Fundamentals of Nursing

MODULE 1: The Practice of Nursing

Lesson 1: The Philippine Nursing Law of 2012 or RA 9173

RA 9173 was enacted in 2002 to provide a comprehensive definition and understanding

of the nursing profession. This is in recognition of the vital role nurses play in the
delivery of quality health services not only in the country, but all over the world.
Professional responsibility as applied to nurses refers to the ethico-moral and legal
obligations permeating the nursing profession.

AN ACT PROVIDING FOR A MORE RESPONSIVE NURSING PROFESSION, REPEALING

FOR THE PURPOSE REPUBLIC ACT NO. 7164, OTHERWISE KNOWN AS "THE
PHILIPPINE NURSING ACT OF 1991" AND FOR OTHER PURPOSES.

Excerpt from Article VI, Section 28, Scope of Nursing Practice:

Scope of Nursing. - A person shall be deemed to be practicing nursing within the

meaning of this Act when he/she singly or in collaboration with another, initiates and
performs nursing services to individuals, families and communities in any health care
setting. It includes, but not limited to, nursing care during conception, labor, delivery, infancy,
childhood, toddler, preschool, school age, adolescence, adulthood, and old age. As
independent practitioners, nurses are primarily responsible for the promotion of health and
prevention of illness. As a member of the health team, nurses shall collaborate with other
health care providers for the curative, preventive, and rehabilitative aspects of care,
restoration of health, alleviation of suffering, and when recovery is not possible, towards a
peaceful death. It shall be the duty of the nurse to:

(a) Provide nursing care through the utilization of the nursing process. Nursing care includes,
but not limited to, traditional and innovative approaches, therapeutic use of self, executing
health care techniques and procedures, essential primary health care, comfort measures,
health teachings, and administration of written prescription for treatment, therapies, oral
topical and parenteral medications, internal examination during labor in the absence of
antenatal bleeding and delivery. In case of suturing of perineal laceration, special training
shall be provided according to protocol established;

(b) establish linkages with community resources and coordination with the health team;

(c) Provide health education to individuals, families and communities;

(d) Teach, guide and supervise students in nursing education programs including the
administration of nursing services in varied settings such as hospitals and clinics; undertake
consultation services; engage in such activities that require the utilization of knowledge and
decision-making skills of a registered nurse; and

(e) Undertake nursing and health human resource development training and research, which
shall include, but not limited to, the development of advance nursing practice;
Provided, that this section shall not apply to nursing students who perform nursing
functions under the direct supervision of a qualified faculty: Provided, further, That in
the practice of nursing in all settings, the nurse is duty-bound to observe the Code of
Ethics for nurses and uphold the standards of safe nursing practice. The nurse is
required to maintain competence by continual learning through continuing professional
education to be provided by the accredited professional organization or any recognized
professional nursing organization: Provided, finally, That the program and activity for the
continuing professional education shall be submitted to and approved by the Board.

Lesson 2: National Nursing Core Competency Standard

The 2012 National Nursing Core Competency Standards (2012 NNCCS) will serve as a
guide for the development of the following:

● Basic Nursing Education Program in the Philippines through the Commission on

Higher Education (CHED).
● Competency-based Test Framework as the basis for the development of course
syllabi and test questions for “entry level” nursing practice in the Philippine Nurse
Licensure Examination.
● Standards of Professional Nursing Practice in various settings in the Philippines.
● National Career Progression Program (NCPP) for nursing practice in the
Philippines.

The 2012 National Nursing Core Competency Standard is compose of the following:

1. BEGINNING NURSE’S ROLE ON CLIENT CARE

Responsibility 1: Practices in accordance with legal principles and the code of ethics in
making personal and professional judgment.

Responsibility 2: Utilizes the nursing process in the interdisciplinary care of clients that
empowers the clients and promotes safe quality care.

Responsibility 3: Maintains complete and up to date recording and reporting system.

Responsibility 4: Establishes collaborative relationships with colleagues and other

members of the team to enhance nursing and other health care services.

Responsibility 5: Promotes professional and personal growth and development.

2. BEGINNING NURSE’S ROLE ON MANAGEMENT AND LEADERSHIP

Responsibility 1: Demonstrates management and leadership skills to provide safe and

quality care.

Responsibility 2: Demonstrates accountability for safe nursing practice.

Responsibility 3: Demonstrates management and leadership skills to deliver health
programs and services effectively to specific client groups in the community settings

Responsibility 4: Manages a community/village based health facility component of a

health program or a nursing service.

Responsibility 5: Demonstrates ability to lead and supervise nursing support staff.

Responsibility 6: Utilizes appropriate mechanisms for networking, linkage building and

referrals.

3. BEGINNING NURSE’S ROLE ON RESEARCH

Responsibility 1: Engages in nursing or health related research with or under the

supervision of an experienced researcher.

Responsibility 2: Evaluates research study/report utilizing guidelines in the conduct of a

written research critique.

Responsibility 3: Applies the research process in improving client care in partnership

with a quality improvement /quality assurance/nursing audit team.

Lesson 3: Patient’s Bill of Rights

The Patient Bill of Rights strives to keep the client well informed, encourages
participation in the treatment choices, and promotes continuous open communication
with the health care team.

The Rights of the Patients

1. Right to Appropriate Medical Care and Humane Treatment. Every person has a right
to health and medical care corresponding to his state of health, without any discrimination
and within the limits of the resources, manpower and competence available for health and
medical care at the relevant time.

2. Right to Informed Consent. The patient has a right to a clear, truthful and substantial
explanation, in a manner and language understandable to the patient, of all proposed
procedures, whether diagnostic, preventive, curative, rehabilitative or therapeutic, wherein
the person who will perform the said procedure shall provide his name and credentials to
the patient.

Provided, That the patient will not be subjected to any procedure without his written
informed consent, except in the following cases:

A. In emergency cases, when the patient is at imminent risk of physical injury,

decline Of death if treatment is withheld or postponed. In such cases, the
physician can perform any diagnostic or treatment procedure as good practice
of medicine dictates without such consent;
 B. when the health of the population is dependent on the adoption of a mass
health program to control epidemic;
C. when the law makes it compulsory for everyone to submit a procedure;
D. When the patient is either a minor, or legally incompetent, in which case. a
third party consent Is required;
E. when disclosure of material information to patient will jeopardize the
success of treatment, in which case, third party disclosure and consent shall
be in order;
F. When the patient waives his right in writing.

Informed consent shall be obtained from a patient concerned if he is of legal age

and of sound mind. In case the patient is incapable of giving consent and a third
party consent is required. The following persons, in the order of priority stated
hereunder, may give consent:

I. spouse;
II. son or daughter of legal age;
III. either parent;
IV. brother or sister of legal age, or
V. guardian

3. Right to Privacy and Confidentiality. The privacy of the patients must be assured at all
stages of his treatment. The patient has the right to be free from unwarranted public
exposure, except in the following cases: a) when his mental or physical condition is in
controversy and the appropriate court, in its discretion, order him to submit to a physical or
mental examination by a physician; b) when the public health and safety so demand; and c)
when the patient waives this right in writing.

Any health care provider or practitioner involved in the treatment of a patient and all
those who have legitimate access to the patient's record is not authorized to divulge any
information to a third party who has no concern with the care and welfare of the
patient without his consent.

Except:
a) when such disclosure will benefit public health and safety;
b) when it is in the interest of justice and upon the order of a competent court; and
c) when the patients waives in writing the confidential nature of such information;
d) when it is needed for continued medical treatment or advancement of medical
science subject to de-identification of the patient and shared medical confidentiality for
those who have access to the information.

4. Right to Information. In the course of his/her treatment and hospital care, the
patient or his/her legal guardian has a right to be informed of the result of the evaluation
of the nature and extent of his/her disease, any other additional or further
contemplated medical treatment on surgical procedure or procedures.
5. The Right to Choose a Health Care Provider and Facility. The patient is free to
choose the health care provider to serve him as well as the facility except when he is
under the care of a service facility or when public health and safety so demands or when
the patient expressly waives this right in writing.

6. Right to Self-Determination. The patient has the right to avail himself/herself of any
recommended diagnostic and treatment procedures.

7. Right to Religious Belief. The patient has the right to refuse medical treatment or
procedures which may be contrary to his religious beliefs, subject to the limitations
described in the preceding subsection: Provided, That such a right shall not be imposed
by parents upon their children who have not reached the legal age in a life threatening
situation as determined by the attending physician or the medical director of the facility.

8. Right to Medical Records. The patient is entitled to a summary of his medical history
and condition. He has the right to view the contents of his medical records, except
psychiatric notes and other incriminatory information obtained about third parties, with
the attending physician explaining contents thereof.

The health care institution shall issue a medical certificate to the patient upon request.
Any other document that the patient may require for insurance claims shall also be made
available to him within forty-five (45) days from request.

9. Right to Leave. The patient has the right to leave hospital or any other health care
institution regardless of his physical condition: Provided. That a) he/she is informed of
the medical consequences of his/her decision b) he/she releases those involved in
his/her care from any obligation relative to the consequences of his decision; c) his/her
decision will not prejudice public health and safety.

10. Right to Refuse Participation in Medical Research. The patient has the right to
be advised if the health care provider plans to involve him in medical research,
including but not limited to human experimentation which may be performed only with
the written informed consent of the patient.

11. Right to Correspondence and to Receive Visitors.The patient has the right to
communicate with relatives and other persons and to receive visitors subject to
reasonable limits prescribed by the rules and regulations of the health care institution.

12. Right to Express Grievances. The patient has the right to express complaints
and grievances about the care and services received without fear of discrimination or
reprisal and to know about the disposition of such complaints. Such a system shall afford
all parties concerned with the opportunity to settle amicably all grievances.

13. Right to be Informed of His Rights and Obligations as a Patient. Every person
has the right to be informed of his rights and obligations as a patient.
 Lesson 4: Data Privacy Law

In 2012, the Philippines passed Republic Act No. 10173 or the Data Privacy Act of
2012 (DPA) “to protect the fundamental human right to privacy of communication while
ensuring free flow of information to promote innovation and growth [and] the [State’s]
inherent obligation to ensure that personal information in information and
communications systems in government and in the private sector are secured and
protected”.

Implications to Nursing Practice:

1. Do not collect unnecessary information during health interviews or data collection.

2. Safeguard the contents and information of the patient’s medical chart.

3. Do not divulge any client information concerning medical treatment to any person
who is involved in his/her medical care.

4. Observe tactfulness and professionalism at all times.

5. When confronted with an ethical equipoise related to data privacy concerns, consult
your immediate supervisor or data privacy officer.

Lesson 5: Code of Ethics for Nurses

The Code of Ethics for Nurses with Interpretive Statements establishes the ethical
standard for the profession and provides a guide for nurses to use in ethical analysis and
decision-making. It is non-negotiable in any setting, neither is it subject to revision or
amendment except by formal process of revision by the Board of Nursing.

A highlight on the creation of the Nurses Code of Ethics was composed by a nursing
instructor Lystra Gretter in 1893. She was the one who wrote the following words that
best describes the code of ethics of nurses in the oath for nurses:

“to abstain from whatever is deleterious and mischievous and will not take or
knowingly administer any harmful drug.”

Lesson 6: Philippine Professional Nursing Roadmap of 2030

In order to keep abreast with the demands of the nursing profession, the PRC- Board of
Nursing formulated the Philippine Professional Nursing Practice Standards (PPNPS).
The primary purpose of the standards is to promote, guide, and direct professional
nursing practice. Specifically, the Standards will be useful to the following:

1. Professional Nurses – to have a better understanding of their professional

obligations; use the same basis for their own continuing competence and
professional development; advocate for enhancing changes in policies and
practice; and define and resolve professional practice issues and concerns.
 2. The Employers – to be able to develop systems that support nurses to meet
prescribed standards of practice focusing on: developing job descriptions;
developing orientation and in-service programs; and creating performance
appraisal tools.
3. To the Nursing Education Leaders – to serve as guide in the development of
standards that shall serve as bases for curriculum development.
4. The Public can be ensured of competent, safe, quality nursing care and ethical
practice.
5. The Board of Nursing – to use the same basis in regulating nursing practice;
using it as framework for Nurse Licensure Examination (NLE).

MODULE 2: Health & Illness, Health Care Delivery System

Lesson 1: Health & Illness

The Filipino concept of kalusugan (health) came from the root word “lusog” which is
defined as “full development, progressiveness”. Progressiveness is qualified as vigorous
development particularly in the physical sense”. A person who is “payat” (thin) has not
attained the full potential of physical development, but he is not consider ill either. A child
who is “mataba” (stout) is considered healthy but an adult who is “mataba” stout) is
considered obese or unhealthy.

The concept of “kalusugan” denotes maturative processes or development in

correspondence to the ability to function properly, to be active. Having attained the
maximal degree of development to one’s stage in life. An obvious manifestation of this
development is the capacity to do one’s tasks. “Malakas” (strong) is a term often
associated with “kalusugan.” “Malakas” means to have a strong body which implies that
one is able to work, to function because the body is fully developed in relation to one’s
need to work.

The World Health Organization (WHO) definition (1947) of health states that “health
is a state of complete mental, physical, social well-being, and not merely the absence of
disease or infirmity”.

Dun (1961) describes health in terms of wellness. He points out that a person has
different levels of wellness. According to this definition one’s state of health is never
constant; it is always changing.
Parsons (1972) defines health as possessing the ability to perform one’s task. Healthy
individuals are actively and continually adapting to their environments.

Rogers (1961) describes health by referring to the “fully functioning person”.

According to Potter (2014), health is the actualization of inherent and acquired human
potential through goal-directed behavior, competent self-care, and satisfying
relationships with others, while adjustments are made as needed to maintain structural
integrity and harmony with the environment.

Pender (1996) explains that “all people free of disease are not equally healthy”. To help
clients identify and reach health goals, the nurse must discover and use information
about their concepts of health.

Wellness - It is a state of well-being.

Anspaugh, Hamrick, and Rosato (2013) proposed seven components of wellness,

people must deal with the factors within each component:

➔ Physical
➔ Social
➔ Emotional
➔ Intellectual
➔ Spiritual
➔ Occupational
➔ Environmental

Well-being is a subjective perception of vitality and feeling well, can be described

objectively, experienced, and measured and can be plotted on a continuum. It is a
component of health.

Illness is a highly personal stage in which the person feels unwell. It can be defined as
“a state of disturbance in the normal functioning of the total human individual, including
both the state of the organism as a biological system and of his person and social
adjustments”.

Filipino perception of illness is closer to the concept of “sakit.” “Sakit'' literally means
pain. In the traditional Philippine conceptual framework, “sakit” is used in many ways,
e.g., “sakit ng ulo” for headache, “sakit ng tiyan” for stomach ache. When “sakit” is used
to refer to illness, it is used to mean the conclusion after a long process of verifying that
one feels unwell (diagnosis).

Disease is a state of disturbance in the normal functioning of the total organism and his
social adjustments.
According to Frake “disease is a diagnostic category, a conceptual entity which
classifies particular illnesses, symptoms or pathological components of illness or states
of illnesses.”

Engle defines disease as “failure or disturbances in the growth, development functions

and adjustments of the organism as a whole or any of its system.”

Disease is the body’s response to a stimulus which is beyond the capacity of the
individual in terms of reserve and adaptability.

To maintain health, the person must be protected from assaults by different agents. The
capacity must also be enhanced.

A. Primary Prevention—intervening before health effects occur, through measures such as

vaccinations, altering risky behaviors (poor eating habits, tobacco use), and banning
substances known to be associated with a disease or health condition.

B. Secondary Prevention—screening to identify diseases in the earliest stages, before the

onset of signs and symptoms, through measures such as mammography and regular blood
pressure testing.

C. Tertiary Prevention—managing disease post diagnosis to slow or stop disease

progression through measures such as chemotherapy, rehabilitation, and screening for
complications.

People vary in their ideas concerning health. This may be due to differences in social,
educational and cultural backgrounds. It is important for the nurse to understand the
client’s ideas on health in order to be supportive of health practices. What a person believes
influences his behavior.

Positive health behaviors are activities related to maintaining, attaining or regaining good
health and preventing illness. Negative health behavior includes practices actually or
potentially detrimental to health, i.e., smoking, drug or alcohol abuse, poor diet, refusal to
take necessary medications.

A healthy person is in a state of homeostasis. It is the tendency of the body to maintain

itself in a state of relative constancy. A person is maintaining homeostasis if he is meeting
his psychological needs, even if these needs may be changing with time

A model is a theoretical way of understanding a concept or idea. Models present different

ways of approaching complex issues. Because health and illness are complex concepts,
models are used to understand the relationship between these concepts and the client’s
attitudes towards health and health behaviors.
 1. Health Belief Model (Rosentock’s 1974 and Maiman’s 1975)

Addresses the relationship between a person’s belief and behaviors. It provides a way of
understanding and predicting how clients will behave in relation to their health and how they
will comply with health therapies.

2. Medical; Model (M.B. Bellock & L. Breslow, 1972)

Health is a state of being free of signs or symptoms of disease and illness. Illness is the
absence of health.
 3. Health-Illness Continuum (McCann/Flynn & Heffron), 1984)

Health is constantly changing state, with high level wellness and death being on opposite
ends of a graduated scale or continuum.

4. Role Performance Model ( Parsons, 1958)

Health is the ability to perform all those roles for which one has been socialized.

5. High-Level Wellness (Dunn, 1961)

High Level Wellness refers to functioning to one’s maximum potential while maintaining
balance of purposeful direction in the environment.

6. Health Promotion Model (Pender 1982, revised 1996)

It defines health as a positive, dynamic state not merely the absence of disease. The model
focuses on the following three areas: (1) individual characteristics and experiences (2)
behavior with specific knowledge and affect, and (3) behavioral outcomes.

7. Holistic Health Model (Smuts 1926, Dunbar 1945, Selye 1956)

In this model, nurses using the nursing process consider clients the ultimate experts
regarding their own health and respect the client's subjective experience as relevant in
maintaining health or assisting in healing.

8. Ecologic Model

Also called multiple causation or multiple etiology attributed to the operation of anyone
factor, rather more than one factor is required to be present for the disease process to be
initiated. Disease results from an imbalance between host (Man) and the disease agent.

Variables Influencing Health

A. Internal Variables

1. Developmental Stage – a person’s thought and behavior patterns change

throughout life.
2. Intellectual Background – a person’s belief about health is shaped in part by the
person’s knowledge, lack of knowledge, or incorrect information about body functions
and illness, educational background, and past experiences.
3. Perception of Functioning – the way people perceive their physical functioning
affects health beliefs and practices.
4. Emotional Factors – spirituality is reflected in how a person lives his or her life,
including the values and beliefs exercised, the relationships established with family
and friends, and the ability to find hope and meaning in life.
B. External Variables

1. Family Practices – the way the client’s family use health care services generally
affects their health practices.
2. Socioeconomic Factors – social and psychosocial factors can increase the risk for
illness and influence the way that a person defines and reacts to illness.
3. Cultural Background – influences beliefs, values and customs. It influences the
approach to the health care system, personal health practices, and the nurse-client
relationship.
4. Risk Factor – is any situation, habit, social or environmental condition, physiological
or other psychological condition, developmental or intellectual condition, or spiritual
or other variables that increase the vulnerability of an individual or group to an illness.

Lesson 2: The Philippine Health Care Delivery System

Definition of Terms:

System – a set of interrelated and independent parts that form a complex whole, and each
of those parts can be viewed as a subsystem with its own set of interrelated and
independent parts.

Health System – is the interrelated ways in which a country organizes available resources
for the maintenance and improvement of the health of its citizens and communities. It
consists of interrelated components in homes, educational institutions, workplace,
communities, the health sectors and other related sectors.

Health Sector – groups of services or institutions in the community/country which are

concerned, with the health protection of the population.

Health Care Delivery System – the network of the health facilities and personnel; which
carry out the task of rendering health care to the people.

Levels of Health Care Facilities:

1. Primary Level Facilities

- Health services at this level are offered to individuals in fair health and to clients with
diseases in the early symptomatic stages.

- Include the rural health units, their cub-centers, chest clinics, malaria eradication units, etc.
operated by the government, private and non-government institutions.

2. Secondary Level Facilities

- Offer services to clients with symptomatic stages of the disease which require moderately
specialized knowledge and technical resources for adequate treatment.

- Include emergency/district hospitals, provincial/city health services and facilities.

3. Tertiary Level Facilities

- Include the highly technology and sophisticated services offered by medical centers and
large hospitals. These are the specialized hospitals/institutions.

- Services offered at this level are for clients afflicted with diseases which seriously threaten
certain disease conditions.
 Module 3: Communication

I. Communication Concepts & Principles

Communication is a critical skill for nursing. It is the process by which humans meet their
survival needs, build relationships, and experience emotions. In nursing, communication
is a dynamic process used to gather assessment data, to teach and persuade, and to
express caring and comfort. It is an integral part of the helping relationship (Kozier,
2016).

A. Characteristics of the Communication Process

1. Human interaction
● Verbal and nonverbal
● Written and unwritten
2. Planned and unplanned
3. Conveys thoughts and ideas
4. Transmits feelings
5. Exchanges information
6. Means various things - transmission of feelings or a more personal and social
interaction between people or a parent expressing his or her authority.

B. Effective Communication

The ability to collect assessment data, initiate interventions, evaluate outcomes of

interventions, initiate change that promotes health, and prevent the safety and legal
problems associated with nursing practice. It also happens in intrapersonal level such as
self-talk

1. Clear Communication Essentials

A. Client safety
B. Collaboration with diverse team challenged by current health care environment.
C. Professional communication and collaboration
D. Cultural gaps
E. Available resources and technology

C. Elements of the Communication Process

1. Sender - a person or group who wishes to communicate a message to another,

can be considered the source-encoder.
2. Encoding- involves the selection of specific signs or symbols (codes) to transmit
the message, such as which language and words to use, how to arrange the
words, and what tone of voice and gestures to use.
3. Message - what is actually said/written, body language
● How words are transmitted refers to the channel.
4. Receiver - is the listener, who must listen, observe, and attend. This person is the
decoder, who must perceive what the sender intended (interpretation).
 5. Response - is the message that the receiver returns to the sender. It is also
called feedback.

D. Elements of Effective Verbal Communication

1. Pace and intonation - the manner of speech, as in the rate or rhythm and tone,
will modify the feeling and impact of a message.
2. Simplicity - includes the use of commonly understood words, brevity, and
completeness.
3. Clarity and brevity – clarity is saying precisely what is meant, and brevity is
using the fewest words necessary. The result is a message that is Timing and
relevance - no matter how clearly or simply words are stated or written, the timing
needs to be appropriate to ensure that words are heard.
4. Adaptability - to alter spoken messages in accordance with behavioral cues
from the client.
5. Credibility - means worthiness of belief, trustworthiness, and reliability.
Credibility may be the most important criterion of effective communication.
6. Humor - can be used to help clients adjust to difficult and painful situations.

E. Non-Verbal Communication

1. Body language
2. Gestures, movements, use of touch
3. Essential skills: observation, interpretation
4. Personal appearance
5. Posture and gait
6. Facial expression of self, others; eye contact
7. Gestures – involves cultural component

F. Electronics Communication

1. Advantages
● Fast
● Efficient
● Legible
● Improves communication, continuity of care
2. Disadvantages
● Client confidentiality risk
● Data Privacy
● Socioeconomics
3. Guidelines in the Use of Electronic Communication
● Do not use e-mail – especially on urgent information because it may result to
jeopardy to client’s health.
● Highly confidential information
● Abnormal lab data
● Follow agency-specific standards and guidelines
● Part of medical record
 ● Consent, identify as confidential

G. Characteristics of Effective Written Communication

● Does not convey nonverbal cues

● Same as verbal and non-verbal
● Use appropriate language and terminology
● Use Correct grammar, spelling, punctuation
● Must be with logical organization
● Appropriate use and citation of resources

H. Factors Affecting the Communication Process

1. Developmental Nursing Considerations

a. Language and communication skills develop through stages

b. Communication techniques for children

● Play
● Draw, paint, sculpt
● Storytelling, word games
● Read books; watch movies, videos
● Writing

c. Establish rapport with children

● Sit or lower self to child’s eye level

● Note what child is playing with or reading
● If appropriate, agree with child/share feelings
● Compliment a physical features, activity
● Use calm tone of voice, appropriate language
● Pace discussion, procedure in non hurried manner
● Preschoolers have limited concept of time

2. Gender

● Females and males communicate differently from early age

● Boys - establish independence, negotiate status
● Girls - seek confirmation, intimacy

3. Sociocultural Characteristics

● Culture
● Education
● Economic level

4. Values & Perception

 ● Culture
● Education
● Economic level

5. Personal Space - defined as distance people prefer in interactions with others.

a. Proxemics

1) Intimate distance - frequently used by nurses

2) Personal distance - less overwhelming
3) Social distance - increased eye contact, out of reach for touch
4) Public distance

6. Territoriality

a. Space and things

● Individual considers as belonging to self

● Knock before entering space

b. May be visible

● Curtains around bed unit

● Walls of private room
● Removing chair to use at another bed

7. Roles and Relationships

● Between sender and receiver

● First meeting versus developed relationship
● Informal with colleagues
● Formal with administrators
● Length of relationship
● Environment
● Can facilitate effective communication
● Key factors
● Comfort
● Privacy

9. Congruence

➔ Verbal and nonverbal aspects match

➔ Seen by nurse and clients
➔ Incongruence
➔ Sender’s true meaning in body language
➔ Improving nonverbal communication
➔ Relax; use gestures judiciously
➔ Practice; get feedback on nonverbal
10. Interpersonal attitudes

➔ a. Attitudes convey beliefs, thoughts, feelings

➔ b. Caring, warmth, respect, acceptance
● Facilitate communication
➔ c. Condescension, lack of interest, coldness
● Inhibit communication
➔ d. Effective nursing communication
● Significantly related to client satisfaction
➔ e. Respect

I. Barriers to Communication

1. Stereotyping - offering generalized and oversimplified beliefs about groups of

people that are based on experiences too limited to be valid.

Examples:

“Two-year-olds are brats.”

2. Agreeing and disagreeing - imply that the client is either right or wrong and that
the nurse is in a position to judge this. These responses deter clients from
thinking through their position and may cause a client to become defensive.

Example:

Client: “I don’t think Dr. Broad is a very good doctor.

He doesn’t seem interested in his clients.”

Nurse: “Dr. Broad is head of the department of surgery and is an excellent surgeon.”

3. Being defensive - attempting to protect a person or health care services from

negative comments. These responses prevent the client from expressing true
concerns.

Examples:

“You have no right to complain.”

“You’re not the only client, you know.”

4. Challenging - Giving a response that makes clients prove their statement or point
of view.

Examples:

Client: “I felt nauseated after that red pill.”

Nurse: “Surely you don’t think I gave you the wrong pill?”

5. Probing - asking for information chiefly out of curiosity rather than with the intent
to assist the client.

Example:

Client: “I was speeding along the street and didn’t see the stop sign.”

Nurse: “Why were you speeding?”

6. Testing - asking questions that make the client admit to something.

Example:

“Who do you think you are?” (forces people to admit their status is only that of client)

“Do you think I am not busy?” (forces the client to admit that the nurse really is busy)

7. Rejecting - refusing to discuss certain topics with the client.

Example:

“I don’t want to discuss that. Let’s talk about. . . .”

“Let’s discuss other areas of interest to you rather than the two problems you keep
mentioning.”

8. Changing topics - directing the communication into areas of self-interest rather

than considering the client’s concerns is often a self-protective response to a
topic that causes anxiety.

Example:

“I can’t talk now. I’m on my way for coffee break.”

Client: “I’m separated from my wife. Do you think I should have sexual relations with
another woman?”

Nurse: “I see that you’re 36 and that you like gardening. This sunshine is good for my
roses. I have a beautiful rose garden.”

9. Unwarranted reassurance - using clichés or comforting statements of advice as a

means to reassure the client. These

Examples:

You’ll feel better soon.”

“I’m sure everything will turn out all right.”

“Don’t worry.”

10. Passing judgment - giving opinions and approving or disapproving responses,

moralizing, or implying one’s own values.

Examples:

“That’s good (bad).”

“You shouldn’t do that.”

11. Giving common advice - Telling the client what to do. These responses deny the
client’s right to be an equal partner. Note that giving expert rather than common
advice is therapeutic.

Examples:

Client: “Should I move from my home to a nursing home?”

Nurse: “If I were you, I’d go to a nursing home, where you’ll get your meals cooked for
you.”

J. Therapeutic Communication

1. Empathizing - empathy is process; people feel with one another

SOLER – Face squarely, open posture, lean toward the person, eye contact and
relaxed.

2. Attentive listening - mindful listening; paying attention to verbal, nonverbal cues.

a. Blocks to Attentive Listening
● Being concerned with oneself
● Assuming
● Judging
● Identifying
● Getting off track
● Filtering

3. Using silence

● Encouraging the client to communicate

● Allowing client time to ponder what has been said
● Allow client time to collect thoughts
● Allow client time to consider alternatives
● Look interested
● Uncomfortable silence should be broken
● Analyzed

Example:
Sitting quietly (or walking with the client) and waiting attentively until the client is able to
put thoughts and feelings into words.

4. Reflecting

● Repeating the client’s message

Example:

Client: “Do you think I should tell my husband?”

Nurse: “You seem unsure about telling your husband.”

5. Clarifying

● Attempt to understand client’s statement

● Ask client to give an example

Example:

Client: “I vomited this morning.”

Nurse: “Was that after breakfast?”

Client: “I feel that I have been asleep for weeks.”

Nurse: “You had your operation Monday, and today is Tuesday.”

6. Paraphrasing

Example:

Client: “I couldn’t manage to eat any dinner last night—not even the dessert.”

Nurse: “You had difficulty eating yesterday.”

Client: “Yes, I was very upset after my family left.”

7. Providing general leads - using statements or questions that (a) encourage the client
to verbalize, (b) choose a topic of conversation, and (c) facilitate continued verbalization.

Examples:

“Can you tell me how it is for you?”

“Perhaps you would like to talk about. . . .”

8. Using open-ended questions- asking broad questions that lead or invite the client to
explore (elaborate, clarify, describe, compare, or illustrate) thoughts or feelings.
Examples:

“I’d like to hear more about that.”

“Tell me more. . . .”

“How have you been feeling lately?”

9. Use of Touch - Providing appropriate forms of touch to reinforce caring feelings.

Because tactile contacts vary considerably among individuals, families, and cultures, the
nurse must be sensitive to the differences in attitudes and practices of clients and self.

Example:

Putting an arm over the client’s shoulder. Placing your hand over the client’s hand.

10. Seeking Clarification - A method of making the client’s broad overall meaning of the
message more understandable. It is used when paraphrasing is difficult or when the
communication is rambling or garbled.

Examples:

“I’m puzzled.”

“I’m not sure I understand that.”

“Would you please say that again?”

11. Perception Checking or Consensual Validation – a method similar to clarifying that

verifies the meaning of specific words rather than the overall meaning of a message.

Examples:

Client: “My husband never gives me any presents.”

Nurse: “You mean he has never given you a present for your birthday or graduation
day?”

Client: “Well—not never. He does get me something for my birthday and graduation day,
but he never thinks of giving me anything at any other time.”

12. Giving Information- providing, in a simple and direct manner, specific factual
information the client may or may not request.

Examples:

“Your surgery is scheduled for 11 am tomorrow.”

“You will feel a pulling sensation when the tube is removed from your abdomen.”
“I do not know the answer to that, but I will find out from Mrs. King, the nurse in charge.”

13. Acknowledging- giving recognition, in a nonjudgmental way, of a change in

behavior, an effort the client has made, or a contribution to a communication.

Examples:

“You trimmed your beard and mustache and washed your hair.”

“I notice you keep squinting your eyes. Are you having difficulty seeing?”

14. Presenting Reality- Helping the client to differentiate the real from the unreal.

Examples:

“That telephone ring came from the program on television.”

“Your magazine is here in the drawer. It has not been stolen.”

15. Focusing- helping the client expand on and develop a topic of importance.

Example

Client: “My wife says she will look after me, but I don’t think she can, what with the
children to take care of, and they’re always after her about something—clothes,
homework, what’s for dinner that night.”

Nurse: “Sounds like you are worried about how well she can manage.”

16. Summarizing- stating the main points of a discussion to clarify the relevant points
discussed.

Examples:

“During the past half hour we have talked about. . . .”

“Tomorrow afternoon we may explore this further.”

“In a few days I’ll review what you have learned about the actions and effects of your
insulin.”

“Tomorrow, I will look at your feeling journal.”

17. Offering Self- suggesting one’s presence, interest, or wish to understand the client
without making any demands or attaching conditions that the client must comply with to
receive the nurse’s attention.

Examples:

“We can sit here quietly for a while; we don’t need to talk unless you would like to.”
“I’ll help you to dress to go home, if you like.”

K. Characteristics of Therapeutic Relationship

1. Intellectual and emotional bond

2. Focused on client
3. Respects client as individual
4. Respects client confidentiality
5. Focuses on client’s well-being
6. Based on mutual trust, respect, acceptance

L. Phases of Therapeutic Relationship

1. Pre-interaction phase
2. Introductory phase
● Orientation, pretherapeutic phase
● Nurse and client observe each other
● Open relationship
● Clarify problem
● Structure and formulate contract
● Client may display resistive behaviors

By end of this phase client begins to:

● Develop trust in nurse

● View nurse as honest, open, concerned
● Believe nurse will try to understand, respect
● Believe nurse will respect client confidentiality
● Feel comfortable talking about feelings
● Understand purpose of relationship, roles
● Feel an active participant in plan
3. Working Phase
a. Stage One
● Exploring and understanding thoughts and feelings
● Empathetic listening and responding
● Respect, genuineness
● Concreteness
● Reflecting, paraphrasing, clarifying, confronting
● Intensity of interaction increases
b. Stage Two
● Facilitate and take action
● Collaborate
● Make decisions
● Provide support
● Offer options

4. Termination Phase
 ● Difficult, ambivalent
● Summarizing
● Termination discussions
● Allow time for client adjustment to independence

M. Skills Needed for Therapeutic Relationship

● Listen actively
● Help identify the client’s feelings
● Be empathetic, honest, genuine, and credible
● Use ingenuity
● Be aware of cultural differences
● Maintain confidentiality
● Know your role and your limitations
● Establishing rapport
● Include adolescent in discussion
● Listen more than you talk
● Avoid distractions
● Be truthful with the child

9. Establishing trust

● Follow through with promises

● Respect confidentiality
● Be truthful, even if it isn’t what they want

N. Nursing Diagnoses Related to Communication

1. Readiness for enhanced communication – a pattern of exchanging information and

ideas with others, which can be strengthened.

Defining characteristics: Expresses desire to enhance communication.

2. Impaired verbal communication - decreased, delayed, or absent ability to receive,

process, transmit, and/or use a system of symbols.

Defining characteristics:

● Absence of eye contact

● Difficulty comprehending communication
● Difficulty expressing thoughts verbally
● Difficulty forming sentences
● Difficulty forming words
● Difficulty in selective attending
● Difficulty in use of body expressions
● Difficulty in use of facial expressions
● Difficulty maintaining communication
● Difficulty speaking
 ● Difficulty verbalizing
● Disoriented to person
● Disoriented to place
● Disoriented to time
● Dyspnea
● Inability to speak
● Inability to speak language of caregiver
● Inability to use body expressions
● Inability to use facial expressions
● Inappropriate verbalization
● Partial visual deficit
● Slurred speech
● Stuttering
● Total visual deficit

Related Factors:

● Alteration in self-concept
● Cultural incongruence
● Emotional disturbance
● Environmental barrier
● Insufficient information
● Insufficient stimuli
● Low self-esteem
● Vulnerability

II. Conclusion

● Nurse’s role requires communication skills

● Effective communication broadens nurse’s role
● Ability to deliver highest quality of care
● Nurse needs to be understood
● Nurse needs to understand messages
● Strong verbal, written communication skills
● Monitor own nonverbal communication

Module 4: Critical Thinking & The Nursing Process

Lesson 1: Critical Thinking

The term “thinking like a nurse” was introduced by Dr. Christine Tanner in 2006. Critical
thinking is the process of intentional higher-level thinking to define a client’s problem,
examine the evidence-based practice in caring for the client, and make choices in the
delivery of care.
In contrast with clinical reasoning, it is the cognitive process that uses thinking strategies
to gather and analyze client information, evaluate the relevance of the information, and
decide on possible nursing actions to improve the client’s physiological and psychosocial
outcomes.

Clinical reasoning requires the integration of critical thinking in the identification of the
most appropriate interventions that will improve the client’s condition.

The concept of clinical reasoning “evolved from the application of decision-making to the
health care professions” (Kozier, 2016).

Clinical reasoning is often defined in practice-based disciplines, such as nursing and

medicine, as the “application of critical thinking to the clinical situation” (Victor-Chmil,
2013).

In order to fulfill the premise cited above, the following skills must be developed by a
nurse:

1. Critical Analysis – determine essential information & discard superfluous ideas.

2. Socratic Questioning – recognize and examine assumptions, examine multiple
points of views, differentiate what one knows from what one merely believes.
3. Deductive Reasoning – from general to specific
 Lesson 2: The Nursing Process

The nursing process is a set of steps followed by nurses in order to care for patients.
How a particular nurse uses the nursing process varies based on the nurse, the patient,
and the situation, but the process generally follows the same steps: assessment,
diagnosis, plan, implementation, evaluation.

definition of the Nursing Process

It is a systematic problem-solving approach toward giving individualized care. Nurses

use the NP as a PSM in ALL SETTINGS with clients of ALL AGES to identify and treat
human responses to potential or actual problems. It also facilitates the development of
individualized care used to identify and treat potential or actual NP of family and
community.

Characteristics of the Nursing Process

1. It has a framework for providing nursing care.

2. It is orderly and systematic.
3. It is independent.
4. Provides specific care for individuals, family and community.
5. It is client-centered, using the client’s strength.
6. It is appropriate to use throughout the lifespan.
 7. It can be used in any setting.

Importance of Nursing Process Application to the Practice of Nursing:

1. The importance of critical thinking skills for clinical practice

2. The managed care environment with increasing standardization of patient care
3. The need for nurses to be involved in the economic side of care and for this to be
reflected in their practice
4. The increasing multiculturalism of society
5. The increasing percentage of clients who will be elderly.

Phases of the Nursing Process

Types of Nursing Diagnosis

1.) Actual Nursing Diagnosis – describes a human response to a health problem

that is being manifested. Its is written in three statements:

I. Diagnostic Label
II. Defining Characteristics
III. Related Factor

2.) Risk Nursing Diagnosis – describes human responses to health conditions/life

processes that may develop in a vulnerable client. It is written in two statements
because they do not include defining characteristics.

3.) Wellness Nursing Diagnosis – is a diagnostic statement that describes the

human response to levels of wellness to clients that have a potential for enhancement to
a higher state.

Ex. Readiness for enhanced self concept

4.) Possible Nursing Diagnosis – is made when no evidence supports the

presence of the problem but the nurse thinks that it is highly probable and wants to
collect more information.

Ex. Possible impaired adjustment r/t unknown etiology

 5.) Syndrome Nursing Diagnosis – associated with a cluster of other diagnosis.

Ex. Risk for disuse syndrome

Outcome Identification & Planning

- It is the formulation of goals and measurable outcomes that provide a basis for
evaluating nursing diagnosis.

High Priorities – life-threatening situations, something that needs immediate attention

Ex. Ineffective airway clearance

Medium Priorities – involve problems that could result in unhealthy circumstances

(physical or emotional) but are not likely to threaten life.

Ex. Activity intolerance

Social Isolation

Low Priorities – involves problems that usually can be resolved easily with minimal
interventions and has a little potential to cause significant dysfunctions.

Ex. Risk for loneliness

Interrupted breastfeeding
Types of Nursing Interventions

1.) Supplemental (Tertiary) – may be referred to dependent/independent nursing

actions.

Ex. Health promotion, nurse-initiated orders and interventions

2.) Facilitative (Secondary) – may also be referred to interdependent intervention in

which the nurse performs in collaboration with other professionals.

Ex. Referrals

3.) Developmental (Primary) – purely teaching/coaching/instructing the client.

Module 5: Documentation & Reporting

Purpose of the Nursing Documentation

A basic purpose of the nursing documentation is the creation of a database in

which the patients’ files are included. The patient’s file is kept for many reasons, from
which the most important ones are the following:

1. Communication
2. Legal Documentation
3. Reimbursement - diagnosis-related groups (DRGs) are the basis for establishing
reimbursement for patient care. A DRG is a classification based on patients’
medical diagnoses. Hospitals are reimbursed a predetermined currency amount
by Philhealth or Medicare for each DRG.
4. Education- a patient’s record contains a variety of information, including
diagnoses, signs and symptoms of disease, successful and unsuccessful
therapies, diagnostic findings, and patient behaviors. One way to learn the nature
of an illness and the individual patient’s response to it is to read the patient care
record.
5. Research
6. Evaluation and Monitoring

Common charting mistakes that result in malpractice include:

I. failing to record pertinent health or drug information,

II. failing to record nursing actions,
III. failing to record that medications have been given,
IV. failing to record drug reactions or changes in patients’ conditions,
V. writing illegible or incomplete records, and
VI. failing to document discontinued medications.

Table 1. Legal Guidelines for Recording*

 Guidelines Rationale Correct Action

Do not erase, apply Charting becomes illegible: Draw single line through
correction fluid, or scratch it appears as if error, write word error
above it,
out errors made while you were attempting to
recording. hide information and sign your name or
initials and date it. Then
or deface a written record. record

note correctly.

Do not document Statements can be used as Enter only objective and

retaliatory or critical evidence for factual observations of
comments patient’s
nonprofessional behavior
about patient or care by or poor quality of behavior; quote all patient
other health care comments.
care.
professionals. Do not enter
personal opinions.

Correct all errors promptly. Errors in recording can Avoid rushing to complete
lead to errors in charting; be sure that

treatment or may imply an information is accurate and

attempt to complete.

mislead or hide evidence.

Record all facts. Record must be accurate, Be certain entry is factual

factual, and and thorough. A person

objective. reading the documentation

should be able to

determine that patient had

adequate care.

Do not leave blank spaces Another person can add Chart consecutively, line by
in nurses’ notes. incorrect line; if space is left, draw

information in space.
 line horizontally through it
and sign your name at end.

Record all written entries Illegible entries can be Never erase entries or use
legibly and in black misinterpreted, correction fluid and never
use
ink. Do not use felt-tip pens causing errors and
or erasable ink. lawsuits; ink from pencil.

felt-tip pen smudges or

runs when wet

and may destroy

documentation; erasures

are not permitted in patient

charting; black

ink is more legible when

records

If an order is questioned, If you perform order known Do not record “physician

record that clarification to be incorrect, made error.” Instead, chart
that
was sought. you are just as liable for
prosecution as “Dr. Smith was called to
clarify order for analgesic.”
the health care provider.
Include the date and time
of phone call, with whom

you spoke, and the

outcome.
Chart only for yourself. You are accountable for Never chart for someone
information that you else (exception: if caregiver
has
enter into a patient’s
record. left unit for day and calls
with information that needs

to be documented; include
date and time of entry and

reference specific date and

time to which you are

referring and name of

source of information in
entry;

include that information

was provided via
telephone).

Avoid using generalized, This type of documentation Use complete, concise

empty phrases such as is subjective and descriptions of care so

“status unchanged” or “had does not reflect patient documentation is objective

good day.” assessment. and factual.

Begin each entry with date This guideline ensures that Do not wait until end of
and time and end correct sequence shift to record important

with your signature and of events is recorded; changes that occurred

title. signature documents several hours earlier; be
sure to
who is accountable for care
delivered. sign each entry (e.g.,
Lambert Valera, RN).
For computer This maintains security and Once logged into
documentation keep your confidentiality. computer, do not leave
password computer

to yourself. screen unattended. Log out

when you leave the

computer. Make sure that

computer screen is not

accessible for public

viewing

Guidelines for Quality Documentation & Reporting

1. Be factual - factual record contains descriptive, objective information about what

a nurse sees, hears, feels, and smells.
2. Be accurate - correct spelling demonstrates a level of competency and attention
to detail.
3. Be complete - the information within a recorded entry or a report must be
complete, containing appropriate and essential information.
4. Be current - timely entries are essential in a patient’s ongoing care.
5. Be organized - communicate information in a logical order.

Documentation Systems

1. Source-Oriented Record
● Notations for each discipline in separate sections of chart
● Narrative charting
● Being replaced or augmented
● Organize information in clear, coherent manner
● Convenient
● Scattered
 Figure 2. An example of narrative notes

Components of Source-Oriented Record:

● Admission sheet
● Graphic record
● MAR
● Nurses notes
● Progress notes
● Diagnostic reports
● Physician’s order sheet
● Referral summary
● Initial nursing assessment
● Daily care record
● Special flow sheet
● Medical H&P
● Consultation records
● Discharge plan

2. Problem-Oriented Record

● Also known as Problem-oriented medical record (POMR)

● Arranged according to client problems
● Charting by Exception

3. Charting by exception (CBE)

● Flow sheets
● Standards of nursing care
● Bedside access to chart forms

4. Computerized Documentation
 ● Manage huge volume of information
● Information easily retrieved, format variety
● Can generate work list for shift
● Relatively easy
● Standardized lists, add narrative information
● Speech recognition technology
● Transmit information between settings

5. Case Management

● Emphasizes quality, cost-effective care

● Multidisciplinary approach

- In planning and documenting client care

● Uses Critical pathway

Figure 3. An Example of Critical Pathway

Documenting Nursing Activities

1. Admission nursing assessment

2. Nursing care plans
3. JCI requires clinical record include

- Evidence of client assessments

- Nursing diagnoses and/or client needs

- Nursing interventions

- Client outcomes

- Evidence of a current nursing care plan

- Traditional care plan written for each client

- Standardized care plans save time

3. Kardexes
● Concise method for organizing, recording
● May/may not be part of permanent record
● May be in pencil
● May be organized into sections

- Pertinent information, allergies

- Medications, IV fluids

- List of treatments, procedures

- Procedures orders

● Specific data on how physical needs to be met

- Diet, assistance needed with feeding

- Elimination devices

- Activity

- Hygienic needs, safety precautions

● Problem list with stated goals, nursing approaches

● Quick visual guide

4. Flow sheet

● Record data quickly, concisely

● Graphic record
● Input and output (I & O)
● Medication administration record (MAR)
● Skin assessment record

5. Progress notes

● Progress, interventions, re/assessment data

6. Nursing discharge

● Completion on discharge/transfer

- If given to client, family understandable terms

● Transferred within facility, to/from long-term care facility

- Report goes with client for continuity of care

● Usually includes:

- Client’s status description, resolved problems

7. Referral Summaries

Usually include:

● Unresolved continuing health problems

● Treatments to be continued
● Current medications
● Restrictions related to activity, diet, bathing
● Activities of daily living (ADL) abilities
● Comfort level
● Support networks
● Client education provided in relation to Disease process
● Activities and exercise, special diet, medications
● Specialized care or treatment
● Follow-up appointments
● Discharge destination and mode
● Referrals

Recording – the process of making an entry on a client record.

Documentation – is anything written or printed that relied on as a record or proof for

authorized persons.

Methods of Recording

1. Narrative Documentation – is the traditional method for recording nursing care. It is

simply the use of story-like format to document information specific to client conditions
and nursing care.

2. SOAP Format - is a problem-oriented technique (an acronym for subjective, objective,

assessment, and plan) whereby the nurse identifies and lists the patient’s health
concerns. It is commonly used in primary health-care settings.

3. SOAPIER Format (Subjective, Objective, Assessment, Planning, Intervention,

Evaluation, Re-assessment)

4. ADPIE Format (Assessment, Diagnosis, Planning, Intervention, Evaluation)

5. FOCUS (FDAR) CHARTING - focuses on complaints (subjective) signs and

symptoms, event, concerns or problems.

Three (3) Elements: DATA, ACTION, RESPONSE

 Date/Time Focus Data, Action, Response

04/14/21 Fever D – “Mainit and pakiramdam ko”. Skin warm

to touch, temperature 39˚C.

A – Tepid sponge bath given. Encourage to

increase fluid intake. Referred to Dr. Chua.
Paracetamol 500 mg 1 tab p.o given.

R – “Pinagpawisan ako”. Tenmperature is

38˚C. Tolerated 2 glasses of water.

A – Continue Tepid sponge bath. Change

clothing and linen. Monitored temperature.

L. Valera, R.N.

5. Change-of-Shift Reports

– Handoff communication

– Information communicated in a consistent manner including an opportunity to ask

and respond to questions

– Provide basic identifying information

Sample SBAR Communication Tool

S = Situation

▪ State your name, unit, and client name.

▪ Briefly state the problem.

B = Background
▪ State client admission diagnosis and date of admission.

▪ State pertinent medical history.

▪ Provide a brief summary of treatment to date.

▪ Code status (if appropriate).

A = Assessment

▪ Vital signs

▪ Pain scale

▪ Is there a change from prior assessments?

R = Recommendation

▪ State what you would like to see done or specify that the care provider needs to
come and assess the client.

▪ Ask if the health care provider wants to order any tests or medications.

▪ Ask the health care provider if she or he wants to be notified for any reason.

▪ Ask, if no improvement, when you should call again.

Table 3. Charting Principles

PRINCIPLES ACTION RATIONALE

1. Do not erase. Draw a line through the May convey an attempt at

wrong entry, sign your cover-up information.
name and enter the correct
information.

2. Include the date and Chart sequentially and give Reveals the sequence in
time. the date and time of each which events occurred.
entry.

3. Do not leave spaces Endeavor to fill the total Protects from erroneous
between lines of entry. space on each line or draw entry by others.
lines to fill empty spaces.
 4. Be factual. Write the facts as you Avoids subjectivity and
observe them including bias.
quotations from the client.

5. Avoid criticism of client Chart objectively and avoid Statements have

and health-care workers.
critical statements and implications. Subjective
name calling. For example: statements convey
Do not say “Nurse M. unprofessional behavior
Escalada took 2 hours the and poor judgment.
client’s BP after she was
informed that it was 90/40.
Subsequently the client
slipped into a coma”.

6. Clarify all unclear orders. Ask questions about
illegible and possible
wrong orders such as
names and dosage of
medications.
The nurse is a liable as the
physician for carrying out a
wrong order.

Module 6: The Teaching-Learning Process

Teaching client education is a major aspect of nursing practice and an important

independent nursing function (Wilkinson, 2016). 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.

Similarly, The Joint Commission includes standards for Patient and Family Education
(PFE) to “help patients better participate in their care and make informed care decisions”
(Joint Commission International, 2011). This requirement means that providers must
“perform a learning needs assessment that includes the patient’s cultural and religious
beliefs, emotional barriers, desire and motivation to learn, physical or cognitive
limitations, and barriers to communication” (The Joint Commission, 2012).
Teaching

Teaching is a system of activities intended to produce learning. The teaching process is

intentionally designed to produce specific learning.

The teaching–learning process involves dynamic interaction between teacher and

learner. Each participant in the process communicates information, emotions,
perceptions, and attitudes to the other. The teaching process and the nursing process
are much alike.
Learning

Learning is a change in human disposition or capability that persists and that cannot be
solely accounted for by growth. Learning is represented by a change in behavior.

A learning need is a desire or a requirement to know something that is presently

unknown to the learner. Learning needs include new knowledge or information but can
also include a new or different skill or physical ability, or a new behavior or a need to
change an old behavior.

Compliance

An important aspect of learning is the individual’s desire to learn and to act on the
learning, referred to as compliance.

In the health care context, compliance is the extent to which a person’s behavior
coincides with medical or health advice.

Compliance is best illustrated when the person recognizes and accepts the need to
learn, and then follows through with the appropriate behaviors that reflect the learning.

Adherence

Adherence is the degree to which clients follow the agreed-on recommendations of

health care providers (Kozier, 2016). Adherence implies a collaborative and cooperative
relationship between nurses and clients that is based on shared responsibility. Nurses
view clients as active participants in promoting, maintaining, and restoring their health.

Learning Disciplines

Andragogy is the art and science of teaching adults.

Pedagogy, the discipline concerned with helping children learn.

Geragogy is the term used to describe the process involved in helping older adults to
learn.

Assessment of Client’s Learning

The purpose of assessment is to identify client’s needs for learning with respect to his or
her health.
Guidelines for Teaching

1. A respectful relationship between teacher and learner is essential. A relationship that

is accepting, friendly, and positive will best assist learning.

2. The teacher who uses the client’s previous learning in the present situation
encourages the client and facilitates learning new skills.

3. The optimal time for each session depends largely on the learner.

4. Using a layperson’s vocabulary enhances communication.

5. An environment can detract from or assist learning; for example, noise or interruptions
usually interfere with concentration.
Evaluating Learning

The process of evaluating learning is the same as evaluating client achievement of

desired outcomes for other nursing diagnoses.

Learning is measured against the predetermined learning outcomes selected in the

planning phase of the teaching process. Thus the outcomes serve not only to direct the
teaching plan but also to provide outcome criteria for evaluation.

In cognitive learning, the client demonstrates acquisition of knowledge.

Examples of the evaluation tools for cognitive learning include the following:

• Direct observation of behavior (e.g., observing the client selecting the solution to a
problem using the new knowledge)

• Written measurements (e.g., tests)

• Oral questioning (e.g., asking the client to restate information or correct verbal
responses to questions)

• Self-reports and self-monitoring. These can be useful during follow-up phone calls and
home visits. Evaluating individual self-paced learning, as might occur with computer
instruction, often incorporates self-monitoring.

The acquisition of psychomotor skills is best evaluated by observing how well the client
carries out a procedure such as self-administration of insulin.

Affective learning is more difficult to evaluate. Whether attitudes or values have been
learned may be inferred by listening to the client’s responses to questions, noting how
the client speaks about relevant subjects, and observing the client’s behavior that
expresses feelings and values. For example, have parents learned to value health
sufficiently to have their children immunized? Do clients who state that they value health
actually use condoms every time they have sex with a new partner?

Module 7: Evidence-based Practice in Nursing

Evidence-based practice (EBP), or evidence-based nursing, occurs when the nurse can
“integrate best current evidence with clinical expertise and patient/family preferences
and values for delivery of optimal health care” (Kozier, 2016).

Thus, as evidence changes, so must practice. Polit (2017) further emphasized that
Evidence-Based Practice (EBP) is the meticulous use of current best evidence in making
clinical decisions about patient care.
4. Critically appraise the evidence. Several toolkits or schema are available to assist
the nurse in determining the most valid, reliable, and applicable evidence. In
some cases, relevant studies may already have been synthesized.
5. Integrate the evidence with clinical expertise and client/family preferences and
values. Evidence must not be automatically applied to the care of individual
clients. Each nurse must determine how the evidence fits with the clinical
condition of the client, available resources, institutional policies, and the client’s
wishes. Only then can an appropriate intervention be established.
6. Implement and evaluate the outcomes of the intervention. The nurse gathers all
relevant data that may indicate whether or not the intervention was successful. If
the outcomes varied from those reported in the evidence, this evaluation can help
determine the reasons for the variable responses and will contribute to improving
the evidence available for future situations.
Research Utilization VS Evidence-based Practice

Research utilization is the use of findings from disciplined research in a practical

application that is unrelated to the original research. The emphasis is on translating
empirically derived knowledge into real-world application. It should answer the question
“How can I put this innovation to good use in my clinical setting?”. Research utilization
was an important concept in nursing before the EBP movement took hold.

Evidence based practice is broader than research utilization because it integrates

research findings with other factors. The start point in EBP is a clinical question: “What
does the evidence say is the best approach to solving this problem?”.

Overview of the Evidence-based Practice Movement

1. Cochrane (British epidemiologist) in early 1970s called for efforts to make

research summaries about intervention available to physicians and health care
providers.
2. Development of Cochrane center in Oxford in 1993.
3. The international with centers now established in over a dozen locations through
out the world.
4. The aim now of Cochrane International Collaboration is to help providers make
good decisions about health care by preparing, maintaining, and disseminating
systematic reviews of the effects of health care interventions.
Sources of Evidence

1. Systematic reviews:- can take various forms. It is much like a thorough literature
review.
2. Meta analysis:- is a technique for integrating quantitative research findings
statistically. Meta analysis treats the findings from a study as one piece of
information. The findings from multiple studies on the same topic are combined
and then all of the information is analyzed statistically in a manner similar to that
in a usual study. It also provides a convenient, objective method of integrating a
body of findings and of observing patterns that might not have been detected.
3. Individual studies - are the unit of analysis in a meta analysis.
4. Cochrane database of systematic reviews - contains thousands of systematic
reviews relating to health care interventions.

Five Components Scheme for Formulating EBP Questions Using (PICOT) Format

1. Population (P).
2. Intervention or issue (I).
3. Comparison of interest (C) is not always essential.
4. Outcome (O).
5. Time (T) is not always essential.

Barriers to Evidence-Based Practice

1. Work schedule, workload demands

2. Client preferences
3. Lack of access to technology
4. Limited knowledge
5. Lack of experience, confidence in development of strategies
6. Lack of support
7. Lack of access to continuing education
8. Attitudes