Republic act no.

9173 (Philippine Nursing Act of 2002)

Article 6- Section 28 – stated the scope of nursing practice
To provide nursing care through the utilization of the nursing process.

NURSING PROCESS
Definition of Nursing Process
 Systematic problem-solving approach to give individualized nursing care.
 A tool for identifying and treating human responses to potential or actual health
problems.
 Fosters continuity of care and therefore quality of care.
 Nursing process is exactly a step by step system for what you do as a nurse. All
you need to do is to follow the steps
 The nursing process is a systematic, rational method of planning and providing individualized nursing care.
 ADOPIE

1. ASSESMENT
 Most important thing to do

COMPONENTS
 Collecting Data
o Taking VS, Pt history, asking questions about their lifestyles, perform head to toe assessment.
Be asking questions about their day to day activities, their spirituality, their relationships with
other people, their major life stressors, etc.

 Critical Thinking
o You are constantly thinking on what to be going on with the patient and what you need to
further asses your patient to better understand the pt and for you to give better care
o What is underlying problem
o Always assess the pt, not the monitors
o Asking the question – what is happening? – gather the basic information and begin to think of
questions.

2. DIAGNOSIS
 Different from medical diagnosis
 Patient response to what is happening with them. I revolves around the patients response.
 Ex. ASTHMA – restless, nervous – Anxiety is the response to their asthma.
o Anxiety related to asthma as manifested by restlessness.
 STROKE with left side weakness, he cannot make use of his body.
o Impaired physical mobility or impaired swallowing related to stroke as manifested by left
sided weakness.

 ND is standardized
 North American Nursing Diagnosis Association or (NANDA – International)
o Made a whole list of standardized nursing diagnosis
THREE PART STATEMENT

TWO PART STATEMENT

Problem Related to Etiology

Constipation related to prolonged laxative use
Anxiety related to possible cancer diagnosis

** Problem related to Etiology as manifested by Signs and Symptoms

-Hypersensitivity to criticism; states “I don’t know if I can take it by myself” and rejects positive feedback
(observation or as verbalized)
-Situational low self-esteem (problem)
-Feelings of rejection by husband (what caused the problem)

Situational low self-esteem related to feelings of rejection by husband as manifested by hypersensitivity to

criticism; states “I don’t know if I can take it by myself” and rejects positive feedback

3. OUTCOME IDENTIFICATION
 You decide what it looks like when the patient actually meets their goal. It’s actually goal setting.
 Establish goal of expected outcome
 Identify the outcome or the goal for your patient to achieve what you want to see

Ex. Nursing Diagnosis : impaired swallowing

What is the goal or outcome?
My patient will show NO signs of aspiration after eating
My patient will demonstrate techniques to prevent aspiration during meals.

4. PLANINNG
 Process of creating plans and setting goals
 This is how you figure out the game plan and how your patients meet your goal.
 What is the game plan that help them meet their goal?
 What will you do to help them get there?
EX: Patient Goal
Patient to demonstrate techniques to prevent aspiration during meals
** you have to continue to educate them on those techniques. These are part of the planning game, exactly
what will you do as a nurse to help patient meet their goal
TYPES OF PLANS
 A. According to
Use 2. IP – Initial Plan – upon admission

4. OP – On-going Plan – daily plan

6. DP – Discharge – after discharge

Plan

B. According to 1. Standardized – For groups of clients w/ same

User needs
2. Individualized – custom one patient only

D. According to 1. Student-care plan – made by a student

Setting
2. Institutional plans – made by hospital

3. Community-based – made for the community

care plans

G. According to 1. 3-column – Diagnosis, Outcome, Evaluation

Format (DPE)
2. 4-column – Diagnosis, Outcome,
Implementation, Evaluation
(DPIE)
3. 5-column – Assessment, Diagnosis, Outcome,
Implementation, Evaluation
(ADPIE)
4. 6-column – Assessment, Diagnosis, Outcome,
Implementation, Rationale,
Evaluation (ADPIRE)
H. According to 1. Formal – Written
Style
2. Informal – Unwritten

STEPS IN PLANNING
A. Set Priorities
 Identifying what should come FIRST

TYPES OF PRIORITIES
Types of Priorities Description Situations

1. HIGH PRIORITY Life-threatening problems Cardiac Arrest

Respiratory Arrest
2. MEDIUM Health threatening Paralysis
PRIORITY problems

3. LOW PRIORITY Normal development needs Hygiene practices

(example: Oral Care)
 How to know what comes FIRST?
A. Use Maslow’s Hierarchy of needs
 B. Use the Rule of ABC’s
Airway, Breathing and Circulation
C. Use the rule of thumb.
1. Actual problems over potential concerns.
2. Airway first.
3. Unstable patients over stable ones.

B. Outcomes
Types of Goals Description Example

1. Short-term Goals short time (<1 week) That “client’s lungs will remain clear within
the shift.”
2. Long-term Goals long time (weeks/month) That “client’s lungs will remain clear
throughout postop period.”
3. Broad Goals General in focus To improve nutritional status.
4. Specific Goals Single focused To lose 2 kgs. in 2 weeks.

CHARACTERISTICS OF GOALS
S – specific
M –measurable
A –a ttainable
R – realistic
T – time bounded

COMPONENTS OF GOALS
Components Description Example #1 Example #2 Example #3
1. SUBJECT CLIENT Patient Patient Patient

2. VERB ACTION drinks administers recalls

3. CONDITION EXPLAINS WHAT, WHERE, 2500 ml of fluid correct insulin 5 symptoms

WHEN & HOW dosage of diabetes
4. CRITERION OF INDICATES STANDARD daily (time). using aseptic Before
DESIRED USED FOR EVALUATION technique discharge
PERFORMANCE (time, accuracy, distance, (quality). (time and
quality) accuracy).

C. Select and Write Interventions

 Actions to achieve client goals

Types of Intervention
1. INDEPENDENT INTERVENTIONS – nurses do
2. DEPENDENT INTERVENTIONS – nurses do + w/ doctor’s orders
3. COLLABORATIVE INTERVENTIONS – nurses do + doctor + others
5. IMPLEMENTATION
 Process of doing client care. FOCUS: to do and Document
 You work with them, you take actions.
 Complete the intervention that will help them meet their goal. Be consistently encouraging patient to
use the following technique and educating them on how to use them properly. Its all about making
those interventions happen.

Skills Needed
Types of Skills Description Pictures
1. COGNITIVE SKILLS Intellectual skills
1. Critical Thinking
2. Decision Making
3. Clinical reasoning
4. Creativity

2. AFFECTIVE SKILLS Interpersonal skills

Communication skills

3. PSYCHOMOTOR SKILLS Technical skills

Hands- on Skills

Steps in Implementation – R-I-S-E

1. REASSESS
 To assess again  Is Intervention still NEEDED?

2. IMPLEMENT
 To do

Types of Interventions
1. Independent Nursing Interventions
2. Dependent Nursing Interventions
3. Collaborative Nursing Interventions

3. SUPERVISE
 To see to it that things are done according to standards
 What to delegate?
Right Task
Right Time (not in a crisis)
Right Information
Right Person (KSA)
Right Supervision (task performed correctly?)
Right Follow- up (formalized feedback)

 IMPORTANT! Nurse delegator remains accountable.

4. EFFECTIVELY DOCUMENT NURSING ACTIVITIES

 Document What is Done!

Purposes:
a. For Safety
 b. Legal protection

6. EVALUATION
 It’s actually an assessment all over again. You are always evaluating the patient’s progress.
 Determining whether goals are met.
 Reassess your patient to make sure that they are meeting the goals
 Was their goal met?
 What needs to be changed?
 What new goals should they have?

Characteristics of Effective Evaluation Process

1. COMPLETE
2. CORRECT
3. CONTINUOUS

Steps in Evaluation: C-C-C

1. COLLECT DATA related to the DESIRED OUTCOMES

SUJECTIVE
OBJECTIVE

2. COMPARE DATA W/ DESIRED OUTCOMES

 Are goals met?

3. CONCLUDE about PROBLEM STATUS

 Is the problem …
Conclude Decision
SOLVED? Goal met… Terminate the plan
REDUCED? Goal partially met… Continue the plan
STILL EXISTS? Goal not met… Modify the plan

Methods of Evaluating the Quality of Care

1. QUALITY ASSURANCE
 Aims at healthcare excellence

 3 COMPONENTS to Evaluate
1. Structure – environmental and organizational structures (equipment, staffing)
2. Process – the manner in which the nurse uses the nursing process.
3. Outcome – client responses or health status

2. QUALITY IMPROVEMENT

 internal assessment by health care providers

 Bad systems ---- not bad people ------lead to most errors.
 Aims at improvement of healthcare

3. NURSING AUDIT

 Examination or review of records.

 Retrospective audit – evaluation of a client’s record after discharge from health care agency.
 Concurrent audit – evaluation of a client’s health care while the client is still receiving care from the
health care agency.

4. PEER REVIEWS
 A. INDIVIDUAL REVIEW – the nurse evaluates herself.
B. PEER REVIEW – the nurse is evaluated by other nurses in the area.

DOCUMENTATION AND REPORTING

Definition of Documentation
>> Documentation refers to the process of making entries in
the patient’s records.
>> It also means RECORDING OR CHARTING.

Definition of Clinical Record

The patient’s CLINICAL RECORD is also called the PATIENT’S CHART.

Documentation Systems

1. Source- oriented Record

 A person makes notations in a separate section of the client’s chart.
 Format: Narrative charting
>> Consists of written notes in paragraph form.

2. Problem-oriented Medical Record (POMR) or problem-oriented record (POR)

 Arranged according to the problems of client.
 Format: Progress Notes
>> Uses the SOAPIE

3. Focus Charting
 The patient’s problems is the focus of attention.
 Format: DAR

Purposes of Client Records

1. Communication – health professionals communicate with each other.
2. Planning patient care – uses baseline data to plan care for the client.
3. Auditing health agencies – review client records for QA purposes.
4. Research – a valuable source of data for research.
5. Education – provide a comprehensive view of the client records as educational tool.
6. Reimbursement – facilitates reimbursement from insurance companies.
7. Legal documentation – a legal document admissible in court as evidence; confidentiality of records.
8. Health care analysis – used to establish costs of various services.

Documenting Nursing Activities

1. Admission Nursing Assessment
2. Nursing Care Plans

3. Kardex/HAND OVER REPORTS

4. Graphic Record

5. Intake and output Record

6. Medication Record

7. Skin Assessment Record

 8. Progress Notes

9. Nursing Discharge Notes

General Guidelines for Documenting and Recording

1. Date and Time

2. Timing
3. Legibility
4. Permanence
5. Accepted terminology/abbreviations
6. Correct Spelling – Incorrect spelling gives a negative impression to the reader
and decreases the nurse’s credibility.
7. Signature
 8. Accuracy – Avoid writing the word “ error” when a recording mistake has been
made – can lead to the assumption that a clinical error has caused a client injury.
9. Sequencing
10. Appropriateness
11. Completeness – Do not assume that the person reading your charting will know
that a common intervention has occurred because you believe it to be an
“obvious” component of care.
12. Conciseness
13. Legal prudence – complete charting is the best defense against malpractice.

Definition of REPORTING
 An oral or written information about the patient

Types of Reports

1. Change- of-Shift A quick summary of patient’s

Reports needs.

“Handoff communication”

Up- to-date information

2. Telephone Orders A physician’s order for the
client by telephone

Tips:
A. WRITE the order on the
physician’s order form. Put
T.O. or V.O.
B. READ the order BACK.to
ensure accuracy.
C. Question what is
UNCLEAR.
3. Nursing Rounds 2 or more nurses visit clients at
the bedside.

Phases (Steps) of the Nursing Process: A-N-P-I-E

CHARACTERISTICS OF NURSING PROCESS

1. Systematic
 Orderly, step-by-step

2. Dynamic
 Always changing

3. Purposeful
  Goal oriented

4. Interpersonal
 patient and problem oriented

NURSING ASSESSMENT
Definition
Nursing assessment is the gathering of information about a patient's physiological, psychological,
sociological, and spiritual status.

Purpose: TO CREATE A DATABASE – contains all the information about a client; it includes the nursing
health history.

Types of Assessment: I-P-E-T

1. Initial – during admission
- To establish a complete database
for problem identification.

2. Problem-focused – on-going
- Hourly assessment of client’s I & O
in ICU

3. Emergency – crisis (physiologic or

psychologic)
- Rapid assessment of a client’s
airway, breathing and circulation
during cardiac arrest

4. Time-lapsed – after discharge; follow-up

- Reassessment of a client’s health
patterns in outpatient setting.

Steps in Assessment: C-O-V-D

I. COLLECT
 GATHER DATA
Examples: Chief complaint
HEALTH History
Vital Signs

SOURCE
DESCRIPTION EXAMPLES
TYPES OF DATA OF DATA
1. SUBJECTIVE  What PATIENT Primary
DATA feels or tells the “I feel good today.”
“I have terrible headache this
nurse morning.”
 SYMPTOMS
 2. OBJECTIVE  What the NURSE Secondary Red eyes
DATA sees and measures Nasal flaring
Vital signs:
(family, friends) BP – 120/80mmHg
 SIGNS T – 37.3°C
RR – 18 breaths/min
PR – 75 beats/min

METHODS OF DATA DESCRIPTION PICTURES

COLLECTION
1. Interviewing  Planned
communication

2. Observation  Use of senses

3. Physical Examination  Head to toe

examination

TECHNIQUES IN PHYSICAL DESCRIPTION PICTURES

EXAMINATION
1. Inspection Visual Examination

2. Auscultation Listening

3. Percussion Tapping

4. Palpation Feeling

Light palpation Deep palpation

II. ORGANIZE
 Grouping of data in a standard framework
 Example: NANDA (North American Nursing Diagnosis Framework)

III. VALIDATE
 The act of “double checking” or verifying data

Processes:
1. Is the subjective = objective data?
 2. Is data CLEAR?
3. Is there any ABNORMAL data?

IV. DOCUMENTING DATA

 Record the collected data