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Cardiac Failure

D e s c r i p t i o n -
I s t h e i n a b i l i t y o f t h e h e a r t t o p u m p s u f f i
c i e n t b l o o d t o m e e t t h e needs of the tissues for oxygenation and nutri
ents

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

- Formerly called Congestive Heart Failure

Etiologic Factors:

-Increased metabolic rate (egg. fever, thyrotoxicosis)

-Hypoxia

-Anemia Pathophysiology:

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

Left-Sided Cardiac Failure-

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

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

Right-Sided
Cardiac Failure

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

Clinical Manifestations

Edema of the lower extremities (dependent edema)


- Weight gain
- Hepatomegaly (enlargement of the liver)
- Distended neck veins
- Ascites (accumulation of fluid in the peritoneal cavity) - Anorexia and nausea
- Nocturnal (need to urinate at night)
- Weakness
Diagnostics
-
Chest X-ray (may show cardiomegaly or vascular congestion)
-
Echocardiogram (shows decreased ventricular function and decreased ejection fraction
CVP (elevated in right-sided failure)

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

Nursing Diagnoses-

Activity intolerance r/t imbalance between oxygen supply andd


emand secondary to decreased CO

- Excess fluid volume r/t excess fluid/sodium intake or retention secondary to CHF and its medical
therapy
Anxiety r/t breathlessness and restlessness secondary to inadequate oxygenation
- Non-compliance r/t to lack of knowledge-
Powerlessness r/t inability to perform role responsibilitiessecondary to chronic illness and
hospitalizationNursingManagementa. Acute phase
- Monitor and record BP, pulse, respirations, ECG and CVP to detect changes in cardiac output
- maintain client in sitting position to decrease pulmonarycongestion and facilitate improved gas
exchange
- auscultate heart and lung sounds frequently: increasing crackles, increasing dyspnea, decreasing
lung sounds indicate worsening failure
- administer O2 as ordered to improve gas exchange and increaseoxygenation of blood; monitor
arterial blood gases (ABG) as ordered to assess oxygenation
- administer prescribed medications on accurate schedule
- Monitor serum electrolytes to detect hypokalemia secondary to diuretic therapy
- Monitor accurate input and output (may require Foley catheter tallow accurate measurement of urine
output) to evaluate fluid status
- If fluid restriction is prescribed, spread the fluid throughout the dayto reduce thirst

- encourage physical rest and organized activities with frequentrest periods to reduce the work of the
heart- provide a calm reassuring environment to decrease anxiety; thisdecreases oxygen
consumption and demands on the heart. Chronic heart failure-
educate client and family about the rationale for the regimen-
establish baseline assessment for fluid status and functionalabilities-
monitor daily weights to evaluate changes in fluid status-
assess at regular intervals for changes in fluid status or functionalactivity
level PharmacologicTherapy-
ACE Inhibitors (promotes vasodilation and diuresis by decreasingafterload and preload eventually
decreasing the workload of the heart.)- Diuretic Therapy. A diuretic is one of the first
medications prescribed to a patient with CHF. Diuretics promote the excretion of sodium and water
through the kidneys- Digitalis (increases the force of myocardial contraction and slows conduction
through the AV node. It improves contractility thus, increasing left ventricular output.)-

. (Dobutrex) is an intravenous medication given topatients with significant left ventricular dysfunction.
Acatecholamine, it stimulates the beta1-adrenergic receptors. Itsmajor action is to increase cardiac
contractility.- Milrinone (Primacor). A phosphodiesterase inhibitor that prolongsthe release and
prevents the uptake of calcium. This in
, causing a decrease in preload and afterload
The workload of the heart. - Nitroglycerine (a vasodilator reduces preload) -
Morphine to sedate and vasodilator, decreasing the work of theheart-
Anticoagulants may be prescribed. Beta-adrenergic blockersmaybe indicated in patients with mild or
moderate failure Client Education
-
Include family member or others in teaching as appropriate
-
Weight monitoring: teach client the importance of measuring and recording daily weights and report
unexplained increase of 3-5pounds
-
Diet: sodium restriction to decrease fluid overload and potassium rich foods to replenish loss from
medications; do not restrict water intake unless directed
-
Medication regime: explain the importance of following all medication instruction
-
Activity: help client plan paced activity to maximize available cardiac output
-
Symptoms: report to MD promptly any of the following: chest pain, new onset of dyspnea on exertion,
paroxysmal and nocturnal dyspnea
-
Report even minor changes to MD as they may be an early signoff

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

E t i o l o g i c f a c t o r s
- P h y s i c a l e x e r t i o n
- Emotional stress- Weather extremes
- Digestion after a heavy meal
- Valsalva maneuver
- Hot baths or showers
- Sexual excitation
Pathophysiologic characteristic (Coronary artery disease)

Pathophysiology
Coronary artery blood flow is blocked by atheroscle
r o t i c narrowing, thrombus formation or persistent vasospasm; myocardium supplied by the
arteries is deprived of oxygen; persistent ischemia may rapidly lead to tissue death

ClinicalManifestations
- Chest pain or discomfort (described as aching or squeezing pain, most common location is sub
sternal, radiating to neck, jaw, back, shoulders, left arm or occasionally the right arm)
-Complain of heartburn or indigestion
-pallor, diaphoresis, cold skin, shortness of breath, weakness, dizziness, anxiety, and feelings of
impending doom.

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

-Cardiac Enzymes elevated CK with MB is enzymes >5percent (early diagnosis); elevated Troponin
(early to late diagnosis); or elevated LDH with flipped is enzymes (late diagnosis)
-WBC count leukocytosis (10,000/mm3 to 20,000/mm3) appears on the second day after AMI and
dis appears after 1 week

-Positron Emission Tomography (PET) is used to evaluate cardiac


I m a g i n g S t u d i e s
m e t a b o l i s m a n d t o a s s e s s t i s s u e p e r f
u s i o n
-Magnetic Resonance Imaging helps identify the site and extent of an MI
-Tran esophageal Echocardiography (TEE) is an imaging technique in which transducer is placed
against the wall of the esophagus; the image of the myocardium is clearer when the esophageal sites
used. Nursing Diagnoses
-Acute Pain related to myocardial ischemia resulting from coronary artery occlusion
-Ineffective Tissue Perfusion related to thrombus in coronary artery
-Decreased Cardiac Output related to negative inotropic changes in the heart secondary to
myocardial ischemia
-Impaired Gas Exchange related to decreased cardiac output
-Anxiety and Fear related to hospital admission and fear of death Nursing Management
-Assess pain status frequently with pain scale
-Assess hemodynamic status including BP, HR, LOC, skin color, and temperature (every 5 minutes
during with pain; every 15minutes)
-Monitor continuous ECG to detect dysrhythmias
-Perform 12-lead ECG immediately with new pain or changes in level of pain
-Monitor respirations, breath sounds, and input and output to dtectearly signs of heart failure
-Monitor O2 saturation and administer O2 as prescribed
-Provide for physiological rest to decrease oxygen demands on heart
-Keep client NPO or progress to liquid diet as ordered; maintain I access for medication as needed
-Provide a calm environment and reassure client and family to decrease stress, fear and anxiety
-Report significant changes immediately to physician to ensure rapid treatment of complications
-Maintain bed rest for 24 to 36 hours and gradually increase activity as ordered while closely
monitoring CO, ECG and painstatusPharmacologicTherapy
-Nitroglycerine (to dilate coronary vessels and increase blood flow)
-Morphine Sulfate (to relieve chest pain)
-Anticoagulant (heparin) and Antiplatelet (aspirin) - to prevent additional clot formation
-Streptokinase (to dissolve clot)
-Beta blockers (to decrease cardiac work)
-Anti-dysrhythmia

Surgical Interventions
-Percutaneous Trans luminal coronary angioplasty (PTCA) involves the passage of an inflatable
balloon catheter into thestenonic coronary vessel, which is then dilated, resulting in compression of the
atherosclerotic plaque and widening of the vessel
-Coronary artery bypass grafting (CABG) done by harvesting either a saphenous vein from the leg
or the left internalmammaryartery and then used to bypass areas of obstruction in the heart Client
Education
-Include appropriate family members whenever possible
-Explain cardiac rehabilitation program if ordered
-Explain modifiable risk factors and develop a plan with client including supportive resources to change
lifestyle to decrease these factors
-Explain medication regime as prescribed; identify side effects to report (provide written
instructions for later reference)
-Stress the importance of immediate reporting of chest pain or signs of decreased CO2
-Instruct about bleeding precautions if client is on anticoagulant therapy: use soft toothbrush, electric
razor, avoid trauma or injury; wear or carry medical alert identification.

Acute Pulmonary Failure


D e s c r i p t i o n

D e f i n e d a s a f a l l i n a r t e r i a l o x y g e n t e n s i o n a
n d a r i s e i n a r t e r i a l carbon dioxide tension.
- The ventilation and/or perfusion mechanisms in the lung are impaired.
Etiologic factors
-Alveolar hypoventilation
-Diffusion abnormalities
-Ventilation-perfusion mismatching
-Shunting Pathophysiology
-Progression of pulmonary edema occurs when capillary hydrostatic pressure is increased, promoting
movement of fluid into the interstitial space of the alveolar-capillary membrane. Initially, increased
lymphatic flow removes the excess fluids, but continued leakage eventually overwhelms this
mechanism. Gas exchange becomes impaired by the thick membrane. Increasing interstitial fluid
pressure ultimately causes leaks into the alveolar sacs, impairing ventilation and gas exchange.

ClinicalManifestations
-Tachypnea
-Tachycardia
-Cold, clammy skin and frank diaphoresis are apparent especially around the forehead and face

-Percussion reveals hyper resonance in patients with COPD; dull or flat on patients with atelectasis or
pneumonia
-Diminished breath sounds; absence of breath sounds of the affected lung in patients with
pneumothorax; wheezes on patients with asthma; rhonchi on patients with bronchitis and crackles
may reveal suspicion of pulmonary edema Diagnostics
-ABG analysis indicates respiratory failure when PaO2 is low andPaCO2 is high and the HCO3 level
is normal
-Chest X-ray is used to identify pulmonary diseases such as emphysema, atelectasis, pneumothorax,
infiltrates and effusions
-Electrocardiogram (ECG) can demonstrate arrhythmias, commonly found with core pulmonale and
myocardial hypoxia
-Pulse oximetry reveals a decreasing SpO2 level
-WBC count aids detection of an underlying infection; abnormally low hemoglobin and hematocrit
levels signal blood loss, indicating decrease oxygen carrying capacity
-PA catheterization is used to distinguish pulmonary causes from cardiovascular causes of acute
respiratory failure Nursing Diagnoses
-Impaired Gas Exchange related to capillary membrane obstruction from fluid
-Excess Fluid Volume related to excess preloadNursingManagement
-Assess the patients respiratory status at least every 2 hours or more as indicated
-Position the patient for optimal breathing effort when he isnt intubated. Put the call bell within easy
reach to reassure the patient and prevent necessary exertion
-Maintain the norm thermic environment to reduce patients oxygen demand
-Monitor vital signs, heart rhythm, and fluid intake and output, including daily weights, to identify fluid
overload or impending dehydration
-After intubation, auscultate the lungs to check for accidental intubation of the esophagus or main stem
bronchus.
-Dont suction too often without identifying the underlying cause of an equipment alarm.
-Watch oximetry and scenography values because these may indicate changes in patients condition
-Note the amount and quality of lung secretions and look for changes in the patients status
-Check cuff pressure on the ET tube to prevent erosion from an overinflated cuff
-Implement measures to prevent nasal tissue necrosis
-Be alert of GI bleeding
-Provide a means of communication for patients who are intubated and alertPharmacologicTherapy
-Reversal agents such as Naloxone (Narran) are given if drug overdose is suspected
-Bronchodilators are given to open airways
-Antibiotics are given to combat infection
-Corticosteroids may be given to reduce inflammation
-Continuous IV solutions of positive inotropic agents may be given to increase cardiac output, and
vasopressors may be given
Vasoconstrictions to improve or maintain blood pressure
-Diuretics may be given to reduce fluid overload and edemaC l i e n t E d u c a t i o n -
Include family member or others in teaching as app
ropriate
-Weight monitoring: teach client the importance of measuring and recording daily weights and report
unexplained increase of 3-5pounds
-Diet: sodium restriction to decrease fluid overload and potassium rich foods to replenish loss from
medications; do not restrict water intake unless directed
-Medication regime: explain the importance of following all medication instructions
-Instruct client and family to maintain elevation of the head of the client at least 45 degrees; position
increases chest expansion and mobilizes fluid from the chest into more dependent areas Acute Renal
Failure Description
-a sudden loss of kidney function caused by failure of renal circulation or damage to the tubules or
glomeruli.

Etiologic factor.
Prerenal -
caused by decrease blood flow to kidneys like seve
r e dehydration,diuretic therapy, circulatory collapse,hypovolemia or shock; readily reversible when
recognized and treatedb.Intrarenal caused by disease process, ischemia, or
toxic conditions such as acute glomerulonephritis, vascular disorders,toxicagents, or severe infection
Post renal caused by any condition that obstructs urine flow such as benign prostatic hyperplasia,
renal or urinary tract calculi, or tumors.
Pathophysiology
-Acute renal failure is classified as perennial, intracranial or post renal. All conditions that lead to
perennial failure impair blood flow to the kidneys (renal perfusion), resulting in a decreased glomerular
filtration rate and increased tubular desorption of sodium and water. Intracranial failure results from
damage to the Kidneys. Post renal failure results from obstructed urine flow.

ClinicalManifestations
*A change in blood pressure and volume signals pre renal failure, the patient may have the following:
-Oliguria
-Tachycardia
-Hypotension
-Dry mucous membranes
-Flat jugular veins
-Lethargy progressing to coma
-Decreased cardiac output and cool, clammy skin in patient with heart failure
*As renal failure progresses, the patient may manifest the following signs and symptom:
- uremia
- confusion
- GI complaints
- fluid in the lungs
- infection
Diagnostics
-Blood studies reveal elevated BUN, serum keratinize, and potassium levels and decreased blood pH,
bicarbonate, HCT, and Hob levels
-Urine studies show cats, cellular debris, decreased specific gravity and, in glomerular diseases,
proteinuria and urine osmolality close to serum osmolality.
-Keratinize clearance testing is used to measure the GFR and estimate the number of remaining
functioning nephrons
-Electrocardiogram (ECG) shows tall, peaked T waves, widening QRS complex, and disappearing P
waves if increased potassium is present

*Other studies used to determine the cause of renal failure


:- kidney ultrasonography
- plain films of the abdomen
- KUB radiography
- excretory urography
- renal scan
- retrograde pyelography
computed tomography scan and nephrotomography

Nursing Diagnoses
-Excess Fluid Volume
-Imbalanced Nutrition: Less than Body Requirements
-Deficient Knowledge
-Riskfor Infection

NursingManagement
-Monitor intake and output
-Observe for oliguria followed by polyuria
-Weigh daily and observe for edema
-Monitoring of complications of electrolyte imbalances, such as acidosis and hyperkalemia
-Allow client to verbalize concerns regarding disorder
-Encourage prescribed diet: moderate protein restriction, high in carbohydrates, restricted potassium
-Once diuresis phase begins, evaluate slow return of BUN, keratinize, phosphorus, and potassium to
normalPharmacologicTherapy
-Use volume expanders are prescribed to restore renal perfusion in hypotensive clients and
Dopamine IV to increase renal blood flow
-Loop diuretics to reduce toxic concentration in nephrons and establish urine flow
-ACE inhibitors to control hypertension
-Antacids or H2 receptor antagonists to prevent gastric ulcers
-Kayexelate to reduce serum potassium levels and sodium bicarbonate to treat acidosis
*Avoid nephrotoxic drugs

Client Education
-Dietary and fluid restrictions, including those that may be continued after discharge
-Signs of complications such as fluid volume excess, CHF, and hyperkalemia
-Monitor weight, blood pressure, pulse, and urine output
-Avoid nephrotoxic drugs and substances: NSAIDs, some antibiotics, radiologic contrast media, and
heavy metals; consult care provider prior to taking any OTC drugs
-Recovery of renal function requires up to 1 year; during this period, nephrons are vulnerable to
damage from nephrotoxinsStroke/Cerebrovascular accident Description
-Is a condition where neurological deficits occur as a result of decreased blood flow to a localized area
of the brain?

-Thrombosis of the cerebral arteries supplying the brain or of the Intracranial vessels occluding blood
flow
-Embolism from a thrombus outside the brain, such as in the heart, aorta, or common carotid artery
-Hemorrhage from an intracranial artery or vein, such as from hypertension, ruptured aneurysm, AVM,
trauma, hemorrhagic disorder, or septic embolism
Pathophysiology
-the underlying event leading to stroke is oxygen and nutrient deprivation; if the arteries become
blocked, auto regulatory mechanisms maintain cerebral circulation until collateral circulation develops
to deliver blood to the affected area; if the compensatory mechanisms become overworked or
cerebral blood flow remains impaired for more than a few minutes, oxygen deprivation leads to
infarction of brain tissue
Risk factors
-Hypertension
-Family history of stroke
-History of TIA
-Cardiac disease, including arrhythmias, coronary artery disease, acute myocardial infarction, dilated
myopathy, and alular disease
-Diabetes mellitus
-Familial hyperlipidemia
-Cigarette smoking
-Increased alcohol intake
-Obesity, sedentary lifestyle
-Use of hormonal contraceptivesClinicalManifestations
-Hemiparesis on the affected side (may be more severe in the face and arm than in leg)
-Unilateral sensory defect (such as numbness, or tingling) generally on the same side as the
hemiparesis
-Slurred or indistinct speech or the inability to understand speech
-Blurred or indistinct vision, double vision, or vision loss in one eye (usually described as a curtain
coming down or gray-out of vision)
-Mental status changes or loss of consciousness (particularly if associated with one of the above
symptoms)
-Very severe headache (with hemorrhagic)
*A stroke in the left hemisphere produces symptoms on the right side of the body; in the right
hemisphere, symptoms on the left side

Diagnostics
-CT scan discloses structural abnormalities, edema, and lesions, such as no hemorrhagic infarction
and aneurysms
-MRI is used to identify areas of ischemia, infarction and cerebral swelling
-DSA is used to evaluate patency of the cerebral vessels and shows evidence of occlusion of the
cerebral vessels, a lesion or Vascular abnormalities
-Cerebral angiography shows details of disruption or displacement of the cerebral circulation by
occlusion or hemorrhage
-Carotid Duplex scan is a high frequency ultrasound that shows blood flow through the carotid arteries
and reveals stenosis duet atherosclerotic plaque and blood clots
-Trans cranial Doppler studies are used to evaluate the velocity of blood flow through major
intracranial vessels, which can indicate vessel diameter
-Brain scan shows ischemic areas but may not be conclusive for up to 2 weeks after stroke
-Single photon emission CT scanning and PET scan show areas of altered metabolism surrounding
lesions that arent revealed bother diagnostic tests
-Lumbar puncture reveals bloody CSF when stroke is hemorrhagic
-EEG is used to identify damaged areas of the brain and to differentiate seizure activity from
stroke
-A blood glucose test shows whether the patients symptoms are related to hypoglycemia
-Hemoglobin and hematocrit level may be elevated in severe occlusion
-Baseline CBC, platelet count, PTT, PT, fibrinogen level and chemistry panel are obtained before
thrombolytic therapy Nursing Diagnoses
-Ineffective Tissue Perfusion related to decreased cerebral blood flow
-Risk for Prolonged Bleeding related to use of thrombolytic agents
-Increased Risk for Aspiration related to depressed gag reflex, Impaired swallowing
-Impaired Physical Mobility related to loss of muscle toneNursingManagement
-Encourage active range of motion on unaffected side and passive range of motion on the affected
side
-Turn client every 2 hours
-Monitor lower extremities for thrombophlebitis
-Encourage use of unaffected arm for ADLs
-Teach client to put clothing on affected side first
-Resume diet orally only after successfully completing swallowing evaluation
-Collaborate with occupational and physical therapists
-Try alternate methods of communication with aphasia patients
Accept clients frustration and anger as normal to loss of function
-Teach client with homonymous hemianopia to overcome the deficit by turning the head side to side to
be able to fully scan the visual fieldPharmacologicTherapy
-Thrombolytic for emergency treatment of ischemic stroke
-Aspirin or Ticlopidine (Tic lid) as an antiplatelet agent to prevent recurrent stroke
-Benzodiazepines to treat patients with seizure activity
-Anticonvulsants to treat seizures or to prevent them after the patients condition has stabilized
-Stool softeners to avoid straining, which increase ICP
-Antihypertensive
And antiarrhythmic to treat patients with risk factors for recurrent stroke
-Corticosteroids to minimize associated cerebral edema
-Hyperosmolar solutions (Manito) or diuretics are given to clients with cerebral edema
-Analgesics to relieve the headaches that may follow hemorrhagic stroke Surgical Intervention
-Craniotomy to remove hematoma
-Carotid endarterectomy to remove atherosclerotic plaques from the inner arterial wall
-Extra cranial bypass to circumvent an artery thats blocked by occlusion or stenosis Client Education
-Educate client and family about CVA and CVA prevention
-Educate client and family about community resources
-Educate client and family about physical care and need for psychosocial support
-Educate client and family about medication Increased
Intracranial Pressure

Description-
prolonged pressure greater than 15mmHg or 18
0 m m H 2 O m e a s u r e d i n the lateral ventricles

Etiology
-Cerebral Edema is an increase in volume of brain tissue due to alterations in capillary permeability,
changes in functional or the structural integrity of the cell membrane or an increase in the interstitial
fluids
-Hydrocephalus is an increase in the volume of CSF within the ventricular system; it may be no
communicating hydrocephalus where the drainage from the ventricular system is impaired

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

Clinicalmanifestations
-Blurring of vision, decreased visual acuity and diplopia are the earliest signs of increased ICP
-Headache, papilledema or the swelling of optic disk and vomiting
-Change of LOCDiagnostics
-Skull radiography
-CT scan
-MRI
* Lumbar puncture is not performed because of brain herniation caused by sudden release of
pressure*Laboratory tests are performed to augment and monitor treatment approaches; serum
osmolality monitors hydration status and ABGsmeasure pH, oxygen and carbon dioxide

Nursing Diagnoses
-Ineffective Cerebral Tissue Perfusion related to Increased ICP
-Risk for Infection
-Impaired Physical Mobility
-Risk for Ineffective Airway Clearance
NursingManagement
- Assess neurological status every 1 to 2 hours and report any deterioration; include LOC, behavior,
motor/sensory function, pupil size and response, vital signs with temperature
-Maintain airway; elevate head of 30 degree or keep flat as prescribed; maintain head and neck in
neutral position to promote venous drainage
-Assess for bladder distention and bowel constipation; assist client when necessary to prevent Val
Sava maneuver
-Plan nursing care so it is not clustered because prolonged activity may increase ICP; provide quiet
environment and limit noxious stimuli; limit stimulants such as radio, TV and newspaper; avoid
ingesting stimulants such as coffee, tea, cola drinks and cigarette smoke
-Maintain fluid restriction as prescribed
-Keep dressings over catheter dry and change dressings as prescribed; monitor insertion site for CSF
leakage or infection; monitor clients for signs and symptoms of infection; use aseptic technique when
in contact with ICP monitor

Pharmacologic therapy
-Osmotic diuretics such as Manito and loop diuretics such as Furosemide (Lasix) are mainstays used
to decrease ICP
-Corticosteroids are effective in decreasing ICP especially withtumorsSurgical Intervention
-A drainage catheter, inserted via ventriculostomy into lateral ventricle, can be done to monitor ICP
and to drain CSF to maintain normal pressure; if used the system is calibrated with transducer is
leveled 1 inch above the ear; sterile is of utmost

Importance Client Education


-Teach the client at risk for increased ICP to avoid coughing, blowing the nose, straining for bowel
movements, pushing against the bed side rails, or performing isometric exercises
-Advice the client to maintain neutral head and neck alignment
-Encourage the family to maintain quiet environment and minimize stimuli
-Educate the family that upsetting the client may increase ICP

METABOLIC EMERGENCIES DKA


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

Etiology
-Decreased or missed dose of insulin
-Illness or infection
-Undiagnosed and untreated diabetes Pathophysiology
-In the absence of endogenous insulin, the body breaks down fats for energy. In the process, fatty
acids develop too rapidly and are converted to ketones, resulting to severe metabolic acidosis. As
acidosis worsens, blood glucose levels increase and hyperkalemia worsens. The cycle continues until
coma and death occur.
Clinical manifestations
- Acetone breath
- Poor appetite or anorexia
- Nausea and vomiting
- Abdominal pain
- Blurred vision
- Weakness
- Headache
- Dehydration
- Thirst or polydipsia
- Orthostatic hypotension
- Hyperventilation (Kussmaul respirations)
- Mental status changes in DKA vary from patient to patient
- weight loss
- Muscle wasting- leg cramps- recurrent infections Diagnostics
-Serum glucose is elevated (200 to 800 mg/dl)
-Serum Ketone Level is increased
-Urine acetone test is positive
-Arterial Blood Gas analysis reveals metabolic acidosis
-ECG findings shows tall tented T waves and widened QRScomplex changes related to
hyperkalemia; later with hypokalemia, shows flattened T wave and the presence of Wave
-Serum osmolality is elevated

Nursing Diagnoses
-Deficient Fluid Volume
-Risk for Injury
-Risk for Skin Impaired Integrity
-Ineffective Breathing Pattern
-Disturbed Sensory Perception
-Knowledge Deficit
-Anxiety

Nursing Management
-Restore fluid, electrolyte and glucose balance with IV infusions and medications, analyze intake and
out, blood glucose, urine ketones, vital signs, oxygenation and breathing pattern
-Maintain skin integrity; promote healing of impaired skin; prevent infection by turning and positioning
client every 2 hours; provide pressure relief as indicated; manage incontinence and perspiration with
skin protective barriers and cleansing; provide appropriate nutrition and oxygen support
-Promote safety by analyzing vital signs, client communication, LOC and emotional response, and
activity tolerance; implement falls prevention measures
-Assist client to verbalize concerns and cope effectively with illness and fears
-Assist client to update Medic-Alert bracelet information asappropriatePharmacotherapy
-Administer IV Insulin and fluid and electrolyte replacements based on laboratory test results Client
Education
-Instruct client about the nature and causes of DKA (such as excess glucose intake, insufficient
medications or physiological and/or psychological stressors) any new medications.

HYPEROSMOLAR HYPERGLYCEMIC NONKETOTIC COMA


Description
-Life threatening metabolic disorder of hyperglycemia usually recurring with DM types 2 medications,
infections, acute illness, invasive procedure, or a chronic illness

Etiology

-Medications
-Infections
-Acute illness
-Invasive procedure
-Chronic illness
Pathophysiology
-glucose production and release into the blood is increased or glucose uptake by the cells is
decreased; when the cells dont receive glucose, the liver responds by converting glycogen to glucose
for release into the bloodstream; when all excess glucose molecules remain in the serum, osmosis
cause fluid shifts.; the cycle continues until fluid shifts in the brain cause coma and death.

Clinical Manifestations
-Severe dehydration
-Hypotension and tachycardia
-Diaphoresis
-Tachypnea
-Polyuria, polydipsia and polyphagia
-Lethargy and fatigue
-Vision changes
-Rapid onset of lethargy
-Stupor and coma
-Neurologic changes

Diagnostics
-Serum glucose is elevated, sometimes 800 to 2,000 mg/dl
-Ketones are absent, urine and serum ketones are absent
-Urine glucose levels are positive
-Serum osmolality is increased
-Serum Sodium levels are elevated and the serum potassium level is usually normal
-ABG results are usually normal, without evidence of acidosis

Nursing Diagnoses
-Decreased Cardiac Output
-Deficient Fluid Volume
-Hyperthermia
-Disturbed Sensory Perception
-Risk for Impaired Skin Integrity
-Risk for Aspiration
-Deficient Knowledge

Nursing Management
-Assess the patients LOC, respiratory status and oxygenation
-Monitor the patients VS; changes may reflect the patients hydration status
-Monitor patients blood glucose and serum electrolytes
-Administer regular insulin IV as ordered, by continuous infusion and titrate dosage based on the
patients blood glucose levels
-Maintain intact skin integrity by turning every 2 hours, use of pressure relief aids, nutritional
support, use of skin moisturizers and barriers, and management of incontinence
-Prevent aspiration by using appropriate feeding precautions, elevate head of bed 15 to 30 degrees
during and after feeding for 1 hour; if BP is too unstable to elevate head of bed with feeding, then
withhold oral feedings.

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

Client Education
-Instruct client and family about HHNK, symptoms to report, and administration of new medications
-Provide patient and family education to foster prevention of future episodes.

Massive Bleeding

Description
-Uncontrolled bleeding
Etiology
-Result of blunt or penetrating trauma
-Gastrointestinal or genitourinary bleeding
-Hemoptysis

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

Clinical lManifestations
-Cool, clammy, pale skin (esp. distal extremities)
-Delayed capillary refill (>3 seconds)
-Weak, rapid pulses
-Decreased blood pressure (systolic pressure <90mmHg)
-Rapid shallow respirations (>28/ min)
-Restless, anxious, decreased LOC
-Cardiac dysrhythmias (abnormalities of cardiac rhythm)
-Decreased urinary output

Diagnostics
-Evidence of bleeding from thoracotomy that indicates bleeding from chest area
-Abdominal or pelvic CT scan, abdominal ultrasound or peritoneal lavage indicate intra-abdominal
bleeding
-Endoscopy indicates upper or lower GI bleeding
-Angiography procedures diagnose severe vascular damage
-Extremity radiographs show long bone fractures
-Hemoglobin and hematocrit from the CBC are decreased due to blood loss
-Elevated serum lactate if bleeding continues and client becomes acidotic
-ABGs show metabolic acidosis as blood loss continues
-Baseline coagulation studies should be reviewed; initial PT/Stand platelet counts will be within normal
limits but as coagulation factors become depleted, clotting times will increase and platelet counts will
decrease
-Serum electrolytes to assess renal function

Nursing Diagnoses
-Impaired Tissue Perfusion
-Deficient Fluid volume
-Decreased cardiac Output

Nursing Management
-Establish an adequate airway, breathing pattern, and applying supplemental oxygen
-Give priority interventions to control bleeding such as direct pressure to wound site, or assisting with
surgical interventions
-Establish IV access and begin with fluid replacement
-Draw blood specimens as ordered to assist in evaluation of hemoglobin, hematocrit, electrolyte, and
oxygenation andhydrationstatus
-Insert an indwelling catheter and NG tube to assist in accurate recording of fluid balance status
-Perform and document continuous serial assessments of hemodynamic parameters such as VS,
capillary refill, CVP, cardiac rhythm, LOC, urinary output and laboratory findings

Pharmacotherapy
-Crystalloids and blood products to maintain adequate circulating volume status
-Sodium Bicarbonate to correct acidosis state
-Vasopressor such as Dopamine

Client Education
-Explain procedures to the client
-Support the family by explaining emergency measures

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

E t i o l o g y

T y p e s o f b u r n
i n j u r y
a.Thermal: results from dry heat (flames) or moist heat (steam or hot liquids); it is
the most common type; it causes cellular destruction that results in vascular, bony, muscle, or nerve
complications; thermal burns can also lead to inhalation injury if the head and neck area is affected

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

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

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

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

ClinicalManifestations
-Localized pain and erythema, usually without blisters in the first24 hours (first degree burn)
-Chills, headache, localized edema, nausea and vomiting (most severe first degree burn)
-Thin-walled, fluid filled blisters appearing within minutes of the injury, with mild to moderate edema
and pain (second degree superficial partial thickness burn)
-White, waxy appearance to damaged area (second degree partial-thickness burn)
-White, brown or black leathery tissue and visible thrombosedvessels due to destruction of skin
elasticity (dorsum of hand, most common site of thrombosis veins), without blisters (third-degree burn)
-Silver-colored, raised or charred area, usually at the site of electrical contact
D i a g n o s t i c s * Rule
of Nines chart determines the percentage of body surface area (BSA) covered by the burn
-ABG levels may be normal in the early stages but may reveal hypoxemia and metabolic acidosis
-Carboxyhemoglobin level may reveal the extent of smoke inhalation due to the presence of carbon
monoxide
-Complete blood count may reveal decrease hemoglobin due
O hemolysis, increased hematocrit and leukocytosis
-Electrolyte levels show hypernatremia and hyperkalemia, other laboratory tests reveals elevated
BUN, decreased total protein and albumin
-Keratinize kinase (CK) and myoglobin levels may be elevated
-Presence of myoglobin in urine may lead to acute tubular necrosis
Nursing Diagnoses

-Risk for Deficient Fluid Volume


-Risk for Infection
-Impaired Physical Mobility
-Imbalanced Nutrition: Less than Body Requirements
-Ineffective Breathing Pattern
-Impaired Tissue Perfusion
-Risk for Impaired Gas Exchange
-Anxiety
-Risk for Ineffective Thermoregulation
-Pain
-Impaired Skin Integrity

Nursing Management
-Assess patients ABCs; monitor arterial oxygen saturation and serial ABG values and anticipate the
need for ET intubation and mechanical ventilation
-Auscultate breath sounds
-Administered supplemental humidified oxygen as ordered
-Perform or pharyngeal or tracheal suctioning as indicated by the patients inability to clear
his airway
-Monitor the patients cardiac and respiratory status
-Assess LOC for changes such as confusion, restlessness or decreased responsiveness
-solution for chemical burns
-Place the patient in semi-Fowlers position to maximize chest expansion; keep patient as quiet and
comfortable to minimize oxygen demand
-Prepare the patient for an emergency escharotomy of the chest and neck for deep burns
-Administer rapid fluid replacement therapy as ordered

*For burn patient in shock -

-Monitor VS and hemodynamic parameters


-Assess patients intake and output every hour, insert an
indwelling catheter
-Assess the patients level of pain, including nonverbal indicators and administer analgesics such as
Morphine Sulfate IV as ordered
-Keep the patient calm, provide periods of uninterrupted rest between procedures and use no
pharmacologic pain relief measures as appropriate
-Obtain daily weights and monitor intake, including daily calorie counts; provide high calorie, high
protein diet
-Administer histamine 2 receptor antagonists as ordered to reduce risk of ulcer formation
-Assess the patients sign and symptoms of infection; may obtain wound culture and administer
antimicrobials antipyretics as ordered
-Administer tetanus prophylaxis if indicated
-Perform burn wound care as ordered; prepare patient for grafting as indicated
-Assess the neurovascular status of the injured area, including pulses, reflexes, parenthesis, color and
temperature of the injured area at least 2 to 4 hours or more frequently as indicated
-Assist with splinting, positioning, compression therapy and exercise to the burned area as indicated;
maintain the burned area in a neutral position to prevent contractures and minimize deformity
-Explain all procedures to the patient before performing them
Pharmacotherapy
-Antibiotic prophylaxis will eradicate bacterial component
-Pain therapy
-Tetanus prophylaxis
-Topical antimicrobial
-Enzymatic debriding agents such as collagenase, fibrinolysin-desoxyribonuclease, pain or sustains
are used with a moisture barrier to protect surrounding tissue
-Recommended dressings include polyurethane films (Op-site, Tegaderm), absorbent hydrocolloid
dressings (Dodder)

Client Education
-Environmental safety: use low temperature setting for hot water heater, ensure access to and
adequate number of electrical cords/outlets, isolate household chemicals, and avoid smoking imbed
-Use of household smoke detectors with emphasis on maintenance
-Proper storage and use of flammable substances-
Evacuation plan for family
-Care of burn at home
-Signs and symptoms of infection
-How to identify risk of skin changes
-Use of sunscreen to protect healing tissue and other protective skin care

Poisoning

Description
-Substances that are harmful to humans that are inhaled, ingested (food, drug overdose) or acquired
by contact
Etiology
-Carbon monoxide inhalation
-Food poisoning
-Drug overdose
-Insecticide surface absorption

Pathophysiology
-The pathophysiology of poisons depends on the substance thats inhaled or ingested. The extent of
damage depends on the of the substance, the amount ingested, its form and the length of exposure to
it. Substances with an alkaline pH cause tissue damage by liquefaction necrosis, which softens the
tissue. Acids produce coagulation necrosis. Coagulation necrosis denatures proteins when substance
contacts tissue. This limits the extent of the injury by preventing penetration of the acid into the tissue.
-*The mechanism of action for inhalants is unknown, but theyre believed to act on the CNS similarly to
a very potent anesthetic. Hydrocarbons sensitize the myocardial tissue and allow it to be sensitize to
catecholamines, resulting in arrhythmias.

ClinicalManifestations

a.Carbon monoxide inhalation: mild exposure nausea, vomiting, mild throbbing headache,
flu-like symptoms; moderate exposure dyspnea, dizziness, confusion, increased severity of mild
symptoms; severe/prolonged exposure seizures, coma,respiraotory arrest, hypotension and
dysrhythmias
B.Food poisonings: nausea, vomiting, diarrhea, abdominal cramps, fever , chills, dehydration,
headache
c.Drug overdose: depends upon the substance ingested; symptoms may include
nausea, vomiting, CNS depression or agitation, altered pupil response, respiratory changes such as
tachypnea or bradypnea, alterations in temperature control, seizures or cardiac arrest

D.Surface absorption of insecticides (organophosphates or carbonates): nausea, vomiting, diarrhea,


headache, dizziness, weakness or tremors, mild to severe respiratory distress, slurred speech,
seizures, and cardio-pulmonary arrest

D i a g n o s t i c s *

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

laboratory toxicology screens (serum,vomitus, stool and urine)determine the extent of the absorption
baseline blood work such as CBC, electrolytes, renal and hepatic studies enable future determination
of organ and tissue damage

Chest Xray may show aspiration pneumonia in inhalation poisoning


-Abdominal X-rays may reveal iron pills or other radiopaque substances
-ABG analysis used to evaluate oxygenation Nursing Diagnoses
-Risk for Ineffective Airway Clearance
-Risk for Decreased Cardiac Output
-Deficient Fluid Volume
-Ineffective Breathing Pattern
-Impaired Tissue Perfusion
-Risk for Injury
-Anxiety
-Risk for Self-directed Violence
-Hopelessness

Nursing Management
-Assist with the management of an effective airway, breathing pattern and circulatory status
-Give treatment of life-threatening dysrhythmias and conditions as ordered; continual monitoring of
vital signs, cardiac rhythm and neurological status and supportive care is essential
-Assist in the hastening in the elimination of the medication or poison, decrease the amount of
absorption and administer antidotes as ordered
-for specific treatment contact the poison center

Pharmacotherapy

*antidotes will vary with medication ingested-


Ipecac syrup 30ml PO followed by 240ml water is used for adults- Activated charcoal powder slurry
30 to 100g PO or per NG tube
- Magnesium Citrate will be used for GI evacuation
Naloxone (Narcan) for respiratory depression caused by narcoticoverdose
-Flumazenil (Romazicon) for benzodiazepine ingestions

Client Education
-Assist the client and family in seeking the appropriate referrals and provide client education to further
complications or incidence of overdose
-Ensure that the client and family understand discharge instruction for follow up care or reason for
admission.

Multiple Injuries

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

Etiology
-Weapons
-Automobile collision
-Physical confrontation
-Falls
-Unnatural occurrence to the body
*Type of trauma which determines the extent of injury
-Blunt trauma leaves the body intact
-Penetrating trauma disrupts the body surface
-Perforating trauma leaves entrance and exit Pathophysiology
-A physical injury can create tissue damage caused by stress and strain on surrounding tissue which
results to infection, pain, swelling and potential compartment syndrome or it can be life-threatening if it
affects a highly vascular or vital organ

Diagnostics
-Chest X-ray detect rib and sterna fractures, pneumothorax, flail chest, pulmonary contusion and
lacerated or ruptured aorta
-Angiography studies performed with suspected aortic laceration or rupture
-Ct scan, cervical spine X-rays, skull X-rays, Angiogram test for a patient with head trauma
-ABG analysis to evaluate respiratory status and determine acidotic and alkaloid states
-CBC to indicate the amount of blood loss
-Coagulation studies to evaluate clotting ability
-Serum electrolyte levels to indicate the presence of electrolyteimbalances

Nursing Diagnoses
-Ineffective Airway Clearance
-Ineffective Breathing Pattern
-Impaired Gas Exchange
-Deficient Fluid Volume
-Decreased Cardiac Output
-Impaired Tissue Perfusion
-Impaired Skin Integrity
-Risk for infection
-Anxiety
-Pain
-Disturbed Body Image

Nursing Management

-Assess the patients ABCs and initiate emergency measures


-Administer supplemental oxygen as ordered
-Immobilize the patients head and neck with an immobilization device, sandbags, backboard and
tape
-Assist with cervical X-rays
-Monitor VS and note significant changes
-Immobilize fractures
-Monitor the patients oxygen saturation and cardiac rhythm for arrhythmias
-Assess the patients neurologic status, including LOC and papillary and motor response
-Obtain blood studies, including type and crosshatch
-Insert large bore IV catheter and infuse normal saline or lactated Ringers solution
-Assess the patient for multiple injuries
-Assess the patients wounds and provide wound care as appropriate; cover open wounds and
control bleeding by applying pressure and elevating extremities
-Assess for increased abdominal distention and increased diameter of extremities
-Administer blood products as appropriate
-Monitor the patient for signs of hypovolemic shock
-Provide pain medication as appropriate
-Provide reassurance to the patient and his family

Pharmacotherapy

-Tetanus immunization
-Antibiotics for infection control
-Analgesics for pain Client Education
-Provide explanations of all procedures done
-Families usually require emotional support and honest discussions about therapeutic interventions
and plans

-Assist with cervical X-rays


-Monitor VS and note significant changes
-Immobilize fractures
-Monitor the patients oxygen saturation and cardiac rhythm for arrhythmias
-Assess the patients neurologic status, including LOC and papillary and motor response
-Obtain blood studies, including type and crosshatch
-Insert large bore IV catheter and infuse normal saline or lactated Ringers solution
-Assess the patient for multiple injuries
-Assess the patients wounds and provide wound care as appropriate; cover open wounds and
control bleeding by applying pressure and elevating extremities
-Assess for increased abdominal distention and increased diameter of extremities
-Administer blood products as appropriate
-Monitor the patient for signs of hypovolemic shock
-Provide pain medication as appropriate
-Provide reassurance to the patient and his family

- Pharmacotherapy

Tetanus immunization
-Antibiotics for infection control
-Analgesics for pain Client Education
-Provide explanations of all procedures done
-Families usually require emotional support and honest discussions about therapeutic interventions
and plans
2. Assessment
: A systematic procedure for collecting qualitative and quantitative data to describe progress and
ascertain deviations from expected outcomes and achievements.
3. Attributes: Characteristics that underpin competent performance.
4. Benchmark: Essential standard
5. Client: An individual, family, group or community that is a consumer of nursing service.
6. Competence: The combination of skills, knowledge, attitudes, values and abilities that underpin
effective performance as a nurse.
7. Competent: The person has competence across all domains of competencies applicable tithe
registered nurse, at a standard that is judged to appropriate for the level of nurse beingassessed.
8. Competency: A defined area of skilled performance.
9. Context: The setting/environment where competence can be demonstrated or applied.
10. Domain: An organized cluster of competencies in nursing practice.
11. Effective: Having the intended outcome.
12. Enrolled nurse: A nurse registered under the enrolled nurse scope of practice.
13. Indicator: Key generic examples of competent performance. They are neither comprehensive nor
exhaustive. They assist the assessor when using their professional judgment in assessing nursing
practice. They further assist curriculum development.
14. Performance criteria: Descriptive statements that can be assessed and that reflect the intent of a
competency in terms of performance, behavior and circumstance.
15. Registered nurse: A nurse registered under the registered nurse scope of practice
16. Reliability: The extent to which a tool will function consistently in the same way with repeated use.
17. Validity: The extent to which a measurement tool measures what it purports to measure.

Pre Test CLINICAL COMPETENCE

DIRECTION: Circle the one best answer for each test question. Write your rationale
for selecting the answer. To enhance your learning and test taking skill, discuss your answer
and rationale with a partner.
A: Physical Examination 5 pts. Each (15 items) 1.The nurse is using a digital thermometer to
take an oral temperature. After taking the oral temperature, the nurse obtains a reading of 94.2
degree F. Which of the follow-up actions is most appropriate for the nurse to do? A.used another
digital thermometer to retake the temperature
b.Feel the clients skin temperature
c.Takea rectal temperature
d.Document the findings Rationale for your selection:
____________________________________________________________ __________________
______________________________________
2.The nurse obtains an axillary temperature of 97.4 degree F on a client. In graphing the
temperature, it is most appropriate for the nurse to:
a.Write see nurses notes above the temperature reading
b.Identify the temperature reading with an Ax
c.Graph the oral equivalent temperature of 98.4 degree
d. Adjust graph 97.4 degree F on the form. Rationale for
your selection:_______________________________________________________________ ___
_______________________________________________________
3.The nurse is caring for a client who has an oral temperature of 99.6 degree F
at8:00AM, the start of the day shift. The clients RAND indicates that the vital signs should be taken
once a shift. In planning care for the client, which action is most appropriate?
a.Ensure that the temperature is taken promptly at 4:00PM
b.Call the doctor for a more frequent order.
c.Take the temperature as necessary
d.Begin cooling measures Rationale for
your selection____________________________________________________________ _______
___________

KEY ANSWER: 1.The nurse is using a digital thermometer to take an oral temperature.
After taking the oral temperature, the nurse obtains a reading of 94.2 degree F. Which of the follow-
up actions is most appropriate for the nurse to do? Abused another digital thermometer to
retake the temperatureb . F e e l t h e c l i e n t s s k i n t e m p e r a t u r e c . T a k e
a rectal temperatured.Document
T h e f i n d i n g s Rationale: A is the answer. Since the nurse is using a digital thermometer, it is
important for the nurse to ensure that the equipment is functioning. The temperature recording should
be low and should be taken again. Option B & C are not appropriate: option D should be done after
verifying the temperature.2.The nurse obtains an axillary temperature of 97.4 degree F on a
client. In graphing the temperature, it is most appropriate for the nurse to:a.Write see nurses
notes above the temperature readingb.Identify the temperature
reading with an Axc.Graph the oral equivalent temperature of 98.4 degree
Adjust graph 97.4 degree F on the formRationale:B is the answer. It is important for the
nurse to identify the appropriate information on where the temperature was taken. Option A, C, & D do
not accurately document the temperature information.3.The nurse is caring for a client who has
an oral temperature of 99.6 degree F at8:00ARE, the start of the day shift. The clients RAND
indicates that the vital signssould be taken once a shift. In planning care for the client, which action is
most appropriate? A.Ensure that the temperature is taken promptly at
4:00PMb.Call the doctor for a more frequent order.c . T a k e t h e t e m p e r a t u r e
a s n e c e s s a r y d . B e g i n c o o l i n g m e a s u r e s Rationale: C is the answer. The nurse can
make an independent decision to take the temperature more frequently to ensure safe nursing care.
Option A does not allow for through ongoing assessment. Option B & D are not necessary at this time.

Lesson A.
1CORE COMPETENCIES
Tell me, I might forget; teach me and I might remember; involve me and I learn!-
Benjamin Franklin

Definition:

A competency appraisal is a process in which an individual is assessed for his or her competence in a
particular area of employment. The main objective of the competency appraisal is to ascertain whether
an employee is able to carry out his or her duties in a professional role. A typical scenario would
involve an employee the person being assessed for competence and one or more of his or her
seniors. It normally
Would take place in a private location, such as an unused office. The duration of a competency
appraisal depends on the nature of the appraisal; the actual meeting between the senior professional
and the employee typically lasts one to two hours.
Legal Basis:
Article 3 Sec.9 (c) of R.A. 9173/ Philippine Nursing Act 2002"Board shall monitor & enforce quality
standards of nursing practice necessary to ensure the maintenance of efficient, ethical and technical,
moral and professional standards in the practice of nursing taking into account the health needs of the
nation.
SIGNIFICANCE OF CORE COMPETENCY STANDARDS
There are certain professions in which a competency appraisal is of critical importance, such
as medical professions in which human safety is an essential priority. If patients are exposed to
incompetent medical practitioners, this could be a potential threat to the patient's health and safety. In
developed nations, competency appraisal in the medical professional is highly prevalent as it is
considered to be absolutely necessary; medical practitioners, particularly in their first years of practice,
are monitored closely by senior medical professionals.
Unifying framework for nursing practice, education, regulation
Guide in nursing curriculum development
Framework in developing test syllabus for nursing profession entrants
Tool for nurses performance evaluation
Basis for advanced nursing practice, specialization
Framework for developing nursing training curriculum
Public protection from incompetent practitioners
Yardstick for unethical, unprofessional nursing practice

Phases of developing competency standards


1st Phase Competency identification through Developing a Curriculum (DACUM)

Workshop and series of focus group discussions with the participation of nurse experts

And consumers of nursing practice such as administrators, doctors and clients 2nd Phase
Verification of identified competencies

among nursing experts from the different regions of the country 3rd Phase Pilot testing ( senior
student in 8 nursing colleges) 4th Phase Benchmarking with exiting standards from 3 countries as
well as International Council for Nurses (ICN)
FOUR DOMAINS OF COMPETENCIES
There are four domains of competence for the registered nurse scope of practice. Evidence of safety
to practice as a registered nurse is demonstrated when the applicant meets the competencies within
the following domains: Domain one: Professional responsibility This domain contains competencies
that relate to professional, legal and ethical responsibilities and cultural safety. These include being
able to demonstrate knowledge and judgment and being accountable for own actions and decisions,
while promoting an environment that maximizes clients safety, independence, quality of life and
health. Domain two: Management of nursing care This domain contains competencies related to client
assessment and managing client care, which is responsive to clients needs, and which is supported
by nursing knowledge and evidence based research. Domain three: Interpersonal relationships this
domain contains competencies related to interpersonal and therapeutic communication with clients,
other nursing staff and inter professional communication and documentation. Domain four: Inter
professional health care & quality improvement this domain contains competencies to demonstrate
that, as a member of the health care team, the nurse evaluates the effectiveness of care and of the
team.
Competencies and Indicators

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

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

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

The indicators further assist curriculum development for bachelors degrees in nursing or first year of
practice programmes.Registered nurses are required to demonstrate competence. They are
accountable for their actions and take responsibility for the direction of nurse assistants, enrolled
nurses and others. The competencies have been designed to be applied to registered nurse practice
in a variety of clinical contexts. They take into account the contemporary role of the registered nurse,
who utilizes nursing knowledge and complex nursing judgment to assess health needs, provide care,
and advice and support people to manage their health. The registered nurse practices independently
and in collaboration with other health professionals. The registered nurse performs general nursing
functions, and delegates to, and directs enrolled nurses and nurse assistants. The registered nurse
also provides comprehensive nursing assessments to develop, implement, and evaluate an
integrated plan of health care, and provides nursing interventions that require substantial scientific
and professional knowledge and skills. This occurs in a range of settings in partnership with
individuals, families, and communities. Nursing students are supervised in practice by a registered
nurse. Nursing students are assessed against all competencies on an ongoing basis, and will be
assessed for entry to the registered nurse scope of practice at the completion of their program. Nurses
involved in management, education, policy and research The competencies also reflect the scope
statement that some registered nurses use their nursing expertise to manage, teach, evaluate and
research nursing practice. Registered nurses, who are not practicing in direct client care, are exempt
from those competencies in domain two(management of nursing care) and domain three
(interpersonal relationships) that only apply to clinical practice. There are specific competencies in
these domains for nurses working in management, education, policy and/or research. These are
included at the end of domains two and three. Nurses who are assessed against these specific
competencies are required to demonstrate how they contribute to practice. Those practicing in direct
client care and in management, education, policy and/or research must meet both sets of
competencies.
Concepts and Definitions of 11 Key areas of Responsibility
. SAFE AND QUALITY NURSING CARE
CORE COMPETENCY 1:Demonstrate knowledge based on health/illness status of individual/ groups
Indicators : Identifies health needs of patients/groups Explains patient/group status CORE
COMPETENCY 2:Provides sound decision making in care of individual/groups considering their
beliefs, values Indicators : Problem identification Data gathering related to problem Data
analysis Selection appropriate action Monitor progress of action taken

CORE COMPETENCY 3:Promotes patient safety and comfort Indicators : Performs age-specific
safety measures and comfort measure in all aspects of patient care CORE COMPETENCY 4:Priority
setting in nursing care based on patients needs Indicators : Identifies priority needs of patients
Analysis of patients needs Determine appropriate nursing care to be provided CORE
COMPETENCY 5:Ensures continuity of care Indicators : Refers identified problems to appropriate
individuals/ agencies Establish means of providing continuous patient care CORE COMPETENCY
6:Administers medications and other health therapeutics Indicators : Conforms to the 10 golden rules
in medication administration and health therapeutics CORE COMPETENCY 7:Utilizes nursing
process as framework for nursing. Performs comprehensive, systematic nursing assessment
Indicators : Obtains consent Complete appropriate assessment forms Performs effective
assessment techniques Obtains comprehensive client information Maintains privacy and
confidentiality Identifies health needs CORE COMPETENCY 8:Formulates care plan in collaboration
with patients, other health team members Indicators : Includes patients, family in care planning
States expected outcomes in nursing interventions Develops comprehensive patient care plan
Accomplishes patient centered discharge plan CORE COMPETENCY 9:Implements NCP to achieve
identified outcomes Indicators : Explain interventions to patient, family before carrying them out
Implement safe, comfortable nursing interventions Acts according to clients health conditions,
needs Performs nursing interventions effectively and in timely manner CORE COMPETENCY 10:

Implements NCP progress toward expected outcomes Indicators : Monitors effectiveness of nursing
interventions Revises care plan PRNCORE COMPETENCY 11:Responds to urgency of patients
condition Indicators : Identifies sudden changes in patients health conditions Implements
immediate, appropriate interventions
II. MANAGEMENT OF RESOURCES AND ENVIRONMENT
CORE COMPETENCY 1:Organizes workload to facilitate patient care Indicators: Identifies task or
activities that need to be accomplished Plans the performance of task or activities based on priority
Finishes work assignment on time CORE COMPETENCY 2:Utilizes resources to support
patient care Indicators: Determines the resources needed to deliver patient care Control the use of
equipment CORE COMPETENCY 3:Ensures the functioning of resources Indicators: Check proper
functioning of the equipment Refers Malfunctioning equipment to appropriate unit CORE
COMPETENCY 4:Check the Proper functioning of the Equipment Indicators: Determines the task
and procedures that can be safely assigned to the other members of the team Verifies the
competence of the staff prior to delegating tasks CORE COMPETENCY 5:Maintains safe
Environment Indicators: Observe proper disposal of waste Adheres to policies, procedures and
protocols on prevention and control of infection Defines steps to follow incase of fire , earthquake and
other emergency situation
III. HEALTH EDUCATION
CORE COMPETENCY 1:Assesses the learning needs of the patient and the family Indicators:
Obtains learning information through interview, observation and validation Defines relevant
information Completes assessment records appropriately Identify priority needs CORE
COMPETENCY 2:Develops Health Education plan based on assessed and anticipated needs.
Indicators: Considers nature of the learner in relation to social, cultural, political, economic,
educational, and religious factor CORE COMPETENCY 3:Develops learning material for health
education Indicators: Involves the patient, family and significant others and other resources
Formulates a comprehensive health educational plan with the following components ,objectives,
content and time allotment Teaching-learning resources and evaluation parameters Provides for
feedback to finalize plan CORE COMPETENCY 4:Implements the health Education Plan Indicators:
Provides for conducive learning situation in terms of timer and place Considers client and family
preparedness Utilize appropriate strategies Provides reassuring presence through active listening,
touch and facial expression and gestures Monitors client and familys responses to health education
CORE COMPETENCY 5:Evaluates the outcome of health Education Indicators:
Utilizes evaluation parameters Documents outcome of care Revises health education plan
when necessary
IV. ETHICO-MORAL RESPONSIBILITY
CORE COMPETENCY 1: Respects the rights of individual/ groups Indicator: Renders nursing care
consistent with the patients bill of rights (i.e. confidentiality of information, privacy, etc.)CORE
COMPETENCY 2Accepts responsibility & accountability for own decisions and actions Indicators:

Meets nursing accountability requirements as embodied in the job description Justifies basis for
nursing actions and judgment Protects a positive image of the profession CORE COMPETENCY
3Adheres to the national and international code of ethics for nurses Indicators: Adheres to the Code
of Ethics for Nurses and abides by its provisions Reports unethical and immoral incidents to proper
authorities
V. LEGAL RESPONSIBILITY
CORE COMPETENCY 1:Adheres to practices in accordance with the nursing law and other relevant
legislation including contract and informed consent. Indicators: Fulfill legal requirements in
Nursing Practice Holds current professional license Acts in accordance with the terms of contract
of employment and other rules and regulation Complies with the required CPE Confirms
information given by the doctor for informed consent Secures waiver of responsibility for refusal to
undergo treatment or procedures Check the completeness of informed consent and other legal
forms CORE COMPETENCY 2:Adheres to organizational policies and procedures, local and national
Indicators: Articulates the vision and mission of the institution where one belongs Acts in
accordance with the established norms and conduct of the institution/ organization CORE
COMPETENCY 3:Document care rendered to patients. Indicators: Utilizes appropriate patient
care records and reports Accomplish accurate documentation in all matters concerning patient
care in accordance with the standard of nursing practice.
VI. PERSONAL & PROFESSIONAL DEVELOPMENT
CORE COMPETENCY 1Identifies own learning needs Indicators: Verbalizes strengths,
weaknesses, limitations. Determines personal and professional goals and aspirations. CORE
COMPETENCY 2Pursues continuing education Indicators: Participates in formal and non-formal
education. Applies learned information for the improvement of care.
CORE COMPETENCY 3Gets involved in professional organizations and civic activities Indicators:
Participates actively in professional, social, civic and religious activities Maintain
membership to professional organizations Support activities related to nursing and health issues
CORE COMPETENCY 4Projects a professional image of nurse Indicators: Demonstrate good
manners and right conduct at all times. Dresses appropriately. Demonstrates congruence of words
and actions. Behaves appropriately at all times. CORE COMPETENCY 5Possesses positive
attitude towards change and criticism Indicators: Listens to suggestions and recommendations.
Tries new strategies or approaches. Adapts to changes willingly. CORE COMPETENCY 6Performs
function according to professional standards Indicators: Assesses own performance against
standards of practice. Sets attainable objectives to enhance nursing knowledge and skills. Explains
current nursing practices, when situations call for it.
VII. RESEARCH
CORE COMPETENCY 1:Gathers data using different methodologiesIndicators:Identifies
researchable problems regarding patient care and community healthIdentifies appropriate methods of
research for a particular patient/community problemCombines quantitative and qualitative nursing
design thru simple explanation on thephenomena observedAnalyzes data gatheredCORE
COMPETENCY 2:Recommends actions for implementationIndicator:Based on the analysis of data
gathered, recommends practical solutions appropriate for theproblemCORE COMPETENCY
3:Disseminates results of research findingsIndicators:Communicates results of findings to
colleagues/patients/family and to others

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


appropriateCORE COMPETENCY 4:Applies research findings in nursing practiceIndicators:Utilizes
and findings in research in the provision of nursing care toindividuals/groups/communitiesMakes use
of evidence-based nursing to ameliorate nursing practice
VIII. RECORDS MANAGEMENT
CORE COMPETENCY 1:Maintains accurate and updated documentation of patient
careIndicator:Completes updated documentation of patient careCORE COMPETENCY 2:Records
outcome of patient careIndicator:Utilizes a record systemCORE COMPETENCY 3:Observes
legal imperatives in recording keepingIndicators:Observes confidentially and privacy of patients
recordsMaintains an organized system of filing and keeping patients records in a designated
areaRefrains from releasing records and other information without proper authority
IX. COMMUNICATION
CORE COMPETENCY 1:Establishes rapport with patients, significant others and members of the
health team.Indicators: Creates trust and confidence Listens attentively to clients queries and
requests Spends time with the client to facilitate conversation that allows client to express
concern.CORE COMPETENCY 2:Identifies verbal and non-verbal cuesIndicator: Interprets and
validates clients body language and facial expressionCORE COMPETENCY 3:Utilizes formal and
informal channelsIndicator: Makes use of available visual aidsCORE COMPETENCY 4:

Meets nursing accountability requirements as embodied in the job description Justifies basis for
nursing actions and judgment Protects a positive image of the professionCORE COMPETENCY
3Adheres to the national and international code of ethics for nursesIndicators: Adheres to the Code
of Ethics for Nurses and abides by its provisions Reports unethical and immoral incidents to proper
authorities
V. LEGAL RESPONSIBILITY
CORE COMPETENCY 1:Adheres to practices in accordance with the nursing law and other relevant
legislation includingcontract and informed consent.Indicators: Fulfill legal requirements in
Nursing Practice Holds current professional license Acts in accordance with the terms of contract
of employment and other rules and regulation Complies with the required CPE Confirms
information given by the doctor for informed consent Secures waiver of responsibility for refusal to
undergo treatment or procedures Check the completeness of informed consent and other legal
formsCORE COMPETENCY 2:Adheres to organizational policies and procedures, local and
nationalIndicators: Articulates the vision and mission of the institution where one belongs Acts in
accordance with the established norms and conduct of the institution/ organizationCORE
COMPETENCY 3:Document care rendered to patients.Indicators: Utilizes appropriate patient
care records and reports Accomplish accurate documentation in all matters concerning patient
care in accordance withthe standard of nursing practice.
VI. PERSONAL & PROFESSIONAL DEVELOPMENT
CORE COMPETENCY
1Identifies own learning needsIndicators: Verbalizes strengths, weaknesses, limitations.
Determines personal and professional goals and aspirations.
CORE COMPETENCY
2 Pursues continuing educationIndicators: Participates in formal and non-formal education. Applies
learned information for the improvement of care.

CORE COMPETENCY
3 Gets involved in professional organizations and civic activitiesIndicators: Participates actively
in professional, social, civic and religious activities Maintain membership to professional
organizations Support activities related to nursing and health issues
CORE COMPETENCY
4 Projects a professional image of nurseIndicators: Demonstrate good manners and right conduct at
all times. Dresses appropriately. Demonstrates congruence of words and actions. Behaves
appropriately at all times.
CORE COMPETENCY
5 Possesses positive attitude towards change and criticismIndicators: Listens to suggestions and
recommendations. Tries new strategies or approaches. Adapts to changes willingly.
CORE COMPETENCY
6 Performs function according to professional standardsIndicators: Assesses own performance
against standards of practice. Sets attainable objectives to enhance nursing knowledge and skills.
Explains current nursing practices, when situations call for it.
VII. RESEARCH
CORE COMPETENCY 1:
Gathers data using different methodologiesIndicators:Identifies researchable problems regarding
patient care and community health Identifies appropriate methods of research for a particular
patient/community problem Combines quantitative and qualitative nursing design thru simple
explanation on the phenomena observed Analyzes data gathered
CORE COMPETENCY 2:
Recommends actions for implementationIndicator:Based on the analysis of data gathered,
recommends practical solutions appropriate for theproblemCORE COMPETENCY 3:Disseminates
results of research findingsIndicators:Communicates results of findings to colleagues/patients/family
and to others

Endeavors to publish research Submits research findings to own agencies and others as appropriate
CORE COMPETENCY 4:Applies research findings in nursing practiceIndicators:Utilizes and findings
in research in the provision of nursing care to individuals/groups/communities Makes use of evidence-
based nursing to ameliorate nursing practice
VIII. RECORDS MANAGEMENT
CORE COMPETENCY 1:Maintains accurate and updated documentation of patient
careIndicator:Completes updated documentation of patient care CORE COMPETENCY 2:Records
outcome of patient careIndicator:Utilizes a record system CORE COMPETENCY 3:Observes
legal imperatives in recording keepingIndicators:Observes confidentially and privacy of patients
records Maintains an organized system of filing and keeping patients records in a designated area
Refrains from releasing records and other information without proper authority
IX. COMMUNICATION
CORE COMPETENCY 1:Establishes rapport with patients, significant others and members of the
health team. Indicators: Creates trust and confidence Listens attentively to clients queries and
requests Spends time with the client to facilitate conversation that allows client to express concern.
CORE COMPETENCY 2: Identifies verbal and non-verbal cues Indicator
: Interprets and validates clients body language and facial expression CORE COMPETENCY 3:
Utilizes formal and informal channels Indicator: Makes use of available visual aids CORE
COMPETENCY 4:
Responds to needs of individuals, family, group and community Indicator: Provides re- assurance
through therapeutic, touch, warmth and comforting words of encouragement Readily smiles CORE
COMPETENCY 5: Uses appropriate information technology to facilitate communication Indicator:
Utilizes telephone, mobile phone, email and internet, and informatics Identifies a significant other so
that follow up care can be obtained Provides holding or emergency numbers of services
X. COLLABORATION and TEAMWORK
CORE COMPETENCY 1:Establishes collaborative relationship with colleagues and other members
of the health team Indicators: Contributes to decision making regarding patients needs and
concerns Participates actively in patients care management including audit Recommends
appropriate intervention to improve patient care Respects the role of the other members of the health
team Maintains good interpersonal relationships with patients, colleagues and other members of the
health team CORE COMPETENCY 2:Collaborates plan of care with other members of the health
team Indicator: Refers patients to allied health team partners Acts liaison / advocate of the patients
Prepares accurate documentation of efficient communication of services
XI. QUALITY IMPROVEMENT
CORE COMPETENCY 1:Gathers data for quality improvementIndicators:Demonstrates knowledge
of method appropriate for the clinical problems identified Detects variation in the vital signs of the
patient from day to day Reports necessary elements at the bedside to improve patient stay at hospital
Solicits feedback from patient and significant others regarding care rendered CORE COMPETENCY
2:Participates in nursing audits and roundsIndicators:Contributes relevant information about patient
condition as well as unit condition and patient current reactions Shares with the team current
information regarding particular patients condition Encourages the patient to speak about what is
relevant to his condition Documents and records all nursing care and actions Performs daily check of
patient records/condition Completes patients records Actively contributes relevant information of
patients during rounds thru readings and sharing
Acute Biologic Crisis By: Raids L. Della Cruz, RN,MAN Page

with others CORE COMPETENCY 3:Identifies and reports variancesIndicators:Documents observed


variance regarding patient care and submits to appropriate group within24 hours Identifies actual and
potential variance to patient care Reports actual and potential variance to patient care Submits report
to appropriate groups within 24 hours CORE COMPETENCY 4:Recommends solutions to identified
problemsIndicators:Gives appropriate suggestions on corrective and preventive measures
Communicates and discusses with appropriate groups Gives and objective and accurate report on
what was observed rather than an interpretation of the event.

LesssonB.1APPLICATION OF CORE COMPETENCY IN NURSING PRACTICEPRE TEST


2ASSESSMENT OF INDIVIDUAL PATIENT NEEDS FOR NURSINGINSTRUCTIONS: Circle the
one best answer for each test question. Write your rationale for selecting the answer. To
enhance your learning and test taking skill, discuss your answer and rationale with a partner.
1.
The nurse is preparing to assess neuron status of an adult client who had hip fracture 5days ago and
was reported to have experienced confusion the previous shift. Which statement will provide the nurse
with the most appropriate information? A . C a n y o u t e l l m e t o d a y s
you know that you are in the hospital?c . W h e n d i d y o u h a v e h i p
surgery?d . W h a t is your
n a m e ? Rationale:_________________________________________________ 2.The
nurse is informed that the newly admitted client is complaining of itching and has arash
all over the body. The most appropriate nursing intervention initially is to:a.Inform the doctor of
the objective and subjective complaintsb.Inspect the client and
describe the rashc.Ask the client to try not to scratch the areasd.Check the
medication record for anti-itch
medicationRationale:____________________________________________________ 3.The
nurse is assigned to a client who was admitted for a blood clot in the right leg.Which of
the following describes the appropriate assessment technique initially?a . I n s p e c t i o n o f
t h e r i g h t l e g b . L i g h t p a l p a t i o n o f t h e r i g h t l e g c.Inspection followed by
deep palpation of edematous areasd.Light palpation followed by inspection of
any reddened
areas.Rationale:____________________________________________________
Key answers
1.
The nurse is preparing to assess neuro status of an adult client who had hip fracture 5days ago and
was reported to have experienced confusion the previous shift. Whichstatement will provide the nurse
with the most appropriate information?a . C a n y o u t e l l m e t o d a y s d a t e ? b.Do you
know that you are in the hospital?c . W h e n d i d y o u h a v e h i p s u r g e r y ?
d.
What is your name?Rationale: Eliciting orientation to person is part of assessing client
orientation.Options A & B encourages yes or no response, and option c may not give accuratedata if
the client does not remember the date.2.The nurse is informed that the newly admitted client
is complaining of itching and has arash all over the body. The most appropriate nursing
intervention initially is to:a.Inform the doctor of the objective and subjective
complaintsb.Inspect the client and describe the rashc.Ask the client to try not
to scratch the areasd.Check the medication record for anti-itch
medicationRationale:it is most appropriate for the nurse to initially gather data by using
theassessment skill of inspection and then to further describe the observations. OptionsA,C, & D are
follw-up nursing interventions.3.The nurse is assigned to a client who was admitted for a
blood clot in the right leg.Which of the following describes the appropriate assessment technique
initially?a . I n s p e c t i o n o f t h e r i g h t l e g b . L i g h t p a l p a t i o n o f t h e r i g h t
l e g c.Inspection followed by deep palpation of edematous areasd.Light
palpation followed by inspection of any reddened areas.Rationale: Inspection is the
initial step in the assessment process that providesinformation on color, size, shape and movement of
the extremity. Options B and Dare not appropriate initially and option C should not be done in
this situation.

Lesson B.1APPLICATION OF CORE COMPETENCY IN NURSING PRACTICE


INTEGRATINGNURSING PROCESSINTRODUCTION:
Stressing the point that the entire plan of care depends on the accuracy and completeness
of Assessment, this section examines how to do an assessment in a way that facilitates the next step,
Diagnosis. It addresses characteristics of an assessment that promotes critical thinking and
competency indicators that relate to assessment. Finally it gives the tips for interviewing and examining
patients and explains the how tos and the whys of the six phases of assessment.
EXPECTED LEARNING OUTCOMES
After studying the content of this section, the students should be able to:1.Describe the
five characteristics of an assessment that promotes competency, and explain how the
phases of Assessment described in this section promote criticalthinking.2.Explain how
the interview and physical assessment complement and clarify each other.3.Give
an example of an open-ended question, a closed ended question, a leading question and
an exploratory statement.4.Differentiate between cues and inferences5.Explain why
organizing data more than one way promotes competence and critical thinking.
ASSESSMENT OF INDIVIDUAL PATIENT NEEDS FOR NURSINGANA STANDARD
The nurse collects comprehensive data pertinent to the patients health situation (ANA, 2004)
SIX PHASES OF ASSESSMENT
1.
Collecting of data- gathering data (information) about health status
2.
Identifying cues and making inferences- recognizing significant data and drawing somebeginning
conclusions about what the data may indicate.
3.
Validating the data- double checking to make sure that your data are accurate andcomplete.
4.
Clustering the data- organizing or grouping related pieces of information to help youidentify patterns of
health or illness (eg, Clustering data about nutrition together, the dataabout rest together and so forth)
5.
Identifying patterns/ testing first impressions- looking for the patterns and focusing your assessment to
gain more information to better understand the situations at hand. For example, you suspect that
someones data shows a pattern of poor nutrition and decideto find out whats contributing to this
pattern( does the person have poor eating habits or could it be something else, such as not having
enough money to eat well?)
6.
Reporting and recording data- Reporting significant data (eg. High fever) and charting onthe patients
record.

CHARACTERISTICS OF AN ASSESSMENT THAT PROMOTES


COMPETENCY1 . P U R P O S E F U L
To promote Critical thinking, your approach to assessment must change, depending onyour purpose
and the circumstances(c0ntext) of your patient situation.For example:Are you aiming to assess all
aspects of care, or are you monitoring one specificproblem?Are your assessing a hospitalized patient
or someone in the home?Is the person an adult or a child?NOTE: Your aim is to gain all the
information needed to ensure that your patients haveindividualized plans that are designed to help
them achieve outcomes in the best waypossible, in context of their particular situation (eg, their age,
culture, and level of independence)
2.FOCUSED AND RELEVANT
Your assessment must be focused to gain relevant information, depending onpurpose and context as
above.For example:Physicians Data: (Disease focus)
Mrs. Garcia has pain and swelling in all joints. Diagnostic studies indicates that she has rheumatoid
arthritis. We will start her on a course of anti inflammatory drugsto treat the rheumatoid arthritis. (focus
on the treatment modalities)
Nurses Data: (holistic focus, considering both problems and their effect on thepersons ability to
function independently)Mrs. Garcia has pain and swelling in all joints, making it difficult to feed and
dressherself. She has voiced that its difficult to feel worthwhile when she cant feedherself. She states
that she is depressed because she misses seeing her two smallgrandchildren. We need to to develop
a plan to help her with her pain, to assist her with feeding and dressing, to work through feelings of self-
esteem, and for specialvisitations with the grandchildren. ( Focus is on Mrs. Garcia)
3.SYSTEMATIC
Developing a systematic approach to assessment helps you pay attention to what isimportant, learn
how to prioritize, be comprehensive, and avoid omission errors.For example:

What are your symptoms?

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

When did they start?

What makes them better?

What makes them worse?

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

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

4 . C O M P R E H E N S I V E AN D A C C U R A T E
The most common error that happens in critical thinking is identifying problems or making judgments
based on sufficient or incorrect information. Your information mustbe factual, and as complete as is
warranted by your purpose.For example:An assessment aims to get information about one specific
problem is shorter thanone that aims to get comprehensive data about all aspects of care.
DISPLAY B
.
1.1
:How to ensure Comprehensive Data CollectionComprehensive data collection often occurs in three
phases:1.Before you see the person: You find what you can. This information may
belimited( only name and age) or extensive ( medical records may be available for you to
read)2.When you see the person: You interview the person and do PhysicalExamination
(PE).3.After you see the person: You review the resources(consumer like patient,
familyand community, significant others, nursing and medical records, verbal andwritten
consultations, diagnostic and laboratory results) you used and determineswhat other resources may
offer additional information (e.g. You may consult apharmacist to gain more information about a
medication regimen)Comprehensive Data Collection have several factors:1.The purpose of the
assessment- example is when you do data base(start of care) assessment or a focus
assessmentData base assessment- Comprehensive information gathered on initialcontact with the
person to assess all aspect of health statusFocus Assessment- Data gathered to determine the status
of a specificcondition like someones bowel habits2.The needs and problems commonly
encountered in a particular clinicalsetting.For example: An adult assessment tool is different from
a newbornassessment tool.3.Standards of care for the assessment as defined by
regulatory agencies andprofessional associationsFor example: Maternal and Child Nursing
Association of the Philippines/MCNAP, Operating Room Nurses association of the
Philippines/ORNAP,Philippine Nurses Association/PNA etc.4.The nursing model or theory
adopted by the school or facilitiesFor example: Gordons Functional Health Patterns or
Orems Self Caretheory.
5 . R E C O R D E D I N A S T AN D AR D I Z E D W AY
Like pilots who follow computerized or pre-printed checklists (instead of relying onmemory), you must
value the importance of completing a standardized tool that isdesigned to promote an assessment that
is purposeful, relevant, systematic, andcomplete.
NOTE: You cannot rely your brain to do it all, even if you have years of experience
DISPLAY B.1.2:
Major Intellectual Skills & Critical Thinking Skills R/T Assessment (Behavior Evidence
Suggesting Competence in Nursing

Practice)
The competent nurse:

Applies standard and principles

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

Detects bias; determines credibility of information sources

Distinguishes normal from abnormal; identifies risks for abnormal

Determines significance of data; distinguishes relevant from irrelevantclusters relevant data together

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

Communicates effectively orally and in writing

Establishes empowered partnerships with patients, families, peers, and coworkers

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

Weigh risks and benefits

Identifies ethical issues and take appropriate action

Identifies and uses technologic, information, and human resources

Address conflicts fairly, fosters positive interpersonal relationships

Facilitates and navigates change

Organize and manages time and environment

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

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

IDENTIFYING CUES AND MAKING INFERENCES


Identifying subjective and objective data both aids in critical thinking and competencebecause each
complements and clarifies the other.For example:
Subjective data:
States, I feel like my heart is racing.
Objective data
: Right radial pulse 150 beats per minute, regular, and strong.
The preceding objective data support the subjective data
- what you observe confirmswhat the person is stating.
Sometimes, what you observe and what the person states are different
.For example:Subjective data: States, I feel fine.Objective data: Color pale, becomes easily short of
breath.Above, what the person states isnt supported by what you observe. You need toinvestigate
then further to understand fully the scope of the problems.The subjective and objective data you
identified acts as
cues.
Cues are data that promptyou to get a beginning impression of patterns of health or illness.For
example:Subjective data: I started taking penicillin for a tooth abscess.Objective data: Fine rash over
the trunk.The above gives you cues that may lead you to
infer
(suspect) that there is an allergicreaction to penicillin. How you interpret or perceive a cue- the
conclusion you draw aboutthe rash: you decide that rash may indicate a penicillin allergy.Your ability to
identify cues and make correct inferences is influenced by your observational skills, your nursing
knowledge, and your clinical expertise. Your valuesand beliefs also affect how you interpret some
cues, so make an effort to avoid makingvalue judgments ( for example, inferring that a person who
bathes only once a weekneeds to be taught better hygiene when the practice may be a part of his
culture.
GENERAL RULE

* ** Factual, relevant, and comprehensive assessment is the


key to accurate
diagnosis(problem and risk identification) and to developing a plan that is safe, effective, efficient,and
individualized.1. Establishes rapport and trust with the patient, family and significant others.Quality
Indicators:a.Welcomes the patient, family and
significant others upon admission.b.Greets patient by name, introduces self and
co- staff c.Encourages verbalization of needs and feelings
through attentive listening.d.Conveys availability and willingness to help by attending to
needs at the soonesttime possible.2. Obtain a nursing history and document an initial physical
examination throughapplication of the general principles of and follows a logical sequence in history
takingand physical examination.3. Recognizes normal and abnormal findings from common
laboratory and diagnosticexamination results. As indicated by comparing results from standard listing
of normalvalues/ results of common laboratory and diagnostic examination.4.Defines health needs
and problems from data gathered by identifying the significantfindings from the accurate
nursing history, PE and laboratory/diagnostic results.
CLASSROOM ACTIVITY 1

The Nursing Interview and Physical AssessmentInstructions:


Divide the class into 4 groups. Each group is entitled to answer task Part 1 and Part2. Presentation
should be in a clinical setting and is limited to 15 minutes only.Part 1: Interviewing1.Practice asking
open-ended questions. Restate each question below so its anopen ended
question.a . A r e y o u f e e l i n g b e t t e r ? B o d i e d y o u l i k e d i n n e r ? C a r e y o u
happy here? Dare you having pain?
2.

D making open-ended questions. For


Statement below, write a reflective statement and an open-ended question that would help you to
clarify what has been said. A. Ive been sick off and on for a month.B . N o t h i n g
e v e r g o e s r i g h t f o r m o c k . I seem to have a pain in my side that comes
and goes.d. Ive had this funny feeling for a week. Part 2: Physical
Assessment1.Because physical assessment and interviewing go hand in hand, use the
following situations to practice focusing you interview questions on areas of concern noted during the
Pea. You examine and find: The patients hands and fingernails are filthy with ground-in
dirt, although the rest of him is clean. What will you say next? Buyout examines and find: The
patient has a lump on the back of his head. What will you say next? You examine and
find: The patients RR is 40. What will you say next? You examine and find: The
patients right eye is red, teary, and inflamed. What will you say next? 2. Now practice
focusing your PE on areas of concern voiced by the patienta.Patient states: I have had
a rash that comes and goes. What will you reply and examine? Patient states:
My stomach has been hurting me, What will you reply and examine? Patient states:
I find it burns when I urinate, What will you reply and examine?
D.
Patient states: I feel like Im heavier than usual, like Im bloated with fluid, What will reply and
examine?
Example Responses to Activity 1
Part 1: Interviewing

1. Practice asking open-ended questions. Restate each question below so its an open
ended question.
A.
Are you feeling better? Tell me how youre feeling
B.
Did you like dinner?
How was your dinner?
C.
Are your happy here?
How do you feel about being here?
D.
Are you having pain?
Describe what you are feeling; tell me how youre feeling.
2.
Practice clarifying ideas by using reflection (restating what you hear) and making open-ended
questions. For each statement below, write a reflective statement and an open-ended question that
would help you to clarify what has been said.
A.
Ive been sick off and on for a month.
So, youve been sick off and for month. What do you mean by sick off and on?
B.
Nothing ever goes right for me.
You feel like nothing ever goes right for you. What is been happening?
c.
I seem to have a pain in my side that comes and goes.
You have pain inyour side that comes and goes- can you explain more?
d.
Ive had this funny feeling for a week.
Youve had a funny feeling for aweek. What do you mean by funny?
Part 2: Physical Assessment1.Because physical assessment and interviewing go hand
in hand, use thefollowing situations to practice focusing you interview questions on areas of concern
noted during the PEa.You examine and find: The patients hands and fingernails are filthy
withground-in dirt, although the rest of him is clean. What will you say next?You have a lot of ground-
in dirt here. What is it from?b.You examine and find: The patient has a lump on the back of
his head. Whatwill you say next?I feel a lump on the back of your head. How did it happen?
Does it hurt whenI touch it?c.You examine and find: The patients RR is 40. What
will you say next?Your breathing is a little fast. How do you feel?d.You examine and
find: The patients right eye is red, teary, and inflamed.What will you say next?Your eyes
seem inflamed. How does it feel?2.Now practice focusing your PE on areas of
concern voiced by the patienta.Patient states: I have had a rash that comes and goes.
What will you replyand examine?Show me where (and examine that area). Is there anything you
think causesit?b.Patient states:My stomach has been hurting me, What will you reply
andexamine?

Show me where (and examine that area). Tell me more how it feels.c.Patient states: I find it
burns when I urinate, What will you reply andexamine?That is a common symptom of
infection. Let us get a urine sample( andexamine it)d.Patient states: I feel like Im heavier
than usual, like Im bloated with fluid,What will reply and examine?Where do you feel this
bloating? Your stomach? Ankles? Where? Examinethe areas
Lesson B.2Health Promotion: Screening for Prevention and Early Diagnosis

Depending on where you work, your assessments may include helping withscreening for prevention
and early diagnosis of common health problems.Usually screening is done at significant points during
the life cycle.For example:

Assessing infant development using standardized scales

Measuring height, weight, and vision in school aged children

Assessing for problem drinking and depression beginning in adolescence.

Measuring cholesterol and fecal occult blood in adultsTo meet the goals of healthy people. Which
aims to increase the length and quality of lifeof all people, all health care providers are encouraged to
record health promotioncounseling that occurs during all important interactions.A key part of
assessment is helping patients make informed and jointdecisions about what screening and
prevention measures they should follow.The length of discussions about screening for health
problems and use of medication to prevent diseases varies according to:a.The scientific
evidence addressing how useful the service is.b.The health, preference, and
concerns of each patientc.The decision making style of each
cliniciand.Practical constraints, such as the amount of time availableNOTE:A
decision can be considered informed and mutually decided only if patients:1 . U n d e r s t a n d t h e
risk or seriousness of the disease or condition to
b e prevented.2 . C o m p r e h e n d w h a t t h e p r e v e n t i v e s e r v i c e i n v o l v e s ( i n c l u d
i n g t h e r i s k s , benefits, alternatives and
uncertainties)3 . H a v e w e i g h e d t h e i r v a l u e s r e g a r d i n g t h e p o t e n t i a l h a r m s
a n d b e n e f i t s associated with the service.
4.
Have engaged in decision-making at level at which they want and
feelcomfortable (US Preventive Task Force 2004)
Display B.2.1Recommended Screening for Health Promotion
The Department of Health must rigorously evaluate clinical research
toassess the merits of preventive measures, including screening tests,counselin
g immunization and preventive medications.
Lesson C.1Communication

Your ability to establish rapport, ask questions, listen, and observe is thekey to establishing the positive
nurse- patient relationship needed to builda therapeutic relationship. People seeking health care are in
a veryvulnerable position. They need to know that theyre in good hands andthat their main concerns
will be addressed. This is where you come in asnurses. Consider the following guidelines that can help
you establishtrust, positive attitude, and reduce anxiety.Display C.1.1Guidelines in Promoting a
Caring Interaction/CommunicationHow to establish rapportBefore you go into the interview:
Get organized
:
When you know what youre going to do, youre moreconfident and able to focus on the personDont
rely on memory: Have a written or printed plan to guide thequestions youll be asking. Some nurses
use the nursing data base as aguide.Plan enough time: The admission interview usually takes 30
minutes to 1hour.Ensure privacy: Make sure you have a quiet, private setting, free frominterruptions or
distractions.Get focused: Take a minute to clear your mind of other concerns( other duties, worries
about yourself). Say to yourself, Getting to know this person is most important thing I have to do right
now.Visualize yourself as being confident, warm and helpful: Seeing yourself in this light helps you to
be confident, warm and helpful- your genuineinterest comes through.When you begin interview:Give
your name and position: (if the person can read, give it in writing).This sends the message that you
accept responsibility and are willing tobe accountable of your actions.Verify the persons name and
ask what he or she would like to be called (eg. I have your name listed here as Michael Riles. Is that
correct? What would you like us to call you?). Using the preferred name helps the person to feel more
relaxed and sends the message that you recognizethat this person is an individual who has likes and
dislikes. Most facilitiesrequire that you use two unique identifiers to identify the patient (eg,asking the
person his name and also checking ID bracelets)Briefly explain your purpose(eg, Im here to do the
admission interview tohelp us plan your nursing care.).During the interview:Give the person your full
attention. Avoid the impulse to becomeengrossed in your notes or in reading the assessment
tool.Dont hurry: Rushing sends the message that youre not interested inwhat the person has to say.
Sit down: This communicates that youre willing to take your time.How to listenBe an empathetic
listener
To listen empathetically
1.Eliminates thoughts about how you, yourself, see the situation.
2.
Listen carefully for feelings, trying to identify with how the other personperceives his situation. Dont
allow yourself to think about how you feel or how youre going to respond; think only about the content
of what yourehearing3.Reflect on what youve been told, then rephrase the feelings
you have heard.4.Seek validation that you understood the message, content,
and emotioncorrectly. Keep trying until youre sure you understand.
5.
Detach, come back to your own frame of reference, and separate yourself from the emotions
involved.DISPLAY C.1.2
TEN CARING BEHAVIORS
1.Monitoring patients closely and telling them you know youre doing
it.Example: I will be checking on you every 15 minutes2.Inspiring someone, or instilling hope
and faith ( creating a vision of canbe)3.Showing patience, compassion, and
willingness to persevere4.Taking time, rather than hurrying through just to get things
done.5.26.Offering companionship or presence7.Helping someone stay in
touch with positive aspects of his
life.8 . D e m o n s t r a t i n g t h o u g h t f u l n e s s 9.Bending the rules when it really
counts10.Showing your human side by sharing humor or stories of daily life.NOTE:

Simply Being Nice and Making Work Fun Can Improve Patient Outcomes(Studies show that)
patients who come away from a positive encounter with a nurse are morelikely to follow prescribed
directions, take medications, and seek follow-up care (however if) apatient encounters a health care
worker whos in a negative emotional state, it becomes aspringboard into other negative behaviors.
Down the road, their own outcomes to suffer, andthey just dont fare well..try to make the work
environment as fun as possible> If you see a staff member in a bad mood, jump in and try to derail it
before itr becomes contagious.- HowaredWeiss (Farella, 2009)

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

Today Patricia/Pat is caring for Sharon, whos just given birth to her fifth child,a healthy baby girl. Pat
never has been able to conceive, has always wanted children, and feels a little envious of Sharons
family of two boys and (now) of three girls.Pat notes that Sharon seems very quiet. Recognizing the
importance of beingempathetic listener, Pat has the following conversation with Sharon.Pat: Youve
been pretty quiet since I came on.Sharon: I cant help it. Im supposed to be happy, but Im really
disappointed-I was so sure Id had a baby boy.Pat: (making a conscious effort to eliminate thoughts
about the fact that shedbe happy with any child, and rephrasing what Sharon seems to be feeling):
you feel like youre supposed to be happy, but you really feel sort of sad?Sharon: yes,Pat pauses
to reflect on the feeling of sadness and encourages Sharon tocontinue.Sharon: I was going to name
this baby after my father. He died 2 monthsago.Pat (connecting to what Sharon must be feeling): Im
sorry. That would be adisappointment. Being able to name the baby after him would have been
alovely thing to do.Sharon (crying): Yes, I had it all pictured in my mind.Pat conveying acceptance
and understanding, sits quietly, allowing Sharon tocry.Pat (detaching and coming back to her own
frame of reference):Sharon, I think you needed to cry and you may need to cry again. But right now
youve got a very beautiful baby girl; with the longest hair Ive ever seen, waiting to meet her mother.
How would you feel if I

Brought her into you? Sharon: (smiling) Yes, I really havent seen her for more than 5 minutes. Ive
got to admit, Ive always gotten along better with my girls than my boys.

CLASSROOM ACTIVITY 2 CRITICAL THINKING ABILITY AND WILLINGNESS AND ABILITY


TOCARE

1.List five critical thinking indicators youd like to acquire or improve.


2.Complete the following sentence, using as many words as you choose: If I were to tell
someone how I think, I would say that I..
3.In five sentences or less, describe what critical thinking means to you
4.Give three examples of caring behaviors
5.Explain how the statements relates to willingness and ability to care: a.Health and
Illness are human experiencesb.The presence of illness does not preclude health
nor does optimal health precludeillness.c.An essential feature of contemporary nursing
practice is the provision of a caring relationship that facilitates healing.
ASSIGNMENT
1. Improve your interpersonal skills by learning about your innate personality and how to
get along well with difficult people.
Read: Dont Worry Be Happy! Harmonize Diversity through Personality Sensitivity, at
http:nsweb.nursingspectrum.com/ce/ce236.htm
2.Are you stressed out? Managing stress is an important part of staying healthy. Take the Life Stress
Test at http://www.cliving.org/lifstrstst.htm . Think of somethings that you can do to reduce your
stress level.
3 . P r a c t i c e e m p a t h e t i c l i s t e n i n g Ask someone to tell you about an upsetting experience
in his or her childhood and listen using the steps of empathetic listening taught. Discuss in the class
what can happen when you are too emotionally involved inpatient situations.

Identify ways you can manage your emotions to remain empathetic, but also objective and logical.
Lesson C.3Ethico-Moral /Legal Responsibilities
His success of nurse- patient interaction and examination is influenced by your awareness of ethical,
cultural, and spiritual concerns. As a nurse you must:
1.Provide service with respect for human dignity and the uniqueness of the patient, unrestricted by
considerations of social or economic status, personal attributes, or the nature of health problems
(ANA, 2004)

2.Safeguard the clients right to privacy by judiciously protecting information of a confidential nature.
3.Be honest. Tell the person the truth about how youll see the data (egg. I have to write a
paper examining someones eating patterns. Would you be willing to tell me about your eating habits?

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

Biologic variations for example: Differences among racial and ethnic groups like skin color, texture,
and susceptibility to diseases like hypertension and sickle cell anemia.
Comfortable communication patterns For example: How language and gestures are used, whether
eye contact or touching is acceptable, and whether the person is threatened by being in close
proximity to another.
Family organization and practices we have diverse family units and practices. We must understand
them to gain insight into factors that influence health status.
Beliefs about whether people are able to control nature and influence their ability to be healthy (egg,
whether blood transfusions are allowed or whether rituals are required)
The persons concept of God and beliefs about the relationship between spiritual beliefs and health
status. (Egg, God gives you what you deserve.).