level of wellness. higher level of wellness. Ex. Readiness for enhanced spiritual well Ex. Readiness for enhanced spiritual well beingbeing

Diagnostic StatementsDiagnostic StatementsA. One-PartA. One-Part

Just the label or the problemJust the label or the problemEx. Readiness for enhanced parentingEx. Readiness for enhanced parenting

B. Two-PartB. Two-PartProblem r/t to etiology or risk factorsProblem r/t to etiology or risk factorsEx. Risk for impaired skin integrity related to Ex. Risk for impaired skin integrity related to immobility secondary to fractured hipimmobility secondary to fractured hip

C. Three-PartC. Three-PartDiagnostic label + contributing factors + Diagnostic label + contributing factors + signs and symptoms.signs and symptoms.Ex. Anxiety related to unpredictable nature Ex. Anxiety related to unpredictable nature of operative procedure as evidenced by of operative procedure as evidenced by statements of: “Natatakot akong hindi statements of: “Natatakot akong hindi makahinga.” makahinga.”

Nursing DiagnosisNursing DiagnosisTo use NANDA (2003 edition)To use NANDA (2003 edition)Use the 2-part Diagnostic Use the 2-part Diagnostic

StatementsStatements

Problem r/t etiology or risk factors Problem r/t etiology or risk factors + secondary to+ secondary to

Don’tsDon’ts Using medical diagnosisUsing medical diagnosis

ex. Self care deficit related to strokeex. Self care deficit related to strokeSelf care deficit related to neuromuscular Self care deficit related to neuromuscular

impairmentimpairment Relating the problem to an unchangeable Relating the problem to an unchangeable

situationsituationex. paralysisex. paralysis

Confusing etiology or s/sx for the problemConfusing etiology or s/sx for the problemex. Post op lung congestion related to bedrestex. Post op lung congestion related to bedrest

Ineffective airway clearance related to general Ineffective airway clearance related to general weakness and immobilityweakness and immobility

Use of procedure instead of a human responseUse of procedure instead of a human responseex. Catheter related to urinary retentionex. Catheter related to urinary retention

Urinary retention related to perineal swellingUrinary retention related to perineal swelling

Lack of specificityLack of specificityex. Constipation related to nutritional imbalanceex. Constipation related to nutritional imbalance

Combining two nursing dxCombining two nursing dxex. Anxiety and fear related to separation from ex. Anxiety and fear related to separation from parentsparents

Relating one nursing dx to anotherRelating one nursing dx to anotherex. Ineffective coping related to anxietyex. Ineffective coping related to anxiety

Use of judgmental / value laden languageUse of judgmental / value laden languageex. Pain related to monetary gainex. Pain related to monetary gain

Making assumptionsMaking assumptionsex. Risk for altered parenting related to ex. Risk for altered parenting related to inexperienceinexperience

Writing a legally inadvisable statementsWriting a legally inadvisable statementsex. Impaired skin integrity related to not being ex. Impaired skin integrity related to not being turned 2 hourlyturned 2 hourly

PLANNING PLANNING

Involves determining beforehand the Involves determining beforehand the strategies or course of actions to be strategies or course of actions to be taken before implementation of taken before implementation of nursing care. nursing care.

To be effective, involve the client and To be effective, involve the client and his family in planning.his family in planning.

Purpose: To identify the client’s goal Purpose: To identify the client’s goal and appropriate nursing and appropriate nursing interventions. interventions.

PLANNING PLANNING

1.1. Set priorities in collaboration with Set priorities in collaboration with the patient the patient

E.g. Lessened pain scale from 9 – 5E.g. Lessened pain scale from 9 – 5

Increase weight from 110 lbs Increase weight from 110 lbs – 115 lbs – 115 lbs

PLANNINGPLANNING

2.2. Set goals and objectives in Set goals and objectives in collaboration with the client.collaboration with the client. Short- Short-term goal (STG) or Long-term goal (LTG)term goal (STG) or Long-term goal (LTG)

S – Specific S – Specific

M – Measurable M – Measurable

A – Attainable A – Attainable

R – Realistic R – Realistic

T – Time-framed T – Time-framed

PLANNINGPLANNING

Example: STGExample: STG

At the end of 8 hrs of nursing At the end of 8 hrs of nursing interventions, the patient’s temperature interventions, the patient’s temperature will be equal to or less than 37.8 C per will be equal to or less than 37.8 C per axilla.axilla.

At the end of 4 hrs of nursing At the end of 4 hrs of nursing interventions, the patient’s pain will be interventions, the patient’s pain will be relieved if not lessened as manifested by relieved if not lessened as manifested by decrease in pain scale from 9-5 and decrease in pain scale from 9-5 and presence of unguarded behavior. presence of unguarded behavior.

PLANNINGPLANNING

Example: LTGExample: LTG After one week of nursing After one week of nursing

interventions, theinterventions, the

patient’s body temperature will remain patient’s body temperature will remain underunder

normal range of =/> 37.8 C per axilla.normal range of =/> 37.8 C per axilla.

AAfter 2 weeks of nursing intervention, fter 2 weeks of nursing intervention, the patient’s weight will increased from the patient’s weight will increased from 110 lbs – 115 lbs. 110 lbs – 115 lbs.

IMPLEMENTATIONIMPLEMENTATION

Putting the nursing care plan into Putting the nursing care plan into action action

Purpose: To carry out planned Purpose: To carry out planned nursing interventions to help the nursing interventions to help the client attain goalsclient attain goalsRequirements:Requirements:

1. Knowledge 1. Knowledge

2. Technical skills 2. Technical skills

3. Communication Skills 3. Communication Skills

IMPLEMENTATION IMPLEMENTATION

STEPS: STEPS:

1. Reassess the client 1. Reassess the client

2. Set priorities 2. Set priorities

a. ABCa. ABC

b. Maslow’s hierarchy of needs b. Maslow’s hierarchy of needs

3. Implement nursing interventions 3. Implement nursing interventions

4. Documentation 4. Documentation

IMPLEMENTATION IMPLEMENTATION Implementing Nursing interventionsImplementing Nursing interventions

1. Assessment – for baseline data 1. Assessment – for baseline data ex: Assess breath sounds, assess wt ex: Assess breath sounds, assess wt

2. Independent nursing interventions 2. Independent nursing interventions ex: Positioned pt to high-fowlers ex: Positioned pt to high-fowlers position position Encouraged slow but deep breathing Encouraged slow but deep breathing Instructed to small but frequent Instructed to small but frequent feedingfeeding

IMPLEMENTATION IMPLEMENTATION

3. Dependent nursing interventions 3. Dependent nursing interventions

ex: Administered pain reliever as ex: Administered pain reliever as ordered. ordered.

4. Interdependent nursing interventions 4. Interdependent nursing interventions ex: Secured specimen for urinalysis as ex: Secured specimen for urinalysis as

orderedordered

5. Psychosocial interventions 5. Psychosocial interventions

ex: Encouraged verbalization of feelings ex: Encouraged verbalization of feelings

EVALUATION EVALUATION

Assessing the client’s response to Assessing the client’s response to nursing interventions and then nursing interventions and then comparing the response to comparing the response to predetermined standards or outcome predetermined standards or outcome criteria. criteria.

Purpose: To determine the extent to Purpose: To determine the extent to which goals if nursing care have which goals if nursing care have been achieved. been achieved.

EVALUATION EVALUATION

STEPS:STEPS:

1. Collect data about client’s 1. Collect data about client’s response response

2. Compare the client’s 2. Compare the client’s response to outcome criteria response to outcome criteria

3. Analyze the reasons for the 3. Analyze the reasons for the outcomes outcomes

4. Modify care plan as needed. 4. Modify care plan as needed.

EVALUATION EVALUATION

Example:Example:After 8 hours of nursing After 8 hours of nursing

intervention, the patient verbalizes intervention, the patient verbalizes relief of pain with Pain scale from 9 – relief of pain with Pain scale from 9 – 5. Patient manifests relaxed and 5. Patient manifests relaxed and unguarded behavior. unguarded behavior.

After 8 hrs of nursing After 8 hrs of nursing intervention, the pt’s body intervention, the pt’s body temperature was 37.8 C per axilla. temperature was 37.8 C per axilla.

Characteristics . . . . . Characteristics . . . . .

Problem-oriented – it is comparable with scientific Problem-oriented – it is comparable with scientific problem solving approachproblem solving approach

Goal oriented Goal oriented Orderly, planned, step by step Orderly, planned, step by step Open to accepting new information during its Open to accepting new information during its

application application InterpersonalInterpersonal Permits creativity among nurses and clients in Permits creativity among nurses and clients in

devising ways to solve the health problems devising ways to solve the health problems Cyclical Cyclical Universal Universal

Benefits for clients Benefits for clients

Quality of care Quality of care

Continuity of careContinuity of care

Participation by the clients in their Participation by the clients in their health care health care

Benefits for the Nurse Benefits for the Nurse

Consistent and systematic nursing Consistent and systematic nursing education education

Job satisfaction Job satisfaction Professional growth Professional growth Avoidance of legal action Avoidance of legal action Meeting professional nursing standards Meeting professional nursing standards Meeting standards of accredited Meeting standards of accredited

hospitals hospitals