3. IMPLEMENTING
Action phase in which the nurse performs
the nursing intervention
Consists of doing and documenting the
activities that are the specific nursing
actions needed to carry out the
interventions.
4. IMPLEMENTING SKILLS
Cognitive Skills (Intellectual Skills)
Include problem solving, decision making,
critical thinking and creativity
Interpersonal Skills
All the activities, verbal and nonverbal,
people use when interacting directly with
one another.
Use of therapeutic communication
5. IMPLEMENTING SKILLS
Technical Skills
Purposeful “hands-on” skills such as
manipulating equipment, giving injections,
bandaging, moving, lifting and
repositioning clients
Also called procedures or psychomotor
skills.
6. PROCESS OF IMPLEMENTING
Reassessing the client
Determining the nurse’s need for
assistance
Implementing the nursing interventions
Supervising the delegated care
Documenting nursing activities
7. Reassessing the Client
Nurse must reassess the client to make
sure the intervention is still needed
New data may indicate a need to change
the priorities of care or the nursing
interventions.
8. Determining the Nurse’s Need for
Assistance
The nurse is unable to implement the
nursing activity safely or efficiently along.
Assistance would reduce stress on the
client.
The nurse lacks the knowledge or skills to
implement a particular nursing activity.
9. Guidelines in Implementing the
Nursing Interventions
1. Base nursing interventions on scientific
knowledge, nursing research and
professional standards of care .
2. Clearly understand the interventions to
be implemented and question any that
are not understood.
3. Adapt activities to the individual client.
4. Implement safe care.
10. Guidelines in Implementing the
Nursing Interventions
5. Provide teaching, support and comfort.
6. Be holistic
7. Respect the dignity of the client and
enhance the client’s self-esteem.
8. Encourage clients to participate actively
in implementing the nursing intervention.
11. Supervising Delegated Care
If care has been delegated to other health
personnel, the nurse responsible for the
client’s overall care must ensure that the
activities has been implemented according
to the care plan.
12. Documenting Nursing
Activities
Record the interventions and client
responses in the nursing progress notes.
The nurse may record routine or recurring
activities in the client record at the end of
a shift.
14. EVALUATING
Planned, ongoing, purposeful activity in
which clients and health care
professionals determine:
a. The client’s progress toward achievements
of goals/outcomes.
b. The effectiveness of the nursing care plan.
15. Evaluation Process
Collecting fata related to the desired
outcomes
Comparing the data with outcomes
Relating nursing activities to outcomes
Drawing conclusions about problem status
Continuing, modifying or terminating the
nursing care plan
16. Collecting Data
The nurse collects data so that
conclusions can be drawn whether goals
have been met.
Collect both objective and subjective data.
Data must be recorded concisely and
accurately to facilitate the next process of
evaluation.
17. Comparing Data with Outcomes
Both the nurse and client play an active role in
comparing the client’s actual responses with
the desired outcomes.
Three possible conclusions:
1. The goal was met; the client response is
the same as the desired outcome.
2. The goal was partially met; either a short
term goal was achieved but the long term
goal was not or the desired outcome was
only partially attained
3. The goal was not met.
18. Evaluation Statement consists of two parts:
Conclusion – statement that the
goals/desired outcome was met, partially
met or not med
Supporting data – list of client response
that support the conclusions
Example: Goal met: Oral intake 300 ml
more than output; skin turgor resilient;
mucous membranes moist.
19. Relating Nursing Activities to
Outcomes
Determine whether the nursing activities
had any relation to the outcomes.
Never assumed that a nursing activity was
the cause of or only factor in meeting,
partially meeting or not meeting a goal.
20. Drawing Conclusions about
Problem Status
When goals are met, the nurse can draw one of
the following conclusions:
The actual problem stated in the nursing
diagnosis has been resolved or the potential
problem is being prevented and the risk
factors no longer exist.
The potential problem stated in the nursing
diagnosis is being prevented, but the risk
factors are still present.
The actual problem exits even though some
goals are being met.
21. Drawing Conclusions about
Problem Status
When goals have been partially met or when
goals have not been met, two conclusions may
be drawn:
The care plan may need to be revised, since
the problem is only partially resolved.
The care plan does not need revisions,
because the client merely needs more time to
achieve the previously established goal(s).
22. Continuing, Modifying and
Terminating the Nursing Care Plan
Whether or not goals were met, a number
of decisions need to be made about
continuing, modifying or terminating
nursing care for each problem.
Before making modifications, the nurse
must determine if the plan as a whole was
completely effective.
23. EVALUATING THE QUALITY OF
NURSING CARE
Quality Assurance
Ongoing, systematic process designed to
evaluate and promote excellence in the health
care provided to clients.
Three Components of Care to be Evaluated:
1. Structure Evaluation
2. Process Evaluation
3. Outcome Evaluation
24. Structure evaluation focuses on the
setting in which care is given.
Process evaluation focuses on how the
care was given.
Outcome evaluation focuses on
demonstrable changes in the client’s
health status as a result of nursing care
25. Quality Improvement
Evaluating and improving the quality of
health care based on internal assessment
by health care providers and increasing
awareness by the public in medical errors
are not uncommon and can be lethal.
Sentinel event –unexpected occurrence
involving death or serious physical or
psychological injury or the risk thereof.
Root cause analysis – process of
identifying the factors that bring about
deviations in practices that lead to the
event.
26. Nursing Audit
Audit means the examination or review of
records.
Retrospective audit is the evaluation of a
client’s record after discharge from an
agency.
Concurrent audit is the evaluation of a
client’s health care while the client is still
receiving car from the agency.
27. DOCUMENTATION &
REPORTING
Discussion – informal oral consideration
of a subject by two or more health care
personnel to identify a problem or
establish strategies to solve a problem.
Report – oral, written, or computer-based
communication intended to convey
information to others.
Record - a written or computer based
28. Recording/Charting/Documenting
The process of making an entry on a client
record.
Client record, also called a chart or client
record
A formal, legal document that provides
evidence of a client’s care.
29. Ethical and Legal Considerations
“The nurse has the duty to maintain
confidentiality of all patient information.”
Nurses’ Code of Ethics
Patient’s Bill of Rights
Data Privacy Law
30. Ensuring Confidentiality of Computer
Records.
1. A personal password is required to enter and sign off
computer files. Do not share password with anyone.
2. After logging on, never leave a computer terminal
unattended.
3. Do not leave a client information displayed on the
monitor.
4. Shred all unneeded computer-generated worksheets.
5. Know the facility’s policy and procedure for correcting
an entry error.
6. Follow agency procedures for documenting sensitive
material such as a diagnosis of AIDS.
7. IT personnel must install a firewall to protect the server
from unauthorized access.
31. Purposes of Client Records
Communication
Planning Client Care
Auditing Health Agencies
Research
Education
Reimbursement
Legal Documentation
Health Care Analysis
32. Documentation System
Source-oriented record
Problem-oriented medical record
Problem, intervention, evaluation (PIE)
model
Focus charting
Charting by exception (CBE)
Computerized documentation
Case management
33. SOURCE-ORIENTED RECORD
The traditional client record.
Each person or department makes
notations in a separate section or sections
of the client’s chart
Narrative Charting – a traditional part of
the source-oriented record; consists of
written notes that include routine care,
normal findings and client problems,
34.
35. Advantage:
Convenient because care providers from each
discipline can easily locate the forms on which
to record data and easy to trace the
information specific to one’s discipline.
Disadvantage
Information about a particular client problem
is scattered throughout the chart; it is difficult
to find chronological information on a client’s
problem and progress.
36. PROBLEM-ORIENTED MEDICAL
RECORD
(POMR or POR)
The data are arranged according to the
problems the client has rather than the
source of the information.
Four basic components:
Database
Problem list
Plan of care
Progress notes
37. Database
Consists of all information known about
the client when the client first enters the
health care agency.
Includes the nursing assessment, the
physician’s history, social and family data
and the results of the physical examination
and baseline diagnostic tests.
38. Problem List
Derived from the database
Listed in the order in which they are
identified, and the list is continually
updated as new problems are identified
and others resolved.
39. Plan of Care
The initial list of orders or plan of care is
made with reference to the active
problems.
Generated by the person who lists the
problems.
Nurses write nursing orders or nursing
care plans.
40. Progress Note
A chart entry made by all health
professional involved in a client’s care.
Are numbered to correspond to the
problems on the problem list and may be
lettered for the type of data
41. SOAP,SOAPIE, SOAPIER, APIE
S Subjective Data
O Objective Data
A Assessment
P Plan
I Interventions
E Evaluations
R Revision
42. SOAP Format
3/4/2020
14:00
S
O
A
P
“My skin is itchy on my back and arms, and it’s
been like this for a week.”
Skin appear clear – no rash or irritation noted.
Marks where client has scratched noted on left and
right forearms. Allergic to elastoplast has not been
in contact. No previous history of pruritus.
Altered comfort (pruritus): cause unknown
Instructed not to scratch skin
Applied calamine lotion to back and arms at 1430
Cut fingernails
Assess further to determine whether recurrence
associated with specific drugs or foods.
Refer to physician and pharmacist for assessment.
Tiglao RN
43. SOAPIER Format
3/4/2020
14:00
S
O
A
P
I
E
R
“My skin is itchy on my back and arms, and it’s been like this
for a week.”
Skin appear clear – no rash or irritation noted. Marks where
client has scratched noted on left and right forearms.
Allergic to elastoplast has not been in contact. No previous
history of pruritus.
Altered comfort (pruritus): cause unknown
Instruct not to scratch skin
Apply calamine lotion to back and arms
Cut fingernails
Assess further to determine whether recurrence associated
with specific drugs or foods.
Refer to physician and pharmacist for assessment.
Instructed not to scratch skin.
Applied calamine lotion to back and arms at 1430
Assisted to cut fingernails
Notified physician and pharmacist of problem
States “I’m still itchy. That lotion didn’t help.”
Remove calamine lotion and apply hydrocortisone cream as
ordered.
M. Nebiar RN
44. APIE Format
3/4/2020
14:00
A
P
I
E
Generalized pruritus r/t unknown cause
States “My skin is itchy on my back and arms, and it’s
been like this for a week. Skin appear clear. No rash or
irritation noted. Marks where client has scratched noted
on left and right forearms. Allergic to elastoplast has not
been in contact. No previous history of pruritus.
Instruct not to scratch skin
Apply calamine lotion to back and arms at 1430
Cut fingernails
Assess further to determine whether recurrence
associated with specific drugs or foods.
Refer to physician and pharmacist for assessment.
Instructed not to scratch skin.
Applied calamine lotion to back and arms at 1430
Assisted to cut fingernails
Notified physician and pharmacist of problem
States “I’m still itchy. That lotion didn’t help.”
C. Nealega, RN
45. FOCUS CHARTING
Intended to make the client and client
concerns and strengths the focus of care.
The focus may be a condition, a nursing
diagnosis, a behavior, a sign or symptom,
an acute change in the client’s condition or
a client strengths.
The progress notes are organized into (D)
data, (A) action and (R) response, referred
to as DAR.
46. Data – reflects assessment phase
(subjective and objective data)
Action – reflects planning and
implementation
Response – reflects the evaluation phase
Date/Hour Focus Progress Notes
3/5/2011
0900
0930
Pain D: Guarding abdominal incision.
Facial grimacing. Rates pain at
“8” on scale of 0-10
A: Administered morphine sulfate
4mg IV
R: Rate pain at “1”. States willing
to ambulate.
47. CHARTING BY EXCEPTION
A documentation system in which only
abnormal or significant findings or
exceptions to norms are recorded.
Three Elements:
Flow Sheets – Ex: graphic record, fluid
balance record, daily nursing assessment
record, client teaching record, client
discharge record and skin assessment
record
48.
49. Standards of nursing care – Documentation
by reference to the agency’s printed
standards of nursing practice eliminates
much of the repetitive charting of routine
care. For example, “the nurse must ensure
that the unconscious client has oral care at
least q4h. – only a check mark in the routine
standard box on the graphic record.
Bedside access to chart forms – All
flowsheets are kept at the client’s bedside to
allow immediate recording and to eliminate
the need to transcribe data from the nurse’s
worksheet to the permanent record.
50.
51. COMPUTERIZED
DOCUMENTATION
Developed as a way to manage the huge
volume of information required in
contemporary health care.
Nurse use computers to store the client’s
database, add new data, create and revise
care plans and document client progress.
52. Advantages of Computer Documentation
Computer records can facilitate a focus on client outcomes.
Bedside terminals can synthesize information from
monitoring equipment
It allows nurses to use their more efficiently.
The system links various sources of client information
Client information, requests and results are sent and
received quickly.
Link to monitors improve accuracy of documentation.
Bedside terminals eliminate the need to take notes on a
worksheet before recording.
Bedside terminals permit the nurse to check an order
immediately before administering a treatment or medication.
Information is legible
The system incorporates and reinforces standards of care.
Standard terminology improves communication.
53. Disadvantages of Computer Documentation
Client’s privacy may be infringed on if security
measures are not used.
Breakdown make information temporarily
unavailable.
The system is expensive
Extended training periods may be required when a
new or updated system is installed.
54. CASE MANAGEMENT
Emphasizes quality, cost-effective care
delivered within an established length of
stay
This uses a multidisciplinary approach to
planning and documenting client care,
using critical pathway
55. DOCUMENTING NURSING
ACTIVITIES
Admission Nursing Assessment
A comprehensive admission assessment, also
referred to as an initial database, nursing
history or nursing assessment, is completed
when the client is admitted to the nursing unit
Nursing Care Plans
Traditional care plan – written for each client
Standardized care plan – developed to save
documentation time; base on institution’s
standards of practice.
56. Kardexes
A widely used, concise method of organizing and
recording data about a client, making information
quickly accessible to all health professionals.
Client’s name, age, admission date, physician’s name,
diagnosis and type of surgery and date.
Allergies
List of medications (date of order and times of
administration)
List of IV (date)
List of daily treatment or procedures
List of diagnostic procedures
Diet
Problem list, stated goals and list of nursing
approaches to meet goals and relieve the problems.
57.
58. Flow Sheets
Graphic Record
Input and Output Record
Medication Administration Record
Skin Assessment Record
Progress Notes
Made by nurses provide information about
the progress a client is making toward
achieving desired outcomes.
59. Nursing Discharge/ Referral Summaries
Completed when the client is being discharged and
transferred to another institution or to a home setting
where a visit by a community health nurse is required.
Client’s physical, mental and emotional status at
discharge
Resolved health problems
Unresolved continuing problems and continuing care
needs
Treatment to be continued
Current medication
Restrictions to activity
Functional/self-care abilities
Comfort level
Support network
Client education provided
Discharge destination
60. GUIDELINES FOR RECORDING
Date and Time
Timing
Legibility
Permanence
Accepted Terminology
Correct Spelling
Signature
Accuracy
Sequence
Appropriateness
Completeness
Conciseness
Legal Prudence
61. REPORTING
Purpose: To communicate specific
information to a person or group of
people.
A report, whether oral or written, should be
concise, including pertinent information
but no extraneous detail.
62. Change-of-Shift Records
Given to all nurses on the next shift
Purpose: Provide continuity of care for
clients by providing the new caregivers a
quick summary of clients needs and
details of care to be given.
ROOM 201 – C.W.
Admitted last night for pneumonia
Allergic Penicillin
DNR
IV of D5/0.45 NS at 100ml/hr in L forearm
Need sputum for C&S
Temp102.4F; Tylenol given at 0600
Lung sound diminished in lower lobes
63. Key Elements of a Change-of-Shift
Report
Follow a particular order
Provide basic identifying information for each client
For new clients, provide the reason for admission or medical
diagnosis, surgery, diagnostic tests, and therapies in past 24 hours.
Include significant changes in client’s condition and present
information in order
Provide exact information
Report client’s need for special emotional support
Include current nurse-prescribed and primary-care provider-
prescribed orders
Provide a summary of newly admitted clients
Report on clients who have been transferred or discharged from the
unit
Clearly states priority of care and care that is due after shift begins
Be concise
64. Telephone Reports
Nurses inform primary care provides about a
change in a client’s condition; a radiologist
reports; transfer of client.
The nurse receiving telephone report should
document the date and time, the person giving
the information, the subject of information
received and sign the notation.
Example: 3/4/2021 1050 Ms. Carreras,
laboratory technician reported by telephone
that Mrs.Buena hematocrit was 39/100 ml
- AM.Bigueja, RN
65. The person receiving the information should
repeat it back to the sender to ensure accuracy,
Telephone reports usually include the client’s
name and medical diagnosis, changes in nursing
assessment, vital signs related to baseline,
significant laboratory data and related nursing
interventions.
Example:
1200- Admitted from ER c/o burning upper right
quadrant abdominal pain. Rates pain at 6/10,
BP115/80, PR-100bpm, RR-15 bpm. Demerol 100 mg
given IM per order
1300- BP 100/40, PR-115bpm, RR-30bpm, Pain
unchanged. Color pale and diaphoretic. Reported by
telephone to Dr. Berce at 13:10
-L. Babilonia RN
66. Telephone Orders
Some agencies allow only registered nurses to take
telephone orders.
When primary care provider gives the order, write
the complete order down and read it back to the
primary care provider to ensure accuracy.
Question for any order that is ambiguous, unusual
or contraindicated by the client’s conditions
Then transcribe the order onto the physician’s
order sheet, indicating it as a verbal order or
telephone order.
The order must be countersigned by the primary
care provider within 24 hours.
67. Guidelines for Telephone and
Verbal Orders
1. Know the state nursing board’s position on who
can give and accept verbal and phone orders.
2. Know the agency’s policy regarding phone orders
3. Ask the prescriber to speak slowly and clearly
4. Ask the prescriber to spell out the medication if
you are not familiar with it.
5. Question the drug, dosage or changes if they
seem inappropriate for this client.
6. Write the order down or enter into a computer
68. 7. Read the order back to the prescriber. Use
words instead of abbreviations
8. Write the order on the physician’s order
sheet. Record date and time and indicate it
was telephone order. Sign name and
credentials.
9. When writing a dosage always put a number
before a decimal but never after a decimal.
10. Write out units
11. Transcribe the order
12. Follow agency protocol about the
prescriber’s protocol for signing telephone
orders
69. Nursing Rounds
Procedures in which two or more nurses
visit selected clients at each client’s
bedside to:
Obtain information that will help plan
nursing care.
Provide clients the opportunity to discuss
their care.
Evaluate the nursing care the client
received.
