FUNDAMENTALS OF NURSING HISTORY OF NURSING PERIODS OF NURSING INTUITIVE NURSING/ PRIMITIVE NURSING/ INSTINCTIVE NURSING (Primitive times – 6 th century) PRIMITIVE TIMES - Women practice nursing because of low status in society. - Took Took care of children and sick members of the family. family. - Personalistic cause of disease. - Sickness is due to active intervention of: a. human – caused by witchcraft. b. non human – caused by ghosts. c. superhuman beings – caused by deities. - Superstitious and believes in magic. - Slave society “slave nurses” - Wet nursing, take care of babies/children of their masters - Women also practices midwifery. - Masters/healers are the people who are responsible in decision making when it comes to health. 6th CENTURY - Founding of religious orders. 3 Attributes of Nurses 1. Self denial 2. Devotion to hard work and duty. 3. With spiritual calling. Main Guiding Principles 1. “Love thy neighbor as thy self”. 2. Parable of the Good Samaritan. - Beneficence (doing good to others). 2 Types of Beneficence 1. Ordinary – doing good to others. 2. Ideal – entails sacrifice. APPRENTICE NURSING PERIOD (6th Century – 18th Century) 6TH CENTURY - founding of religious orders. - women practiced nursing. - Daughters of Charity/Sisters of Charity founded by St. Vincent de Paul and Augustinian Sisters. CRUSADES - Men practiced nursing. - Knights of St. Lazarus a. established a standard among hospitals in Europe. b. took care of clients with skin problems like leprosy. - Knights of St. John of Jerusalem a. also known as Knights Hospitalers. Hospitalers . b. founded hospitals. TH 18 CENTURY 1836 - Theodore Fleidner reestablished order of Deaconesses. - Founded school of nursing in Kaisserwerth, Germany where Florence Nightingale was the most known student. 1854-1856 (CRIMEAN WAR) - Florence Nightingale was known as the Lady with a Lamp. Lamp . - Compiled the “Notes on Nursing: What it is and What is not” and became the first nurse theorist. theorist .
EDUCATIONAL NURSING PERIOD (18th Century – 20th Century) 18TH CENTURY - Florence Nightingale established a nursing school in St. Thomas Hospital in London which adopted the Nightingale Nightingale System. System. - Made Florence Nightingale the mother of modern nursing . Philosophy of Nightingale System 1. Government funds should be allotted to nursing education. - earned her the title of being the first nurse political activist. activist. 2. Training Training schools of nursing should be in close affiliation. 3. Professional nurses should train nurses. 4. Nursing students should be provided with residence near their training hospitals. - written orders of doctors insisted. - nurses should go with doctors during rounds. LATE 20TH CENTURY - Specialization in medicine. - Conceptualization of the role of clinical nurse specialist. - Increase clinical content of education (1900’s). CONTEMPORARY PERIOD (21st Century) - Globalization of nursing. - Period after world war II. - Borderless nursing or transcultural nursing. - Professionalization of nursing. PROFESSION – a special calling that requires special, skills, knowledge and attitudes. PROFESSION – 7 CRITICAL ATTRIBUTES OF PROFESSION 1. Specialized Specialized education 2. Code of ethics 3. Research of orientation 4. Autonomy 5. Body of knowledge 6. Service orientation 7. Professional Organization SOCIALIZATION – process where a person learns the ways and means or skills, knowledge, attitudes of the group to which he belongs to. BENNER LEVEL OF PROFICIENCY 1. Novice – student nurse entering a clinical setting where he has no experience at all. 2. Advance – nurse who demonstrates a marginally acceptable performance: depends on rules and maxims. 3. Competent – 2 – 3 years experience demonstrates organizational ability but lacks speed and flexibility of a proficient nurse. 4. Proficient – concerned with long term goals, performance is fluid and flexible compared to competent nurse - has a wholistic view of the client. 5. Expert – no longer relies on maxims, performance is highly proficient, fluid flexible and has a wholistic view. view. - has high perceptual acuity or a clinical eye. DIMENSIONS OF NURSING 1. Nursing Practice 2. Nursing Education 3. Nursing Research FOCUS OF NURSING 1. Health Promotion – improve clients well being. 2. Health Maintenance 3. Health Instauration – help clients with illness to recover. 4. Care of the Dying – clients with cancer. ROLE – ROLE – patterns of behavior expected of person assuming a status/position in society or a group. TASK – TASK – specific activities required of a person.
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PATIENT Has a disease Very dependent on health professional
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CLIENT Not necessarily sick Health promotion act till disease prevention Client collaborates with health professional
LEVELS OF CLIENTELE 1. Individual 2. Family 3. Community 4. Population Groups – special g roups with special needs attributed to the following: a. Cultural characteristics – indigenous people. b. Developmental stage c. Occupation – commercial sex workers are more prone to STD’s. ROLES OF NURSE 1. Nurse Educator - 3 domains of learning a. Cognitive – knowledge aspect b. Psychomotor – skills c. Affective – interest/emotion interest/emotion 2. Caregiver - Attends to physical/emotional (mostly physical) needs of the client. 3. Nurses as Leader - Process of influencing people to work towards the attainment of goals. 4. Manager - Organizational goals/works within an organization. PROCESS OF MANAGEMENT a. Plan Planni ning ng (res (resou ourc rces es)) b. Organi Organizin zing g (delega (delegatin ting g tasks/t tasks/task asking ing)) c. Direct Directing ing (moti (motivat vating ing people people)) d. Controlli Controlling ng – evaluation evaluation of output output against against standar standards. ds. 5. Client advocate – protects rights of clients. 6. Change agent – improvement in organization. 7. Researcher – Researcher – research process 8. Facilitator THEORIES – relationship between concepts THEORIES – 4 CONCEPTS OF NURSING THEORIES 1. Individual/Person 2. Nursing 3. Health 4. Environment
NURSING THEORIES A. GENERAL THEORIES 1. NIGHTINGALE’S ENVIRONMENTAL THEORY - What nursing has to do is to put the individual in best position for nature to work on him. - Nursing Action: manipulation manipulation of elements in the environment to contribute to reparative process. 10 ELEMENTS FOUND IN ENVIRONMENT 1. Air – Air – importance to have moving air in room of patient to contribute in proper ventilation. 2. Light – patient should be near windows to be able to see sunlight and give hope. 3. Health of houses – environmental sanitation. 4. Cleanliness 5. Beddings – change linens/beddings in patients room to promote comfort. 6. Nutrition 7. Variety – change in environment for patient. 8. Ventilation – promote warming. 9. Noise – due to nurses clothing or roaming around. 10. Chattering hopes – deals with social aspect; nurse should be cautious with words when at bedside, talk about positive things. 2. VIRGINIA HENDERSON’S DEFINITION OF NURSING - Assisting individuals sick or well in the performance of activity. activity. - Role of nurse is complimentary. - Supplementary - Individual person is a whole, complete and individual being. NURSE- PERSON INTERACTION GOALS
NURSINDEPENDENCE ES
PERSON
KNOWLEDGE RESTORATION
WILL
MAINTENANCE STRENGTH ENVIRONMENT
14 BASIC COMPONENTS OF NURSING CARE 1. Breathe normally 2. Eat, drink adequately 3. Eliminate body waste 4. Move and maintain desirable posture 5. Sleep and rest 6. Select suitable clothes 7. Maintain body temperature 8. Keep body clean and well groomed 9. Avoid dangers in environment 10. Communicate with others 11. 11. Worship according to ones faith 12. Work for accomplishment 13. Participate in recreation 14. Learn to satisfy the curiosity that leads to normal development
1-9 PHYSIOLOGIC 10 – 14 PSYCHOLOGICAL 12 – 13 SOCIOLOGIC 11 SPIRITUAL/MORAL
3. MARTHA ROGER’S SCIENCE OF UNITARY HUMAN BEINGS A. Nursing is humanistic science B. Parallel with Ludwig von Bertalanffy’s General System Theory C. 5 assumptions about human beings 1. Man is a unified whole – whole not equal to sum of parts. 2. Individual and environment are continuously exchanging matter and energy. 3. Lifecycle evolves irreversibly and uni-directionally along space and time continuum. 4. Life patterns identify individuals. 5. Humans have the capacity for absorption and imagery, imagery, language and thought, sensation and emotion. GENERAL SYSTEM THEORY - A set of interacting parts/ components with a boundary that filters the input and output from and to the environment. - Input and output: matter, energy, information. - Whole: physical, psychological, spiritual, intellectual. 4. DOROTHEA OREM’S SELF CARE DEFICIT THEORY - Man is an integrated whole, biologically, biologically, symbolically and socially. socially. - Man is self reliant and responsible for self care. - Man is requisite for all. - Nursing is a service, art and technology. 3 SUB THEORIES 1. Self Care – universal self care, developmental. 2. Self Care Deficit – demands, capabilities, deficits. 3. Theory of Nursing Systems – wholly compensatory, compensatory, partly supportive-educative. UNIVERSAL SELF CARE REQUISITES 1. Sufficient intake of air 2. Sufficient intake of water 3. Sufficient intake of food 4. Satisfactory eliminative functions 5. Activity balanced with rest 6. Time spent alone balanced with time spent with others 7. Prevention of danger 8. Being normal DEVELOPMENT OF SELF CARE REQUISITES - Specialized expression of universal self-care requisites for development process. HEATH DEVIATION - Additional demands for health care due to illness, disease or injury. THEORY OF NURSING SYSTEM 1. Wholly compensatory – nurse acts for patient. 2. Partly compensatory – both nurse and patient. 3. Supportive-Educative – patient able to perform self care. B. SYSTEM THEORIES 5. SISTER CALLISTA ROY’S ADAPTATION ADAPTATION MODEL MOD EL - Grounded on humanism. - Person is adaptive system s ystem with coping mechanism. - Goal of nursing is to promote persons adaptation. STIMULI 1. Focal - immediate 2. Contextual – other internal and external factors 3. Residual – may or may not have effect like attitudes and beliefs.
COPING MECHANISMS 1. Regulator – neural – chemical – endocrine. 2. Cognator – processed through cognition. ADAPTIVE MODES - Physiologic – adaptive mode - Self concept mode - Interdependence mode - Role function mode - Adaptive/effective response - Maladaptive/ineffective response 6. IMOGENE KING’S GOAL-ATTAINMENT THEORY - Nursing is a process of human interaction between the nurse, client, each person perceive the other and situation and explore the means to achieve them. - Humans are open systems in constant interaction with their environment. - Nursing focus: human interact with the environment. - Nursing Goal: humanistic maintenance of individuals and groups. - Interacting components are personal, interpersonal, social. - Elements: interaction, communication, transaction role, stress. COMPONENTS PERSONAL SYSTEM - Perception, self, growth and development, image, space, learning time. - Organization, authority, power, status, decision making. 7. BETTY NEUMAN’S HEALTH CARE SYSTEMS MODEL - Based on 2 components stress, reaction to stress. - Client (individual, group, community) is an open system in interaction with environment. 4 CONCEPTS A. CLIENT Flexible – keeps system free from stressor reaction or symptom-matology. symptom-matology. Line of Resistance – consist of internal defensive processes. Ex. Immune response. B. ENVIRONMENT - Environment has potential to alter system stability due to internal and external stressors. STRESSORS CAN BE
1. Extra personal – unemployment, microorganisms, peer pressure, radiation. 2. Inter personal – between 2 or more individual (parent expectations). 3. Intra personal – anger, physical abilities, financial condition. condition. - Environment can also be source of resources that may help client cope with stressors. C. HEALTH D. NURSING - Primary: protection of normal line of defense. - Secondary: protection of basic structure b y strengthening internal line of resistance. Ex. Treatment of symptoms, energy conservation - Tertiary: Tertiary: promotion of reconstitution by supporting existing strengths and resources. 8. DOROTHY JOHNSON’S BEHAVIORAL SYSTEMS MODEL Mans subsystem - Behavioral subsystem: addressed by nursing intervention. - Biological subsystem: addressed by medical intervention. Goal of Nursing a. demonstrate behavior commensurate to social demands. b. modify behavior to support biological needs. c. benefit from physicians skill and knowledge. d. demonstrate behavior that does not give evidence of unnecessary trauma. - Nursing focus: behavior modification to foster equilibrium.
C. INTERPERSONAL/CARING THEORIES 9. HILDEGARD PEPLAU’S INTERPERSONAL RELATIONSHIP IN NURSING - purpose of nursing is to educate and to be a nurturing force to a patient for him to get a new view of himself. - interaction is a maturing force. Nurse Counselor – identify stressor Resource Person – Person – health educator Surrogate – Surrogate – acts as caregiver
Patient (with a need)
Congruent Goals
PHASE OF NURSE – PATIENT PATIENT RELA REL ATIONSHIP 1. Orientation – leveling off between nurse and client in term of expectation. 2. Identification – selective response of the client to those who can meet his needs; affected by clients belief. 3. Exploitation – client takes control of the situation by extracting help from nurse. 4. Resolution – evaluation of care and discharge of client.
10. MADELEINE LEININGER’S TRANSCULTURAL CARE THEORY - Culture: way of life, total of all the material and non material’s produced by the people at their level of social development. - has universalities: same as other culture (hygiene, nutritional needs). - diversities: cultural peculiarities (caring ). 11. IDA JEAN ORLANDO’S DYNAMIC NURSE-CLIENT RELATIONSHIP - Types of nursing response: deliberate action(based on correct identification of patients needs) and automatic action. - nursing function is concerned with providing direct assistance to individuals in whatever setting to avoid, diminish, relieve individual’s sense of h elplessness. - Nursing disciplined professional response. 12 JEAN WATSON’S PHILOSOPHY AND SCIENCE OF CARING - Nursing is the science of caring. - Caring is more healthogenic than caring. - Main focus of nursing is on curative factors that are derived from humanistic perspectives combined with a scientific base. 10 CARA C ARATIVE TIVE FACTORS 1. Formation of a humanistic-altruistic value system. 2. Faith – hope 3. Cultivation of sensitivity to self and others. (First 3 factors are the foundations foundations for caring) ca ring) 4. Establishing a helping trust relation 5. Expression of feelings, both positive and negative. 6. Research and systematic problem solving. 7. Promotion of interpersonal teaching-learning. 8. Provi Provisio sions ns for a suppor supportiv tive, e, protec protectiv tive e and correc correcti tive ve mental mental,, physic physical, al, socioc sociocult ultura urall and spirit spiritual ual environment. 9. Assistance with the gratification of human. 10. Allowance for existential phenomenological factors. D. CLIENT CENTERED THEORIES 13. FAYE GLEN ABDELLAH’S 21 NURSING PROBLEMS - Nursing in the use of the problem solving approach - Covert: psychological problem - Overt: obvious (physical manifestations of health problems)
14. LYDIA HALL’S THEORY OF CORE, CARE, CURE - Patient is composed of 3 elements: body, pathology, pathology, person - Nursing is helping clients move in the direction of self awareness - Nursing operates in all 3 elements - Core: the person, therapeutic use of self - Care: the body, intimate body care (nurturing component) - Cure: the disease, medical care (client advocate) 15. MYRA ESTRINE LEVINE’S FOUR CONSERVATION PRINCIPLES OF NURSING - Promotion of the wholeness of the person - By improving the clients patterns of adaptive response CONSERVATION CONSERVATION OF
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Energy
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Structural Integrity
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Personal Integrity
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Social Integrity
Prom Promoti otion on of “whol “wholene eness” ss” of the the client client towar towards ds health health maintenance or health restoration.
CONSERVATION - Defends wholeness of living systems by ensuring their ability to confront change 16. NOLA J. PENDER’S HEALTH PROMOTION MODEL - Directed towards increasing the level of well being and self actualization of a given individual or group - Example: 6 – 8 hours of sleep - Disease prevention/Health prevention/Health protection: protection: action directed towards decreasing the probability of experiencing illness by active protection of the body against pathological stressors. - Example: BCG vaccination COGNITIVE PERCEPTUAL FACTORS
MODIFYING FACTORS FACTORS
Importance of health
Demographic character
Perceived control of health
Biologic
Perceived self efficacy
Interpersonal influences
Depth of health
Situational factors
Perceived health status
Behavioral factor
LIKELIHOOD IN ENGAGING IN HEALTH PROMOTING BEHAVIORS
Ex. Mass media Perceived benefits of health promoting behaviors
Cues to action Perceived barriers of health promoting behaviors
HEALTHY LIFESTYLE - Adequate nutrition 3 times a day - Regular exercise 3 times a week - Not smoking - Moderate intake of alcohol CONCEPT OF MAN Atomistic – whole or sum of parts Holistic – the whole is not equal to the sum of parts Physiologic – genetic character, organs and functioning Psychological – emotions, affect, rationality, rationality, merciful Socio-cultural – socialization, family, family, language Intellectual – perception, cognition Spiritual – faith (unquestioning belief in someone, serves to unite humans), hope, charity Charity – outward expression of love for others BASIC HUMAN NEEDS 1. Universal 2. Met in different ways 3. Stimulated by external and internal factors 4. Maybe differed 5. Interrelated 6. Priorities maybe altered MASLOW’S HEIRARCHY OF NEEDS - Need: Need: anything that is essential to the survival of man - Framework: Framework: basic need is something whose - Absence: Absence: may cause illness - Presence: Presence: prevent illness/signal health - Meeting unmet needs restore health
Physiologic - sex, nutrition, shelter, clothing, water, elimination, rest and sleep Safety and Security - physical freedom from harm, psychological knowing what to expect from others and what others expect from you. Love and Belongingness - nurturance with affection Self Esteem - persons sense of achievement and independence, competence, confidence and strength Self Actualization Actualization - not all people attain self actualization (attained by only 15%) - Accepts himself - Balance between rest and activity - Open mind - Positive outlook in life HEALTH - Health is a state of complete ph ysical, mental and social well-being and not merely the absence of disease or infirmity. WELLNESS - State of well being - Subjective perception of balance, harmony and vitality engaging in attitudes and behaviors that enhance the quality of life and maximizes personal p otential.
DIMENSION OF WELLNESS - Physical: ADL, fitness of organ structures and functioning - Spiritual: faith and hope - Intellectual: use knowledge for personal, family, social, career development - Emotional: able to manage stress, express feelings and emotions appropriately - Social: interact successfully with others, tolerant of people with different beliefs
MODELS OF HEALTH AND WELLNESS LEAVELL AND CLARKS AGENT – HOST ENVIRONMENT MODEL OR ECOLOGICAL MODEL/EPIDEMIOLOGIC Agent
Host
Environment
DUNN’S HIGH LEVEL WELLNESS GRID Very Favorable Environment Protected poor health ( in favorable environment)
High level wellness (in favorable environment)
HEALTH AXIS Death Poor health (in an unfavorable environment)
Peak Wellness Energetic, High level wellness (in an unfavorable environment)
Environmental axis Very Unfavorable Environment Both physical and social cultural environment
TRAVIS ILLNESS – WELLNESS CONTINUUM
Wellness model
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Premature Death Disability Symptoms/Signs Symptoms/Signs
Awareness/ Education/ Growth
High Level Wellness
Treatment Models
Neutral Point (no discernable illness or wellness) - Movement to the right of the neutral point indicates high level of health and well being for an individual and this may be achieved through awareness and education and growth. In contrast, movement to the left of the neutral point indicates a progressively decrease state of health
HEALTH BELIEF MODEL - Intended to predict whether individuals would or would not use preventive measure - Based on the motivational theory - Assumption: Assumption: Good health is a motivation common to all people ILLNESS - Highly personal state in which the person feels unhealthy or ill, may or may not b e related to disease DISEASE - Alteration in body function resulting in a reduction of capacities or a shortening of the normal lifespan CAUSES OF DISEASE 1. Geneti Genetic c – inher inherite ited, d, genet genetic ic defec defects ts 2. Development Developmental al – resulting resulting to exposu exposure re to virus virus or chemicals chemicals during during pregnancy pregnancy 3. Biologic Biologic – microorgani microorganisms sms (virus, (virus, bacteria, bacteria, protozoa protozoa,, fungi) and their their toxins and helminthe helminthes s 4. Physical Physical – tempera temperature ture extre extremes, mes, electri electricity city,, radiation radiation 5. Chemic Chemical al – alcoho alcohol, l, stron strong g acid and and base, base, drugs drugs 6. Mechanical Mechanical – generalize generalized d tissue response response to injury injury or irritation irritation (trauma (trauma shearing shearing force, force, friction) friction) 7. Physiologi Physiologic c and and Emoti Emotional onal reaction reaction to stress stress 8. Faulty Faulty Chemical Chemical or Metabolic Metabolic Processe Processes s – excessive or insuffi insufficient cient producti production on of hormones, hormones, enzymes IGUN’S 11 STAGES OF HEAL HE ALTH TH SEEKING - Any activity undertaken by a person who feels ill in order to define his state of health and seek a suitable remedy Stage 1: Symptom experience Stage 2: Self treatment or self medication Stage 3: Communication to others Stage 4: Assessment of symptoms Stage 5: Sick-role assumption Characteristics of Sick Role a. Expect Expected ed to seek seek comp compete etent nt help help b. Expected Expected to to get well in the the shortes shortestt possible possible time
c. Person Person is not not blam blamed ed for for his his diseas disease e d. Exem Exempt pted ed fro from m usu usual al task task Stage 6: Concern Stage 7: Efficacy of treatment Stage 8: Selection of treatment Stage 9: Treatment Stage 10: Assessment of effectiveness of treatment Stage 11: Recovery and rehabilitation SUCHMAN’S 5 STAGES OF ILLNESS Stage I: Symptom S ymptom Experience - Person believes that something is wrong - Physical experience of the symptoms - Cognitive aspect: interpretation of the symptoms - Emotional response: fear or anxiety Stage II: Assumption of Sick Role - People are excused from normal duties and role expectations - Clients are not held responsible for their condition - Clients are obliged to get well and resume normal activity - Clients are obliged to seek competent help Stage III: Medical Care Contact - Seeking medical advice to ask for the following o Validation of real illness Explanation of symptoms in understandable terms o o Reassurance that they will be fine or for a prediction of what the outcome would be - Client may accept or deny diagnosis Stage IV: Dependent Client Role - The client is dependent on the professional for help and give up their independence - Client accepts treatment plan Stage V: recovery or Rehabilitation - Client relinquishes role and resumes former role a nd responsibilities - For perman permanent ent disabi disabili lity ty,, this this may requir require e therap therapy y to learn learn how to make make major major adjust adjustmen ments ts in functioning.
1. 2. 3. 4. 5. 6.
CHARACTERISTICS OF NURSING PROCESS Cycli Cyclic c and dynami dynamic c rather rather than than stat static ic Client Client centered centered – nurse organize organizes s plan of care accordi according ng to client client problems problems rather rather that nursing nursing goals goals Interperso Interpersonal nal and collaborat collaborative ive – depends on open and meaningf meaningful ul communicat communication ion between between client client and the nurse Univer Universal sally ly applica applicable ble – can be used with with clients clients of any age at any point point of the wellne wellness ss – illnes illness s continuum and useful useful in a variety of settings Adaptation Adaptation of problem problem solving solving techniqu techniques es and system system theory theory based on the scientif scientific ic method method It can be be viewed viewed as parallel parallel to but separat separate e from the the medical medical process process
ASSESSMENT - Objective (physical exam) and subjective (nursing history) SOURCES OF DATA 1. Prim Primar ary y – clie client nt 2. Second Secondary ary – relat relative ives, s, membe members rs of healt health h team FOR NURSING HISTORY USE GORDON’S TYPOLOGY OF 11 FUNCTIONAL PATTERN 1. Health Health perception perception – health health management management pattern pattern – describes describes clients clients perceived perceived pattern pattern of health health and well being and how health is managed. 2. Nutritio Nutritional nal – metabolic metabolic pattern pattern – describes pattern pattern of food and fluid fluid consumption consumption relative relative to metabolic metabolic need and pattern indicators of local nutrient supply. 3. Eliminati Elimination on – describes describes pattern pattern of excretory excretory functio function n (bowel, (bowel, bladder bladder and skin). skin). 4. Activity Activity – exercise exercise – describes describes pattern pattern of exercise, exercise, activity activity,, leisure leisure and recreation recreation 5. Cognitive Cognitive percept perceptual ual – describes describes sensory sensory percep perceptual tual and and cognitive cognitive system system 6. Sleep Sleep rest – describes describes pattern pattern of sleep, sleep, rest rest and recrea recreation. tion. 7. Self Self percep percepti tion on – self self concep conceptt – self self concep conceptt patter pattern n and percept perception ions s of self self (body (body comfort comfort,, body body image, feeling state). 8. Role relati relationship onship – descri describes bes pattern pattern of role role engagements engagements and and relationsh relationships ips 9. Sexual Sexual reprod reproduct uctive ive – client client patter patterns ns of satisf satisfact action ion and dissat dissatisf isfact action ion with with sexual sexuality ity:: descri describes bes reproductive pattern 10. Coping Coping stress tolerance tolerance – general general coping pattern pattern and effectiv effectiveness eness of the pattern in terms of stress stress tolerance. 11. Value belief – patterns of values, beliefs beliefs (including spiritual) or goals goals that guide choices of decisions. NURSING DIAGNOSIS - Clinical judgment about an individual, family or community responses to actual and potential health problems - Professional nurses are responsible for making nursing diagnosis. - Nursing diagnosis describe a continuum of health states. Actual
Potential Health Problem
NURSING DIAGNOSIS - Focus Focus on ident identif ifyin ying g human human respon responses ses to health and illness - Describe problems treated by nurses within the scope of independent nursing practice - Changes from day to day as client responses change
Healthy Responses
MEDICAL DIAGNOSIS - Identifies disease - Descri Describe be proble problems ms for which which the physic physician ian directs the primary treatment - Remains the same for as long as the disease is present
6 TYPES OF NURSING DIAGNOSIS 1. Actual nursing diagnosis diagnosis – judgme judgment nt about about a client clients s respon response se to a healt health h proble problem m at the time time of assessment and is signified by the presence of associated signs and s ymptoms. Format: 2 part (problem related to etiology) 3 part (problem, etiology and signs and symptoms format)
2. Risk nursing diagnosis – clinical judgment about a clients vulnerability to develop a problem Format: 2 part statement (diagnostic label related to risk factors) 3. Possible nursing diagnosis – evidence about a certain problem is unclear and need to gather more data to support it Format: 2 part statement 4. Wellness nursing diagnosis – clinical judgment about an individual, family and community in transition from a specific level of wellness to a higher level of wellness Format: potential + desired higher level of wellness Readiness for + higher level of wellness 5. Syndrome nursing diagnosis – comprises of a cluster of problems Format: 1 part statement (rape trauma syndrome) 6. Alfaro’s rule for a collaborative problem – focus on potential complications complications Format: potential problem + related to + list of complications that may occur First Priority – is any threat to the vital functions of breathing, heart beat, blood pressure. Medium Priority – health-threatening problems that may result in delayed development or cause destructive physical or emotional changes. Low Priority – problems that arise from normal development needs or those that require minimal nursing support. OBJECTIVES - Should be SMART, SMART, client centered, statement of a single human response EVALUATION - Conclusion and supporting data - Goal met - Goal partially met - Goal not met GROWTH - Physical change - Increase in size - Periods of very rapid growth rate: pre – natal, neonatal, infancy, infancy, adolescence DEVELOPMENT - Increase in complexity of function and skill progression - The behavioral aspect of growth PRINCIPLES OF DEVELOPMENT 1 Growth and development are continuous orderly, sequential process influenced by maturational environment and genetic factors 2. All humans follow the same pattern of growth 3. The sequence of each stage is predictable although the time of onset, the length of the stage and the effects of each stage vary with the person. 4. Growth and development occur in cephalocaudal direction. 5. Growth and development occur in a proximal to distal direction 6. Development occurs from simple to complex or from single acts to integrated acts. 7. Development becomes increasingly differentiated, begins with generalized response and progresses to a skilled specific response. 8. The pace of growth and development is asynchronous or uneven.
KOHLBERG’S STAGES OF MORAL DEVELOPMENT LEVEL AND STAGE Level I: Pre Conventional (Egocentric Focus) Stage 1 Punishment and obedience orientation - Activity Activity is wrong if one is punished, (toddler – 7 years) activity is right if one is not punished. Stage 2 Instrumental – Relativist Orientation (4 – 12 years) - Action is taken to satisfy ones needs. Level II: Conventional (Societal Focus) Stage 3 Interpersonal concordance, good boy, nice girl (6 years thru adult years) Stage 4 Law and order orientation (adolescent – adult) Level III: Post Conventional or Principled Level (Universal Focus) Stage 5 Social contract, legalistic orientation (middle age or older adult)
Stage 6 Universal ethical principles (middles age or older adult)
- Action is taken to please another and gain approvals. - Right behavior is obeying the law and follow the rules
- Standard of behavior is based on adhering laws that protect the welfare and rights of others: violating the rights of others is avoided: personal values and opinions are recognized. - Universal moral principles are internalized, person respects other humans and believes that relationship are based on mutual trust.
TYPES OF OLDER ADULT 1. Young 1. Young old (65 – 74) – adaptation to retirement and changing physical abilities, chronic illness may develop. 2. Middle old (75 – 84) – adaptation adaptation to decline decline in speed of movement, movement, reaction reaction time time and sensory abilities: abilities: increasing dependence in others. 3. Old old (85 – over) – increase physical problems.
DEVELOPMENTAL TASK TASK AND WHOLISTIC APROACH APRO ACH BY ROBERT HAVIGHURST HAVIGHURST AGE PERIOD Infancy and Early Childhood
DEVELOPMENTAL TASK - Learning to walk, to taste solid foods, to talk, to control elimination of body wastes, sex differences and sexual modes - Learning to relate emotionally to parents, siblings and others - Learning to distinguish right from wrong and developing a conscience - Learning to form concepts of social and physical reality
Middle Childhood
- Learning physical skills for ordinary games - Building wholesome attitude towards oneself - Learning to get along with age mates - Learning an appropriate masculine or feminine social role - Developing fundamental skills in reading, writing and calculating - Develop concepts necessary for everyday living - Achieving personal independence
Adolescence
- Achieving new and more mature relations with age mates of both sexes - Achieving masculine/feminine social role - Accepting Accepting ones physique and using the body effectively - Achieving emotional independence from parents - Selecting and preparing for an occupation - Preparing for marriage and family life - Developing intellectual skills necessary for civic competence - Acquiring a set of values and an ethical system as a guide to behavior
Early Adulthood Adulthood (20 – 40 yrs)
- Selecting a mate - Learning to live with a partner - Starting a family and rearing children - Managing a home - Getting started in an occupation - Taking on civic responsibility - Finding a congenial social group
Middle Age (Emptiness Stage)
- Achieving adult civic and social responsibility - Establishing and maintaining an economic standard of living - Assisting teenage children to become responsible and happy adults - Developing adult leisure time activity - Accepting and adjusting the physiologic changes of middle age - Adjusting Adjusting to aging parent
Late Maturity
- Adjusting to decrease physical strength - Adjusting Adjusting to retirement and reduced income - Adjusting Adjusting to death of a spouse - Meeting social and civic obligations - Establishing satisfactory living arrangements
NURSE – CLIENT RELATIONSHIP - Helping relationship for growth PHASES OF NURSE – CLIENT RELATIONSHIP Phase I: Pre Interaction - No face-to-face interaction with client Phase II: Introductory/Orientation - Rapport setting, contract setting, sets tone for rest of relationship - Testing Testing behavior (orientation) resisting behavior (non compliance) Phase III: Working - Implementation of nursing care plans - View as unique individuals - Employ decision-making and technical skills and communication skills Phase IV: Termination - Characterized by ambivalence on both nurse and client - Discharge phase - Evaluation of care given by nurse
COMMUNICATION - Human function that enables people to relate with each other MODES Verbal – spoken language Non-Verbal – Non-Verbal – symbols, sign language ELEMENTS OF COMMUNICATION 1. Stimulus – reason why people communicate, motivation with each other (object, ideas, feeling) referent 2. Message – idea, feelings and emotions 3. Sender – Sender – also known as encoder, one that sends the message 4. Channels – kinesthetic: tactile stimulus, visual: symbols, auditory: spoken language 5. Receiver – Receiver – decoder 6. Feedback – answer to questions, whether receiver understood or not FACTORS THAT THAT AFFECT COMMUNICATION PROCESS 1. Ability of communicator – communicator – ability to speak, hear, see and comprehend stimulus 2. Perceptions – each has a unique trait, values, life experiences 3. Personal space – distance people prefer in interactions with one another Four distances a. Intimate - Physical contact to 1 ½ feet characterized by body contact heightened sensation of body heat and smell, low vocalization - Threatening to client b. Personal - 1 ½ feet to 4 feet - Less overwhelming than intimate distance - Usual distance between nurse and client - Best distance c. Social - 4 feet to 12 feet - Communication is non-formal - Allows more activity and movement back and f orth - Often misused by nurse d. Public - 12 feet and beyond - Individuality is lost - Mass health education 4. Territoriality – Territoriality – concept of space and things that an individual considers as belonging to the self
5. Roles and Relationships 6. Time – events that precede and follow interactions 7. Environment – Environment – environment is comfortable, communication is more effective 8. Attitudes THERAPEUTIC COMMUNICATION Using silence
RATIONALE Accepting pauses or silences without interjecting any verbal response
Providing general leads
Using statements or questions that a. encourage client to verbalize b. choose a topic of conversation
Being specific and tentative
Statement Statements s that are specific specific rather than general and tentative rather than absolute
Using open ended questions
Specify only topic to be discussed and invite answers longer than one or two words
Using touch
Touch ouch reinfo reinforce rces s caring caring feelin feelings, gs, howeve howeverr, nurse nurse should be sensitive to difference in attitude’s practice of clients self
Restating/Rephrasing
Actively listening for the client’s basic message then repeat repeats s those those though thoughts ts and/or and/or feelin feelings gs in simila similar r words.
Seeking clarification
Used Used when when comm commun unic icat atio ion n is ramb rambli ling ng or when when paraphrasing is difficult
Clarifying time or Sequence
Help Helpin ing g the the clie client nt clar clarif ify y an even eventt situ situat atio ion n or happening with respect to time
Offering self
Sugg Sugges esti ting ng ones ones pres presen ence ce,, inte intere rest st or wish wish to understand the client without making any demands that could make client comply to suggestion
Giving information
A simp simple le and and information
Acknowledging
Giving recognition in a non judgmental way of a. change in behavior b. effort the client has made c. contribution to a communicator
Presenting reality
Helping client differentiate real from unreal
Focusing
Helping the client expand on and develop a topic of importance
Reflecting
The focus may be an idea or a feeling.Directing feeling.Directing ideas, feel feelin ings gs,, ques questi tion ons s or cont conten entt back back to clie client nts s to enable them to explore their own feelings
dire direct ct
mann manner er,,
spec specif ific ic
fact factua uall
Summarizing and Planning
Stat Statin ing g the the main main poin points ts of disc discus ussi sion on to clar clarif ify y relevant parts discussed
Perception checking
Verif erifie ies s mean meanin ing g of spec specif ific ic word words s than than over overal alll meaning of a message
NON THERAPEUTIC COMMUNICATION Stereotyping
RATIONALE Offering generalized and over simplified beliefs about groups of people
Agreeing and Disagreeing
Akin to judgmental responses implies client is either right or wrong
Being defensive
Attempting to protect a person
Challenging
Givi Giving ng resp respon onse se that that make makes s clie client nt prov prove e thei their r statement or point of view
Probing
Asking information chiefly out of curiosity rather than intent
Testing
Question than make a client admit something
Changing topic
Directing communication into areas of self intent
Unwarranted reassurance
Using clichés or comforting statements of advice as a means to reassure the client
Passing judgment
Givi Giving ng opin opinio ions ns and and response
Giving common advice
Telling client what to do
VITAL SIGNS TEMPERATURE 1. Oral - Most accessible and convenient - Normal value: 37 o C – 98.6 o F - 2 – 3 minutes 2. Rectal - Most reliable - Normal value: 37.7 o C – 99.6 o F - 3 – 5 minutes 3. Axila - Less accurate - Normal value: 36.4 o C – 97.5 o F - 5 – 10 minutes 4. Tympanic membrane - Directly reflects core temperature - Normal value: 37.7 o C – 99.9 o F - Automatic results
appr approv ovin ing g or disa disapp ppro rovi ving ng
CONVERSION
-
Fahrenheit to Celsius = (F-32) x 5/9 Celsius to Fahrenheit = (C x 9/5) + 32
PULSE SITE 1. Temporal 6. Femoral 2. Carotid 7. Popliteal 3. Apical 8. Posterior tibial 4. Brachial 9. Dorsalis pedis 5. Radial When palpating for pulse use 2 – 3 fingers except when taking the apical pulse use stethoscope Apical pulse is in the 5th intercostals space Landmark is the angle of Louie 4th intercostals space left mid clavicular line child apical pulse When using the stethoscope use the flat part when looking for high pitch sounds like (lung and bowel sounds) and use the bell for vascular or heart sounds RESPIRATION - Adult: 12 – 20 c/min - Newborn – 30 – 60 c/min ERRORS IN I N TAKING RESPIRAT RES PIRATORY ORY RATE Patient Factor Insufficient rest before assessing Assessing immediately after a meal or while client smokes or has pain Equipment Factor Stethoscope fits poorly or hearing impaired Bladder or cuff too wide Bladder or cuff too narrow Errors in technique Arm unsupported Arm above heart level and not perpendicular to the body Cuff wrapped to loosely Deflating cuff to slowly Deflating cuff to quick Failure to identify auscultatory gap Auscultatory gap Temporary cessation of sounds after initiation Gap of 10 – 40 mmHg Common among hypertensive Repeating assessment too quickly (wait for 2 – 3 minutes after taking again the bp, and maximum of 3 takes same arm and if still inaudible rest arm for 5 – 15 minutes) Multiple examiner using different Kortkoff sounds for diastolic readings Failure to use the same arm consistently Effects Erroneously high readings
False low systolic and false high diastolic - False low reading - False high reading - Erroneously high readings - Erroneously low readings - False high readings - False low diastolic reading - False high diastolic reading - False low systolic bp and diastolic bp - False high systolic blood pressure, false low diastolic blood pressure
Inaccurate interpretation Inconsistent measurements For a client who’s blood pressure is to be taken for the first time, take the blood pressure of both arms Difference of blood pressure for both arms should only be 10 mm Hg Use higher value as baseline PALPATORY SYSTOLIC PRESSURE Point of pulsation stops with the use of stethoscope Maximum pressure + 30 mmHg that is you limit when taking the blood pressure KOROTKOFF SOUNDS Phases 1. Characterized by a thud, thump and tapping sound 2. Swooshing, whoosing sound 3. Sound decrease in intensity when compared to Korotkoff one 4. Muffling sound 5. Disappearance of sound - in adults record Korotkoff 1 and Korotkoff 5 of able to hear Korotkoff 4 record also - in children record Korotkoff 1 and Korotkoff 4 HYPERTENSION Average of 2 or more diastolic reading on at least 2 subsequent visits is 90 mmHg or higher or when an average of 2 or more systolic readings on at least 2 visits is higher than 140 mmHg
Optimal/ Normal Above Normal Hypertension Grade 1 (Mild) Grade 2 (Moderate) Grade 3 (Severe)
SYSTOLIC 120 – 129 130 – 139
DIASTOLIC 80 – 84 85 – 89
140 – 159 160 – 179 Greater than 180 Greater than 140Less 80
90 – 99 100 – 109 Greater than 110 Less 90
