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2 nursing process
- 1. NURSING PROCESS Prepared by: ROWENA R.TOSOC RN, MAN, PhD
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- 3. IMPLEMENTING Action phasein 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’sNeed 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 Implementingthe 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 Implementingthe 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 Recordthe 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.
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- 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 Collectingfata 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 Thenurse 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 withOutcomes 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 consistsof 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 Activitiesto 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 ProblemStatus 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 ProblemStatus 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 Terminatingthe 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 QUALITYOF 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 evaluationfocuses 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 Evaluatingand 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 Auditmeans 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 processof 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 LegalConsiderations “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 ofComputer 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 ClientRecords Communication Planning Client Care Auditing Health Agencies Research Education Reimbursement Legal Documentation Health Care Analysis
- 32. Documentation System Source-orientedrecord Problem-oriented medical record Problem, intervention, evaluation (PIE) model Focus charting Charting by exception (CBE) Computerized documentation Case management
- 33. SOURCE-ORIENTED RECORD Thetraditional 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,
- 35. Advantage: Convenient becausecare 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 orPOR) 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 ofall 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 Derivedfrom 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 Achart 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 skinis 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 skinis 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 pruritusr/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 Intendedto 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
- 49. Standards ofnursing 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.
- 51. COMPUTERIZED DOCUMENTATION Developed asa 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 ComputerDocumentation 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 ComputerDocumentation 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 Emphasizesquality, 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 NursingAssessment 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 widelyused, 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.
- 58. Flow Sheets GraphicRecord 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/ ReferralSummaries 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: Tocommunicate 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 Givento 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 ofa 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 Nursesinform 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 personreceiving 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 Someagencies 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 Telephoneand 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 theorder 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 Proceduresin 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.
- 70.