o Emancipated

o Emergency
1. ETHICO LEGAL CONSIDERATION BATTERY
- is any harmful or offensive touching of another without
*informed consent his or her consent or without a legally justifiable
1. PATIENT BILL OF RIGHTS reason, permission or in the absence of an emergency
2. DATA PRIVACY situation (Aiken, 2009)
RELEVANT ETHICO-LEGAL GUIDELINES IN INFORMED CONSENT
CONDUCTING HEALTH ASSESSMENT
 VOLUNTARY – without coercion or force informed
 BIOETHICS – ethics that deal with patients and  Competent, has the capacity
health care  Knowledgeable information provided
 ETHICS – declaration if what is right or wrong and of  Signed prior to pre-op med
what is ought to be
WHAT NURSES SHOULD INFORM CLIENTS ABOUT?
1. ETHICO-LEGAL CONSIDERATIONS
 PRINCIPLE OF AUTONOMY  Current medical status and general course of illness
 freedom to choose  Risks and benefits of proposed treatment
 Alternatives to proposed treatment
 PRINCIPLE OF BENEFICIENCE
 Proposed treatment rationale
 do only what’s GOOD
2. PATIENTS’ BILL OF RIGHTS
 PRINCIPLE OF MALEFICENCE 2.1 PATIENTS’ RESPOSIBILITIES
 tell them the truth
 PRINCIPLE OF CONFEDENTIALITY THE PATIENT HAS THE RIGHT TO:
 keep private
 PRINCIPLE OF JUSTICE 1. Considerate and respectful care
 be fair 2. Obtain from his physician complete current information
 PRINCIPLE OF FIDELITY concerning his diagnosis, treatment and prognosis in
 keep your word terms the patient can be reasonably expected to
understand. If not medically advisable to withhold such
 PRINCIPLE OF AUTONOMY
information to the patient, it should be made available to
- the freedom to make choices about the issues that an appropriate person in his behalf.
affect one’s life. 3. Receive from his physician information necessary to
o It is the right to choose what will happen to one’s own give informed consent prior to the start of a procedure
person and/or treatment.
o It is the right to determine personal care given and by 4. Refuse treatment to the extent permitted by law and to
whom be informed of the medical consequences of his action.
o Nurses should support client’s independence to make 5. Every consideration of his privacy concerning his own
decisions and take actions themselves medical care, program, case, discussion, consultation,
 PRINCIPLE OF BENEFICIENCE examinations, and treatment are confidential and
- do only what’s good should be conducted discreetly.
o is the principle that requires nurses to act in ways that 6. Expect that all communications and records pertaining
to his care are treated confidential.
benefit clients
7. Expect that, within the hospital’s capacity, it has to
THERE ARE 3 COMPONENTS OF THE PRINCIPLE OF make reasonable response to the requests of a patient
BENEFICIENCE NAMELY: for services.
1. One ought to do or promote good 8. Obtain information as to any relationship of the hospital
2. One must prevent evil or harm in all instances and to other health care facilities and educational institutions
always advocate for what is in the client’s best interest in o far as in care is concerned.
3. The nurse must not only prevent but also must remove 9. Be advised if the hospital proposes to engage in or
evil or harm. Nurses have the responsibility to help perform human experimentation affecting his care or
others by doing what is best for them. treatment. He has the right to refuse to participate in
INFORMED CONSENT such research projects.
- The process of providing adequate information for a 10. He has the right to expect reasonable continuity of care.
patient in an understandable fashion o enable the 11. Examine and receive explanation of his bill regardless
of source payment.
patient to make a knowledgeable, informed decision
12. Know what hospital rules and regulations apply to his
about whether to accept or refuse a proposed
conduct as a patient.
treatment.
DISCOLUSRE REQUIREMENTS INCLUDE:
1. Type of procedure to be perfumed PATIENTS’ RESPONSIBILITIES
2. Nature and Purpose or proposed treatment
3. Material risks and consequences 1. A patient has the responsibility to provide to the best of
4. Alternatives his knowledge-accurate and complete information about
5. Consequences of no treatment his complaints, past illness, hospitalization,
INFORMATION medications, and other matters relating to his health.
2. A patient is responsible for complying with the treatment
 PRESENTATION - disclosure to the person must be in
plan recommended by the physician or health team.
understandable works and manner 3. A patient must inform the physician of refusal to
 UNDERSTANDING – the person must comprehend treatment.
the information 4. A patient is responsible for ensuring that financial
CONSENT obligations of his care are fulfilled as promptly as
 COMPETENCE – this is the ability of the person to possible
receive the information, remember, understand and 5. The patient is responsible for following the hospital’s
assess it rules and regulations and shall advise his family to do
 FREEDOM AND VOLUTARITIES – this is the so.
independence of the person to make a free choice 6. The patient must be considerate of the rights of other
SUMMARY patients and hospital personnel.
o FREE (Competent) 7. The patient must respect the property of other persons
and that of the hospital.
o INFORMED ( Full Disclosure)
o Right to Refuse
o Nurses as Witness
o GUARDIANSHIP 3. DATA PRIVACY
o Psychiatric Patients – consent taken from legal Republic Act 10173 is also knows as Data Privacy
guardian Act of 2012. “It is the policy of the State to PROTECT
 THE FUNDAMENTAL HUMAN RIGHT OF PRIVACY,
of communication while ensuring free flow of
information to promote innovation and growth.”
Scope and Limitations of the Data Privacy Act of 2012
Data privacy principles General Principles:
 The law applies to all who process data of Filipino
current health records licenses or its denials,
suspension or revocation, and tax returns.
4 Information specifically established by an executive
order or an act of Congress to be kept classified
PRIVILEGED INFORMATION

- Any and all forms of data which under the rules of court
UNAUTHORIZED ACCESSING PERSONAL and other pertinent laws constitute privileged
PROCESSING OF INFORMATON AND communication
INFORMATION and SESITIVE SENSITIVE PERSONAL  “PRIVILEGED COMMUNICATION is interaction
PERSONAL INFORMATION: INFORMATION DUE TO between two parties which the law recognizes as
NEGLIGENCE: PRIVATE, PROTECTED relationship. Whatever
is communicated between these parties shall
1-3 YEARS in PERSON 1-3 YEARS in PRISON remain CONFIDENTIAL and the law CANNOT
PHP 500,000 > FINE > PHP PHP 500,000 > FINE > PHP FORCE DISCLOSURE of these communications.
2,000,000 and sensitive 2,000,000
personal info: and sensitive personal info: Ex. A client confessing medical conditions to a doctor, etc.
3-6 YEARS in PRISON 3-6 YEARS in PRISON
PHP 500,000 > FINE > PHP PHP 500,000 > FINE > PHP SCOPE: IS MY INFORMATION COVERED?
4,000,000 4,000,000
 “This Act applies to the processing of ALL TYPES
OF INFORMATION and to any natural and
judicial person involved in personal information
processing INCLUDING those personal
citizens or those who process data of the Philippines. information controllers and processors who,
although not found on established in the
 Processing personal data is not a right.
Philippines, or those who maintain an office,
 Non-applicability is proven by the party asserting the
branch or agency in the Philippines subject to the
UNAUTHORIZED ACCESS CONCEALMELMENT OF immediately succeeding paragraph; Provided,
on INTENTIONAL SECURITY BREACHES that the requirements of section 5 (Protection
BREACH: INVOLVING SENSITIVE Afforded to Journalists and Their Sources) are
PERSONAL INFORMATION: complied with.”
1-3 YEARS in PRISON
PHP 500,000 > FINE > PHP 1 YEAR AND 6 MONTHS –
2,000,000 5 YEARS IN PRISON
PHP 500,000 > FINE > PHP
1,000,000

MALICIOUS DISCLOSURE: UNAUTHORIZED

DISCLOSURE:
1 YEAR AND 6 MONTHS - 5
YEARS IN PRISON 1-3 YEARS in PRISON
PHP 500,000 > FINE > PHP PHP 500,000 > FINE > PHP
1,000,000 1,000,000

If information Controller/
Processor
3-6 YEARS in PRISON
PHP 500,000 >
FINE > PHP 2,000,000 SCOPE: IS MY INFORMATION COVERED?
exemption.
 In case of doubt, the law is interpreted in favor of the PENALTIES
data subject.

COMBINATION or SERIES OF ACTS:

3-6 YEARS in PRISON AND PHP 1,000,000 > FINE > PHP
5,000,000
PERSONAL INFORMATION

- Any information whether recorded in a material form or

not, from which the identity of an individual is apparent
or can be reasonably and directly ascertained by the
entity holding the information, or when put together
with other information would directly and certainly
identify an individual.
KEYWORDS to REMEMBER
SENSITIVE PERSONAL INFORMATION
 CONSENT, COMPLIANCE and GOOD FAITH
PERSONAL INFORMATION THAT IS ABOUT AN Keeping these three keywords in mind can help you to
INDIVIDUAL’S: NOT violate the Data Privacy Act!

1 Pace, ethnic origin, mental status, age, color, and CONSENT

religious, philosophical or political affiliations.
2 Health, education, genetic or sexual life of a
person, or to any proceeding for any offense
committed or alleged to have been committed by
such person, the disposal of such proceedings, or
the sentence of any court in such proceedings.
3 Information issued by government agencies
peculiar to an individual which includes, but not
limited to, social security numbers, previous or
- Consent of the data subject refers to any freely given,
specific, informed indication of will, whereby the data
subject agrees to the collection and processing of
personal information about and/or relating to him or
her.
- Consent, shall be evidenced by written, electronic or
recorded means.
- It may also be given on behalf of the data subject by an
agent specifically authorized by the data subject to do
so.
WHAT IS LAWFUL PROCESSING OF PERSONAL
INFORMATION?
1. The data subject has given his or her CONSENT.
2. The processing of personal information is necessary
and is related to the FULFILLMENT OF A CONTRACT
with the data subject or in order to take steps at the
request of the data subject prior to entering into a
contract.
3. The processing is necessary for COMPLIANCE WITH
LEGAL OBLIGATION to which the personal information
controller is subject.
4. The processing is necessary to PROTECT VITALLY
IMPORTANT INTERESTS OF THE DATA SUBJECT,
including life and health;
5. The processing is necessary in order to RESPOND TO
NATIONAL EMERGENCY, to comply with the
requirements of public order and safety or to fulfill
functions of public authority which necessarily includes
the processing of personal data fir the fulfillment of its
mandate; or
6. The processing is necessary FOR THE PURPOSS OF
THE LEGITIMATE INTERESTS PURSUED BY THE
PERSONAL INFORMATION CONTROLLER or by a
third party or parties to whom the data is disclosed,
EXCEPT where such interests are overridden by
fundamental rights and freedoms of the data subject
which require protection under the Philippine
Constitution.
BREACH OF CONFIDENTIALITY
- Occurs when someone who has legitimate access to
health information about a patient shares it without the
patient’s consent with others who have no legitimate
reason to know.
HEALTH CARE TEAM IN HEALTH ASSESSMENT
 Health Team
 a group of persons who share a common
objectives determined by community needs and
toward the achievement of which each member of
the team contributes in accordance with her/his
competence and skills, and respecting the
functions of the other.”
 Physician
 Responsible for the medical diagnosis
 Determines the therapy required by a person who
is ill or injured.
 Nurse
 Evaluates personal health and home environment
 Provides education and resources to help control
negative symptoms
 Coordinates care
 Communicates progress with caregivers and
doctors
 Provides skilled nursing services
 Responsible for delegation of duties to members
of her team and care given to the patients. (Head
nurse)
 Physical Therapist
 Provides individual exercise plan
 Helps improve strength, mobility and balance
 encourage safety and independence
 Recommends assistive devices and medical
equipment
 Assesses risk of falling
 Occupational Therapist
 Evaluates personals function level and home
environment
 Assist patient with some impairment of function to
gain skills as related to ADL
 Recommends solutions and techniques to
increase independence
 Provides personalized exercise plan
 helps improve strength, balance and overall safety
 Identifies new ways to do activities of daily living
 Speech Therapist
 Evaluates speech limitations and disorders
 Maximize functional independence in
communicating and swallowing
 Reduces the risk of aspiration and choking
 Improves memory and thinking
 Medical Social Worker
 Assess needs and identifies limitations, barriers
and/or safety concerns
 Provides education and counseling to patients and
families
 Connects patients and families to necessary
resources and support in the community
 Provides assistance to the family and patient
 LABORATORY TECHNICIAN: examines & study
specimens (urine, feces, blood & wound discharge)
 RADIOLOGIC TECHNOLOGIST: assists with X-Ray
procedures
 PHARMACISTS: Dispense medications prescribed by
physicians, physician assistants, nurse practitioners,
and dentists.
 DIETICIAN: Design special diets and they supervise the
preparation of meals according to doctor's prescription.
LEVELS OF PREVENTIVE HEALTHCARE
 Primary preventive care - focuses on health promotion
and guards against health problems.
- focus is not only wellness but also to minimize the risk
of health problems.
- Ex: health fairs, immunizations, nutritional instructions.
 Secondary preventive care - focuses on early detection,
prompt intervention, and health maintenance for
patients with health problems.
- addresses acute health problems seen with
inpatient hospitalization.
 Tertiary preventive care deals with rehabilitative or
extended care.
- Ex: Skilled nursing care facilities, rehabilitative
hospitals, long-term care facilities, home care,
and hospice
Skills of Assessment
COGNITIVE SKILLS
o Assessment is a “thinking” process. Cognitive skills are
needed for critical thinking, creative thinking, and
clinical decision making.
Your theoretical knowledge base enables you to assess
your patient holistically.
 Critical Thinking
 is reflective reasonable thinking
 it is not just doing, it is asking “why?”.
 involves inquiry, interpretation, analysis, and
synthesis
 It is the art of thinking about thinking that enables
you to think better (Paul, 1990)
Critical Thinking Skills
 Divergent Thinking - involves analyzing various
viewpoints, differentiating relevant/ irrelevant data,
and making inferences (conclusions)
 Reflection - allows you to step back and think,
considering “if… then” possibilities.
 Creativity - allows you to “think outside of the box.”
 Clarification - involves addressing assumptions,
comparing and contrasting.
 Basic support - is based on sound, credible, known
facts. Evidence-based practice that is research
based leads to best practice.
 Reasoning - is the ability to differentiate fact (truth)
from assumptions (beliefs)
Ex: suppose your patient is admitted to the hospital with the
diagnosis of Congestive Heart Failure (CHF). Knowing this
enables you to look for specific signs and symptoms as you
perform the assessment and determine your patient’s
response to illness. In this case, you will use deductive
reasoning, looking for specific clues that support the
diagnosis of decrease cardiac output.
o Inductive reasoning would be appropriate when
assessing a post-operative patient who states, “It hurts
too much to take deep breaths,” and who has
decreased breath sounds and crackles at the bases,
pulse oximetry of 90% on room air, Temperature of 101
F, pulse of 106 BPM, and respirations 26 and shallow.
When you piece together all of the pertinent
assessment data, you formulate diagnoses of Impaired
Gas Exchange and Ineffective Airway Clearance.

Essentials of Critical Thinking
 Intellectual Humility
 Know what you don’t know.
 Know your limits
 Be aware of your biases and prejudices
 Intellectual Courage
 Be open and listen to other points of view.
 Intellectual Empathy
 Put yourself in another’s shoes, so that you can
understand his or her perspective.
 Intellectual Integrity
 Maintain high standards
 Hold yourself to the same standards as you do to
others.
 Intellectual Perseverance
 Persist to find the answer or reach understanding
 Faith in Reason
 Look out for the best interest for all involved.
 Consider the consequences.
 Intellectual Sense of Justice
 Be open to all viewpoints, with the sense of
impartiality and fairness.
 Clinical Decision Making
 Assessment also requires clinical decision making.
 As you collect data, you will make clinical
decisions as to its relevance.
 With experience, you will be able to identify
patterns and recognize what differs from the norm
and then use the data to make decisions that will
best meet your patient’s need.
 PROBLEM SOLVING SKILLS
 With experience, you will develop your problem
solving skills.
 Reflexive thinking is automatic, without conscious
deliberation, and comes with experience.
 Trial-and-error approach is hit-or-miss thinking-
random, not systematic and inefficient.
- Use it for situations that don’t quite fit the
picture, look beyond the obvious, and keep
looking until you find an answer.
 Scientific method is a systematic, critical thinking
approach to problem solving. It involves identifying a
problem and collecting supporting data, formulating a
hypothesis, planning a solution, implementing a plan
and then evaluating its effectiveness.
 Intuition is a problem solving method that develops
through experience, in which the theory and practice
are intertwined.
- Expert nurse - Through experience, she has a
well-established experiential base of pattern
recognition, an intuitive grasp the situation, and
the ability to zero in on problem areas.
PSYCHOMOTOR SKILLS
o Assessment is “doing.”
Psychomotor skills are needed to perform the four
techniques of physical assessment: inspection,
palpation, percussion, and auscultation.
o As a beginning practitioner, you may feel unsure of your
technique and your findings, but practice will hone your
skills.
AFFECTIVE/ INTERPERSONAL SKILLS
o “feeling” process
o Affective skills are needed to practice the “art” of
nursing.
 The quality of your assessment depends on your
communication skills and the relationship that you
develop with your patient.
 Establishing trust and mutual respect is essential
before you begin the assessment.
 Seeing your patient as individual and being
sensitive to his or her feelings conveys a message
of caring and promotes human dignity.
 Needed to communicate with family members and
members of the healthcare team.
ETHICAL SKILLS
Part of assessment is being responsible and
accountable.
 You are responsible and accountable for your
practice.
 You are also an advocate of your patient.
 The data collected through assessment are used to
plan the patient’s car, but it is important to remember
that the data are the patient’s information.
The Code for Nurses
 The nurse, in all professional relationships, practices
with compassion and respect for the inherent dignity,
worth, and uniqueness of every individual, unrestricted
by considerations of social or economic status, personal
attributes, or the nature of health problems.
 The nurse’s primary commitment is to the patient,
whether an individual, family, group, or community.
 The nurse promotes, advocates for, and strives to
protect the health, safety, and rights of the patient.
 The nurse is responsible and accountable for individual
nursing practice and determines the appropriate
delegation of tasks consistent with the nurse’s
obligation to provide optimum patient care.
 The nurse owes the same duties to self as to others,
including the responsibility to preserve integrity and
safety, to maintain competence, and to continue
personal and professional growth.
 The nurse participates in establishing, maintaining, and
improving healthcare environments and conditions of
employment conducive to the provision of quality health
care and consistent with the values of the profession
through individual and collective action.
 The nurse participates in the advancement of the
profession through contributions to practice, education,
administration, and knowledge development.
 The nurse collaborates with other health professionals
and the public in promoting community, national, and
international efforts to meet health needs.
 The profession of nursing, as represented by
associations and their members, is responsible for
articulating nursing values, for maintain the integrity of
the profession and its practice, and for shaping social
policy.
Core Values of Nursing in Conducting Health
Assessment
1. Apply knowledge of physical, social, natural and health
sciences and humanities in the practice of nursing by
using multidisciplinary approaches.
2. Perform safe, appropriate, humanistic and holistic care
to individuals, families, population groups, and
community utilizing nursing process while taking
personal responsibility and accountability.
3. Utilize guidelines and principles of evidence-based
practice in the delivery of care by differentiating relevant
from irrelevant information in various contexts.
4. Practice nursing in accordance with existing laws, legal,
ethical, moral and Christian (principles perspective and
gospel) values.
5. Communicate effectively and confidently in various
settings.
6. Report and document client care accurately and
comprehensively by using technology responsibly.
7. Collaborate effectively with inter, intra, and
multidisciplinary and multicultural teams by channeling
issues and concerns to the proper body/individual.
8. Practice beginning management and leadership skills
by using systems approach and analyzing situations in
the delivery of client care.
9. Conduct nursing and health-related studies as a
member of the research team by taking concrete action
on societal and global concerns.
10. Engage in lifelong learning with a passion to keep
current with national and global developments in
general and nursing and health developments in
 particular, by nurturing one's faith and in communion
with others.
11. Demonstrate responsible citizenship and pride in being
a Filipino Lasallian nurse including but not limited to the
care, protection and preservation of the environment.
12. Design and apply techno-intelligent care systems and
processes in health care delivery through innovative
methods.
13. Adapt the nursing core values in the delivery of nursing
care and become an instrument of God’s work.
14. Apply entrepreneurial skills in the delivery of La Sallian
Nursing care.