Funda lec

Midterm | 2nd sem

1. Initial nursing assessment:

Performed within specified time after admission.
Topic Outline: NURSING PROCESS
To establish a complete database for problem
identification.
Nursing process Eg: Nursing admission assessment
- critical thinking process that professional nurses
use to apply the best available evidence to 2. Problem-focused assessment :
caregiving and promoting human functions and To determine the status of a specific problem identified
responses to health and illness (American in an earlier assessment.
Nurses Association, 2010). Eg: hourly checking of vital signs of fever patient
- systematic method of providing care to clients.
- a systematic method of planning and providing 3. Emergency assessment:
individualized nursing care. During emergency situation to identify any life
- threatening situation.
Purposes of nursing process Eg: Rapid assessment of an individual’s airway,
- To identify a client’s health status and actual or breathing status, and circulation during a cardiac arrest.
potential health care problems or needs.
- To establish plans to meet the identified needs. 4. Time-lapsed reassessment:
- To deliver specific nursing interventions to meet Several months after initial assessment.
those needs. To compare the client’s current health status with the
data previously obtained.
Components of nursing process
- It involves assessment (data collection), nursing Collection of data
diagnosis, planning, implementation, and - process of gathering information about a client’s
evaluation. health status. It includes the health history,
physical examination, results of laboratory and
Characteristics of Nursing Process diagnostic tests, and material contributed by
- Cyclic other health personnel.
- Dynamic nature,
- Client centeredness Two types of data collection
- Focus on problem solving and decision making 1. Subjective data
- Interpersonal and collaborative style referred to as symptoms or covert data, are clear only to
- Universal applicability the person affected and can be described only by that
- use of critical thinking and clinical reasoning. person.
Itching, pain, and feelings of worry are examples of
ASSESSMENT subjective data.
- systematic and continuous collection,
organization, validation, and documentation of 2. Objective data
data (information) referred to as signs or overt data, are detectable by an
observer or can be measured or tested against an
Types of assessment accepted standard.
They can be seen, heard, felt, or smelled, and they are
The four different types of assessments are; obtained by observation or physical examination.
1. Initial nursing assessment For example, a discoloration of the skin or a blood
2. Problem-focused assessment pressure reading is objective data.
3. Emergency assessment
4. Time-lapsed reassessment Sources of data

Type your initials here | 1

1. Primary : It is the direct source of information. The - The information gathered during the assessment
client is the primary source of data. is “double-checked” or verified to confirm that it
is accurate and complete.
2. Secondary: It is the indirect source of information. All
sources other than the client are considered secondary Documentation of data
sources. Family members, health professionals, records - To complete the assessment phase, the nurse
and reports, laboratory and diagnostic results are records client data. Accurate documentation is
secondary sources. essential and should include all data collected
about the client’s health status.

Methods of data collection —---------------------------------------------------------

• The methods used to collect data are observation,
interview and examination. DIAGNOSIS
- second phase of the nursing process. In this
Observation: phase, nurses use critical thinking skills to
It is gathering data by using the senses. Vision, Smell interpret assessment data to identify client
and Hearing are used. Interview : An interview is a problems.
planned communication or a conversation with a - North American Nursing Diagnosis Association
purpose. (NANDA) define or refine nursing diagnosis

There are two approaches to interviewing: - The official NANDA definition of a nursing
diagnosis is: “a clinical judgment concerning a
The directive interview human response to health conditions/life
- highly structured and directly ask the questions. processes, or a vulnerability for that response,
- the nurse controls the interview. by an individual, family, group, or community

nondirective interview Status of the Nursing Diagnosis

- (rapport building interview) The status of nursing diagnosis are actual, health
- the nurse allows the client to control the promotion and risk.
interview. 1. An actual diagnosis is a client problem that is
present at the time of the nursing assessment.
STAGES OF AN INTERVIEW 2. A health promotion diagnosis relates to clients’
- An interview has three major stages: preparedness to improve their health condition
1. The opening or introduction
2. The body or development A risk nursing diagnosis is a clinical judgment that a
3. The closing problem does not exist, but the presence of risk factors
indicates that a problem may develop if adequate care is
not given
Examination : The physical examination is a systematic
data collection method to detect health problems. To Components of a NANDA Nursing Diagnosis
conduct the examination, the nurse uses techniques of A nursing diagnosis has three components:
inspection, palpation, percussion and auscultation. (1) The problem and its definition
(2) The etiology
Organization of data (3) The defining characteristics.
- The nurse uses a format that organizes the
assessment data systematically. 1. The problem statement describes the client’s health
- This is often referred to as nursing health history problem.
or nursing assessment form. 2. The etiology component of a nursing diagnosis
identifies causes of the health problem.
Validation of data 3. Defining characteristics are the cluster of signs and
symptoms that indicate the presence of health problem.

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 1. Initial Planning: Planning which is done after the initial
Formulating Diagnostic Statements assessment
The basic three-part nursing diagnosis statement is 2. Ongoing Planning: continuous planning
called the PES format and includes the following: 1. 3. Discharge Planning: Planning for needs after
Problem (P): statement of the client’s health problem discharge
(NANDA label)
2. Etiology (E): causes of the health problem Planning process
3. Signs and symptoms (S): defining characteristics Planning includes;
manifested by the client. Acute pain related to abdominal ● Setting priorities
surgery as evidenced by patient discomfort and pain ● Establishing client goals/desired outcomes
scale. ● Selecting nursing interventions and activities
● Writing individualized nursing interventions on
Differentiating Nursing Diagnosis from Medical care plans.
Diagnosis
Setting priorities
Differentiating Nursing Diagnosis from Medical - The nurse begin planning by deciding which
Diagnosis nursing diagnosis requires attention first, which
- A nursing diagnosis is a statement of nursing second, and so on.
judgment that made by nurse, by their - Nurses frequently use Maslow’s hierarchy of
education, experience, and expertise, are needs when setting priorities
licensed to treat.
- Nursing diagnoses may change as the client’s
responses change.
- Nursing diagnosis describe the human
response to an illness or a health problem.
Nursing diagnosis
1. Ineffective breathing pattern
2. Activity intolerance
3. Acute pain
4. Disturbed body image

- A medical diagnosis is made by a physician.

- Medical diagnoses refer to disease processes. Establishing client goals/desired outcomes
- A client’s medical diagnosis remains the same
for as long as the disease is present. - After establishing priorities, the nurse set goals
Medical diagnosis for each nursing diagnosis.
1. Asthma - Goals may be short term or long term.
2. Cerebrovascular accident
3. Appendicitis Nursing interventions
4. Amputation - any treatment, that a nurse performs to improve
patient’s health
PLANNING
- involves decision making and problem solving. TYPES OF NURSING INTERVENTIONS
- It is the process of formulating client goals and 1. Independent interventions - those activities that
designing the nursing interventions required to nurses are licensed to initiate on the basis of their
prevent, reduce, or eliminate the client’s health knowledge and skills.
problems. 2. Dependent interventions - activities carried out
under the orders or supervision of a licensed physician.
3. Collaborative interventions - actions the nurse
carries out in collaboration with other health team
TYPES OF PLANNING members
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 - The interactions between and among health
Writing Individualized Nursing Interventions professionals, clients, their families, and
- After choosing the appropriate nursing healthcare organizations.
interventions, the nurse writes them on the care
plan. - The administration of tests, procedures,
- Nursing care plan is a written or computerized treatments, and client education.
information about the client’s care
- The results or client's response to these
IMPLEMENTATION diagnostic tests and interventions.
- consists of doing and documenting the activities

The process of implementation includes; Purposes of client’s record chart

• Implementing the nursing interventions
• Documenting nursing activities 1. Communication- Provides an efficient and
effective method of sharing information.
2. Legal Documentation- It is admissible as
EVALUATION evidence in a court of law.
3. Research- Provides valuable health-related
Evaluation is a planned, ongoing, purposeful activity in data for research.
which the nurse determines 4. Statistics- Provides statistical information that
(a)the client’s progress toward achievement of can be utilized for planning people's future
goals/outcomes and needs.
(b)the effectiveness of the nursing care plan. 5. Education- Serves as an educational tool for
students in health discipline
The evaluation includes; 6. Audit & Quality Assurance- Monitors the
• Comparing the data with desired outcomes quality of care received by the client and the
• Continuing, modifying, or terminating the nursing competence of health caregivers.
care plan. 7. Planning Client Care- Provides data which the
entire health team uses to plan care for the
client.
Topic Outline:
● Documentation 8. Reimbursement- Provides the basis for
● Recording decisions regarding care to be provided and
subsequent reimbursement to the agency, to
cover health-related expenses.
Documentation
Types of Medical Records
- serves as a permanent record of client
information and care.
Components of medical record:-
● Patient identification & demographic data
● Present complains
● Informed consent for treatment & procedure
Admission nursing history
● Family history
Documentation as Communication
● Physical examination finding
● Medical history
- Reporting and recording - the major
● Tentative history
communication techniques used by health care
● Medical diagnosis Therapeutic order
providers.
● Treatment given
● Medical progress notes
Documentation is defined as written evidence of:
● Supportive care given
● Reports of diagnosis studies
● Final diagnosis
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● Patient education - Improves communication and lessens the
● Summary of operative procedures Discharge chance of misunderstanding between members
plan and summary of the health team.
● Any specific instructions
2. Legibility

Types of Nursing Records ● Print if necessary.

● Do not erase or obliterate writing.
● Admission nursing assessment ● State the reason for the error.
● Nursing care plan ● Sign and date the correction.
● Kardexes
● Pertinent information about patient
● Medication with date of order & time of
administration
● Daily treatment & procedures
● Flow chart
● Graphic record (TPRBP)
● Fluid balance record
● Medication
● Skin assessment record
● Progress notes

3. Abbreviations and Symbols

Legal and Practice Standards
● Always refer to the facility's approved listing.
- Informed consent- means that the client ● Avoid abbreviations that can be misunderstood.
understands the reasons and risks of the
proposed intervention. 4. Organization

- Witnessing- confirms that the person who signs ● Start every entry with the date and time.
the consent is competent. ● Chart in chronological order.
● Chart medications immediately after
administration.
Elements of Effective Documentation ● Sign your name after each entry.

● Use of Common Vocabulary

● Legibility Abbreviations and Symbols 5. Accuracy
● Organization
● Accuracy ● Use descriptive terms to chart exactly what was
● Documenting a Medication Error observed or done.
● Confidentiality ● Use correct spelling and grammar.
● Factual ● Write complete sentences.
● Complete
● Current
● Organized 6. Documenting a Medication Error

● Document in the nurses' progress notes:

1. Use of Common Vocabulary - Name and dosage of the medication
- Name of the practitioner who was notified of
the error
- Time of the notification
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 - Nursing interventions or medical treatment Recording
-Client's response to treatment
- takes place when two or more people share
information about client care, either face to
7. Confidentiality face or by telephone

- The nurse is responsible for protecting the Types of Records

privacy and confidentiality of client interactions,
assessments, and care. ● Patient clinical records
● Individual staff records
● Ward records
8. Factual ● Administrative records with educational value

● A factual record contains descriptive, objective

information about what a nurse sees, hears, COMMON WARD RECORDS
feels & smells.
● An objective description is the result of direct ● Patient clinical records
observation & measurement. ● Staff attendance record
● Staff leave record
9. Complete ● Staff patient assignment record
● Student attendance and patient assignment
- The information within a recorded entry or a record
record must be complete, containing appropriate ● Ward indent record
and essential information. ● Ward inventory record
● Equipment maintenance record
10. Current ● Ward incidence record
● Infection surveillance record
● Timely entries are essential in a patient's ● Ward quality indicator record
ongoing care. Delays in documentation leads to ● Ward diet supply record
unsafe patient care. ● Emergency drug and crash card record
● Health organizations use military time to avoid ● Patient admission/discharge/shift record
misinterpretation of AM & PM.
METHODS OF DOCUMENTATION
● Following activities should enter timely : ● Narrative Charting
● Source-Oriented Charting
Vital signs, ● Problem-Oriented Charting
Pain assessment, ● PIE Charting
Administration of medication & treatment, ● Focus Charting
● Charting by Exception (CBE)
Preparation for diagnostic test or surgery, Change in patient's status & who notified,
● Computerized Documentation
● Case Management with Critical Paths
Admission, transfer, discharge or death of the patient, Patient's response to treatment
1. Narrative charting (TRADITIONAL CLIENT
RECORD)
11. Organized - Describes the client's status, interventions and
treatments; response to treatments is in story
● Communicate information in a logical order. format.
● It is effective when notes are concise, clear, & to - Narrative charting is now being replaced by
the point other formats.

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 - Five Basic Components of a Traditional ● I: Intervention
Client-Record ● E: Evaluation
1. Admission sheet
2. Physician's order sheet Example:
3. Medical history P: Patient reports pain at surgical incision as 7/10 on
4. Nurse's notes 0 to 10 scale
5. Special records and reports (referrals, I: Given morphine 1mg IV at 23:35.
X-ray, reports, laboratory findings, report E: Patient reports pain as 1/10 at 23:55.
of surgery, anesthesia record, flow
sheets, vital signs, I&O, Medications) 4. Focus Charting (DAR)
- A method of identifying and organizing the
2. Source-Oriented Charting narrative documentation of all client concerns.
- Each person or department makes notations in a - Uses a columnar format within the progress
separate section/s of the client's chart. notes to distinguish the entry from other
- Narrative recording by each member (source) of recordings in the narrative notes (Date & Time,
the health care team on separate records. Focus, Progress note)
- Most Traditional ● DATA-SUBJECTIVE OR OBJECTIVE THAT
- Different disciplines chart on separate forms SUPPORTS THE FOCUS (CONCERN)
- Each reader must consult various parts of the ● ACTION - NURSING INTERVENTION
record to get a complete picture ● RESPONSE - PT. RESPONSE TO
- Records become bulky INTERVENTION
- For example the admission department has an
admission sheet, nurses use the nurses' notes, Example of Focus Charting
physicians have a physician notes, etc.... Date & Time: 09.Sept.2013
Focus: Abdominal Pain due to abdominal incision
Progress Notes:
3. Problem-oriented medical Record( POMR) /Nurse': D:Patient reports pain as 7/10 on 0 to 10 scale
or narrative notes (SOAPIE format) A: Given morphine 1 mg at IV 2335
- Uses a structured, logical format called S.O.A.P. R: Patient reports pain as 1/10 at 2335
● S - SUBJECTIVE. WHAT PT TELLS
YOU. 4. Focus Charting (DAR)
● O - OBJECTIVE. WHAT YOU - The nurse documents only deviations from pre-
OBSERVE, SEE. established norms (document only abnormal or
● A - ASSESSMENT. WHAT YOU THINK significant findings).
IS GOING - Avoids lengthy, repetitive notes
● ON BASED ON YOUR DATA.
● P - PLAN. WHAT YOU ARE GOING TO 5. Computerized Documentation
DO. - Increases the quality of documentation and save
time.
CAN ADD TO BETTER REFLECT NURSING - Increases legibility and accuracy.
PROCESS - Facilitates statistical analysis of data.
● I - INTERVENTION (SPECIFIC
INTERVENTIONS IMPLEMENTED) 6. Case Management Process
● E - EVALUATION. PT RESPONSE TO - A methodology for organizing client care through
INTERVENTIONS. an illness, using a critical pathway.
● R - REVISION. CHANGES IN TREATMENT. - A critical pathway is a multidisciplinary plan or
Uses flow sheets to record routine care. SOAP entries tool that specifies assessments, interventions,
are usually made at least every 24 hours on any treatments and outcomes of health related
unresolved problem problems across a timeline.

3. PIE Charting Forms of Recording Data

● P: Problem statement ● Kardex
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● Flow Sheets 4. Discharged Summary
● Nurses' Progress Notes ● Client's status at admission and discharge.
● Discharge Summary ● Brief summary of client's care.
● Interventions and education outcomes.
1. Kardex ● Resolved problems and continuing need.
- is used as a reference throughout the shift and ● Referrals.
during change-of-shift reports. ● Client instructions.
- Client data (eg name, age, admission
date, allergy)
- Medical diagnoses and nursing REPORTING
diagnoses - Verbal communication of data regarding the
- Medical orders, list of medications client's health status, needs, treatments
- Activities, diagnostic tests, or specific outcomes, and responses
data on the pt. - Reporting is based on the nursing process
- Provides a concise method of organizing and
recording data about a client, making Types of Reporting
information readily accessible to all members of ● Summary/ Hand-Off Reports
the health team. ● Walking Round Reports
- It is a series of flip cards usually kept in portable ● Incident or Occurrence Reports
file ● Telephone Reports and Orders
- It is a way to ensure continuity of care from one
shift to another and from one day to the next. Summary / Hand-Off Reports
- It is a tool for change - of - shift report. But - Commonly occur at change of shift (or when
endorsement is not simply reciting content of client care is transfers to another health care
kardex. Health care needs of the client is still provider).
primary basis for endorsement.
- Usually include the following data: Walking Rounds Reports
● Personal data - Occur in the client's room
● Basic needs - Include Nursing, physician, interdisciplinary
● Allergies team.
● Diagnostic tests
● Daily nursing procedures Incident or Occurrence Reports
● Medications and intravenous (IV) - Used to document any unusual occurrence or
therapy, blood transfusions accident in the delivery of client care
● Treatments like oxygen therapy, steam
inhalation, suctioning, change of Telephone Reports and Orders
dressings, mechanical ventilation. - Provide clear accurate and concise information
- Entries usually written in pencil. This implies the - The nurse documents telephone report by
kardex is for planning and communication including
purpose only. The following information:
- when the call was made
2. Flow Sheets - who made the call/report
- The information on flow sheets can be formatted - who was called
to meet the specific needs of the client. (e.g.: - to whom information was given
graphic sheets for vital signs, intake & output - what information was given
record, skin assessment record). - what information was received
- Only RN's may receive telephone orders
3. Nurses; Progress Notes - The order need to be verified by reporting it
- Used to document the client's condition, clearly and precisely
problems and complaints, interventions, - The order should be countersigned by the
responses, achievement of outcomes. physician who made the order within the
prescribed period of time (within 24 hours)
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 General Documentation Outline
● Ensure that you have the correct client record or
chart
● Document as soon as the client encounter is
concluded to ensure accurate recall of data. Correcting Orders
● Date and time of each entry. - IF YOU SPILL SOMETHING ON THE CHART,
● Sign each entry with your full legal name and DO NOT DISCARD NOTES. RECOPY, PUT
with your professional credentíals. ORIGINAL AND COPIED SHEETS IN CHART.
● Do not leave space in between entries WRITE "COPIED" ON COPY
● If an error is made while documenting, use a - DO NOT SCRIBBLE OUT CHARTING
single line to cross out the error, then date, time - AVOID USING "ERROR" OR WRONG
and sign the correction PATIENT" WHEN MAKING CORRECTION
● Never change another person's entry even if it is - FOLLOW YOUR FACILITIES POLICY
incorrect - DO NOT ALTER CHARTING, IT IS A LEGAL
● Use quotation marks to indicate direct client DOCUMENT
responses - Correct errors by drawing a single
● Document in chronological order horizontal line through the error
● Use permanent ink - Write the word error above the line, then
● Document all telephone calls that you received sign your signature
that are related to - No ink eradication, erasures or use of
occlusive materials
Minimizing legal liability through effective record
keeping
● Date & time
● Timing
● Legibility
● Permanence
● Correct spelling
● Signature
● Accuracy
● Sequence
● Appropriateness
● Completeness
● Copyright
● Conciseness
● Accepted terminology

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