NCM 103: FUNDAMENTALS OF NURSING PRACTICE

HANDOUTS – 4

A. TEACHING
 A system of activities intended to produce learning. The teaching-learning process involves dynamic interaction
between teacher and learner.
 Areas of Client Education: Promotion of Health; Prevention of Illness / Injury / Restoration of Health / Rehabilitative
I. Promotion of Health
 Increasing a person’s level of wellness
 Growth and development topics
 Fertility control
 Hygiene
 Nutrition
 Exercise
 Stress management
 Lifestyle modification
 Resources with the community
II. Prevention of Illness / Injury
 Health screening (e.g., blood glucose level, blood pressure, blood cholesterol, Pap test, mammogram,
vision, hearing, routine physical examinations)
 Reducing health risk factors (e.g., lowering cholesterol level)
 Specific protective health measures ( e.g., immunizations, use of condoms, use of sunscreen, use of
medication, umbilical cord care)
 First aid
 Safety (e.g., using seat belts, helmets, walkers)
III. Restoration of Health
 Information about tests, diagnosis, treatment, medications
 Self-care skills or skills needed to care for family members
 Resources within health care setting and community
IV. Adaptation of Altered Health & Function
 Adaptations in lifestyle
 Problem-solving skills
 Adaptation to changing health status
 Strategies to deal with current problems
 Information about treatments & likely outcomes
 Referrals to other healthcare facility or service
 Facilitation of strong self-image
 Grief & bereavement counseling
 Setting Learning Outcomes (Objectives)
 State the client behavior or performance, not nurse behavior.
 Reflect an observable, measurable activity. Avoid using words such as knows, understands, believes and
appreciates because they are neither observable nor measurable.
 May add conditions or modifiers as required to clarify what, where, when or how the behavior will be
performed.
 Include criteria specifying the time by which learning should have occurred.
 OR – S M A R T (S = specific; M = measurable; A = attainable; R = realistic; T = time-bound)
 Domains: Cognitive = Knowledge; Psychomotor = Skills; Affective = Attitude
 Example:
Gen. Objective: After 1 day of RLE, the Level I Nursing students will be able to learn the proper giving
of hygiene to their respective clients.
Specific Objectives: Within 5 hours of RLE, the Level I nursing students will be able to:
COGNITIVE:
1. Explain the importance of proper hygiene in taking care of the client.
AFFECTIVE:
1. Participate in the demonstration of the different procedures in providing proper hygiene to a client.
PSYCHOMOTOR:
1. Demonstrate the different procedures in providing proper hygiene to a client such as hair care, bed
shampoo, oral hygiene, complete bed bath and back rub/ massage.

B. NURSING AS A SCIENCE
I. Nursing Process – a systematic and rational method of providing nursing care.
II. Definition of Terms:
a) Assessment – first step of the nursing process in which data are gathered to identify actual or potential health
problems.

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 b) Nursing Diagnosis – second step of the nursing process & includes clinical judgements made about wellness
states, illness states & syndromes, & the readiness to enhance current states of wellness experienced by
individuals, families & communities.
c) Planning – third step of the nursing process. Includes the formulation of guidelines that establish the proposed
course of nursing action in the resolution of nursing diagnoses and the development of the client’s plan of care.
d) Nursing Care Plan (NCP) – written summary of the care that the client is to receive.
e) Implementation – the fourth step of the nursing process which involves the execution of the nursing care plan
derived during the planning phase.
f) Nursing Intervention – is an action performed by the nurse that helps the client to achieve the results specified
by the goals & expected outcomes.
g) Evaluation – last step of the nursing process which determines the efficacy of nursing care and ensures the
delivery of quality care.
h) Priority setting – a decision-making process that ranks the order of nursing diagnosis in terms of importance to
the client.
i) Accountability – the condition of being answerable and responsible to someone for specific behaviours that are
part of the nurse’s professional role.

III. Steps of the Nursing Process:

1. Assessment; 2. Nursing Diagnosis; 3. Planning; 4. Implementation; 5. Evaluation
IV. Goals of the Nursing Process:
1. Identify client’s health status and health care problems.
2. Establish plans to meet the identified needs.
3. Deliver the specific nursing interventions to meet those needs.
V. Skills needed to Successfully Use the Nursing Process:
1. Cognitive Skills, it offers a scientific rationale for a patient’s plan of care – select those nursing interventions that
are most likely to yield the desired outcomes; use critical thinking to solve problems creatively.
2. Technical Skills – use technical equipment with sufficient competence & ease to achieve goals with minimal
distress to participants’ involved. Creatively adapt equipment and technical procedures to the needs of
particular clients.
3. Interpersonal Skills – use interactions with patients, their significant others & colleagues to affirm their worth.
Elicit personal strengths & abilities of patients to achieve valued health goals. Provide health care team with
knowledge about the patient’s valued goals & expectations. Work collaboratively with the health care team.
4. Ethical & Legal Skills – be trusted to act in ways that advance the interest of the patients. Be accountable for
their practice to themselves, the patient they serve, the team & the society. Act as effective patient advocates.
Practice nursing faithful to the tenets of professional code of ethics & appropriate standards of practice.
VI. Characteristics of the Nursing Process
1. The system is open & flexible.
2. It is planned.
3. It is goal-oriented.
4. It is client-centered.
5. It permits creativity for the nurse & client to solve health problems.
6. It is interpersonal & collaborative.
7. It is cyclic & dynamic.
8. It emphasizes feedback.
9. It is universally applicable.
VII. Benefits of the Nursing Process
A. For the Client
 Quality client care
 Continuity of care
 Participation by the clients in their health care
B. For the Nurse
 Consistent & systematic nursing education
 Job satisfaction
 Professional growth
 Avoidance of legal action
 Meeting professional nursing standards.
VIII. NURSING PROCESS STEP 1: ASSESSMENT
 PURPOSE: To establish a database concerning a client’s physical, psychosocial & emotional health in order
to identify health promoting behaviors as well as actual & potential health problems.
 Four Different Types of Assessment:
a) Initial – establish complete data base.
b) Focused – to determine status of a specific problem identified in an earlier assessment.
c) Emergency – to identify life threatening problems.
d) Time-lapsed – to compare current status from previous baseline data.
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  4 Closely Related Activities Involved:
a) Collecting Data
b) Organizing Data – nurse writes data gathered in different database forms
c) Validating Data – act of double checking or verifying data to confirm that it is factual. Benefits: (1) ensure
that assessment information is complete; (2) ensured that objective and related subjective data agree;
(3) obtain additional information that may have been overlooked; and (d) differentiate between cues &
inferences.
d) Recording data – accurate documentation is essential & should include all data collected about the
client’s health status.
 Methods of Collecting Data:
a) Observation – gathering of data by using the five senses. Includes looking, watching, surveying,
scanning & appraising. There are 2 aspects: (1) noticing the data & (2) selecting, organizing &
interpreting the data.
b) Interview – planned communication or a conversation with purpose. Purpose: (1) gather & give
information; (2) identify problems; (3) evaluate change; (4) teach; (5) provide support; (6) provide
counselling or therapy. Approaches: (1) directive – highly structured; (2) non-directive – client controls
the purpose, subject matter & pacing (rapport-building).
 Kinds of Interview Questions: (1) Open-ended – it is broad, specifies only the topic to be
discussed & invites ansers longer that 1-2 words; (2) Closed – restrictive, generally requires
only specific answers or information; (3) neural questions – client can answer without direction
or pressure from the nurse; (4) leading questions – usually closed & thus directs the client’s
answer.
 Factors that Influence Interview: time, place, seating arrangement, distance, language
 Stages of Interview: (1) opening or introduction – establishing rapport & orienting the
interviewee; (2) body or development – uses communication techniques that makes both
parties feel comfortable& serve the purpose of the interview. The client communicates what he
feels, thinks, knows & perceives in response to questions.
 Closing – when needed information is obtained, the nurse terminates the activity or the client
otherwise.
c) Examining: Purpose – obtain baseline data, supplements, confirm data obtained in nursing history,
obtain data that will help the nurse establish nursing diagnosis & plan client’s care, evaluate the
physiologic outcomes of health care. Approaches: cephalocaudal or body system. Methods of
examining: IPPA
 Types of Data: (a) subjective – symptoms, covert cues & (b) objective – signs, overt cues, measurable
 Sources of Data: (1) primary data; (2) secondary data; (3) health care professionals; (4) literature
IX. NURSING PROCESS STEP 2: DIAGNOSIS
 PURPOSE: To effectively communicate the healthcare needs of the individuals & aggregates among
members of the health care team and with the health care delivery system. Quality client care is enhanced.
 Diagnosis – science & art of identifying problems or conditions.
 Nursing Diagnosis – a clinical judgement about the individual, family or community responses to actual
health problems / life processes. Nursing Diagnosis provides the basis for selection of nursing interventions
to achieve outcomes for which the nurse is accountable.
 Nursing Diagnosis VS Medical Diagnosis
a) Medical Diagnosis – terminology used for a clinical judgement by the physician that identifies or
determines a specific disease, condition or pathologic state.
b) Nursing Diagnosis – terminology used for a clinical judgement by the professional nurse that identifies
client’s actual, risk, wellness or syndrome responses to a health state, problem or condition.
 Activities involved in Diagnosing: Analyze data; Identify health problems, risks, and strengths;
Formulate diagnostic statements
 Types of Nursing Diagnoses (according to Status)
 “Status of the nursing diagnosis refers to the actuality or potentiality of the problem/syndrome or the
categorization of the diagnosis as a health promotion diagnosis” (Herdman & Kamitsuru, 2014, p. 100).
 The kinds of nursing diagnoses according to status are actual, health promotion, risk, and syndrome.
a) Actual diagnosis – a client problem that is present at the time of the nursing assessment. Examples
are Ineffective Breathing Pattern and Anxiety. An actual nursing diagnosis is based on the presence of
associated signs and symptoms.
b) Health promotion diagnosis – relates to clients’ preparedness to implement behaviors to improve their
health condition. These diagnosis labels begin with the phrase Readiness for Enhanced, as in Readiness
for Enhanced Nutrition.
c) Risk nursing diagnosis – a clinical judgment that a problem does not exist, but the presence of risk
factors indicates that a problem is likely to develop unless nurses intervene. For example, Risk for
Infection to describe the client’s health status.

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 d) Syndrome diagnosis is assigned by a nurse’s clinical judgment to describe a cluster of nursing
diagnoses that have similar interventions (Herdman & Kamitsuru, 2014, p. 23). It is associated with a
cluster of other diagnosis. For example: Risk for Disuse Syndrome
 3 Kinds of Problems That Can Lead to Errors in Identifying the Nursing Diagnosis:
1) Inaccurate collection of data
2) Inaccurate interpretation of data
3) lack of knowledge or practice
 FORMULATING DIAGNOSTIC STATEMENTS
 3 Essential Components of a Nursing Diagnosis
o (P) Problem – statement of the client’s response
o (E) Etiology – factors contributing to or a probable cause of the response
o (S) Signs and Symptoms – defining characteristics manifested by the client.
 Variations in the Basic Format
1) Writing UNKNOWN ETIOLOGY – when the defining characteristic are present but the nurse does
not know the cause or contributing factors.
o Altered Nutrition, less than body requirement related to unknown etiology
2) Using the phrase COMPLEX FACTORS – when there are too many etiologic factors or when they
are too complex to state in a brief phrase.
o Risk for suicide related to complex factor
3) Using the word POSSIBLE – when more data are needed about the client’s problem or the
etiology
o Possible risk for suicide R/T loss of loved ones and rejection of friends
4) Using SECONDARY TO – to divide the etiology into two parts thereby making the statement more
useful and descriptive
o Altered body temperature, Hyperthermia R/T presence of infection secondary to SARS.
5) Adding a second part to the general response or NANDA label to make it more precise
o Impaired skin integrity (left lateral ankle) R/T decreased peripheral circulation

Taxonomy of Nursing Diagnoses. The main categories or classification of the nursing diagnoses is under
“DOMAIN”.