STUDY GUIDE BY APRIL MAE LABRADOR
NCM 106 CARE OF THE CLIENTS WITH PROBLEMS IN
ACUTE BIOLOGIC CRISIS
Course Description:
 It deals with the principles and
techniques of nursing care
management of sick clients across the
lifespan with the emphasis on the
adult and older person with
alteration/problems in acute biologic
crisis.
Objectives:
At the end of the course, and given actual
clients with problems in acute biologic crisis,
the student should be able:
1. Academic Excellence
a. Utilize the nursing process in the care of
individuals, families, in community and
hospital settings.
i. Assess with the client his/her
condition/health status through interview,
physical examination, interpretation of laboratory
findings
ii. Identify actual and potential diagnosis
iii. Plan appropriate nursing interventions
with client and family for identified nursing
diagnosis
iv. Implement plan of care with client and family
v. Evaluate the progress of the client’s condition and
outcomes of care
 
b. Ensure a well-organized and accurate
documentation system
2. Virtues  underlying conditions that lead to
 Observe bioethical principles and the core
values (love of God, caring, love security and
of people
 Utilize the bioethical principle and
core values and nursing standards in
the care of client
 Integrate the various principles,
concept and application of bioethics
in the care of the client.
3 . C o m m u n i ti e s ( C o m m u n i t y
Service)
 A.Determine the diff erent principl
es and techniques of nursing car
e management inpromoting the health
of the community
 Be taken part in the community
projects that would require the
utilization of appropriate health
promotion and disease prevention
 Correlate with client and their
family and the health team
appropriately.
 Promote personal and
professional growth of self and
others.
 
CARDIAC FAILURE
Description
 Is the inability of the heart to pump sufficie
nt blood to meet theneeds of the tissues for 
oxygenation and nutrients
 CHF is most commonly used when ref
erring to left-sided and right-sided
failure
 Formerly called Congestive Heart Failur
e
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
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   CVP (elevated in right-sided failure)
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 feel
s cool and clammy
- Tachycardia and palpitations
- Weak, thread pulse
- Easy fatigability and decreased activi
ty 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
o Edema of the lower extremities (depende
nt edema)
o Weight gain
o Hepatomegaly (enlargement- liver)
o Distended neck veins
o Ascites (accumulation of fluid in the p
eritoneal cavity)
o Anorexia and nausea
o Nocturnal (need to urinate at night)
o Weakness
Diagnostics
 Chest X-ray (may show cardiomegaly
or vascular congestion)
 Echocardiogram (shows decreased
ventricular function and decreased
ejection fraction
*pulmonary artery pressure monitoring may
be used as guide treatment in serious case of
pulmonary edema
Nursing Diagnoses 
 Activity intolerance r/t imbalance bet
ween oxygen supply anddemand
secondary to decreased CO
 Excess fluid volume r/t excess fluid/so
dium intake or retention secondary to
CHF and its medical therapy
  Anxiety r/t breathlessness and restles
sness secondary to inadequate
oxygenation
 Non-compliance r/t to lack of knowledge
 Powerlessness r/t inability to perform role 
responsibilities secondary to chronic
illness and hospitalization
Nursing Management and Acute phase
 Monitor and record
BP, pulse, respirations, ECG and CVP to
detect changes in cardiac output
 maintain client in sitting position to decr
ease pulmonarycongestion and
facilitate improved gas exchange
 auscultate heart and lung sounds freque
ntly: increasing crackles, increasing
dyspnea, decreasing lung sounds
indicate worsening failure
 administer O2 as ordered to improve ga
s exchange and increaseoxygenation of
blood; monitor arterial blood gases
(ABG) as ordered to assess oxygenation
 administer prescribed medications on a
ccurate schedule
 Monitor serum electrolytes to detect hy
pokalemia secondary to diuretic
therapy
 Monitor accurate input and output (ma
y  prevents the uptake of calcium. This in
require Foley catheter tallow accurate
measurement of urine output) to
evaluate fluid status
 If fluid restriction is prescribed, spread t
he fluid throughout the day to reduce
thirst
 Encourage physical rest and organized a
ctivities with frequent rest periods to
reduce the work of the heart
 Provide a calm reassuring environment  indicated in patients with mild or
to decrease anxiety; this decreases
oxygen consumption and demands on
the heart.
Chronic heart failure:  teaching as appropriate
 Educate client and family about the ratio
-nale for the regimen
 Establish baseline assessment for fluid st
atus and functional abilities
 Monitor daily weights to evaluate chang
es in fluid status
 Assess at regular intervals for changes in 
fluid status or functional activity level 
Pharmacologic Therapy
 ACE Inhibitors (promotes vasodilation an
d 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 gi
ven to patients with significant left
ventricular dysfunction.
 Catecholamine, it stimulates the beta1-
adrenergic receptors. Its major action is
to increase cardiac contractility.
 Milrinone (Primacor). A phosphodiestera
se inhibitor that prolongsthe release and
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 the heart
 Anticoagulants may be prescribed.
 Beta-adrenergic blockers maybe
moderate failure.
Client Education
o Include family member or others in
o Weight monitoring: teach client the
importance of measuring and recording
daily weights and report unexplained
increase of 3-5pounds
o Diet: sodium restriction to decrease fluid
overload and potassium rich foods to
 replenish loss from medications; do not
restrict water intake unless directed
o Medication regime: explain the
importance of following all medication
instruction
o Activity: help client plan paced activity to
maximize available cardiac output
o Symptoms: report to MD promptly any
of the following: chest pain, new onset of
dyspnea on exertion, paroxysmal and
nocturnal dyspnea
o 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.
Etiologic factors  identify the site and extent of an MI
- Physical exertion
- Emotional stress- Weather extremes
- Digestion after a heavy meal
- Valsalva maneuver
- Hot baths or showers
- Sexual excitation
Pathophysiologic characteristic (Coronary arte
ry disease) Pathophysiology
 Coronary artery blood flow is blocked by  ischemia resulting from coronary artery
atherosclerotic narrowing, thrombus
formation or persistent vasospasm;
myocardium supplied by the arteries is
deprived of oxygen; persistent ischemia
may rapidly lead to tissue death
Clinical Manifestations
 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.
Diagnostics Laboratory Tests
 Electrocardiogram (12-lead) 
 Capable of diagnosing MI in 80% of patie
nts, 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
Imaging Studies:
metabolism and to assess tissue perfusion
 Magnetic Resonance Imaging helps
 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
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 detect early
signs of heart failure
 Monitor O2 saturation and administer
O2 as prescribed
 Provide for physiological rest to
decrease oxygen demands on heart
 Keep client NPO or progress to liquid
diet as ordered; maintain 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 pain status
Pharmacologic Therapy
 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 the
stenosis coronary vessel, which is then
dilated, resulting in compression of the
atherosclerotic plaque and widening of
the vessel
 Coronary artery bypass grafting (CABG) –
done by harvesting either a saphenous
vein from the leg or the left internal
mammary artery and then used to
bypass areas of obstruction in the heart
Client Education
 Include appropriate family members
whenever possible
 Explain cardiac rehabilitation program if
ordered
 Explain modifiable risk factors and
develop a plan with client including
supportive resources to change lifestyle
to decrease these factors
 Explain medication regime as prescribed;
identify side effects to report (provide
written instructions for later reference)
 Stress the importance of immediate
reporting of chest pain or signs of
decreased CO2
 Instruct about bleeding precautions if
client is on anticoagulant therapy: use
soft toothbrush, electric razor, avoid
trauma or injury; wear or carry medical
alert identification.
ACUTE PULMONARY FAILURE
Description  Defined as a fall in arterial
oxygen tension and a rise in arterial carbon
dioxide tension.
 The ventilation and/or perfusion
mechanism 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.

Clinical Manifestations
 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
preload
Nursing Management
 Assess the patient’s respiratory status at
least every 2 hours or more as indicated
 Position the patient for optimal
breathing effort when he isn’t
intubated. Put the call bell within easy
reach to reassure the patient and
prevent necessary exertion
 Maintain the norm thermic
environment to reduce patient’s oxygen
demand
 Monitor vital signs, heart rhythm, and
fluid intake and output, including daily
weights, to identify fluid overload or
impending dehydration
 After intubation, auscultate the lungs to
check for accidental intubation of the
esophagus or main stem bronchus.
 Don’t suction too often without
identifying the underlying cause of an
equipment alarm.
 Watch oximetry and scenography
values because these may indicate
changes in patient’s condition
 Note the amount and quality of lung
secretions and look for changes in the
patient’s status
 Check cuff pressure on the ET tube to
prevent erosion from an overinflated
cuff 
 Implement measures to prevent nasal
tissue necrosis
 Be alert of GI bleeding
 Provide a means of communication for
patients who are intubated and alert
Pharmacologic Therapy
 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 edema
Client Education
  Include family member or others in teac
hing 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
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 a failure of renal
circulation or damage to the tubules or
glomeruli.
Etiologic factor
Prerenal caused by decrease blood flow to  Diagnostics
kidneys like severedehydration,diuretic
therapy, circulatory collapse,hypovolemia
or shock; readily reversible when recognized
and treated.
Intrarenal  caused by disease process,
ischemia, or toxic conditions such as acute
glomerulonephritis, vascular disorders, toxic
agents, 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.
Clinical Manifestations
*A change in blood pressure and volume
signals pre renal failure, the patient may have
the following:
o Oliguria
o Tachycardia
o Hypotension
o Dry mucous membranes
o Flat jugular veins
o Lethargy progressing to coma
o 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:
o uremia
o confusion
o GI complaints
o fluid in the lungs
o infection
 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
 nephrotomography
Nursing Diagnoses
 Excess Fluid Volume
 Imbalanced Nutrition: Less than Body
Requirements
 Deficient Knowledge
 Risk for Infection
Nursing Management
 Monitor intake and output
 Observe for oliguria followed
by polyuria
 Weigh daily and observe for edema
 Monitoring of complications of
electrolyte imbalances, such as
acidosis and hyperkalemia
 Allow client to verbalize concerns
regarding disorder  flow
 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 normal
Pharmacologic Therapy
 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 nephrotoxins
STOKE/CEREBROVASCULAR ACCIDENT (CVA)
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
 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
o Hypertension
o Family history of stroke
o History of TIA
o Cardiac disease, including arrhythmias,
coronary artery disease, acute
 myocardial infarction, dilated myopathy,
and alular disease
o Diabetes mellitus
o Familial hyperlipidemia
o Cigarette smoking
o Increased alcohol intake
o Obesity, sedentary lifestyle
o Use of hormonal contraceptives
Clinical Manifestations
 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 lefthemisphere produces
symptoms on the right side of the body; in the
right hemisphere, symptoms on the leftside
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
 Tran’s 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
aren’t 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
patient’s symptoms are related to
hypoglycemia
 Hemoglobin and hematocrit level may be
elevated in severe occlusion
 Baseline CBC, platelet count, PTT, PT,
fibrinogen level and chemistry panel are
obtained before thrombolytic therapy
Nursing Diagnoses
 Ineffective Tissue Perfusion related to
decreased cerebral blood flow
 Risk for Prolonged Bleeding related to
use of thrombolytic agents
 Increased Risk for Aspiration related to
depressed gag reflex, Impaired
swallowing
 Impaired Physical Mobility related to loss
of muscle tone
Nursing Management
 Encourage active range of motion on
unaffected side and passive range of
motion on the affected side
 Turn client every 2 hours
 Monitor lower extremities for
thrombophlebitis
 Encourage use of unaffected arm for
ADLs
 Teach client to put clothing on affected
side first
 Resume diet orally only after successfully
completing swallowing evaluation
 Collaborate with occupational and
physical therapists
 Try alternate methods of communication
with aphasia patients
 Accept client’s frustration and anger as
normal to loss of function
 Teach client with homonymous
hemianopia to overcome the deficit by
turning the head side to side to be able
to fully scan the visual field
Pharmacologic Therapy
 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 patient’s
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 end arterectomy to remove
atherosclerotic plaques from the inner
arterial wall
 Extra cranial bypass to circumvent an
artery that’s blocked by occlusion or
stenosis Client Education
 Educate client and family about CVA
and CVA prevention
 Educate client and family about
community resources
 Educate client and family about physical
care and need for psychosocial support
 Educate client and family about
medication
INCREASED INTRACRANIAL PRESSURE (ICP)
Description
prolonged pressure greater than 15mmHg 
or 180mmH2O measured in the lateral
ventricles
Etiology
 Cerebral Edema is an increase in volume
of brain tissue due to alterations in
capillary permeability, changes in
functional or the structural integrity of
the cell membrane or an increase in the
interstitial fluids
 Hydrocephalus is an increase in the
volume of CSF within the ventricular
system; it may be 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.
Clinical Manifestations
o Blurring of vision, decreased visual
acuity and diplopia are the earliest signs
of increased ICP
o Headache, papilledema or the swelling
of optic disk and vomiting
o Change of LOC
Diagnostics
o Skull radiography
o CT scan
o 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 ABGs measure
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
Nursing Management
 Assess neurological status every 1 to 2
hours and report any deterioration;
include LOC, behavior, motor/sensory
function, pupil size and response, vital
signs with temperature
 Maintain airway; elevate head of 30
degree or keep flat as prescribed;
maintain head and neck in neutral
position to promote venous drainage
 Assess for bladder distention and bowel
constipation; assist client when
necessary to prevent Val Sava
maneuver  hyperglycemia and breakdown of fats into
 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  rapidly and are converted to ketones,
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 with tumors
Surgical Intervention
 A drainage catheter, inserted via
ventriculostomy into lateral ventricle,
can be done to monitor ICP and to drain
CSF to maintain normal pressure; if
used the system is calibrated with
transducer is leveled 1 inch above the
ear; sterile is of utmost
Importance Client Education
 Teach the client at risk for increased ICP
to avoid coughing, blowing the nose,
straining for bowel movements, pushing
against the bed side rails, or performing
isometric exercises
 Advice the client to maintain neutral
head and neck alignment
 Encourage the family to maintain 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
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
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  bracelet information as appropriate
patient to patient
- Weight loss
- Muscle wasting- leg cramps- recurrent in
fections
Diagnostics
 Serum glucose is elevated (200 to 800
mg/dl)
 Serum Ketone Level is increased
 Urine acetone test is positive
 Arterial Blood Gas analysis reveals
metabolic acidosis
 ECG findings shows tall tented T waves
and widened QRS complex changes
related to hyperkalemia; later with
hypokalemia, shows flattened T wave
and the presence of 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
Pharmacotherapy
 Administer IV Insulin and fluid and
electrolyte replacements based on
laboratory test results
Client Education
 Instruct client about the nature and
causes of DKA (such as excess glucose
intake, insufficient medications or
physiological and/or psychological
stressors) any new medications.
HYPEROSMOLAR HYPERGLYCEMIC
NONKETOTIC COMA
Description  Life threatening metabolic
disorder of hyperglycemia usually recurring
with DM 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
don’t receive glucose, the liver responds
by converting glycogen to glucose for
release into the bloodstream; when all
excess glucose molecules remain in the
serum, osmosis cause fluid shifts.; the
cycle continues until fluid shifts in the
brain cause coma and death.
Clinical Manifestations
o Severe dehydration
o Hypotension and tachycardia
o Diaphoresis
o Tachypnea
o Polyuria, polydipsia and polyphagia
o Lethargy and fatigue
 o Vision changes
o Rapid onset of lethargy
o Stupor and coma
o Neurologic changes
Diagnostics
 Serum glucose is elevated, sometimes
800 to 2,000 mg/dl
 Ketones are absent, urine and serum
ketones are absent
 Urine glucose levels are positive
 Serum osmolality is increased
 Serum Sodium levels are elevated and
the serum potassium level is usually
normal
 ABG results are usually normal,
without evidence of acidosis
Nursing Diagnoses
-Decreased Cardiac Output
-Deficient Fluid Volume
-Hyperthermia
-Disturbed Sensory Perception
-Risk for Impaired Skin Integrity
-Risk for Aspiration
-Deficient Knowledge
Nursing Management
 Assess the patient’s LOC, respiratory
status and oxygenation
 Monitor the patient’s VS; changes may
reflect the patient’s hydration status
 Monitor patient’s blood glucose and
serum electrolytes
 Administer regular insulin IV as ordered,
by continuous infusion and titrate
dosage based on the patient’s blood
glucose levels
 Maintain intact skin integrity by turning
every 2 hours, use of pressure relief aids,
nutritional support, use of skin
moisturizers and barriers, and
management of incontinence
 Prevent aspiration by using appropriate
feeding precautions, elevate head of bed
15 to 30 degrees during and after
feeding for 1 hour; if BP is too unstable
to elevate head of bed with feeding, then
withhold oral feedings.
Pharmacotherapy
 IV infusion of NS to replace fluids and
sodium, regular insulin 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);
 Sympathetic nervous system stimulation,
hormonal release of antidiuretic
hormone and the angiotensin-renin
mechanisms and neural responses
attempt to compensate for the loss of
circulating volume but eventually
metabolic acidosis, multi organ system
failure occurs.
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
and hydration status
 Insert an indwelling catheter and NG
tube to assist in accurate recording of
fluid balance status
 Perform and document continuous serial
assessments of hemodynamic
parameters such as VS, capillary refill,
CVP, cardiac rhythm, LOC, urinary output
and laboratory findings
Pharmacotherapy
o Crystalloids and blood products to
maintain adequate circulating volume
status
o Sodium Bicarbonate to correct acidosis
state
o Vasopressor such as Dopamine
Client Education
o Explain procedures to the client
o 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.
Etiology
Types of burn injury
a. Thermal: results from dry heat (flames)
or moist heat (steam or hot liquids); it is
the most common type; it causes
cellular destruction that results in
vascular, bony, muscle, or nerve
complications; thermal burns can also
lead to inhalation injury if the head and
neck area is affected
b. Chemical burns are caused by direct
contact with either acidic or alkaline
agents; they alter tissue perfusion
leading to necrosis
c. Electrical burns; severity depends on
type and duration of current and amount
of voltage; it follows the path of least
resistance (muscles, bone, blood vessels
and nerves); sources of electrical injury
include direct current, alternating
current and lightning
d. Radiation burns: are usually associated
with sunburn or radiation treatment for
cancer; are usually superficial; extensive
exposure to radiation may lead to tissue
damage
Pathophysiology
 It depends on the cause and classification
of the burn; the injuring agents denatures
cellular proteins; some cells die because of
traumatic or ischemic necrosis; loss of
collagen cross-linking also occurs with
denaturation, creating abnormal osmotic and
hydrostatic pressure gradients that cause
intravascular fluid to move into interstitial
spaces; Cellular injury triggers the release of
mediators of inflammation, contributing to
local and in the case of major burns , systemic
increases in capillary permeability.
Clinical Manifestations
 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
Diagnostics*
Rule of Nines chart determines the
percentage of body surface area (BSA)
covered by the burn
 ABG levels may be normal in the early
stages but may reveal hypoxemia and
metabolic acidosis 
 Carboxy-hemoglobin level may reveal
the extent of smoke inhalation due to
the presence of carbon monoxide
 Complete blood count may
reveal decrease hemoglobin due
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
o Risk for Deficient Fluid Volume
o Risk for Infection
o Impaired Physical Mobility
o Imbalanced Nutrition: Less than Body
Requirements
o Ineffective Breathing Pattern
o Impaired Tissue Perfusion
o Risk for Impaired Gas Exchange
o Anxiety
o Risk for Ineffective Thermoregulation
o Pain
o Impaired Skin Integrity
Nursing Management
 Assess patient’s ABCs; monitor arterial
oxygen saturation and serial ABG values
and anticipate the need for ET
intubation and mechanical ventilation
 Auscultate breath sounds
 Administered supplemental humidified
oxygen as ordered
 Perform or pharyngeal or tracheal
suctioning as indicated by the patient’s
inability to clear his airway
 Monitor the patient’s cardiac and
respiratory status
 Assess LOC for changes such as
confusion, restlessness or decreased
responsiveness solution for chemical
burns
 Place the patient in semi-Fowler’s
position to maximize chest expansion;
keep patient as quiet and comfortable
to minimize oxygen demand
 Prepare the patient for an emergency
escharotomy of the chest and neck for
deep burns
 Administer rapid fluid replacement
therapy as ordered

*For burn patient in shock:
 Monitor VS and hemodynamic
parameters
 Assess patient’s intake and output every  absorbent hydrocolloid dressings
hour, insert an indwelling catheter  (Dodder)
 Assess the patient’s level of pain,
including nonverbal indicators and
administer analgesics such as Morphine
Sulfate IV as ordered
 Keep the patient calm, provide periods
of uninterrupted rest between
procedures and use 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 patient’s 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),
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 that’s inhaled or ingested.
The extent of damage depends on the
substance, the amount ingested, its form and
the length of exposure to it. Substances with
an alkaline pH cause tissue damage by
liquefaction necrosis, which softens the tissue.
Acids produce coagulation necrosis.
Coagulation necrosis denatures proteins when
substance contacts tissue. This limits the
extent of the injury by preventing penetration
of the acid into the tissue.
*The mechanism of action for inhalants is
unknown, but they’re believed to act on the
CNS similarly to a very potent anesthetic.
Hydrocarbons sensitize the myocardial tissue
and allow it to be sensitize to
catecholamine’s, resulting in arrhythmias.
Clinical Manifestations
 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, respiratory
arrest, hypotension and dysrhythmias
 Food poisonings: nausea, vomiting,
diarrhea, abdominal cramps, fever,
chills, dehydration, headache
 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
 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
Diagnostics*
 The diagnosis of many poisonings is
based on a thorough client history and
clinical manifestations laboratory
toxicology screens (serum, vomitus,
stool and urine) determine the extent of
the absorption
 Baseline blood work such as CBC, electr
olytes, renal and hepatic studies enable
future determination of organ and
tissue damage
 Chest X-ray 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
o Risk for Ineffective Airway Clearance
o Risk for Decreased Cardiac Output
o Deficient Fluid Volume
o Ineffective Breathing Pattern
o Impaired Tissue Perfusion
o Risk for Injury
o Anxiety
o Risk for Self-directed Violence
o Hopelessness
Nursing Management
o Assist with the management of an
effective airway, breathing pattern and
circulatory status
o 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
o 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 e
vacuation
 Naloxone (Narcan) for respiratory depressio
n caused by narcotic overdose
 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
that’s inflicted by an external or violent act; it
may be intentional or unintentional; involve
injuries to more than one body area or organ
Etiology
o Weapons
o Automobile collision
o Physical confrontation
o Falls
o Unnatural occurrence to the body
o *Type of trauma which determines the
extent of injury   Immobilize the patient’s head and neck
o Blunt trauma – leaves the body intact
o Penetrating trauma – disrupts the body
surface
o Perforating trauma – leaves entrance
and exit Pathophysiology
o 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 electrolyte imbalances
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 patient’s ABCs and initiate
emergency measures
 Administer supplemental oxygen as
ordered
with an immobilization device, sandbags,
backboard and tape
 Assist with cervical X-rays
 Monitor VS and note significant changes
 Immobilize fractures
 Monitor the patient’s oxygen saturation
and cardiac rhythm for arrhythmias
 Assess the patient’s neurologic status,
including LOC and papillary and motor
response
 Obtain blood studies, including type and
crosshatch
 Insert large bore IV catheter and infuse
normal saline or lactated Ringer’s
solution
 Assess the patient for multiple injuries
 Assess the patient’s wounds and provide
wound care as appropriate; cover open
wounds and control bleeding by applying
pressure and elevating extremities
 Assess for increased abdominal
distention and increased diameter of
extremities
 Administer blood products as
appropriate
 Monitor the patient for signs of
hypovolemic shock
 Provide pain medication as appropriate
 Provide reassurance to the patient and
his family
Pharmacotherapy
 Tetanus immunization
 Antibiotics for infection control
 Analgesics for pain
Client Education
  Provide explanations of all procedures
done
 Families usually require emotional
support and honest discussions about
therapeutic interventions and plans
 Assist with cervical X-rays
 Monitor VS and note significant changes
 Immobilize fractures
 Monitor the patient’s oxygen saturation
and cardiac rhythm for arrhythmias
 Assess the patient’s neurologic status,
including LOC and papillary and motor
response
 Obtain blood studies, including type and
crosshatch
 Insert large bore IV catheter and infuse
normal saline or lactated Ringer’s
solution
 Assess the patient for multiple injuries
 Assess the patient’s wounds and provide
wound care as appropriate; cover open
wounds and control bleeding by applying
pressure and elevating extremities
 Assess for increased abdominal
distention and increased diameter of
extremities
 Administer blood products as
appropriate
 Monitor the patient for signs of
hypovolemic shock
 Provide pain medication as appropriate
 Provide reassurance to the patient and
his family
Pharmacotherapy
1. Tetanus immunization
a. Antibiotics for infection control
b. Analgesics for pain Client Education
c. Provide explanations of all
procedures done
d. 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 being assessed.
8. Competency: A defined area of skilled
performance.
9. Context: The setting/environment where
competence can be demonstrated or
applied.
10. Domain: An organized cluster of
competencies in nursing practice.
11. Effective: Having the intended outcome.
12. Enrolled nurse: A nurse registered under
the enrolled nurse scope of practice.
13. Indicator: Key generic examples of
competent performance. They are
neither comprehensive nor exhaustive.
They assist the assessor when using their
professional judgment in assessing
nursing practice. They further assist
curriculum development.
14. Performance criteria: Descriptive
statements that can be assessed and
that reflect the intent of a competency in
terms of performance, 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 client’s skin temperature
c. Takea rectal temperature
d. Document the findings Rationale for
your selection:
_____________________________________
_______________________ ______________
_____________________________________
_____  2. The nurse obtains an axillary temperature
2. The nurse obtains an axillary temperature
of 97.4 degree F on a client. In graphing the
temperature, it is most appropriate for the
nurse to:
a.Write “see nurse’s notes” above the
temperature reading
b.Identify the temperature reading with an
“Ax”
c.Graph the oral equivalent temperature of
98.4 degree
d. Adjust graph 97.4 degree F on the form.
Rationale for
your selection:_________________________
_____________________________________
_  ____________________________________
______________________  the start of the day shift. The client’s RAND
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 client’s 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? a. used another digital
thermometer to retake the temperature
b.Feel the client’s skin temperature c.Take
a rectal temperatured. Document the findings
Rationale: A is the answer. Since the nurse is
using a digital thermometer, it is important
for the nurse to ensure that the equipment is
functioning. The temperature recording
should be low and should be taken again.
Option B & C are not appropriate: option
D should be done after verifying
the temperature.
of 97.4 degree F on a client. In graphing the
temperature, it is most appropriate for the
nurse to: a.Write “see nurse’s notes” above
the temperature reading, b. Identify the
temperature reading with an “Ax”, c. Graph
the oral equivalent temperature of 98.4
degree Adjust graph 97.4 degree F on
the form Rationale: B is the answer. It is
important for the nurse to identify the
appropriate information on where the
temperature was taken. Option A, C, & D do
not accurately document the temperature
information.
3. The nurse is caring for a client who has an
oral temperature of 99.6 degree F at8:00ARE,
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 necessaryd.
Begin cooling measures Rationale: C is the
answer. The nurse can make an independent
decision to take the temperature more
frequently to ensure safe nursing care. Option
A does not allow for through ongoing
assessment. Option B & D are not necessary
at this time.
Lesson A.
1 CORE COMPETENCIES
“Tell me, I might forget; teach me and I might
remember; involve me and I learn!”-Benjamin
Franklin
Definition: A competency appraisal is a
process in which an individual is assessed for
his or her competence in a particular area of
employment. The main objective of the
competency appraisal is to ascertain whether
an employee is able to carry out his or her
duties in a professional role. A typical scenario
would involve an employee — the person
being assessed for competence — and one or
more of his or her seniors. It normally would
take place in a private location, such as an
unused office. The duration of a competency
appraisal depends on the nature of the
appraisal; the actual meeting between the
senior professional and the employee
typically lasts one to two hours.
Legal Basis:
Article 3 Sec.9 (c) of R.A. 9173/ “Philippine
Nursing Act 2002"Board shall monitor &
enforce quality standards of nursing practice
necessary to ensure the maintenance of
efficient, ethical and technical, moral and
professional standards in the practice of
nursing taking into account the health needs
of the nation.
SIGNIFICANCE OF CORE COMPETENCY STANDARDS
There are certain professions in which a
competency appraisal is of critical
importance, such as medical professions in
which human safety is an essential priority. If
patients are exposed to incompetent medical
practitioners, this could be a potential threat
to the patient's health and safety. In
developed nations, competency appraisal in
the medical professional is highly prevalent as
it is considered to be absolutely necessary;
medical practitioners, particularly in their first
years of practice, are monitored closely by
senior medical professionals.
•Unifying framework for nursing practice,
education, regulation
•Guide in nursing curriculum development
•Framework in developing test syllabus for
nursing profession entrants
•Tool for nurses’ performance evaluation
•Basis for advanced nursing practice,
specialization
•Framework for developing nursing training
curriculum
•Public protection from incompetent
practitioners
•Yardstick for unethical, unprofessional
nursing practice
Phases of developing competency standards
 1st Phase Competency identification
through Developing a Curriculum
(DACUM). Workshop and series of focus
group discussions with the participation
of nurse experts and consumers of
nursing practice such as administrators,
doctors and clients
 2nd 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:
1. 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.
2. 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.
3. 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.
4. 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
programs. 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
1. CORE COMPETENCY 1: Demonstrate
knowledge based on health/illness status
of individual/ groups Indicators:
a. Identifies health needs of
patients/groups
b. Explains patient/group status.
2. CORE COMPETENCY 2: Provides sound
decision making in care of
 individual/groups considering their
beliefs, values Indicators:
a. Problem identification
b. Data gathering related to problem
c. Data analysis
d. Selection appropriate action
e. Monitor progress of action taken
3. CORE COMPETENCY 3: Promotes patient
safety and comfort Indicators :
a. Performs age-specific safety
measures and comfort measure in
all aspects of patient care
4. CORE COMPETENCY 4: Priority setting in
nursing care based on patients’ needs
Indicators :
a. Identifies priority needs of patients
b. Analysis of patients’ needs
c. Determine appropriate nursing care
to be provided
5. CORE COMPETENCY 5:Ensures continuity
of care Indicators :
a. Refers identified problems to
appropriate individuals/ agencies
b. Establish means of providing
continuous patient care
6. CORE COMPETENCY 6: Administers
medications and other health
therapeutics Indicators :
a. Conforms to the 10 golden rules in
medication administration and
health therapeutics
7. CORE COMPETENCY 7: Utilizes nursing
process as framework for nursing.
Performs comprehensive, systematic
nursing assessment Indicators :
a. Obtains consent
b. Complete appropriate assessment
forms
c. Performs effective assessment
techniques
d. Obtains comprehensive client
information
e. Maintains privacy and
confidentiality
f. Identifies health needs
8. CORE COMPETENCY 8: Formulates care
plan in collaboration with patients, other
health team members Indicators :
a. Includes patients, family in care
planning
b. States expected outcomes in
nursing interventions
c. Develops comprehensive patient
care plan
d. Accomplishes patient centered
discharge plan
9. CORE COMPETENCY 9: Implements NCP to
achieve identified outcomes Indicators :
a. Explain interventions to patient,
family before carrying them out
b. Implement safe, comfortable
nursing interventions
c. Acts according to client’s health
conditions, needs
d. Performs nursing interventions
effectively and in timely manner
10. CORE COMPETENCY 10: Implements NCP
progress toward expected outcomes
Indicators :
a. Monitors effectiveness of nursing
interventions
b. Revises care plan PRN
11. CORE COMPETENCY 11: Responds to
urgency of patient’s condition Indicators :
a. Identifies sudden changes in
patient’s health conditions
b. Implements immediate, appropriate
interventions
II. MANAGEMENT OF RESOURCES AND
ENVIRONMENT
1. CORE COMPETENCY 1:Organizes workload
to facilitate patient care Indicators:
a. Identifies task or activities that need
to be accomplished
b. Plans the performance of task or
activities based on priority
c. Finishes work assignment on time
2. CORE COMPETENCY 2:Utilizes resources
to support patient care Indicators:
a. Determines the resources needed
to deliver patient care
b. Control the use of equipment
3. CORE COMPETENCY 3:Ensures the
functioning of resources Indicators:
a. Check proper functioning of the
equipment
b. Refers Malfunctioning equipment to
appropriate unit
4. CORE COMPETENCY 4:Check the Proper
functioning of the Equipment Indicators:
 a. Determines the task and
procedures that can be safely
assigned to the other members of
the team
b. Verifies the competence of the staff
prior to delegating tasks
5. CORE COMPETENCY 5:Maintains safe
Environment Indicators:
a. Observe proper disposal of waste
b. Adheres to policies, procedures and
protocols on prevention and control
of infection
c. Defines steps to follow in case of
fire , earthquake and other
emergency situation
III. HEALTH EDUCATION
1. CORE COMPETENCY 1:Assesses the
learning needs of the patient and the
family Indicators:
a. Obtains learning information
through interview, observation and
validation
b. Defines relevant information
c. Completes assessment records
appropriately○ Identify priority
needs
2. CORE COMPETENCY 2: Develops Health
Education plan based on assessed and
anticipated needs. Indicators:
a. Considers nature of the learner in
relation to social, cultural, political,
economic, educational, and
religious factor  national and international code of ethics
3. CORE COMPETENCY 3: Develops learning
material for health education Indicators:
a. Involves the patient, family and
significant others and other
resources
b. Formulates a comprehensive health
educational plan with the following
components ,objectives, content
and time allotment
c. Teaching-learning resources and
evaluation parameters
d. Provides for feedback to finalize
plan
4. CORE COMPETENCY 4: Implements the
health Education Plan Indicators:
a. Provides for conducive learning
situation in terms of timer and place
b. Considers client and family
preparedness
c. Utilize appropriate strategies
d. Provides reassuring presence
through active listening, touch and
facial expression and gestures
e. Monitors client and family’s
responses to health education
5. CORE COMPETENCY 5: Evaluates the
outcome of health Education Indicators:
a. Utilizes evaluation parameters
b. Documents outcome of care
c. Revises health education plan when
necessary
IV. ETHICO-MORAL RESPONSIBILITY
1. CORE COMPETENCY 1: Respects the rights
of individual/ groups Indicator:
a. Renders nursing care consistent
with the patient’s bill of rights (i.e.
confidentiality of information,
privacy, etc.)
2. CORE COMPETENCY 2: Accepts
responsibility & accountability for own
decisions and actions Indicators:
a. Meets nursing accountability
requirements as embodied in the
job description
b. Justifies basis for nursing actions
and judgment
c. Protects a positive image of the
profession
3. CORE COMPETENCY 3: Adheres to the
for nurses Indicators:
a. Adheres to the Code of Ethics for
Nurses and abides by its provisions
b. Reports unethical and immoral
incidents to proper authorities
V. LEGAL RESPONSIBILITY
1. CORE COMPETENCY 1: Adheres to
practices in accordance with the nursing
law and other relevant legislation
including contract and informed consent.
Indicators:
a. Fulfill legal requirements in Nursing
Practice
b. Holds current professional license
 c. Acts in accordance with the terms
of contract of employment and
other rules and regulation
d. Complies with the required CPE
e. Confirms information given by the
doctor for informed consent
f. Secures waiver of responsibility for
refusal to undergo treatment or
procedures
g. Check the completeness of
informed consent and other legal
forms
2. CORE COMPETENCY 2: Adheres to
organizational policies and procedures,
local and national Indicators:
a. Articulates the vision and mission of
the institution where one belongs
b. Acts in accordance with the
established norms and conduct of
the institution/ organization
3. CORE COMPETENCY 3: Document care
rendered to patients. Indicators:
a. Utilizes appropriate patient
care records and reports
b. Accomplish accurate
documentation in all matters
concerning patient care in
accordance with the standard of
nursing practice.
VI. PERSONAL & PROFESSIONAL
DEVELOPMENT
1. CORE COMPETENCY 1: Identifies own
learning needs Indicators:
a. Verbalizes strengths, weaknesses,
limitations.
b. Determines personal and
professional goals and aspirations.
2. CORE COMPETENCY 2: Pursues continuing
education Indicators:
a. Participates in formal and non-
formal education.
b. Applies learned information for the
improvement of care.
3. CORE COMPETENCY 3: Gets involved in
professional organizations and civic
activities Indicators:
a. Participates actively in professional,
social, civic and religious activities
b. Maintain membership to
professional organizations
c. Support activities related to nursing
and health issues
4. CORE COMPETENCY 4: Projects a
professional image of nurse Indicators:
a. Demonstrate good manners and
right conduct at all times.
b. Dresses appropriately.
c. Demonstrates congruence of words
and actions.
d. Behaves appropriately at all times.
5. CORE COMPETENCY 5: Possesses positive
attitude towards change and criticism
Indicators:
a. Listens to suggestions and
recommendations.
b. Tries new strategies or approaches.
c. Adapts to changes willingly.
6. CORE COMPETENCY 6: Performs function
according to professional standards
Indicators:
a. Assesses own performance against
standards of practice.
b. Sets attainable objectives to enhance
nursing knowledge and skills.
c. Explains current nursing practices,
when situations call for it.
VII. RESEARCH
1. CORE COMPETENCY 1: Gathers data using
different methodologies Indicators:
a. Identifies researchable problems
regarding patient care and
community health.
b. Identifies appropriate methods of
research for a particular
patient/community problem
c. Combines quantitative and
qualitative nursing design thru
simple explanation on the
phenomena observed
d. Analyzes data gathered
2. CORE COMPETENCY 2: Recommends
actions for implementation Indicator:
a. Based on the analysis of data
gathered, recommends practical
solutions appropriate for the
problem
3. CORE COMPETENCY 3: Disseminates
results of research findings Indicators:
a. Communicates results of findings to
colleagues/patients/family and to
others.
b. Endeavors to publish research.
c. Submits research findings to own
agencies and others as appropriate
4. CORE COMPETENCY 4: Applies research
findings in nursing practice Indicators:
a. Utilizes and findings in research in
the provision of nursing care to
individuals/groups/communities
b. Makes use of evidence-based
nursing to ameliorate nursing
practice
VIII. RECORDS MANAGEMENT
1. CORE COMPETENCY 1: Maintains accurate
and updated documentation of patient
care Indicator:
a. Completes updated documentation
of patient care
2. CORE COMPETENCY 2:Records outcome of
patient care Indicator:
a. Utilizes a record system
3. CORE COMPETENCY 3: Observes legal
imperatives in recording keeping
Indicators:
a. Observes confidentially and privacy
of patient’s records
b. Maintains an organized system of
filing and keeping patient’s records
in a designated area
c. Refrains from releasing records and
other information without proper
authority
IX. COMMUNICATION
1. CORE COMPETENCY 1: Establishes rapport
with patients, significant others and
members of the health team. Indicators:
a. Creates trust and confidence
b. Listens attentively to client’s queries
and requests
c. Spends time with the client to
facilitate conversation that allows
client to express concern.
2. CORE COMPETENCY 2: Identifies verbal
and non-verbal cues Indicator:
a. Interprets and validates client’s body
language and facial expression
3. CORE COMPETENCY 3: Utilizes formal and
informal channels Indicator:
a. Makes use of available visual aids
4. CORE COMPETENCY 4: Responds to needs
of individuals, family, group and
community Indicator:
a. Provides re- assurance through
therapeutic, touch, warmth and
comforting words of encouragement
b. Readily smiles
5. CORE COMPETENCY 5: Uses appropriate
information technology to facilitate
communication Indicator:
a. Utilizes telephone, mobile phone,
email and internet, and informatics
b. Identifies a significant other so that
follow up care can be obtained
c. Provides “holding” or emergency
numbers of services
X. COLLABORATION and TEAMWORK
1. CORE COMPETENCY 1: Establishes
collaborative relationship with colleagues
and other members of the health team
Indicators:
a. Contributes to decision making
regarding patients” needs and
concerns
b. Participates actively in patients care
management including audit
c. Recommends appropriate
intervention to improve patient care
d. Respects the role of the other
members of the health team
e. Maintains good interpersonal
relationships with patients,
colleagues and other members of
the health team
2. CORE COMPETENCY 2: Collaborates plan
of care with other members of the health
team Indicator:
a. Refers patients to allied health team
partners
b. Acts liaison / advocate of the
patients
c. Prepares accurate documentation of
efficient communication of services
XI. QUALITY IMPROVEMENT
1. CORE COMPETENCY 1:Gathers data for
quality improvement Indicators:
a. Demonstrates knowledge of method
appropriate for the clinical problems
identified
b. Detects variation in the vital signs of
the patient from day to day
c. Reports necessary elements at the
bedside to improve patient stay at
hospital
d. Solicits feedback from patient and
significant others regarding care
rendered
2. CORE COMPETENCY 2: Participates in
nursing audits and rounds Indicators:
a. Contributes relevant information
about patient condition as well as
unit condition and patient current
reactions
b. Shares with the team current
information regarding particular
patient’s condition
c. Encourages the patient to speak
about what is relevant to his
condition
d. Documents and records all nursing
care and actions
e. Performs daily check of patient
records/condition
f. Completes patients records
g. Actively contributes relevant
information of patients during
rounds thru readings and sharing
with others
3. CORE COMPETENCY 3: Identifies and
reports variances Indicators:
a. Documents observed variance
regarding patient care and submits
to appropriate group within 24 hours
b. Identifies actual and potential
variance to patient care
c. Reports actual and potential variance
to patient care
d. Submits report to appropriate
groups within 24 hours
4. CORE COMPETENCY 4: Recommends
solutions to identified problems
Indicators:
a. Gives appropriate suggestions on
corrective and preventive measures
b. Communicates and discusses with
appropriate groups
c. Gives and objective and accurate
report on what was observed rather
than an interpretation of the event.
Lesson B. 1 APPLICATION OF CORE
COMPETENCY IN NURSING PRACTICE PRE-
TEST 2 ASSESSMENT 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 5 days ago and was
reported to have experienced
confusion the previous shift. Which
statement will provide the nurse with
the most appropriate information?
a. “Can you tell me today’s
b. do you know that you are in the hospital?”
c.“When did you have hip surgery?”
d.“What is your name?”
Rationale:_____________________________
____________________ 
2. The nurse is informed that the newly
admitted client is complaining of
itching and has a rash all over the
body. The most appropriate nursing
intervention initially is to:
a.Inform the doctor of the objective and
subjective complaints
b.Inspect the client and describe the rash
c.Ask the client to try not to scratch the areas
d. Check the medication record for anti -itch
medicati on
Rationale:_____________________________
_______________________ 
3. The nurse is assigned to a client who
was admitted for a blood clot in the right leg.
Which of the following describes the
appropriate assessment technique initially?
a. Inspection of the right leg
b. Light palpation of the right leg
c. Inspection followed by deep palpation of
edematous areas
d. Light palpation followed by inspection of
any reddened
areas.Rationale:________________________
____________________________  COMPETENCY IN NURSING PRACTICE
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
have hip surgery?”
d.
“What is your name?” Rationale: Eliciting
orientation to person is part of assessing
client orientation.Options A & B encourages
yes or no response, and option c may not give
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
objecti ve and subjecti ve complaints
b.Inspect the client and
describe the rash c.Ask the client to try
not to scratch the areasd.Check the
medicati on record for anti -itch
medicati on Rationale: it is most appropriate
for the nurse to initially gather data by using
theassessment skill of inspection and then to
further describe the observations. Options
A,C, & D are follow-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 ti o n   o f
t h e   r i g h t   l e g , b . L i g h t palpation of the
right leg c.Inspection followed by deep
palpation of edematous areas; d.Light
palpation followed by inspection of any
reddened areas. Rationale: Inspection is the
initial step in the assessment process that
provides information on color, size, shape and
movement of the extremity. Options B and
Dare not appropriate initially and
option C should not be done in this situation.
Lesson B.1 APPLICATION OF CORE
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 to’s and the
why’s of the six phases of assessment.
EXPECTED LEARNING OUTCOMES
After studying the content of this section, the
students should be able to:
1. Describe the five characteristics of an
assessment that promotes competency, and
explain how the phases of Assessment
described in this section promote critical
thinking.
2. Explain how the interview and physical
assessment complement and clarify each
other.
3. Give an example of an open-ended
question, a closed ended question, a leading
question and an exploratory statement.
4. Differentiate between cues and inferences
5. Explain why organizing data more than one
way promotes competence and critical
thinking.
ASSESSMENT OF INDIVIDUAL PATIENT NEEDS
FOR NURSING ANA STANDARD
The nurse collects comprehensive data
pertinent to the patient’s health situation
(ANA, 2004)
SIX PHASES OF ASSESSMENT
1. Collecting of data- gathering data
(information) about health status
2. Identifying cues and making inferences-
recognizing significant data and drawing
some beginning conclusions about what
the data may indicate.
3. Validating the data- double checking to
make sure that your data are accurate
and complete.
4. Clustering the data- organizing or
grouping related pieces of information to
help you identify patterns of health or
illness (example, Clustering data about
nutrition together, the data about rest
together and so forth)
5. Identifying patterns/ testing first
impressions- looking for the patterns and
focusing your assessment to gain more
information to better understand the
situations at hand. For example, you
suspect that someone’s data shows a
pattern of poor nutrition and decide to
find out what’s contributing to this
pattern (does the person have poor eating
habits or could it be something else, such
as not having enough money to eat well?)
6. Reporting and recording data- Reporting
significant data (ex. High fever) and
charting on the patient’s record.
CHARACTERISTICS OF AN ASSESSMENT THAT
PROMOTES COMPTENCY
1. PURPOSEFUL
To promote Critical thinking, your approach to
assessment must change, depending on your
purpose and the circumstances (context) of
your patient situation. For example: Are you
aiming to assess all aspects of care, or are
you monitoring one specific problem? Is your
assessing a hospitalized patient or someone in
the home? Is the person an adult or a child?
NOTE: Your aim is to gain all the information
needed to ensure that your patients have
individualized plans that are designed to help
them achieve outcomes in the best way
possible, in context of their particular
situation (eg, their age, culture, and level
of independence)
2. FOCUSED AND RELEVANT
Your assessment must be focused to gain
relevant information, depending on purpose
and context as above. For example:
Physician’s Data: (Disease focus)
“Mrs. Garcia has pain and swelling in all joints.
A diagnostic study indicates that she has
rheumatoid arthritis. We will start her on a
course of anti-inflammatory drugs to treat the
rheumatoid arthritis.” (Focus on the
treatment modalities)
Nurse’s Data: (holistic focus, considering both
problems and their effect on the person’s
ability to function independently)“Mrs. Garcia
has pain and swelling in all joints, making it
difficult to feed and dress herself. She has
voiced that it’s difficult to feel worthwhile
when she can’t feed herself. She states that
she is depressed because she misses seeing
her two small grandchildren. We need to
develop a plan to help her with her pain, to
assist her with feeding and dressing, to work
through feelings of self-esteem, and for
special visitations with the grandchildren.”
( Focus is on Mrs. Garcia)
3. SYSTEMATIC
Developing a systematic approach to
assessment helps you pay attention to what is
important, learn how to prioritize, be
comprehensive, and avoid omission errors.
For example:
•What are your symptoms?
•Can you point out with one finger to the
areas that are bothering you?
•When did they start?
•What makes them better?
•What makes them worse?
•Are you taking any medications- prescribed,
over-the-counter, or herbal remedies- that
may be causing some of these symptoms?
•Can you think of anything else that might be
contributing to your symptoms?
4. COMPREHENSIVE AND
ACCURATE
The most common error that happens in
critical thinking is identifying problems
or making judgments based on sufficient or
incorrect information. Your information must
be factual, and as complete as is warranted by
your purpose. For example: An assessment
aims to get information about one specific
problem is shorter than one that aims to get
comprehensive data about all aspects of care.
DISPLAY B
.
1.1
:How to ensure Comprehensive Data
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
someone’s 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 faciliti es For
example: Gordon’s Functional Health Patterns or
Orem’s Self Caretheory.
5.RECORDED IN A STANDARDIZED
WAY
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  care systems)
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
 
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  normalvalues/ results of common laboratory and
.For example:Subjective data: States, “I feel
fine.”Objective data: Color pale, becomes easily short
of breath.Above, what the person states isn’t
supported by what you observe. You need
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  questions. Restate each question below so
(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
pati ent by name, introduces self and
co- staff  c.Encourages verbalization of needs
and feelings
through attentive listening.d.Conveys availabil
ity 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
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
it’s anopen ended
question.a . A r e   y o u   f e e l i n g   b e tt e r ?
Bodied you like dinner? Care
you 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. “I’ve 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. “I’ve 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
patient’s 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
fi nd: The pati ent’s RR is 40. What will
you say next? You examine and find: The
patient’s right eye is red, teary, and inflamed.
What will you say next? 2. Now practice focusing
your PE on areas of concern voiced by
the 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? Pati ent states:” I fi nd it burns
when I urinate,” What will you reply
and examine?
D.
Patient states: “I feel like I’m heavier than usual, like I’m
bloated with fluid, “What will reply and examine?
Example Responses to Activity 1
Part 1: Interviewing
1. Practice asking open-ended questions.
Restate each question below so it’s an open
ended question.
A.
Are you feeling better? Tell me how you’re feeling
B.
Did you like dinner?
How was your dinner?  focusing your PE on areas of
C.
Are your happy here?
How do you feel about being here?  What will you replyand examine?Show me where
D.
Are you having pain?
Describe what you are feeling; tell me how you’re
feeling.
2.
Practice clarifying ideas by using reflection
(restating what you hear) and making open-ended
questions. For each statement below, write a reflective
statement and an open-ended question that would
help you to clarify what has been said.
A.
“I’ve been sick offand on for a month.”
So, you’ve been sick offand for month. What do you
mean by sick offand on?  bloating? Your stomach? Ankles? Where? Examinethe
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.
“I’ve had this funny feeling for a week.”
You’ve 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 patient’s 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 fi nd: The pati ent’s RR is
40. What will you say next?Your breathing is
a little fast. How do you feel?d.You examine and
find: The patient’s right eye is red, teary, and
inflamed.What will you say next?Your eyes seem
inflamed. How does it feel?2.Now practice
concern voiced by the patienta.Patient states:
“I have had a rash that comes and goes.”
(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.Pati ent states:” I fi nd 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 I’m heavier
than usual, like I’m bloated with fluid,”What
will reply and examine?Where do you feel this
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:
• and observe is thekey to establishing the positive
Assessing infant development using standardized
scales
• are in a veryvulnerable position. They need to know
Measuring height, weight, and vision in school aged
children
• Consider the following guidelines that can help you
Assessing for problem drinking and depression
beginning in adolescence.
• Caring Interaction/CommunicationHow to establish
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 scienti fi c
evidence addressing how useful the
service is.b.The health, preference, and
concerns of each pati entc.The decision
making style of each cliniciand.Practi cal
constraints, such as the amount of ti me
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 r i s k
or seriousness of the disease
o r   c o n d i ti o n   t o
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 ti 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 ti a l   h a r m s
a n d   b e n e fi 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 preventi ve measu
res, including screening tests,counseling
immunization and preventive medications.
Lesson C.1Communication
Your ability to establish rapport, ask questions, listen,
nurse- patient relationship needed to builda
therapeutic relationship. People seeking health care
that they’re in good hands andthat their main concerns
will be addressed. This is where you come in asnurses.
establishtrust, positive attitude, and reduce
anxiety.Display C.1.1Guidelines in Promoting a
rapportBefore you go into the interview:
Get organized 
:
When you know what you’re going to do, you’re
moreconfident and able to focus on the personDon’t
rely on memory: Have a written or printed plan to
guide thequestions you’ll 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 person’s name and ask what he or
she would like to be called (eg. I have your name listed
here as Michael Riles. Is that correct? What would you
like us to call you?”). Using the preferred name helps
the person to feel more relaxed and sends the
message that you 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, I’m 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.Don’t hurry: Rushing
sends the message that you’re not interested inwhat
the person has to say.

Sit down: This communicates that you’re willing to take
your time.How to listenBe an empathetic listener  CLINICAL SCENARIO
To listen empathetically
1.Eliminates thoughts about how you,
yourself, see the situati on.
2.
Listen carefully for feelings, trying to identify with how
the other personperceives his situation. Don’t allow
yourself to think about how you feel or how you’re
going to respond; think only about the content of what
you’rehearing3.Reflect on what you’ve been
told, then rephrase the feelings you have
heard.4.Seek validation that you understood
the message, content, and emotioncorrectly.
Keep trying until you’re sure you understand.
5.
Detach, come back to your own frame of reference,
and separate yourself from the emotions
involved.DISPLAY C.1.2
TEN CARING BEHAVIORS
1.Monitoring pati ents closely and
telling them you know you’re doing
it.Example: “I will be checking on you every 15
minutes”2.Inspiring someone, or instilling hope
and faith ( creating a vision of
“canbe”)3.Showing pati ence,
compassion, and willingness to
persevere4.Taking time, rather than
hurrying through just to get things
done.5.26.Off ering companionship or pr
esence7.Helping someone stay in touch
with positi ve aspects of his
life.8 . D e m o n s t r a ti n g   t h o u g h tf 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 who’s in a
negative emotional state, it becomes aspringboard into
other negative behaviors. Down the road, their own
outcomes to suffer, andthey just don’t fare well..try to
make the work environment as fun as possible> If you
see a staff member in a bad mood, jump in and try to
derail it before itr becomes contagious.”-
HowaredWeiss (Farella, 2009)
Listening Empathetically Promotes Understanding of
the Real Issues,Fostering Caring Human Responses
Today Patricia/Pat is caring for Sharon, who’s just given
birth to her fifth child,a healthy baby girl. Pat never has
been able to conceive, has always wanted children,
and feels a little envious of Sharon’s family of two boys
and (now) of three girls.Pat notes that Sharon seems
very quiet. Recognizing the importance of
beingempathetic listener, Pat has the following
conversation with Sharon.Pat: “You’ve been pretty
quiet since I came on.”Sharon: “I can’t help it. I’m
supposed to be happy, but I’m really disappointed-I
was so sure I’d had a baby boy.”Pat: (making a
conscious effort to eliminate thoughts about the fact
that she’dbe happy with any child, and rephrasing
what Sharon seems to be feeling): “you feel like you’re
supposed to be happy, but you really feel sort of
sad?”Sharon: “yes”,Pat pauses to reflect on the
feeling of sadness and encourages Sharon
tocontinue.Sharon: “I was going to name this baby
after my father. He died 2 monthsago.”Pat (connecting
to what Sharon must be feeling): “I’m 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 you’ve got a very beautiful baby
girl; with the longest hair I’ve ever seen, waiting to
meet her mother. How would you feel if I
Brought her into you? “Sharon: (smiling) “Yes, I really
haven’t seen her for more than 5 minutes. I’ve got to
admit, I’ve always gotten along better with my girls
than my boys.”
CLASSROOM ACTIVITY 2 CRITICAL THINKING ABILITY
AND WILLINGNESS AND ABILITY TOCARE

1.List fi ve criti cal thinking indicators
you’d like to acquire or improve.
2.Complete the following sentence, using as
many words as you choose: If I were to tell
someone how I think, I would say that I………..
3.In five sentences or less, describe what critical
thinking means to you
4.Give three examples of
caring behaviors
5.Explain how the statements relates to
willingness and ability to care: a.Health and
Illness are human 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: “Don’t Worry Be Happy! Harmonize Diversity
through Personality Sensitivity,” at
http:nsweb.nursingspectrum.com/ce/ce236.htm
2.Are you stressed out? Managing stress is an
important part of staying healthy. Take the Life Stress
Test
at  http://www.cliving.org/lifstrstst.htm . Think
of something’s that you can do to reduce your stress
level.
3 . P r a c ti c e e m p a t h e ti 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 client’s right to privacy by judiciously
protecting information of a confidential nature.
3.Be honest. Tell the person the truth about
how you’ll see the data (egg. “I have to write a
paper examining someone’s eating patterns. Would
you be willing to tell me about your eating habits?
4.Respect individual cultural and religious beliefs and
be aware of physical tendencies related to culture. This
include being aware of:
•Biologic variations for example: Differences among
racial and ethnic groups like skin color, texture, and
susceptibility to diseases like hypertension and sickle
cell anemia.
•Comfortable communication patterns For example:
How language and gestures are used, whether eye
contact or touching is acceptable, and whether the
person is threatened by being in close proximity to
another.
•Family organization and practices we have diverse
family units and practices. We must understand them
to gain insight into factors that influence health status.
•Beliefs about whether people are able to control
nature and influence their ability to be healthy (egg,
whether blood transfusions are allowed or whether
rituals are required)
•The person’s concept of God and beliefs about the
relationship between spiritual beliefs and health status.
(Egg, God gives you what you deserve.).