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NURSING PROCESS • To prevent illness and promote,

maintain or restore health (in terminal illness: to

A. Nursing Process control and promote comfort and well being until
– Assessment death)
– Nursing Diagnosis (as a concept and • Maximize sense of well being and ability
process) to function in desired roles
– Planning ( long-term, short-term, priority • Provide cost-effective efficient care that
setting, formulation of objectives) pays attention to individual wants and needs
– Intervention (collaborative, independent • Find ways to improve consumer
nursing interventions) satisfaction with health care delivery
– Evaluation (formative, summative)
– Documentation of plan of care/reporting BENEFITS IN USING THE NURSING
• According to American Nurses’ 1. Speeds up the diagnosis add treat ment
Association, it is a critical thinking model for of actual and potential health problems,
nursing reducing the incidence of (and length of)
hospital stays
• It encompasses all significant actions 2. Creates a plan that’s cost effective, both
taken by the registered nurses and forms the in terms of human suffereing and
foundation for decision making monetary expense
3. Promotes quality of life
• Nursing consists of 5 interrelated steps:
4. Has precise documentation
assessment, diagnosis, planning, requirements designed to
implementation and evaluation a. improve communication
b. leave a paper trail
PURPOSES 5. Prevents clinicians from losing sight of
• Organize and prioritize patient care the importance of human factor
6. Promotes flexibility and independent
• Keep the focus on what’s important –the thinking
patients health status and the quality of life 7. Tailors interventions for individual
• Form thinking habits that help you gain 8. Helps patient realize their input is
important and helps nurses have
confidence and skills you need to think critically
in the clinical setting satisfaction of getting results



Critical Thinking in Nursing:
• Is based on principles of nursing
process and scientific method (eg, making
• OUTCOME FOCUSED (RESULT judgments based on evidence, rather than
ORIENTED) guesswork)
• PROACTIVE • Entails purposeful, informed, outcome-
• EVIDENCED-BASED focused (results-oriented) thinking that requires
careful identification of key problems, issues,
• INTUITIVE-LOGICAL and risks involved.
• REFLECTIVE, CREATIVE AND • Is driven by patient, family, & community
ULTIMATE GOALS OF NURSING • Uses both logic & intuition
• Requires knowledge, skills, and • signs and symptoms of common
experience. problems
• Calls for strategies to maximize human
and related potential complications.
potential (eg, use of tools to jog mind) Examples of CTIs Demonstrating Intellectual
• Requires reflection, self-correction, and Skills/Competencies
a desire to improve • Assesses systematically &
• Is guided by professional standards and comprehensively
ethics codes.
• Identifies assumptions
Critical Thinking: Picture This
• Detects bias; determines credibility of
information sources

• Develop critical thinking attitudes, TOP 10 REASONS

characteristics and behaviors TO IMPROVE THINKING
• Acquire theoretical and experiential #10. Things aren’t what they used to be, nor
knowledge as well as intellectual skills what they will be.
• Gain interpersonal skills #9. People are sicker with multiple
• Practice technical skills #8 More consumer involvement (patients &
Critical Thinking Indicators ™ #7 Nurses must be able to move from one
Behaviors that evidence suggests promote setting to another.
critical thinking in clinical practice. #6 Rapid change and information explosion
require us to develop new learning and
• Give concrete descriptions and
workplace skills.
examples. #5 Consumers and payers demand to see
• Listed in context of what’s likely to be evidence of benefits, efficiency, and results.
observed when a nurse is thinking critically in #4 Today’s progress often creates new
the clinical setting. problems that can’t be solved by old ways of
Three Categories of CTIs thinking.
#3 Redesigning care delivery and nursing
• General characteristics/attitudes curricula is useless if nurses don’t have
promoting critical thinking the
thinking skills required to deal with
• Knowledge required today’s world.
• Intellectual skills/competencies required
#2 It can be done, and it doesn’t have to be
that difficult.
#1 Your ability to clearly and quickly focus
Examples of CTIs™ Demonstrating your thinking to get the results you need can
CT Characteristics / Attitudes make the difference between whether:
• Self-aware: Clarifies biases, inclinations, You succeed Or Fail
strengths, and limitations.
Are you ready?
• Curious and inquisitive: Looks for What will happen in the steps of the Nursing
reasons, explanations, and meaning; seeks new Process?
information to broaden understanding.
Examples of Knowledge CTIs ASSESSMENT:
Clarifies: You collect and record all the
information needed to be able to:
• nursing vs. medical and other models,
roles, and responsibilities.  Predict, detect, prevent, manage or
eliminate health problems
 Clarify expected outcomes EXAMPLE
 Develop a comprehensive plan ASSESSMENT:
Mr. Santa is 80 years old and lives
DIAGNOSIS: alone. He wants to be independent and keeps
You analyze assessment data, draw an immaculate home. However, today he has a
conclusions, and determine: cold, is weak and states that he is feeling very
tired. Other than that, his health is unchanged.
 Actual and potential health problem and
their cause DIAGNOSIS
 Presence of risk factors he is at risk for falls
Strength: He desires for independence
 Resources, strengths and use of healthy Weakness: His independence is also a
behaviors weakness because he might nor ask for help
 Health states that are satisfactory but ****Make it known to him
could be improved
PLANNING: Plan for outcome with Mr. Santa:
You clarify expected outcomes, set He will be free of injury with educed risk
priorities and determine interventions. The factors for falls
interventions are designed to: Plan for prevention of falls:
arrange furniture, stress importance of
 Detect, prevent and manage health nutrition and hydration, decide to m,onitor bp
problem and risk factors
 Promote optimum function, IMPLEMENTATION:
independence and sense of well being Monitor him closely
Check vital signs
 Achieve the expected outcomes safely Monitor food and fluid intake
and efficiently Find out if he has help each day
Stress the importance of accepting help
You put the plan into action by: Encourage to keep his strength by
avoiding being in bed all day
 Assessing appropriateness of (and
readiness for) interventions EVALUATION
 Performing interventions, then Assess Mr. Santa and determine
reassesing to determine initial responses whether he is free from injury and whether risk
factors of weakness and fatigue are still present.
 Making immediate changes as needed If strength is regained: encourage to
 Charting to monitor progress if not: reassess and make changes in
the plan.
You assess the patient to decide
whether expected outcomes have been met. 1. ASSESSMENT
Then you decide whether to:
 Discharge the patient or Definition of Terms

 Modify the plan as appropriate

• Assessment
the deliberate and systematic collection
 Plan for ongoing continuous of data to determine a client’s current, past, and
assessment for risk factors for problems functional health status and to evaluate the
client’s present and past coping patterns
– It is the first step in determining the Data – base assessment
health status Most facilities have data – base forms to collect
information. The data-base tools usually contain
– It involves physical examination, the following :
interview, and gathering of information
necessary to get a clear picture of the patient’s
• needs and problems commonly
health status. encountered
• nursing model or theory adopted by the
FIVE PHASES facility
• COLLECTING DATA (COLLECTING • the standards of care.
• VALIDATING (VERIFYING DATA) Although there are some forms that guide focus
• ORGANIZING DATA (CLUSTERING) assessment, often there is no guide. The 4 key
questions to ask are :
• IDENTIFYING PATTERNS AND • what is the current status of the
TESTING FIRST IMPRESSIONS problem, compared with the baseline data?
• DECIDING WHAT TO RECORD AND • is the problem worse, same, or better?
REPORT • What factors are contributing to the
FIVE PHASES • what is the patient’s perspective on the
status of the problem and how is it being
1. Collecting data (Gathering Data) managed ?
• It is an ongoing process
• It begins the first time you meet the
Subjective data refer to what the person states
patient and it continues until the patient is verbally (Ex. : “I feel like my heart is racing.
• The resources to use include Objective data is what you observe (Ex. :
(consumer - patient, family, and community, Pulse 150 beats, regular, and strong
significant others, nursing and medical records,
verbal and written consultations, diagnostic and SOURCES OF DATA
laboratory studies) • Client – best source of data
• The data that are classified are of 2 • Support People – can supplement or
categories: verify the information
direct data – from the patient • Client records – information
indirect data – data gained from other documented by health care
sources professionals, types are medical
records, records of therapies and
• Comprehensive data collection happens
laboratory records
in 3 phases :
• Health care professionals – verbal
before you see the person
when you see the person
• Literature – can provide additional
after you see the person
information for database
Data-base Assessment – comprehensive
1. observing – gathering date by the use of
gathering of information done on initial contact
the senses
with the client to assess all aspects of the health
2. interviewing – planned communication
or conversation with a purpose
3. examining – systematic data collection
Focus Assessment – part of comprehensive
that uses observation to detectc health
data-base assessment used to monitor specific
problems or aspects of care.
OBSERVATION avoid the impulse to interrupt, allow for pauses
Using the senses to observe client data in conversation
• vision – overall appearce, signs of
distress or discomfort facial and body • How to ask questions: ask about the
gestures, skin color and lesions, person’s main problem first, focus your
abnormalities of movement, nonverbal questions to be able to gain specific information
demeanor, religious or cultural artifacts on signs and symptoms, don’t use leading
• smell – body or breath odor questions, do use exploratory statements, use
• hearing – lung and heart sounds, bowel communication techniques (use phrases that
sounds, ability to communicate, help you see the other person’s perspective,
language spoken, ability to initiate restate the persons words, ask open-ended
conversation, ability to respond when questions), avoid close-ended questions
spoken to, orientation to time person
and place, thoughts and feelings about • How to observe: carefully assess areas
self others and health status connected to verbal complaints, use your
• touch – skin temperature and moisture, senses, note general appearance, observe body
muscle strength, pulse rate rhythm and language, notice interaction patterns
volume, palpatory lesions
• How to terminate interviews: give
INTERVIEW warning if the session has been a long one, ask
the person to summarize her most important
concerns, ask if there were concerns that were
• Ethical, spiritual, and cultural
not discussed, Offer yourself as a resource and
considerations during interview :
answer questions that may arise, explain care
– Provide services with respect to human routines and provide information about who is
dignity accountable for nursing care decisions, end on a
– Safeguard the patient’s right to privacy positive note.
– Be honest
– Respect individual cultural and religious Common Communication Errors
beliefs (biological variations, comfortable – Using first names without permission
communication patterns, family organization and – Using endearing names
practices, beliefs whether people are able to – Talking down
control nature and influence their ability to be
– Using medical terminology with lay
healthy. The person’s concept about God.
Guidelines in promoting a caring interview – Using communication techniques you’re
comfortable with, without paying attention to the
• Get organized, don’t rely on memory, person’s response.
plan enough time, ensure privacy, get focused,
visualize yourself as being confident, warm, and NURSING HEALTH HISTORY
Components of Nursing Health History
• When you begin the interview: give your
name and position, verify the person’s name and Biographic Data
ask how he prefers to be called, briefly explain Client’s name, address, age, sex, marital status,
your purpose occupation, religious preference, health care
financing, and usual source of medical care
• During the interview: give the person
your full attention, don’t hurry, sit down. Chief complaint of reason for visit
The answer given to the question “what is
• How to listen: be an empathic listener, troubling you?” or “Can you tell me the reason
use short supplementary phrases, listen for you came to the hospital or clinic today?” The
feelings as well as words, let the person know chief complaint should be recorded in the client’s
when you see body language that sends a own words.
message that conflicts with what is being said,
be patient if the person has a memory block, History of present illness
• When the symptoms started • Personal habits: The amount,
• Whether the onset of symptoms was frequency, and duration of substance
sudden or gradual use (tobacco, alcohol, coffee, cola, tea
• How often the problem occurs and illicit or recreational drugs)
• Exact location of the distress • Diet: description of a typical diet on a
• Character of the complaint (e.g. normal day or any special diet, number
intensity of pain or quality of sputum, of meals and snacks per day, who
emesis or discharge) cooks and shops for food, ethnically
• Activity in which the client was involved distinct food patterns, and allergies
when the problem occurred • Sleep/rest patterns: usual daily
• Phenomena or symptoms associated sleep/wake times, difficulties sleeping,
with the chief complaint and remedies used for difficulties
• Factors that aggravate or alleviate the • Activities of daily living (ADLs): any
problem difficulties experienced in the basic
activities of eating, grooming, dressing,
Past History elimination, and locomotion
• Childhood illnesses, such as chicken • Instrumental activities of daily living: any
pox, mumps, measles, rubella (German difficulties experienced in food
measles), rubeola (red measles), preparation, shopping, transportation,
streptococcal infections, scarlet fever, housekeeping, laundry and ability to use
rheumatic fever, and other significant the telephone, handle finances, and
illnesses manage medications
• Childhood immunizations and the date • Recreation/hobbies: exercise activity
of the last tetanus shot and tolerance, hobbies and other
• Allergies to drugs, animals, insects, or interests and vacations
other environmental agents, the type of
reaction that occurs, and how the Social data
reaction was treated. • Family relationships/friendships: the
• Accidents and injuries: how, when, and client’s support system in times of stress
where the accident occurred, type of (who helps in time of need), what effect
injury, treatment received, and any the client’s illness has on the family, and
complications whether any family problems are
affecting the client.
• Hospitalization for serious illnesses:
reasons for the hospitalization, dates, • Ethnic affiliation: health customs and
surgery performed, course of recovery, beliefs; cultural practices that may affect
and any complications health care and recovery
• Medications: all currently used • Educational history: Data about the
prescription and all over the counter client’s highest level of education
medications such as aspirin, nasal attained and any past difficulties with
spray, vitamins, or laxatives learning
• Occupational history: Current
Family History of Illness employment status, the number of days
• To ascertain factors for certain missed from work because of illness,
diseases, the ages of siblings, parents, any history of accidents on the job, any
grandparents and their current state of occupational hazards with a potential for
health or if they are deceased, the future disease or accident, the client’s
cause of death are obtained. Particular need to change jobs because of past
attention should be given to disorders illness, the employment status of
such as heart disease, cancer, diabetes, spouses or partners and the way child
hypertension, obesity, allergies, arthritis, care is handled, and the client’s overall
tuberculosis, bleeding, alcoholism and satisfaction with the work
any mental health disorders • Economic status: Information about how
the client is paying for medical care
Lifestyle (including what kind of medical and
hospitalization coverage the client has),
and whether the client’s illness presents
• Home and neighborhood conditions: ASSESSMENT
Home safety measures and adjustments • promote communication
in physical facilities that may be required • provide privacy
to help the client manage a physical • don’t rely on memory
disability, activity intolerance, and • choose a way to organize your
activities of daily living; the availability of assessment and use it consistently
neighborhood and community services
to meet the client’s needs DIAGNOSTIC STUDIES

Psychological Data
• Major stressors experienced and the • Identifying cues and making
client’s perception of them Inferences (how you interpret or perceive a
• Usual coping pattern with a serious cue, the conclusion you draw about a cue. The
problem or a high level of stress nurses ability to make inferences is influenced
• Communication style: ability to by : observational skills, nursing knowledge,
verbalize appropriate emotion; non- and clinical expertise
verbal communication – such as eye
movements, gestures, use of touch, 2. Validating (Verifying data) is checking if the
and posture; interactions with support data are factual and complete. It helps one to
persons; and the congruence of avoid making assumptions, missing pertinent
nonverbal behavior and verbal information, misunderstanding situations,
expression jumping to conclusions or focusing in the wrong
direction making errors in problem identification.
Patterns of health care
All health care resources the client is currently Guidelines in validating data :
using and has used in the past. These include 1. data that can be measured accurately
the primary care provider, specialists (e.g. can be accepted as factual
ophthalmologist, gynecologists), dentists, folk 2. data that someone else observes may
practitioners (e.g. herbalist or curandero), health be or may not be true
clinic, or health center; whether the client 3. validate questionable information
considers the care being provided adequate; 4. Look for factors that may alter accuracy
and whether access to health care is a problem 5. ask someone else preferably an expert,
6. double-check information that is
PHYSICAL ASSESSMENT extremely abnormal, clarify statements
and verify your inferences.
Physical Assessment Skills
• Inspection – observing carefully by 3. Organizing (Clustering ) data Cluster or
using your fingers, eyes, ears and sense organize using the following:
of smell
• Auscultation – listening with a
• According to a Nursing Model Many
nurses use the functional health patterns by
• Palpation – touching and pressing to Gordon
test for pain and feel inner structures,
such as the liver • According to Body Systems
• Percussion – directly or indirectly • According life-threatening
tapping a body surface to determine
reflexes or to determine whether are
contains fluid
(Please refer to your copy)
Organization of Assessment is influenced by two
1. the person’s condition
2. your own preference
• Reporting data in a timely fashion
Describes the client’s perceived pattern of health expedites diagnosis and treatment of urgent
and well-being and how health is managed problems
NUTRITIONAL AND METABOLIC PATTERN • Guidelines for reporting significant
Describes the clients pattern of food and fluid findings:
consumption relative to metabolic need and
pattern indicators of local nutrient supply
– If you find yourself thinking, “ I am not
ELIMINATION PATTERN sure if there is anything abnormal here to
Describes the pattern of excretory function report,” you probably don’t have enough
(bowel, bladder and skin) knowledge to make the decision. You need help
ACTIVITY-EXERCISE PATTERN – Report abnormal findings as soon as
Describe the pattern of exercise, activity, leisure possible
and recreation – Before reporting, take a moment to be
SLEEP-REST PATTERN sure you have all the necessary information
Describes pattern of sleep, rest and recreation readily at hand
Describes sensory-perceptual and cognitive – If you’re nervous about giving the report
patterns jot your report in order of importance and read.
PATTERN • Give precise information State the
Described the client’s self concept pattern and facts rather than how you interpret the facts
perceptions of self (e.g. self-conception/worth,
comfort, body image, feeling state)
Describes the client’s pattern of role participation
and relationships FIVE PHASES
SEXUALITY-REPRODUCTIVE PATTERN • Creating a list of suspected
Describes the client’s pattern of satisfaction and problems/diagnoses
dissatisfaction with sexuality pattern; describes
reproductive patterns • Ruling out similar problems/diagnoses
Describes the client’s general coping pattern
• Naming actual and potential
problems/diagnoses and clarifying what’s
and the effectiveness of the pattern in terms of causing or contributing to them
stress tolerance
VALUE BELIEF PATTERN • Determine risk factors that must be
Describes the patterns of values, beliefs managed
(including spiritual) and goals that guide the
client’s choices or decisions
• Identifying resources, strengths and
areas of health promotion
4. Identifying Patterns and Testing first
• Get some initial impression of patterns • Competency – knowledge, skills, and
of health functioning behaviors necessary to perform actions safely
and efficiently in various patient situations.
• Determine what is relevant and
irrelevant • Nursing Domain – actions which a
nurse is qualified to perform.
• Remember cause and effect
• Medical Domain – activities and actions
5. Deciding what to record and report a medical doctor is qualified to perform.
• Accountable – being responsible and
• The final phase of assessment is
answerable for something
recording and reporting • Definitive Intervention – the most
specific treatment required to prevent, resolve,
or manage a health problem.
• Taxonomy – is a classification system • Wellness Diagnosis – a clinical
or set of categories arranged based single judgment by an individual, family, or community
principle or set of principles in transition from a specific level of wellness to
• Outcome – The result of prescribed a higher level of wellness.
interventions or plan of care. Usually it is • Sign – objective data that have been
referred to as desired interventions. known to signify a health problem
• Diagnose – make judgment and name • Symptom – subjective data that have
actual and potential health problems or risk been known to signify a health problem.
factors based on evidence from an assessment • Defining characteristics a cluster of
• Diagnosis – may mean two things : signs and symptoms and risk factors usually
the process of analyzing data and putting related present patients with specific nursing diagnosis.
cues together to make judgments about health • Cues – signs, symptoms, and defining
status or it is the result of diagnostic process characteristics noted in a patient.
• Life Processes – events or changes
• Diagnose – make judgment and name
that happen during one’s lifetime
actual and potential health problems or risk
• NANDA – North American Nursing factors based on evidence from assessment
Diagnosis Association
• Diagnosing – reasoning process
• Nursing Diagnosis (NANDA, 1990) –
clinical judgment about individual, family, or
• Nursing Diagnosis – a clinical community responses to actual or potential
judgment about an individual, family, or health problems or life processes.
community response to actual and potential
health problems and life processes.
• Medical Diagnosis – health problem Over time, literatures reveal that Nursing
that requires definite diagnosis by a qualified Diagnosis had been and is being used in 3
primary care provider ( physicians, nurses or contexts :
physicians’ assistants 1. As the second step of the nursing process
2. As a list of diagnostic labels or titles
• Potential Complications- organ or 3. As a one-part, two-part, or three-part
system problems that may arise because of the statement
presence of certain diagnoses or treatment
modalities. 1. As the second step of the nursing
• Carpenito (2000) uses the term process
collaborative problem to address potential • The nurse analyzes data collected
physiologic complications during assessment and evaluates the client’s
• Multidisciplinary Problem – a problem health status
requiring treatment by more than 1 discipline.
• Some conclusions resulting from data
• Related Factor – something known to analysis lead to nursing diagnoses; while others
be associated with a specific health problem do not
• Risk Factor – something known to • Recognize that the outcome of this
cause or contribute to specific problem. The process can include problems treated primarily
terms related and risk factors are often used by
• nurses (INDEPENDENT)
• Etiology – something known to cause a
disease or problem. The terms risk factor and
• problems requiring treatment by
etiology are oftentimes used interchangeably. professionals from several disciplines
To completely understand a problem, one must (DEPENDENT AND INTERDEPENDENT)
know its cause. Ex. While assessing, the nurse may record
observations that point to medical problems of
• Risk (Potential ) Diagnosis – a health seizures, pneumonia, and hypertension, as well
problem that may develop[p if preventable if as nursing diagnosis of risk for injury)
preventive actions are not taken.
• Using the term nursing diagnosis to
designate the 2nd step of the nursing process Prevent
may be confusing and have the undesirable
effect of leading nurses to try to state all Manage
conclusions or problems as nursing diagnoses,
• After the 1st conference on nursing Promote
diagnosis in 1973, the term nursing diagnosis
was applied to specific labels describing health Key Points
states that nurses could legally diagnose and
treat • The PPMP model is more proactive than
the DT model.
• These labels are concise descriptors of
a cluster of signs and symptoms such as Anxiety
or Risk for Injury
• It’s based on evidence and applies
2. As a list of diagnostic labels or titles
• An individual, family, or group’s
response to a situation or health problem
Thus it is necessary for us to be clear on
what context are we using the term Nursing • RISK DIAGNOSIS
Diagnosis: A Pivotal Point • WELLNESS DIAGNOSIS
This is because of 3 reasons :
– The accuracy and relevance of the 1. ACTUAL NURSING DIAGNOSIS
entire plan of care depends on the nurse’s ability • Actual Nursing Diagnosis- represents
to clarify and specifically identify both the a problem that had been validated by the
problems and what is accusing them. presence of major defining characteristics
– Creating a proactive plan that promotes PARTS OF ACTUAL NURSING DIAGNOSIS
health and prevents problems before they begin • Diagnostic label or label (such as
depends on your ability to recognize risk factors those developed by NANDA) is a concise term
– The resources and strengths you that convey the meaning of the diagnosis.
identify are key to reducing costs and • Defining characteristics are signs and
maximizing efficiency. symptoms that, when seen together, represent
There are major factors that impact on the the nursing diagnosis
nurses’ diagnosis- role today, as follows :
• Major defining characteristics – for
– Shift from diagnosis and treat (DT) to
nonresearched diagnosis, at least 1 must be
Predict, Prevent, Manage (PPM) approach present for validation of the diagnosis and for
– Development and refinement of Critical researched diagnosis, at least 1 must be present
Pathways (Clinical Pathways, Care Maps) 80-100% of the time.
– Computer-assisted Diagnosis • Minor defining characteristics –
– Emphasis on the importance of characteristics provide supporting evidence but
collaborative and multidisciplinary approach may not be present.
– A greater awareness that nursing’s • Related Factors – in actual nursing
scope of practice has a flexible boundary that diagnosis, these are contributing factors that
responds to the changing needs of society and have influenced the change in health status.
its expanding knowledge base.
There are 4 categories :
Diagnose & Treat (DT) versus Predict, Prevent,
Manage, Promote (PPMP) 1. Pathophysiologic (Biologic or
Psychological) Ex.
Shift to Predictive Model
Compromised immune system. Inadequate
• The “at risk concept is also very useful
2. Treatment-Related – Ex. Medications, for healthy individuals who are vulnerable
diagnostic because of age or a condition such as
studies, surgery, and treatments pregnancy Pregnant women are not at high risk
3. Situational – Ex. Enviornmental, home, for injury but are at risk during the third semester
instituion, personal, life experiences, and 3. POSIBLE NURSING DIAGNOSIS
roles • the person’s data base does not
4. Maturational – age related influences demonstrate the defining characteristics or
related factors of the diagnosis but your intuition
• Risk Factors – represent those tells you that the diagnosis may be present
situations that increase the vulnerability of the • Statements that describe a suspected
client or group. data but require additional data. It is unfortunate
The related factors for risk that nurses had been socialized to avoid
nursing diagnosis are the same risk factors appearing tentative.
previously explained for actual nursing
diagnosis. That is why the terms related and • In scientific decision-making a tentative
risk factors are used interchangeably approach is not a sign of weakness or
indecision, but an essential part of the process.
• Etiology is something known to cause a
disease or problem. The terms risk factor and • The nurse should delay a final diagnosis
etiology are often used interchangeably. until he / she has gathered and analyzed all
• Unknown Etiology – if the defining necessary information to arrive at a sound
characteristics of a nursing diagnosis are scientific conclusion
present, but the etiologic and contributing factors
are unknown. Ex. Fear related to unknown 4. WELLNESS NURSING DIAGNOSIS
etiology as evidenced by rapid speech, pacing, • recognizing when healthy clients
and “I am worried.” The use of unknown etiology indicate a desire to achieve a higher level of
alerts the physician or the nurse to assess for functioning in a specific area.
contributing factors as they intervene.
• Clinical judgment about an individual,
2. RISK NURSING DIAGNOSIS group, or community in transition from a specific
level of wellness to a higher level of wellness.
• the person’s data base contains
evidence of the related (risk) factors of the • Diagnostic statements for wellness
diagnosis but no evidence of defining nursing diagnosis are one-part, containing the
characteristics. label only (which begins with Potential for
The concept of “at risk” is useful clinically enhanced…….) followed by the higher level
because, it allows nurses to routinely prevent wellness that individuals or groups desire
problems in people who are at high risk. (readiness for enhanced family processes)
• All operative patients are at risk for • It does not contain a related factor
infection related to loss of protective barrier
secondary to incision. This generic diagnosis for
• The NANDA taxonomy (2001)uses
“readiness for enhanced” as a prefix for
all surgical clients is routine, as such nurses do wellness diagnosis. In most acute e care
not (actually) need to include it in the client’s settings, however only the actual and potential
plan of care in the hospitals because it is part of diagnoses are addressed but there is more
the unit’s standard of care. opportunitit6esyto focus wellness diagnoses
• In contrast, a patient with diabetes who .
has undergone emergency surgery for a 5. SYNDROME NURSING DIAGNOSIS
perforated gastric ulcer may have a nursing
diagnosis of High risk for infection related to the
• Used when the diagnosis is associated
with a cluster of other diagnoses
surgical incision and impaired healing secondary
to diabetes mellitus and blood loss
Impaired – made worse, weakened, damaged,
• They comprise a cluster of predictive
reduced, deteriorated
actual or high- risk nursing diagnosis related to a Decreased – lesser in size, amount or degree
certain event or situation. Ineffective – not producing the desired effect
• The clinical advantage of a syndrome Compromised – to make vulnerable to threat
diagnosis is that it alerts the nurse o a complex NANDA approved meaning
clinical condition requiring expert nursing All diagnostic labels have meaning that clarifies
assessment and intervention. the definition of each
• Examples are : Rape Trauma Open your NANDA list Dx Handbook recite the
Syndrome, Disuse Syndrome, Post Trauma meaning of…
Syndrome Ineffective Breathing Pattern
Imbalanced Nutrition: less than body
3. As a one-part, two-part, or three-part requirements
One-Part (Problem or Diagnostic Label) Identifies one or more probable causes of the
1. Wellness diagnosis health problem, gives direction to required
2. Syndrome diagnosis nursing therapy and enables the nurse to
Two-Part (Problem or Diagnostic Label + individualized client care
Risk Factor) Example:
1. Risk Diagnosis Recite the etiologies of the following:
2. Possible Diagnosis Sleep Disturbance
Three-Part (Problem or Diagnostic Label + Deficient Fluid Volume
Are the cluster of signs and symptoms that
COMPONENTS OF NANDA NURSING indicate the presence of the diagnostic label
DIAGNOSIS Characteristics are listed separately according to
• The problem whether they are subjective or objective in
• The etiology In actual nursing dx, the defining characteristics
• The defining characteristics are the signs and symptoms
In risk nursing dx, no subjective or objective
signs are present
Describes the client’s health problem or
Writing Diagnostic Statements
response for which nursing therapy is given
Describes the client’s health status briefly and
concisely in a few words
Problem Etiology
PURPOSE: to direct the formation of client goals
and desired outcomes and may also suggest
(Diagnostic Contributing Factor Signs &
some nursing interventions
When the word specify follows the NANDA label
the nurse states the area in which the problem
Diagnostic labels that are well refined and does
Example: Deficient Knowledge (Medications)
not need etiology
Wellness diagnosis:
Words that have been added to some NANDA
Readiness for Enhanced + desired higher level
labels to give additional meaning to the
of functioning
diagnostic statement
Example: Readiness for enhance Parenting
Or with descriptor
Deficient – inadequate in amount, quality or
Health Seeking Behavior (Low-Fat Diet)
degree, not sufficient, incomplete
5. using descriptors – making it more precise
• Problem (P) – statement of the client’s
and specific
response (NANDA label) Example:
• Etiology (E) – factors contributing to or Impaired skin integrity (Left Lateral Ankle)
probable causes of the responses
Use “related to” to join 2 parts, because this REASONING
implies relationship  Verify
Risk for infection related to _____________  Build a good knowledge base and
acquire clinical experience
THREE-PART STATEMENT  Have a working knowledge of what is
• Problem (P) normal
• Etiology (E)  Consult resources
• Signs and Symptoms (S) – defining  Base diagnosis on patterns—that is, on
characteristics as manifested by the client behavior over time—rather than on an isolated
Example: incident
Noncompliance (Diabetic Diet) related to
unresolved anger about diagnosis as manifested
 Improve critical-thinking skills
by verbalization “I can’t live without sugar in my
1. unknown etiology- when the defining
State in terms of a problem, not a need.
characteristics are present but the nurse does
not know the contributing factors
Deficient Fluid Volume (problem) related
to fever
Noncompliance (Medication Regimen) related to
unknown etiology
Fluid Replacement (need) related to
2. complex factors – when there are too many
etiologic factors or they are to complex to state
in a brief phrase
Word the statement so that it is legally
Chronic Low Self-Esteem related to complex
Impaired Skin Integrity related to
immobility (legally acceptable)
3. possible – when the nurse believes more
data are needed about the client’s problem or
Impaired Skin Integrity related to
improper positioning (implies legal liability)
Possible low self-esteem related to loss of job
and rejection by family
Use nonjudgmental statements.
Altered thought processes possible related to
unfamiliar surroundings
Spiritual Distress related to inability to
attend church services secondary to immobility
4. secondary to – to divide the etiology in 2
parts, thereby making the statement more
descriptive and useful
Spiritual Distress related to strict rules
necessitating church attendance (judgmental)
Risk for impaired skin integrity related to
decreased peripheral circulation secondary to
Make sure that both elements of the
statement do not stay the same thing
Risk for Impaired Skin Integrity related
to immobility PLANNING- Is a deliberative, systematic phase
INCORRECT OR AMBIGUOUS STATEMENT of the nursing process that involves decision
Impaired Skin Integrity related to making and problem solving
ulceration of sacral area (response and probable CONCEPT MAP – a visual tool in which ideas
cause are the same) or data are enclosed in circles or boxes of some
shape and relationships between these are
GUIDELINE #5 indicated by connecting lines or arrows.
Be sure that the cause and effect are NURSING CARE PLAN – end product of the
correctly stated (i.e., the etiology causes the planning phase, include the actions nurses must
problem or puts the client at risk for the take address the client’s nursing diagnoses and
problem). produce desired outcomes.
Pain: Severe headache related to fear of for action that exists in the nurse’s mind.
addiction to narcotics FORMAL NSG CARE PLAN – is a written or
INCORRECT OR AMBIGUOUS STATEMENT computerized guide that organizes information
Pain related to severe headache about the client’s care.
GUIDELINE #6 care plan that specifies the nursing care for
Word the diagnosis specifically and groups of clients with common needs.
precisely to provide direction for planning INDIVIDUALIZED CARE PLAN – is tailored to
nursing intervention meet the unique needs of a specific client –
CORRECT STATEMENT needs that are not addressed by the
Impaired Oral Mucous Membrane standardized plan.
related to decreased salivation secondary to MULTIDISCIPLINARY CARE PLAN
radiation of neck (specific) (collaborative care plans/critical pathway) – is a
INCORRECT OR AMBIGUOUS STATEMENT standardized plan that outlines the care required
Impaired Oral Mucous Membrane for clients with common, predictable – usually
related to noxious agent (vague) medical – conditions.
GOAL – (intent) what you intend to do
GUIDELINE #7 EXPECTED OUTCOME – (results) what you
Use nursing terminology rather than expect the patient to be able to do
medical terminology to describe the client’s INDICATOR is “a more concrete individual,
response. family, or community state, behavior, or
CORRECT STATEMENT perception that serves as a cue for measuring
Risk for Ineffective Airway Clearance an outcome.”
related to accumulation of secretion in lungs GOAL/ OBJECTIVES/ OUTCOMES/
(nursing terminology) INDICATORS may be used interchangeably
Risk for Pneumonia (medical PRIORITY SETTING – is the process of
terminology) establishing a preferential sequence for
addressing nursing diagnosis and interventions
Use nursing terminology rather tha based upon clinical judgment and knowledge,
medical terminology to describe the probable that a nurse performs to enhance patient/client
cause of the client’s response. outcomes.
CORRECT STATEMENT RATIONALE – is the scientific principle given as
Risk for Ineffective Airway Clearance the reason for selecting a particular nursing
related to accumulation of secretions in lungs intervention.
(nursing terminology)
Risk for Ineffective Airway Clearance
related to emphysema (medical terminology)
• Promote communication among
PLANNING caregivers
• Direct care and documentation
3. Deciding problems that must be recorded
• Create a record that can later be used
4. Determine Interventions
for evaluation, research, and legal reasons. 5. Ensuring plan is adequately recorded
• Provide documentation of health care
needs for insurance reimbursement purposes 1. Setting priorities
– is an essential critical thinking skill that
TYPES OF PLANNING requires you to be able to decide :
1. Initial Planning  Which problems need immediate
- Planning should be initiated as soon as attention, which ones can wait ?
possible after the initial assessment. The nurse  Which problems are your responsibility
has the benefit of the slient’s body language as and which do you need to refer to someone else
well as some intuitive kinds of info that are not ?
available solely from the written database.
2. Ongoing Planning  Which problems will be dealt with by
- occurs at the beginning of a shift as the using standard plans
nurse plans the care to be given that day. As  Which problems aren’t covered by
nurses obtain new information and evaluate the protocols or standard plans but must be
client’s responses to care to be given that day. addressed to ensure a safe hospital stay and
3.Discharge Planning timely discharge ?
– the process of anticipating and planning for
the needs after discharge. Effective discharge Priority-Setting Principles
planning begins at first client contact and In setting priorities, be guided by the following
involves comprehensive and ongoing principles :
assessment to obtain information about the • Choose a method of assigning priorities
client’s ongoing needs. and use it consistently
• Assign a high priority to problems that
FORMAT OF NURSING contribute to other problems
• Your ability to understand priorities is
influenced by your understanding of the patient’s
• NURSING DIAGNOSIS understanding of priorities, the whole picture of
problems, patient’s overall health status,
• GOALS / EXPECTED OUTCOME expected length of stay, and whether there are
• NURSING INTERVENTIONS standard plans that apply
***In developing plans, applies laws and
• EVALUATION standards practice

Major Components of Care Plans Basis for PRIORITIZATION

 Expected (desired) outcomes : What
results do you expect and when do you expect
• Maslow’s Hierarchy of Needs
to see these results ? • Airway, Breathing, Circulation
 Actual and Potential Problems : • Urgency ( life-threatening / health
What are the actual and potential diagnoses and threatening )
problems that must be addressed to ensure safe
and efficient care ? MASLOW’S HIERARCHY OF NEEDS
 Specific Interventions : What is going Priority 1. PHYSIOLOGIC NEEDS
to be done to prevent or manage the major - eg, problems with breathing,
problems and achieve the expected objectives ? circulation, nutrition, hydration, elimination,
 Evaluation / Progress Notes : Where temperature regulation, physical comfort
can you find out how the person is responding to Priority 2. SAFETY AND SECURITY
the plan of care ? - eg, environmental hazards, fear
Steps in Planning - eg, isolation or loss of a loved one
1. Setting priorities Priority 4. SELF-ESTEEM
2. Establishing expected outcomes - eg, inability to perform normal activities
- Problems posing a threat to the ability 2. Determine Outcomes
to achieve personal goals Outcomes describe what you expect to observe
in the patient that will demonstrate that he has
ABC been benefited by nursing care.
For identifying initial urgent priorities, some Indicators are specifically measurable data that
nurses use the ABC method ( make sure the will indicate that the outcome had been
patient has no threats to his.. achieved. Oftentimes, these two words are
used interchangeably.
A – Airway
B – Breathing OUTCOME: Patient’s skin remains intact
C – Circulation INDICATORS:

• Skin shows no sign of discoloration or
Assign high priority problems that contribute to • Control of listed risk factors (nutrition,
other problems. hydration, skin care every 8 hours)
Example : EXAMPLES
if someone has chest pain and difficulty OUTCOME: With the help of printed materials,
breathing, pain management is a high priority the patient will demonstrate knowledge of
because pain causes increased stress and medication regimen by discharge
oxygen demand. INDICATORS:


• Lists drug names, doses, actions,
PRIORITIES administration routes and side effects
• Demonstrates special administration
 Ask, “What problems need immediate techniques
attention and what could happen if I wait until
later to attend to them?” • Lists reportable signs and symptoms

 Identify problems with simple solutions 3 Purposes of Outcomes

and initiate actions to solve them
• There are the measuring sticks of the
 Develop an initial problem list, plan of care
identifying actual and potential problems, and
their causes, if known.
• They direct interventions
• They are motivating factors
TEN KEY QUESTIONS Standards for Outcomes:
1. What major outcomes (observable
beneficial results) do we expect to see
 Derived from the diagnoses
in this particular person, family, or group  Documented using measurable terms
when the plan of care is terminated?
2. What problems, risks, or issues must be
 Mutually formulated with the clients and
addressed to achieve the major health care provider, when possible.
outcomes?  Realistic in terms of client’s present and
3. What are the circumstances (what is the potential capabilities
4. What knowledge is required?
 Attainable in relation to resources
available to the patent.
5. How much room is there for an error?
6. How much time do I/we have?  Written in such a way that they include a
7. What resources can help? time estimate for attainment and provide
8. What perspectives must be considered? direction for continuity of care
9. What’s influencing thinking?
10. What must we do to prevent, manage, TYPES OF OUTCOMES
or eliminate the problems, issues, and • Clinical Outcomes describe the
risks identified in #2 above? expected status of medical, nursing, or
multidisciplinary problems at certain points in
time, after treatments had been given. They PRINCIPLE 3: Outcome statements are very
resolve whether the problems are resolved or to specific which include the following components:
what degree they are resolved. Ex : chest tube subject, verb, condition, performance criteria,
out 3rd post-op day, lungs clear, absence of time
signs of infection
• Functional Outcomes describe the Parents will bathe the newborn in room
person’s ability to function in relation to desired s v c
usual activities. Ex : Four days after total knee independently by May 17
replacement, Mr. Palmer will be discharged to a pc t
rehabilitation facility able to perform straight leg
raises and range of motion exercises twice a PRINCIPLE 4: Use measurable verbs
day. Example:
suppose you write an outcome for a
• Quality of Life Outcomes focus on key woman that says, “Will understand how to use
factors that affect someone’s ability to be sterile technique.”
physically and spiritually comfortable. Ex. :
absence of depression, absence of depression, The only way you can really know how well she
usual sleep patterns, able to perform work and understands is if she actually verbalizes or
leisure activities demonstrates sterile technique
OUTCOMES identify state describe perform list,
PRINCIPLE 1: Outcomes describe specific express share verbalize exercise hold,
benefits you see in the patient after care has perform cough demonstrate
been given (short term or long term) communicate

eg, “Father will safely bathe the newborn.” Non-measurable:

Know understand accept
Short term outcomes – describe early expected Think appreciate feel
benefits of nursing intervention.
eg, Will be able to walk to the bathroom PRINCIPLE 5: Consider cognitive, affective, and
tomorrow unassisted. psychomotor outcomes

Long term outcomes – describe the benefits

expected to be seen at a certain point in time  Affective domain: associated with
after the plan has been implemented changes in attitudes, feelings, or values
eg, Will be able to walk independently to the end eg, Identifies old eating habits that are to be
of the hall, 3 times within 10 days after the changed
surgery  Cognitive domain: dealing with acquired
knowledge or intellectual skills
PRINCIPLE 2: Outcomes relate to problems or eg, Enumerates signs ad symptoms of diabetic
interventions (intervention outcomes, problem shock
 Psychomotor domain: dealing with
Problem outcomes – state what you expect to developing motor skills
observe in the patient when the problems are eg, Demonstrates how to walk with crutches
resolved or controlled
eg, The patient will not have signs and GUIDELINES IN DETERMINING PATIENT-
symptoms of infection CENTERED OUTCOMES

Intervention outcomes – state the benefit you  Be realistic and consider:

expect to observe in the patient after an  Patient’s health state, overall prognosis
intervention is performed  Expected length of stay
eg, Breath sounds will clear after suctioning
 Growth and Development 6. Make sure the client considers the
goals/desired outcomes important and
 Patient values and cultural
values them.
 Other planned therapies for the patient 3. Deciding problems that must be recorded
 Available human, material, and financial DECIDING WHICH PROBLEMS MUST BE
resources RECORDED
 Risks, benefits, and current scientific influenced by your understanding of:
evidence  The whole picture of all the problems
 Changes in status that indicate you present
need to modify usual expected outcomes
 The person’s overall health status and
GUIDELINES IN DETERMINING PATIENT- expected discharge outcomes
CENTERED OUTCOMES  The expected length of contact with the
 Partner with patients and families, patient. Focus on what must be achieved before
determining outcomes together and involving what’s nice to do
other key members of the health care team
 In complex cases, develop both short-
and long-term outcomes
 Be sure the outcomes and indicators are  The patient’s perception of priorities. If
measurable: that they describe something you the patient doesn’t agree with your priorities, it’s
can hear, see, feel, or smell in the person to unlikely the plan will succeed.
demonstrate that the outcomes are achieved  Whether there are standard plans that
apply. For example, are there critical pathways,
GUIDELINES IN DETERMINING PATIENT- guidelines, protocols, procedures, or standard
CENTERED OUTCOMES plans that address daily priorities for this
 Consider the five components – particular patient’s situation?
subject, verb, condition, performance criteria,
 Identify only one behavior per indicator
• Create a problem list
 Sometimes outcomes and indicators • Decide which problems must be
already will be developed for your patient’s
managed in order to achieve the overall
problems in standard plans
outcomes of care
GUIDELINES FOR WRITING GOALS AND • Determine what documentation will
DESIRED OUTCOMES guide how each problem will be managed
1. Write goals and outcomes in terms of eg, Nurse-developed individualized plan?
client responses, not nurse activities. Patient self-manages?
2. Be sure that desired outcomes are
realistic for the client’s capabilities, 4. Determine Interventions
limitations, and designated time span, if Interventions are actions performed by the
is indicated. nurse to monitor health status, reduce risks,
3. Ensure that the goals and desired resolved, prevent, manage a problem, facilitate
outcomes are compatible with the independence or assist with activities of daily
therapies of other professionals. living, promote optimum sense of physical,
4. Make sure that each goal is derived psychological and spiritual wellbeing.
from only one nursing diagnosis.
5. Use observable, measurable terms of CLASSIFICATION OF INTERVENTIONS
outcomes. Avoid words that are vague Interventions can be classified into:
and require interpretation or judgment
by the observer.
• direct interventions which are
Standardized Plans
performed through interactions with patients
• indirect care interventions are those
 Guides that generally, but not
completely apply to individual situations
done away from the patient, such as monitoring
results of laboratories.  Nurses can help individualized these
plans accordingly
Interventions should:
 direct, prevent and manage health 5. Ensuring plan is adequately recorded
problems and risks
Remember the E.A.S.E. mnemonic?
 promote optimum function and sense of E= expected outcome
well being A= actual and potential problems
S= specific interventions
 achieve the desired outcomes safely E= evaluation/progress notes
Questions to ask for individualized care
• What can be done to minimize or GUIDELINES FOR WRITING NURSING CARE
prevent risk?
1. Date and sign the plan
• What can be done to manage 2. Use category headings
problems? 3. Use standardized/approved medical or
English symbols and key words rather
• How can I tailor interventions to meet than complete sentences to
the expected outcomes? communicate your ideas unless the
• How likely are we able to get desired agency policy dictates otherwise.
versus adverse responses to the intervention? 4. Be specific
5. Refer to procedures books or other
TEACHING sources of information rather than
TEACHING: THE KEY TO EMPOWERMENT including all the steps on a written plan
Teaching patients about their health and 6. Tailor the plan to the unique
treatment plan and motivating them to become characteristics of the client by ensuring
involved in managing their care is the key to that the client’s choice, such as
empowering them to become their best preferences about the times of care and
advocate and caregiver. the methods used, are included.
7. Ensure that the nursing plan
GUIDELINES IN PLANNING FOR TEACHING: incorporates preventive and health
maintenance aspects as well as
– Assess readiness to learn and previous
restorative ones
knowledge before developing a teaching plan.
8. Ensure that the plan contains
– Ask about preferred learning styles interventions for ongoing assessment of
– Plan for environment that is conducive the client.
to learning 9. Include collaborative and coordination
– Identify active learning experiences activities in the plan.
(with client involvement) 10. Include plans for the client discharge
– Use simple words and home care needs.
– Determine learning outcomes mutually
– Encourage asking questions ACTIVITIES IN IMPLEMENTATION
– Plan to pace learning 1. Preparing for report and getting report
– Allow time to discuss progress 2. Setting daily priorities
– Find ways to include significant others in 3. Assessing and re-assessing
the teaching session.
4. Performing interventions and making
necessary changes Delegate when…
5. Charting
6. Giving report
• The patient is stable
• The task is within the worker’s job
1. Preparing for report and getting report description and capabilities
• Learning about patient’s problems • The amount of RN time with the patient
• Reading chart isn’t significantly reduced

• Getting to the unit early What not to delegate?

• Receiving inter-shift report  Complex assignments
• Using your worksheet  Unpredictable outcomes

2. Setting daily priorities  Increased risk of harm

• Make initial quick rounds  Problem-solving and creativity
• Immediately after shift report, verify
3. Assessing and re-assessing
critical information
• Identify urgent problems
• Assess with and open mind

• List your patient’s major problems in

• It is fine to use critical paths, but nurses
should be able to identify and manage care
relation to expected outcomes for the day variances
• Determine the interventions that must
be done to prevent, resolve or manage the 4. Performing interventions and making
problem necessary changes
Interventions may be:
• Decide what things the patient and/or
• Independent
significant others can do on their own and things
you must do by yourself • Dependent
• Make personal worksheet for getting • Collaborative
things done for the day and refer
Interventions may be:
• Psychological
DELEGATING • Spiritual
Transferring to a competent individual the • Social
authority to perform selected tasks in a situation
while retaining accountability for results
• Interventions may be:
Five Rights of Delegation
• Promotive
• RIGHT Task
• Preventive
• RIGHT Person
• Curative
• RIGHT Situation
• Rehabilitative
• RIGHT Communication
• RIGHT Evaluation
1. Base nursing interventions on scientific
Delegate with full knowledge of: standards knowledge, nursing research and
of care, specific job descriptions, knowledge professional standards of care
of competencies of delegatees
2. Clearly understand the interventions to be - Essential for client safety.
implemented and question any that are not - Record in conventional manner (eg, 9:00 am or
understood 3:15 pm) or in military clock (24 hour clock)
3. Adapt activities to the individual client which avoids confusion about whether a time
4. Implement safe care was am or pm.
5. Provide teaching, support and comfort • TIMING
6. Be holistic - Done as soon as possible after an assessment
7. Respect the dignity of the client and enhance or intervention.
the client’s esteem - No recording should be done before providing
8. Encourage clients to participate actively in nursing care.
implementing nursing interventions • LEGIBILITY
- All entries must be legible and easy to read to
5. Charting prevent interpretation errors.
• Communicate care - All entries on the client’s record are made in
• Help identify patterns dark ink so that the record is permanent and
changes are identified.
• Provide basis for evaluation
- Dark ink reproduces well on microfilm and in
• Create legal document duplication processes.
• Supply validation for insurance • ACCEPTED TERMINOLOGY
purposes - Use only commonly accepted
Types of Charting abbreviations, symbols, and terms that are
• Source-Oriented – caregivers of specified by the agency.
different disciplines’ charting - When in doubt about whether to use an
• Focus charting – specifies concerns of abbreviation, write the term in full until certain
patients (Ex. DAR-data, Action, Response) about the abbreviation.
• Multidisciplinary – different disciplines • CORRECT SPELLING
write on the same form - Essential for accuracy in recording.
• Flow sheet – monitoring (if none specify - If unsure how to spell a word, look it up in a
so) dictionary or other resource book.
• Charting by exception (CBE) • SIGNATURE
- Includes the name and title; for example,
• Addendum Sheets (Patients education “Lorivi May C. Cruz, RN” or “LMC Cruz, RN.”
plan, Discharge Instructions)
- The following title abbreviations are
• Computerized Patient Records (CPR) / often used but nurses need to follow agency
Electronic Medical Records (EMR) policy about how to sign their names.
Memory Jogs Used for Charting RN registered nurse
• AIR-A (Assessment, Intervention, LVN licensed vocational nurse
Response, Action) LPN licensed practical nurse
NA nursing assistant
• DIE (Data, Intervention, Evaluation) NS nursing student
• PIE (Problem, Intervention, Evaluation) PCA patient care associate
SN student nurse
• SOAP, SOAPIE (Subjective/Objecctie • ACCURACY
data, Assessment, Plan, Intervention, - Notations on records must be accurate and
Evaluation) correct. Accurate notations consists of facts or
observations rather than opinions or
• Keep your data up-to-date and interpretations.
constantly evaluate Example:
Fact: “refused medication” opinion:
• DATE AND TIME observation: “was crying” interpretation: “was
- Similarly, when a client expresses worry about nursing care but also follow agency policy and
the diagnosis or problem, this should be quoted procedures for intervention and documentation
directly on the record: “Stated: ‘I’m worried about in all situations – especially high risk situations.
my leg.’ ”
- When describing something, avoid general 6. Giving report
words, such as large, good or normal, which Change of shifts report should be accurate,
can be interpreted differently. factual and organized
Example: chart specific date such as “2cm x 3 Endorsements
cm bruise” rather than “ large bruise.” • Inter-shift reports
- When recording mistake is made, draw a line
through it and write the words • Intra-shift reports
mistaken entry above or next to the original
entry, with your initials or name GUIDELINES: CHANGE OF SHIFT REPORT
(depending on agency policy) • Use a written printed guide
- Do not erase, blot out, or use correction fluid.
- The original entry must remain visible. • Begin by giving a general background
- Write on every line but never between lines. information
- If a blank appears in a notation, draw a line
through the blank space and sign the
• Be specific
notation • If you make an inference back it up with
• SEQUENCE evidence
- Document events in the order in which they
occur; for example, record assessments, then
• Describe the status of all invasive lines
nursing interventions, and then the client’s • Stress abnormal findings
- Record only information that pertains to the
client’s health problems and care. Evaluation
- Recording irrelevant information may be • A critical, careful and deliberate
considered an invasion of the client’s privacy appraisal of various aspects of patient care
and/or libelous.
• Involves examining all of the steps of
the nursing process
- Nurses’ notes need to reflect the nursing
- Record all assessments, dependent and
independent nursing interventions, client • Determining outcome achievement
problems, client comments and responses to
interventions and tests, progress towards goals,
• Identifying variables affecting outcome
and communication with other members of the achievement
health team. • Deciding whether to discharge patient or
- Care that is omitted because of the client’s to continue care
condition or refusal of treatment must also be
recorded. Document what was omitted, why it is STEPS IN EVALUATION
omitted, and who was notified. 1. Determine current health status and
• CONCISENESS readiness to test for outcome achievement
- Recording need to be brief as well as complete 2. List the outcomes set forth in planning
to save time in communication. 3. Compare what the patient is able to do in
Client’s name and the word client are omitted. relation to the outcome.
Example ”Perspiring profusely. Respirations 4. Decide the extent of outcome achievement
shallow, 28/min.” by asking the following questions
End each thought or sentence with a period.  Have the outcomes been completely
- For the best legal protection, the nurse should  Have the outcomes been partially met
nit only adhere to professional standards of
 Have the outcomes not at all been met ?
5. Record your findings on the patient’s record. Focuses on the setting in which the care was
What effect does the setting have on the quality
• Outcome studies the results or
outcomes of care
• Process studies how the care had been Nurses’ Role in Preventing Mistakes
given • Think analytically
• Structure studies the setting where carre • Remember that how you document is
had been rendered important
OUTCOME EVALUATION • Work on your own personal
Focuses on demonstrable changes improvement
“How many clients undergoing hip repairs MISTAKES
develop pneumonia?” • SENTINEL EVENTS an unexpected
“How many clients who have a colostomy incident which cause the death or serious
experience an infection that delays discharge? physical or psychological injury to the client
PROCESS EVALUATION • NEAR MISS anything that happened
Focuses on how the care was given during the process of care that didn’t affect the
EXAMPLES outcome, but for which a reoccurrence carries a
“Is the care relevant to the client’s needs? significant chance of a serious adverse outcome
“Is the care appropriate, complete and timely? • HAZARDOUS CONDITION any set of
circumstances which significantly increases the
STRUCTURE EVALUATION likelihood of a serious adverse outcome