INTEGRAL COMPONENTS OF CLIENT CARE: ASEPSIS PROFESSION-an occupation that requires extensive education

or requiring advance training and experience in some specific

-to promote safely, as part of hygiene as infection control specialized body of knowledge
-involved in providing a biologically safe environment
-microorganisms exists everywhere: water, soil, skin, intestinal PROFESSIONALIZATION- the process of becoming professional
tract and others
PROFESSIONALISM- professional character, spirit or methods, a
INFECTION-is the growth of microorganism in body tissues set of attributes that implies commitment
ASEPSIS-“absence of microorganism” What is NURSING?
-the freedom from disease-causing microorganism -the act of utilizing the environment of the patient to assist in
recovery (Nightingale 1860-1969)
2 Types of ASEPSIS -assisting the individual sick or well in the performance of those
MEDICAL ASEPSIS activities contributing to health (Henderson 1966)
-intended to confine specific microorganism -the protection and optimization of health and abilities
-limiting the number of growth and transaction of microorganism preventions, and treatment advocacy (ANA 2003)
-CLEAN- absence of almost all microorganism -encompasses autonomous and collaborative care of individuals
-DIRTY-means likely to have microorganism of all ages, family groups , community sick or well in all setting
(International council of nurses 2002)
SURGICAL ASEPSIS
-refers to those practices that keep an area or object free of all Characteristics of nursing
microorganism 1. Caring
-includes practices that destroy all microorganism and spores 2. Art and applied science
3.Goal oriented
SEPSIS-it is the condition in which acute organ dysfunction 4. Holistic
occurs secondary to infection 5. Adaptive (health restoration, promotion, maintenance)

NOSOCOMIAL INFECTION-infection that originate in the hospital

that can either develop during a client’s stay in a facility or
manifest after discharge
IATROGENIC INFECTION- the direct result of diagnostic or
therapeutic procedures
CHAIN OF INFECTION
ETHIOLOGIC
AGENT

SUSEPTIBLE
RESORVOIR
HOST

PORTAL OF PORTAL OF
ENTRY EXIT
MODE OF
TRANSMISSION:1.
CONTACT
TRANSMISSION2.
AIR BORNE
TRANSMISSION3.
DROPLET
TRANSMISSION

HAND HYGIENE- considered one of the most effective infective

prevention measure

VITAL SIGNS
NURSING AS A PROFESSION -a.k.a “cardinal signs”
-indicator of the body’s physiological status and response to
physical environment and psychological stressor.
-effectiveness of circulatory respiration neural and endocrine BLLOD PRESSURE
body functions -the force on the wall of blood vessels by blood as it is pumped
1. TEMPERATURE around the body by the force of ventricular contraction
2. PULSE -SBP- pressure of the blood as a result of contraction of
3. RESPIRATION ventricles
4. BLOOD PRESSURE -DBP- pressure when the ventricles are at rest
5. OXYGEN SATURATION
6. PAIN OXYGEN SATURATION
-the measurement of oxygen attached to the haemoglobin cell in
NORMAL VITAL SIGNS the circulatory system
TEMPERATURE -the normal SPO2 is 90- 100%
Average Temperature 36° to 38° C (96.8° to 100.4°F)
Oral/Tympanic 37°C (98.6°F) PAIN
Rectal 37.5°C (99.5°F) -unpleasant sensory and emotional experience associated with
Axillary 36.5°C (97.7°F) actual or potential tissue damage, or described in terms of such
damage.
PULSE -subjective and highly individualized; Its stimulus is physical
60- 100 beats per minutes in adult and/or mental in nature.
RESPIRATION SIGNS AND SYMPTOMS OF PAIN:
16 cycle per minute in adult (12-20) -Increased respiratory rate
-Increased heart rate
BLOOD PRESSURE -Peripheral vasoconstriction
-SYSTOLIC <120 mmHg -Pallor
-DIASTOLIC <80 mmHg -Elevated B.P.
TEMPERATURE -Increased Blood Glucose Levels
-measurement of the average kinetic energy of the molecules in -Diaphoresis
an object or system and can be measured with a thermometer or -Dilated pupils
calorimenter
-the difference between the amount of heat produced by body
process and the heat lost to the external environment PAIN IS
CLASSIFIED

CELSIUS AND FAHRENHEIT SCALE

C=(F-32)x 5/9 BASED ON BASED ON BASED ON BASED ON
F=(C x 9/5) + 32 DURATION INTENSITY LOCATION ETIOLOGY

ALTERATION IN BODY TEMPERATURE

-FEVER or PYREXIA
-A.K.A febrile BASED ON DURATION
-occurs heat loss mechanism are unable to keep pace with
excessive heat production; usually not harmful
-HYPERPYREXIA- the fever goes above 105°F ACUTE PAIN CHRONIC PAIN

-HYPOPYREXIA- the fever goes above 95°F

CHRONIC CHRONIC CANCER CHRONIC NON-
PULSE EPISODIC PAIN PAIN CANCER PAIN
-is a palpable bounding of blood flow noted at various points in
the body where the artery passes over a bone. ACUTE PAIN
-normal pulse rate is 60- 100 per minute in adult -pain lasts only through the expected recovery period
CARDIAC OUTPUT -protective, has an identifiable cause, is of short duration, and
=stroke volume x pulse rate has limited tissue damage and emotional response.
=70ml x 80 BPM -It eventually resolves, with or without treatment, after an injured
= 5600ML area heals.
=5.6 L/min
CHRONIC PAIN
PULSE POINT -pain that lasts longer than 6 months and is constant or recurring
-temporal artery -radial artery with a mild-to-severe intensity
- facial artery -femoral artery -It does not always have an identifiable cause and leads to great
-carotid artery -popliteal artery personal suffering.
-apical artery -posterior tibial artery -Examples: arthritic pain, head ache, peripheral neuropathy.
-brachial artery -dorsalis artery CHRONIC NON-CANCER PAIN- pain that resulted due
to non cancer disease conditions is termed as chronic non
RESPIRATION cancer pain.
-is the mechanism the body uses to exchange gases between CHRONIC CANCER PAIN- pain that is caused by
atmosphere and blood tumor progression and related pathological processes, invasive
procedures, toxicities of treatment, infection, and physical
limitations. -genes
CHRONIC EPISODIC PAIN- Pain that occurs -neurological functioning
sporadically over an extended period of time is episodic pain; 3. SOCIAL FACTORS
last for hours, days, or weeks. Examples are migraine -attention
headaches. -previous experience
-family and social support
-spiritual factors
BASED ON INTENSITY 4.PSYCHOLOGICAL FACTORS
-MILD (1-3) -anxiety
-MODERATE (4-6) -coping style
-SEVERE (7-10) 5. CULTURAL FACTORS
PAIN ASSESSMENT AND MANAGEMENT
P-precipitating/ alleviating factors
Q-quality of pain
R-radiation
S-severity
T-timing
ASSESS FOR OBJECTIVE SIGNS OF PAIN:
-Facial Expression
-Vocalization- crying, moaning
Types of Scale: -Body Movements- guarding, resistance to moving
-Facial expression- Wong Baker’s Scale MANAGEMENT OF PAIN
-Numerical Scale- 1-10
-Descriptive Scale- mild, moderate, severe 1.PHARMACOLOGICAL INTERVENTIONS
2. NON-PHARMACOLOGICAL INTERVENTIONS
BASED ON
ETIOLOGY PHARMACOLOGICAL INTERVENTIONS
-therapy is given by using Analgesics
-the analgesics may be non opiods (NSAIDS) or opiods or
NOCICEPTIVE NEUROPATHIC adjuvants
PAIN PAIN
-NSAIDS- Non Steroidal Anti-Inflammatory Drugs
-OPIODS- are medications that relieve pain, derived frm opium
PERIPHERAL CENTRAL
-ADJUVANTS- are drugs originally developed to treat conditions
SOMATIC PAIN VISCERAL PAIN NEUROPATHIC NEUROPATHIC othr than pain but also have analgesics properties
PAIN PAIN

NOCICEPTIVE PAIN
-experienced when an intact, properly functioning nervous system NON-PHARMACOLOGICALPAIN MANAGEMENT
sends signals that tissue damaged, requiring attention and proper -the use of non-pharmacologic methods enhances pain relief
care 1.Heat and Cold applications
-example: pain experienced following a cut or broken bone alerts 2.Meditation
the person to avoid further damage until properly heal 3.Distraction
4. Imagery
SOMATIC- pain originating from the skin, muscle, bone or 5.TENS application
connective tissue 6.Music Theraphy
VISCERAL- pain is resulted from the activation of nociceptors of 7.Massage
the thoracic, pelvic, or abdominal viscera (organs) 8.YOGA
NEUROPATHIC PAIN 9.Acupunture
-pain is associated with damaged or malfunctioning nerves due to 10.Herbal theraphy- garlic, echinacea, ginseng
illness, injury, or undetermined reasons FUNDAMENTALS OF NURSING PRACTICE REVIEWER
-usually chronic, described as burning “electric-shock”, tends to ROLES AND RESPONSIBILITIES
be difficult to treat, based on which part of the nervous system is 1. CAREGIVER
damaged - Addresses the client’s holistic care needs
-example: diabetic peripheripal neuropathy, phantom limb pain Ø full care
PERIPHERAL-due to damaged to peripheral NS Ø partial care
CENTRAL-results from malfunctioning nerves in the CNS Ø supportive-educative care
FACTORS INFLUENCING PAIN
1.DEVELOPMENTAL FACTORS 2. COMMUNICATOR
-age - Effectiveness as a communicator is central to the nurse-
2.PHYSIOLOGICAL FACTORS patient relationship.
-fatigue Ø To give comfort and emotional support
Ø To give care effectively
 Ø To assists patients in rehabilitation - Nurse practitioner- provide health care to a group of
patients usually in an outpatient, ambulatory or community based
3. TEACHER setting.
- Share expertise with health care team members - Anesthetist Nurse- provides surgical anesthesia under the
Ø client’s learning needs guidance and supervision of anesthesiologist
Ø readiness to learn - Midwife nurse- educated in midwifery, involved in providing
Ø specific learning goals independent care of women during pregnancy, labor and delivery
Ø teaching strategies of new born.
- Nurse researcher- conducts evidence-based practice and
4. CLIENT ADVOCATE research to improve nursing care.
- preserve client’s legal and human rights during: - Nurse administrator- manages patient care and the
Ø health delivery of specific nursing services within a health care agency.
Ø illness - Nurse educator- works primarily in school of nursing,
Ø dying provides practical skills and theoretical knowledge.
- Entrepreneur nurse
5. COUNSELOR
- provides emotional, intellectual, psychological support
- counsels primarily to
healthy individuals with normal adjustment difficulties
(ATTITUDES)

6. CHANGE AGENT
- assisting clients to make modifications in their behavior
make changes in a system

7. LEADER

8. MANAGER
- management and coordination of client care (ESTABLISH &
EVALUATE STANDARDSPLANNING ORGANIZING
DIRECTING COORDINATING)
Ø control human, financial, material resources
GLOBAL EVOLUTION/ HISTORY OF NURSING
Ø set goals
I. INTUITIVE NURSING
Ø make decisions
INTUITIVE- instinctive or untaught; based on common sense
Ø solve problems
based on effect of past experience
- WOMEN- as custodian or nurse
9. CASE MANAGER -SHAMAN (witch doctor/ medicine man)- white magic (healing
- coordinate all aspects of the care of individual patients. The power)
one who oversees patients' long-term care plans. -TREPHINATION- hole drilled in the skull via rock or stone
w/o anesthesia
10. RESEARCH CONSUMER A. NURSING IN THE NEAR EAST
- aware of research process & language -roots of western civilization
- sensitive to issues on rights of human subjects -birthplace of Judaism, Christianity, and Mohammedanism
- participate in identifying research problems a. Babylonia
- discriminate research findings consumer - Metropolis of the near East
- King Hammurabi- ruler from 1945 BC to 1902 BC
11. EXPANDED CAREER ROLES Code of Hammurabi
 -Practice of medicine II. APPRENTICE NURSING
-fees -Nursing care performed by people who were directed by
-discouraged experimentation experienced nurses; the beginning of organized nursing
-specialty for diseases -On-the-job training performed without any formal education:
-right of patient to choose attributed to the religious orders of the Christian church
-excavated 1849 -Built hospitals were staffed by religious orders who dedicated
-no mention of nursing their lives to the care of the patients
b. Egypt -Organized nursing was found in the military, secular and
-embalming mendicant or begging orders
-record of 250 diseases A. THE CRUSADERS
-still no mention of nursing - considered as Holy Wars during Christian soldiers fought to re-
B. NURSING IN THE NEAR EAST capture the Holy Land from the Moslems
a. CHINA - KNIGHT OF ST. JOHN OF JERUSALEM (Rhodes, Malta) &
- belief in spirits and demons Teutonic Knights- fought in the battlefield
-prohibited dissection of human body -KNIGHT OF ST. LAZARUS- established their hospitals primarily
-Materia Medica (Pharmacology) for nursing of the lepers
- prescribed methods of treating wounds, infections and muscular -ALEXIAN BROTHER
afflictions -founded in 1348
-no mention of nursing but presumed female as in-charge of -established the Alexian Brothers Hospital School of Nursing
nursing the sick in Chicago
B. INDIA -closed in 1969
- men of medicine built hospitals -RELIGIOUS NURSING ORDERS
-practiced intuitive form of asepsis -founded by queens, princesses and other royal ladies
-proficient in the practice of medicine and surgery -some orders found before the Reformation
-the mention of nurses were in reference to the first lay brothers -Augustinians
or the priest nurses, who by virtue of their vocation, voluntarily -Poor Clares
took charge of taking care of the sick -Beguines
- SUSHURUTU/SUSRUTA- his writings (written 200 or 300 -Benedictines
BC) is a list of functions and qualifications of the priest-nurses -Ursulines
who were described as a combination of pharmacist, masseurs, -Tertiaries (lay people)
physical therapists and cooks. -HOTEL DIEU (in Paris)- were the Augustinian nurses
-BUDDHISM- contributed to the decline of medical practice -NURSING SAINTS-arouse in the 12th to 16th centuries
when the religion itself fell in this era -St. Clare (1194-1253)
C. NURSING IN THE ANCIENT GREECE -founder of the 2nd order of St. Francis of Assisi
a. GREECE -took care of the sick particularly the lepers
- nursing was the task of untrained slave -St. Catherine of Siena (1374-1380)
-women were considered inferior to men & were made to stay -the first to be called “Lady with the Lamp”
at the background to do house chores and care for the sick. -nursed patients in the hospital of Santa Maria
-AESCULAPIUS- Father of Medicine in Greek Mythology -1347- BUBONIC PLAGUE- struck Sienna
-CADUCEUS -Catherine still took care of the victims
-could be traced in GM but developed into an official
insigma (sign; symbol of identity of the medical profession)
-composed of the staff of travelers intertwined with 2
serpents and wings of Hermes or Mercury B. IMPACT OF SOCIAL REVOLUTIONS
a.1 VINCENT DE PAUL
-HIPPOCRATES -organized the works of charity so as they could have
-born in Greece in 460 BC directions
-given a title of Father of Medicine due to notable -organized a group of women and then named the LA
contributions to medical practice CHARITE
-developed a philosophy of medicine and practice medical -founder of “the community of sisters of charity”
ethics a.2 LOUISE DE GRAS (nee de MARILLAC)
-rejected the belief that the origin of diseases could be -co-foundress and the 1st superior
found in the supernatural C. THE REFORMATION AND THE COUNTER REFORMATION
-role of nursing wasn’t mentioned c.1 THE REFORMATION
-MARTIN LUTHER- head of the reformation movement;
D.TRANSITION FROM PAGAN TO CHRISTIANITY initiated some significant changes in the church
PHILOSOPHY -an era that gave rise to some violent conflicts
a. ROME -contributed to the rise of Protestants, other Christian
- illness was a sign of weakness denominations served as volunteers for the care of the sick.
-care of the sick was left to the slaves and Greek physicians c.2 THE COUNTER-REFORMATION
-some were however converted to Christianity and left their -a movement that encouraged a virtuous Christian life but
pleasure-seeking life (i.e., story of FABIOLA) discouraged violent conflicts
-focused in peaceful means of change
 -virtuous men and women gave examples of dedicated civilians; founded by Gov. Francisco de Sande.
service to society including service to the sick
c.3 RENAISSANCE (rebirth) San Lazaro Hospital (1578) – founded by Brother Juan
-rise of progress in arts and culture but NOT in moral and Clemente and was administered for many years by the
religious values
-society was filled with thieves due to social deprivations Hospitalliers of San Juan de Dios; built exclusively for patients
-care of the sick was entrusted to those who were proven guilty with leprosy.
of a crime of theft
-care takers were not given humane facilities Hospital de Indios (1586) – established by the Franciscan
c.3.1 CHARLES DICKEN
-writer who depicted the inhuman situation of the care takers in Order; service was in general supported by alms and
1 of his novels entitled MARTIN CHUZZLEWIT contributions from charitable persons.

EFFECTS OF SOCIAL REFORM IN NURSING Hospital de Aguas Santas (1590) – established in Laguna; near
-physical and mental illnesses a medicinal spring, founded by Brother J. Bautista of the
BEDLAM- Bethlehem hospital in London
-tickets were sold to the public to show the insane Franciscan Order.
-doctors became convinced of the need for training nurses
San Juan de Dios Hospital (1596) – founded by the
-protestants and catholic groups established nursing orders
-DEACONESS SCHOOL OF NURSING Brotherhood of Misericordia and administered by the Hospitaliers
-1st organized training school for nurses established by
Pastors Theodore Fliedner started with 6 students of San Juan de Dios; support was delivered from alms and rents;
C. NURSING IN THE NEW WORLD rendered general health service to the public.
JEAN MANCE
-1st lay woman who worked as a nurse on the North American
Continent and the founder of Hotel Dieu of Montreal in October
1644 Nursing During the Philippine Revolution
a. PRE-CIVIL WAR NURSING
MRS. ELIZABETH SETON In the late 1890’s, the war between Philippines and Spain
-american who founded the Sisters of Charity of Emmetsburg in
Maryland in 1809 emerges which resulted to significant amount of casualties. With
this, many women have assumed the role of nurses in order to
HISTORY OF NURSING IN THE PHILIPPINES assist the wounded soldiers. The emergence of Filipina nurses
Two words—mysticism and superstitions.
brought about the development of Philippines Red Cross.
Early Care of the Sick
Josephine Bracken — wife of Jose Rizal, installed a field
-subscribed to superstitious belief and practices in relation to
health and sickness. hospital in an estate house in Tejeros. She provided nursing care
-Herb men were called “herbicheros” meaning one who practiced to the wounded night and day.
witchcraft. Difficult childbirth and some diseases (called “pamao”) Rosa Sevilla de Alvero — converted their house into quarters
were attributed to “nunos”. Midwives assisted in childbirth. During for the Filipino soldiers; during the Philippine-American War that
labor, the “mabuting hilot” (good midwife) was called in.
broke out in 1899
Dona Hilaria de Aguinaldo — wife of Emilio Aguinaldo who
Health Care During the Spanish Regime
organized that Filipino Red Cross under the inspiration of Mabini.
The context of nursing has manifested through simple nutrition,
wound care, and taking care of an ill member of the family. Provided nursing care to Filipino soldiers during the revolution
Certain practices when taking care of a sick individuals entails Melchora Aquino a.k.a. “Tandang Sora” — nursed the
interventions from babaylan (priest physicians) or albularyo (herb wounded Filipino soldiers and gave them shelter and food.
doctor). In 1578, male nurses were acknowledged as Spanish
Hospitals and Nursing Schools
Friars’ assistants for caring sick individuals in the hospital. These
-Americans began training the first Filipino nursing students in
male nurses were referred as practicante or enfermero.
1907. Nursing students in the Philippines studied many of the
The earliest hospitals were: same subjects as nursing students in the U.S.
Hospital Real de Manila (1577) – it was established mainly to Hospital School of Nursing’s Formal Training (1901 – 1911)
care for the Spanish king’s soldiers, but also admitted Spanish -The first hospital in the Philippines which trained Filipino nurses
in 1906 was Iloilo Mission Hospital, established by the Baptist imprisonment of not less than one (1) year nor more than six
Missionaries. When this health institution was built, there were no (6) years, or both, upon the discretion of the court; shall be
strict requirements for the applicants as long as they are all imposed upon:
willing to work.
A .without a certificate of registration/professional license

Iloilo Mission Hospital School of Nursing B. who uses an invalid certificate of registration/professional
In April 1944 graduate nurses took the first Nurses Board license or an expired or cancelled special/temporary permits
Examination at the Iloilo Mission Hospital.
C. who gives any false evidence to the Board in order to
Saint Paul’s Hospital School of Nursing (Manila, 1907) obtain a certificate of registration/professional license
Philippine General Hospital School of Nursing (Manila, 1907)
D. who appends B.S.N./R.N. without having been conferred
St. Luke’s Hospital School of Nursing (Quezon City, 1907) said degree or registration
Mary Johnston Hospital and School of Nursing (Manila, 19
E. assists the illegal practice of a person who is not lawfully
Philippine Christian Mission Institute Schools of Nursing
qualified to practice nursing.
Sallie Long Read Memorial Hospital School of Nursing
(Laoag Ilocos Norte, 1903) NEGLIGENCE- a legal wrong committed against a person, failure
to preform duty
BATTERY- unlawful touching
ASSAULT- treat to injury
ILLEGAL DETENTION- unjustifiable detention
INVASION OF PRIVACY- unwarranted publicity (images)
DEFAMATION- character assasination
SLANDER- oral defamation- information is being spoken

PHILIPPINE NURSING LAWS AND LEGISLATION LIBEL- written defamation, information is being written

Republic Act No. 9173 TORTS- wrongful acts that do not involved contract

- An act providing for a more responsive nursing profession, SIGNATURE-

repealing for the purpose republic act no. 7164, otherwise RECIPROCITY-certificate of registration/professional license may
not be issued without examination to nurses under the laws of a
foreign state or country
Known as "The Philippine Nursing Act Of 1991" and for other
MALPRACTICE- failure of a professional to use the degree of
purposes
skill and learning commonly expected in that individulas
Section 3. Creation and Composition of the Board profession resulting in injury loss or damage to the person

- Composed of a Chairperson and six (6) members receiving care

ABUSE-any care that results in physical harm, pain
Salary CONTRACTS- an agreement made between two or more parties

-the minimum base pay of nurses working in the public ETHICS-a set of principles relating to what is morally right or

health institutions shall not be lower than salary grade 15 wrong provide a standard of conduct or code of behavior
LICENSURE- process whereby a government agency authorize
Prohibitions in the Practice of Nursing individual to work in a given occupation

-A fine of not less than Fifty thousand pesos (P50,000.00) nor OATH/OATHTAKING- all successful candidates in the

more than One hundred thousand pesos (P100,000.00) or examination shall be required to take an oath of professional
before the Board or any government official authorized to DISEASE PREVENTION
-to protect the patients from actual or potential health threats
administer oaths prior to entering upon the nursing practice
II. SECONDARY PREVENTION
GROUNDS FOR REVOCATION/ SUSPENSION
-those preventive measures that lead to early diagnosis and
-unprofessional and unethical conduct, serious ignorance, prompt treatment of disease, illness or injury
-to prevent more severe problems developing
malpractice, negligence in the practice of nursing
III. TERTIARY PREVENTION: REHABILITATION
-to improve treatment and recovery
CRIMES, MISDEAMENORS, FELONY -to restore the patient to an optimum level of functioning
CRIME- an act ocommitted or ommitted in violation LEVELS OF CARE
CONSPIRACY- two or more person agree to commit a felony -nurse- centered
PRINCIPAL- the mastermind
ACCOMPLICE- the person who cooperate in the execution I. HEALTH PROMOTION
ACCESORY- have knowledge on the crime, assisted in -to increase well-being and actualized human health potentials
concelaing or assisting in the escape
MISDEAMENORS- crime that is punishable by fines or II. DISEASE PREVENTION/ HEALTH PROTECTION
imprisonment of less than a year -to actively avoid illness, motivated by “AVOIDANCE”
FELONY- crime that is punishable by fines or imprisonment to be -HEALTH MAINTENANCE-person strives to prevent relapse
sentenced to death or to be imprisonment for a longer time
THEIFT- taking personal property of another person in his III. CURATIVE
presence -care that tends to overcome disease and promote recovery
CRIMINAL LAW-focuses on wrong against a person property or IV. REHABILITATION
society -assisting the client to function adequately
CIVIL LAW- crime focuses on legal relationships between people
and protection of civil right DOCUMENTATION
-written, legal record of all pertinent interactions with the client
CLASSIFICATION OF FELONIES
-GREATER Two types of documentation
-LESER 1. Traditional
-LIGHTER 2. Problem- Oriented Records

CLASSES OF FELONIES Traditional

-CONSUMMATED -notations are entered chronologically with the most recent entry
-FRUSTRATED being nearest the front of the record
-ATTEMPTED -progress notes are written in narrative form
MORAL TORPITUDE
Problem-Oriented Records
MURDER- unlawful killing of a human being with an intent
-organized around a patient’s problem rather than around
HOMICIDE- killing a human being without criminal intention
sources of information
INFANTICIDE-killing of a human being less than 3 days of age
-progress notes clearly focus on the patient’s problem
SIMULATION OF BIRTH- certificate to a birth that did not occur
PARRICIDE- killing of mother, father or child whether legitimate THE NURSING PROCESS AND POR
or illegitimate
NURSING PROCESS POR

LEVELS OF PREVENTION I. ASSESSMENT I. DATA-BASE

-patient – centered Data Collection
Data Processing
I. PRIMARY PREVENTION 1. Health Promotion Problem Identification With II.PROBLEM LIST
2. Disease Prevention Priority Setting
II. SECONDARY 3. Early Diagnosis Nursing Diagosis
PREVENTION 4. Prompt Treatment II. PLANNING III. INITIAL PLAN OF
III. TERTIARY PREVENTION 5. Rehabilitation Objectives Of Nursing CARE
Action
Plan Of Care (Selection Of
Alternatives)
I. PRIMARY PREVENTION
-to decrease the risk of exposure of the individual or community III. IMPLEMENTATION IV. PROGRESS NOTES
to decrease (SOAPIE)
HEALTH PROMOTION
-to increase control over the determinants of health IV. EVALUATION DISCHARGE SUMMARY
PURPOSE OF PATIENTS RECORD
Communication
Care Planning
Quality Review
Research
Health Care Analysis
Education
Legal Documentation
Reimbursement
Historical Documentation
GUIDELINES FOR EFFECTIVE DOCUMENTATION
1. Content
-enter information in a complete, accurate, relevant and factual
manner; record patient’s findings rather than own interpretation
*avoid using good, normal, average or sufficient
2. Timing
-indicate each entry, the date and both the time the entry was
written and the time of pertinent observations and interventions
3. Format
-chart on the proper form as designated by agency policy
-print or write legibly in dark ink to ensure permanence
-use correct grammar
-use standard terminology(ies)
-chart nursing interventions chronologically
4. Accountability
-sign your initial, last name and title to each entry
-Do not sign notes describing interventions not performed by you
that you have no way of verifying
5. Confidentiality
-patients have moral and legal rights to expect that the
information contained in their patient health record will be kept
private;keep in strict confidence all the information they learif