FUNDAMENTALS IN NURSING- MIDTERM REVIEWER • End-of-life care conducted in many

settings including the home

CHAPTER 5- HEALTHCARE DELIVERY SYSTEM Types of Healthcare Agencies and Services
• Different settings for different healthcare
• Healthcare system agencies
– Totality of services provided by all Public Health
health disciplines • Local health departments develop programs
Types of Healthcare Services to meet the health needs of the people,
• Categorized by type and level providing necessary nursing and staff to carry
– Primary prevention out these programs, continue evaluating the
▪ Health promotion, illness effectiveness of the program, and monitoring
prevention changing needs.
– Secondary prevention • Public Health Service (PHS) of the U.S.
▪ Diagnosis, treatment Department of Health and Human Services
– Tertiary prevention • National Institutes of Health (NIH)
▪ Rehabilitation, health • Centers for Disease Control and Prevention
restoration, palliative care (CDC)
Primary Prevention: Health Promotion and Illness Physicians' Offices
Prevention • Family practice physicians, specialists
• Healthy People 2030 goals • Routine health screening, illness diagnosis,
– Increase quality and years of healthy and treatment
life • NPs more common than RNs in this setting
– Achieve health equity and eliminate Ambulatory Care Centers
health disparities • Diagnostic treatment facilities
– Create healthy environment for • Minor surgery
everyone Occupational Health Clinics
– Promote health and quality life across • Run by companies for employees
the life span • Health promotion activities
– Engage leadership, key constituents, Hospitals
and public to design policies that • Acute inpatient services
improve health and well-being • Outpatient and ambulatory care
• Address adequate and proper nutrition, • Emergency department
weight control and exercise, and stress • Hospice care
reduction Subacute Care Facilities
• Emphasize the important role clients play in • Variation of inpatient care
maintaining their own health and encourage • Technically complex treatments
them to maintain the highest level of wellness Extended (Long-Term) Care Facilities
they can achieve • Formerly called nursing homes
Secondary Prevention: Diagnosis and Treatment • Independent living
• Hospitals • Assisted, skilled, extended care facilities
– Emergency care • Rehabilitation
– Intensive care • Custodial care
– Around-the-clock care • Insurance criteria, treatment needs, and
• Health promotion services nursing care requirements must all be
– Early detection assessed before admittance
– Routine screening Retirement and Assisted Living Centers
Tertiary Prevention: Rehabilitation, Health • For clients unable to stay at home, but do not
Restoration, and Palliative Care require hospital or nursing home
• Restoration to previous level of health or • Relative independence
highest level possible, given current health Rehabilitation Centers
status • Restore or recuperate health
• Rehabilitation to function adequately in the • Drug and alcohol
physical, mental, social, economic, and Home Healthcare Agencies
vocational areas of their lives • Education to clients and families
• Outreach programs for mental health illness • Care to acute, chronic, or terminally ill
• Palliative care Day Care Centers
• Providing comfort and treatment • Infants or children
 • Adults who cannot be left at home • Administers pulmonary function tests
Rural Care Social Worker
• Federal funding • Counsels clients and support persons
• Services for rural residents regarding finances, marital difficulties,
• Office of Rural Health Programs in each state adoption of children
Crisis Centers Spiritual Support Personnel
• Emergency services for life crises • Chaplains, pastors, rabbis, priests, and other
• Counseling and support religious or spiritual advisers
Mutual Support and Self-Help Groups • Most volunteer
• Health problems Unlicensed Assistive Personnel
• Life crises • Assumes delegated aspects of basic client care
Nurse – Bathing, assisting with feeding,
• RN collecting specimens
• Licensed vocational nurse (LVN) Factors Affecting Healthcare Delivery
• Licensed practical nurse (LPN) • More knowledgeable healthcare consumers
Alternative (Complementary) Care Provider • Information and services related to health
• Practices not commonly part of Western promotion and illness prevention
medicine Increasing Number of Older Adults
Case Manager • By 2035, over 78 million adults over 65
• Ensures fiscally sound, appropriate care in the – Exceeds population under 18 for the
best setting first time
Dentist • Substantial home management, nursing
• Mouth, jaw, and dental problems support services required
Dietitian or Nutritionist • Community involvement
• Dietitian has knowledge about diets required Advances in Technology
to maintain health, treat disease. • New procedures, medications
• Nutritionist has knowledge about nutrition • Bedside charting and computers
and food; works in community. • Costly
Emergency Medical Personnel Economics
• Several categories of first-responder care, • Health spending predicted to reach $5.7
such as fire departments trillion by 2026
Occupational Therapist • Cost increases, mostly in equipment
• Assists clients with impaired functions to gain replacements and prescriptions
skills to perform ADLs Women's Health
Paramedical Technologist • Until recently, only reproductive focus
• Laboratory • Need for research that examines women
• Radiologic equally to men
• Nuclear medicine • Increased emphasis on psychosocial aspects
Pharmacist of women's health
• Prepares, dispenses pharmaceuticals in Uneven Distribution of Services
hospital and community settings • Increased specialization
Physical Therapist – Fragmentation, higher cost of care
• Assists clients with musculoskeletal problems • Lowest number of nurses in Southwest U.S.
Physician • Remote, rural locations
• Responsible for medical diagnosis, Access to Health Insurance
determining therapy • Those without insurance diagnosed later in
• Primary care or specialists illnesses
• Allopathic, osteopathic • Those with greatest need for care often least
Physician Assistant able to pay for it
• Performs certain tasks under direction of The Homeless and the Poor
physician • General poor health exacerbated
• May have similar job description to NP • Lack of convenient, timely transportation
Podiatrist Health Insurance Portability and Accountability Act
• Diagnoses, treats foot and ankle conditions • Regulations to protect privacy of individuals
Respiratory Therapist including electronic health records
• Knowledgeable about oxygen therapy • Clients provided with notice
devices, accessory devices
Demographic Changes • Medicare and Medicaid
• Increasing alternative family structures – Medicare
• Cultural, ethnic diversity ▪ For adults over 65
Frameworks for Care ▪ Part A provides
• Evolved from the need to decrease costs and hospitalization, home care,
improve limited physical resources hospice.
• More than one configuration for any ▪ Part B provides partial
particular agency outpatient and physician
Case Management services (voluntary).
• Range of models for integrating healthcare ▪ Part D prescription plan
services (voluntary)
• Critical pathways ▪ Coinsurance and deductible
– Plan that tracks client's progress ▪ Does not cover dental,
Differentiated Practice eyeglasses, hearing aids, etc.
• Best possible use of nursing personnel based ▪ Federal financial assistance
on education and skill sets – Those with low
• Customized within each institution incomes
Case Method ▪ Each state is distinct.
• Total care • Supplemental Security Income
• One nurse responsible for comprehensive – SSI benefits people with disabilities.
care of a group during an 8- or 12-hour shift – For those not eligible for Social
Team Nursing Security
• Group of providers led by a professional nurse • Children's Health Insurance Program (CHIP)
(RN) – Insurance coverage for poor and
• RNs, LPNs, and UAPs working class children
Primary Nursing – Includes primary care, prescriptions,
• One nurse responsible for overseeing total hospitalization
care of client(s) 24/7 even if care is not all • Women, Infants, and Children Program
delivered personally – Nutritional foods to supplement diets
• Technical knowledge and management – Information on healthy eating
Financing Healthcare – Referrals to healthcare
• Cost containment efforts include health • Mothers and children up to
promotion/illness prevention activities, age 5
managed care, alternative insurance systems. • Prospective Payment System
• Affordable Care Act (ACA) – Limits amount paid to hospitals that
– Controversial and very complex are reimbursed by Medicare
– Individuals will be fined if they do not – Diagnosis-related groups (DRGs)
have health insurance. Insurance Plans
– Expanded Medicaid eligibility • Private Insurance
– American Health Benefit Exchanges – Not-for-profit and for-profit
– Small Business Health Options – Most often pay 80% of costs
Program – Third-party reimbursement
– Extended coverage for children in • Group Plans
modified private plans – Provide blanket medical service in
– Nonprofit Patient-Centered Outcomes exchange for monthly payment
Research Institute • Group Plans
– National Prevention, Health – Health maintenance organizations
Promotion, Public Health Councils (HMOs)
established • Emphasizes client wellness
Payment Sources in the United States • Limited selection of providers,
• Healthcare agencies receive funding from services
several available sources. • Reduced, predetermined
– Medicare costs
– Medicaid
– Private insurance
– Out-of-pocket
▪ Copayment
– Accountable care organizations
(ACOs)
• Provider reimbursements tied
to quality metrics, reductions
in total cost of care
– Preferred provider organizations
(PPOs)
• Choice of healthcare
providers, services
• Tend to be more expensive
than HMOs
– Preferred provider arrangements
(PPAs)
• Can be contracted with
individual healthcare
providers
• Can be limited or unlimited
– Independent practice associations
(IPAs)
• Clients pay fixed prospective
payment to IPA and IPA pays
provider.
– Physician/hospital organizations
(PHOs)
• Primary care providers and
specialists
• May be part of integrated
delivery system (IDS)
CHAPTER 10- ASSESSING Collecting Data
• Gathering information about client's health
• Nursing process status
– Systematic, rational method of • Must be systematic and continuous
planning and providing individualized • Past history and current problem
nursing care • Subjective or objective
– Purposes • Primary or secondary source
▪ Identify client's health status • Database
and actual or potential – Contains all information about a client
healthcare problems of needs Types of Data
▪ Establish plans to meet needs • Subjective data
▪ Deliver specific interventions – Symptoms or covert data
Overview of the Nursing Process – Apparent only to person affected
• Phases of the Nursing Process – Can be described only by person
– Assessing affected
– Diagnosing – Includes sensations, feelings, values,
– Planning beliefs, attitudes, and perception of
– Implementing personal health status and life
– Evaluating situations
– Sometimes included • Objective data
▪ Identifying outcomes, in – Signs or overt data
between diagnosing and – Detectable by an observer
planning – Can be measured or tested against an
– Each phase affects the others accepted standard
▪ Overlapping, continuing – Can be seen, heard, felt, or smelled
processes – Obtained through observation or
– Assessment still carried out during physical examination
implementing, evaluating phases Sources of Data
• Characteristics of the Nursing Process • Client
– Cyclic and dynamic rather than static – Best source unless too ill, young, or
– Client centered confused to communicate clearly
– Problem-solving and systems theory – Family members, significant others
– Decision making can be secondary source if client
– Interpersonal and collaborative cannot speak for themselves
– Universal applicability – Review HIPAA to be able to explain to
– Critical thinking skills patient in an understandable way
– Clinical reasoning skills • Support People
Assessing – Family members, friends, caregivers
• Systematic and continuous collection, – Person giving information may wish to
organization, validation, and documentation remain anonymous
of data (information) – Secondary subjective data
• 4 types of assessment • Person's interpretation of
– Initial nursing assessment client
– Problem-focused assessment – Secondary objective data
– Emergency assessment • May be something client
– Time-lapsed reassessment stated directly
• Data should be relevant to a particular health • Client Records
problem – Medical records
• The Joint Commission – Records of therapies
– Initial nursing assessment for each – Laboratory records
client – By reviewing, nurse can avoid
• History repeated questioning and concerns
• Physical examination about lack of communication among
• Performed and documented health professionals.
within 24 hours of admission • Healthcare Professionals
 – Important to ensure continuity of care • Yes/no
when clients transferred to and from • Factual
home and healthcare agencies • Less effort and
• Literature information from
– Standards or norms against which to client
compare findings • "What medications
– Current methodologies and research did you take?"
findings • "Are you having pain
Data Collection Methods now?"
• Observing – Types of interview questions
– Gathering data using the senses ▪ Open-ended questions
– Used to obtain following types of • Specify broad topic to
data: discuss
▪ Skin color (vision) • Invite longer answers
▪ Body or breath odors (smell) • Get more information
▪ Lung or heart sounds from client
(hearing) • Useful to change
▪ Skin temperature (touch) topics and elicit
• Interviewing attitudes
– Interview ▪ Neutral question
▪ Planned communication or a ▪ Leading question
conversation with a purpose – Planning the interview and setting
▪ Focused interview ▪ Time
• Nurse asks the client • Client free of pain
specific questions to • Limited interruptions
collect information ▪ Place
related to the client's • Private
problem. • Comfortable
– Used to: environment
▪ Get or give information • Limited distractions
▪ Identify problems of mutual – Planning the interview and setting
concern ▪ Seating arrangement
▪ Evaluate change • Hospital
▪ Teach • Office or clinic
▪ Provide support • Group
▪ Provide counseling or therapy ▪ Distance
– Directive interview • Comfortable
▪ Nurse establishes purpose – Planning the interview and setting
▪ Nurse controls the interview ▪ Language
▪ Used to gather and give • Use easily understood
information when time is terms
limited, e.g., in an emergency • Interpreter or
– Nondirective interview translator
▪ Rapport – Stages of an interview
• Understanding ▪ The opening
between two or more • Establish rapport
people • Orient client
▪ Client controls the purpose, ▪ The body
subject matter, and pacing. • Client communicates.
▪ Combination of directive and • Nurse asks questions.
nondirective approaches is ▪ The closing
usually appropriate during • Nurse ends interview
information-gathering when necessary
interview. information is
– Types of interview questions collected.
▪ Closed questions • Examining
• Restrictive – Systematic data-collection method
 – Uses observation and inspection, • Subjective, objective data that
auscultation, palpation, and can be directly observed by
percussion the nurse
– Vital signs, height and weight – Inferences
– Cephalocaudal approach • Nurse's interpretation based
▪ Head-to-toe progression on cues
– Screening examination • Avoid jumping to conclusions
▪ Review of systems Documenting Data
Organizing Data • Record client data
• Conceptual Models and Frameworks • Record in factual manner without stating
– Gordon's functional health pattern interpretations
framework • Record subjective data with quotes in client's
– Orem's self-care model own words
– Roy's adaptation model
• Wellness Models
– Assist clients to identify and explore
lifestyle habits and health behaviors,
beliefs, values, and attitudes
• Non-nursing Models
– Body systems model
• Integumentary, respiratory,
cardiovascular, nervous,
musculoskeletal,
gastrointestinal,
genitourinary, reproductive,
and immune systems
– Maslow's Hierarchy of Needs
• Physiological (survival) needs,
safety and security, love and
belonging, self-esteem, and
self-actualization
– Developmental theories
• Havighurst's age periods and
developmental tasks
• Freud's five stages of
development
– Developmental theories
• Erikson's eight stages of
development
• Piaget's phases of cognitive
development
• Kohlberg's stages of moral
development
Validating Data
• Validation
– The act of "double-checking,"
verifying data to confirm it is accurate
and factual
• Ensure that assessment information is
complete
• Ensure that objective and related subjective
data agree
• Obtain additional information that may have
been overlooked
• Differentiate between cues and inferences
– Cues
CHAPTER 11- DIAGNOSING Components of a Nursing Diagnosis
• Activities preceding the diagnosing phase are • Problem (Diagnostic Label) and Definition
directed toward forming the nursing – Describes the client's health problem
diagnoses. or response
• All other steps flow from nursing diagnoses. – May require specification
• Nurses use critical thinking skills to interpret – Qualifiers added to give additional
assessment data and identify client strengths meaning
and problems. ▪ Such as not sufficient, made
• North American Nursing Diagnosis Association worse, lesser in size, not
(NANDA) International producing the desired effect,
• Define, refine, and promote a vulnerable to threat
taxonomy of nursing diagnostic • Etiology (Related Factors and Risk Factors)
terminology – Identifies one or more probable
Nursing Diagnoses causes of the health problem
• Familiarity with definitions of terms used and – Gives direction to the required
components of nursing diagnoses is essential. nursing therapy
Definitions – Enables the nurse to individualize the
• Diagnosis client's care
– A statement or conclusion regarding • Defining Characteristics
the nature of a phenomenon – Cluster of existing signs and
• Diagnostic labels symptoms indicates actual diagnosis
– Standardized NANDA names for ▪ Clients have signs and
diagnoses symptoms.
• Etiology – Cluster of factors that cause client to
– Causal relationship between ad be more vulnerable to a problem
problem and its related factors indicates "risk for" diagnosis
• Nursing diagnosis ▪ No subjective or objective
– Problem statement consisting of data exist at present.
diagnostic label plus etiology ▪
• Nursing diagnosis Differentiating Nursing Diagnoses from Medical
– Professional nurses responsible for Diagnoses
making Nursing diagnosis
– Includes only those health states that – A statement of nursing judgment
nurses are educated and licensed to based on education, experience,
treat expertise and license to treat
– Judgment made only after thorough, – Describes human response, the
systematic data collection client's physical, sociocultural,
– Continuum of health states psychological, and spiritual responses
Status of the Nursing Diagnoses to an illness or health problem
• Actual nursing diagnosis – Changes when client's responses
– Problem presents at the time of change
assessment. – Independent functions
– Presence of associated signs and • Areas of healthcare that are
symptoms unique to nursing, separate
• Health promotion diagnosis and distinct from medical
– Preparedness to implement behaviors management
to improve their health condition Medical diagnosis
– Example: Readiness for Enhanced – Made by a physician
Nutrition – Refers to a disease process
• Risk nursing diagnosis – Remains the same as long as the
– Problem does not exist. disease process is present
– Presence of risk factors – Dependent functions (physician-
• Syndrome diagnosis prescribed therapies and treatments)
– Cluster of nursing diagnoses that have
similar interventions
Differentiating Nursing Diagnoses from Collaborative Formulating Diagnostic Statements
Problems • Basic Two-Part Statements
• Use both independent and dependent – Problem (P)
(physician-prescribed) interventions – Etiology (E)
• Require monitoring of client's condition and – Joined by the words "related to"
prevention of potential complications – Add words if NANDA label contains
• Occur when a particular disease or treatment the word Specify
is present • Basic Three-Part Statements
– PES format
The Diagnostic Process • Problem (P)
• Critical thinking • Etiology (E)
– Reviewing data and considering • Signs and symptoms (S)
explanations before forming opinions – Recommended for beginning
• Analysis diagnosticians
– Separation into components – List signs and symptoms grouped by
(deductive reasoning) subjective and objective data
• Synthesis • One-Part Statements
– Putting together of parts into whole – Health promotion diagnoses
(inductive reasoning) beginning with Readiness for
Enhanced
Analyzing Data – Seven syndrome diagnoses
• Comparing Data with Standards • Variations of Basic Formats
– Standard or norm – Unknown etiology
▪ Generally accepted measure, • Defining characteristics
rule, model, or pattern present but cause,
– Cue considered significant if: contributing factors unknown
▪ Points to negative, positive • Variations of Basic Formats
change in client's health – Complex factors
status or pattern • When too many etiologic
▪ Varies from norms of client factors to state briefly
population – Possible
▪ Indicates a developmental • Either problem or etiology
delay – Secondary to
• Clustering Cues • Divide etiology into two parts
– Determine relatedness of facts – Adding a second part to make it more
– Inductively or with a framework precise
• Identifying Gaps and Inconsistencies in Data • Indicate location, etc.
– Conflicting data • Collaborative Problems
– All inconsistencies must be clarified – Begin with Potential Complication (PC)
before a valid pattern can be – Etiology may be useful in some
established. situations.
• Evaluating the Quality of the Diagnostic
Identifying Health Problems, Risks, and Strengths Statement
• Determining Problems and Risks – Validate with client
– Problems that support tentative or – Compare signs and symptoms to
actual risks and possible diagnoses NANDA defining characteristics
– Determine whether problem is a
nursing diagnosis, medical diagnosis, Avoiding Errors in Diagnostic Reasoning
or collaborative problem • Verify data
– Resources and abilities to cope • Build a good knowledge base and acquire
– Can be an aid to mobilizing health and clinical experience
regenerative processes • Have a working knowledge of what is normal
– Can include home life, education, • Consult resources
recreation, exercise, work, family and • Base diagnoses on patterns rather than an
friends, religious beliefs, and sense of isolated incident
humor • Improve critical thinking skills
Ongoing Development of Nursing Diagnoses • Involves comprehensive and ongoing
• The first taxonomy was alphabetical. assessment
• Later version based on "human response Developing Nursing Care Plans
patterns" • Informal nursing care plan
• Taxonomy II has three levels. – A strategy for action that exists in
– Domains nurse's mind
– Classes • Formal nursing care plan
– Nursing diagnoses – Written or computerized guide
• Process for acceptance of new and modified • Standardized care plan
labels reviewed biannually – A formal plan that specifies actions for
• Development of standardized nursing a group of clients with common needs
language • Individualized care plan
– Includes NANDA nursing diagnoses – Tailored to meet the unique needs of
– Nursing interventions classification a specific client
– Nursing outcomes classification Standardized Approaches to Care Planning
• Nursing Minimum Data Set for computerized • Established to ensure minimal criteria for care
records are met
• Established for efficient use of time
• Standards of care
• Nursing actions for clients with similar
CHAPTER 12-PLANNING medical conditions
• Achievable rather than ideal nursing
• Planning care
– Deliberate, systematic, problem- • Interventions for which nurses are
solving phase of nursing process accountable
• Nursing interventions • Usually, there are agency records that
– Treatment that a nurse performs to may be referred to in client's care
enhance patient/client outcomes plan.
• Nurse responsible, but input from client • Written from the perspective of the
essential nurse's responsibilities
Types of Planning • Do not contain medical interventions
• Begins with first client contact • Standardized care plans
• Continues until nurse–client relationship ends • Kept with client's individualized care
(discharge) plan, then permanent medical record
• Is multidisciplinary • Provide detailed interventions
Initial Planning • Written in the nursing process format
• Develops initial comprehensive plan of care • Protocols
• Begun after initial assessment • Indicate actions commonly required
Ongoing Planning for a particular groups of clients
• Done by all nurses who work with the client • May include both primary care
• Individualization of initial care plan provider's orders and nursing
• At the beginning of a shift interventions
– Determine whether client's health • Example: Protocol for admitting a
status has changed client to the intensive care unit
– Set priorities for client's care during • Policies and procedures
shift • Developed to govern handling of
• At the beginning of a shift frequently occurring situations
– Decide which problems to focus on • Cover situations pertinent to client
during shift care
– Coordinate nurse's activities so that • Example: Policy specifying the number
more than one problem can be of visitors a client may have
addressed at each client contact • Standing order
Discharge Planning • Written document
• Process of anticipating and planning for needs • Policies
after discharge • Rules
• Addressed in each client's care plan • Regulations
• Begins at first client contact • Orders regarding patient care
 • Gives the nurse authority to carry out such as preferences about the times of care
specific actions under certain and methods used, are included.
circumstances 7. Ensure that the nursing plan incorporates
• Individualization of standardized care plans preventive and health maintenance aspects as
• Fit the unique needs of each client well as restorative ones
• Usually both pre authored and nurse- 8. Ensure that the plan contains ongoing
created sections assessment of the client
• For predictable, commonly occurring 9. Include collaborative and coordination
problems activities in the plan
• Individual plan for unusual problems 10. Include plans for the client's discharge and
or problems needing special attention home care needs
Formats for Nursing Care Plans The Planning Process
• Student Care Plans • Consists of the following activities:
– Rationale – Setting priorities
▪ Evidence-based principle – Establishing client goals/desired
given as the reason for outcomes
selecting a particular nursing – Selecting nursing interventions
intervention – Writing individualized nursing
– Concept maps interventions on care plans
▪ Visual tool in which ideas or
data are enclosed in circles or Setting Priorities
boxes with relationships • Establishing a preferential sequence for
indicated by lines or arrows addressing nursing diagnoses and
• Computerized Care Plans interventions
– Create and store nursing care plans – High priority (life-threatening)
– Can be accessed at a centrally located – Medium priority (health-threatening)
terminal at nurses' station or in – Low priority (developmental needs)
clients' rooms • Factors to consider
– Appropriate diagnoses selected from – Client's health values and beliefs
a menu suggested by the computer – Client's priorities
– Resources available to nurse and
Multidisciplinary (Collaborative) Care Plans client
• Also known as collaborative care plans or – Urgency of the health problem
critical pathways – Medical treatment plan
• Sequence care that must be given on each day Establishing Client Goals or Desired Outcomes
during projected length of stay for each • Goals
condition – Broad statements about the client's
• Usually organized with a column for each day status
listing interventions and outcomes for that • Desired outcomes
day – More specific, observable criteria
• Includes medical treatments to be performed used to evaluate whether goals have
by other providers been met
• The Nursing Outcomes Classification (NOC)
Guidelines for Writing Nursing Care Plans – Taxonomy for describing client
1. Date and sign the plan outcomes that respond to nursing
2. Use category headings interventions
3. Use standardized/approved medical or English – Outcomes broadly stated and
symbols and key words rather than complete conceptual
sentences to communicate your ideas unless – Made more specific by identifying
agency policy dictates otherwise indicators that apply to a particular
4. Be specific client
5. Refer to procedure books or other sources of • Stated in neutral terms
information rather than including all the steps • Each outcome includes a five-
on a written care plan point scale to rate the client's
6. Tailor the plan to the unique characteristics of status.
the client by ensuring that the client's choices, – To write a desired outcome using NOC
taxonomy, indicate:
 • Label – Derive from only one nursing
• Indicators that apply to client diagnosis
• Initial client status – Use observable, measurable terms
• Location on the measuring – Make sure client considers goals
scale desired for each important
indicator Selecting Nursing Interventions and Activities
– Can be stated in traditional (lay) • Actions nurse performs to achieve goals
language • Focus on eliminating or reducing etiology of
• Purpose of Desired Goals or Outcomes nursing diagnosis
– Provide direction for planning • Treat signs and symptoms and defining
interventions characteristics
– Serve as criteria for evaluating • Interventions for risk nursing diagnoses
progress should focus on reducing client's risk factors
– Enable the client and the nurse to • Types of Nursing Interventions
determine when the problem has – Independent interventions
been resolved • Activities nurses are licensed
– Help motivate the client and nurse by to initiate (i.e., physical care,
providing a sense of achievement ongoing assessment)
• Short-Term and Long-Term Goals – Dependent interventions
– By the end of the week or in over the • Activities carried out under
course of many weeks primary care provider's orders
– Short-term goals useful for clients or supervision, or according
who: to specified routines
• Require healthcare for a short • Types of Nursing Interventions
time – Collaborative interventions
• Are frustrated by long-term • Actions nurse carries out in
goals that seem difficult to collaboration with other
attain health team members
• Need the satisfaction of • Reflect overlapping
achieving a short-term goal responsibilities of healthcare
• Relationship of Goals or Desired Outcomes to team
Nursing Diagnoses • Considering the Consequences of Each
– Goals derived from diagnostic label Intervention
– Diagnostic label contains the – Choose those that are most likely to
unhealthy response (problem) achieve the desired client outcomes'
– Safe and appropriate for the client's – Requires nursing knowledge and
age, health, and condition experience
– Goal is opposite, healthy response. • Criteria for Choosing Nursing Interventions
– How client will look or behave if – Safe and appropriate for the client's
health response is achieved age, health, and condition
(observable, time-limited) – Achievable with the resources
– Achieving goal demonstrates available
resolution of the problem – Congruent with the client's values,
• Components of Goal or Desired Outcome beliefs, and culture
Statements – Congruent with other therapies
– Subject – Based on nursing knowledge and
– Verb experience or knowledge from
– Conditions or modifiers relevant sciences
– Criterion of desired performance – Within established standards of care
• Guidelines for Writing Goals or Desired
Outcomes
– Write in terms of client responses
– Must be realistic Writing Individualized Nursing Interventions
– Ensure compatibility with therapies of • Date when they are written
other professionals • Verb
• Guidelines for Writing Goals or Desired – Action verb starts the interventions
Outcomes and must be precise.
 • Conditions CHAPTER 13-IMPLEMENTING AND EVALUATING
• Modifiers • Nursing process
• Time element – Action oriented
– How long or how often the nursing – Client centered
action is to occur – Outcome directed
• Relationship of Nursing Interventions to • Clients and support persons encouraged to
Problem Status participate as much as possible
– Observations Implementing
– Prevention interventions • Doing and documenting the activities that are
– Treatments the specific nursing actions needed to carry
– Enhancement or promotion out interventions
interventions • Fifth standard of the ANA Standards of
Delegating Implementation Practice
• Delegation occurs during planning. – Coordination of care
– Who is decided to do each task? – Health teaching and promotion
• Nurse is responsible for correct – Consultation
implementation of task delegated, analysis of Relationship of Implementing to Other Nursing
data, and evaluation of outcome. Process Phases
• First three phases (assessing, diagnosing,
The Nursing Interventions Classification planning) provide basis for nursing actions
performed.
Taxonomy of nursing interventions • Doing and documenting specific nursing
• Developed by the Iowa Intervention Project activities and resulting client responses
• First published in 1992 • Results examined during evaluating phase
• Updated every 4 years Implementing Skills
• Consists of three levels • Cognitive (intellectual) skills
– Level 1 – Problem solving
• Domains – Decision making
– Level 2 – Critical thinking
• Classes – Creativity
– Level 3 • Interpersonal skills
• Interventions – Verbal and nonverbal
• Interventions – Effectiveness depends largely on
– More than 542 developed ability to communicate.
– Each intervention includes: – Therapeutic communication
• A label (name) necessary for caring, comforting,
• A definition advocating, referring, counseling, and
• A list of activities that outline supporting
key actions – Includes conveying knowledge,
– Linked to NANDA diagnostic labels attitudes, feelings, interest
– Select appropriate intervention – Appreciation of the client's cultural
and customize values and lifestyle
• Technical skills
• Nursing process – Purposeful "hands-on" skills
– Action oriented – Often called tasks, procedures, or
– Client centered psychomotor skills
– Outcome directed – Psychomotor
• Clients and support persons encouraged to • Physical actions that are
participate as much as possible controlled by the mind, not by
reflexes
– Require knowledge and often require
manual dexterity
Process of Implementing
• Reassessing the client
• Determining nurse's need for assistance
• Implementing nursing interventions
• Supervising delegated care
 • Documenting nursing activities – Some may require interpretation.
• Comparing Data with Desired Outcomes
• Reassessing the Client – Conclusions
– Reassess to make sure the intervention is ▪ Goal was met.
still needed ▪ Goal was partially met.
– Client's condition may have changed. ▪ Goal was not met.
• Determining the Nurse's Need for Assistance • Comparing Data with Desired Outcomes
– Inability to implement the nursing – Evaluation statement
activity safely ▪ Conclusion
– Assistance will reduce stress on ▪ Supporting data
the client. • Relating Nursing Activities to Outcomes
– Nurse lacks knowledge or skills to – Determine whether nursing activities
implement a particular nursing had any relation to the outcome
activity. without assuming that the activity
• Implementing the Nursing Interventions was the cause or only factor of
– Base actions on scientific meeting a goal
knowledge • Drawing Conclusions About Problem Status
– Clearly understand interventions – Actual problem has been resolved or
– Adapt activities to individual client potential problem's risk factors no
– Implement safe care longer exist.
– Provide teaching, support, and – Potential problem is being prevented
comfort but risk factors still exists.
– Be holistic – Actual problem still exists even though some
– Respect the dignity of the client goals are being met
and enhance self-esteem – When goals partially met or not met:
– Encourage active client • Care plan may need to be revised
participation • Client merely needs more time to
• Supervising Delegated Care achieve previously established goals
– Nurse still responsible for client's – Continuing, Modifying, or Terminating the
overall care Care Plan
– Must validate and respond to any • Critique each phase of the nursing
adverse findings or client process
responses • Assessing
• Documenting Nursing Activities  Incomplete or inaccurate
– Record nursing interventions and databases influence all
client responses subsequent steps.
– Do not record in advance • Diagnosing
Evaluating  If incomplete, add new diagnosis
• Judgment and appraisal statements
• Planned, ongoing, purposeful activity  If complete, analyze whether
• Determines client's progress, effectiveness of nursing diagnoses relevant
care plan • Planning: desired outcomes
• Continuous process  If inaccurate, goals/outcomes
• Demonstrates nursing responsibility and need revision
accountability for their actions  If accurate, goals/outcomes
Relationship of Evaluating to Other Nursing Process realistic and obtainable
Phases  Have priorities changed?
• Depends on effectiveness of preceding steps - Does client still agree with
• Assessment data must be accurate and priorities?
complete. - Continuing, Modifying, or
• Desired outcome must be stated concretely in Terminating the Care Plan
behavioral terms to be useful for evaluating. • Planning: nursing interventions
• Without implementation/interventions, there  Relate to goal achievement
would be nothing to evaluate.  Investigate whether best nursing
• Evaluating and assessing overlap. interventions were selected
Process of Evaluating Client Responses • Implementing
• Collecting Data
  After modifications, begin nursing  Performance improvement (PI)
process again  Persistent quality improvement
Evaluating the Quality of Nursing Care (PQI)
Quality Assurance – National Quality Forum
– Ongoing, systematic process  12 nursing-sensitive care
– Evaluates and promotes excellence in measures to evaluate quality of
provision of healthcare nursing care
– May evaluate level of care provided  Serious reportable events (SREs)
– May evaluate performance of a nurse or "never events"
or agency or country • Facility may not be paid for
– Three components: care if SRE has occurred.
• Structure evaluation – National Database of Nursing Quality
o Focuses on setting Indicators (NDNQI)
• Process evaluation  ANA database
o Focuses on care given  Nursing-Sensitive Indicators
• Outcome evaluation – National Quality Forum (NQF)
o Focuses on demonstrable  Serious reportable events (SRE)
changes in client's health also known as "never events"
status as result of nursing • Consistent gathering of data
care to evaluate quality of nursing
care

• Quality Improvement – Nursing Audit

– The Joint Commission Mission  Examination or review of records
 "To continuously improve the  Retrospective audit
safety and quality of care o Evaluation of a client's record
provided to the public the after discharge from an
provision of healthcare agency
accreditation and related services o Concurrent audit
that support performance  Evaluation of a client's healthcare
improvement in healthcare while client still receiving care
organizations" from the agency
– Great emphasis on sentinel event
 Unexpected occurrence involving
death or serious physical or
psychological injury or the risk
thereof
o Focuses on process
o Uses a systematic
approach to improve
quality of care
– Sentinel event
 Unexpected occurrence involving
death or serious physical or
psychological injury, or risk
thereof
– Root cause analysis
 Process for identifying the factors
that bring about deviations in
practices that lead to the event
– Often focuses on identifying and correcting a
system's problems
– Also known as:
 Continuous quality improvement
(CQI)
 Total quality management (TQM)
CHAPTER 14-DOCUMENTING AND REPORTING • Reimbursement
• Discussion – From the federal government
– Informal oral consideration of a – Must contain correct DRGs
subject by two or more healthcare • Legal Documentation
personnel – Admissible in court as evidence unless
• Report client objects because information
– Oral, written, or computer-based client gives to primary care provider is
communication intended to convey confidential
information to others • Healthcare Analysis
• Record – Identify agency needs such as
– Also called chart or client record overutilized and underutilized hospital
– Formal, legal document that provides services
evidence of a client's care Documentation Systems
– Can be written or computer based • Source-oriented record
• Process of making an entry on a client record • Problem-oriented medical record
is called recording, charting, or documenting. • Problems, interventions, evacuation (PIE)
Ethical and Legal Considerations model
• Confidentiality of all patient information • Focus charting
• Client's record protected legally as a private • Charting by exception (CBE)
record of client's care • Computerized documentation
• HIPAA regulations updated on April 14, 2003 • Case management
• Responsibility in using records for the purpose Source-Oriented Record
of education and research • Traditional client record
• Ensuring Confidentiality of Computer Records • Each discipline makes notations in a separate
– Personal password that is not to be section.
shared • Information about a particular problem
– Never leave a computer terminal distributed throughout the record
unattended after logging on • Narrative charting
– Do not leave client information – Written notes that include routine
displayed on the monitor where care, normal findings, and client
others may see it problems
– Shred all unneeded computer- – Often chronologic
generated worksheets Problem-Oriented Medical Record
– Know facility's policy and procedure • Data arranged according to client problem
for correcting an entry error • Health team contributes to the problem list,
– Follow agency procedures for plan of care, and progress notes.
documenting sensitive material • Encourages collaboration
– IT personnel must install a firewall to • Easier to track status of problems
protect server from unauthorized • Vigilance required to maintain problem list
access • Assessments and interventions must be
Purposes of Client Records repeated when more than one problem exists.
• Communication • Database
– Prevents fragmentation, repetition, – All information known about the client
and delays in care when the client first enters the healthcare
• Planning Client Care agency
– Nurses use baseline and ongoing data • Problem List
to evaluate effectiveness of the care – Listed in order in which they are identified
plan. and others resolved
• Auditing Health Agencies • Plan of Care
– Review client records for quality – Made with reference to active
assurance purposes problems
• Research – Generated by individual who lists the
– Treatment plans for a number of problems
clients with the same health problems
can yield information helpful in
treating other clients
• Education
 • Progress Notes – A goal that is not met
– Made by all health professionals involved • Documentation of variances includes:
in a client's care – Actions taken to correct the situation
– Uses SOAP, SOAPIE, SOAPIER – Justification of actions taken
documentation Documenting Nursing Activities
PIE • Describe client's ongoing status in record
• Groups information into three categories • Reflect the full range of the nursing process
– Problems Admission Nursing Assessment
– Interventions • Comprehensive admission assessment when
– Evaluation client first admitted to nursing unit
• Ongoing client assessment flow sheet and • Ongoing assessments and reassessments
progress notes recorded on flow sheets or nursing progress
Focus Charting notes
• Focus on client concerns and strengths Nursing Care Plans
• Progress notes organized into DAR format • The Joint Commission requires clinical record
– Data to include:
▪ Assessment phase – Evidence of client assessment
– Action – Nursing diagnosis
▪ Planning and implementing – Nursing interventions
phase – Client outcomes
– Response – Current nursing care plans
▪ Evaluation phase • Traditional care plans
• Holistic perspective of client needs – Written for each client
• Nursing process framework for progress notes • Standardized care plans
• DAR progress notes – Based on institutions standards of
– Data practice
– Action Kardexes
– Response • Concise method of organizing and recording
Charting by Exception data
• Incorporation of: • Series of cards kept in a portable index file or
– Flow sheets on computer-generated form
– Standards of nursing care • Information quickly accessible
– Bedside chart forms • Pertinent information about the client
• Agencies develop standards of nursing arranged in sections
practice. – Allergies
• Documentation according to standards – List of medications including IV fluids
involves a check mark. • Pertinent information about the client
• Exceptions to standards described in narrative arranged in sections
form on nurses' notes – List of daily treatments and
Computerized Documentation procedures
• Developed to manage volume of information – List of diagnostic procedures
• Used by nurses to: – Physical needs to be met
– Store client's database, new data – Stated goals
– Create and revise care plans Flow Sheets
– Document client's progress • Graphic Record
• Information easily retrieved – Body temperature, pulse, respiratory
• Speech-recognition technology rate, blood pressure, weight, other
– Nurse must be alert and aware of significant clinical data
others who might hear the dictation. • Intake and Output Record
• Possible to transmit information from one – All routes measured and recorded
care setting to another • Medication Administration Record
Case Management – Date of order, expiration date, name
• Quality, cost-effective care delivered within and dose, frequency and route of
established length of stay administration, nurse's signature
• Uses multidisciplinary approach, critical • Skin Assessment Record
pathways, CBE – Such as the Braden Assessment
• Variance
Progress Notes – Home health certification and plan-of-
• Provide information about progress client is treatment form
making toward achieving desired outcomes – Medical update and patient
• Include information about client problems information form
and nursing interventions General Guidelines for Recording
Nursing Discharge and Referral Summaries • Date and Time
• Completed when client discharged – Conventional a.m./p.m. or 24-hour
– Terms that can be readily understood • Timing
• Completed when client transferred to another – No recording before providing care
institution • Legibility
• Include some or all of the following: – Must prevent interpretation errors
– Description of client's physical, • Permanence
mental, and emotional status – Entries made in dark ink
– Resolved health problems • Accepted Terminology
– Treatments to be continued – When in doubt, write the term out
– Current medications fully
– Include restrictions that relate to – May be different between agencies
activity, diet, and bathing • Correct Spelling
– Functional/self-care abilities – Look up in dictionary or resource book
– Comfort level if unsure
– Support networks • Signature
– Client education – Includes name and title
– Discharge destination • Accuracy
– Referral services – Before making an entry, check that
Long-Term Care Documentation the chart is the correct one
• Based on professional standards, federal and • Sequence
state regulations, policies of healthcare – Document events in the order they
agency occur
• Laws and requirements • Appropriateness
– Health Care Financing Administration – Record only information that pertains
– Omnibus Budget Reconciliation Act to the client's health and care
(OBRA) of 1987 • Completeness
– Medicare and Medicaid – Include care that is omitted because
• Complete assessments, screening forms, and of client's condition, refusal
plan of care within the time period • Conciseness
• Keep record of visits and phone calls – No extra details
• Write nursing summaries and progress notes – Client's name and "client" omitted
according to specified time periods • Legal Prudence
• Summaries should include: – Usually viewed by juries and attorneys
– Specific problems noted in the care in court as a legal document
plan Reporting
– Mental status • Change-of-Shift Reports
– Activities of daily living – Handoff communication
– Hydration and nutrition status – Information communicated in a
– Safety measures needed consistent manner including an
– Medications opportunity to ask and respond to
– Treatments questions
– Preventive measures – Provide basic identifying information
– Behavioral modification assessments, • Change-of-Shift Reports
if pertinent – Features
Home Care Documentation • Two way, face-to-face
• Influenced by: communication
– Health Care Financing Administration • Written support tools
(1985) • Content in handover which
– Medicare and Medicaid captures intention
– Other third-party payers – I PASS, I-SBAR, PSYCH, I PUT PATIENTS
• Two records are required. FIRST
• Telephone Reports
– Be concise and accurate
– Have chart ready to give any further
information needed
– Document date, time, and content of
the call
• Telephone and Verbal Orders
– Many agencies only allow registered
nurses to take telephone orders.
– Write complete order down and read
it back to primary care provider to
ensure accuracy
– Question any order that is ambiguous,
unusual, or contraindicated
– Have primary care provider verbally
acknowledge the read-back
– Counter-sign by provider in 24 hours
• Care Plan Conference
– A meeting of a group of nurses to
discuss possible solutions to certain
problems of a client
– Allows each nurse the opportunity to
offer an opinion about possible
solutions
– Other healthcare providers invited to
offer expertise
• Nursing Rounds
– Two or more nurses visit selected
clients at bedside.
– Obtain information that will help plan
nursing care and evaluate care given
– Provides clients opportunity to discuss
their care
– Need to use terms client can
understand