NCM 103

• Subject


  Noun, is the client, any part of the client or some attribute of the client
• Verb


  Specifies an action that the client is to perform (demonstrate, explain, show, walk)
• Conditions or Modifiers


  Added to the verb to explain the circumstance under which the behavior is to be performed (walks with a cane, when at home . . , )
• Criteria of Desired Performance

  Standard at which the client may perform the specified behavior
• Guidelines for Writing Goals

  • Combining goals and outcomes statements
  • Client-centered
  • Singular goal or outcome
  • Observable
  • Measurable
  • Time limited
  • Mutual factors
  • Realistic
• Expected Outcomes


  Statements that describe what we expect, statements of measurable action for the patient within a specific time frame that are responsive to nursing interventions
• Criteria for Choosing Nursing Strategies

  • Safe and appropriate for individual's age, health, etc.
  • Achievable with the resources available
  • Congruent with the client's values and beliefs
  • Congruent with other therapies
  • Based on nursing knowledge and experience
  • Within established standard of care
• Nursing Intervention


  Any treatment based upon clinical judgment and knowledge that a nurse performs to enhance client outcomes
• Types of Nursing Intervention

  • Independent / Nurse Initiated
  • Dependent
  • Collaborative / Interdependent
• Factors in Selection of Interventions

  • Characteristics of nursing diagnosis
  • Goals and expected outcomes
  • Evidence base for interventions
  • Feasibility of the intervention
  • Acceptability to the client
  • Nurse's competency
• Purpose of a Written Care Plan


  • Provides directions for individualized plan of care
  • Provides for continuity of care
  • Provides direction about what needs to be documented on the client's progress notes
  • Serves as a guide for reimbursement from medical insurance companies
  • Serves as a guide for assigning staff to care for the client
• Guidelines for Writing Nursing Care Plan (NCP)

  • Date and sign the plan
  • Use category headings
  • Use standardized medical or English symbols and keywords rather than the complete sentence
  • Be specific
  • Refer to procedure book and other sources of information rather than including all the steps on a written care plan
  • Tailor the plan to the unique characteristics of the client by ensuring that the client's choices are included
  • Ensure that nursing plan incorporates preventive and health maintenance aspects as well as restorative ones
  • Ensure that the plan contains interventions for ongoing assessment of the client
  • Include collaborative and coordination activities in the plan
  • Include plans for the client's discharge and homecare needs
• Infection


  • Growth of microorganisms in the body tissue where they are not normally found
  • An invasion of the body tissue by microorganisms and their proliferation there
• Types of Microorganisms that Cause Infection

  • Virus
  • Fungi
  • Parasites
  • Bacteria
• Types of Infection


  • Local Infection - limited to the specific part of the body where the microorganism remains
  • Systemic infection - microorganisms spread and damage different parts of the body
• Bacteremia


  A culture of the person's blood reveals microorganisms
• Septicemia


  Transport of an infection or the products of infection throughout the body or by blood
• Nosocomial infection


  Infections that originate in the hospital. It could develop during the client's stay in a facility or manifest after discharge. It is a sub-group of healthcare-associated infections.
• Health-care-associated infections


  Infections that originate in any healthcare setting
• Factors that contribute to Nosocomial Infection

  • Iatrogenic infections - these are direct results of diagnostic or therapeutic procedures
  • Compromised host
  • Insufficient hand hygiene
• Stages of Infection


  • Incubation period - extends from the entry of microorganisms into the body to the onset of signs and symptoms
  • Prodromal period - extends from the onset of non-specific signs and symptoms to the appearance of specific signs and symptoms
  • Illness period - specific signs and symptoms develop and become evident
  • Convalescent period - signs and symptoms start to abate until the client returns to a normal state of health
• The Chain of Infection

  • Infectious or etiologic agent - microorganism (bacteria, fungi, virus, parasites)
  • Reservoir - source (human beings, animals, inanimate objects, plants, general environment such as air, water, and soil)
  • Portal of exit from the reservoir - sputum, emesis, stool or blood
  • Modes of Transmission
  • Portal of entry - permits the organism to gain entrance into the host. This could be the mucous membrane, non-intact skin, GI tract, GU tract, respiratory tract
  • Susceptible host - a person who is at risk for infection; whose own body defense mechanism when exposed is unable to withstand the invasions of pathogens
• Body Defenses against Infection

  • Non-specific Defenses
  • Specific Defenses - involves the immune system. Active and passive immunity is either natural or artificial.
• Inflammation


  Local or non-specific defensive response of the tissues to an injurious or infections agent. It is an adaptive mechanism. It is characterized by: (a) pain (dolor); (b) swelling (tumor); (c) redness (rubor); (d) heat (calor / color); (e) impaired function of the part if severe.
• Factors influencing the Host's Susceptibility

  • First line of defense of the body - intact skin & mucous membrane
  • Normal pH levels of the genito-urinary tract help ward off microbial invasion
  • The body's WBC influence resistance to certain pathogens
  • Age, sex & race
  • Immunization
  • Fatigue, climate, general health status, presence of pre-existing illness, previous/current treatment & some kind of medications
• Principles Underlying Medical and Surgical Asepsis

  • The patient is the source of pathogenic microorganisms
  • Patient's microorganisms leave through specific routes
  • There are always microorganisms in the environment which in some individuals and under circumstances can cause illness
  • Microorganisms harmful to man can be transmitted by direct or indirect contact
  • The spread of infection from the source to others can be prevented by various methods to stop the spread as close to the source as possible
  • The effectiveness of medical/surgical asepsis is dependent on the conscientiousness of those carrying them out
  • In observing medical asepsis, areas are considered contaminated if they bear or are suspected of having pathogens
  • In observing surgical asepsis, areas are considered contaminated if touched by an any object that is not sterile
• Nursing Management - Assessment


  • History, conduct of physical assessment, laboratory data
  • Physical Assessment - Signs & symptoms of infection will vary according to the body area involved
  • Laboratory Data - Elevated leukocyte (WBC) count, Increases in the specific WBC types, Elevated ESR, Cultures of urine, blood, sputum, or other drainage
• Nursing Diagnosis


  • Risk for Infection - State in which an individual is at increased risk for being invaded by pathogenic microorganisms
  • Related Nursing Diagnoses - Potential Complication of Infection: Fever, Imbalanced Nutrition: Less than Body Requirements, Acute Pain, Impaired Oral Mucous Membrane, Risk for Impaired Skin Integrity, Impaired Social Interaction or Social Isolation, Anxiety, Impaired Tissue Integrity
• Interventions - Reduce the Risk of Infection


  • Proper hand hygiene techniques
  • Environmental controls
  • Sterile technique if warranted
  • Identification & management of clients risk for infections
  • Adequate rest and regular exercise
  • Acute Care
• Breaking the Chain of Infection: Aseptic Practices


  • Hand hygiene / Handwashing
  • Cleaning, Disinfection, Sterilization
• Cleaning


  The physical removal of visible dirt and debris by washing, dusting or mopping surfaces that are contaminated. Soap and water are use for mechanical cleaning. A detergent, disinfectant, & proper mechanical scrubbing can also be done.
• Disinfection


  The chemical or physical processes used to reduce the number of potential pathogens on an object's surface. But spores of the pathogens are not necessarily destroyed.
• Sterilization


  The complete destruction of all micro-organisms, including spores, leaving no viable forms of organisms.
• Infection Prevention and Control - Isolation systems

  • Standard precautions
  • Transmission-based Precautions
  • Protective Isolation - implemented to prevent infection for people whose resistance to infection / body defenses are lowered or compromised.
• Safe Environment


  One where the likelihood of being ill or injured is reduced. A place in which people can function safely and can have a sense of security.
• Characteristics of a Safe Environment

  • Adequate lighting
  • Neat and clean
  • Safe equipment
  • Noise level is comfortable
  • Cleanliness
  • Medication is kept separately
  • Temperature
  • Free of pollution (air, water and noise)
• Factors that People's ability to Protect Themselves

  • Age (Developmental Stage)
  • Orientation and level of consciousness - unable to perceive stimuli that may cause trauma or injury
  • Emotions - alter the ability to perceive environmental hazards
  • Injury or illness - ill, weak people are prone to accidents
  • Sensory or communication impairment - unable to perceive potential danger or to express the need for assistance
  • Information / Safety Awareness - knowledge deficit on safety increases risk for various types of accidents
• Risks in the Health Care Agency

  • Falls
  • Client-inherent accidents
  • Procedure-related accidents
  • Equipment-related accidents
• Environmental Factors - Health Care Setting

  • Incidence of medical errors that result to harm / death among our clients
  • Medical errors - Examples: medication errors (most common); diagnostic errors; communication errors
  • If errors occur, how do we deal with it?
  • Occupational safety among health care practitioners - especially nurses who are with patients 24 / 7
• Environmental Factors - Workplace


  • Occupational hazards