NURSING PROCESS ● Using assistive devices correctly.
- Implementation Five Activities of the Implementation
Implementation and Its Relation to Other Phase
Phases of the Nursing Process 1. Reassessing the Client - Nurses verily if
● Assessment provides the data that the client's condition has changed, which
guide implementation. may require modifying the care plan.
● Diagnosis determines the problems 2. Determining the Nurse's Need for
that interventions target. Assistance - Not all interventions can or
● Planning ensures interventions are should be done alone.
tailored to the client's needs. 3. Implementing Nursing Interventions -
● Evaluation follows implementation Executing planned interventions safely,
to determine the effectiveness of accurately, and according to the client's
interventions. needs in accordance with standards of
Three Categories of Skills Used to practice.
Implement Nursing Interventions Direct Care - Hands-on procedures like
1. Cognitive Skills (Thinking Skills) Insertion, dressing changes, or emotional
-These involve knowledge-based support.
decision-making or clinical reasoning, Indirect Care - Activities like infection
problem-solving & decision-making or control,documentation, and coordination
evidence-based practice, and critical with other healthcare professionals
thinking. 4. Supervising Delegated Care - Ensure that
● Prioritize care tasks delegated to other team members (eg.,
● Apply knowledge nursing assistants) are carried out correctly and
● Predict outcome safely.
5. Documenting Nursing Activities - Accurate
2. Interpersonal Skills (Communication &
documentation is essential for legal protection
Relationship-Building Skills)
and continuity of care.
- Effective communication, empathy, and Guidelines for Implementing Nursing
collaboration are vital in interacting with Interventions
patients, families, and healthcare teams. ● Use Evidence-Based Practice
● Promote therapeutic relationships ● Individualize Care
● Ensure cultural competence ● Ensure Patient Safety
● facilitate teamwork ● Promote Patient Participation
3. Technical Skills (Hands-on Clinical ● Document Accurately
Skills) - These include hands-on procedures EVALUATION
such as administering medications, wound ● Fifth phase of the nursing process
● A planned, ongoing, purposeful activity
care, IV therapy, and using medical
in which clients & health care
equipment safely and correctly.
professionals determine:
● Administering injections correctly. ● The clients progress toward
● Performing sterile wound dressing. achievement of goals/outcomes
● The effectiveness of the nursing care Steps in Reviewing and Modifying the Client's
plan Care Plan
Evaluation and Its Relation to Other Phases of When goals are not met, the nurse must reassess,
the Nursing Process adjust, and implement revised strategies:
●Assessment Revising a care plan involves:
●Diagnosis ● Reassessing the Client's Condition
●Planning ● Revising Nursing Diagnoses
●Implementation ● Adjusting Goals and Outcomes
Evaluation determines whether: ● Changing Nursing Interventions
The client's condition has improved, ● Continuing, Modifying, or Terminating
remained unchanged, or worsened. the Care Plan
Interventions need to be continued, modified, or Three Components of Quality Evaluation:
discontinued. Structure, Process, and Outcomes
●A different approach is needed to Structure Evaluation - Examines the
achieve the desired outcome. environment in which care is provided,
If a goal is unmet, the nursing process must loop including
back to reassessment, diagnosis, and planning. staff qualifications, facility resources, and
●If the desired outcomes are not met, policies.
nurses must reassess the situation, Process Evaluation -Assesses if nurses follow
modify the care plan, and continue the standards and protocols effectively.
nursing process cyclically. Outcome Evaluation -Measures patient
Five Components of the Evaluation Phase improvement, satisfaction, and safety indicators.
● Collecting Data Related to Expected All three components contribute to ensuring
Outcomes - Observing physical signs, safe, effective, and high-quality patient care.
lab results, and verbal feedback to Quality Improvement vs. Quality Assurance
measure progress. ● Quality Assurance (QA) focuses on
● Comparing Data with maintaining standards and detecting
ExpectedOutcomes - Checking if errors in nursing care. It is often
interventions achieved the SMART retrospective.
goals. ● Quality Improvement (QI) is a
● Analyzing Factors Affecting Outcome continuous, proactive approach. A
Achievement - Determining if continuous proactive process that seeks
complications, noncompliance, or to enhance efficiency errors, and
external factors (eg., financial improve client outcomes.
constraints) influenced results. QA ensures compliance, while QI focuses on
● Modifying or Continuing the Care progressive enhancement of care delivery.
Plan- If goals are unmet, nurses adjust FUNDAMENTALS OF NURSING
interventions or redefine the expected PRACTICE
outcomes -Concepts, Process, and Practice
● Documenting Evaluation Findings - EHR- Electronic Health Record
Recording progress ensures continuity 2 Documentation Method:
of care and helps in decision-making. ● Source-Oriented
● Problem-Oriented
2 Types of Report: ● I: Administered analgesics and
-ISBAR (Identify, Situation, Background, repositioned patient.
Assessment, Recommendation) ● E: Patient reports pain reduced from
-After-shift report 8/10 to 3/10.
Law of privacy in US: HIPAA (Health .Focus Charting (DAR - Data, Action,
Insurance Portability and Accountability Act) Response)
DOCUMENTATION AND REPORTS Example:
1. Maintaining Confidentiality and Security ● D: Patient reports nausea.
of Computerized Client Records ● A: Administered prescribed antiemetic.
● Use secure passwords ● R: Nausea subsided after 30 minutes.
● Log out after documentation Charting by Exception (CBE)
● Access only necessary information • Only abnormal findings or deviations are
● Follow hospital policies on record documented.
retention and disposal • Example: A normal respiratory assessment is
● Utilize encrypted devices not recorded, but labored breathing is.
● Report breaches immediately • Computerized Records
2. Purposes of Client Records • Allows real-time documentation and
● Communication integration with other healthcare systems.
● Legal Documentation 4. Forms Used in Client Records and the
● Reimbursement Nursing Process
● Education ● Critical Pathways-
● Research ● Care Plans-interventions, rationale,
● Quality Improvement evaluation.
3. Comparison of Documentation Methods ● Kardexes- Endorsement purposes,
Source-Oriented Medical Records (SOMR)- summary of patient’s chart, one page
Each discipline (nursing, medicine, pharmacy) back to back paper, relate and seen by
has its section in the chart. the doctor
pros- information easy to find with in specific ● Flow Sheets- individual notes Ex. vitals,
discipline intake/output IV with time taken.
cons- fragmented view of patients progress ● Progress Notes- FDAR
Problem-Oriented Medical Records (POMR)- ● Discharge & Transfer Forms- final
Organized around patient problems using SOAP diagnosis, when patient is about to be
(Subjective, Objective, Assessment, Plan). discharged
Example: A client admitted for pneumonia has 5. Documentation in Different Healthcare
documentation structured as: Settings
S: "I have difficulty breathing." ● Acute Care: Detailed, frequent
O: RR = 28, SpO2= 89%, crackles in lungs. documentation due to rapid patient
A: Impaired gas exchange. changes. ICU, records real time changes
P: Administer oxygen therapy and monitor ABG ● Long-Term Care: Periodic
levels. documentation with a focus on
PIE Charting (Problem, Intervention, functional status, nursing homes,
Evaluation) outpatient care, weekly documents
Example: ● Home Healthcare: Requires detailed
● P: Acute pain due to surgery. reports for continuity across caregivers.
6. Guidelines for Effective Recording ● Father of microbiology
● Be objective and precise - never alter Who was Joseph Lister?
records ● Lister(1827-1912) was the first to
● Use correct spelling and grammar realise that Pasteur's Germ Theory had
● Chart promptly - Means you chart the Implications for surgery.
medication after you use ● He realised the need to kill the germs in
● Do not erase or alter records the operating theatre.
7. Prohibited Abbreviations, Acronyms, and ● He developed Antiseptic
Symbols Surgery(concept of asepsis) and the
Some abbreviations cause errors and are banned results were dramatic.
(e.g., JCAHO's "Do Not Use" list: ● Lister tested the results of spraying
● U (Unit) → Write "Unit" to avoid carbolic acid on instruments, the
confusion with "0" or "4." surgical incisions, and dressings with a
● IU (International Unit) → Write solution of it.
"International Unit" to prevent ● It was clear to surgeons that removing
misreading as "IV." germs from operating theatres was
● QD (Daily) → Write "Daily" to avoid crucial to lowering death rates.
confusion with QID (four times a day). ● 90-95% isopropyl alcohol
8. Guidelines for Reporting Client Data Ignaz Semmelweis (1818-1865) and Oliver
● Face-to-face handoffs: Ensure critical Wendell Holmes (1809-1894)
information is communicated. ● Demonstrated that puerperal fever was
● ISBAR (Identify, Situation, carried from patient to patient by
Background, Assessment, doctors.
Recommendation): Structured ● Promoted handwashing as a means of
communication during shift reports. reducing the spread of Puerperal fever to
● Emergency Reporting: Notify women in childbirth
physicians immediately of Who was William Halsted?
life-threatening changes. ● Halsted(1852-1922) emphasised the
ASEPSIS, INFECTION CONTROL & need to wear hats, gloves, masks and
SAFETY (Sir Baltazar) protective clothing to limit germs in the
● Asepsis is the state of being free from operating environment.
disease-causing contaminants (such as STAGES OF INFECTIOUS DISEASE
bacteria, viruses, fungi, and parasites) PROCESS
or, preventing contact with INFECTIOUS DISEASE PROCESS
microorganisms. STAGE 1: INCUBATION PERIOD
● The term asepsis often refers to those extends from the entry of microorganisms into
practices used to promote or induce the body to the onset of signs and symptoms.
asepsis in an operative field in surgery types of dengue: Aedes aegypti,
or medicine to prevent infection. Aedes albopictus,Aedes polynesiensis
History Aedes niveus.
● Louis Pasteur (1822-1895) proposed STAGE 2: PRODROMAL PERIOD
germ cell theory of disease. extends from the onset of non-specific signs and
● He stated that disease is caused by symptoms to the appearance of specific signs
germs - microorganisms. and symptoms.
STAGE 3: ILLNESS PERIOD MODE OF TRANSMISSION OR ROUTE
- specific signs and symptoms develop and OF TRANSMISSION
become evident. CONTACT, DROPLET, VEHICLE,
STAGE 4: CONVALESCENT PERIOD AIRBORNE, VECTOR-BORNE( animals)
- signs and symptoms start to abate until the TRANSMISSION
client returns to normal state of health. PORTAL OF ENTRY
THE CHAIN OF INFECTION Pathogens can enter susceptible hosts through
body orifices such as the mouth, nose, ears,
eyes, vagina, rectum or urethra. Breaks in the
skin or mucous membranes from wounds or
abrasions increase the chance of organisms to
enter hosts.
SUSCEPTIBLE HOST
A host is a person who is at risk for infection,
whose own body defense mechanisms, when
exposed, are not able to withstand the invasion
Infectious agent/Pathogen- Ex. dengue of pathogens. Example: elderly, malnourished
Reservoir- Source,Mosquito children, chronically ill, those with trauma or
Portal of exit- Mosquito saliva during bite surgery.
Means of transmission- Bite of infected ROUTES OR MODES OF TRANSMISSION
mosquito DIRECT CONTACT TRANSMISSION
Portal of entry-skin, blood stream - involves immediate and direct transfer from
Susceptible host- People in dengue prone areas person to person (body surface to body surface).
PATHOGEN CAUSATIVE/ ETIOLOGIC/ - Example: health care personnel to clients
INFECTIOUS AGENT during bathing, dressing changes, insertion of
These may be bacteria, virus, fungi or parasites tubes and catheters, direct transfer between two
that may cause disease depending on its clients with one acting as the source and the
pathogenicity, virulence, invasiveness and other as host.
specificity. INDIRECT CONTACT TRANSMISSION
RESERVOIR (SOURCE) HUMANS - occurs when a susceptible host is exposed to a
(clients, visitors, health care personnel) contaminated object such as dressing, needle,
ANIMALS (insects, rats, etc) PLANTS surgical instrument.
GENERAL ENVIRONMENT (air, water, food - REMEMBER: Contact transmission of
soil) infectious organisms on the hands of caregivers
PORTAL OF EXIT is the most frequent mode of transmission in
RESPIRATORY TRACT: droplets, sputum health care facilities.
GI TRACT: vomitus, feces, saliva, drainage DROPLET TRANSMISSION
tubes URINARY TRACT: urine, urethral - this maybe considered as a type of contact
catheters REPRODUCTIVE TRACT: semen, transmission
vaginal discharge BLOOD: open wound, needle - It occurs when mucous membranes of the nose,
puncture site mouth or conjunctiva are exposed to secretions
of an infected person who Is coughing, sneezing,
laughing, or talking, usually within a distance of
3 feet.
VEHICLE TRANSMISSION TYPES OF IMMUNIZATION
- this involves the transfer of microorganisms by ACTIVE
way of vehicles or contaminated items that Antibodies are produced by the body in response
transmit pathogens. to infection.
- Examples: food, water, milk, blood, eating PASSIVE
utensils, pillows, mattress. Antibodies are produced by another source such
AIRBORNE TRANSMISSION as animal or human.
- this occurs when fine particles are suspended ACTIVE IMMUNIZATION
in the air for a long time or when dust particles NATURAL
contain pathogens. Antibodies are formed in the presence of active
- Air current disperses microorganisms, which infection in the body. It is lifelong.
can be inhaled or deposited in the skin of a Example. mumps/chicken pox
susceptible host. ARTIFICIAL
VECTOR-BORNE TRANSMISSION Antigens (vaccines or toxoids) are administered
- vectors can be biologic or mechanical. to stimulate antibody production. Requires
- Biologic vectors are animals like rats, snalls, booster inoculation after many years.
mosquitos. Example TT, OPV
- Mechanical vectors are inanimate objects that PASSIVE IMMUNIZATION
are infected with infected body fluids like NATURAL
contaminated needles and syringes. Antibodies are transferred from the mother to
FACTORS INFLUENCING THE HOST'S her newborn through the placenta or in the
SUSCEPTIBILITY colostrum.
● Intact skin and mucous membranes are ARTIFICIAL
the body's first line of defense. from vaccination and hemoglobin
● The normal pH levels of secretions and Immune serum (antibody) from an animal or
of the genito-urinary tract help ward off another human is
microbial invasion. Injected to a person.
Water ph- 7 Example: HTIG
Stomach ph- 3 Types of antibodies
Urine ph- 6-6.5 IgA, IgD, IgE, IgG, and IgM
● The body's WBC influence resistance to
certain pathogens.
● Age, sex and race have shown to
influence susceptibility.
● Immunization acts to resist infection. -
NATURAL & ACQUIRED
● Fatigue, climate, general health status,
presence of pre-existing illness,
previous/current treatments and some
kinds of medications may play a part in
the susceptibility of a potential hosts.
