The document discusses the roles and responsibilities of nurses. It outlines four main goals of nursing: promoting health, preventing illness, treating human responses to health or illness, and advocating for patients. Key aspects of the nursing process are also summarized, including assessment, diagnosis, planning, implementation, and evaluation. Assessment involves collecting both subjective and objective data to understand a patient's health status. The nursing process provides an organized framework for delivering patient care.
Easy to discuss and understand by the summarize topics of 3 which is Community Health Nursing, COPAR and Primary Health Care. Sources from different presentations and Shield book. MOSTLY COMPLETE AND COMPREHENSIBLE!!!
Among the many models of health related quality of life, Pender’s Health promotion behavior model helps to identify factors influenced the decisions and actions of individuals that were made to prevent disease and promote a healthy lifestyle.
A lecture on the impact of illness on the community; delivered to second year medicine students of the UP College of Medicine as part of the HS 2020 Biopsychosocial Dimensions of Illness course.
Easy to discuss and understand by the summarize topics of 3 which is Community Health Nursing, COPAR and Primary Health Care. Sources from different presentations and Shield book. MOSTLY COMPLETE AND COMPREHENSIBLE!!!
Among the many models of health related quality of life, Pender’s Health promotion behavior model helps to identify factors influenced the decisions and actions of individuals that were made to prevent disease and promote a healthy lifestyle.
A lecture on the impact of illness on the community; delivered to second year medicine students of the UP College of Medicine as part of the HS 2020 Biopsychosocial Dimensions of Illness course.
The American Nurses Association (ANA) defines the nursing process as “the essential core of practice for the registered nurse to deliver holistic, patient-focused care.
Or
Defined as a systematic approach to care, using the fundamental principles of critical thinking, client-centered approaches to treatment, goal-oriented tasks, evidence-based practice (EBP) recommendations, and nursing intuition.
It is considered the framework upon which all nursing care is based.
Nursing Diagnosis for Care Plans
This section is the list or database of the common NANDA nursing diagnosis examples
DIAGNOSTIC LABEL
Activity Intolerance
Acute Pain
Anxiety
Chronic Pain
Constipation
Decreased Cardiac Output
Deficient Fluid Volume
Deficient Knowledge
Diarrhea
Excess Fluid Volume
Fatigue
Fear
Grieving
Hopelessness
Hyperthermia
Hypothermia
Imbalanced Nutrition: Less Than Body Requirements
Impaired Gas Exchange
Impaired Tissue (Skin) Integrity
Impaired Urinary Elimination
Ineffective Airway Clearance
Ineffective Breathing Pattern
Ineffective Tissue Perfusion
Risk for Falls
Risk for Impaired Skin Integrity
Risk for Infection
Risk for Injury
Risk for Unstable Blood Glucose Level
Patient problem present during A nursing assessment is known as A problem-focused diagnosis
Risk factors require intervention from the nurse and healthcare team prior to A real problem developing
Improve the overall well-being of an individual, family, or community
A cluster/group of nursing diagnoses that occur in a pattern or can all be addressed through the same or similar nursing interventions
A possible diagnosis is a statement about a health problem that the client might have now, but the nurse doesn’t yet have enough information to make an actual diagnosis.
An example of a possible diagnosis is: Possible fluid volume deficit in case of frequent vomiting for three days .
Cerebrovascular accident (CVA), also known as stroke, acute ischemic stroke, cerebral infarction, or brain attack.
Definition:
It is the sudden impairment of cerebral circulation in one or more blood vessels supplying the brain caused by hemorrhage from a tear in the vessel wall or impairs cerebral circulation by partial or complete occlusion of the vessel lumen
Strokes can be classified into 2 main categories:
Ischemic strokes. These are strokes caused by blockage of an artery (or, in rare instances, a vein). About 87% of all strokes are ischemic.
Hemorrhagic stroke. These are strokes caused by bleeding. About 13% of all strokes are hemorrhagic.
2 main categories, Ischemic strokes :
Thrombotic strokes. These are caused by a blood clot that develops in the blood vessels inside the brain.
Embolic strokes. These are caused by a blood clot or plaque debris that develops elsewhere in the body and then travels to one of the blood vessels in the brain through the bloodstream.
2 main categories, Hemorrhagic strokes”
Intracerebral hemorrhage.
Bleeding is from the blood vessels within the brain.
Subarachnoid hemorrhage.
THESE SLIDES ARE PREPAREED TO UNDERSTAND nursing IN EASY WAY Important links- NOTES- https://mynursingstudents.blogspot.com/ youtube channel https://www.youtube.com/c/MYSTUDENTSU... CHANEL PLAYLIST- ANATOMY AND PHYSIOLOGY-https://www.youtube.com/playlist?list=PL93S13oM2gAPM3VTGVUXIeswKJ3XGaD2p COMMUNITY HEALTH NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gAPyslPNdIJoVjiXEDTVEDzs CHILD HEALTH NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gANcslmv0DXg6BWmWN359Gvg FIRST AID- https://www.youtube.com/playlist?list=PL93S13oM2gAMvGqeqH2ZTklzFAZhOrvgP HCM- https://www.youtube.com/playlist?list=PL93S13oM2gAM7mZ1vZhQBHWbdLnLb-cH9 FUNDAMENTALS OF NURSING- https://www.youtube.com/playlist?list=PL93S13oM2gAPFxu78NDLpGPaxEmK1fTao COMMUNICABLE DISEASES- https://www.youtube.com/playlist?list=PL93S13oM2gAOWo4IwNjLU_LCuhRN0ZLeb ENVIRONMENTAL HEALTH- https://www.youtube.com/playlist?list=PL93S13oM2gAPkI6LvfS8Zu1nm6mZi9FK6 MSN- https://www.youtube.com/playlist?list=PL93S13oM2gAOdyoHnDLAoR_o8M6ccqYBm HINDI ONLY- https://www.youtube.com/playlist?list=PL93S13oM2gAN4L-FJ3s_IEXgZCijGUA1A ENGLISH ONLY- https://www.youtube.com/playlist?list=PL93S13oM2gAMYv2a1hFcq4W1nBjTnRkHP facebook profile- https://www.facebook.com/suresh.kr.lrhs/ FACEBOOK PAGE- https://www.facebook.com/My-Student-S... facebook group NURSING NOTES- https://www.facebook.com/groups/24139... FOR MAKING EASY NOTES YOU CAN ALSO VISIT MY BLOG – BLOGGER- https://mynursingstudents.blogspot.com/ Instagram- https://www.instagram.com/mystudentsu... Twitter- https://twitter.com/student_system?s=08 #PEM, #hemophilia,#NEW,#BORN,#ASSESSMENT, #APPEARENCE,#PULSE,#GRIMACE,#REFLEX,#RESPIRATION,#RESUSCITATION,#NEWBORN,#BABY,#VIRGINIA, #CHILD, #OXYGEN,#CYANOSIS,#OPTICNERVE, #SARACHNA,#MYSTUDENTSUPPORTSYSTEM, #rashes,#nursingclasses, #communityhealthnursing,#ANM, #GNM, #BSCNURING,#NURSINGSTUDENTS, #WHO,#NURSINGINSTITUTION,#COLLEGEOFNURSING,#nursingofficer,#COMMUNITYHEALTHOFFICER
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
We understand the unique challenges pickleball players face and are committed to helping you stay healthy and active. In this presentation, we’ll explore the three most common pickleball injuries and provide strategies for prevention and treatment.
Navigating the Health Insurance Market_ Understanding Trends and Options.pdfEnterprise Wired
From navigating policy options to staying informed about industry trends, this comprehensive guide explores everything you need to know about the health insurance market.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
3. Roles of the Professional Nurse
Nursing is the protection, promotion, and optimization of
health and abilities, prevention of illness and injury,
alleviation of suffering through the diagnosis and treatment
of human response, and advocacy in the care of individuals,
families, communities, and populations.
4. Four Main Goals of Nursing
1. Promote Health
2. Prevent Illness
3. Treat human responses to health or illness
4. Advocate for individuals, families, communities,
and populations
5. Nursing and Health Promotion
• Health behaviors are influenced by one’s beliefs,
cultures, and perception
• Health beliefs and experiences determine who is
likely to practice healthy behaviors and why.
6. WELLNESS and ILLNESS
• Wellness is an integrated method of functioning
oriented toward maximizing the potential of the
individual.
• Illnesses are separate short or long events that may
challenge a person’s desire for health. Health is
more than merely the absence of illness.
7. Health Assessment
• gathering information about the health status of
the patient, analyzing and synthesizing those
data, making judgments about nursing
interventions based on the findings, and
evaluating patient care outcome
• includes both a health history and physical
assessment.
8. NURSING PROCESS
• a systematic problem-solving approach
• Serves as a framework
• Focuses on solving problems and enhancing strengths
• Applicable to patients in all stages of the lifespan and in all
settings.
• Central to all nursing care
• Encompasses all steps taken by the nurse in caring for a
patient
9. Characteristics of the Nursing Process
• Within the legal scope of nursing
• Based on knowledge-requiring critical thinking
• Planned-organized and systematic
• Client-centered
• Goal-directed
• Prioritized
• Dynamic
10. Benefits of the Nursing Process
• Provides an orderly & systematic method for planning &
providing care
• Enhances nursing efficiency by standardizing nursing
practice
• Facilitates documentation of care
• Provides unity of language for the nursing profession
• Is economical
• Stresses the independent function of nurses
• Increases care quality through the use of deliberate
actions
11. Responsibilities as a Nurse?
• Recognize health problems.
• Anticipate complications.
• Initiate actions to ensure appropriate and timely
treatment.
• Begin to think CRITICALLY!
12.
13.
14. Nursing Assessment
The first phase of the nursing process, called assessment,
is the collection of data for nursing purposes.
Information is collected using the skills of observation,
interviewing, physical examination, and intuition and
from many sources, including clients, their family
members or significant others, health records, and other
health team members.
15. Assessment
using the nurse's five senses
critical thinking skills
good clinical judgment as to what seems to be the
priority problem
taken thru observation, interview, physical
examination
16. Nursing Diagnosis
The second step in the nursing process involves further
analysis (breaking the whole down into parts that can be
examined) and synthesis (putting data together in a new
way) of the data that have been collected.
17. Nursing Diagnosis
Sort, cluster, and analyze information
Identify potential problems and strengths
Write a statement of problem or strength
Example of a nursing diagnosis:
Risk of infection related to compromised nutrition
18. Purposes of Nursing Diagnosis:
Nursing diagnosis is unique in that it focuses on a
client’s response to a health problem, rather than
on the problem itself, and it provides the
structure through which nursing care can be
delivered.
Nursing diagnosis also provides a means for
effective communication.
19. According to the North American Nursing
Diagnosis Association (NANDA) a nursing diagnosis
is a clinical judgment about individual, family, or
community responses to actual or potential
health problems/life processes.
Nursing diagnoses provide the basis for the
selection of nursing interventions to achieve
outcomes for which the nurse is accountable.
20. NANDA International (NANDA-I)
earlier known as the North American Nursing
Diagnosis Association (NANDA) is the principal
organization for defining, distributing, and
integration of standardized nursing diagnoses
worldwide.
21. Components of a Nursing Diagnosis
A nursing diagnosis has typically three components:
(1) the problem and its definition,
(2) the etiology, and
(3) the defining characteristics.
22. Physical nursing diagnoses include those that pertain to
physical processes, such as circulation (ineffective renal
Tissue Perfusion), ventilation (impaired Gas Exchange),
and elimination (Constipation).
Psychosocial nursing diagnoses include those that
pertain to the mind (acute Confusion), emotions (Fear),
or lifestyle and relationships (ineffective Role
Performance).
Types of Diagnosis
23. Differentiating Nursing Diagnosis vs
Medical Diagnosis
Nursing Diagnosis Medical Diagnosis
focus on unhealthy
responses to health and
illness.
identify diseases
describe problems treated by
nurses within the scope of
independent nursing practice.
describe problems for which
the physician directs the
primary treatment .
may change from day to day
as the patient’s responses
change
remains the same for as long
as the disease is present
24.
25. Planning
The process of prioritizing nursing diagnoses and
collaborative problems, identifying measurable goals or
outcomes, selecting appropriate interventions, and
documenting the plan of care.
The nurse consults with the client while developing and
revising the plan.
29. Functional Health Patterns
1.Health Perception – Health Management Pattern
⮚ describes the client’s perceived pattern of health and well-
being and how health is managed.
2. Nutritional – Metabolic Pattern
⮚ describes the pattern of food and fluid consumption
relative to metabolic needs and pattern indicators of local
nutrient supply.
30. 3. Elimination Pattern
⮚ describes the pattern of excretory function (bowel,
bladder)
4. Activity – Exercise Pattern
⮚ describes the pattern of exercise, activity, leisure, and
recreation.
5. Cognitive–Perceptual Pattern
⮚ describes the sensory, perceptual, and cognitive pattern
31. 6. Sleep – Rest Pattern
⮚ describes patterns of sleep, rest, and relaxation.
7. Self-perception – Self-concept Pattern
⮚ describes self-concept and perceptions of self (body
comfort, image, feeling state)
8. Role – Relationship Pattern
⮚ describes a pattern of role engagements and
relationships.
32. 9. Sexuality – Reproductive Pattern
⮚ describes client’s pattern of satisfaction and
dissatisfaction with sexuality pattern, describes
reproductive patterns.
10. Coping – Stress Tolerance Pattern
⮚describes general coping patterns and the effectiveness
of the pattern in terms of stress tolerance.
11. Value – Belief Pattern
⮚describes the pattern of values and beliefs, including
spiritual and /or goals that guide choices or decisions.
33. GOAL:
A general statement of purpose.
end towards which all efforts are directed.
OBJECTIVES:
more specific statements.
step-by-step family responses toward the attainment
of the goal
34. Nursing Interventions
✔ Road maps directing the best ways to provide nursing
care.
✔ Evidence-based nursing.
1. Monitor health status.
2. Minimize risks.
3. Resolve or control a problem.
4. Assist with ADLs.
5. Promote optimum health and independence.
✔ must be based on the perceived diagnosis and objectives
✔ must be RATIONAL enough; realistic
35. Types of Interventions:
Direct interventions:
- actions performed through interaction with clients.
Indirect interventions:
- actions performed away from the client, on behalf of a
client or group of clients.
Independent
Dependent
Collaborative/interdependent
36. Evaluation
1. Determining outcome achievement (met or unmet)
2. Identifying the variables affecting outcome achievement
3. Deciding whether to continue, modify or terminate the
plan
– must be in the present or past tense
– nursing interventions can be modified at this stage.
37. Determining Outcome Achievement
Must be aware of outcomes set for the client.
Must be sure the patient is ready for evaluation.
Is the patient able to meet outcome criteria?
Is it:
Completely met?
Partially met?
Not met at all?
Record in progress in notes.
Update care plan.
38. Documenting the Plan of Care
To ensure continuity of care, the plan must be
written and shared with all healthcare personnel
caring for the client.
Consists of:
1. Prioritized nursing diagnostic statements.
2. Outcomes.
3. Interventions.
39. Documentation
Clear and concise
Appropriate terminology
Physical assessment
- Usually by Review of Systems
Overview of symptoms
Diet
Each body system
40. Documentation
✔ Use patient’s own words in subjective data –
enclose in “ ___” (quotation marks)
✔ Avoid generalizations – be specific
41. Types of Nursing Assessment
1. Initial Comprehensive assessment
2. On-going assessment
3. Focused or problem-oriented assessment
4. Emergency assessment
42. 1. Initial Comprehensive Assessment
✔ involves the collection of subjective data about the
client’s perception of her health of all body parts or
systems, past health history, family history, and lifestyle
and health practices as well as objective data gathered
during a step-by-step physical examination.
✔ The nurse typically collects subjective data, especially
those related to the client’s overall function.
43. 2. Ongoing or Partial Assessment
✔ consists of data collection that occurs after the
comprehensive database is established.
✔ a mini-overview of the client’s body systems and holistic
health patterns as a follow-up on his health
✔ Problems that were initially detected in the are reassessed
✔ Usually performed whenever the nurse or another health
care professional has an encounter with the client.
44. 3. Focused or Problem-Oriented Assessment
✔ it does not take the place of the comprehensive health
assessment.
✔ Performed when a comprehensive database exists for a
client who comes to the health care agency with a specific
health concern.
✔ Consists of a thorough assessment of a particular client
problem and does not cover areas not related to the
problem.
45. 4. Emergency Assessment
✔ A very rapid assessment performed in life-threatening
situations.
✔ Example: the evaluation of the client’s airway, breathing,
and circulation (known as the ABCs) when cardiac arrest is
suspected.
✔ The major and only concern during this type of assessment
is to determine the status of the client’s life-sustaining
physical functions.
46. - To establish baseline information on the client
- To determine the client’s normal function
- To determine the client’s risk for dysfunction
- To determine the client’s strengths
- To provide data for the diagnosis phase
Reasons for doing assessment:
48. Essential Parts of Communication
⮚ Sender
⮚ Message
⮚ Receiver
⮚ Feedback
49. Importance of Good Communication
1. Enhances good rapport.
2. Builds a trusting relationship with the patient and
client.
3. Aids in obtaining accurate data necessary for
formulating a good plan of care.
4. Helps ensure that the message you want to send is
the one your patient actually receives.
53. 1. Appearance
✔ Ensure that your appearance is professional.
✔ Wear comfortable clothes.
✔ Make yourself presentable.
✔ Keep yourself clean.
54. 2. Demeanor
✔ Demeanor should also be professional.
✔ Display poise.
✔ Make yourself known.
✔ Don't be snobbish but don't be overly friendly or
touchy.
55. 3. Facial Expression
✔ Often shows what you are truly thinking.
✔ Keep a close check on your facial expression.
✔ Keep your expression neutral and friendly.
56. 4. Attitude
✔ One of the most important nonverbal skills
- nonjudgmental attitude.
✔ Keep in mind that ALL clients should be accepted,
regardless of beliefs, ethnicity, lifestyle, and health care
practices.
✔ Do not act superior to the client or appear shocked,
disgusted, or surprised at what you are told.
57. 5. Silence
✔ Periods of silence allow you and the client to reflect and
organize thoughts, which facilitates more accurate
reporting and data collection.
58. 6. Listening
✔ Most important skill
✔ Becoming an effective listener takes concentration and
practice.
✔ How?
- Maintain good eye contact
- Smile or display an open, appropriate facial expression
- Maintain an open body position (open arms and hands and
lean forward).
✔ Avoid preconceived ideas or biases; keep an open mind.
60. Verbal Communication Techniques:
1. Open-ended questions
2. Close-ended questions
3. Laundry list
4. Rephrasing
5. Well-placed phrases
6. Inferring information
7. Providing Information
61. 1. Open-ended questions
✔ elicit the client’s feelings and perceptions.
✔ Begin with the words “how” or “what.”
✔ Requires more than a one-word response from the client.
Thus, helps reveal significant data about the client’s
health status.
Example:
“How have you been feeling lately?”
62. 2. Closed-ended questions
✔ obtain facts focusing on specific information.
✔ typically begin with the words “when” or “did.”
✔ Clarifies information disclosed in response to open-ended
questions.
Example:
In response to the open-ended question “How have you been
feeling lately?” the client says, “Well, I’ve been feeling really
sick in my stomach and I don’t feel like eating because of it.”
You may be able to follow up and learn more about the
client’s symptoms with a closed-ended question such as
“When did the nausea start?”
63. 3. Laundry List
✔ Providing the client with a choice of words to choose
from in describing symptoms, conditions, or feelings.
✔ Helps you obtain specific answers and reduces the
likelihood of the client’s perceiving or providing an
expected answer.
Example:
“Is the pain severe, dull, sharp, mild, cutting, or piercing?”
“Does the pain occur once every year, day, month, or
hour?”
* Repeat choices as necessary.
64. 4. Rephrasing
✔ Helps you to clarify information the client has stated; it
also enables you and the client to reflect on what was
said.
Example:
Mr. G., tells you that he has been really tired and nauseated
for 2 months and that he is scared because he fears that he
has some horrible disease.
You might rephrase the information by saying, “You are
thinking that you have a serious illness?”
65. 5. Well-placed phrases
✔ Encourages client verbalization.
✔ If the client is in the middle of explaining a symptom or
feeling and believes that you are not paying attention,
you may fail to get all the necessary information.
✔ Listen closely to the client during his or her description
and use phrases such as “um-hum,” “yes,” or “I agree” to
encourage the client to continue.
66. 6. Inferring information
✔ Inferring information from what the client tells you and
what you observe in the client’s behavior may elicit more
data or verify existing data.
Example:
Your client, Mrs. J., tells you that she has bad pain. You ask
where the pain is, and she says, “My stomach.” You notice
the client has a hand on the right side of her lower abdomen
and seems to favor her entire right side.
You say, “It seems you have more difficulty with the right
side of your stomach” (use the word “stomach” because that
is the term the client used to describe the abdomen).
67. 7. Providing Information
✔ Another important thing to consider.
✔ Make sure you answer every question as well as you can.
If you do not know the answer, explain that you will find
out for the client.
✔ The more clients know about their own health, the
more likely they are to become equal participants in
caring for their health.
69. Therapeutic Communication
a process in which the healthcare professional consciously
uses specific techniques to help patients better understand
their condition or situation. At the same time, they also
encourage patients to freely express their ideas and
feelings in a relationship of mutual respect and acceptance
71. Phases of Interview
1. Pre-introductory phase
2. Introductory phase
3. Working phase
4. Summary / Closing phase
72. Phases of Interview
1. Pre-introductory phase - reviewing the medical record
2. Introductory phase - introduction of self, explain the
purpose, discuss types of questions, explain the need of
taking notes, ensure confidentiality
3. Working phase - eliciting client's comments on
biographic data, past health history, etc.
4. Summary / Closing phase - summarizing and validating
data; identifying and discussing a plan of care; asking
patient about any concern
73. Communication During the Interview
Verbal - its goal is to elicit as much information about the
client's health status as possible.
Non-verbal - your appearance, demeanor, posture, facial
expressions, and attitude.
74. COMPONENTS OF A NURSING HEALTH HISTORY
⮚ Biographic data
⮚ Reason for seeking health care/ chief complaint.
⮚ History of present Illness
⮚ Past health history
⮚ Family history
⮚ Review of systems
⮚ Lifestyle
⮚ Socio-cultural History
⮚ Psychological History
⮚ Occupational and environmental History
75. Biographic data
Personal data including name, address, age and date
of birth, gender, religion, race / ethnic origin, bed
number, ward, medical diagnosis, surgery (if
performed), occupation, education, and type of
health plan/insurance.
76. Reason for seeking health care / chief
complaint.
• It should be written in the client’s statement.
• In case of multiple problems, ask the client to
indicate the priority of the complaint.
• Avoid using medical terminology.
• Write problems in chronological order.
77. History of Present Illness
Expansion of Chief of Complaints
Chronological order
Location, quality, quantity, chronology, setting,
exaggerating and relieving factors, associated symptoms,
effect on sleep, and daily activities.
78. Past Health History
• Allergies
• Medical diseases such as Hypertension, Diabetes, TB,
Anemia, Seizures, Arthritis, Heart Disease, Glaucoma etc.
• Trauma, Injury: Fracture, abdominal trauma, burns,
blunt/penetrating injury, altered consciousness level.
• Hospitalization
• Childhood disease and immunization
• Obstetric History
• Drug history
79. FAMILY HISTORY- Family Health History
The family history should include causes and age of death
of parents, details about the health of siblings and
children, and information about heart diseases,
hypertension, diabetes, asthma, allergies & ethnic origin.
80. Review of Systems (ROS)
A brief account from the client of any recent signs or
symptoms associated with any of the body systems.
81. Respiratory History
• Presenting Problem / Complaint: Cough, Sputum,
Hemoptysis, Wheeze, Chest Pain, Shortness of breath,
Systematic symptoms,
• Drug History: Allergies, inhalers, nebulizer, home
oxygen
• Social History: Smoking history measured in pack-
years Contact with animals/pets Presence of stairs in
or leading into flat/house Hobbies.
• Family History: e.g. asthma/hay fever
82. Cardiovascular History
• 4 main cardiovascular symptoms: Chest pain, Shortness
of breath, Presence, and extent of edema, Palpitations
• Main risk factors for Ischemic Heart Disease:
Smoking, Hypertension, Diabetes mellitus,
Hyperlipidemia, Family history
• Past Medical History: e.g. angina, myocardial
infarction, bypass operation, rheumatic fever, stroke
• Social History: Smoking, alcohol, etc.
• Family History
• Drug History: Allergies
83. LOCOMOTOR HISTORY
• Evolution of condition - Acute or chronic,
Associated events and Response to treatment
• Current symptoms - Pain, Stiffness, Swelling,
Pattern of joint involvement
• Involvement of other symptoms – Skin, lung,
eye, or kidney symptoms, malaise, weight
loss, fevers, or night sweats
• Impact of lifestyle - Patient’s needs/ aspirations, Ability
to adapt to functional loss
• Pain History: PQRST
• Use of medication for pain relief
84. Personal Data / Life Style
• Habit
• Diet
• Elimination pattern
• Sleep and rest pattern
• Activity and exercise pattern
85. Obstetric History
• Menstrual Pattern – regular/irregular
• History of pregnancy, labor, puerperium, and
complications if any
87. Psychosocial History
• Psychosocial history refers to an assessment of dimensions
such as self-concept and self-esteem as well as usual
sources of stress and the client’s ability to cope.
• Sources of support for clients in crisis, such as family,
significant others, religion, or support groups, should be
explored
88. Occupational and Environmental History
• It includes collecting data regarding the client’s
occupation, lifestyle in the job, working environment, etc.
• Collecting information includes designation, location of
work, exposure to hazardous material, residing near mines,
farms, factories, or shipyards, congestion, and
overcrowding, which may spread communicable diseases.