Personality Disorders - Cluster C

1. UNIVERSITY OF SOUTHERN MINDANAO
NCM 118 : Nursing Care of Clients with Life-
Threatening Conditions, Acutely Ill/Multi-Organ
Problems, High Acuity and Emergency Situations
A.D.P.I.E.
Prepared by: LALYN N. CABAUATAN, MAN, RN
EMMALYN M. MAMALUBA, MAN, RN, LPT
JZA A.TAPOSOK-DANA, MAN, RN

2. 2
Topic Outline:
1. Introduction to Critical Care nursing
2. ADPIE process: Criteria on structure, process and outcome

3. Intended Learning Outcomes:
At the end of this discussion, the students are expected to:
1. Obtain knowledge on the definition of critical care nursing.
2. Identify goals, scope and qualification of Critical Care Nursing
3. Determine the standards of critical care nursing practice
4. Utilize the structure-process-outcome model on nursing care
process.
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4. Introduction:
Critical care nursing is the specialty within nursing that deals specifically
with human responses to life-threatening problems. These problems
deal dynamically with human responses to actual or potential life-
threatening illnesses.
It is focused on restorative, curative, rehabilitative, maintainable, or
palliative care, based on identified patient’s need
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Goals of Critical Care Nursing include the following:
 To promote optimal delivery of safe and quality care to the critically
ill patients and their families.
 To care for the critically ill patients with a holistic approach.
 To use relevant and up-to date knowledge, caring attitude and skills.
 To provide palliative care to the critically ill patients in situations
where their health status is progressing to unavoidable death, and
to help the patients and families go through their painful sufferings.
On the whole, Critical care nursing should be patient-centered,
safe, effective and efficient.

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Scope of Critical care nursing:
Defined by the dynamic interactions of the critically ill
patient/family, the critical care nurse and the critical care
environment to bring about optimal patient outcomes through
nursing proficiency in an environment conducive to the provision
of this highly specialized care.

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Who are critical care nurses?
Are registered nurses who are trained and qualified to practice
critical care nursing
Qualification/s:
1. Licensed Professional Nurse

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11 Standards of Critical Care Nursing Practice:
1. Functions in accordance with legislations, common laws,
organizational regulations and by-laws, which affect nursing
practice.
2. Provides care to meet individual patient needs on a 24-hour basis
3. Practices current critical care nursing competently.
4. Delivers nursing care in a way that can be ethically justified.
5. Demonstrates accountability for his/her professional judgment
and actions.

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6. Creates and maintains an environment which promotes safety and
security of patients, visitors, and staff.
7. Masters the use of all essential equipment, available services and
supplies for the immediate care of patients.
8. Protects the patients from developing environmental induced
infection.
9. Utilizes the nursing process in an explicit systematic manner to
achieve the goals of care.
10. Carries out health education for promotion and maintenance of
health.
11. Acts to enhance the professional development of self and others.

10. Assessment of LifeThreatening Conditions
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Performance of Health Assessment
1. Guidelines for critical care nurse to perform health assessment are
available.
2. An agreed conceptual model for guiding nursing practice is available.
3. The health assessment form is available for documentation of
patient data.
4. Experienced staffs are available to give advice on health assessment
to less experienced staff
5. The critical care nurse possess the knowledge and skills in
performing physical examination and psycho-social assessment

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Process of Assessment:
1. Collects data on a continuous basis starting from admission.
2. Collects subjective and objective data to determine patient needs.
3. Collects data in systematic manner to ensure completeness of
assessment.
4. Uses appropriate PE techniques to gather data.
5. Uses effective communication skills to obtain data from the
patient/family.
6. Collects, documents, and updates all relevant data in the patient
record.
7. Ensures pertinent data are accessible to all health care team members

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Outcome Criteria on Assessment:
1. Individualized patient assessment is performed in an accurate,
continuous and systematic manner.
2. There is a documented evidenced that patient’s physical,
psycho-social and spiritual needs are identified.
3. The intensive care nurse is cognizant of the current condition
of each patient under his/her care.
4. Patient’s data are kept up-to-date.

13. Nursing Diagnosis
Formulation of nursing diagnoses/ identification patient problems in
priority of patient’s needs
1. References to guide formulating nursing diagnosis are available.
2. Guidelines for formulating nursing diagnosis are established.
3. Experienced staff are available to advise nurse in formulating
nursing diagnosis.
4. The critical care nurse possesses the knowledge and skills to make
accurate nursing diagnosis to identify patient problems.
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Process on formulation of Nursing Diagnosis on Critical Care Nursing:
1. Utilizes collected data to establish a list of actual and potential patient
problems/needs.
2. Collaborates with the patient, family and other health care team
members in the identification of problems.
3. Formulates appropriate nursing dx relevant to the patients condition
wherein the nurse has the ability and experience to implement plan of
care.
4. Establishes the priority of problems according to the actual or
potential threats.
5. Documents prioritized nursing diagnosis.
6. Updates nursing diagnosis when patient condition changes.

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Outcome Criteria:
1.There is a documented evidence that nursing diagnosis
are formulated. Patient problems are identified according
to priority of needs.

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“Clinical judgement about individual, family or
community responses to actual or potential health
problems/ life processes. A nursing diagnosis provides
the basis for selection of nursing interventions to achieve
outcomes for which the nurse is accountable”( Herdman,
2009).

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What are nursing diagnoses???
• Supported by clinical information obtained during
assessment
• Describes a patient problem that a nurse can professionally
and legally manage. (SMART)
• Although the identification of problems overlaps in nursing
and medicine, the approach clearly differs. Medicine focuses
on curing disease; nursing focuses on holistic care that
includes care and comfort.
• It expresses your professional judgement of the patient’s
clinical status, response to treatment and nursing care
needs.

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Guidelines in formulating correct diagnostic statement
• Use Proper terminology that reflects the patient’s
nursing needs.
• Make your statement concise so it’s easily understood
by other healthcare team members.
• Use the most precise words possible
• Use a problem-and-cause format stating the problem
and its related cause.

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Sample:
Heading: impaired skin integrity
Etiology: select the appropriate “related to” immobility
Signs and symptoms: assessment “as evidenced by”
assessment
Secondary to medical diagnosis.

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Don’t state a need instead of a problem
-Incorrect: Fluid replacement related to fever
-Correct: Deficient fluid volume related to fever
Don’t reverse the two parts of the statement
-Incorrect: Lack of understanding related to noncompliance with diabetic diet.
-Correct: Noncompliance with diabetic diet related to lack of understanding.
Don’t identify an unhealthful response that would be appropriate allowed or culturally acceptable
-Incorrect: Anger related to terminal illness
-Correct: Ineffective therapeutic regimen management related to anger over terminal illness
Don’t make tautological statement (both parts are the same)
-Incorrect: pain related to alteration in comfort
-Correct: Acute pain related to postoperative abdominal distention
Don’t make tautological statement (both parts are the same)
-Incorrect: pain related to alteration in comfort
-Correct: Acute pain related to postoperative abdominal distention
Don’t identify a nursing problem instead of a patient problem
-Incorrect: Difficulty suctioning related to thick secretions
-Correct: Ineffective airway clearance related to thick tracheal secretions.

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23. Planning
Planning for Collaboration of Care:
1. References and information on nursing care plans are available.
2. Experienced staff advises novice nurse in care planning when
appropriate.
3. The critical care nurse possesses knowledge and skills to devise an
individualized care plan pertinent to patient needs.
4. An agreed nursing care delivery model and medical treatment
protocol, algorithm is available.
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Process on Planning for Collaboration of care:
1. Develops goals for each nursing diagnosis/patient problem.
2. Plans appropriate nursing interventions in collaboration with the
patient, family and other health care team members whenever
necessary.
3. Devises an individualized care plan.
4. Communicates the plan with those involved in caring the patients.
5. Updates planned nursing actions in accordance with changes in
patient health status.
6. Provides coordinated continuity of care.
7. Identifies activities through which care will be evaluated.
8. Documents the nursing care plan in patient record.

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Outcome Criteria:
1. Patient care reflects the identified patient problems/needs.
2. The planned care reflects appropriate nursing interventions.

26. Implementation
Implementation of Planned Nursing Care:
1. The critical care nurse possesses the knowledge and skills in
implementing the agreed care plan.
2. Standards of nursing care and practice are established.
3. Experienced staffs are available to give advice on the
implementation of care.
4. Appropriate equipment for the implementation of the agreed care
plan is available.
5. A policy to ensure the continuity of patient care is in place.
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Process on the Implementation of Planned Care:
1. Utilizes accepted principles for nursing interventions according to the
dynamic environment.
2. Implements care according to standards and protocols.
3. Implements the planned care in collaboration with the patient, family and
other health care team members.
4. Implements the planned care in an organized and humanistic manner.
5. Integrates current scientific knowledge with technical and psychomotor
competencies.
6. Provides care in such a way as to anticipating and preventing complications
and life-threatening situations.
7. Provides individualized and continuous care to achieve identified goals.
8. Documents interventions in patient records
9. Review and modifies interventions based on patients progress.

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Outcome Criteria:
1. The agreed nursing care plan is implemented.
2. A nursing intervention record for individual patient is kept.
3. The identified goals for individual patient care are achieved.

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NURSNG INTERVENTIONS
Independent- A nurse can carry out interventions on their own to
achieve patient outcomes. (monitoring,
education, assessment, positioning, rescuing,
psychosocial support, coaching)
Dependent- it needs a primary health provider, usually a
physician to perform tasks (administering
medications, suctioning, catheterization, feeding, etc.)
Interdependent/ collaborative- Involve team members across
disciplines or other health care team. ( Referring to
psychologist, nutritionist, social workers, therapists, etc)

30. Evaluation
Evaluation of Outcome of Nursing Care:
1. The critical care nurse possesses the knowledge and skills to
evaluate the implemental care.
2. Experienced staff are available who advises nurses on the
evaluation of delivered care.
3. A policy is available to evaluate the patient’s responses to nursing
care in continuous manner.
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Process on Evaluation of Outcome of Nursing Care:
1. Collects data for evaluation within an appropriate time
interval after intervention.
2. Compares the patient’s responses with expected outcomes.
3. Determines the causes of significant differences between the
patient’s responses and the expected outcomes.
4. Reviews and revises the plan of care based on the evaluation.
5. Documents evaluation findings in patient record.

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Outcome Criteria:
1. The implemented care is evaluated and documented.

33. Activities:
Activity 1.
Instructions:
1. Watch again the video presented to you on our first meeting entitled “Emergency Room: A documentary
by Jay Taruc” ( You can watch it on youtube. GMA news affair. I-witness).
2. Choose only 1 from the following patient:
a. “ERIC- the tattooed man”
b. “ALFREDO- the intubated elderly”
c. “PJ- the Pedicab Accident”
d. “JOSHUA- the severe dehydration”
3. List as much assessment as you could for your chosen patient.
4. Out of your listed assessment, prioritized 1 problem and create a nursing care plan utilizing nursing care
process (ADPIE).
5. Submit a soft copy of your activity today via gdrive/email and a hard copy on September 2, 2022.
A4 bond paper, Font Arial
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Activity 2.
1. Review our discussion.
2. Short Quiz next meeting.

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Activity 3.
Instructions:
1. Make a scrapbook/creative compilation of emergency drugs required
by the DOH for Emergency cart. You can choose for Level 1, 2 or 3
hospital.
2. You can download the list on hfsrb.doh.gov.ph
3. Include on your compilation the Generic Name, Brand Name,
Indication, Mechanism of action, Side Effects, Adverse Reaction,
Nursing Considerations, drug-drug interaction, drug-food interaction
and antidote for toxicity.
4. Submit 1 week after Midterm exam.
5. Be creative as you can. You can use any materials of your choice.
6. Criteria for Grading:
a. Content------ 50%
b. Creativity----50%

36. References:
• Nursing Care of Clients with Life Threatening Conditions. University
of San Carlos. https://www.studocu.com
• Sparks and Taylor’s Nursing Diagnosis Pocket Guide 2011
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