NURSING NOTES http://www.nursingnotes.info/

FIVE (5) PHASES OF NURSING CARE(American Nurses Association (ANA) Standards of Clinical Nursing Practice)

I. ASSESING – is the systematic and continuous collection, organizing, validation, and

documentation of data.

PURPOSE: To establish a database about client’s response to health concerns or

illness and the ability to manage health care needs.

TYPES OF ASSESSMENT:TYPE TIME PERFORMED PURPOSE EXAMPLE

Initial Assessment Within specified time after admission

To establish a complete data base for problem identification, reference and future comparison

Nursing admission assessment

Problem-focused assessment

Ongoing process integrated with nursing care

To determine status of specific problem identified in an earlier assessmentTo identify new or overlooked problems

I & O q 1 hr in ICU

Assess client’s ability to perform self care while assisting to bathe

Emergency Assessment

During any physiologic and psychologic crisis of the client

To identify life-threatening problems

Rapid assessment of ABC during cardiac arrestAssessment for suicidal tendencies and potential for violence

Time-lapsed reassessment

Several months after initial assessment

To compare client’s current status to baseline data previously obtained

Reassessment of client’s functional health patterns.

A. DATA COLLECTION – is the process of gathering info about a client’s health status.

DATABASE – is all info about the client; includes nursing health history, physical assessment,

doctor’s history and physical exam, results of lab and diagnostic tests, and material contributed

by other health personel.

CLIENT DATA – past history and current problems.

TYPES OF DATA:

1. SUBJECTIVE DATA – symptoms or covert (secret) data. It is described or verified only by

the affected person.

Examples: itching, pain, worry, sensations, feelings, values, attitudes, perception of

personal status and life situation.

2. OBJECTIVE DATA – signs or overt (obvious) data. It is detectable by the observer, can be

measured or tested against accepted standard. They can be seen, heard and felt, or

smelled, can be obtained by observation or physical exam.

SOURCES OF DATA:

1. PRIMARY DATA – from the CLIENT, it is the best source of data unless too ill, young,

confused to communicate clearly.

2. SECONDARY DATA – are SUPPORT PEOPLE(family members, friends, caregivers), CLIENT

RECORD, HEALTH CARE PROFESSIONALS(doctors, nurses, physiotherapist, social

workers), LITERATURE (standards/norms,cultural and health practices, spiritual beliefs)

DATA COLLECTION METHODS

1. OBSERVATION – is a conscious, deliberate skill that is developed through effort and with

an organized approach.

2. INTERVIEW – is planned communication or a conversation with a purpose.

TWO APPROACHES:

a. DIRECTIVE INTERVIEW. The nurse establishes the purpose and controls the

interview. The client responds to questions but may limited opportunity to ask

questions or discuss concerns

b. NONDIRECTIVE INTERVIEW – rapport-building interview. The nurse allows the client

to control the purpose, subject matter, and pacing.

RAPPORT- is the understanding b/w 2 or more people.

TYPES OF INTERVIEW:

a. CLOSED QUESTION – (directive interview) restrictive and answered by YES/NO,

questions begin by WHEN, WHERE, WHO, WHAT, DO or IS.

b. OPEN-ENDED QUESTIONS – (indirective interview) invite clients to discover, explore,

elaborate, clarify, or illustrate their thoughts and feelings. It may begin with

WHAT/HOW.

c. NEUTRAL QUESTION – (open ended and indirective) is a question a client can

answer without direction or pressure from the nurse ( regarding feelings and point

of views)

d. LEADING QUESTIONS – (closed and directive) directs the client’s answer. It gives the

client less opportunity to decide whether the answer is true or not. (Ex. You’re

stressed about the surgery tomorrow, aren’t you?)

PLANNING AND SETTING OF INTERVIEW

a. Time. comfortable and unhurried

b. Place. Well lighted, well ventilated, moderate sized room, free from noise,

movements and interruptions.

c. Seating arrangement.

Two parties are seated on two chairs placed at right angles to a desk or table /

few feet apart without table between.

A horseshoe or circular chair arrangements

When a client in bed, sit at a 45 degrees angle to bed, not standing and looking

down the client who is in bed.

d. Distance. Maintaining a distance of 2 to 3 feet.

PROXEMICS – term for the study of human use and perception of social and

personal space.

INTIMATE ZONE (0-18 inches) –use for comforting, protecting, counseling

and preserved for people who feel close.

PERSONAL ZONE (18 inches to 3 feet) – maintained with friends or in some

counseling interactions

SOCIAL/PUBLIC ZONE (3 – 6 feet) – used when impersonal business is

conducted or with people who are working together.

e. Language. Failure to communicate is a form of discrimination.

Translate medical terminologies into common English understandable to

both client and family members.

STAGES OF INTERVIEW

1. The Opening – most important part.

Purpose: to establish rapport (process of creating a goodwill and trust) and orient the

interviewee.

begin with a greeting, self intro accompanied by smile or handshake

Explain the purpose and nature of interview

Tell the client how the info will be used and usually states the client’s right not

to provide the info.

2. The Body – the client communicates what he feels or thinks. Knows, and

perceives in response to questions from the nurse.

3. The Closing – the termination is important for maintaining rapport and trust

and for facilitating future interactions.

TECHNIQUES:

a. Offer to answer questions. Do u have any questions?b. Conclude by saying “Well, ….” , that generally signals that the need of interactionsc. Thank the client. d. Express concern for person’s welfare and future. “Take care of urself….”e. Plan for the next meeting, if there’s a need.f. Provide summary to verify accuracy and agreement.

3. EXAMING – a physical exam/ assessment is the systematic data-collection method used

observation (the senses) to detect health problems.

APPROACHES:

a. CEPAHALOCAUDAL / HEAD-TO-TOE APPROACHES – begins the examination at the

head, progresses to the neck, thorax, abdomen, and extremities, and ends at the

toes.

b. BODY SYSTEMS APPROACH – investigates each systems individually. That is,

respiratory, circulatory, nervous systems, and so on.

c. SCREENING EXAMINATION/ REVIEW OF SYSTEMS – is a brief review of a screening

examination measured against norms/standards, such as ideal wt & ht for body tem /

BP.

B. ORGANIZING DATA – the nurse uses a written/computerized format that organizes the

assessment data systematically.

OTHER TERM: Nursing Health History, Nursing Assessment, Nursing Database Form

NURSING CONCEPTUAL MODELS

1. Gordon (2000) –provides a framework of 11 functional health patterns. It collects

data about dysfunctional as well as functional behavior.

2. Orem, Taylor, and Renpenning (2000) – delineate 8 universal self care requisites of

humans.

3. Roy and Andrews (1998) – classify observable behavior into 4 categories: self

concept, role function and interdependence.

4. Others

WELLNESS MODELS – to assist clients to identify health risks and to explore lifestyle

habits and health behaviors, beliefs, beliefs, values, and attitudes that influence levbels

of wellness.

NONNURSING MODELS

1. BODY SYSTEMS MODEL – focuses on abnormalities in anatomic systems of the body.

2. MASLOW’S HIERARCHY OF NEEDS

3. DEVELOPMENTAL THEORIES – for physical, psychosocial, cognitive and moral

developmental theories.

C. VALIDATING DATA – is verifying data to confirm that it is accurate and factual

CUES – are subjective or objective data that can be directly observed by the nurse.

INFERENCES – nurse’s interpretation or conclusions made based on the cues.

D. DOCUMENTING DATA – the nurse records the data.

ACCURATE DOCUMENTAION – is essential and should include all data collected about

the client’s health status.

II. DIAGNOSING – is analyzing data; identification of health problems, risks and strengths; and

formulation of diagnostic statement.

Diagnostic Labels – are standardized NANDA names for diagnoses

Diagnosis – is the statement or conclusion regarding the nature of phenomenon.

Nursing Diagnosis – the client’s problem statement, consisting of the diagnostic label plus the

etiology (casual relationship b/w a problem and its related or risk factors)

TYPES OF NURSING DIAGNOSES

1. ACTUAL DIAGNOSIS is a client problem that is present at the time of nursing assessment.

2. RISK NURSING DIAGNOSIS is a clinical judgment that a problem does not exist, but the

presence of risk factors indicates a problem is likely to develop unless nurse intervenes.

3. WELLNESS DIAGNOSIS – describe a human response to level of wellness that have a

readiness for enhancement.

4. POSSIBLE NURSING DIAGNOSIS is one in which evidence about a health problem is

incomplete or uncler.

5. SYNDROME DIAGNOSIS is a diagnosiss that is associated with a cluster of other

diagnosis.

THREE COMPONNETS OF NURSING DIAGNOSIS

1. PROBLEM and its definition – describes the client’s health problem or response for hich

nursing therapy is given.

QUALIFIERS – are words that have been added to some NANDA labels to give additional meaning to the diagnostic statement.

Deficient – inadequate, incomplete Impaired – made worse, weakened, damaged, reduced, deteriorated Decreased – lesser Ineffective – not producing a desired effect Compromised – to make vulnerable to threat

2. EtTOLOGY (Related factors/Risk factors) – identifies one/more probable causes of the

health problem, gives direction to the required nursing therapy, and enables the nurse

to individualized the client’s care.

3. DEFINING CHARACTERISTICS – are the cluster of signs and symptoms that indicate the

presence of a particular diagnostic label.

THREE STEPS OF DIAGNOSTIC PROCESS

1. Analyzing data- a. compare data against standards/ norms

(generally acceptable measure, rule, model or pattern)

b. cluster cues

c. identify gaps and inconsistencies

2. Identify health problems, risks, and strengths – decision making process

3. Formulation diagnostic statements

BASIC TWO-PART STATEMENTS (Problem + Etiology)

BASIC THREE-PART STATEMENTS – PES format

(Problem + Etiology + Signs and Symptoms)

ONE-PART STATEMENTS – NANDA LABEL ONLY (Wellness/Syndrome diagnosis)

BASIC FORMATS VARIATIONS:

a. Writing unknown etiology when the defining characteristics are present but the nurse does not know the cause or contributing factors.

Ex: Noncompliance (medication Regimen) r/t unknown etiology

b. Using the phrase complex factors when there are too many etiologic factors or when they are too complex to state in a brief phrase.Ex: Chronic Low Self-Esteem r/t complex factors

c. Using word possible to describe either the problem of etiology.Ex: Possible low self esteem r/t loss of job Altered thought process possibly r/t unfamiliar surroundings

d. Using secondary to divide the etiology into two parts, thereby making the statements more descriptive and useful. The part following the secondary to is often the pathophysiology/disease process.Ex: Risk for impaired skin integrity r/t decreased peripheral circulation secondary to diabetes.

e. Adding a second part to the general response or NANDA label to make it more precise.Ex: Impaired skin integrity (Left lateral ankle) r/t decreased peripheral circulation

III.PLANNING – is a deliberative, systematic phase that involves decision making and problem

solving. It begins with the first client contact and continues until the nurse-client relationship

ends, usually when client is discharged from the health care agency.

Prioritize problems/diagnosis Formulate goals/desired outcomes Select nursing interventions Write nursing orders

NURSING INTERVENTION- is any treatment, based upon clinical judgment and knowledge that a

nurse performs to enhance patient’s outcomes.

TYPES OF PLANNING

Initial Planning. Planning is initiated as soon as possible after initial assessment

Ongoing Planning. Planning occurs at the beginning of a shift to the end of the shift.

Discharge Planning. The process of anticipating and planning for the needs after

discharge.

NURSING CARE PLAN. Is the end product of the planning phase of the nursing process

Informal nursing care plan. Is a strategy of action that exists in the nurse’s mind.

Formal nursing care plan. A written/computerized guide that organizes info about the

client’s care.

Standardized care plan. A formal plan that specifies the nursing care fro groups of

clients with common needs.

Individualized care plan. Is tailored to meet the unique needs of a epecific client –

needs that are not addressed by the standardized plan.

STANDARDS OF CARE. It describes nursing actions forclients with similar medical conditions

rather than individuals, and they describe achievable rather than ideal nursing care.

PROTOCOLS. They are preprinted to indicate actions commonly required for a particular group

of clients.

STANDARDIZED CARE PLANS. They are preprinted guides for the nursing care of a client who

has a need that arises frequently in the agency. They written from the perspective of what care

the client can expect.

POLICIES AND PROCEDURES. They are developed to govern a handling of frequent occurring

situations.(institutional records)

STANDING ORDER. Is a written document about policies, rules, regulations, or orders regarding

client care. It gives nurses the authority to carry out specific actions under certain

circumstances, often when a physician is not immediately available.

STUDENT CARE PLANS – plan of care made by the students with a” rationale” column.

RATIONALE - is the scientific principle given as the reason for selecting a particular nursing

intervention.

CONCEPT MAP – is a visual tool in which ideas or data are enclosed in circles or boxes of some

shape and relationships b/w these are indicated by connecting lines and arrows.

COMPUTERIZED CARE PLANS – computer are used to create and store NCP.

MULTIDISCIPLINARY (Collaborative) CARE PLAN – standardized paln outlines the care

required for clients with common, predictable – usually medical – conditions.

THE PLANNING PROCESS

1. PRIORITY SETTING is the process of establishing a preferential sequence for addressing

nursing diagnoses and interventions

2. ESTABLISHING CLIENT GOALS/DESIRED OTCOMES – what the nurse hopes to achieve by

implementing the nursing interventions.

COMPONENTS

a. Subject. Is the client, any part of the client, or some attributes such as BP/ Temp.

b. Verb. It specifies an action the client is to perform.

c. Conditions/ modifiers. It may be added to the verb to explain the circumstances

under which the behavior is to be performed. They explain what, where, when and

how.

d. Criterion of desired outcome. It indicates the standard by which a performance is

evaluated or at the level at which the client will perform the specified behavior. It

specifies time or speed, accuracy, distance and quality.

3. SELECTING NURSING INTERVENTIONS.

INDEPENEDENT INTERVENTIONS - are those activities that nurses are licensed

to initiate on the basis of their knowledge and skills.

DEPENDENT INTERVENTIONS - are activities carried out under the physician’s

orders or supervision, or according to specified routines.

Collaborative interventions – are actions the nurse caries out in collaboration

with other health team members, such as PT, SW, Dietitians, and physicians.

IV.IMPLEMENTING – consist of doing and documenting the activities that are the specific

nursing actions needed to carry out the interventions.

IMPLEMENTING SKILLS

COGNITIVE (intellectual) SKILLS – includes problem solving, decision making. Critical

thinking and creativity

INTERPERSONAL SKILLS -