History of Nursing a. b.

Intuitive prehistoric times Apprentice begins with foundation of religious nursing orders and ends with establishment of the Kaiserswerth Institute by Fliedner in 1836. c. Educated begins with establishment of the St. Thomas Hospital School of Nursing by Nightingale in June 15, 1860 d. Contemporary begins after World War II up to the present Florence Nightingale Born on May 12, 1820 Born in Florence, Italy Raised in England Educated in Germany Titles: a. b. c. d. e. f. Theorist g. First Nurse Researcher Mother of Modern Nursing Lady with the Lamp Hero of the Crimean War Founder of Nursing Work Social Entrepreneur First Nurse Scientist c. b.

Each person or department has a separate section in record Narrative Charting written descriptive notes Problem Oriented Medical Record/ Problem Oriented Record Data are arranged according to the problems the has rather than the source of the information 4 Basic Components: (DPPP) a. b. c. d. Database Problem List Plan of Care Progress Notes S Subjective O Objective A Assessment Nursing Diagnosis P Planning Focus Charting focuses on client needs Three columns are used for recording: Date and Time Focus Progress Notes Data Assessment Phase Action Planning and Implementation Phase Response Evaluation the medical

Her research work Nursing Education Authored 12,000 letters 200 manuscripts Published Notes on Hospital (1859) Notes on Nursing (1860) Home Health Nursing Home Care Nursing Visiting Nursing Hospice Nursing subspecialty area Factors (CAR) CHRONIC ILLNESS management AGING population Rising health care costs Delegation Do not delegate: (ATE) Assessment Teaching Evaluation Documentation Systems a. Source Oriented Record (Traditional Client Record) d.

o o o

Charting by Exception only EXCEPTIONS to the rule are documented ABNORMAL FINDINGS

Therapeutic Nurse Client Relationships Phases: (POWT) 1. Pre interaction begins before the nurses initial contact with client Task (NPR) Nurses SELF AWARENESS

Planning for the FIRST INTERACTION with the client Reviewing client data 2. Orientation begins when the nurse and the client meet for the first time domain

Reinforcing NEW ADAPTIVE BEHAVIOR Teaching and Learning Process 3 Domains or Areas of Learning a. b. c. Cognitive thinking domain Affective feeling domain Psychomotor skills

Psychomotor Skills Physical Abilities Task (TRUST SM) TRUST building ROLE CLARIFICATION Stranger Upholding clients rights SELF DISCLOSURE TERMINATION Setting CONTRACT Maintaining CONFIDENTIALITY 3. Working begins when the client identifies the issues or concerns causing problems Task (FEW PT) Facilitating BEHAVIOR CHANGE EXPLORATION Working through RESISTANCE PROBLEM IDENTIFICATION Transference and Counter transference 4. Termination begins when the problems are resolved and ends when the relationship is ended Task (3 Rs) Recapitulating GOALS and OBJECTIVES achieved REFERRALS (MMES) a. b. c. d. Muscle strength Motor coordination Energy Sensory acuity