FUNDAMENTALS OF NURSING PRACTICE

MID-TERM COVERAGE

Therapeutic Relationship:
 is directed towards helping a patient heal, both physically and
emotionally.
 it is a professional relationship between a nurse, physician or
therapist and a client. ,
 it is focused on helping the patient solve problems and achieve
certain well –defined, mutually agree upon, health-related goals.
 it is a means for more smoothly implementing the five steps of
the nursing process; assessing, making a nursing diagnosis,
planning, implementing the
 plan and evaluating the client’s progress.
 The foundation of a therapeutic relationship is ---- therapeutic
communication.
 Therapeutic communication ---- is goal oriented and essentially
considers culture of clients, explore the life experiences, value
and belief systems and reactions to illness and treatment.
 RAPPORT ---- implies special feeling on the part of both the client
and nurse based on acceptance, warmth, friendliness, common
interest and sense of trust and non judgmental attitude.
 To establish rapport is to create a sense of harmony based on
knowledge and appreciation of each individual’s uniqueness.
 to trust another, one must feel confident in that person’s
presence, reliability, integrity, veracity and sincere desire to
provide assistance when requested.
 Therapeutic Nurse patient relationship --- is a result of series of
interactions between the nurse and the patient over a period of
time with the nurse focusing on need and problem of patient and
his family while using the scientific knowledge and specific skills of
nursing profession.
Phases of Therapeutic Nurse- patient Relationship
1. Pre interaction Phase --- during this phase of relationship
, you will need to learn as much as possible about your client,
including reasons reason to seeking care;
begin your assessment by;
 review the clients medical record and nursing notes
 note the clients history of previous hospitalization , as well
as any procedures that he had undergone in the past.
 note the symptoms that brought the client in the clinic or
hospital
 speak with other health care providers who may have, ,
cared for the client, inquire about the client’s cultural
background and emotional state, and the client’s ability to
comprehend his disorder and its treatment.
2. Orientation Phase ------ during this orientation phase , you need
to continue gathering information about your client’s history and
current problem. this is also the time to;
a. perform physical, psychosocial and cultural assessment
b. formulate patient outcomes
c. plan interventions
 throughout the orientation phase, it is important to show the
client respect and to establish trust and rapport.
3. Working phase ----- as soon and the client have established a
therapeutic relationship , the working phase begins.
 you begin by;
a. assess the person’s concerns, strengths and weaknesses
b. establish a contract with the client regarding expectations and
responsibilities.
c. decide on mutually agreed upon goals
d. establish a plan of action that satisfies you and the client
e. set limits
f. discuss the time frame for your relationship. during this phase,
continue to establish rapport and build trust. in doing so,
encourage the client to speak openly about feelings, fears and
regrets.
4. Termination phase----- a therapeutic relationship may be
terminated for a variety of reasons: the client may be discharge,
the nurse or nursing student may change services, or the client’s
goals may be met. regardless of the reason for termination, it
should not come as a surprise to the client.
Ingredients of Therapeutic Communication:
1. Empathy ----- is the ability to enter into another person’s
experience to perceive it accurately and to understand how
situation is viewed from the client’s perspective…. this is done ,
through reflective or active listening,
simple actions such as touch, kindness, attentiveness and
information sharing also signify empathy.
2. Positive regard ----- senserefers to warmth, caring, interest and
respect for the person, seeing the person unconditionally or non-
judgmentally.
positive regard ---- does not mean that the nurse accepts all
aspects of a person’s behavior, the nurse does not condone or
encourage behavior that is socially inappropriate or abusive.
however the nurse must separate that behavior from the person,
 with the assumption is the person is worthwhile and has value
and dignity.
positive regard means that the professional avoids unnecessary
labeling of clients. the focus of healthcare professionals on
disease tends to label the client as an object (e.g. a diabetic, an
amputee, an alcoholic). as a result, viewing a client as his or her
disease rather than as someone who has that
disease can interfere with seeing the person behind the label.
3. comfortable sense of self ------
 the nurse with comfortable sense of self can evaluate his /her
strength and weaknesses. example… I work well with postop
clients, but I have less
 aptitude for working with rehabilitation clients because I like
things to happen more quickly. or another nurse might enjoy
working with psychiatric clients because he/she find working on
interpersonal goals rewarding.

Communication Techniques
Therapeutic Techniques:
1. using silence
2. accepting
 yes
 uhmm
 nodding
 I follow what you said
 yes------ that must have been difficult for you
3. giving recognition
 Good morning ms. smith
I noticed that you’ve combed your hair
4.offering self
 I’’ll it with you for a while
 I’ll stay here with you
 I’m interested in your comfort
 I’ll walk with you…
5.Give broad openings
 Is there something you’d like to talk about?




 this can be a good way to allow an opportunity to discuss what’s
on your mind.
 what are you thinking about?
 I notice that you’re Where would you like to begin?
6. Offering general leads
 Go on….
 and then?
 tell me about it
 you were saying
7. making observations
 you appear tense
 I notice that you are biting your lip
 it makes me uncomfortable when you.
5. encouraging descriptions of perception
 it can be helpful to ask about the client in an encouraging and
non-judgmental way. phrases like “What does that look like to
 you? give patients a prompt to explain what they are perceiving
without casting their perceptions in a negative light.
6. Encouraging comparisons ----- often, patients can draw upon
experience to deal with current problems, by e them to make
comparisons, nurses can help patients discover solutions to their
problems.
7. Summarizing ----- it is frequently useful for nurses to summarize
what patients have said after the fact. this demonstrates to
patients that the nurse was listening and allows the nurses to
document conversations. like “Does the sound correct? give
patients explicit permission to make corrections if they are
necessary.

COM
MUNICATION IN NURSING:
Intro:
Communication ------- is a process to which people affect one
another through exchange of information, ideas and feelings.
 as a member of the health team, nurses need to communicate
information through discussion, reports and records.
 documentation /recording is vital in nursing practice.
 generally, health personnel communicate through discussion,
reports and records. reports include both oral and written
exchange of information between caregivers. at the end of the
duty in the hospital nurses give both verbal and written reports
to the next shift.
 there is a well known adage “if you give a man a fish, you feed
him for a day, but if you teach a man how to fish you feed him for
a lifetime. this signifies the importance of client education.
  the teaching and learning process empowers clients and usually
enable them to achieve a higher level of wellness or to manage
specific health care needs.
Modes of Communication:
1. verbal communication ----- uses spoken or written words.
2. non verbal communication ----- uses gestures, facial expression,
posture /gait, body movements, physical appearance , eye
contact, body language and tone of voice.

Characteristics of Communication:
1. Simplicity ----- includes use of commonly understood words,
brevity and completeness.
2. clarity ---- involve saying exactly what is meant. the nurse also
needs to speak slowly and enunciate words well. repeat the
message as needed, reduce distractions.
3. timing and relevance ---- require choice of appropriate time and
consideration of the client’s interests and concerns. ask one
question at a time, wait for an answer before making any
comment.
4. adaptability ------ involves adjustment on what the nurse says and
how it is said depending on moods and behavior of the client.
5. credibility ------ means worthiness of belief. to become credible,
the nurse
6. requires adequate or accurate information, to convey confidence
and certainty in what he says.

Components of communication:

sender -------- message ------- receiver

----response/feedback
encoder decoder
communication ---- is a basic component of human relationships
and nurse-client relationship.
  non- verbal communication ---- is a more accurate expression of a
person’s thoughts and feelings than verbal communication.
Documenting and Reporting:
 documentation ----- serves ass a permanent record of client
information and care.
 reporting ---- takes place when two or more people share
information about client care, either face to face or by telephone.

Purposes of client’s Record/Chart

1. communication ----- provides efficient and effective method of
sharing information. it allows to convey meaningful data about
the client.
2. legal documentation ----- it is admissible as evidence in a court of
law.
3. research ---- provides valuable healthy related data for research.
4. statistics ---- provides statistical information that can be utilized
for planning
5. people’s future needs.
6. education ---- serves as an educational tool for students in health
discipline.
7. audit and quality assurance ---- monitors the quality of care
received by the client and the competence of health care givers.
8. planning client care ---- provides data which the entire health
team uses to plan care for the client.
9. reimbursement ---- provides the basis for decisions regarding care
to be provided and subsequent reimbursement to the agency.

Types of Record:
A. Source oriented medical record (traditional client record)
 each person or department makes notations in a separate
section/s of the client’s chart.
 Five basic components of the traditional client record.
1. admission sheet
 2. physician’s order sheet
3. medical history
4. nurses notes
special records and report (referrals. x-ray reports, laboratory
findings, report of surgery, anesthesia record, flow sheets, vital
signs, I& O, mediations.
B. Problem-oriented medical record (POMR or POR)
1. database….. contains all the initial information about the client.
2. problem list ….. contains all the aspects of the person’s life
requiring
3. initial list of orders or care plans
4. progress notes:

 nurse’s or narrative notes (SOAPIE format)

S ------- subjective data
O ------- objective data
A ------- assessment
P ------- planning
I -------- intervention
E -------- evaluation

 flow sheets (data that are monitored)

 discharge notes or referral summaries

Kardex
 provides a concise method of organizing and recording data about
a client, making information readily accessible to all members of
the health team.

 it is a series of flip cards usually kept in portable file.

 it is a way to ensure continuity of care from one shift to another

and from one day to the next.

 it is a tool for change – of ---- shift report, but endorsement is not

simply reciting content of kardex. the health care needs of the
client is still primary basis for endorsement.

 kardex usually includes the following data;

1. personal data (demographic data)
2. basic needs
3. allergies
4. diagnostic tests
5. daily nursing procedures
6. medications and intravenous therapy, blood transfusions,
7. treatments like oxygen supply, steam inhalation, suctioning,
change of dress, mechanical ventilation.

 entries are usually in pencil so that they can be changed as clients

condition changes. this implies the kardex is for planning and
communication purposes only.
Characteristics of Good Recording
1. Brevity ----
 a. entries are concise
b. complete sentences are required
c. start each entry with a capital letter and end the entry with
a period even if the entry is a single word or phrase.
2. use of ink/permanence

 avoid felt pen or pencil for permanence of data, because the

client’s chart can be used as an evidence in a legal court.
3. Accuracy

 chart objective facts, not your interpretations or opinions.

 e.g

 correct: ate 50% of the food served

 incorrect: ate with poor appetite

 correct: refused medications

 incorrect: uncooperative

 correct seen crying:

 incorrect : depressed

*place complaint of the client in quotation marks to indicate that it is

his statement.
* e.g complained of “ chest pain radiating down the left arm”
* objective data are also to be charted
* e.g. skin cold and clammy. diaphoretic, prefers to sit up. vital signs
taken as follows Temp =37.6 C, PR = 110/min, RR -26, BP =
146/90mmHg.
* describe behaviors rather than feelings to allow other health team
members to determine the actual problems of the client.

4. Appropriateness

 only information that pertain to the client’s health problems and

care are recorded.

 any other personal information that is conveyed to the nurse is

inappropriate for the record.
5…completeness and chronology/organizations/sequence/timing

 notes should appear on each succeeding line

 continuous charting is done for each entry unless a time change

occurs. no need for a new line for each new idea or entry.

 date is entered in the date column on the first line of every page
of nurses notes and whenever t he date changes.

 time is entered in the time column whenever a new time entry

occur

 avoid time changes in the text of the nurses notes.

 avoid double chart. , if something appears on a particular sheet, it

does not need to appear on the nurses notes, unless there is
alteration from the normal e.g body temperature, blood pressure.
  avoid squeezing information into a space because you forgot to
chart earlier. add the information on the first available line. write
the time the event occurred, not the time you entered the
information.
The following information should be charted:

 the physician’s visit

 times the patient leaves and returns to the unit, mode of

transportation and destination.

 medications should be charted immediately after given.

 treatments should be charted immediately after given

6. use of standard terminology

 use only those abbreviations and symbols approved by the

institution; spell correctly; use proper grammar.
7. Signed

 affix signature, place at the end of the charting at the right hand
margin of the nurses notes.

 sign each entry with your full name and status, e.g SN for student
nurses, RN for registered nurses

 Script not printing is used for the signature.

8. in case of ERROR

 y have done, observed, hearedcorrect errors by drawing a

single (horizontal) line through the error.

 write the word error above the line, then sign your
signature
  no ink eradication, erasures or use of occlusive materials

 E.g ERROR JU
Pulse 180 beats/min 108 beats/min.
9. confidentiality ----- only the health personnel who participate in
the care of the client are allowed to read the chart.
10. legal awareness

 chart only what you personally have done, observed,

heard, smelled or felt

 do not discard any part of the client record.

11. legible

 writing must be clear and easily read by others

 if writing is not legible, then print

12. Do not use the word patient or pt. in the chart; the chart
belongs to the patient. all information in the chart pertain to
the patient.
13. A horizontal line drawn to fill up a partial line. this is to
prevent other persons from adding information in the nurses
notes.
Q. e.g ------------------ Josie Q. Roldan, RN

Reporting:
Types of Reporting
1. change of shift reports or endorsements
 a. for continuity of care
b. it is based on health care needs of the client
c. it is not mere reciting the content of the kardex

2. telephone reports
a. provide clear, accurate, and concise information
b. the nurse documents telephone report by including the
following information,
1. when the call was made
2. who made the call/report
3. who was called
4. to whom information was given
5. what information was given
6. what information was received
3. telephone orders
a. only RNs may receive telephone orders
b. the order needs to be verified by reporting it clearly and
precisely.
c. the order should be countersigned by the physician who made
the order within prescribed period of time (within 24 hours)
4. transfer reports
 a. this is done when transferring a client from one unit to
another.

Commonly used abbreviations:

Abbreviations Latin English
a.c. ante cebum before meals
ad Lib. ad libum as desired
ADL activities of daily
living
Ax. axillary
Bid Bis in die twice a day
BMR basal metabolic
rate
BP Blood Pressure
c.c cum with
Cap capsula capsule
Gtt gutta drop
h.s. hora somni hours of sleep
IM intramuscular
IV intravenous
mcgtt microdrop
Od omni die once a day
OD oculos dexter right eye
o.m. omni mane every morning
OS oculus sinister left eye
OU oculus uterque both eyes
p.c. post cebum after meals
p.o. per orem by mouth
p.r.n. pro re nata as necessary
q.h. quaque hora every hour
q.i.d. quarter in die 4 times a day
s.s sine without
s.c. sub cutem subcutaneous
ss. semis one half
stat statim immediately
Tid ter in die thrice a day