FUNDAMENTALS OF NURSING 3.

Plan of Care - the initial list of orders or plan of care is made with
reference to the active problems.

4. Progress Notes - is a chart entry made by all health professionals

involved in client’s care; it has different format:

DOCUMENTING/RECORDING AND  SOAP – subjective, objective data, analysis, and planning

REPORTING  SOAPIE or SOAPIER – soap with interventions,
evaluation, and revision
“Effective communication among health professionals is vital to the  PIE – problems, interventions, and evaluations
quality of client care.”
ADVANTAGES OF POMR
Discussion - is an informal oral consideration of a subject by two or
 encourages collaboration
more health care personnel to identify a problem or establish
 the problem list in the front of the chart alerts caregivers to
strategies to resolve a problem.
the client’s needs and make it easier to track the status of its
Report – an oral, written, or computer-based communication intended problems.
to convey information to others.
DISADVANTAGES OF POMR
Record – is a written or computer-based.
 caregivers differ in their ability to use the required charting
Recording – also called charting or documenting; the process of format
making an entry on a client record.  takes constant vigilance to maintain an up-to-date problem
list
Clinical Record – also called chart or client record; it is a formal and  is inefficient because assessments and interventions that
legal document that provides evidences of a client’s care. apply more than one problem must be repeated

Focus Charting – is intended to make the client and client concerns

ETHICAL AND LEGAL PRINCIPLES and strengths the focus of care; 3 columns for recording (date and
“The nurse has a duty to maintain confidentiality of all patient time, focus, and progress note).
information” It utilizes DAR (data, action, and response)
“The client’s record is also protected legally as a private record of the Example:
client’s care.”
DATE/HOUR FOCUS PROGRESS NOTE
“Access to the record is restricted to health professionals involved in 2/11/2016 – pain Data: guarding
giving care to the client” 9:00 AM abdominal incision;
facial grimacing; rates
“The institution or agency is the rightful owner of the client’s record” pain at “8” on scale of
1-10
PURPOSES OF CLIENT RECORDS Action: administered
morphine sulfate 4mg
Communication, planning client care, auditing health agencies, IV
research, education, reimbursement, legal documentation, and health 9:30 AM Response: rates pain at
care analysis. “1” states willing to
ambulate
DOCUMENTATION SYSTEMS
Source-oriented Record - the traditional client’s record; each person Charting by Exception – a documentation system in which only
or department makes notations in a separate section/s of the client’s abnormal or significant findings or exceptions to norms are recorded;
record. incorporates 3 key elements:

Example: the admission dept. – admission sheet 1. Flow sheets - like graphic record, fluid balance record, daily
nursing assessment record, client teaching record, client discharge
Narrative Charting - the traditional part of the source-oriented record and skin assessment record
record; consists of written notes that include routine care, normal
findings, and client problems. 2. Standard of nursing care – the agency’s printed standards of
nursing practice
Problem-oriented Medical Record (POMR) – the data arranged
according to the problems the client has rather than the source of the 3. Bedside access to chart forms – all flow sheets are kept at the
information; established by Lawrence Weed in the 1960’s; it has 4 client’s bedside
basic components:
Computerized Documentation – developed as a way to manage the
1. Database - consists of all information known about the client when huge volume of information required in contemporary health care;
the client first enters the health care agency. nurses use computers to store the client’s database, add new data,
create, and revise care plans and document client progress.
2. Problem List - problems are listed in the order in which they are
identified, and the list is continually updated as new problems are Case Management – emphasizes quality, cost-effective care delivered
identified and others are resolved. within an established length of stay; uses multidisciplinary approach
to planning and documenting client care using critical pathways.
DOCUMENTING NURSING ACTIVITIES ANA standards of Nursing 1973 - referred to a five-step process:
assessing, diagnosing, planning, intervention, and evaluation
1. Admission Nursing Assessment – an initial database, nursing
history, or nursing assessment, is completed when the client is Gebbie and Lavin 1975 - formulated the 5 phases: assessment,
admitted to the nursing unit. nursing diagnosis, planning, intervention, and evaluation.

Process – a series of planned actions or operations directed towards a

particular result or goal.
2. Nursing Care Plans – has 2 types:
Nursing Process – a systematic and rational method of planning and
 Traditional Care Plans – written for each client; has 3 providing individualized nursing care.
columns (nursing diagnosis, expected outcomes, and
nursing interventions) PURPOSES OF NURSING PROCESS
 Standardized Care Plans – were developed to save
documentation time  to identify a client’s health status, actual or potential health
care problems or needs.
3. Kardexes – widely used and concise method of organizing and  to establish plans to meet the identified needs, and;
recording data about a client, making information quickly accessible  to deliver specific nursing interventions to meet those
to all health professionals; consists of a series of cards kept in a needs.
portable index file or on a computer-generated form.  it is the underlying scheme that provides order and
4. Flow Sheets - enables nurses to record nursing data quickly and direction to nursing care.
concisely and provides an easy-to-read record of the client’s  it is the essence of professional nursing practice.
condition over time; it includes graphic record, intake and output  it has been conceptualized as a systematic series of
record, medication administration record, and skin assessment independent nursing actions directed toward promoting an
record. optimum level of wellness for the client.
 it is cyclical; the components follow a logical sequence, but
5. Progress Notes – made by nurses to provide information about the more than one component may be involved at any one time.
progress a client is making toward achieving desired outcomes.
 it helps nurses in arriving at decisions and in predicting and
evaluating consequences.
GENERAL GUIDELINES FOR  it was developed as a specific method for applying a
RECORDING scientific approach or a problem-solving approach to
nursing practice.
Date and time, timing, legibility, permanence, accepted terminology,
correct spelling, signature, accuracy sequence, appropriateness, PHASES OF THE NURSING PROCESS – Assessment, Diagnosis,
completeness, conciseness, and legal prudence. Planning, Implementation, and Evaluation.

REPORTING CHARACTERISTICS OF THE NURSING

Purpose – to communicate specific information to a person or group PROCESS
of people.
 Data from each phase provide input into the next phase
Change of Shift Reports – is given to all nurses on the next shift; to  The nursing process is client centered
provide continuity of care.  The nursing process is an adaptation of problem solving
Telephone Reports – reports done through telephone. and systems theory
 Decision making is involved in every phase of nursing
Telephone Orders – orders made by physicians through telephone; process
transcribed onto the physician’s order sheet and should be counter  The nursing process is interpersonal and collaborative
signed within 24hrs.  The universally applicable characteristics of nursing
process means that it is used as a framework for nursing
Care Plan Conference – a meeting of a group of nurses to discuss
care in all types of health care settings, with clients of all
possible solutions to certain problems of a client.
age groups
Nursing Rounds – are procedures in which two or more nurses visit  Nurses must use variety of critical-thinking skills to carry
selected clients at each client’s bedside. out the nursing process.
 It is cyclical and dynamic
 It is planned
 It is goal directed
NURSING PROCESS  It permits creativity for the nurse and the client in devising
ways to solve the stated health problem
Lydia Hall - the first to use the term “Nursing Process” in 1955.  It emphasizes the feedback, which leads either to
Johnson 1959, Orlando 1961, and Wiedenbach 1963 – the first to use reassessment of the problem or to revision of the care plan.
it to refer to a series of phases describing the process of Nursing.  It is universally applicable.

Catholic University of America, Yura and Walsh in !976 - published BENEFITS OF THE NURSING PROCESS
the first comprehensive book in Nursing Process describing the 4
steps: assessment, planning, intervention, and evaluation. Clients – by improving the quality of care they receive.

Nurse – enables the nurse to use time and resources efficiently.

 2. Objective Data – referred to as signs or over data. Are detectable
by an observer o can be measured or tested against an accepted
standard. Can be seen, heard, felt or smelled and they are obtained by
observation or physical examination.

Examples: a discoloration of the skin and bp reading during physical

examination.
ASSESSMENT - is the systematic and continuous,  Constant Data – is information that does not change over
collection, organizing, validation and documentation of data; a time such as race or blood type.
continuous process carried out during all phases of the nursing  Variable Data – can change quickly, frequently or rarely
process. such as bp, age, and level of pain.
TYPES OF ASSESSMENT SOURCES OF DATA
Initial Assessment – performed within specified time after admission 1. Primary Source – the client.
to a health care agency.
2. Secondary Source – family members, friends, and caregivers;
Purpose: to establish a complete database for problem identification, client records; health care professionals; and literature.
reference, and future comparison.
DATA COLLECTION METHODS
Example: Nursing admission assessment.
Observation/ Observing – to gather data by using the senses; a
Problem-Focused Assessment – ongoing process integrated with conscious, deliberate skill that is developed through effort and with
nursing care. an organized approach.
Purpose: to determine the status of a specific problem identified in Interviewing – a planned communication or a conversation with a
earlier assessment. purpose.
Example: Hourly assessment of client’s fluid intake and urinary Example: to get or give information, identify problems of mutual
output in ICU. concern, evaluate change, teach, provide support, and provide
counseling or therapy.
Time Lapsed Reassessment – done several months after initial
assessment.

Purpose: to compare the client’s current status to baseline data TYPES OF INTERVIEW QUESTIONS
previously obtained.
1. Closed Questions – are restrictive and generally require only “yes”
Example: Reassessment on client’s functional health patterns in a or “no” or short factual answers giving specific information. Often
home care or outpatient setting or in a hospital at shift change. begins with “when”, “where”, “who”, “what”, “do, did, does” or “is,
are, was”.
Emergency Assessment – during any physiologic or psychologic
crisis of the client. Examples: “What medication did you take?”, “Are you having pain
now?”, “How old are you?”.
Purpose: to identify life-threatening problems and identify new or
overlooked problems. 2. Open-ended Questions – invite clients to discover, explore,
elaborate, clarify, or illustrate their thoughts or feelings. Often begins
Example: Rapid assessment of a person’s airway, breathing status,
with “what” or “how”.
and circulation during cardiac arrest.
Examples: “How have you been feeling lonely?”, “What brought you
ACTIVITIIES OF ASSESSMENT
to the hospital?”, “What would you like to talk about?”.
1. Collecting Data – the process of gathering information about a
3. Neutral Questions – is a question the client can answer without
client’s health status; it must be both systematic and continuous to
direction or pressure from the nurse, is also an open-ended.
prevent the omission of significant data and reflect a client’s
changing health status. Examples: “How do you feel about that?” and “Why do you think
you had the operation?”
Database – all information about a client; includes the nursing health
history, physical assessment, primary care provider’s health history 4. Leading Questions – by contrast, is usually closed, and directs the
and physical examination, result of laboratory and diagnostic tests, client’s answer.
and material contributed by other health personnel.
Examples: “You’re stressed about the surgery tomorrow, aren’t you?”
TWO TYPES OF DATA and “You will take your medicines, will you?”
1. Subjective Data – referred to as symptoms or covert data. Apparent STAGES OF INTERVIEW
only to the person affected and can be described or verified only by
that person. Include the client’s sensation, feelings, values, beliefs, 1. The Opening – the most important part of the interview; what is
said and done at that time sets the tone for the reminder of the
attitudes, and perception of personal health and life situations.
interview. The purposes are to establish rapport and orient the client.
Examples: itching, pain, and feelings of worry
2. The Body – the client communicates what he or she thinks, feels,
knows, and perceives in response to questions from the nurse.

3. The Closing – the nurse terminates the interview when the needed
information has been obtained.

Examining – also known as the “Physical Examination” or “Physical

Assessment”; a systematic data collection method that uses
observation or detect health problems.

Instead of giving a complete examination, the nurse may focus on a

specific problem area noted from the nursing assessment. Alternately,
the nurse may perform a screening examination.

Screening examination – also called the review of systems. A brief

review of essential functioning in a various body parts or systems.