FUNDAMENTALS OF NURSING (LECTURE) NCM 101

SEM 2 | A.Y. 2024 - 2025 | PROF. NORWENA CUSTODIO

ASSESSING
●​ Nursing process
○​ Systematic, rational method of planning and
providing individualized nursing care
○​ Purposes
■​ Identify client's health status and actual
or potential healthcare problems of
needs
■​ Establish plans to meet needs
■​ Deliver specific interventions
●​ The client may be an individual, a family, a community, or
a group. ●​ The nursing process has distinctive characteristics that
●​ Hall originated the term nursing process in 1955, and enable the nurse to respond to the changing health status of
Johnson (1959), Orlando (1961), and Wiedenbach (1963) the client. These characteristics include its cyclic and
were among the first to use it to refer to a series of dynamic nature, client centeredness, focus on
phases describing the practice of nursing. Since then, problem-solving and decision-making, interpersonal and
various nurses have described the process of nursing collaborative style, universal applicability, and use of critical
thinking and clinical reasoning.
and organized the phases in different ways.
●​ Data from each phase provides input into the next phase.
Findings from the evaluation phase feed back into
assessment. Hence, the nursing process is a regularly
repeated event or sequence of events (a cycle) that is
continuously changing (dynamic) rather than staying the
same (static).

●​ The nursing process is client-centered. The nurse organizes

the plan of care according to client problems rather than
nursing goals. In the assessment phase, the nurse collects
data to determine the client’s habits, routines, and needs,
enabling the nurse to incorporate client routines into the care
plan as much as possible.

●​ The nursing process is an adaptation of problem-solving

and systems theory. It can be viewed as parallel to but
OVERVIEW OF THE NURSING PROCESS separate from the process used by physicians (the medical
●​ Phases of the Nursing Process model). Both processes (a) begin with data gathering and
analysis, (b) base action (intervention or treatment) on a
○​ Assessing problem statement (nursing diagnosis or medical diagnosis),
○​ Diagnosing and (c) include an evaluative component. However, the
○​ Planning medical model focuses on physiologic systems and the
disease process, whereas the nursing process is directed
○​ Implementing
toward a client’s responses to real or potential disease and
○​ Evaluating illness.
○​ Sometimes included
■​ Identifying outcomes, in between ●​ Decision-making is involved in every phase of the nursing
process. Nurses can be highly creative in determining when
diagnosing and planning and how to use data to make decisions. They are not bound
●​ Each phase affects the others by standard responses and may apply their repertoire of skills
○​ Overlapping, continuing processes and knowledge to assist clients. This facilitates the
individualization of the nurse’s plan of care.
●​ Assessment still carried out during implementing,
evaluating phases ●​ The nursing process is interpersonal and collaborative. It
●​ Characteristics of the Nursing Process requires the nurse to communicate directly and consistently
with clients and families to meet their needs. It also requires
○​ Cyclic and dynamic rather than static
that nurses collaborate, as members of the healthcare team,
○​ Client-centered in a joint effort to provide quality client care.
○​ Problem-solving and systems theory
○​ Decision making ●​ The universally applicable characteristic of the nursing
process means that it is used as a framework for nursing care
○​ Interpersonal and collaborative in all types of healthcare settings, with clients of all age
○​ Universal applicability groups.
○​ Critical thinking skills
●​ Nurses must use a variety of critical thinking skills to carry out
○​ Clinical reasoning skills
the nursing process

NCM 101: FUNDA (LEC) COMPILED BY ALTHEA LORRINE L. CABUTAJE 1

 FUNDAMENTALS OF NURSING (LECTURE) NCM 101

SEM 2 | A.Y. 2024 - 2025 | PROF. NORWENA CUSTODIO

threatening problems. To
●​ Nurses must utilize clinical reasoning throughout the delivery identify new or overlooked
of nursing care. By reflecting, the nurse determines whether problems
the outcome of care was appropriate.
●​ Example: Rapid assessment of
an individual’s airway,
breathing status, and
ASSESSING
circulation during a cardiac
●​ Assessing is the systematic and continuous collection, arrest. Assessment of suicidal
organization, validation, and documentation of data tendencies or potential for
(information). In effect, assessing is a continuous process violence
carried out during all phases of the nursing process. For
Time-lapsed ●​ Time: Several months after
example, in the evaluation phase, the client is
assessment initial assessment
reassessed to determine the outcomes of the nursing ●​ Purpose: To compare the
strategies and to evaluate goal achievement. All phases client’s current status to
of the nursing process depend on the accurate and baseline data previously
complete collection of data. obtained
●​ 4 types of assessment ●​ Ex. Reassessment of a client’s
○​ Initial nursing assessment functional health patterns in a
home care or outpatient setting
○​ Problem-focused assessment
or, in a hospital, at shift change
○​ Emergency assessment
○​ Time-lapsed reassessment
●​ Assessments vary according to their purpose, timing, ●​ Data should be relevant to a particular health problem
time available, and client status. ●​ The Joint Commission (2019)
○​ Initial nursing assessment for each client
○​ History
Initial nursing ●​ Time: Performed within ○​ Physical examination
assessment specified time after
○​ Performed and documented within 24 hours of
admission to a healthcare
agency admission
●​ Purpose: To establish a
complete database for
●​ Nursing assessments focus on a client’s responses to a
problem identification, health problem. A nursing assessment should include the
reference, and future client’s perceived needs, health problems, related
comparison experience, health practices, values, and lifestyle. To be most
●​ Ex. Nursing admission useful, the data collected should be relevant to a particular
assessment health problem. Therefore, nurses should think critically about
what to assess.
Problem-focused ●​ Time performed: Ongoing
●​ The Joint Commission is a United States-based nonprofit
assessment process integrated with tax-exempt 501 organization that accredits more than 22,000
nursing care US health care organizations and programs. The international
●​ Purpose: To determine the branch accredits medical services from around the world.
status of a specific problem ○​ To improve the safety and quality of care in the
identified in an earlier international community through the provision of
assessment education, publications, consultation, and
●​ Example: evaluation and accreditation services.
○​ Hourly assessment of
●​ In 2008, The Joint Commission established a nursing practice
client’s fluid intake guideline stating that each client should have an initial
and urinary output in nursing assessment consisting of a history and physical
an intensive care unit examination performed and documented within 24 hours of
(ICU) admission as an inpatient. This assessment guideline
○​ Assessment of client’s remains in effect today. The guideline states further that a
ability to perform licensed practical nurse (LPN) may gather the data but the
self-care registered nurse (RN) is responsible for care and must
assess the data determining the needs of the client. The RN
○​ While assisting a
also has the responsibility for developing the client’s plan of
client to bathe care. In regards to the use of scribes to gather subjective
data, The Joint Commission (2019) does not endorse or
Emergency ●​ Time: During any physiologic prohibit scribes. However, there must be a sufficient
assessment or psychological crisis of the orientation and training that is specific to the scribe’s role and
client the organization. The licensed practitioner or physician must
●​ Purpose: To identify life authenticate the information, and it must be signed and dated

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 FUNDAMENTALS OF NURSING (LECTURE) NCM 101

SEM 2 | A.Y. 2024 - 2025 | PROF. NORWENA CUSTODIO

by the practitioner.

COLLECTING DATA
●​ Gathering information about client's health status
●​ Must be systematic and continuous
●​ Past history and current problem
●​ Subjective or objective
●​ Primary or secondary source
●​ Database
○​ Contains all information about a client

●​ Data collection is the process of gathering information about

a client’s health status. Data collection must be both
systematic and continuous to prevent the omission of
significant data and reflect a client’s changing health status.

●​ A database contains all the information about a client; it

includes the nursing health history (Box 1), physical
assessment, primary care provider’s history and physical
examination, results of laboratory and diagnostic tests, and
material contributed by other health personnel.

●​ Client data should include past history as well as current

problems. For example, a history of an allergic reaction to
penicillin is a vital piece of historical data. Past surgical
procedures, folk healing practices, and chronic diseases are
also examples of historical data. Current data relate to
present circumstances, such as pain, nausea, sleep patterns,
and religious practices.

●​ To collect data accurately, both the client and nurse must

actively participate. Data can be of the subjective or objective
and constant or variable types, and from a primary or TYPES OF DATA
secondary source. The collection of data allows the nurse,
client, and health-care team to identify health-related ●​ Subjective data
problems or risk factors that could cause changes in a client’s ○​ Is also referred to as symptoms or covert data,
health status. are apparent only to the individual affected and
can be described or verified only by that
COMPONENTS OF A NURSING HEALTH HISTORY individual. Itching, pain, and feelings of worry
are examples of subjective data. Subjective data
●​ Biographic data
include the client’s sensations, feelings, values,
●​ Chief complaint or reason to visit
beliefs, attitudes, and perception of personal
●​ Past history
health status and life situation.
●​ Family history of illness
○​ Example:
●​ Lifestyle
■​ “I feel weak all over when I exert
●​ Social data
myself.”
●​ Psychological data
■​ “I’m short of breath.”
●​ Patterns of healthcare

●​ Objective data
○​ Is also referred to as signs or overt data, are
detectable by an observer or can be measured
or tested against an accepted standard. They
can be seen, heard, felt, or smelled, and they
are obtained by observation or physical
examination. For example, a discoloration of the
skin or a blood pressure reading is objective
data. During the physical examination, the nurse
obtains objective data to validate subjective data

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 FUNDAMENTALS OF NURSING (LECTURE) NCM 101

SEM 2 | A.Y. 2024 - 2025 | PROF. NORWENA CUSTODIO

and to complete the assessment phase of the data because it is an interpretation of the client’s
nursing process behavior by the daughter. The nurse should
○​ Example: attempt to verify the reported confusion by
■​ Blood pressure 90/50 mmHg* interviewing the client directly. However, if the
■​ Apical pulse 104 beats/min daughter says, “Dad said he thought it was the
■​ Skin pale and diaphoretic year 1941 today,” that may be considered
secondary objective data since the daughter
SOURCES OF DATA heard her father state this directly.
●​ Client
●​ Client Records
○​ Best source unless too ill, young, or confused to
○​ Medical records
communicate clearly
○​ Records of therapies
○​ Family members, significant others can be
○​ Laboratory records
secondary source if client cannot speak for
○​ By reviewing these records, nurses can avoid
themselves
repeated questioning and concerns about lack
○​ Review HIPAA to be able to explain to patient in
of communication among health professionals.
an understandable way
○​ If the client is hesitant to provide data, remind
●​ Healthcare Professionals
the client that the privacy of all data collected is
○​ Important to ensure continuity of care when
protected and data can be shared only with
clients transferred to and from home and
individuals who have legitimate health-related
healthcare agencies
needs to know it. If necessary, review for
○​ Because assessment is an ongoing process,
yourself the mandates of the Health Insurance
verbal reports from other healthcare
Portability and Accountability Act of 1996
professionals serve as other potential sources of
(HIPAA) so you can explain this in a way that
information about a client’s health. Nurses,
the client can understand. Summarized
social workers, primary care providers, and
information about HIPAA in terms
physiotherapists, for example, may have
understandable to both nurses and clients is
information from either previous or current
available in the U.S. Department of Health and
contact with the client. Sharing of information
Human Services website.
among professionals is especially important to
ensure continuity of care when clients are
●​ Support People
transferred to and from home and healthcare
○​ Family members, friends, caregivers
agencies.
○​ Person giving information may wish to remain
anonymous
●​ Literature
○​ Secondary subjective data
○​ Standards or norms against which to compare
■​ Person's interpretation of client
findings
○​ Secondary objective data
○​ Current methodologies and research findings
■​ May be something client stated directly
○​ The review of nursing and related literature,
○​ Support people are an especially important
such as professional journals and reference
source of data for a client who is very young,
texts, can provide additional information for the
unconscious, or confused. In some cases—a
database.
client who is physically or emotionally abused,
○​ A literature review includes but is not limited to
for example—the individual giving information
the following information:
may wish to remain anonymous. Before eliciting
■​ Standards or norms against which to
data from support people, the nurse should
compare findings (e.g., height and
ensure that the client, if mentally able,
weight tables, normal developmental
authorizes such input. The nurse should also
tasks for an age group)
indicate on the nursing history that the data
■​ Cultural and social health practices
were obtained from a support person.
■​ Spiritual beliefs
○​ Information supplied by family members,
■​ Assessment data needed for specific
significant others, or other health professionals
client conditions
is considered subjective if it is not based on fact.
■​ Nursing interventions and evaluation
If the client’s daughter says, “Dad is very
criteria relevant to a client’s health
confused today,” that is secondary subjective
problems

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 FUNDAMENTALS OF NURSING (LECTURE) NCM 101

SEM 2 | A.Y. 2024 - 2025 | PROF. NORWENA CUSTODIO

■​ Information about medical diagnoses,

flushing, labored breathing, and behavior indicating
treatment, and prognoses pain or emotional distress)
■​ Current methodologies and research 2.​ Threats to the client’s safety, real or anticipated
findings. (e.g., a lowered side rail)
3.​ The presence and functioning of associated
equipment (e.g., IV equipment and oxygen)
DATA COLLECTION METHODS 4.​ The immediate environment, including the people
in it
●​ Observing
●​ Interviewing
INTERVIEWING
OBSERVING ●​ Interview
●​ Gathering data using the senses ○​ Planned communication or a conversation with
●​ Used to obtain following types of data: a purpose
○​ Skin color (vision) ●​ Focused interview
○​ Body or breath odors (smell) ○​ Nurse asks the client specific questions to
○​ Lung or heart sounds (hearing) collect information related to the client's problem
○​ Skin temperature (touch) ○​ This allows the nurse to collect information that
may have previously been missed and yields
more in-depth information
●​ Vision: Overall appearance (e.g., body size, general weight,
●​ Used to:
posture, grooming); signs of distress or discomfort; facial and
body gestures; skin color and lesions; abnormalities of ○​ Get or give information
movement; nonverbal demeanor (e.g., signs of anger or ○​ Identify problems of mutual concern
anxiety); religious or cultural artifacts (e.g., books, icons, ○​ Evaluate change
candles, beads)
●​ Smell: Body or breath odors ○​ Teach
●​ Hearing: Lung and heart sounds; bowel sounds; ability to ○​ Provide support
communicate; language spoken; ability to initiate ○​ Provide counseling or therapy
conversation; ability to respond when spoken to; orientation
to time, person, and place; thoughts and feelings about self,
others, and health status ●​ The directive interview is highly structured and elicits
●​ Touch: Skin temperature and moisture; muscle strength specific information. The nurse establishes the purpose
(e.g., hand grip); pulse rate, rhythm, and volume; palpable of the interview and controls the interview, at least at the
lesions (e.g., lumps, masses, nodules)
outset. The client responds to questions but may have
●​ Observing has two aspects: limited opportunity to ask questions or discuss concerns.
(a)​ noticing the data and Nurses frequently use directive interviews to gather and
(b)​ selecting, organizing, and interpreting the data.
to give information when time is limited (e.g., in an
●​ A nurse who observes that a client’s face is flushed must emergency situation).
relate that observation to findings such as body temperature,
activity, environmental temperature, and blood pressure. ●​ By contrast, during a nondirective interview , or
Errors can occur in selecting, organizing, and interpreting
data. For example, a nurse might not notice certain signs, rapport-building interview, the nurse allows the client to
either because they are unexpected or because they do not control the purpose, subject matter, and pacing.
conform to preconceptions about a client’s illness. Nurses ○​ Rapport is an understanding between two or
often need to focus on specific data in order not to be
overwhelmed by a multitude of data. Observing, therefore, more people.
involves distinguishing data in a meaningful manner. For ○​ A combination of directive and nondirective
example, nurses caring for newborns learn to ignore the approaches is usually appropriate during the
usual sounds of machines in the nursery but respond quickly
information-gathering interview. The nurse
to an infant’s cry or movement.
begins by determining areas of concern for the
●​ The experienced nurse is often able to attend to an client.
intervention (e.g., give a bed bath or monitor an IV infusion) ○​ If, for example, a client expresses worry about
and at the same time make important observations (e.g., note
a change in respiratory status or skin color). The beginning surgery, the nurse pauses to explore the client’s
student must learn to make observations and complete tasks worry and to provide support. Simply noting the
simultaneously. worry, without dealing with it, can leave the
●​ Nursing observations must be organized so that nothing
impression that the nurse does not care about
significant is missed. Most nurses develop a particular the client’s concerns or dismisses them as
sequence for observing events, usually focusing on the client unimportant.
first. For example, a nurse walks into a client’s room and ○​ The client controls the purpose, subject matter,
observes, in the following order:
1.​ Clinical signs of client distress (e.g., pallor or and pacing.

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 FUNDAMENTALS OF NURSING (LECTURE) NCM 101

SEM 2 | A.Y. 2024 - 2025 | PROF. NORWENA CUSTODIO

inaccurate data.
TYPES OF INTERVIEW QUESTIONS
Open-ended ●​ Specify broad topic to discuss Closed questions ●​ Restrictive
questions ●​ Invite longer answers ○​ Yes/no
●​ Get more information from client ○​ Factual
●​ Useful to change topics and elicit ●​ Less effort and information from
attitudes client
●​ Neutral question ●​ "What medications did you take?"
●​ Leading question ●​ "Are you in pain now?"

●​ Open-ended questions , ●​ Closed questions used in the

associated with the nondirective directive interview are restrictive
interview, invite clients to discover and generally require only “yes” or
and explore, elaborate, clarify, or “no” or short factual answers that
illustrate their thoughts or feelings. provide specific information.
An open-ended question specifies Closed questions often begin with
only the broad topic to be “when,” “where,” “who,” “what,” “do
discussed and invites answers (did, does),” or “is (are, was).”
longer than one or two words. ●​ Examples of closed questions are
●​ Such questions give clients the “What medication did you take?”
freedom to divulge only the “Are you in pain now? Show me
information that they are ready to where it is.” “How old are you?”
disclose. The open-ended question “When did you fall?”
is useful at the beginning of an ●​ Closed questions are often used
interview or to change topics and to when information is needed
elicit attitudes. quickly, such as in an emergency
●​ Open-ended questions may begin situation. Individuals who are highly
with “what” or “how.” Examples of stressed or have difficulty
open-ended questions are “How communicating will find closed
have you been feeling lately?” questions easier to answer than
“What brought you to the hospital?” open-ended questions.
“How did you feel in that situation?”
“Would you describe more about
how you relate to your child?” PLANNING THE INTERVIEW AND SETTING
“What would you like to talk about ●​ Before beginning an interview, the nurse reviews
today?” available information, for example, the operative report,
●​ The type of question a nurse
chooses depends on the needs of
information about the current illness, or literature about
the client at the time. Nurses often the client’s health problem. The nurse also reviews the
find it necessary to use a agency’s data collection form to identify which data must
combination of closed and
be collected and which data are within the nurse’s
open-ended questions throughout
an interview to accomplish the discretion to collect based on the specific client. If a form
goals of the interview and obtain is not available, most nurses prepare an interview guide
needed information. to help them remember areas of information and
●​ A neutral question is a question determine what questions to ask. The guide includes a
the client can answer without list of topics and subtopics rather than a series of
direction or pressure from the questions.
nurse, is open ended, and is used
●​ Both nurses and clients are made comfortable in order to
in nondirective interviews.
Examples are “How do you feel encourage an effective interview by balancing several
about that?” “What do you think led factors. Each interview is influenced by time, place,
to the operation?” seating arrangement or distance, and language.
●​ A leading question , by contrast,
is usually closed, used in a
Time ●​ Client free of pain
directive interview, and thus directs
●​ Limited interruptions
the client’s answer. Examples are
“You’re stressed about surgery
●​ Nurses need to plan interviews with clients
tomorrow, aren’t you?” “You will
when the client is physically comfortable
take your medicine, won’t you?”
and free of pain, and when interruptions by
The leading question gives the
friends, family, and other health
client less opportunity to decide
professionals are minimal. Nurses should
whether the answer is true or not.
schedule interviews with clients in their
Leading questions create problems
homes at a time selected by the client.
if the client, in an effort to please
the nurse, gives inaccurate
responses. This can result in Place ●​ Private

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 FUNDAMENTALS OF NURSING (LECTURE) NCM 101

SEM 2 | A.Y. 2024 - 2025 | PROF. NORWENA CUSTODIO

●​ Comfortable environment spoken in a particular geographic region).

●​ Limited distractions Translating medical terminology is a
specialized skill because not everyone
●​ A well-lit, well-ventilated room that is who is fluent in the conversational form of
relatively free of noise, movements, and a language is familiar with anatomic or
distractions encourages communication. In other health terms. Interpreters, however,
addition, a place where others cannot may make judgments about precise
overhear or see the client is desirable. wording but also about subtle meanings
that require additional explanation or
Seating ●​ Hospital clarification according to the specific
arrangement ●​ Office or clinic language and ethnicity. They may edit the
●​ Group original source to make the meaning
clearer or more culturally appropriate.
●​ By standing and looking down at a client
who is in bed or in a chair, the nurse risks
intimidating the client. When a client is in STAGES OF AN INTERVIEW
bed, the nurse can sit at a 45-degree
angle to the bed. This position is less The opening ●​ Establish rapport
formal than sitting behind a table or ●​ Orient client
standing at the foot of the bed.
●​ During an initial admission interview, a ●​ The opening can be the most important part
client may feel less confronted if there is of the interview because what is said and
an overbed table between the client and done at that time sets the tone for the
the nurse. Sitting on a client’s bed hems remainder of the interview. The purposes of
the client in and makes staring difficult to the opening are to establish rapport and
avoid. orient the interviewee.
●​ A seating arrangement with the nurse ●​ Establishing rapport is a process of creating
behind a desk and the client seated across goodwill and trust. It can begin with a
creates a formal setting that suggests a greeting (“Good morning, Mr. Johnson”) or
business meeting between a superior and a self introduction (“Good morning. I’m
a subordinate. In contrast, a seating Becky James, a nursing student”)
arrangement in which the parties sit on two accompanied by nonverbal gestures such
chairs placed at right angles to a desk or as a smile, a handshake, and a friendly
table or a few feet apart, with no table manner. The nurse must be careful not to
between, creates a less formal overdo this stage; too much superficial talk
atmosphere, and the nurse and client tend can arouse anxiety about what is to follow
to feel on equal terms. In groups, a and may appear insincere.
horseshoe or circular chair arrangement ●​ In orientation, the nurse explains the
can avoid a superior or head-of the table purpose and nature of the interview, for
position. example, what information is needed, how
long it will take, and what is expected of the
client. The nurse tells the client how the
Distance ●​ Comfortable
information will be used and usually states
that the client has the right not to provide
●​ The distance between the interviewer and
data.
interviewee should be neither too small nor
too great, because people feel
uncomfortable when talking to someone The body ●​ Client communicates.
who is too close or too far away. ●​ Nurse asks questions.
Proxemics is the study of use of space.
As a species, humans are highly territorial ●​ In the body of the interview, the client
but we are rarely aware of it unless our communicates what he or she thinks, feels,
space is somehow violated. Most people knows, and perceives in response to
feel comfortable maintaining a distance of questions from the nurse. Effective
2 to 3 feet during an interview. Some development of the interview demands that
clients require more or less personal the nurse use communication techniques
space, depending on their cultural and that make both parties feel comfortable and
personal needs. serve the purpose of the interview.

Language ●​ Use easily understood terms The closing ●​ Nurse ends the interview when necessary
●​ Interpreter or translator information is collected.

●​ Failure to communicate in language the ●​ The nurse terminates the interview when
client can understand is a form of the needed information has been obtained.
discrimination. The nurse must convert In some cases, however, a client terminates
complicated medical terminology into it, for example, when deciding not to give
common English usage, and interpreters any more information or when unable to
or translators are needed if the client and offer more information for some other
the nurse do not speak the same language reason—fatigue, for example. The closing is
or dialect (a variation in a language important for maintaining rapport and trust

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 FUNDAMENTALS OF NURSING (LECTURE) NCM 101

SEM 2 | A.Y. 2024 - 2025 | PROF. NORWENA CUSTODIO

○​ Gordon's functional health pattern framework

and for facilitating future interactions.
○​ Orem's self-care model
○​ Roy's adaptation model
●​ Examining
○​ Systematic data-collection method
GORDON’S FUNCTIONAL HEALTH PATTERNS
○​ Uses observation and inspection, auscultation,
palpation, and percussion ●​ Gordon (2016) provides a framework of 11 functional
○​ Vital signs, height and weight health patterns. Gordon uses the word pattern to signify
○​ Cephalocaudal approach a sequence of recurring behavior. The nurse collects data
■​ Head-to-toe progression about dysfunctional as well as functional behavior. Thus,
○​ Screening examination by using Gordon’s framework to organize data, nurses
■​ Review of systems are able to discern emerging patterns.

●​ Marjory Gordon was a nursing theorist and professor who

●​ The physical examination or physical assessment is a created a nursing assessment theory known as Gordon's
systematic data collection method that uses observation (i.e.,
the senses of sight, hearing, smell, and touch) to detect functional health patterns. The Functional Health Pattern
health problems. To conduct the examination, the nurse uses Model (FHPM) (Gordon 2010) is a nursing model that
techniques of inspection, auscultation, palpation, and standardizes data collection in practising the nursing
percussion.
process, simplifies the process of making a nursing
●​ The physical examination is carried out systematically. It may diagnosis and considers the individual holistically.
be organized according to the examiner’s preference, in a
head-to-toe approach or a body systems approach. Usually, ●​ 11 GORDON’S FUNCTIONAL HEALTH PATTERNS
the nurse first records a general impression about the client’s
overall appearance and health status: for example, age, body 1.​ Health Perception Health Management Pattern
size, mental and nutritional status, speech, and behavior. 2.​ Nutritional Metabolic Pattern
Then the nurse takes such measurements as vital signs, 3.​ Elimination Pattern
height, and weight. The cephalocaudal or head-to-toe
approach begins the examination at the head; progresses to
4.​ Activity Exercise Pattern
the neck, thorax, abdomen, and extremities; and ends at the 5.​ Sleep Rest Pattern
toes. The nurse using a body systems approach investigates 6.​ Cognitive-Perceptual Pattern
each system individually, that is, the respiratory system, the 7.​ Self-Perception-Self-Concept Pattern
circulatory system, the nervous system, and so on.
8.​ Role-Relationship Pattern
●​ During the physical examination, the nurse assesses all body 9.​ Sexuality-Reproductive
parts and compares findings on each side of the body (e.g., 10.​ Coping-Stress Tolerance Pattern
lungs). These techniques are discussed in detail in Chapters
28 and 29. 11.​ Value-Belief Pattern

●​ Instead of giving a complete examination, the nurse may OREM’S SELF-CARE MODEL
focus on a specific problem area noted from the nursing
assessment, such as the inability to urinate. On occasion, the ●​ Orem’s self-care model (2001) delineates eight
nurse may find it necessary to resolve a client complaint or universal self-care requisites of humans. The model
problem (e.g., shortness of breath) before completing the
examination. Alternatively, the nurse may perform a describes the client’s need for adequate nutrition, normal
screening examination. A screening examination , also elimination, and adequate rest to promote normal human
called a review of systems, is a brief review of essential functioning and development. Roy (2009) outlines the
functioning of various body parts or systems. An example of a
screening examination is the nursing admission assessment
data to be collected according to the Roy adaptation
form shown in Figure 5. Data obtained from this examination model and classifies observable behavior into four
are measured against norms or standards, such as ideal categories: physiologic, self-concept, role function,
height and weight standards or norms for body temperature and interdependence (Box 2).
or blood pressure levels.

ORGANIZING DATA (1)

●​ The nurse uses a written (or electronic) format that
organizes the assessment data systematically. This is
often referred to as a nursing health history, nursing
assessment, or nursing database form. The format may
be modified according to the client’s physical status such
as one focused on musculoskeletal data for orthopedic
clients.
●​ Conceptual Models and Frameworks

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●​ Non Nursing Models

○​ Frameworks and models from other disciplines
may also be helpful for organizing data. These
frameworks are narrower than the model
required in nursing; therefore, the nurse usually
needs to combine these with other approaches
to obtain a complete history.

Body Systems The body systems model focuses on

Model abnormalities of the following anatomic
systems:
●​ Integumentary system
●​ Respiratory system
●​ Cardiovascular system
●​ Nervous system
●​ Musculoskeletal system
ROY’S ADAPTATION MODEL ●​ Gastrointestinal system
●​ Genitourinary system
ADAPTIVE MODES
●​ Reproductive system
1.​ Physiologic needs ●​ Immune system.
●​ Activity and rest
●​ Nutrition
●​ Elimination
●​ Fluid and electrolytes
●​ Oxygenation
●​ Protection
●​ Regulation: temperature
●​ Regulation: the senses Maslow’s Maslow’s hierarchy of needs clusters
●​ Regulation: endocrine system Hierarchy of data pertaining to the following:
2.​ Self-concept Needs ●​ Physiologic needs (survival
●​ Physical self needs)
●​ Personal self ●​ Safety and security needs
3.​ Role function ●​ Love and belonging needs
●​ Self-esteem needs
4.​ Interdependence
●​ Self-actualization needs.

ORGANIZING DATA (2)

●​ Wellness Models
○​ Assist clients to identify and explore lifestyle
habits and health behaviors, beliefs, values, and
attitudes
○​ Nurses use wellness models to assist clients to
identify health risks and to explore lifestyle
habits and health behaviors, beliefs, values, and
attitudes that influence levels of wellness. Such Developmental Several physical, psychosocial,
models generally include the following: Theories cognitive, and moral developmental
theories may be used by the nurse in
■​ Health history
specific situations. Examples include the
■​ Physical fitness evaluation following:
■​ Nutritional assessment ●​ Havighurst’s age periods and
■​ Life-stress analysis developmental tasks
■​ Lifestyle and health habits ●​ Freud’s five stages of
■​ Health beliefs development
■​ Sexual health ●​ Erikson’s eight stages of
development
■​ Spiritual health
●​ Piaget’s stages of cognitive
■​ Relationships development
■​ Health risk appraisal.

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○​ Ensure that assessment information is

●​ Kohlberg’s stages of moral
development. complete.
○​ Ensure that objective and related subjective
data agree.
○​ Obtain additional information that may have
been overlooked.

●​ Differentiate between cues and inferences.

●​ Cues are subjective or objective data that can be directly

observed by the nurse; that is, what the client says or
what the nurse can see, hear, feel, smell, or measure.
Inferences are the nurse’s interpretation or conclusions
made based on the cues (e.g., a nurse observes the
cues that an incision is red, hot, and swollen; the nurse
makes the inference that the incision is infected).

●​ Avoid jumping to conclusions and focusing in the wrong

direction to identify problems.

●​ Not all data require validation. For example, data such as

height, weight, birth date, and most laboratory studies
that can be measured with an accurate scale can be
accepted as factual. As a rule, the nurse validates data
when there are discrepancies between data obtained in
the nursing interview (subjective data) and the physical
examination (objective data), or when the client’s
statements vary at different times in the assessment.

DOCUMENTING DATA
●​ To complete the assessment phase, the nurse records
client data. Accurate documentation is essential and
should include all data collected about the client’s health
status. Data are recorded in a factual manner and not
interpreted by the nurse. For example, the nurse
records the client’s breakfast intake (objective data) as
“coffee 240 mL, juice 120 mL, 1 egg, and 1 slice of toast,”
rather than as “appetite good” (a judgment). A judgment
or conclusion such as “appetite good” or “normal
appetite” may have different meanings for different
people. To increase accuracy, the nurse records
subjective data in the client’s own words, using quotation
marks. Restating in other words what someone says
increases the chance of changing the original meaning

●​ Record client data

●​ Record in factual manner without stating interpretations
VALIDATING DATA ●​ Record subjective data with quotes in client's own words
●​ The information gathered during the assessment phase
must be complete, factual, and accurate because the DIAGNOSING
nursing diagnoses and interventions are based on this
●​ Activities preceding the diagnosing phase are directed
information. Validation is the act of “double-checking”
toward forming the nursing diagnoses.
or verifying data to confirm that it is accurate and factual.
●​ All other steps flow from nursing diagnoses.
Validating data helps the nurse complete these tasks:

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●​ Nurses use critical thinking skills to interpret assessment

meaning
data and identify client strengths and problems. ○​ Such as not sufficient,
●​ North American Nursing Diagnosis Association made worse, lesser in size,
(NANDA) International not producing the desired
○​ Define, refine, and promote a taxonomy of effect, vulnerable to threat
nursing diagnostic terminology
Etiology ●​ Identifies one or more probable
(Related causes of the health problem
NURSING DIAGNOSES Factors and ●​ Gives direction to the required
●​ Familiarity with definitions of terms used and components Risk Factors) nursing therapy
of nursing diagnoses is essential. ●​ Enables the nurse to individualize
the client's care

Diagnosis ●​ A statement or conclusion regarding Defining ●​ Cluster of existing signs and

the nature of a phenomenon Characteristics symptoms indicates actual
diagnosis
Diagnostic ●​ Standardized NANDA names for ○​ Clients have signs and
labels diagnoses symptoms.
●​ Cluster of factors that cause client
Etiology ●​ Causal relationship between the to be more vulnerable to a problem
problem and its related factors indicates "risk for" diagnosis
○​ No subjective or objective
Nursing ●​ Problem statement consisting of data exist at present.
diagnosis diagnostic label plus etiology
●​ Professional nurses responsible for
making DIFFERENTIATING NURSING DIAGNOSES FROM MEDICAL
●​ Includes only those health states that DIAGNOSES
nurses are educated and licensed to
treat
●​ Judgment made only after thorough, Nursing ●​ A statement of nursing judgment
systematic data collection diagnosis based on education, experience,
●​ Continuum of health states expertise and license to treat
●​ Describes human response, the
client's physical, sociocultural,
STATUS OF NURSING DIAGNOSES psychological, and spiritual responses
to an illness or health problem
●​ Changes when client's responses
Actual ●​ Problem presents at the time of change
nursing assessment. ●​ Independent functions
diagnosis ●​ Presence of associated signs and ○​ Areas of healthcare that are
symptoms unique to nursing, separate
and distinct from medical
Health ●​ Preparedness to implement behaviors management
promotion to improve their health condition
diagnosis ●​ Example: Readiness for Enhanced Health ●​ Made by a physician
Nutrition promotion ●​ Refers to a disease process
diagnosis ●​ Remains the same as long as the
Risk nursing ●​ Problem does not exist. disease process is present
diagnosis ●​ Presence of risk factors ●​ Dependent functions
(physician-prescribed therapies and
Syndrome ●​ Cluster of nursing diagnoses that have treatments)
diagnosis similar interventions
See how these responses vary among individuals:
COMPONENTS OF NURSING DIAGNOSES ●​ Seventy-year-old Mary Cain and 20-year-old Kristi Vidan
both have rheumatoid arthritis. Their disease processes
are much the same. X Ray studies show that in both
Problem ●​ Describes the client's health clients, the extent of inflammation and the number of
(Diagnostic problem or response joints involved are similar, and both clients experience
Label) and ●​ May require specification almost constant pain. Ms. Cain views her condition as
Definition ●​ Qualifiers added to give additional part of the aging process and is responding with

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acceptance. Ms. Vidan, however, is responding with ○​ Inductively or with a framework

anger and hostility because she views her disease as a ●​ Identifying Gaps and Inconsistencies in Data
threat to her personal identity, role performance, and ○​ Conflicting data
self-esteem. ○​ All inconsistencies must be clarified before a
valid pattern can be established.
DIFFERENTIATING NURSING DIAGNOSES FROM
COLLABORATIVE PROBLEMS
●​ Use both independent and dependent
(physician-prescribed) interventions
●​ Require monitoring of client's condition and prevention of
potential complications
●​ Occur when a particular disease or treatment is present

THE DIAGNOSTIC PROCESS

●​ Critical thinking
○​ Reviewing data and considering explanations
before forming opinions
●​ Analysis
○​ Separation into components (deductive
reasoning)
●​ Synthesis
○​ Putting together of parts into whole (inductive
reasoning)

ANALYZING DATA
●​ Comparing Data with Standards
○​ Standard or norm
■​ Generally accepted measure, rule,
model, or pattern
○​ Cue considered significant if:
■​ Points to negative, positive change in
client's health status or pattern
■​ Varies from norms of client population
■​ Indicates a developmental delay

●​ Clustering Cues
○​ Determine relatedness of facts

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○​ Health promotion diagnoses beginning with

IDENTIFYING HEALTH PROBLEMS, RISKS, AND Readiness for Enhanced
STRENGTHS ○​ Syndrome diagnoses
●​ Determining Problems and Risks
●​ Variations of Basic Formats
○​ Problems that support tentative or actual risks
○​ Unknown etiology
and possible diagnoses
■​ Defining characteristics present but
○​ Determine whether problem is a nursing
cause, contributing factors unknown
diagnosis, medical diagnosis, or collaborative
○​ Complex factors
problem
■​ When too many etiologic factors to
●​ Determining Strengths
state briefly
○​ Resources and abilities to cope
○​ Possible
○​ Can be an aid to mobilizing health and
■​ Either problem or etiology
regenerative processes
○​ Secondary to
○​ Can include home life, education, recreation,
■​ Divide etiology into two parts
exercise, work, family and friends, religious
○​ Adding a second part to make it more
beliefs, and sense of humor
precise
■​ Indicate location, etc
FORMULATING DIAGNOSTIC STATEMENTS
●​ Basic Two-Part Statements ●​ Collaborative Problems
○​ Problem (P) ○​ Begin with Potential Complication (PC)
○​ Etiology (E) ○​ Etiology may be useful in some situations.
○​ Joined by the words "related to"
○​ Add words if NANDA label contains the word ●​ Evaluating the Quality of the Diagnostic Statement
Specify ○​ Validate with client
○​ Compare signs and symptoms to NANDA
defining characteristics

●​ Basic Three-Part Statements

○​ PES format
■​ Problem (P)
■​ Etiology (E)
■​ Signs and symptoms (S)
○​ Recommended for beginning diagnosticians
○​ List signs and symptoms grouped by subjective
and objective data

AVOIDING ERRORS IN DIAGNOSTIC REASONING

●​ Verify data
●​ Build a good knowledge base and acquire clinical
experience
●​ Have a working knowledge of what is normal
●​ Consult resources
●​ Base diagnoses on patterns rather than an isolated
incident
●​ Improve critical thinking skills

ONGOING DEVELOPMENT OF NURSING DIAGNOSES

●​ One-Part Statements

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●​ The first taxonomy was alphabetical. ○​ Set priorities for client's care during shift
●​ Later version based on "human response patterns" ○​ Decide which problems to focus on during shift
●​ Taxonomy II has three levels. ○​ Coordinate nurse's activities so that more than
○​ Domains one problem can be addressed at each client
○​ Classes contact
○​ Nursing diagnoses
DISCHARGE PLANNING
●​ Process of anticipating and planning for needs after
discharge
●​ Addressed in each client's care plan
●​ Begins at first client contact
●​ Involves comprehensive and ongoing assessment

DEVELOPING NURSING CARE PLAN

●​ Informal nursing care plan
○​ A strategy for action that exists in nurse's mind
●​ Formal nursing care plan
○​ Written or computerized guide

●​ Process for acceptance of new and modified labels

reviewed biannually
●​ Development of standardized nursing language
○​ Includes NANDA nursing diagnoses
○​ Nursing interventions classification
○​ Nursing outcomes classification
●​ Nursing Minimum Data Set for computerized records

PLANNING
INTRODUCTION
●​ Planning ●​ Standardized care plan
○​ Deliberate, systematic, problem solving phase ○​ A formal plan that specifies actions for a group
of nursing process of clients with common needs
●​ Nursing interventions ●​ Individualized care plan
○​ Treatment that a nurse performs to enhance ○​ Tailored to meet the unique needs of a specific
patient/client outcomes client
●​ Nurse responsible, but input from client essential
STANDARDIZED APPROACHES TO CARE PLANNING
TYPES OF PLANNING ●​ Established to ensure minimal criteria for care are met
●​ Begins with first client contact ●​ Established for efficient use of time
●​ Continues until nurse–client relationship ends (discharge)
●​ Is multidisciplinary ●​ Standards of care
○​ Nursing actions for clients with similar medical
conditions
INITIAL PLANNING
○​ Achievable rather than ideal nursing care
●​ Develops initial comprehensive plan of care ○​ Interventions for which nurses are accountable
●​ Begun after initial assessment ○​ Usually, there are agency records that may be
referred to in the client's care plan.
ONGOING PLANNING ○​ Written from the perspective of the nurse's
●​ Done by all nurses who work with the client responsibilities
●​ Individualization of initial care plan ○​ Do not contain medical interventions
●​ At the beginning of a shift ○​ Kept with client's individualized care plan, then
○​ Determine whether client's health status has permanent medical record
changed ○​ Provide detailed interventions

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○​ Written in the nursing process format

●​ Protocols
○​ Indicate actions commonly required for a
particular groups of clients
○​ May include both primary care provider's orders
and nursing interventions
○​ Example: Protocol for admitting a client to the
intensive care unit

●​ Policies and procedures

○​ Developed to govern handling of frequently
occurring situations ●​ Computerized Care Plans
○​ Cover situations pertinent to client care ○​ Create and store nursing care plans
○​ Example: Policy specifying the number of ○​ Can be accessed at a centrally located terminal
visitors a client may have at nurses' station or in clients' rooms
●​ Standing order ○​ Appropriate diagnoses selected from a menu
○​ Written document suggested by the computer
■​ Policies
■​ Rules
MULTIDISCIPLINARY (COLLABORATIVE) CARE PLANS
■​ Regulations
■​ Orders regarding patient care ●​ Also known as collaborative care plans or critical
○​ Gives the nurse authority to carry out specific pathways
actions under certain circumstances ●​ Sequence care that must be given on each day during
projected length of stay for each condition
●​ Individualization of standardized care plans ●​ Usually organized with a column for each day listing
○​ Fit the unique needs of each client interventions and outcomes for that day
○​ Usually both pre authored and nurse-created ●​ Includes medical treatments to be performed by other
sections providers
○​ For predictable, commonly occurring problems
○​ Individual plan for unusual problems or GUIDELINES FOR WRITING NURSING CARE PLANS
problems needing special attention 1.​ Date and sign the plan
2.​ Use category headings
FORMATS FOR NURSING CARE PLANS 3.​ Use standardized/approved medical or English symbols
●​ Student Care Plans and key words rather than complete sentences to
○​ Rationale communicate your ideas unless agency policy dictates
■​ Evidence-based principle given as the otherwise
reason for selecting a particular 4.​ Be specific
nursing intervention
○​ Concept maps
■​ Visual tool in which ideas or data are
enclosed in circles or boxes with
relationships indicated by lines or
arrows

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5.​ Refer to procedure books or other sources of information

rather than including all the steps on a written care plan
6.​ Tailor the plan to the unique characteristics of the client
by ensuring that the client's choices, such as preferences
about the times of care and methods used, are included.
7.​ Ensure that the nursing plan incorporates preventive and
health maintenance aspects as well as restorative ones
8.​ Ensure that the plan contains ongoing assessment of the
client
9.​ Include collaborative and coordination activities in the
plan
10.​ Include plans for the client's discharge and home care
needs

THE PLANNING PROCESS

●​ Consists of the following activities:
○​ Setting priorities
○​ Establishing client goals/desired outcomes
ESTABLISHING CLIENT GOALS OR DESIRED OUTCOMES
○​ Selecting nursing interventions
○​ Writing individualized nursing interventions on ●​ Goals
care plans ○​ Broad statements about the client's status
●​ Desired outcomes
○​ More specific, observable criteria used to
SETTING PRIORITIES
evaluate whether goals have been met
●​ Establishing a preferential sequence for addressing
nursing diagnoses and interventions
○​ High priority (life-threatening)
○​ Medium priority (health-threatening)
○​ Low priority (developmental needs)
●​ Factors to consider
○​ Client's health values and beliefs
○​ Client's priorities
○​ Resources available to nurse and client
○​ Urgency of the health problem ●​ The Nursing Outcomes Classification (NOC)
○​ Medical treatment plan ○​ Taxonomy for describing client outcomes that
respond to nursing interventions
○​ Outcomes broadly stated and conceptual
○​ Made more specific by identifying indicators that
apply to a particular client
■​ Stated in neutral terms
■​ Each outcome includes a five-point
scale to rate the client's status.
○​ To write a desired outcome using NOC
taxonomy, indicate:
■​ Label
■​ Indicators that apply to client
■​ Initial client status
■​ Location on the measuring scale
desired for each indicator
○​ Can be stated in traditional (lay) language

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●​ Guidelines for Writing Goals or Desired Outcomes

●​ Purpose of Desired Goals or Outcomes ○​ Write in terms of client responses
○​ Provide direction for planning interventions ○​ Must be realistic
○​ Serve as criteria for evaluating progress ○​ Ensure compatibility with therapies of other
○​ Enable the client and the nurse to determine professionals
when the problem has been resolved ○​ Derive from only one nursing diagnosis
○​ Help motivate the client and nurse by providing ○​ Use observable, measurable terms
a sense of achievement ○​ Make sure client considers goals important
●​ Short-Term and Long-Term Goals
○​ By the end of the week or in over the course of
SELECTING NURSING INTERVENTIONS AND ACTIVITIES
many weeks
●​ Actions nurse performs to achieve goals
○​ Short-term goals useful for clients who:
●​ Focus on eliminating or reducing etiology of nursing
■​ Require healthcare for a short time
diagnosis
■​ Are frustrated by long-term goals that
●​ Treat signs and symptoms and defining characteristics
seem difficult to attain
●​ Interventions for risk nursing diagnoses should focus on
■​ Need the satisfaction of achieving a
reducing client's risk factors
short-term goal

TYPES OF NURSING INTERVENTIONS

Independent ●​ Activities nurses are licensed to

interventions initiate (i.e., physical care, ongoing
assessment)
○​ Physical care
●​ Relationship of Goals or Desired Outcomes to ○​ Teaching
Nursing Diagnoses ○​ Counseling
○​ Goals derived from diagnostic label ○​ Emotional support
○​ Diagnostic label contains the unhealthy ○​ Ongoing assessment
response (problem) ○​ Making referrals other
health care professionals
○​ Goal is the opposite, healthy response.
○​ How client will look or behave if health response Dependent ●​ Activities carried out under primary
is achieved (observable, timelimited) interventions care provider's orders or
○​ Achieving goal demonstrates resolution of the supervision, or according to
problem specified routines
○​ Medications
●​ Components of Goal or Desired Outcome Statements ○​ Treatments
○​ Intravenous therapy
○​ Subject
○​ Diagnostic tests
○​ Verb ○​ Diet and activity
○​ Conditions or modifiers
○​ Criterion of desired performance Collaborative ●​ Actions nurse carries out in
interventions collaboration with other health team
members
●​ Reflect overlapping responsibilities
of healthcare team

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●​ Considering the Consequences of Each Intervention

○​ Choose those that are most likely to achieve the
desired client outcomes
○​ Requires nursing knowledge and experience

●​ Criteria for Choosing Nursing Interventions

○​ Safe and appropriate for the client's age, health,
and condition
○​ Achievable with the resources available
○​ Congruent with the client's values, beliefs, and
culture
○​ Congruent with other therapies
○​ Based on nursing knowledge and experience or
knowledge from relevant sciences
○​ Within established standards of care

WRITING INDIVIDUALIZED NURSING INTERVENTIONS

●​ Date when they are written ●​ Interventions
●​ Verb ○​ More than 542 developed
○​ Action verbs start the interventions and must be ○​ Each intervention includes:
precise. ■​ A label (name)
●​ Conditions ■​ A definition
●​ Modifiers ■​ A list of activities that outline key
●​ Time element actions
○​ How long or how often the nursing action is to ○​ Linked to NANDA diagnostic labels
occur ○​ Select appropriate intervention and customize

●​ Relationship of Nursing Interventions to Problem Status

IMPLEMENTING AND EVALUATING
○​ Observations
○​ Prevention interventions ●​ Nursing process
○​ Treatments ○​ Action oriented
○​ Enhancement or promotion interventions ○​ Client-centered
○​ Outcome directed
●​ Clients and support persons encouraged to participate as
DELEGATING IMPLEMENTATION
much as possible
●​ Delegation occurs during planning.
○​ Who is decided to do each task?
IMPLEMENTING
●​ Nurse is responsible for correct implementation of task
delegated, analysis of data, and evaluation of outcome. ●​ Doing and documenting the activities that are the specific
nursing actions needed to carry out interventions
●​ Fifth standard of the ANA Standards of Practice
THE NURSING INTERVENTIONS CLASSIFICATION
○​ Coordination of care
●​ Taxonomy of nursing interventions ○​ Health teaching and promotion
●​ Developed by the Iowa Intervention Project ○​ Consultation
●​ First published in 1992
●​ Updated every 4 years
RELATIONSHIP OF IMPLEMENTING TO OTHER NURSING
PROCESS PHASES
●​ Consists of three levels
○​ Level 1 ●​ First three phases (assessing, diagnosing, planning)
■​ Domains provide a basis for nursing actions performed.
○​ Level 2 ●​ Doing and documenting specific nursing activities and
■​ Classes resulting client responses
○​ Level 3 ●​ Results examined during evaluating phase
■​ Interventions

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IMPLEMENTING SKILLS comfort

●​ Cognitive (intellectual) skills ●​ Be holistic
○​ Problem solving ●​ Respect the dignity of the client and
○​ Decision making enhance self-esteem
●​ Encourage active client participation
○​ Critical thinking
○​ Creativity
Supervising ●​ Nurse still responsible for client's
Delegated overall care Must validate and
●​ Interpersonal skills Care respond to any adverse findings or
○​ Verbal and nonverbal client responses
○​ Effectiveness depends largely on ability to
communicate. Documenting ●​ Record nursing interventions and
○​ Therapeutic communication necessary for Nursing client responses
Activities ●​ Do not record in advance
caring, comforting, advocating, referring,
counseling, and supporting
○​ Includes conveying knowledge, attitudes, EVALUATING
feelings, interest
●​ Judgment and appraisal
○​ Appreciation of the client's cultural values and
●​ Planned, ongoing, purposeful activity
lifestyle
●​ Determines client's progress, effectiveness of care plan
●​ Continuous process
●​ Technical skills
●​ Demonstrates nursing responsibility and accountability
○​ Purposeful "hands-on" skills
for their actions
○​ Often called tasks, procedures, or psychomotor
skills
■​ Psychomotor RELATIONSHIP OF EVALUATING TO OTHER NURSING
○​ Physical actions that are controlled by the mind, PROCESS PHASES
not by reflexes ●​ Depends on effectiveness of preceding steps
○​ Require knowledge and often require manual ●​ Assessment data must be accurate and complete.
dexterity ●​ Desired outcome must be stated concretely in behavioral
terms to be useful for evaluating.
●​ Without implementation/interventions, there would be
PROCESS OF IMPLEMENTING
nothing to evaluate.
1.​ Reassessing the client
●​ Evaluating and assessing overlap.
2.​ Determining nurse's need for assistance
3.​ Implementing nursing interventions
4.​ Supervising delegated care PROCESS OF EVALUATING CLIENT RESPONSES
5.​ Documenting nursing activities ●​ Collecting Data
○​ Some may require interpretation.
●​ Comparing Data with Desired Outcomes
○​ Conclusions
Reassessing ●​ Reassess to make sure the ■​ Goal was met.
the Client intervention is still needed
■​ Goal was partially met.
●​ Client's condition may have
changed. ■​ Goal was not met.
○​ Evaluation statement
Determining ●​ Inability to implement the nursing ■​ Conclusion
the Nurse's activity safely ■​ Supporting data
Need for ●​ Assistance will reduce stress on the
Assistance client. ●​ Relating Nursing Activities to Outcomes
●​ Nurses lack knowledge or skills to
○​ Determine whether nursing activities had any
implement a particular nursing
activity. relation to the outcome without assuming that
the activity was the cause or only factor of
Implementing ●​ Base actions on scientific knowledge meeting a goal
the Nursing ●​ Clearly understand interventions
Interventions ●​ Adapt activities to individual client ●​ Drawing Conclusions About Problem Status
●​ Implement safe care ○​ Actual problem has been resolved or potential
●​ Provide teaching, support, and problem's risk factors no longer exist.

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SEM 2 | A.Y. 2024 - 2025 | PROF. NORWENA CUSTODIO

○​ Potential problems are being prevented but risk ○​ "To continuously improve the safety and quality
factors still exist. of care provided to the public the provision of
○​ Actual problem still exists even though some healthcare accreditation and related services
goals are being met. that support performance improvement in
○​ When goals partially met or not met: healthcare organizations"
■​ Care plan may need to be revised ●​ Great emphasis on sentinel event
■​ Client merely needs more time to ○​ Unexpected occurrence involving death or
achieve previously established goals serious physical or psychological injury or the
risk thereof
●​ Continuing, Modifying, or Terminating the Care Plan ●​ Focuses on process
○​ Critique each phase of the nursing process ●​ Uses a systematic approach to improve quality of care
○​ Assessing
■​ Incomplete or inaccurate databases ●​ Sentinel event
influence all subsequent steps. ○​ Unexpected occurrence involving death or
○​ Diagnosing serious physical or psychological injury, or risk
■​ If incomplete, add new diagnosis thereof
statements ●​ Root cause analysis
■​ If complete, analyze whether nursing ○​ Process for identifying the factors that bring
diagnoses relevant about deviations in practices that lead to the
○​ Planning: desired outcomes event
■​ If inaccurate, goals/outcomes need
revision ●​ Often focuses on identifying and correcting a system's
■​ If accurate, goals/outcomes realistic problems
and attainable ●​ Also known as:
■​ Have priorities changed? ○​ Continuous quality improvement (CQI)
●​ Does the client still agree with ○​ Total quality management (TQM)
priorities? ○​ Performance improvement (PI)
○​ Planning: nursing interventions ○​ Persistent quality improvement (PQI)
■​ Relate to goal achievement
■​ Investigate whether best nursing ●​ National Quality Forum
interventions were selected ○​ 12 nursing-sensitive care measures to evaluate
○​ Implementing quality of nursing care
■​ After modifications, begin nursing ○​ Serious reportable events (SREs) or "never
process again events"
■​ Facility may not be paid for care if SRE
EVALUATING THE QUALITY OF NURSING CARE has occurred.
●​ National Database of Nursing Quality Indicators
(NDNQI)
QUALITY ASSURANCE
○​ ANA database
●​ Ongoing, systematic process
●​ Evaluates and promotes excellence in provision of NURSING-SENSITIVE INDICATORS
healthcare
●​ National Quality Forum (NQF)
●​ May evaluate level of care provided
○​ Serious reportable events (SRE) also known as
●​ May evaluate performance of a nurse or agency or
"never events"
country
■​ Consistent gathering of data to
evaluate quality of nursing care
●​ Three components:
1.​ Structure evaluation – focuses on setting
●​ Nursing Audit
2.​ Process evaluation – focuses on care given
○​ Examination or review of records
3.​ Outcome evaluation – focuses on
○​ Retrospective audit
demonstrable changes in client’s health status
■​ Evaluation of a client's record after
as result of nursing care
discharge from an agency
○​ Concurrent audit
QUALITY IMPROVEMENT
●​ The Joint Commission Mission

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■​ Evaluation of a client's healthcare while ○​ Treatment plans for a number of clients with the
client still receiving care from the same health problems can yield information
agency helpful in treating other clients
●​ Education
DOCUMENTING AND REPORTING ●​ Reimbursement
○​ From the federal government
●​ Discussion
○​ Must contain correct DRGs
○​ Informal oral consideration of a subject by two
or more healthcare personnel
●​ Legal Documentation
●​ Report
○​ Admissible in court as evidence unless client
○​ Oral, written, or computer-based communication
objects because information client gives to
intended to convey information to others
primary care provider is confidential
○​ Also called chart or client record
●​ Healthcare Analysis
○​ Formal, legal document that provides evidence
○​ Identify agency needs such as overutilized and
of a client's care
underutilized hospital services
○​ Can be written or computer based
●​ Process of making an entry on a client record is called
recording, charting, or documenting. DOCUMENTATION SYSTEMS
●​ Source-oriented record
ETHICAL AND LEGAL CONSIDERATIONS ●​ Problem-oriented medical record
●​ Problems, interventions, evacuation (PIE) model
●​ Confidentiality of all patient information
●​ Focus charting
●​ Client's record protected legally as a private record of
●​ Charting by exception (CBE)
client's care
●​ Computerized documentation
●​ HIPAA regulations updated on April 14, 2003
●​ Case management
●​ Responsibility in using records for the purpose of
education and research
SOURCE-ORIENTED RECORD
●​ Ensuring Confidentiality of Computer Records ○​ Traditional client record
○​ Personal password that is not to be shared ●​ Each discipline makes notations in a separate section.
○​ Never leave a computer terminal unattended ●​ Information about a particular problem distributed
after logging on throughout the record
○​ Do not leave client information displayed on the ●​ Narrative charting
monitor where others may see it ○​ Written notes that include routine care, normal
○​ Shred all unneeded computer-generated findings, and client problems
worksheets ○​ Often chronologic
○​ Know facility's policy and procedure for
correcting an entry error PROBLEM-ORIENTED MEDICAL RECORD
○​ Follow agency procedures for documenting
●​ Data arranged according to client problem
sensitive material
●​ Health team contributes to the problem list, plan of care,
○​ IT personnel must install a firewall to protect
and progress notes.
server from unauthorized access
●​ Encourages collaboration
●​ Easier to track status of problems
PURPOSES OF CLIENT RECORDS ●​ Vigilance required to maintain problem list
●​ Communication ●​ Assessments and interventions must be repeated when
○​ Prevents fragmentation, repetition, and delays in more than one problem exists.
care
●​ Planning Client Care ●​ Database
○​ Nurses use baseline and ongoing data to ○​ All information known about the client when the
evaluate effectiveness of the care plan. client first enters the healthcare agency
●​ Auditing Health Agencies ●​ Problem List
○​ Review client records for quality assurance ○​ Listed in order in which they are identified and
purposes others resolved
●​ Plan of Care
●​ Research ○​ Made with reference to active problems
○​ Generated by individual who lists the problems

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 FUNDAMENTALS OF NURSING (LECTURE) NCM 101

SEM 2 | A.Y. 2024 - 2025 | PROF. NORWENA CUSTODIO

●​ Progress Notes CASE MANAGEMENT

○​ Made by all health professionals involved in a
●​ Quality, cost-effective care delivered within established
client's care
length of stay
○​ Uses SOAP, SOAPIE, SOAPIER documentation
●​ Uses multidisciplinary approach, critical pathways, CBE
●​ Variance
PIE ○​ A goal that is not met
●​ Groups information into three categories ●​ Documentation of variances includes:
○​ Problems ○​ Actions taken to correct the situation
○​ Interventions ○​ Justification of actions taken
○​ Evaluation
●​ Ongoing client assessment flow sheet and progress note DOCUMENTING NURSING ACTIVITIES
●​ Describe client's ongoing status in record
FOCUS CHARTING ●​ Reflect the full range of the nursing process
●​ Focus on client concerns and strengths
●​ Progress notes organized into DAR format ADMISSION NURSING ASSESSMENT
●​ Data
●​ Comprehensive admission assessment when client first
○​ Assessment phase
admitted to nursing unit
●​ Action
●​ Ongoing assessments and reassessments recorded on
○​ Planning and implementing phase
flow sheets or nursing progress notes
●​ Response
○​ Evaluation phase
NURSING CARE PLANS
●​ Holistic perspective of client needs ●​ The Joint Commission requires clinical record to include:
●​ Nursing process framework for progress notes ○​ Evidence of client assessment
●​ DAR progress notes ○​ Nursing diagnosis
○​ Data ○​ Nursing interventions
○​ Action ○​ Client outcomes
○​ Response ○​ Current nursing care plans

CHARTING BY EXCEPTION ●​ Traditional care plans

○​ Written for each client
●​ Incorporation of:
●​ Standardized care plans
○​ Flow sheets
○​ Based on institutions standards of practice
○​ Standards of nursing care
○​ Bedside chart forms
●​ Agencies develop standards of nursing practice. KARDEXES
●​ Documentation according to standards involves a check ●​ Concise method of organizing and recording data
mark. ●​ Series of cards kept in a portable index file or on
●​ Exceptions to standards described in narrative form on computer-generated form • Information quickly accessible
nurses' notes ●​ Pertinent information about the client arranged in
sections
COMPUTERIZED DOCUMENTATION ○​ Allergies
○​ List of medications including IV fluids
●​ Developed to manage volume of information
●​ Pertinent information about the client arranged in
●​ Used by nurses to:
sections
○​ Store client's database, new data
○​ List of daily treatments and procedures
○​ Create and revise care plans
○​ List of diagnostic procedures
○​ Document client's progress
○​ Physical needs to be met
●​ Information easily retrieved
○​ Stated goals
●​ Speech-recognition technology
○​ Nurses must be alert and aware of others who
might hear the dictation. FLOW SHEETS
●​ Possible to transmit information from one care setting to ●​ Graphic Record
another ○​ Body temperature, pulse, respiratory rate, blood
pressure, weight, other significant clinical data

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 FUNDAMENTALS OF NURSING (LECTURE) NCM 101

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●​ Intake and Output Record ○​ Safety measures needed

○​ All routes measured and recorded ○​ Medications
●​ Medication Administration Record ○​ Treatments
○​ Date of order, expiration date, name and dose, ○​ Preventive measures
frequency and route of administration, nurse's ○​ Behavioral modification assessments, if
signature pertinent
●​ Skin Assessment Record
○​ Such as the Braden Assessment HOME CARE DOCUMENTATION
●​ Influenced by:
PROGRESS NOTES ●​ Health Care Financing Administration (1985)
●​ Provide information about progress client is making ○​ Medicare and Medicaid
toward achieving desired outcomes ○​ Other third-party payers
●​ Include information about client problems and nursing ●​ Two records are required.
interventions ○​ Home health certification and plan-of-treatment
form
NURSING DISCHARGE AND REFERRAL SUMMARIES ○​ Medical update and patient information form
●​ Completed when client discharged
○​ Terms that can be readily understood GENERAL GUIDELINES FOR RECORDING
●​ Completed when client transferred to another institution
●​ Include some or all of the following:
Date and Time ●​ Conventional a.m./p.m. or
○​ Description of client's physical, mental, and 24-hour
emotional status
○​ Resolved health problems Timing ●​ No recording before providing
○​ Treatments to be continued care
○​ Current medications
○​ Include restrictions that relate to activity, diet, Legibility ●​ Must prevent interpretation errors
and bathing
○​ Functional/self-care abilities Permanence ●​ Entries made in dark ink
○​ Comfort level
Accepted ●​ When in doubt, write the term out
○​ Support networks Terminology fully
○​ Client education ●​ May be different between
○​ Discharge destination agencies
○​ Referral services
Correct Spelling ●​ Look up in dictionary or resource
book if unsure

LONG-TERM CARE DOCUMENTATION Signature ●​ Includes name and title

●​ Based on professional standards, federal and state
regulations, policies of healthcare agency Accuracy ●​ Before making an entry, check
●​ Laws and requirements that the chart is the correct one
○​ Health Care Financing Administration
Sequence ●​ Document events in the order
○​ Omnibus Budget Reconciliation Act (OBRA) of
they occur
1987
○​ Medicare and Medicaid Appropriateness ●​ Record only information that
●​ Complete assessments, screening forms, and plan of pertains to the client's health and
care within the time period care
●​ Keep record of visits and phone calls
●​ Write nursing summaries and progress notes according Completeness ●​ Include care that is omitted
to specified time periods because of client's condition,
refusal
●​ Summaries should include:
○​ Specific problems noted in the care plan Conciseness ●​ No extra details
○​ Mental status ●​ Client's name and "client" omitted
○​ Activities of daily living
○​ Hydration and nutrition status Legal Prudence ●​ Usually viewed by juries and

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attorneys in court as a legal NURSING ROUNDS

document ●​ Two or more nurses visit selected clients at bedside.
●​ Obtain information that will help plan nursing care and
evaluate care given
REPORTING
●​ Provides clients opportunity to discuss their care
●​ Need to use terms client can understand
CHANGE-OF-SHIFT REPORTS
●​ Handoff communication COMMUNICATING
●​ Information communicated in a consistent manner ●​ Communication is a critical skill
including an opportunity to ask and respond to questions for nursing.
●​ Provide basic identifying information ●​ Critical nursing skill used to
●​ Features gather data, teach and
○​ Two way, face-to-face communication persuade, express caring and
○​ Written support tools ▪ Content in handover comfort
which captures intention ●​ Interchange of information,
●​ I-PASS, I-SBAR, PSYCH, I PUT PATIENTS FIRST ideas, or feelings between two
or more people

COMMUNICATION
●​ Process
○​ To influence
○​ To obtain information
●​ Includes verbal and nonverbal methods
●​ Includes self-talk

THE COMMUNICATION PROCESS

Sender ●​ Source-encoder
TELEPHONE REPORTS
○​ A person or group who wishes
●​ Be concise and accurate to communicate a message to
●​ Have chart ready to give any further information needed another
●​ Document date, time, and content of the call ●​ Encoding
○​ Selecting signs, symbols to
transmit
TELEPHONE AND VERBAL ORDERS
●​ Many agencies only allow registered nurses to take Message ●​ The message itself
telephone orders ●​ What is said or actually written
●​ Write complete order down and read it back to primary
Receiver ●​ The decoder
care provider to ensure accuracy
○​ Relating message perceived
●​ Question any order that is ambiguous, unusual, or to receiver's storehouse to sort
contraindicated out the meaning
●​ Have primary care provider verbally acknowledge the ●​ The listener
read-back
●​ Counter-sign by provider in 24 hours Response ●​ Feedback
●​ Message that receiver returns to
sender
CARE PLAN CONFERENCE
●​ A meeting of a group of nurses to discuss possible
solutions to certain problems of a client MODES OF COMMUNICATION
●​ Allows each nurse the opportunity to offer an opinion ●​ Verbal
about possible solutions ○​ Uses spoken or written word
●​ Other healthcare providers invited to offer expertise ●​ Nonverbal
○​ Uses gestures, facial expressions, touch, and
other forms

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●​ Makes up majority of communication

group.
●​ Electronic
○​ Technology such as e-mail Values and ●​ Standards that influence behavior
Perceptions ●​ Personal view of an event
VERBAL COMMUNICATION
Personal Space ●​ Intimate (0 to 1-1/2 feet)
●​ Pace and intonation
●​ Personal (1-1/2 to 4 feet)
●​ Simplicity ●​ Social (4 to 12 feet)
●​ Clarity and brevity ●​ Public (12 to 15 feet)
●​ Timing and relevance
●​ Adaptability Territoriality ●​ Space, things that individual
●​ Credibility considers as belonging to self
●​ Humor
○​ Consider client's perceptions Roles and ●​ Between sender and receiver
Relationships

NONVERBAL COMMUNICATION Environment ●​ Most effective communication in

●​ Personal appearance comfortable environment
●​ Posture and gait ●​ Privacy
●​ Facial expression
Congruence ●​ Verbal and nonverbal aspects of
●​ Gestures message match
○​ Consider cultural difference
Interpersonal ●​ Caring and warmth
ELECTRONIC COMMUNICATION Attitudes ●​ Respect
●​ Elderspeak
●​ E-mail ○​ Similar to baby talk
●​ Other guidelines ○​ Patronizing to older
●​ Agency standards adults
E-mail consent form ●​ Acceptance
Considered a part of the client's medical record
■​ May be used as evidence during Boundaries ●​ Limits crucial to nurse-client
relationship
litigation
●​ PCA test
●​ Professional judgment

Advantages Disadvantages THERAPEUTIC COMMUNICATION

●​ Promotes understanding
●​ Fast, efficient ●​ Risk to client confidentiality ●​ Establishes constructive relationships
●​ Provides record (HIPAA)
●​ Attentive Listening
●​ Can improve ●​ Socioeconomics
communication ●​ May not enhance ○​ Listening actively, mindfully
and continuity of communication with all ○​ Listen for key themes in communication
care ●​ Avoid when information is ●​ Visibly Tuning In
urgent to client's health, highly
confidential, or potentially ○​ Manner of being present to another
distressing or confusing
○​ E.g., abnormal lab
values
BARRIERS TO COMMUNICATION
●​ Need to be recognized when they occur
●​ Major barriers
FACTORS INFLUENCING THE COMMUNICATION PROCESS ○​ Failure to listen
○​ Improperly decoding client's intended message
○​ Placing nurse's needs above client's needs
Development ●​ Knowledge of client's stage
●​ Varies across lifespan
THE HELPING RELATIONSHIPS
Gender ●​ Girls seek confirmation, minimize ●​ Referred to as:
differences, and establish
○​ Interpersonal relationships
intimacy.
●​ Boys establish independence ○​ Therapeutic relationships
and negotiate status within the ●​ Three basic goals for helping clients

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 FUNDAMENTALS OF NURSING (LECTURE) NCM 101

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○​ Manage problems in living more effectively

■​ Empathy
○​ Become better at helping themselves in their ●​ Ability to experience, in the
everyday lives present, a situation as
○​ Develop action-oriented prevention mentality in another person did at some
their lives time in the past
●​ Keys
○​ Development of trust and acceptance ●​ Exploring and understanding thoughts and feelings
○​ Empathetic listening and responding
○​ Underlying belief that the nurse cares about and
■​ End result of empathy
wants to help the client ●​ Comforting and caring for
the client
●​ Factors influencing helping relationships ●​ Helping, healing
relationship
●​ Age, sex ●​ Ethnic and ○​ Respect
●​ Appearance cultural ■​ Genuineness
●​ Diagnosis background ■​ Concreteness
●​ Education ●​ Personality ■​ Confronting avoidance
●​ Values ●​ Expectations empathetically
●​ Setting
●​ Facilitating and taking action
○​ Clients must make decisions and take action.
○​ The responsibility belongs to the client.
PHASES OF THE HELPING RELATIONSHIPS
○​ Nurses collaborate in these decisions,
provide support, and may offer options or
PRE-INTERACTION PHASE information.
●​ Obtain information before first face-to-face meeting Resolution Phase
○​ Name, address, age, medical history, and/or
social history ●​ Nurse and client accept feelings of loss.
●​ Anxious feelings in nurse addressed by identifying ●​ Client accepts the end of the relationship without
specific information to be discussed feelings of anxiety or dependence.
●​ Positive outcomes can evolve.
DEVELOPING HELPING RELATIONSHIPS
INTRODUCTORY PHASE
●​ Listen actively
●​ Help to identify feelings
Orientation phase ●​ Put yourself in other's shoes
●​ Be honest, genuine, and credible
●​ Sets tone for rest of the relationship ●​ Use ingenuity
●​ Develop trust and security ●​ Be aware of cultural differences
●​ Getting to know each other ●​ Maintain client confidentiality
●​ Resistive behaviors may be displayed. ●​ Know your role and limitations
○​ Inhibit involvement, cooperation, or change
●​ Resistance can be overcome with:
○​ Caring attitude GROUP COMMUNICATION
○​ Genuine interest ●​ Group
○​ Competence
○​ Two or more people with shared needs and
goals
Working Phase
○​ Exists to help people achieve goals that would
●​ View each other as unique individuals be unattainable by individual effort alone
●​ Once caring develops, empathy increases.
●​ Exploring and understanding thoughts and feelings GROUP DYNAMICS
●​ Facilitating and taking action
●​ Helping client explore thoughts, feelings, and actions ●​ Communication between any members of a group,
●​ Helping client plan a program of action to meet affecting the group process
pre-established ●​ Each member has an effect on dynamics.
●​ goals ●​ For a group to be effective, it must:
●​ Exploring and understanding thoughts and feelings ○​ Maintain a degree of unity, cohesion
○​ Empathetic listening and responding

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 FUNDAMENTALS OF NURSING (LECTURE) NCM 101

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○​ Develop, modify structure to improve ●​ Client communication

effectiveness ○​ Listen actively
○​ Accomplish its goals ■​ Observe nonverbal cues
○​ Use therapeutic communication skills
COMMUNICATION AND THE NURSING PROCESS ●​ Nurse communication
○​ Use of process recording
●​ Each phase of the nursing process
■​ A verbatim account of a conversation
●​ Clarify functions and roles
■​ Analyzed in content and meaning of
●​ Clarify what is expected of client, nurse, and primary care
interaction
provider
●​ Increases awareness and
insight
ASSESSING ●​ Identify strengths and need
●​ Impairments to communication for future skills development
○​ Language deficits
○​ Sensory deficits
COMMUNICATING AMONG HEALTH PROFESSIONALS
○​ Cognitive impairments
●​ Effective communication is important among health
○​ Structural deficits
professionals.
○​ Paralysis
●​ Problems cause of most client errors
●​ Style of communication
●​ Outrageous behavior still common in healthcare facilities
●​ Verbal
○​ Whether the pattern is slow, rapid, quiet, etc.
○​ Vocabulary of individual DISRUPTIVE BEHAVIORS
○​ Presence of hostility, aggression, assertiveness, ●​ Incivility
reticence, anxiety ○​ Rudeness, discourtesy, disrespect
○​ Difficulties such as slurring, stuttering ●​ Bullying
○​ Refusal or inability to speak ○​ Offensive, abusive, intimidating, insulting
●​ Nonverbal behavior or abuse of power
○​ Recipient feels upset, threatened, humiliated, or
DIAGNOSING vulnerable.
○​ Occurs repeatedly for at least 6 months
●​ Impaired Verbal Communication
●​ Workplace Violence
○​ Not used when caused by a psychiatric illness
○​ Any act or threat of physical violence,
●​ Anxiety
harassment, intimidation, or other threatening
●​ Powerlessness
disruptive
●​ Situational Low Self-Esteem
○​ Four types
●​ Social Isolation
■​ Criminal intent
●​ Impaired Social Interaction
■​ Customer or client
■​ Worker-on-worker
PLANNING ■​ Personal relationship
●​ Determine outcomes
●​ Plan ways to promote effective communication
RESPONDING TO DISRUPTIVE BEHAVIORS
○​ Impaired Verbal Communication
●​ Establish expectation of mutual respect
■​ Outcome to reduce or resolve factors
●​ Raise awareness of and identify disruptive behaviors
impairing communication
●​ Increase communication skills
●​ Specific nursing interventions planned for the stated
●​ Be as proficient as in clinical skills
etiology
●​ Establish expectation of mutual respect
●​ Raise awareness of and identify disruptive behaviors
IMPLEMENTING ●​ Increase communication skills
●​ Manipulate the environment ○​ Be as proficient as in clinical skills
●​ Provide support ●​ Provide training in conflict management
●​ Employ measures to enhance communication ●​ Establish zero tolerance for disruptive behaviors
●​ Educate the client and support persons ●​ Model respectful, ethical behavior

EVALUATING NURSE AND PHYSICIAN COMMUNICATION

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 FUNDAMENTALS OF NURSING (LECTURE) NCM 101

SEM 2 | A.Y. 2024 - 2025 | PROF. NORWENA CUSTODIO

●​ Communication Styles
○​ Nurses are taught to be descriptive both verbally
and in writing.
○​ Physicians are taught to be brief, to the point,
and focused.
■​ Impatience may result.
○​ SBAR approach describes:
■​ Situation
■​ Background
■​ Assessment
■​ Recommendations
●​ Emotional Intelligence
○​ Forming work relationships with colleagues
○​ Displaying maturity in a variety of situations
○​ Resolving conflicts while taking into
consideration the emotions of others
○​ Being approachable, easygoing
●​ Assertive Communication
○​ Promotes client safety by minimizing
miscommunication with colleagues
○​ Honest, direct, and appropriate; open to ideas
○​ Respects rights of others
●​ Nonassertive Communication
Passive Aggressive
Communication Communication

●​ Allowing one's ●​ Can be blaming

own rights to be and delivered in
violated by a rushed
others manner
●​ Meeting the ●​ Becomes
demands and ineffective and
requests of ●​ leads to
others without frustration for
regard to own the
feelings and ●​ nurse and
needs physician
●​ Believing own
feelings are not
important
●​ Being insecure
and trying to
maintain
self-esteem by
avoiding conflict

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