FUNDAMENTALS OF NURSING
3. Plan of Care - the initial list of orders or plan of care is made with
reference to the active problems.
4. Progress Notes - is a chart entry made by all health professionals
involved in client’s care; it has different format:
DOCUMENTING/RECORDING AND
REPORTING
“Effective communication among health professionals is vital to the
quality of client care.”
Discussion - is an informal oral consideration of a subject by two or
more health care personnel to identify a problem or establish
strategies to resolve a problem.
Report – an oral, written, or computer-based communication intended
to convey information to others.
Record – is a written or computer-based.
Recording – also called charting or documenting; the process of
making an entry on a client record.
Clinical Record – also called chart or client record; it is a formal and
legal document that provides evidences of a client’s care.
ETHICAL AND LEGAL PRINCIPLES
“The nurse has a duty to maintain confidentiality of all patient
information”
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SOAP – subjective, objective data, analysis, and planning
SOAPIE or SOAPIER – soap with interventions,
evaluation, and revision
PIE – problems, interventions, and evaluations
ADVANTAGES OF POMR
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encourages collaboration
the problem list in the front of the chart alerts caregivers to
the client’s needs and make it easier to track the status of its
problems.
DISADVANTAGES OF POMR
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caregivers differ in their ability to use the required charting
format
takes constant vigilance to maintain an up-to-date problem
list
is inefficient because assessments and interventions that
apply more than one problem must be repeated
Focus Charting – is intended to make the client and client concerns
and strengths the focus of care; 3 columns for recording (date and
time, focus, and progress note).
It utilizes DAR (data, action, and response)
“The client’s record is also protected legally as a private record of the
client’s care.”
Example:
“Access to the record is restricted to health professionals involved in
giving care to the client”
DATE/HOUR
2/11/2016 –
9:00 AM
“The institution or agency is the rightful owner of the client’s record”
PURPOSES OF CLIENT RECORDS
Communication, planning client care, auditing health agencies,
research, education, reimbursement, legal documentation, and health
care analysis.
DOCUMENTATION SYSTEMS
9:30 AM
FOCUS
pain
PROGRESS NOTE
Data: guarding
abdominal incision;
facial grimacing; rates
pain at “8” on scale of
1-10
Action: administered
morphine sulfate 4mg
IV
Response: rates pain at
“1” states willing to
ambulate
Source-oriented Record - the traditional client’s record; each person
or department makes notations in a separate section/s of the client’s
record.
Charting by Exception – a documentation system in which only
abnormal or significant findings or exceptions to norms are recorded;
incorporates 3 key elements:
Example: the admission dept. – admission sheet
1. Flow sheets - like graphic record, fluid balance record, daily
nursing assessment record, client teaching record, client discharge
record and skin assessment record
Narrative Charting - the traditional part of the source-oriented
record; consists of written notes that include routine care, normal
findings, and client problems.
Problem-oriented Medical Record (POMR) – the data arranged
according to the problems the client has rather than the source of the
information; established by Lawrence Weed in the 1960’s; it has 4
basic components:
1. Database - consists of all information known about the client when
the client first enters the health care agency.
2. Problem List - problems are listed in the order in which they are
identified, and the list is continually updated as new problems are
identified and others are resolved.
2. Standard of nursing care – the agency’s printed standards of
nursing practice
3. Bedside access to chart forms – all flow sheets are kept at the
client’s bedside
Computerized Documentation – developed as a way to manage the
huge volume of information required in contemporary health care;
nurses use computers to store the client’s database, add new data,
create, and revise care plans and document client progress.
Case Management – emphasizes quality, cost-effective care delivered
within an established length of stay; uses multidisciplinary approach
to planning and documenting client care using critical pathways.
DOCUMENTING NURSING ACTIVITIES
ANA standards of Nursing 1973 - referred to a five-step process:
assessing, diagnosing, planning, intervention, and evaluation
1. Admission Nursing Assessment – an initial database, nursing
history, or nursing assessment, is completed when the client is
admitted to the nursing unit.
Gebbie and Lavin 1975 - formulated the 5 phases: assessment,
nursing diagnosis, planning, intervention, and evaluation.
Process – a series of planned actions or operations directed towards a
particular result or goal.
2. Nursing Care Plans – has 2 types:
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Traditional Care Plans – written for each client; has 3
columns (nursing diagnosis, expected outcomes, and
nursing interventions)
Standardized Care Plans – were developed to save
documentation time
3. Kardexes – widely used and concise method of organizing and
recording data about a client, making information quickly accessible
to all health professionals; consists of a series of cards kept in a
portable index file or on a computer-generated form.
4. Flow Sheets - enables nurses to record nursing data quickly and
concisely and provides an easy-to-read record of the client’s
condition over time; it includes graphic record, intake and output
record, medication administration record, and skin assessment
record.
5. Progress Notes – made by nurses to provide information about the
progress a client is making toward achieving desired outcomes.
GENERAL GUIDELINES FOR
RECORDING
Date and time, timing, legibility, permanence, accepted terminology,
correct spelling, signature, accuracy sequence, appropriateness,
completeness, conciseness, and legal prudence.
REPORTING
Purpose – to communicate specific information to a person or group
of people.
Change of Shift Reports – is given to all nurses on the next shift; to
provide continuity of care.
Telephone Reports – reports done through telephone.
Telephone Orders – orders made by physicians through telephone;
transcribed onto the physician’s order sheet and should be counter
signed within 24hrs.
Nursing Process – a systematic and rational method of planning and
providing individualized nursing care.
PURPOSES OF NURSING PROCESS
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PHASES OF THE NURSING PROCESS – Assessment, Diagnosis,
Planning, Implementation, and Evaluation.
CHARACTERISTICS OF THE NURSING
PROCESS
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Care Plan Conference – a meeting of a group of nurses to discuss
possible solutions to certain problems of a client.
Nursing Rounds – are procedures in which two or more nurses visit
selected clients at each client’s bedside.
NURSING PROCESS
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Lydia Hall - the first to use the term “Nursing Process” in 1955.
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Johnson 1959, Orlando 1961, and Wiedenbach 1963 – the first to use
it to refer to a series of phases describing the process of Nursing.
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Catholic University of America, Yura and Walsh in !976 - published
the first comprehensive book in Nursing Process describing the 4
steps: assessment, planning, intervention, and evaluation.
to identify a client’s health status, actual or potential health
care problems or needs.
to establish plans to meet the identified needs, and;
to deliver specific nursing interventions to meet those
needs.
it is the underlying scheme that provides order and
direction to nursing care.
it is the essence of professional nursing practice.
it has been conceptualized as a systematic series of
independent nursing actions directed toward promoting an
optimum level of wellness for the client.
it is cyclical; the components follow a logical sequence, but
more than one component may be involved at any one time.
it helps nurses in arriving at decisions and in predicting and
evaluating consequences.
it was developed as a specific method for applying a
scientific approach or a problem-solving approach to
nursing practice.
Data from each phase provide input into the next phase
The nursing process is client centered
The nursing process is an adaptation of problem solving
and systems theory
Decision making is involved in every phase of nursing
process
The nursing process is interpersonal and collaborative
The universally applicable characteristics of nursing
process means that it is used as a framework for nursing
care in all types of health care settings, with clients of all
age groups
Nurses must use variety of critical-thinking skills to carry
out the nursing process.
It is cyclical and dynamic
It is planned
It is goal directed
It permits creativity for the nurse and the client in devising
ways to solve the stated health problem
It emphasizes the feedback, which leads either to
reassessment of the problem or to revision of the care plan.
It is universally applicable.
BENEFITS OF THE NURSING PROCESS
Clients – by improving the quality of care they receive.
Nurse – enables the nurse to use time and resources efficiently.
2. Objective Data – referred to as signs or over data. Are detectable
by an observer o can be measured or tested against an accepted
standard. Can be seen, heard, felt or smelled and they are obtained by
observation or physical examination.
Examples: a discoloration of the skin and bp reading during physical
examination.
ASSESSMENT - is the systematic and continuous,
collection, organizing, validation and documentation of data; a
continuous process carried out during all phases of the nursing
process.
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Constant Data – is information that does not change over
time such as race or blood type.
Variable Data – can change quickly, frequently or rarely
such as bp, age, and level of pain.
TYPES OF ASSESSMENT
SOURCES OF DATA
Initial Assessment – performed within specified time after admission
to a health care agency.
1. Primary Source – the client.
Purpose: to establish a complete database for problem identification,
reference, and future comparison.
2. Secondary Source – family members, friends, and caregivers;
client records; health care professionals; and literature.
DATA COLLECTION METHODS
Example: Nursing admission assessment.
Problem-Focused Assessment – ongoing process integrated with
nursing care.
Observation/ Observing – to gather data by using the senses; a
conscious, deliberate skill that is developed through effort and with
an organized approach.
Purpose: to determine the status of a specific problem identified in
earlier assessment.
Interviewing – a planned communication or a conversation with a
purpose.
Example: Hourly assessment of client’s fluid intake and urinary
output in ICU.
Example: to get or give information, identify problems of mutual
concern, evaluate change, teach, provide support, and provide
counseling or therapy.
Time Lapsed Reassessment – done several months after initial
assessment.
Purpose: to compare the client’s current status to baseline data
previously obtained.
TYPES OF INTERVIEW QUESTIONS
Example: Reassessment on client’s functional health patterns in a
home care or outpatient setting or in a hospital at shift change.
1. Closed Questions – are restrictive and generally require only “yes”
or “no” or short factual answers giving specific information. Often
begins with “when”, “where”, “who”, “what”, “do, did, does” or “is,
are, was”.
Emergency Assessment – during any physiologic or psychologic
crisis of the client.
Purpose: to identify life-threatening problems and identify new or
overlooked problems.
Example: Rapid assessment of a person’s airway, breathing status,
and circulation during cardiac arrest.
ACTIVITIIES OF ASSESSMENT
1. Collecting Data – the process of gathering information about a
client’s health status; it must be both systematic and continuous to
prevent the omission of significant data and reflect a client’s
changing health status.
Database – all information about a client; includes the nursing health
history, physical assessment, primary care provider’s health history
and physical examination, result of laboratory and diagnostic tests,
and material contributed by other health personnel.
Examples: “What medication did you take?”, “Are you having pain
now?”, “How old are you?”.
2. Open-ended Questions – invite clients to discover, explore,
elaborate, clarify, or illustrate their thoughts or feelings. Often begins
with “what” or “how”.
Examples: “How have you been feeling lonely?”, “What brought you
to the hospital?”, “What would you like to talk about?”.
3. Neutral Questions – is a question the client can answer without
direction or pressure from the nurse, is also an open-ended.
Examples: “How do you feel about that?” and “Why do you think
you had the operation?”
4. Leading Questions – by contrast, is usually closed, and directs the
client’s answer.
TWO TYPES OF DATA
Examples: “You’re stressed about the surgery tomorrow, aren’t you?”
and “You will take your medicines, will you?”
1. Subjective Data – referred to as symptoms or covert data. Apparent
only to the person affected and can be described or verified only by
STAGES OF INTERVIEW
that person. Include the client’s sensation, feelings, values, beliefs,
attitudes, and perception of personal health and life situations.
1. The Opening – the most important part of the interview; what is
said and done at that time sets the tone for the reminder of the
interview. The purposes are to establish rapport and orient the client.
Examples: itching, pain, and feelings of worry
2. The Body – the client communicates what he or she thinks, feels,
knows, and perceives in response to questions from the nurse.
3. The Closing – the nurse terminates the interview when the needed
information has been obtained.
Examining – also known as the “Physical Examination” or “Physical
Assessment”; a systematic data collection method that uses
observation or detect health problems.
Instead of giving a complete examination, the nurse may focus on a
specific problem area noted from the nursing assessment. Alternately,
the nurse may perform a screening examination.
Screening examination – also called the review of systems. A brief
review of essential functioning in a various body parts or systems.