Unit 1: nursing process

Contents
Overview of the nursing process.
Characteristics of the nursing process.
Assessment.
Collection of data, Types and Sources of data, Data collection
methods, organizing data, validating data, Documenting data.
Diagnosis (Definition, Types of nursing diagnosis,
Components)
Planning (Types of planning, Planning process)
Implementing action (the process of implementation)
Evaluation (Process of evaluating client responses)
Documenting and Reporting.
Purposes of client record.
Documentation system.
Guidelines for recording and Reporting


1

Overview of the nursing process.

• An organizational framework for the practice of nursing

• Orderly, systematic

• Central to all nursing care

• Encompasses all steps taken by the nurse in caring for a patient

Definition:

-A systematic, rational method of planning and providing individualized nursing care.

-The nursing process is a deliberate, problem-solving approach to meeting the health care
and nursing needs of patients. It involves assessment (data collection), nursing diagnosis,
planning, implementation, and evaluation, with subsequent modifications used as
feedback mechanisms that promote the resolution of the nursing diagnoses. The process
as a whole is cyclical, the steps being interrelated, interdependent, and recurrent.

-Nursing Process: Systematic method of giving humanistic care that focuses on achieving
outcomes in a cost effective manner

- is a process by which nurses deliver care to patients, supported by nursing models or

Philosophies

- The nursing process was originally an adapted form of problem-solvingand is

classified as a deductive theory

 Purposes of the nursing process:

1. Identify a client’s health status

2. Identify actual or potential health care problems or needs

3. Establish plans to meet the identified needs

4. Deliver specific nursing interventions to meet those needs

2
 Characteristics of the nursing process.

-A problem-solving method

-It is cyclic and dynamic.

-It is client centered.

-It is planned.

-It is goal directed.

-It is universally applicable.

-Systematic, goal-directed, flexible, rational approach

-Ensures consistent, continuous, quality nursing care

-Provides a basis for professional accountability

Benefits of Nursing Process

• Provides an orderly & systematic method for planning & providing care
• Enhances nursing efficiency by standardizing nursing practice
• Facilitates documentation of care
• Provides a unity of language for the nursing profession
• Is economical
• Stresses the independent function of nurses
• Increases care quality using deliberate actions

Phases of nursing process

 Assessment
 Diagnosis
 Planning
 Implementation
 Evaluation

3
4
 Assessment
Is the systemic and continuous collection, organization, validation, and
documentation of data (information)
All phases of the nursing process depend on the accurate and complete collection of
data.

 Assessment: The first step in determining a patient’s health status.

 Gather information, put pieces of the health puzzle together.
 Entire plan is based on the data you collect, data needs to be complete and accurate
 Collect, verify, and organize data, identify patterns, report and record the data.
Report significant abnormalities immediately

Types of Assessment
 Initial nursing assessment:
 Performed within specified time period
 Establishes complete data base
 Problem-focused assessment:
 Ongoing process integrated with care
 Determines status of specific problem
 Emergency assessment:
 Performed during physiologic or psychological crisis
 Identifies life threatening problems
 Identifies new or overlooked problem
 Time–lapsed assessment:
 Occur several months after initial
 Compares current status to baseline

5
 Activities Needed to Perform a Systematic Assessment

 Collect data
 Verify data
 Organize data
 Report & Record data

1-data collection
♣ It is the process of gathering information about a client's health status
♣ It must be systematic and continuous to prevent the omission of significant data
♣ Database: is all information about clients, which includes health history, physical
assessment and examination, results of diagnostic and laboratory test
♣ Data about clients should include past history as well as current problems.

* Types of data:
I- subjective data (symptoms):
 Symptoms or covert data
 Apparent only to the person affected
 Can be described only by person affected
 Includes sensations, feelings, values, beliefs, attitudes, and perception of personal health
status and life situations

II- Objective data( signs):

 Signs or overt data
 Detectable by an observer
 Can be measured or tested against an accepted standard
 Can be seen, heard, felt, or smelled
 Obtained through observation or physical examination

6
 . Which of the following are objective data and which are subjective data.????????/
A. Nausea
B. Vomiting
C. Unsteady gait
D. Anxiety
E. Bruises on the right arms and face
F. Temperature 39

Sources of data
•Primary: the patient; is always the best source

•Secondary: everything/everybody else

 All other sources of data such as (family member, spouse, support person, primary
care provider,….etc)

Methods of Data Collection

1-Observation:
Requires practice and skill Systematic, head-to-toe
 Gathering data use the senses
 Used to obtain following type of data:
Skin color (vision)
Body or breath odors (smell)
Lung or heart sound (hearing)
Skin temperature (touch)

2-Interview:
Structured form of communication Purpose: to provide care specific to this individual’s needs
and problems.
 Planned communication or conversation with a purpose
 Used to:
Identify problems with mutual concerns
Evaluate change
Teach
Provide support
Provide counseling or therapy

Approaches to interview
 Directive approach:
 Nurse establishes purpose
 Nurse control the interview
Used to gather or give information when time is limited, e.g in an emergency

7
  Non- directive approach:
 Rapport building
 Client controls subject matter, purpose and pacing
Note: combination of directive and non- directive approaches usually appropriate during the
information gathering interview

Types of interview questions:

Closed Questions
♦ Restrictive
- Yes\ No
- Factual
♦ Less effort and information from client
♦ e.g “what medication you take know
“ Are you having pain now

Open ended Questions

♦ Specify broad topic to discus
♦ Invite longer answers
♦ Get more information from client
♦ Useful to change topics and elicit attitude
♦ e.g “how have you been feeling lately “

Neutral questions
 client can answer without direction or pressure
 open ended
 used in nondirective interviews.
 “How do you feel
 about that?” “What do you think led to the operation?”

Leading questions
 Direct the client’s answers.
 Closed ended
 used in directive interviews
 “You’re stressed about surgery tomorrow, aren’t you?”
 “You will take your
 medicine, won’t you?”

 The interview settings

 Time:
 Patient free of pain
 Limited interruption
 Place:
 Private
 Comfortable environment
 Limited distraction

8
  Seating arrangement:
 In hospital
 In clinic
 In office
 Distance:
 Comfortable
 Language:
 Use easily understood terminology
Interpreter or translator

Data collected by interview:

-biographycal data: (name, age, sex, marital status, ……………..etc)

-chief complain: the main cause for seeking medical help (written by pt own words)

-history of present illness: the chronological story of the disease( time of onset, the usual health
status before the health problem, precipitating factors, associated factors, what increase or
decrease the symptoms, duration of the symptoms, and what did the pt do to manage the problem
before seeking the medical help) .

-past health history: chronic diseases, use of medication, past hospitalization, immunization, past
surgical procedures.

3. Examining (physical examination):

 Systematic data collection method
 Uses observation and inspections, auscultation, palpation and percussion
Blood pressure (Bp)
Pulses
Heart and lung sound
Skin temperature and moisture
Muscle strength

2-Verify data (validating)

The information gathered during the assessment phase must be complete, factual, and
accurate because the nursing diagnosis and interventions are based on this information.
- Validation is the act of "double-checking" or verifying data to confirm that it is accurate and
factual.
 Double check personal observation
 Double check equipments
 Check with experts and team member
 Recheck outliers
 Compare objective and subjective data
 Clarify statements
 Use references to explain phenomena

9
Purposes of Data Validation
• ensure that data collection is complete
• ensure that objective and subjective data agree
• obtain additional data that may have been overlooked

3- Organizing data
The nurse uses a written or computerized format that organizes the assessment data
systematically. The format may be modified according to the client's physical status.
 Using written format
 Or according to model or frame work

4- Documenting Data:
To complete the assessment phase, the nurse records client's data.
Accurate documentation is essential and should include all data collected about the client's health
status. Data are recorded in a factual manner and not interpreted by the nurse.

 Record the client’s data.

 Should be accurate,
 recorded in factual manner and not interpreted by the nurse (a judgment).

10
 Diagnosing
Diagnosis:
 The nurse identifies health related problems, analyzing data for abnormal findings that
results in a diagnosis.
 Nursing diagnosis was identified and developed in 1973 because nursing role in the
ambulatory nursing setting needed to be identified
 In 1977 the international recognition of the nursing diagnosis has occurred.
 In 1982 the name North America Nursing Diagnosis Association (NANDA) was
accepted
 The purpose of NANDA is to define, refine and promote a taxonomy of nursing
diagnostic terminology of general use to professional nurses
 Taxonomy is a classification system or set of categories arranged based on set of
principles.

 Nursing Diagnosis : Is a health issue that can be prevented reduced, or enhanced

through independent nursing measures

 Nursing diagnosis: is the client’s problem statement consisting of the diagnostic labels
plus etiology (causal relationship between a problem and its related or risk factors)
 NANDA official definition of nursing diagnosis: is a clinical judgment about
individual, family, or community responses to actual and potential health problem

There are five categories of nursing diagnosis:

 Actual Diagnosis:- e.g. a problem that currently exists.

 Is a client problem that is present at the time of the assessment
 Based on presence of associated signs and symptoms
 e.g., ineffective breathing pattern

 Risk Diagnosis:- A problem the client is uniquely at risk for developing

11
  Is a clinical judgment that a problem does not exist but the presence of risk
factors indicates that the problem is likely to develop unless nurses intervene
e.g., Risk for infection
 Possible Diagnosis:- a problem may be present, but requires more data collection to r/o or
confirm its existence.
 Syndrome Diagnosis:- Cluster of problems predicted to be present because of an event or
situation
 Describe a cluster of predicted high-risk or actual nursing diagnosis, related to a
certain situation or event that have similar interventions

 Wellness Diagnosis:- a health-related problem that requires assistance to perform at a

higher level.
◦ Relates to clients’ preparedness to implement behaviors to improve their health
condition.
◦ Describes human responses to level of wellness
◦ These diagnosis labels begin with the phrase Readiness for Enhanced, as for
example in Readiness for Enhanced Nutrition.

Parts of a Nursing Diagnostic Statement:

 1. The problem or health-related issue:-
 Describes the client’s health problem or response
 Describe the client health status clearly and concisely
 Need to be specific (deficient knowledge (medication))
 Need qualifiers (words have been added to some NANDA label to give
additional meaning) as:
 Deficit (inadequate in amount, quality or degree; not sufficient)
 Impaired (weakened, damaged)
 Decreased (less in size, amount or degree )
 Ineffective (not producing the desired effect)
 Compromised (to make vulnerable to threat)

 2. Etiology or cause:-
 Identifies one or more probable causes of the health problem
 Possible causes should be differentiated because each may require different
nursing intervention

 3. Defining characteristics:-
 Cluster of signs and symptoms indicating the presence of a particular diagnostic
label (actual diagnoses)
 Factors that cause the client to be more vulnerable to the problem (risk diagnoses)

12
Medical diagnosis Nursing diagnosis

Identifies conditions the MD is licensed & Identifies situations the nurse is licensed &
qualified to treat qualified to treat

Focuses on illness, injury, or disease processes Focuses on the client’s responses to actual or
potential health / life problems

Remains constant until a cure is affected Changes as the client’s response and/or the
health problem changes

i.e., Breast cancer i.e. Knowledge deficit

Powerlessness
Grieving, anticipatory
Body image disturbance
Individual coping, ineffective

13
 Medical vs. Nursing diagnosis

Nursing diagnosis Medical diagnosis

Breathing patterns, ineffective Chronic obstructive pulmonary disease

Activity intolerance Cerebrovascular accident

Pain Appendectomy

Body image disturbance Amputation

Body temperature, risk for altered Strep throat

Steps in Diagnostic Process

1. Analyzing Data
◦ Compare data against standards and norms (identifying significant cues)
◦ Cluster cues (generate hypothesis)
◦ Identify gaps and inconsistencies
Comparing Data:
Cues considered significant if it does any of the following:
1. Point to +ve or –ve change in patient health status
2. Varies from norms of client population: the client may consider a pattern to be
normal
Indicate development delay

Cluster Cues:
- Clustering: process of determining the relatedness of facts and determine whether any
pattern present
- Beginning of synthesis
- Involve making inferences about data
- May be deductive (start with a framework and cluster data into appropriate categories) or
inductive (combining data from different assessment areas to form a pattern) approach
Identify gaps and inconsistencies in data:
- It should include final check up to ensure that data complete and correct
- Source of conflict: measurement error, unreliable report
- Data can be found in nursing assessment, patient history

14
 Cues and Inferences

Cues (‫ )اشارة او دالله‬Signs and symptoms Inference (‫)استدالل‬

What you think,

a judgment about the cues

(Cues ) ( Inference )

Swollen finger Broken finger

Reddened
Painful

2. Identifying health problems, risks, and strengths:

- After grouping and clustering data, identify problems, risks, and strengths
Determine if client problem is a nursing, medical or collaborative

3. Formulating diagnostic statements

Writing A Nursing Diagnosis:

 Use accepted qualifying terms (Altered, Decreased, Increased, Impaired)
 Don’t use Medical Diagnosis (Altered Nutritional Status related to Cancer)
 Don’t state 2 separate problems in one diagnosis
 Refer to NANDA list in a nursing text books

15
Case Study
Muna Ahmad is a 33-year-old nursing student. She is married and has a 13-year-old daughter
and 5-year-old son. She is admitted to the hospital with an elevated temperature, productive
cough, and rapid labored respiration. While taking the nursing history, the RN finds that Muna
has had a “chest cold” for two weeks and has been experiencing shortness of breath upon
exertion. Yesterday she developed an elevated temperature and began to experience “pain” in her
“lungs”.

Assessment
Muna Stated “I cant breath, please help” I will never get caught up with my classes”
“ I’m worried about my children, I left them with my in laws, their father is out of town”
“I could not sleep last night, I cant breath when I laydown” “Also, have this chest pain while I’m
coughing”
“ I have no appetite since the cold, I have not eaten today anything, last thing entered my
stomach was two spoons of chicken broth last night”
“The chest pain I complain of is moderate 6/10 increase with coughing, and decrease with rest”.
The patient is coughing continuously, she has a productive cough, sputum is yellowish to
greenish, orthopnea
The patient is trying not to cough to avoid chest pain, puffy eyes, always talking to her kids over
the phone
The patients does not eat very well, her food tray remain as is

Diagnosis
Ineffective airway clearance related to accumulation of secretion in the airways AMB-----
Altered breathing pattern related to obstructed airways AMB---
Imbalanced nutrition: Less than body requirements related to decrease appetite and increased
metabolism secondary to disease process AMB--
Disturbed sleep pattern related to cough, pain, orthopnea AMB----
Anxiety related to difficulty breathing and concerns overwork and parenting role

16
17
 Planning
Third step of the Nursing Process, begins with the first client contact and continues until
discharge.
 Nurse formulate goals to help the client with their problems based on assessment data and
diagnostic statements
 Expected outcomes are identified
 Interventions (nursing orders) are selected to aid the client reach these goals.
 The end product of this phase is a client care plan.

Types of planning:
Initial Planning:
 Initiated on admission after initial assessment
 The nurse conduct the admission assessment develop initial comprehensive plan of care

Ongoing planning:
 Done by all nurses who work with the client
 Individualization of initial plan
 Occur at the beginning of the shift as the nurse plan the given care at that day
 The nurse carries out daily planning (ongoing planning) for the following Purposes:
♣ To determine whether the client’s health status has changed
♣ To set priorities for the clients care during the shift.
♣ To decide which problems to focus on during the shift
♣ To coordinate the nurse’s activities

18
 Discharge Planning
 Process of anticipating and planning for needs after discharge
 Clients usually discharged still needing care
 Begins at first client contact and
 Involves comprehensive and ongoing assessment to obtain information about the client
ongoing needs

Steps in planning
 Setting Priorities
 Establishing Goals
 Selecting Nursing interventions
 Documenting the Plan of Care

1-Setting priorities:
Is the process of establishing a preferential order for nursing diagnosis and interventions.
- The nurse and client begin planning by deciding which nursing diagnosis requires attention
first, which second, and so on.
- Instead of rank-ordering diagnosis, nurses can group them as having high, medium, low
priority.
e.g.- high priority------ loss of respiratory and cardiac function.
- Medium priority----- acute illness, coping ability.
- Low priority------- normal development need or requires minimal nursing support
Factors to Consider When Setting Priorities
 Client’s health values and beliefs
 Client’s priorities
 Resources available to the nurse and client
 Urgency of the health problem
 Medical treatment plan

2- Establishing client goal/desired outcomes:

The nurse client set goals for each nursing diagnosis.
 Goals/desired outcome: describe, in terms of observable client responses, what the
nurse hopes to achieve by implementing the nursing interventions
 (Expected outcome, outcome criterion, objective, predicted outcomes are other
interchangeable names)
Some differentiate between goal and outcome as follows
 Goal (broad statement about the client status): e.g., to maintain fluid volume balance
 Desired outcome (more specific, observable criteria used to evaluate whether the goals
have been met): drink 3L of fluids by the end of the day
*When goals are stated broadly, the care plan must include both goals and desired outcomes.
Some time they are combined (e.g. improved nutritional status as evidenced by weight gain of 5
kg by April 25)
*E.g. (2): Nsg Dx: Impaired physical mobility
Goal (broad): improved mobility

19
Desired outcome (specific): ambulate with crutches by end of the week

* Purpose of Goals:
a- provide direction for planning nursing interventions
b- Serve as criteria for evaluating client progress.
c- Enable the client and the nurse to determine when the problem has been resolved.

Types of Goals:
 Short term goals:
- useful for clients who require health care for a short time
- For patient who are frustrated by long-term goals
- Acute care settings where the nurse spent most of their time on client immediate need
 E.g., “client will raise right arm to shoulder height by Friday”è short-term goal

 Long-term goals: used for clients who live at home and have chronic health problems,
and rehabilitations centers
 E.g., “client will regain full use of right arm in 6wks”

Goals are patient-centered and SMART

Specific
Measurable
Attainable
Relevant
Time Bound
Pt will walk 50 ft.
Pt will eat 75% of meal
Pt will be OOB 2-4hrs
Pt will maintain HR<100
Pt will state pain level is acceptable 6 (0-10)

Measurable verbs
Identify
Describe
Perform
Relate
State
List
Verbalize
Hold
Demonstrate
Cough
Walk

20
 Non measurable verbs (Do not use)
Know
Understand
Appreciate
Think
Accept
feel

Components of Outcomes
 Subject: the client, any part of the client, or some attribute of the client, such as the
client’s pulse or urinary output.
 Verb: an action the client is to achieve/perform.
 Conditions or modifiers: added to the verb to explain the circumstances under
which the behavior is to be performed. They explain what, where, when, or how:
walks with the help of a cane (how). After attending two group DM classes, lists S&S
of DM (when)
 Performance criteria: the standard by which a performance is evaluated or the level
at which the client will perform the specified behavior. These criteria may specify
time or speed, accuracy, distance, and quality (Walks one block per day (distance
and time).

21
Example
Mr. Jamal will walk with a use of crutches at least to the end of the hall and back by
Friday
 Subject: Mr. Jamal
 Verb: Will Walk
 Condition: with the use of crutches
 Performance criteria at least to the end of the
hall and back (accuracy)
 Target time: by Friday (time)

Guidelines for Writing Goals/ Desired outcomes

 Write goals+ outcome in terms of client response, not nurse actions
èstart with : the client will
 e.g., client will drink 100cc of water per hour (client behavior) √
 e.g., maintain client hydration (nursing action) X
 Be sure that desired outcome are realistic for client capabilities or limitation
 e.g., “measure insulin accurately” è unrealistic with poor vision client
 Ensure that Goals & outcome are compatible with therapy of other professional
 e.g., Dr order for pt: bed rest
→the Outcome : “will increase the time spent out of bed by 15 minutes/day” is not
compatible with the Dr. order
 Make sure each goal is derived from only one nursing diagnosis

22
  E.g., “ the client will increase amount of nutrients ingested and show progress in the
ability to feed self” derived from 2 Nsg Dx: feeding self-care deficit & imbalanced
nutrition
 Use observable, measurable terms for outcomes
 (↑) daily exercise→ incorrect
 Make sure the client considers the goal/ desired outcomes important and values
them.
 E.g. self esteem → must involve choices that are best made by the client or in
collaboration with the client

Identify if the statement are written correctly

 Gaber will know the four basic food groups by 3/30/08 X
The verb is not measurable
 √ Gaber will list the four basic food groups by 3/30/08

3. Selecting nursing interventions

Actions nurse performs to achieve goals/desired outcomes
Focus on eliminating or reducing etiology of nursing diagnosis
OR
Treat signs and symptoms and defining characteristics

Types of Nursing Interventions

 Direct care
◦ Intervention performed through interaction with the client
 Indirect care
◦ Intervention performed away from but on behalf of client

Independent interventions
 Those activities nurses are licensed to initiate (i.e., no order needed:
physical care, ongoing assessment, elevate edematous legs)
Dependent interventions
Activities carried out under physician’s orders or supervision, or according to specified routines
(Administering of medications)
Collaborative interventions
◦ Actions nurse carries out in collaboration with other health team members
◦ Reflect overlapping responsibilities of health care team (Assist client with
physical therapy exercises)

criteria for Choosing Appropriate Interventions

 Safe and appropriate for the client’s age, health, and condition
 Achievable with the resources available
 Congruent with the client’s values, beliefs, and culture
 Congruent with other therapies
 Based on nursing knowledge and experience or knowledge from relevant sciences
 Within established standards of care (what is the nursing action during cardiac arrest)

23
 -Implementation:
 Is the action phase in which the nurse performs the nursing interventions.
 Consists of doing and documenting the activities that are the specific nursing actions needed
to carry out the interventions.

Relationship of implementing to other Nursing Process phases

 Based on first three phases (Assessment, Diagnosis, Planning)
 Implementing phase provides the actual nursing activities
 Nursing activities and client responses examined during evaluating phase
 Nursing activities individualized based on assessment data
While the nurse implementing nursing care, the nurse also performing an assessment (auscultate
breath sound q 4h.

 To implement care successfully, nurses need:

 Cognitive skills
 Interpersonal skills
 Technical skills

Cognitive Skills (Intellectual)

 Problem solving
 Decision making
 Critical thinking
 Creativity
Interpersonal Skills
 Are all the activities, verbal and nonverbal, people use when interacting directly with one
another (Ability to communicate with others)
 Effectiveness depends largely on the ability to communicate
 Necessary for all nursing activities ( caring, referring, counseling, and supporting)
 Include conveying knowledge, attitudes, feelings, interest, and appreciation of the client’s
cultural values and lifestyle
Technical Skills
 Are “hands-on” skills
 Often called tasks, procedures, or psychomotor skills
 Psychomotor refers to physical actions that are controlled by the mind, not reflexive
(for example the need to communicate with the client)
 Require knowledge and frequently manual dexterity

* Process of implementing:
 Reassessing the client

 Determining the nurse’s need for assistance

 Implementing nursing interventions
 Supervising delegated care
 Documenting nursing activities

24
1. Reassessing the client:
 to make sure that the intervention is still needed, or new data may indicate a need to
change the priorities of care
2. Determining the nurse’s need for assistance:
 the nurse may require assistance for one or more of the following reasons:
A. Unable to implement the nursing activity safely or efficient alone (positioning an
obese patient)
B. Assistance would reduce stress on client (turning a person who experiencing pain
with movement)
C. The nurse lacks the knowledge or skills to implement a particular nursing activity.
3. Implementing the nursing interventions:
 explain the procedure or the intervention to the patient before implementation.
 For many nursing interventions it is important to ensure patient’s privacy
 Nurses coordinate clients care (scheduling the clients contacts with other departments)
4. Supervising Delegate Care:
 The nurse responsible for the client’s overall care must ensure that the activities have
been implemented according to the care plan.

Other caregivers may be required to communicate their activities to the nurse by:
1. Documenting them on the patient’s records
2. Reporting verbally
3. Filling out a written form
The nurse can validate the intervention implemented and respond to any adverse findings or
client response

5. Documenting Nursing Activities:

 After the activities carried out, the nurse completes the implementing phase by recording
the interventions and client responses in the nursing progress note.
 Nursing care must not be recorded in advance because the nurse may determine on
reassessment of the client that the intervention should not or cannot be implemented
 The nurse may record routine or recurring activities (mouth care) in the client record at
the end of the shift
 It is very important to record the nursing intervention immediately after it is implemented
(treatment and medications) which helps safeguard the client (prevent duplicating dose of
medication)
 Recorded data about the client must be up to date, accurate, and available to other nurses
and health care professionals.
 Nursing activities are communicated verbally as well as in writing (reporting the client
status at changing the shift verbally

25
Guidelines for Implementing nursing Intervention
 Evidence Based practice
 Clearly understand intervention
 Adapt activities to the individual client
 Implement safe care
 Provide teaching, support and comfort
 Be holistic
 Respect the dignity of the client and enhance self esteem
 Encourage active client participation

26
 Evaluation
Evaluating:
Is to judge or to appraise.
- evaluating is a planned, ongoing, purposeful activity in which clients and health care
professionals determine:
- The clients progress toward goals an achievement.
- The effectiveness of the nursing care plan.

The Nursing Process & Evaluation

 Depends on the effectiveness of phases that precede
 Assessing and nursing diagnosis must be accurate
 Goals/desired outcome must be stated behaviorally to be useful for evaluating
 Without implementing phase, there would be nothing to evaluate
 Evaluating and assessing phases overlap

27
Components of the Evaluation Process
1. Collecting data related to the desired outcomes (NOC indicators)
2. Comparing the data with outcomes
3. Relating nursing activities to outcomes
4. Drawing conclusions about problem status
5. Continuing, modifying, or terminating the nursing care plan

1- Collecting data

We use a precise and measurable outcome to conclude whether goal have been met

Collect subjective and objective data

These data may require interpretation (e.g., O: degree of tissue turgor. S: complaints of
pain)
Data collected should recorded accurately and concisely

2- Comparing data with outcomes

 Client and nurse play active role in comparing client response to desired outcomes
 When determining the achievement of goal, nurse determine one of 3 conclusions:
- Goal met ( pt response same as desired outcomes
- Goal partially met (short term goal achieved but the longer one not)
- Goal not met (the client walked unassisted)
 Second step is to write down evaluation statement
 Evaluation statement 2 parts (conclusion & supporting data)
 It is recorded in nursing notes

3- Relating nursing activities to outcome

 Determine whether nursing activities had any relation to the outcomes

 Then collect data in how the pt did the activities
 It is important to identify the relationship of nursing actions to client response.
(e.g planning to lose wt.)

4- drawing conclusion about problem status

 The nurse judge from the achievement of goal that the patient problem resolved, reduced
or prevented
 Conclusions about status of client’s problem when goal met:
- Actual problem resolved, or potential problem is being prevented with its risk factor (goal
documented as met and the care for the problem D/C)
- Potential problem prevented but its risk factor still present (problem kept in nursing CP)
- Actual problems still presents, but some of its goals are met (the intervention continued even
though one goal is met
 When goal partially met, or not met (2 conclusion):
- CP need to revise
- Cp does not need revision but the pt need more time to achieve the established goals

28
5- Continuing, modifying, and terminating NCP
 Done after conclusion drawn about pt. problem status
 Modification done by:
- Drawing a line through portion of a care plan, marking, writing DC and date
 Critique each phase of the nursing process
 Check whether the interventions were
– Carried out
Were unclear or unreasonable

 after making the necessary modifications

- Implement the modified plan
- Begin nursing process again

29
 Documentation
If it is not charted,
it wasn’t done!!!
The written or printed legal record of all pertinent interactions with the client.
It reflects quality of care and accountability in providing care.
Health personals communicate through:
Discussion
Reports
Records

Definitions of nursing communication methods:

A discussion: informal oral consideration of a subject by 2 or more health care personnel
to ID problem or establish strategies to resolve a problem
A report: is oral, written or computer based communication intended to convey
information to others (endorsement).
A record (chart or client record): is a formal, legal document that provides evidence of a
client’s care. Can be written or computer based.
The process of making entry on a client record is called recording, charting, or
documenting.

What are the purposes for using client records?

Communication
Planning client care uses data from the client records to plan care
Auditing heath agencies: review of client records for quality assurance purpose
Research: data can be valuable resource for research
Education: Students often use client records as educational tools
Legal Documentation: used in the court as evidence
Reimbursement: for obtaining payment through Medicare, the client’s record must
contain the correct diagnosis-related group codes and reveal that the appropriate care has
been given
Health care analysis: to ID health care agency needs, ID services that cost money and
those that generate revenue

30
 Documentation Systems

I. SOURCE ORIENTED RECORD

The traditional client record and organized by discipline
Each person or department makes notations in a separate section or sections of the
client’s chart (Admission departments have their own sheet, physicians have their own
sheets, nurses have their own sheets…etc)
Advantage: easy to locate discipline specific information
Disadvantage: not organized by client problem, therefore difficult to track; fragmented
and have repetition in the information which decreases communication among health care
team, an incomplete picture of the client’s care, and lack of coordination of care
Narrative Charting:
A traditional part of the source-oriented record
Consists of written notes that include routine care, normal findings, and client
problems
There is no right or wrong order to the information (may use in emergency situations),
chronological order is used frequently

II. PROBLEM ORIENTED MEDICAL RECORDS (POMR):

Documentation organized around client problems rather than the source of
information all disciplines record on same form
Advantage: encourages collaboration, and the problem list in the front of the chart
alerts care givers to the client’s needs and makes it easier to track the status of each
problem
Disadvantages: caregivers differ in their ability to use the required charting format, it takes
constant awareness to maintain an up to date problem list, and it is somewhat inefficient because
assessments and interventions that apply to more than one problem must be repeated.
4 Components: Database, problem list, Plan of care, and progress note
. Data base: contains all information known about client when the client 1st enters the
health care agency, updated according to change in health status
b. Problem list: derived from the data base, problems are listed in order in which they are
identified, redefined as patient condition changed or more data obtained

31
 c. Plan of care made with reference to active problem list, it generated by the person who
lists the problem, listed under each problem in progress note
d. Progress notes Is a chart entry made by all health professionals involved in a client’s
care

All use same type of sheet for notes

Numbered to correspond to the problems on the problem list
SOAP format is frequently used.
SOAP/SOAPIE/SOAPIER / APIE/ APIER format:
Subjective data
Objective data
Assessment
Plan
Intervention
Evaluation
Revision

III. PIE:
Groups information into three categories
Consist of flow sheet (assessment) and progress note.
Acronym for:
 Problem:
 Intervention
 Evaluation
NANDA used to word the problem
The problem statement, intervention and evaluation where numbered the same
Advantage: eliminate traditional CP and incorporates an ongoing care plan
Disadvantage: all nursing notes should be reviewed before giving care to determine
which problems are current and which intervention were effective.

32
IV. Focus Charting:
It intended to make the client and client concerns and strengths the focus of care.
Three columns for recording are usually used: date and time, focus, and progress note
Focus may be a condition, nursing diagnosis, a behavior, or S/S, client strength
The progress notes are organized into:
DAR
 D: Data: assessment phase
 A: Action: planning and implementation
 R: Response: evaluation phase
V. Charting by Exception (CBE):
Is a documentation system in which only abnormal or significant findings or
exceptions to norms are recorded?
1. Flow sheets: as graphic records, fluid balance records, daily nursing assessment record,
skin assessment record
2. Standards of nursing care eliminates much of the repetitive charting of routine care.
Usually, documentation involves only a check mark in the routine standards box on the
graphic record
3. Bedside access to chart form: all flow sheets are kept at the client’s bed side to allow
immediate recording and to eliminate the need to transcribe data from the nurse’s
worksheet to the permanent record.
Advantage: is the elimination of lengthy, repetitive notes and it makes client changes in
condition more obvious.
VI. Computerized Documentation:
Used to store client’s database, add data, create, and revise CP, and document client
progress
It makes care planning and documentation easy
It made transmission of information from one care setting to another possible

33
VII. Case Management:
Uses multidisciplinary approach to planning and documenting client care, using critical
pathway
Identify the outcome that certain groups of clients are expected to achieve on each day of
care
It uses critical pathway, graphics, and flow sheet
Promote collaboration and teamwork among caregiver, helps decrease length of stay,
make efficient use of time
Work for client with one or two diagnosis and few needs.
Client with multiple diagnosis difficult to document on critical pathway.

Documenting Nursing Activities

Admission Nursing Assessment
Nursing Care Plans
Kardexes
Flow Sheets
Progress Notes
Nursing Discharge\referral

General Guideline for Recording

Date and Time
Timing
Legibility (‫)مقروء‬
Permanence)‫(بالحبر‬
Accepted Terminology
Correct Spelling
Signature
Accuracy

34
 Sequence
Appropriateness
Completeness
Conciseness
Legal prudence ‫حذر‬
Correcting errors in charting:
Single line through error
Write “error” above entry
Date, time and initial “errored” entry

Reporting
to communicate specific information to a person or group of people, whether oral or
written.
Purpose: to communicate specific information to a person or group of people.
Should be concise, include pertinent information no extraneous details
Include change of shift report, telephone report, care plan conference, and nursing round

Examples for Reporting

 1- Change of Shift Reports
Is a report given to all nurses on the next shift?
Purpose: provide continuity of care for pt
May be written or given orally (face to face or by audiotape record)
Sometimes given at the bedside, where client and nurse participate in information change
Verbal reports during your shift to other team members
-Significant changes in Vital signs
-Unusual reactions to treatments, procedures, medications
- Changes in physical or psychological condition

35
  2- Telephone reports
Inform physician of changes
Client transfers to different units
Result reports from lab or radiology
Client transfers to different institutions
Info needed: When call made, to whom, info given
Keep clear, accurate, repeat info if necessary
The nurse receive telephone report should document the date &time, the person’s name
giving the information, the subject of information, then sign the notation.
information should repeat back to the sender to ensure accuracy
Be concise and accurate, begin with name and relationship to the client
It includes (pt. name, medical diagnosis, V\S, significant lab data), keep the pt record
available to give Dr any additional information
After reporting, the nurse document the date and time, call content.

Telephone Orders
Physician states prescribed therapy over the phone to the registered nurse
TO transcribe to the physician order sheet, indicate as verbal order (VO) or TO
Then the order should be signed by the physician in a period of time (24hr’s)
Include the following information:
 Date & time orders accepted
 Stated order
 Signature & credentials of the nurse
Name of the ordering physician
 Physician to RN
 Physician must co-sign within 24 hours
 Nighttime, emergency orders
 Guidelines and procedure per institution

36
  Be careful, precise, and accurate with order
 Write order was said by physician, repeat it back

Care Plan Conference: Meeting of a group of nurses to discuss possible solutions to

certain problems of a client
Nursing Round: procedure in which 2 or more nurses visit selected clients at bedside to :
- Obtain information that help in Nsg CP
- Provide chance for the client to discuss their care
- Evaluate nursing care received to pt

Incident Reports
 Any event not considered routine (falls, needle sticks, med errors, accidental
omissions, visitor injury)
 Risk Management will analyze trends
 Changes in policy/procedure, educational programs may be related to findings
 Notify supervisor, physician of incident
 Nurse who witnesses makes out report
 Do not assign blame, be objective, facts only

37
38