CHAPTER 10: ASSESSING Data Base - contains all information about a client;
it includes the nursing health history, physical
NURSING PROCESS assessment , primary care provider’s history and
is a systematic , rational method of planning physical examination, results of laboratory and
and providing individualized nursing care. diagnostic tests, and material contributed by each
other personnel.
Collect data
Organize data
ASSESSING TYPES OF DATA
Validate data
Document data
Subjective Data [ symptoms / covert]
are apparent only to the individual affected and
Analyze data can be described or verified only by that
Identify health problems,
DIAGNOSING risk, and strengths
individual (ex: itching , pain ,clients sensation).
H Formulate diagnostic
statements Objective Data [signs/ overt]
detectable by an observer , can be measured or
tested against an accepted standard, can be
Prioritize
seen , heard, felt, or smelled, they are obtained
problems/diagnoses
Formulate goals/ desired by observation or physical examination (ex:
PLANNING discoloration of skin, blood pressure reading)
outcomes
Select nursing intervention
Write nursing intervention LITERATURE
review of nursing and related literature , such
Reassess the client as professional journals and reference texts,
Determine the nurse need
can provide additional information about a
for assistance
IMPLEMENTING Implement the nursing
client’s health.
interventions
Supervise delegated care
DATA COLLECTION METHODS
Document nursing activities
(observing, interviewing, examining)
Collect data related to 1. Observing
outcomes to observe is to gather data using the senses
Compare data with outcmes
Relate nursing actions to
client goal/outcomes 2. Interviewing
EVALUATING is a planned communication or a conversation
Draw conclusions about
problem status with a purpose .
Continue, modify or
terminate the client’s care
plan Focused interview - the nurse asks the client
specific questions to collect information related to
the client’s problem.
ASSESSING
Directive interview - is highly structured and
is the systematic and continous collection , elicits specific information. (ex: emergency
organization, validation, and documentation of situation)
data (information)
Nondirective interview- or rapport building
COLLECTING DATA interview the nurse allows the client to control the
purpose , subject matter and pacing.
data collection is a process of gathering
information about client’s health status.
TYPES OF INTERVIEW QUESTIONS
Screening examination/ review of systems (ROS)
Closed questions - used in the directive interview brief review of essential functioning of various
and restrictive , generally required only yes or no or body parts or systems.
short factual answers.
Conceptual Models and Frameworks
Open -ended questions - non directive interview,
clients elaborate, clarify or illustrates their thoughts Wellness Models
and feelings , invites longer answers. use to assist clients to identify health risks and
to explore lifestyle habits and health behaviors,
Neutral questions- is a question the client can beliefs, values, and attitudes that influence
answer without direction or pressure from the levels of wellnes .
nurse , open- ended and used non-directive
interviews. Nonnursing Models
frameworks and models from other disciplines
Leading questions - usually closed , used directive may also be helpful for organizing data.
interview , thus directs the clients stressanswer
(ex: You’re stressed about surgery tomorrow, aren’t Body System Models
you?) focuses on abnormalities of the following
anatomic systems:
PLANNING THE INTERVIEW AND 1. Integumentary system
SETTING 2. Respiratory system
time 3. Cardiovascular system
place 4. Nervous system
seating arrangement 5. Musculoskeletal system
distance 6. Gastrointestinal system
language 7. Genitourinary system
8. Reproductive system
9. Immune system
STAGES OF AN INTERVIEW
The Opening Maslow’s Hierarchy of Needs
the most important part of the interview , what Maslow’s hierarchy of needs clusters data
is said and done at that time sets the tone. pertaining to the following:
1. Physiologic needs
The Body 2. Safety and security needs
the client communicates what he / she thinks, 3. Love and belonging needs
feels, knows, and perceive in response to 4. Self- esteem needs
questions from the nurse 5. Self- actualization needs
The Closing Developmental Theories
the nurse terminates the interview when the several physical, psychosocial, cognitive and
need information has been obtained . moral developmental theories may be used by
the nurse in specific situations.
3. Examining
physical examination or physical assessment is VALIDATION
a systematic data collection method that uses
observation , to conduct examination nurses the act of “double checking” or verifying data
uses techniques of [ inspection, auscultation, to confirm that it is accurate and factual.
palpation, percussion]
Cues- are subjective or objective data that can be
directly observed by the nurse ; that is what the
Cephalocaudal - head -to- toe approach client says or what the nurse can see, hear, smell.
/examination
Inferences- are nurses interpretation or conclusions
made based on the cues.
CHAPTER 11: DIAGNOSING Defining Characteristics
are the clusters of signs and symptoms that
DIAGNOSING indicate the presence of a particular diagnostic
label.
refers to the reasoning process
Independent Functions
DIAGNOSIS
the areas of the healthcare that are unique to
nursing and separate and distinct from the
statement or conclusion regarding to the nature
medical management.
of a phenomenon
Dependent Functions
NURSING DIAGNOSIS
nurses are obligated to carry out physician -
prescribed therapies and treatments.
contains a diagnostic phrase or diagnostic label
followed by an etiology phrase. Collaborative Problem
a type of potential problem that nurses manage
STATUS OF NURSING DIAGNOSIS using both independent and physician -
prescribed intervention.
1. Actual Nursing Diagnosis
also known as a problem-based diagnosis, this
nursing diagnosis is a client problem that is STANDARD / NORM
present at the time of the nursing assessment. a generally accepted measure, rule, model or
pattern.
2. Health Promotion Diagnosis
relates to clients’ preparedness to implement Clustering Cues
behaviors to improve their health condition. data clustering or grouping of cues is a process
of determining the relatedness of facts and
3. Risk Nursing Diagnosis determining whether any patterns are present,
Is a clinical judgement that a problem does not whether the data represent isolated incidents ,
exist , but the presence of risk factors indicates an whether the data are significant.
that a problem is likely to develop unless
nurses intervene.
BASIC TWO- PART STATEMENTS
4. Syndrome Diagnosis
is a clinical nursing judgement when a client 1. Problem (P) : statement of the client’s response
has several similar nursing diagnoses. 2. Etiology (E) : factors contributing to or probable
COMPONENTS OF NURSING DIAGNOSIS causes of the responses.
Problems and definition
Etiology BASIC THREE- PART STATEMENTS
Defining characteristics
1. Problem (P) : statement of the client’s response
Problem ( Diagnostic Label) and Definition (nursing diagnosis label)
describes the client’s health problem or 2. Etiology (E): factors contributing to or probable
response for which nursing therapy is given. causes of the responses.
Qualifiers- are words that are added to the 3. Signs and Symptoms(S):defining characteristics
nursing diagnosis to provide additional manifested by client.
meaning to the diagnostic statement.
Etiology ( Related factors/ risk factors)
component of a nursing diagnosis identifies one
or more probable cause of the health problem,
gives direction to the required nursing therapy
enables nurse to individualize the client’s care.
CHAPTER 12: PLANNING
PLANNING POLICIES AND PROCEDURES
are develop to govern the handling of
is an intentional, systematic phase of the
frequently occurring situations.
nursing process that involves decision making
and problem solving. STANDING ORDER
NURSING INTERVENTION is is a written document about policies, rules ,
regulations, or orders regarding client care.
is any treatment , based upon clinical
judgement and knowledge , that a nurse
FORMATS FOR NURSING CARE PLAN
performs to enhance patient / clinical outcomes.
1. Problem or nursing diagnosis
2. Goals or desired outcomes
TYPES OF PLANNING
3. Nursing intervention
4. Evaluation
Initial Planning
nurse who performs the admission assessment
Student Care Plan
usually develops the initial comprehensive plan
are a learning activity as well as a plan of care,
of care . Nurse has the benefit of seeing the
they may be lengthier and more detailed than
client’s body language and can also gather
care plans, used by working nurses.
some intuitive kinds of information that are not
available solely from the written database.
Rationale
is the evidence- based principle given as the
Ongoing Planning
reason for selecting a particular nursing
all nurses who work with the client do ongoing
intervention.
planning . As nurses obtain new information
and evaluate clients’ response to care.
Concept Map
is a visual tool in which ideas or data are
Discharge Planning
enclosed in circles or boxes of some shape.
the process of anticipating and planning for
needs after discharge ( upon admission).
Computerized Care Plans
DEVELOPING NURSING CARE PLAN computers are increasingly being used to create
and store nursing care plans. Can both generate
standardized and individualized care plan.
Informal Nursing Care Plan
is a strategy for action that exist in the nurse
Multidisciplinary ( collaborative ) Care Plans
mind.
is standardized plan that outlines the care
required for clients with common , predictable-
Standardized Care Plan
usually medical - condition.
is a formal plan that specifies the nursing care
for groups of clients with common needs.
The Planning Process
setting priorities
Individualized Care Plan
establishing client goals or desired outcomes
is tailored to meet the unique needs of specific
selecting nursing interventions and activities
client- needs that are not addressed by the
writing individualized nursing interventions or
standardized plan.
care plans
NURSING PROCESS FORMAT
Priority Setting
Problem Goals / desired outcome nursing
is the process of establishing a preferential
intervention Evaluation
sequence for addressing nursing diagnosis and
PROTOCOLS intervention.
are pre- developed to indicate the actions
commonly required for a particular group of
clients.
Nursing Outcomes Classification (NOC)
for describing client outcomes that respond to
CHAPTER 13:IMPLEMENTING
nursing interventions. AND EVALUATING
Short term Goal IMPLEMENTING
might be client will raise right arm to shoulder
height by Friday
consist of doing and documenting the activities
that are the specific nursing actions needed to
carry out the interventions.
Long term Goal/ outcome
client will regain full use of arm in 6 weeks.
IMPLEMENTING SKILLS
COMPONENTS OF GOAL / DESIRED OUTCOMES
Subject Cognitive skills ( intellectual skills)
Verb include problem- solving , people decision
Conditions or modifiers making , critical thinking , clinical reasoning
Criterion of desired performance and creativity.
TYPES OF NURSING INTERVENTION Interpersonal skills
are all of the activities , verbal and non-
Independent Intervention verbal ,people use when interacting directly
are those activities that nurses are licensed to with one another.
initiate on the basis of their knowledge and
skills. Technical skills
are purposeful “hands on” skills such as
Dependent Intervention manipulating the equipment , giving injections,
Are activities carried out under the orders or bandaging , moving , lifting ,and repositioning
supervision of a licensed physician or other clients .
healthcare providers authorized to write orders
to nurses. PROCESS OF IMPLEMENTING
Collaborative Interventions Reassessing the client
are actions the nurse carries out in Determining the nurse’s need for assistance
collaboration with other health team members , Implementing the nursing intervention
such as physical therapist , social workers , Supervising the assigned care
dietitians and primary care provider . Documenting nursing activities
Relationship of Nursing Interventions to NURSING AUDIT
Problem Status
Audit
Observations refers to the examnation/ review of records
include assessment mode to determine whether
a complication is developing , as well as Retrospective Audit
observation of the clients responses to nursing evaluation of a clients record after discharged
and other therapies .
Concurrent Audit
Prevention Interventions evaluation of client’s healthcare while the
prescribe the care needed to avoid complication client still receiving care from the agency
or reduce risk factors .
QUALITY ASSURANCE
Treatment
include teaching, referrals, physical care and Is an ongoing , systematic process designed to
other care needed for an actual nursing evaluate and promote excellence in the
diagnosis. healthcare provided to the clients .
Structure Evaluation [equipments, staffing ] Plan of Care
the initial list of orders of plan of care is made
Process Evaluation [nursing process/ quality with reference to the active problems
improvement ]
Progress Notes
Outcome Process [ demonstrable changes, in the POMR is a chart entry made by all health
patient response,health status, complications or professionals involve in a client’s care; they all
patient feedback] use the same type of sheet for notes. [SOAP]
Sentinel Event - is an unexpected occurrence SOAP[subjective data, objective data, assessment,
involving death, permanent harm or severe plan]
temporary harm and intervention is required to
sustain life. SOAPIER [subjective data, objective data,
assessment, plan, interventions ,
CHAPTER 14: DOCUMENTING evaluation ,revision]
AND REPORTING PIE
a documentation model groups information into
Discussion three categories. PIE for problems,
is an informal oral consideration of a subject by interventions and evaluation.
two or more healthcare personnel to identify a
problem or establish strategies to resolve a Flow Sheets
problem uses specific assessment criteria in a particular
format , such as human needs or functional
Record health patterns.
also called a chart or client record is formal ,
legal document that provides evidence of a Focus Charting
client’s care and can be written or computer is intended to make the client and client
based. concerns and strengths the focus of care.
Report Charting by Exception (CBE)
is oral, written or computer based is a documentation system in which only
communication intended to convey information abnormal or significant findings or exceptions
to others. to norms are recorded.
DOCUMENTATION SYSTEMS General Guidelines for Recording
Data and Time - document the date and time
Source- Oriented Record of each recording
traditional client record Timing - follow agency’s policy about the
frequency of documentation, and adjusting the
Problem- Oriented Medical Record frequency as a client’s condition indicates.
data arrange according to the problems Legibility- must be legible and easy to read to
POMR (4) Basic Components prevent interpretation errors.
1. Database Permanence- client’s record and made in dark
2. Problem List ink so that the record is permanent and changes
3. Plan of Care can be identified.
4. Progress Notes
REPORTING
Database To communicate specific information to an an
consist all information known about the client , individual or group of people.
when the client first enters the health care Change of Shift Reports-various forms of
agency. change-of -shift report have been used over the
years.
Problem List SBAR
is derived from the database [situation, background,assessment,recommendation]
