THE NURSING

PROCESS
Daniel francis despojo sustento, rn, usrn
 THE NURSING PROCESS
Daniel francis despojo sustento, rn, usrn

CARE
NURSING PROCESS
STEPS
ASSESSMENT
COLLECT



DEVELOP
PLANNING
 THE
ASSESSMENT
ASSESSMENT
C
O
L
ASSESSMENT
L
E
C
T
 ASSESSMENT

INITIAL FIRST
SUBSEQUENT FOLLOW-UP
 DATA COLLECTION

#1 Observation
5 senses
 DATA COLLECTION

#1 Observation
NO SE
SMELL
 DATA COLLECTION

#1 Observation
e a rS
HEAR
 DATA COLLECTION

#1 Observation
TAS TE
TONGUE
 DATA COLLECTION

#1 Observation
NO T I S E
TOUCH
 DATA COLLECTION

#1 Observation
IS
SIGHT
 DATA COLLECTION

#2 Interview
communication
2-3 feet
 DATA COLLECTION

#2 Interview
questions
Open ended vs
Closed ended questions
 DATA COLLECTION

#2 Interview
types
Directive vs Non directive
 DATA COLLECTION

#3 Physical Examination
examination
IPPA
 DATA COLLECTION

#3 Physical Examination
types
Cepahalocaudal vs Systemic
 DATA COLLECTION

#4 Medical Record Review

charts
Health Team
 DATA COLLECTION

#4 Medical Record Review

Data of 2 types
Objective vs Subjective
 DATA COLLECTION

#4 Medical Record Review

Data sources of 2 types
Primary vs Secondary
 ASSESSMENT

DATA VALIDATION
Double Checking
 ASSESSMENT

DATA ORGANIZATION
Arrange Systemically
 ASSESSMENT

DATA DOCUMENTATION
Record Accurately
Types of nsg
ASSESSMENT
 NURSING ASSESSMENT

INITIAL Comprehensive
ASSESSMENT Upon Admission
 NURSING ASSESSMENT

PROBLEM Specific Problem

-FOCUSED Continuously
 NURSING ASSESSMENT

EMERGENCY Fast-paced
ASSESSMENT Life and Death
 NURSING ASSESSMENT

TIME-LAPSED Compare I & C

ASSESSMENT 3-4 mos p discharge
 THE
diagnosis
diagnosis

A
N
A
DIAGNOSIS
L
Y
S
E
 diagnosis

NURSING
DIAGNOSIS
patient’s response to health problems
 diagnosis
Antecedent to, associated with,
Diagnostic Label
contributing to, abetting / Problem
Impaired Airway Clearance
related to retained mucus secretions
as manifested by rales on auscultation

Etiology / Cause

Signs & Symptoms / Defining Characteristics

Types of nsg
diagnoses
 diagnosis

ACTUAL NSG. DX
Existing
 diagnosis

RISK NSG. DX
May exist
 diagnosis

HEALTH PROMOTION NSG. DX

WELLNESS NSG. DX
Enhance health
 diagnosis

POSSIBLE NSG. DX
Noticeable but lacks
evidence
 diagnosis

SYNDROME NSG. DX
Collection of Nursing
Diagnoses
 diagnosis

Impaired Airway Clearance

related to retained mucus secretions
as manifested by rales on auscultation
 diagnosis

Risk for Impaired Skin Integrity

related to total body paralysis
 diagnosis

Potential for Enhanced

Community Coping
 diagnosis

Possible Fluid Volume Excess

related to unknown etiology
 diagnosis

Rape Trauma Syndrome

 THE outcome
identification
OUTCOME IDENTIFICATION
I
D
E
OUTCOME
N
T
I
F
Y
OUTCOME IDENTIFICATION

3 PHASES:
1. PRIORITY SETTING
2. MAKING GOALS
3. MAKING OUTCOMES
 PRIORITY SETTING

HIGH Life and Death

MEDIUM Serious Injury
LOW Minor Care
Priority setting
principles
PRIORITY SETTING principles

MASLOW’S HIERARCHY
OF NEEDS
“Keep them breathing,
“Physiologic FIRST,
keep them safe”
Psychologic LAST”
PRIORITY SETTING principles

PRINCIPLE OF ABC
“Airway FIRST, Breathing
NEXT, Circulation LAST”
PRIORITY SETTING principles

PRINCIPLE OF
OCCURENCE
“Focus on the HERE & NOW
rather than on what is
ABOUT TO OCCUR”
OUTCOME IDENTIFICATION

3 PHASES:

1. PRIORITY SETTING

2. MAKING GOALS
3. MAKING OUTCOMES
 MAKING GOALS & OUTCOMES
NURSING
ITEM STANDARD DESCRIPTION EXAMPLE
LANGUAGE

Nursing
To establish
GOAL Outcome Broad
adequate hydration
Classification

Will be able to
consume 1,500-
OUTCOMES Indicators SMART
2,000 mL of water
in 24 hours
Types of
outcomes
 TYPES OF OUTCOMES

SHORT-TERM OUTCOMES
Easily achievable
 TYPES OF OUTCOMES

LONG-TERM OUTCOMES
Takes longer
THE pLanning
 planning

NURSING
PLANNING
CARE PLAN
Types of
planning
TYPES OF planning

INITIAL PLANNING
Initial NCP
 TYPES OF planning

ONGOING PLANNING
Update NCP
 TYPES OF planning

DISCHARGE PLANNING
NCP after discharge
Types of ncp
 TYPES OF NCP

INFORMAL NCP
Nurse’s mind
TYPES OF NCP

FORMAL NCP
Written
 TYPES OF NCP

STANDARDIZED NCP
Clients with the same
condition
 TYPES OF NCP

INDIVIDUALIZED NCP
Specific client
Types nursing
interventions
TYPES OF nsg interventions

NURSE-INITIATED INT.
INDEPENDENT NSG INT
No prescription
TYPES OF nsg interventions

PHYSICIAN-INITIATED INT.
DEPENDENT NSG INT
With prescription
 TYPES OF nsg interventions

COLLABORATIVE INT.
INTERDEPENDENT NSG INT
Working with the HEALTH
TEAM
TYPES OF nsg interventions

Perform passive leg exercises

TYPES OF nsg interventions

Tramadol 50 mg SLOW IVTT

every 6 hours
TYPES OF nsg interventions

Physical therapy TID

Categories of
nursing
interventions
categories OF nsg int

OBSERVATION INT.
Assessment
categories OF nsg int

PREVENTION INT.
Complication prevention
and
Risk factor reduction
categories OF nsg int

TREATMENT INT.
Cure
 categories OF nsg int

HEALTH PROMOTION INT.

Wellness
categories OF nsg int

Non-weight bearing exercises

30 minutes per session at least
3-5 times a week
categories OF nsg int

Avoid foods high in CHON

categories OF nsg int

Pace daily activities

categories OF nsg int

Digoxin 5 mcg/tab, 1 tab daily

categories OF nsg int

Assess TPR-BP
categories OF nsg int

Measure abdominal girth before

breakfast
PRINCIPLES IN
DELEGATING
PRINCIPLES OF DELEGATING

Act of transferring
tasks
PRINCIPLES OF DELEGATING

“Only the responsibility

is DELEGATED not the
ACCOUNTABILITY”
PRINCIPLES OF DELEGATING

Delegate according to
level of EXPERTISE or
EDUCATION
PRINCIPLES OF DELEGATING

NURSE NURSE ASSISTANT

Assessment
Diagnosis Stable Patients
Planning Routine Bedside Care
Evaluation Routine Assessment
Documentation Assistance in ADL
Sterile Procedures
 THE
IMPLEMENTATION
 IMPLEMENTATION

N
S
G
IMPLEMENTATION
I
N
T
IMPLEMENTATION
SKILLS
IMPLEMENTATION SKILLS

INTELLECTUAL SKILLS
Mind
IMPLEMENTATION SKILLS

TECHNICAL SKILLS
Hands
IMPLEMENTATION SKILLS

INTERPERSONAL SKILLS
Heart
THE evaluation
evaluation

M
E
A
EVALUATION
S
U
R
E
 evaluation

MET, PARTIALLY MET, NOT MET

Conclusion
GOAL NOT MET :
Urinary output 300 mL / 24 hours

Evidence
 Types of
evaluation
Types of evaluation

1. QUALITY ASSURANCE
2. QUALITY IMPROVEMENT
3. NURSING AUDIT
 QUALITY
ASSURANCE
 QUALITY ASSURANCE

QUALITY ASSURANCE
3 CATEGORIES OF
QUALITY
ASSURANCE
3 CAT. OF QUALITY ASSURANCE

STRUCTURE Environment
EVALUATION

PROCESS Performance of Care

EVALUATION

OUTCOME Result of Care

EVALUATION
 QUALITY
IMPROVEMENT
 QUALITY IMPROVEMENT

QUALITY IMPROVEMENT
 QUALITY IMPROVEMENT
CONTINUOUS QUALITY

IMPROVEMENT (CQI)
TOTAL QUALITY
MANAGEMENT (TQM)
PERFORMANCE

IMPROVEMENT (PI)
PERSISTENT QUALITY
IMPROVEMENT (PQI)
NURSING AUDIT
 NURSING AUDIT

NURSING AUDIT
RECORDS REVIEW
 TYPES OF
NURSING AUDIT
 NURSING AUDIT

CONCURRENT During
AUDIT

RETROSPECTIVE After
AUDIT

PEER Fellow nurses

REVIEW
 NURSING AUDIT

“If care was NOT

RECORDED, it was NOT
PERFORMED”
Recording
 recording

PATIENT’S
RECORDINGCharting
R esearch
E ducation
C ommunication
O dit (audit)
R eimbursement
D ata to court
 recording

1. Too many unofficial abbreviation

2. If writing is not legible
3. If client refuses to its use
Types of
charting
 NARRATIVE Story-telling
CHARTING

FOCUS Problem Strengths

CHARTING

SOAPIER
SOAPIE SOAP
Subjective, Objective,
CHARTING CHARTING Assessment, Planning

PIE Problem, Interventions,

CHARTING Evaluation
BY EXCEPTION Significant / abnormal
CHARTING
Types of
records
 Types of records

SOURCE-ORIENTED
RECORD

PROBLEM-ORIENTED
RECORD

CASE MANAGEMENT
RECORD

ELECTRONIC
RECORD
 Types of records

SOURCE-ORIENTED
RECORD

Each health SEPARATE

team member SHEET
 Types of records

Doctor’s Order Sheet Rehabilitation Notes Nurse’s Notes

 Types of records

S
SOURCE-ORIENTED
RECORD
T
O
R Narrative Charting
Y
 Types of records

PROBLEM-ORIENTED
RECORD

Health Problem
 Types of records

Assessment Database Problem List

Care Plan Progress Notes

 Types of records

P
PROBLEM-ORIENTED
RECORD
E
R
L
A SOAP Charting
 Types of records

CASE MANAGEMENT
RECORD

Critical
TOOL
Pathways
 Types of records

Assessment Database Problem List

__ Pallor __ Hyperthermia
__ Jaundice __ Hypothermia
__ Pinkish __ Fluid Vol. Excess
__ Reddish __ Fluid Vol. Deficit

Care Plan Outcomes

__ Assess TPR-BP __ Temp Increased
__ Perform TSB __ Temp Decreased
__ Apply Cold Packs __ Intake Increased
__ Apply Warm Pack __ Intake Decreased
 Types of records

CASE MANAGEMENT
RECORD

LONGEST

Charting by Exception
 Types of records

ELECTRONIC
RECORD

Computerized
 CHARTING
GUIDELINES
 CHARTING GUIDELINES

1. Chart briefly complete with date

and time.
2. Avoid using PATIENT.
3. Update entries in a timely fashion.
DO NOT CHART IN ADVANCE.
 CHARTING GUIDELINES

4. Avoid RELATIVE WORDS.

5. Avoid SPACES in between
entries. Place a line across the
spaces.
6. Sign entries with full name, title
and signature.
 CHARTING GUIDELINES

- urine specimen sent to

pharmacy dfs 7/1/11 12:05 am
laboratory
reporting
 rePORTING

REPORTING
EAM
Recording
documents
 ASSESSMENT Nursing History and
DATABASE Assessment
NURSING CARE Diagnoses, Interventions
PLAN and Outcomes
FLOW
Graphic Record, I&O
SHEETS Record, IV Flow Sheet

MEDICATION Ordered medication w/ dose,

route, freq. and duration
ADMIN. RECORD

Brief summary of care

KARDEX
management
 TYPES OF
reporting
 TYPES OF rePORTING

END-OF-SHIFT-REPORT
SUMMARY REPORT
TYPES OF rePORTING

NURSE’S ROUNDS
WALKING ROUNDS

Room
TYPES OF rePORTING

PROGRESS NOTES
NURSE’S NOTES
 TYPES OF rePORTING

DISCHARGE SUMMARY
DISCHARGE PLAN

Care
 TYPES OF rePORTING
Department or Hospital

REFERRAL SUMMARY

Care & Instructions

 TYPES OF rePORTING

CARE PLAN CONFERENCE

Nurses
 TYPES OF rePORTING

INCIDENT REPORT
OCCURENCE REPORT

Only
ItDo
isstate
done
not
It’sIt’s
just
tell
Be
what
to
notOBJECTIVE!
tales
an
prevent
ayou
explanation.
DEMERIT.
nor
have
same
jump
observed.
thing
into
from happening
conclusions.
again.
 TYPES OF rePORTING

TELEPHONE
COMMUNICATION
7/11/11 5:03 pm
T.O.: Give Digoxin 5 mcg, 1 tab per orem daily
J. Smith, M.D. / D.F. Sustento, RN / M.J. Genzola, RN

within 24 hours