WEEK 2: COMMUNICATION AND NURSING PRACTICE

COMMUNICATION
▪ Method used to
• Act of transferring information from convey the message
one place, person or group to to the receiver
another
• Exchange of info between two or 3. Receiver
more people ▪ The listener
• Exchange of ideas and thoughts
• Transmission of feelings or social Decoding – the translation of
interaction between people message via receiver’s
• Two purposes: To influence and to interpretation (sorts out the meaning
gain information of the message)
- Word interpretation, display
2 referents in Communication: Sender format etc.
and Receiver
4. Response or Feedback
EFFECTIVENESS OF COMMUNICATION ▪ Message of the
IN NURSING receiver returns to the
sender
✓ Ensures the patient’s safety ▪ Feedback can be
✓ Reduces the risk errors verbal or non-verbal
✓ Improves the client’s satisfaction of Examples of Feedback in Hospital
care Setting: Ratings, Likert Scale
✓ Creates effective and professional (Satisfactory Result)
relationship (nurse-client
relationship) Feedback in Nursing: Evaluation
✓ Meets the legal, ethical, and and Response (checks if there’s any
clinical standards of care modifications or changes needed)

COMMUNICATION PROCESS LEVELS OF COMMUNICATION

1. Sender (Source-encoder) 1. Intrapersonal – occurs within

▪ Person who wishes to the individual
communicate the message 2. Interpersonal – one on one
to another interaction between two
people
Encoding – selection of specific signs or 3. Transpersonal – interaction
symbols to transmit the message such as within a person’s spiritual
which words, intonations, gestures and domain
language to use (word choices) 4. Small Group – interaction with
small number of people
2. Message (Communication 5. Public Group – interaction
Channel) with an audience
▪ The message itself and how
1
it was transmitted
TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)
ELEMENTS OF COMMUNICATION client relationship to
1. Verbal – way of a spoken become more effective
language
2. Non-verbal – way of a body 3. Clarity and Brevity
language ▪ Clarity – what is meant
3. Written – way of written language, ▪ Brevity – use of fewest
symbols and numbers words as possible
4. Visual – use of photography, art ▪ Must be simple and
and drawing clear
▪ Refers to the shortness
MODES OF COMMUNICATION: VERBAL but specific and
COMMUNICATION AND ITS precise of the
ASPECTS message tries to
convey
▪ Use of spoken or written word
4. Timing and Relevance
Oral: Speaking ▪ Nurses’ awareness
Non-Oral: Writing, Sign Language when is the time to
communicate with the
client
ASPECTS OF VERBAL COMMUNICATION ▪ The message that is
trying to convey in
1. Pace and Intonation nurse and client
▪ Manner of speech, rate or relationship must
rhythm or tone modifies the include to
feeling and impact of the
message cater the concerns
▪ Tone of message can be and interests
express emotion such as
enthusiasm 5. Adaptability
▪ Rate of speech can express ▪ Knowing the client’s
feeling such as anxiety, language or dialect to
boredom, etc. avoid communication
barriers
2. Simplicity (miscommunication)
▪ Use of simple words ▪ Nurses alter spoken
according to the client’s messages in
level of understanding, accordance with
avoid behavioral cues from
the use of slang language the client
▪ Use of commonly
understood words 6. Credibility
▪ Note: Identifying pt’s level of ▪ Worthiness of belief,
education can help with trustworthiness and
communication in nurse- reliability
2
qw5
TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)
▪ Nurses must always speak 4. Eye Contact
with conviction (confident 5. Gestures
and aware) ▪ Hands and gestures may
emphasize and clarify the
7. Humor spoken word, or they may
▪ Adding humor in the nurse- occur without the use of
client relationship provides words to indicate a particular
a relaxing and comfortable feeling or to give a sign
environment
NURSE-PATIENT RELATIONSHIP
NON-VERBAL COMMUNICATION AND PROCESS
ITS ASPECTS
1. PRE- INTRODUCTORY or PRE-
▪ Also known as body language INTERACTION PHASE
▪ Occurs before meeting the
Oral: Laughing, Crying, etc. patient
Non-oral: Gestures, Body Language ▪ Checks the client’s medical
records if there’s available
ASPECTS OF NON-VERBAL
COMMUNICATION 2. ORIENTATION PHASE or
INTRODUCTORY PHASE or PRE-
1. Personal Appearance HELPING PHASE
▪ Person’s clothing can be a source ▪ Sets the tone for the rest
of information about the person of nursing-pt relationship
▪ Often used as an indicator how process
the person feels ▪ Nurse and the client
meet and get to know
2. Posture and Gait each other
▪ Indicators of self-concept, current ▪ The nurse and the client work
mood and health together to solve problems
and accomplish goals
Erect posture – shows an active, ▪ Inhibition of resistive
purposeful stride that suggests a behaviors (shows involvement
feeling and well-being and active participation of
the client in the nursing
Slouched posture – slow, shuffling process)
gait that suggests depression and Expected outcome at the end of
physical discomfort orientation phase:
▪ Develop trust in the nurse
Tense posture – rapid, determined ▪ View the nurse as a
gait that suggests anxiety and competent, honest, open,
anger and concerned
▪ Believe the nurse will try to
3. Facial Expressions understand and respect
▪ No part of the body is as the client’s cultural values3
expressive as face and beliefs
TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)
▪ Understand the purpose of the ▪ Sociocultural factors
relationship and the roles (Educational attainment)
▪ Feel that they are active ▪ Gender
participants in developing a
mutually agreeable plan of 2. Diagnosis
care ▪ Many clients experience
difficulty with
3. WORKING PHASE communication:
▪ The nurse and the patient work ✓ Lacking skills in attending,
together to solve problems and listening, responding or self-
accomplish goals expression
▪ Nurse and the client begin to view ✓ Inability to articulate,
each other as unique individuals inappropriate verbalization
▪ The nurse helps the client explore ✓ Difficulty forming words
thoughts, feelings, and actions ✓ Difficulty with comprehension
and helps the client plan a Sample Nursing Dx: “Altered
program of action to meet pre- impaired communication
established goals associated with poor verbal
2 stages: communication”
1. Exploring and understanding
thoughts and feelings 3. Planning
2. Facilitating and taking action ▪ Goals and outcomes
▪ Specific and measurable
4. TERMINATION PHASE ▪ Setting of priorities
▪ Occurs at the end of the ▪ Teamwork and collaboration
relationship Outcomes:
▪ Follow up phone calls are emails ✓ The client is able to initiate
are common in termination phase conversation about the
to ease the client’s transition to diagnosis or healthcare
independence problem (showing concern
and interest)
NURSING PROCESS ✓ Patients convey clear and
understandable message to
1. Assessment the healthcare team
▪ Maintain eye contact when ✓ Increases the patient’s
talking to client satisfaction with the
▪ Gather information and communication process
synthesize the information ✓ Setting priorities by
given maintaining an open
▪ Apply critical thinking communication to ensure the
▪ Consider the following during client is comfortable and all
the assessment: the physical needs have
▪ Physical and emotional factors been met
▪ Developmental factors (Cognitive, ✓ Teamwork (In case the client
Motor Skills, Language) is having problems with
4
▪ communication, you may
TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)
need to seek services from a speech HEALTH TEACHING AND ITS
therapist or an interpreter PRINCIPLES

4. Implementation 1. CREDIBILITY
▪ Therapeutic communication ▪ Perceived as trustworthy by
- techniques are specific the client
responses that encourage
the expression of feelings 2. INTEREST
and ideas and convey ▪ Must attract the interest of
acceptance and respect the people (they must listen)
▪ Active listening - means
being attentive to what the 3. PARTICIPATION
pt is saying both verbal and ▪ Letting the client to
nonverbal aspect participate
▪ SOALER
S – Sit down 4. MOTIVATION
O – Open posture (Open ▪ Motivation is a fundamental
arms, legs crossed) desire of learning
A – Must not be apart to the ▪ One day or Day one
client/ receiver (A is
optional and situational) 5. COMPREHENSION
L – Lean (For better hearing ▪ Must be according to the
and active listening) patient’s level of
E – Eye contact understanding
R – Relax
▪ Effective communication – 6. REINFORCEMENT
facilitative and tend to ▪ Repetition in health teaching
encourage the other person ▪ Health teaching that is done
to openly express ideas, in regular intervals/ frequency
feelings or concerns helps client to understand
better
5. Evaluation
▪ Nurse and pt need to 7. LEARNING BY DOING
determine whether the plan ▪ Learning is accompanied by
of care is successful (If the doing new things
expected outcomes are not
met, the plan of care needs 8. KNOWN TO UNKNOWN
to be modified) ▪ Nurses must find out what the
▪ Nursing interventions are client/ people already know
evaluated to determined and how to give or to provide
which strategies or them new knowledge
interventions were effective
9. SETTING AN EXAMPLE
▪ The health educator must
follow what he/she preaches5

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

10. COMMUNITY LEADERS
▪ Community leaders must convince
the people to establish rapport
▪ They will also have an
understanding about what the
community needs

11. SOIL, SEED SOWER

Soil – The community
Seed – The information
Sower – Nurses/ Health Educators

WEEK 2: CLASSIFICATIONS OF FIELDS OF NURSING

1. Hospital or Institutional Nursing ✓ More staff development

2. Public Health Nursing programs are available in
3. Private Duty or Special Duty hospitals
Nursing
4. Industrial or Occupational Health DISADVANTAGES
Nursing ❖ Possibility of understaffing
5. Nursing Education ❖ Don’t find CPD’s
6. Military Nursing ❖ Administrative problems and
7. School Nursing overwork may tend to
8. Clinic Nursing dissatisfy staff nurses
9. Independent Nursing Practice
POSSIBLE AREAS OF SPECIALIZATION
HOSPITAL / CLINICAL / INSTITUTIONAL ▪ Neonatal
NURSING (STAFF NURSE) ▪ Pediatric
▪ Adult Med-Surg
Advantages: ▪ OB-Gyne
✓ There’s a supervisor that can ▪ Psychiatry
consult if a problem exists ▪ Dermatology
✓ Updated to the new trends of ▪ Case Management
medicine and in the nursing care ▪ Hospice/Palliative
of patients ▪ Renal or Nephro
✓ Undergo in rotations ▪ Critical Care
✓ Provision of sick leave, holidays, ▪ Emergency Care
vacation with pay ▪ Perioperative Nurse
✓ Can be promoted to higher ▪ Nursing Informatics
positions ▪ Oncology
✓ Salary increases according to the ▪ Orthopedic
merit system
✓ Important member of the
healthcare team in providing care
to the patients 6

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

QUALIFICATION OF NURSING SERVICE assume responsibility for their
ADMINISTRATORS own health care

According to the Section 29 of the Disadvantages

Republic Act 9173 ❖ Cases with chronic and
communicable diseases
▪ Must be a registered nurse in are only limited
the Philippines ❖ More hazards
▪ Have at least 2 years of ❖ No fixed hours
experience in general nursing ❖ Limited facilities
service administrator ❖ Not immediately aware of
▪ With BSN degree with at least 9 changes/trends in the
units in management and fields of medicine/nursing
administration course at ❖ No immediate supervisor to
graduate level consult in case of
▪ Member of Philippine Nurses emergency
Association
PRIVATE DUTY NURSE
PUBLIC HEALTH NURSING
▪ Roles in service delivery ▪ Directly under the supervision
▪ NARS – “Nurses Assigned in Rural of the nursing service or AP of
Service the patient
▪ Known as the “Warriors for ▪ Responsible for nursing care
Wellness” ▪ Provision of nursing care
▪ Initiator of primary health, before going off duty
maternal health programs, and first
line diagnosis Qualifications:
▪ Teacher of community water ✓ Must be a registered nurse in
sanitation and other the Philippines
environmental practices ✓ Must have atleast 2 years of
▪ Public health nurses are also bedside nursing experience
epidemiologists – ones who ✓ Preferably undergone Critical
practice health surveillance in the Care Nursing Course
community ✓ IV therapist
▪ They are also heath advocates for
child immunization and mothers Advantages
✓ Opportunity to make friends
Advantages ✓ Opportunity to travel
✓ Focuses in nursing care of the ✓ New knowledge and
family and the community procedures
✓ Takes a vital role in nation building ✓ Challenges the nurse
✓ Utilizes various resources and providing the best nursing
maximizes coordination care
✓ Individuals, families, and
communities are motivated to
7
✓
TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)
Disadvantages ✓ Must have a 1 year of clinical
❖ Patients become totally practice in the field of
dependent specialization
❖ Unavailability of nurses in evening ✓ Member of the Philippine
shifts, holidays, weekends Nurses Association
❖ Minimized opportunity for good ✓ Holder of masteral degree in
relationship with other hospital nursing education or other
personnel allied medical and health
❖ Resent supervision by hospital staff sciences conferred by
❖ Little assistance given when the college or universities duly
patient is critically ill recognized by the Philippine
❖ No participation in professional Government
activities
❖ Face problems in private practice MILITARY NURSING
❖ No retirement, insurance and
health benefits ▪ To meet the nursing needs of
today’s patients in AFP
INDUSTRIAL NURSING medical facilities
▪ To prepare each Nurse Corps
▪ Provides and delivers health care Officer (regular and reserve)
services to workers for future assignments at a
▪ Focuses on promotion, protection higher level of responsibility in
and supervision of worker’s health the different stations and
within the context of safe and general hospital in times of
health work environment peace and war
▪ Need to be fully informed about ▪ To teach and train enlisted
their legal responsibilities (PD 442) personnel who perform
▪ Know company policies on nursing functions under
personnel, insurance benefits, sick supervision
leave, pay rates, health programs,
medical matters and records Qualifications
▪ Custodian of employees health ✓ Must be graduated with BSN
records, counselors and advisers to degree
the workers, interpreters of ✓ Registered nurse
company policies, health and ✓ Single
safety teachers as well as first ✓ Physical and mentally fit
aiders to the injury ✓ At most 32 years of age
▪ Day hours duty and day off during ✓ Be interested and willing to
weekends work in both peaceful and
war time conditions
NURSE EDUCATOR ✓ Height requirement:
5’2 in male
Qualifications: 5’0 in female
✓ Must be a registered nurse in the
Philippines 8

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

Privileges and Benefits Disadvantages
• High salary and allowance – ❖ Don’t update themselves to
incentive pay subsistence the current issues and
allowance, quarter unaware changes in the
allowance, clothing, 20% nursing practice
hazard pay 50% flight pay ❖ Accept the educational
for flight nurses functions of the school
• Prestige of uniform and rank
(Lt. II) FLIGHT NURSE
• Hospitalization and free • Provides care to infants,
medical benefits for children, and adult patients
parents, dependent, while performing a variety of
authorized relative with therapeutic interventions
specialists care requiring independent
• Military school and basic decisions
training • Provides education to
• Opportunity to attend gala, outlying communities and
social functions etc. serves as a volunteer in
emergency situations
SCHOOL HEALTH NURSING
• School activities in health service, NURSE ENTREPRENEUR
health education and • Nurse becoming
environmental health and safety entrepreneurs in variety of
• Health promotion, prevention of consultative, educational
disease and follow through of any and technical areas
findings that may indicate a need
for medical care and treatment Advantages:
• Basic screening for vision, hearing, ✓ Independence
and risk factors that would ✓ Job satisfaction
interfere with the development of ✓ Flexibility
a healthy lifestyle ✓ Choice
• Organizing, coordinating and
implementing the school health FORENSIC NURSE
program ✓ Work with law enforcement
• Undertaking functions directly officials as well perpetrators
related to pupil’s health and victims of crime
• Evaluating school health programs
• Carrying out functions related to Specialties included:
the health of school personnel ▪ Death investigators
▪ Correctional nurses
Advantages: ▪ Nurse attorneys
✓ Observe the development health ▪ Domestic violence specialists
of a student ▪ Human rights advocates
✓ No shift duty ▪ Sexual assault nurse
examiners 9

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

Duties include:
▪ Collection of clinical evidence
▪ Determination of origin or
circumstances of trauma
▪ Evaluation and alleviation of crime
victims’ injuries and rehabilitation
of criminals

WEEK 3: NURSING CARE PLAN

NURSING PROCESS Primary Sources

Nursing process is: ➢ The data gathered is from the
✓ Systematic (follows different steps), client (client must be alert
✓ Rational method of planning and oriented, patient’s acuity
(planning what care must be done and its neurological status
and must be realistic) must be accurate)
✓ And providing individualized
(every client under the nursing Secondary Sources
care might have different ➢ From the patient’s family and
diseases/diagnosis, but have significant others, healthcare
different chief complaint) nursing team, medical records, other
care records and the scientific
literature, nurse experience
NURSING PROCESS: ➢ Secondary source is
• Assessment gathered when the client is
• Nursing Diagnosis unable to supply info due to
• Outcomes Identification deterioration of mental status,
• Planning age or seriousness of illness
• Implementation – Rationale
• Evaluation Types of Data
1. Objective (Overt data or
NURSING PROCESS: ASSESSMENT signs)
▪ Detectable by an observer or
A. Data Collection the nurse practitioner
▪ Can be tested against an
Methods of Gathering Data accepted standard
1. Observation (Use of 5 senses) ▪ Can be seen, felt, smelled or
2. Interview (Gathering the heard
subjective data)
3. Physical Examination (Use of IPPA) 2. Subjective (Symptoms or
4. Review of Records (Patient’s chart) Covert Data)
5. Collaboration with the members of ▪ Apparent only to the person
the healthcare team affected and can be
described or verified only by
that person
10

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

▪ Head to toe assessment
▪ Includes client’s sensation, feeling, (Cephalocaudal assessment)
values, beliefs, attitudes and
perceptions of personal health NURSING PROCESS: DIAGNOSIS
status and life situation ▪ Second step in the nursing
process
Components of Nursing Health History ▪ Made by the North American
- Biographical Information Nursing Diagnosis Association
- Patient’s expectations (NANDA)
- Reason of seeking healthcare
- Health History (Overall since Types of Nursing Diagnoses
infancy)
- Psychosocial History 1. Actual nursing diagnoses or
- Review of Systems Problem focused diagnosis
(Cephalocaudal assessment) ▪ The problem is seen
- Spiritual History throughout several shifts or
client’s entire hospitalization
*The organization of data according to ▪ It can be resolved during a
Gordon’s 11 Functional Health Pattern shift depending on the
nursing and medical care
1. Health Perception or Health Examples:
Management - Decreased cardiac output
2. Nutritional-Metabolic - Chronic functional
3. Elimination constipation
4. Activity - Exercise - Impaired gas exchange
5. Cognitive - Perceptual
6. Sleep-Rest 2. Risk nursing diagnosis
7. Self-Perception/ Self-Concept ▪ Diagnosis for the possible
8. Role-Relationship complication of the client
9. Sexuality-Reproductive ▪ When risk factors require
10. Coping / Stress Tolerance intervention from the nurse
11. Values / Beliefs and healthcare team prior to
a real problem developing
Diagnostic and Laboratory Data Examples:
➢ Under the Objective data - Risk for imbalanced fluid
➢ Include items such as blood and volume
urine studies, cultures, X-rays, and - Risk for ineffective
diagnostic procedures childbearing process
- Risk for impaired oral mucous
Physical Assessment membrane integrity
▪ Assessment Techniques
o Inspection 3. Health Promotion
o Palpation ▪ Diagnosis for the promotion
o Percussion of client’s optimal health
o Auscultation ▪ Improve the overall well
being of an individual, family
11
or community
TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)
Example: NURSING PROCESS:
- Readiness for enhanced family IMPLEMENTATION or
processes INTERVENTION
- Readiness for enhanced hope
- Sedentary lifestyle • These are activities that
promote the achievement of
Syndrome diagnosis the desired patient outcome
▪ Refers to a cluster of nursing • Involves the execution of the
diagnoses that occur in a pattern nursing plan of care
or can all be addressed through formulated during the
the same or similar nursing planning phase
interventions
TYPES OF NURSING INTERVENTIONS
Examples:
- Decreased cardiac output 1. Independent Nursing
- Decreased cardiac tissue Intervention
perfusion • A nursing action that
- Ineffective cerebral tissue doesn’t require doctor’s
perfusion order
- Ineffective peripheral tissue • Those action that the nurse
perfusion can perform without
direction from others
NURSING PROCESS: PLANNING
2. Dependent Nursing Intervention
▪ Outcome Identification • Prescribed by the primary
▪ A deliberate, systematic phase care provider
that involves decision making and • Actions prescribed by the
problem solving geared toward doctor or dentist and carried
preventing, reducing and out by the nurse
eradicating a client’s health
problems 3. Interdependent nursing
▪ Must be in a holistic overview intervention or Collaborative
▪ Establish patient goals Interventions
▪ Develop patient outcomes • Those actions that nurses and
o Short-term other health care personnel
o Long-term perform together

In the planning phase of the nursing NURSING PROCESS: EVALUATION

process, priorities must established: • 6th and final step of the
• High emergent – ABC’s nursing process
• Intermediate – non-life threatening • Determine the pt’s progress in
(eg. Immobilization) achieving outcomes
• Low – only affects the client’s well • Evaluate each outcome
being separately
12

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

• Document whether outcome was o Used to check if the
achieved or not achieved nurse performed the
• Can be met, partially met, needed procedure for
unmet/not met the client
• May result in revising the plan of 2. Legal Evidence of Care
care (Nursing process is continual o Charts are stored in
and dynamic process) the hospital library but
the access is limited
STUDENT CARE PLANS that cannot be
• Helps to apply knowledge gained accessed by everyone
from nursing literature and (due to data privacy
classroom to a practice situation and confidentiality)
• More elaborate than a care plan
used in a hospital or community 3. Education
agency for its purpose to teach o Commonly used in
the process of planning care case presentations
where nurses learned
Planning care for patients in community- the lessons/important
based settings involves: moments during
➢ Educating the patient/family patient care
about care
➢ Guiding them to assume more of 4. Financial Billing
the care over time o The first page of the
chart shows the
DOCUMENTATION personal info sheet, on
what health insurance
• Process and art of completing the the client is under
record the care provided to a o Reflects what are the
patient which is done in writing or procedures,
encoded in a computer by the medications that will
nurse be deducted by
• In legal battle, incomplete insurance
medical record may present 5. Evaluation of quality of care
difficulties that cannot be rendered
overcome o Used in post care
• Lack of documentation could be conferences
considered evidence of
negligence in extreme cases 6. Research and statistical
• What is not written is not done information
o Can be used as a
Purposes of Documentation census and statistical
1. Communication cases
o Pertains about the client’s o The documentation
details such as basic gathered can be used
information, medical advice in education (Pt’s
given by the physician chart reflects what
13
cases or problems in
TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)
▪ Write as soon as possible after
healthcare must be seek giving nursing care so that
with attention)

Guidelines for Recording/Documentation you can recall will be most

accurate
✓ Accurate and concise
▪ Accurate notation of facts or 2. Appropriateness
exact observation ▪ Only information that pertains
▪ Avoid unnecessary description to the client’s health problem
▪ Avoid double meaning and care is reported
Example: Refused medication rather than ▪ Personal information that the
uncooperative client conveys to the nurse is
inappropriate for the record
✓ Specific. Avoid the words large, good
or normal 3. Completeness
▪ Must be in correct spelling ▪ Standard of nursing practice
▪ Be precise. Write how, when and specify that nurse’s role must
where events and activities reflect the nursing process
occurred. ▪ Use of standard terminologies
▪ Other professional can
✓ Avoid errors interpret data correctly
▪ Do not destroy or attempt to
obliterate data 4. Timing
▪ Draw one single through the ▪ Indicate the date, time of the
incorrect material, initial it, date recording assessment and
and write down the correct entry intervention is essential not
(depends on the patient policy) only for legal reason but also
▪ Not be erased or blotted so that for client’s safety
there is no doubt about the ▪ Should be done soon after an
charting error made assessment or intervention

✓ Do not leave vacant lines and sign 5. Confidentiality/Restricted

every entry Access
▪ Never leave a blank. Draw a line ▪ Private record
through unused spaces before ▪ Don’t allow access to any
your signature. person
▪ Vacant lines open the way for ▪ Restricted to health workers
others to add materials at a later involve in giving care to the
date client
Example: Urine yellow color, 500cc, no
odor _____ (sign) 6. Used in Ink (Permanence)
▪ Dark colored ink so that the
GUIDELINES FOR RECORDING record is permanent
1. Sequence ▪ Reproduce well on microfilm
▪ Events are in chronological order and in duplication process
14

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

▪ Entries need to be legible 4. SOAP/SAOPIE/SOPIER
S – Subjective data
7. Signature O – Objective data
▪ Include signature over the printed A - Assessment
name, title (depending on P - Plan
agency’s policy) I - Implementation
E - Evaluation
R – Revision
8. Brevity
▪ Do not write complete sentences 5. PIE Charting
but use adjectives and accepted ➢ Problem, Intervention,
abbreviations to give good picture Evaluation
of activities and observations
▪ Name of patient and word patient 6. Focus Charting
is omitted ➢ Method that uses a column
format to chart data, action
9. Legal awareness and response (DAR)
▪ Admissible in court as legal
document, the clinical record 7. Charting by Exception
provides proof of the quality of 8. FACT Charting
care given to the client ➢ A computer ready FACT
▪ Visit by a physician or other system incorporates many
member of the health team Charting by Exception
principles

TYPES OF CHARTING 9. Point of Care

Charting/Computerized
1. Narrative Charting Charting
➢ Chronological account of the
client’s status, interventions, CHARTING DON’TS
treatments and client’s response to ❖ Charting mistakes are legal
treatment land mines.
➢ Traditional method of nursing
documentation takes the form of a 1. Don’t record staffing
story written in paragraphs problems
2. Don’t record staff conflicts
2. Source Oriented Charting 3. Don’t mention incident
reports
3. Problem Oriented Charting (POMR) 4. Don’t use words associated
➢ Focuses on the client’s problem with errors like “by mistake”
and employs a structured, logical 5. Don’t name a second
format called SOAP charting patient instead use
S – Subjective data roommate
O – Objective data 6. Don’t chart casual
A - Assessment conversation with colleagues.
15
P - Plan
TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)
WEEK 4: BASIC INFECTION CONTROL (ASEPSIS)

THINGS TO REMEMBER WHEN

INFECTION PERFORMING HAND HYGIENE
❖ Growth of microorganisms in body
tissues where they are not usually 1. Ensure that the fingernails are
found short (fake nails must be
o Infectious agent removed), no jewelry worn,
o Virulence and no nail polish.
o Communicable Diseases
• Health care personnel
Asepsis – freedom from disease-causing should refrain from wearing
microorganism rings and other jewelry
when providing care and
Sepsis – condition in which organ should keep fingernails
dysfunction occurs secondary to well-trimmed, natural, and
infection polish free.

HAND HYGIENE Rationale: There is an increase

❖ Procedure that is considered as in number of bacteria under
the most effective means of jewelries such as rings and
spreading infection watches. Long fingernails,
❖ It is a procedure that uses any of artificial nails and chipped nail
the following: polish also harbor bacteria.
❖ Handrubbing (alcohol-
based) – hand hygiene 2. Hand hygiene is a requisite
procedure that uses 60%- skill that every health care
95% alcohol professional must perform at
❖ Handwashing – hand key times.
hygiene that uses soap and • These include before and
Water after patient contact,
after contact with blood
WHEN TO PERFORM HAND HYGIENE? or body fluids, after
✓ Before touching the patient contact with
✓ Before clean or aseptic procedure contaminated surfaces,
✓ After body fluid exposure (E.g. before donning and after
Blood) removing gloves
✓ After touching the patient
✓ After touching patient EDUCATION – HAND HYGIENE
surroundings 1. Teach the patient, family and
✓ Before donning and doffing of caregivers proper hand
gloves or PPE hygiene techniques, its
reason, and why it’s required

16

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

2. Provide developmentally and PRECAUTION
culturally appropriate education
based on the desire for 1. STANDARD PRECAUTION
knowledge, readiness to learn and ➢ Set of infection control
overall neurologic and practices used to precent
psychosocial state transmission of diseases that
3. Educate the pt, family and can be acquired by contact
caregivers about the risks for with blood, body fluids, non-
infection with improper hand intact skin (including rashes)
hygiene and mucous membranes

4. Teach the pt, family, and Standard precautions:

caregivers to ensure that the 1. Hand hygiene
home health nurse performs hand 2. Use of PPE
hygiene 3. Respiratory hygiene / cough
5. Encourage questions and answer etiquette
them as they arise 4. Sharps safety (engineering
and work practice controls)
5. Safe injection practices
PERSONAL PROTECTIVE EQUIPMENT (aseptic technique for
(PPE) parenteral medications)
6. Sterile instruments and
• Includes the following: devices (All equipment used
❖ Gown in OR sterile)
❖ Face shields or Goggles 7. Clean and disinfected
❖ Facemasks environmental surfaces
❖ Respirators or Face Masks
❖ Other equipment to protect 2. TRANSMISSION-BASED
frontline workers from injury, PRECAUTION
infection or illness A. Contact Precaution –
intended for the
• PPE sets as a barrier to block prevention transmission of
transmission of infectious materials from infectious agents, including
blood, body fluids, or respiratory epidemiologically
secretions to your skin, mouth, nose important microorganisms,
and eyes that can be spread by
• Also protects in high-risk patients from direct or indirect contact
exposure to potentially infectious with the patient or
material (Through hand hygiene, patient’s environment
proper wearing of PPE, covering
coughs and sneezes, it minimizes the - Used for clients with known or
spread of infection from one person to suspected infections and
another would likely be spread by
direct contact to client’s
environment
17

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)

B. Droplet Precaution – prevent the INFECTION CONTROL PRINCIPLES
spread of pathogens that are AND PRACTICES FOR LOCAL
passed through respiratory HEALTH AGENCIES
secretion and do not survive for
long in transit 1. RA 9003 Ecological Waste
Management – for waste
- Infectious agents that spread segregation
through close respiratory contact 2. MMDA Regulation No. 96-009
– schedule of garbage
- These droplets are relatively large collection
particles that cannot travel
through the air very far Hospital waste management color
codes:
- Can be transmitted through Yellow – infectious
sneezing, coughing and talking Red – sharp materials
Green – biodegradable
C. Airborne Precaution – Orange – radioactive
precaution required to protect Black – non-biodegradble
against airborne Yellow w/ Black – pharmaceuticals

transmission of infectious agents

- The infectious agent remains
suspended in air and over long
distances

PROTECTIVE ENVIRONMENT
❖ Intended for client with
hematopoietic stem cell
transplants
❖ Highly susceptible to fungal
infections
❖ Intended to reduce fungal spore
counts in the air

ISOLATION
1. Reverse Isolation – intended to
protect immunocompromised and
suppressed client
2. Quarantine – intended to limit
spread of infectious agent and
maybe applied to those exposed

18

TRANSCRIBED BY: YUTUC, JULIA FAYE M. (BSN 1A)