FUNDAMENTALS OF NURSING

By: Oscar R. Reyes II, MSN, RN, CNN

NURSING PROCESS à ADPIE

- systematic, rational method of planning and providing nursing care.
-refers to a series of phases describing the practice of nursing.
- the cornerstone of nursing profession

PURPOSES:
1. To identify client’s health status and actual or potential health care problems or needs.
2. To establish plans to meet the identified needs, and
3. To deliver specific nursing intervention to meet those needs.

CLIENT OF CARE: IFC (individual, family, community)

HISTORY:
¡ Lydia Hall - originated the term Nursing Process in 1955. She introduced three-steps of nursing
process: note observation, ministration of care, validation.
¡ Dorothy Johnson - introduced three steps of nursing process as follows: assessment, decision, nursing
action (1959).
¡ Ida Jean Orlando - identified three steps of nursing process: client's behavior, nurse's reaction, nurse's
actions (1961).
¡ Yura and Walsh - suggested the four components of nursing process namely, assessing, planning,
implementing and evaluating (1967).
¡ Knowles - described nursing process as discover, delve, decide, do discriminate (1967).
¡ American Nurses Association introduced the following innovations in the nursing process:
¡ Diagnosis distinguished as separate step of nursing process (1973).
¡ Diagnosis of actual and potential health problems delineated as integral part of nursing practice (1980).
¡ Outcome identification differentiated as a distinct step of the nursing process. Therefore, the six steps of
the nursing process are as follows: Assessment, Diagnosis, Outcome Identification, Planning,
Implementation, Evaluation (2010).

5 PHASES/ STEPS OF NURSING PROCESS (ADPIE)

1. A-SSESSMENT
2. D-IAGNOSIS/ANALYSIS
3. P-LANNING
4. I- MPLEMENTATION/ INTERVENTION/ INTERVENING
5. E-VALUATION

CHARACTERISTICS OF NURSING PROCESS

A) KOZIER (C2 UFI U)
*C-yclic and Dynamic- each phase provide input into the next phase
>CYCLIC- regularly repeated events
>DYNAMIC- continuously changing
*C-lient centered- organize plan of care according to client’s problem
*U-niversally Applicable- used as framework for nursing care
*F-ocus on problem solving and decision making
*I- nterpersonal collaborative- communicate in client, families, etc.
*U-se of critical thinking and clinical reasoning- very important in nursing process

B) UDAN (GOSH EE)

*G-oal oriented
*O-rganized
*S-ystematic composed of sequential and interrelated steps
*H-umanistic- individualized plan of care
à EFFICIENT AND EFFECTIVE NURSING CARE

Nursing care plan – blueprint of the nursing process

1. ASSESSMENT (COVD)
-collection, organization, validation and documentation of data.
-is a continuous process carried out during all phases of the nursing process

* 4 TYPES OF ASSESSMENT (IPET)

TYPE TIME PURPOSE EXAMPLE

I-NITAL after admission complete database nursing admission
ASSESSMENT assessment
P-ROBLEM FOCUSED- ongoing process determine specific hourly I&O in patient in
problem status ICU
E-MERGENCY during physiologic/ identify life threatening assess ABC
psychologic crisis problems suicidal tendencies
T-IME LAPSED several months after compare current status to reassessment
initial assessment baseline data

a) C-ollection of Data
-gathering info. about a client’s health status
*DATABASE- all information about a client
includes: -nursing health history (Biographical Data, Present Health/ Illness, Past History, Family History,
Psychosocial History, Review of Body Systems)
-physical assessment
-primary care providers history and physical examination
-results of laboratory and diagnostic tests
-material contributed by other health personnel

*TYPES OF DATA (SOCV)

1. S-UBJECTIVE DATA- also called as Symptoms/ Covert Data
-verified only by the patient
ex. pain, itching, feelings of worry, sensation, feelings, values, beliefs, attitudes
2. O-BJECTIVE DATA- also called as Signs/ Overt Data
-measurable and observable
ex. discoloration of the skin, BP 120/80, Temperature 41 degree Celsius
3. C-ONSTANT DATA- does not change over time
ex. blood type, race
4. V-ARIABLE DATA- can change quickly
ex. vital signs, age, level of pain

*SOURCES OF DATA
1. Primary Source- clientà best source of data
2. Secondaryà support people, client records, healthcare professionals, literature
*Support People- useful if pt is too young, too ill, confused
*Client Records-medical records, therapy and laboratory records
*Healthcare professionals- nurses, social workers, primary health providers <sharing information among
professionals ensure continuity of care
*Literature- review of nursing/ related literature, journals

*DATA COLLECTION METHODS (OIE)

1. O-bservation –gather data by using senses
Vision- overall appearance, facial/ body gestures, skin color/lesions
Smell- body/ breathe odors
Hearing- lung sounds, heart sounds, bowel sounds, ability to communicate
Touch- skin temperature, skin moisture, muscle strength, pulse rate, palpatory lesions

2. Interviewing -planned communication

-conversation with a purpose à get information, identify problem, teach, provide support and
therapy and counseling

Focused interview – the nurse asks the client specific questions to collect information related to the client’s
problem.

*2 TYPES OF INTERVIEW
1. Directive- nurse controls, get specific information
- used when time is limited (emergency situation)
2. Non Directive- rapport building interview
- client control the interview
*RAPPORT- understanding between two or more people

*TYPES OF INTERVIEW QUESTION (CONL)

1. Closed Questions- require only yes or no
-give short, factual answers giving specific information
-- directive interview
2. Open Ended Question- invite client to discover, explore, elaborate feelings and thoughts
>What? How?
-- non directive interview
3. Neutral Question-client can answer without direction and pressure; open-ended and non directive
>How?
4. Leading Question-client has less opportunity to decide weather the answer is true or not; closed
ended/directive
>Aren’t you? Won’t you?

*PLANNING THE INTERVIEW AND SETTING (TP SA DL)

CONSIDER: TIME, PLACE, SEATING ARRANGEMENT, DISTANCE, LANGUAGE

1. TIME- when client is physically comfortable and free from pain

-minimal interruptions

2. PLACE- well lighted, well ventilated

-free of distractions
-place where others cannot overhear or see client

3. SEATING ARRANGEMENT- *client in bed- 45 degree angle to bed

*initial admission- overbed table between
*standing and looking down at a client can be intimidating
Proxemics – study of space
4. DISTANCE- neither too small or too far
-pts feel uncomfortable when talking to someone who is too close or too far away
-2 to 3 feet during interview
-also varies in ethnicity
8-12 inches- Arab 24 inches- Britain
18 inches- US 36 inches- Japan

5. LANGUAGE-convert medical terminology into common English usage

-interpreters/ translators if nurse don’t speak the same language or dialect

*STAGES OF AN INTERVIEW (OB C)

1. Opening-most important part

-establish RAPPORT that will create trust and goodwill (greeting, self-introduction)
-orient the interviewee (purpose, what info. needed, how long it will take, how info. will be used)

2. Body- client communicates what he/she thinks, feels, knows, perceives

-nurse use communication techniques that make both parties feel comfortable

3. Closing-terminates interview when needed information has been obtained

-important for maintaining trust/ rapport and for facilitating future interactions

TECHNIQUES TO CLOSE THE INTERVIEW

1. Offer to answer questions (do you have any questions?)
2. Conclude ( Well, that’s all I need to know for now)
3. Thank the client (Thank you for your time and help)
4. Express concern (Take care of yourself)
5. Plan for next meeting (I’ll be here to see you on Monday)
6. Summary/ Summarize (Lets review what we have just covered in this interview…)

3. Examining-systematic data collection method that uses observation to detect health problems
-major method used in physical health assessment

TECHNIQUES: (IPPA) -general

Abdomen - IAPePa

I-nspectionàassessing by the use of sense of sight

P-alpationàexamining by sense of touch using fatpads of the finger
P-ercussionàtapping body part to produce sounds
A-uscultationàlistening to body sounds with the use of stethoscope

Diaphragm - High pitched sounds à normal

Bell – Low pitched sounds à abnormal
PALPATION – using hands to touch and feel
Light Palpation § Place your dominant hand lightly on the surface of the structure.
§ There should be very little or no depression (less than 1 cm).
§ Use this technique to feel for pulses, tenderness, surface skin texture,
temperature, and moisture.
Moderate Palpation § Depress the skin surface 1 to 2 cm (0.5
to 0.75 inch) with your dominant hand, and use a circular motion to feel for
easily palpable body organs and masses.
§ Note the size, consistency, and mobility of structures you palpate.
Deep Palpation § Place your dominant hand on the skin surface and your nondominant hand on
top of your dominant hand to apply pressure
§ Surface depression between 2.5 and 5 cm (1 and 2 inches) to feel very deep
organs or structures that are covered by thick muscle.
Bimanual Palpation § Use two hands, placing one on each
§ side of the body part (e.g., uterus, breasts, spleen) being palpated
§ Use one hand to apply pressure and the other hand to feel the structure. Note
the size, shape, consistency, and mobility of the structures you palpate.

Parts of Hand to Use When Palpating

Fingerpads Fine discriminations: pulses, texture, size, consistency, shape, crepitus
Ulnar or palmar surface Vibrations, thrills, fremitus
Dorsal (back) surface Temperature

Percussion.- tapping body parts to produce sound waves.

Direct direct tapping of a body part with one or two fingertips to elicit possible tenderness (e.g.,
tenderness over the sinuses).
Blunt to detect tenderness over organs (e.g., kidneys) by placing one hand flat on the body surface
and using the fist of the other hand to strike the back of the hand flat on the body surface.
Indirect or The tapping done produces a sound or tone that varies with the density of underlying
mediate structures.
As density increases, the sound of the tone becomes quieter.
Solid tissue produces a soft tone, fluid produces a louder tone, and air produces an even
louder tone.
Plexor
pleximeter
Percussion Sounds
Resonance heard over part air and part solid Normal lung
Hyper-resonance Heard over mostly air Lung with emphysema
Tympany heard over air Puffed out cheek, gastric bubble
Dullness Heard over more solid tissue Diaphragm, pleural effusion, liver
Flatness Heard over very dense tissue Muscle, bone, sternum, thigh
3 WAYS OF EXAMINING

1. Cephalocaudal- “head to toe approach”

head-neck-thorax-abdomen-extremities-toes
2. Body System- respiratory system, circulatory system, nervous system, etc.
3. Screening examination- “review of systems”
-brief review of essential functioning (nursing admission assessment form)

b) O-rganizing data
-nurses use an organized assessment framework.

*11 Typology of Functional Health Pattern (Gordon)

1.Health perception/ Health Management-describes the clients perceived pattern of health and well-being and
how health is managed.
2.Nutritional/ Metabolic Pattern-describes client’s pattern of food and fluid consumption.
3.Elimination Pattern-describes pattern of excretory function (bowel, bladder and skin).
4.Activity-Exercise Pattern-describes pattern of exercise, activity, leisure and recreation.
5.Sleep-Rest Pattern-describes pattern of sleep, rest and relaxation
6.Cognitive-Perceptual Pattern-describes sensory-perceptual and cognitive patterns.
7.Self Perception/ Self Concept Pattern-describes client’s self concept and perception of self pattern (self-
worth, comfort, body image, feeling state).
8.Role-relationship Pattern-describes pattern of participation and relationship.
9.Sexuality-reproductive Pattern-describes client’s pattern of satisfaction and dissatisfaction with sexuality
patterns; describes reproductive patterns.
10.Coping/ Stress- tolerance Pattern-describes client’s general coping pattern and effectiveness of pattern in
terms of stress tolerance.
11.Values-beliefs Pattern-describes patterns of values, beliefs and goal that guide the client’s choices or
decisions.

*Abraham Maslow’s Hierarchy of Needs

Self-actualization

Self esteem

Love and belongingness

Safety and Security

Physiologic Needs- FONBERS

(fluid, oxygen, nutrition, body temperature, elimination, rest & sleep)

c) V-alidating Data- double checking or verifying data to ensure that it is accurate and factual
(C2 D2 R)
C-ompare- subjective vs. objective
C-larify- ambiguous/ vague statement
D-ouble check- extremely abnormal data
D-etermine factors that may interfere accurate measurement
R-eferences- explain phenomena
*differentiate CUES from INFERENCES!
CUES- are subjective or objective data that can be directly observed by the nurse
INFERENCES-are the nurse’s interpretation or conclusion based on the cues

d) D-ocumenting Data
-data are recorded in a factual manner and not interpreted by the nurse.
-for example, the nurse must record the client’s intake as “coffee 240 ml, juice 120 ml, 1 egg and 1 slice of
toast” rather than as “appetite good” or “normal appetite” a judgment.
F-actual
A-ctual
T-imely

2. DIAGNOSIS/ DIAGNOSING
- statement or conclusion regarding the nature of phenomena.
- provides basis for the selection of nursing intervention.

NANDA (North American Nursing Diagnosis Association)

-define, refine and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses.
A taxonomy is a classification system or set of categories arranged based on a single principle or set of principles.

*DIAGNOSTIC LABELS-standardized NANDA names for diagnoses

*DIAGNOSING-reasoning process
*NURSING DIAGNOSIS- diagnostic label + etiology

***TYPES OF NURSING DIAGNOSIS (WARPS)

TYPE DESCRIPTION EXAMPLE

W-ellness Dx -describes human responses to level -Readiness for Enhanced Spriritual Well-
of wellness in an individual, family being
or community that have a readiness -Enhanced Family Coping
for enhancement
A-ctual Dx -problem is present -Ineffective Breathing Pattern
Problem-focused (+) signs/ symptoms -Anxiety
R-isk Dx -problem does not exist, but the -Risk for infection
present of risk factors indicates a
problem is likely to develop unless
nurses intervene
P-ossible Dx -health problem is incomplete or -Possible Social Isolation r/t unknown
unclear etiology
S-yndrome Dx -associated with a cluster of other Chronic Pain Syndrome
diagnosis Post-trauma Syndrome
Frail Elderly Syndrome

***COMPONENTS OF NURSING DIAGNOSIS (PED)

P-roblem (diagnostic label)

- describes client’s health problem or response for nursing therapy given.

PURPOSE: to direct the formation of client’s goals and desired outcomes.

àQualifiers- word that have been added to NANDA labels to give additional meaning. (DIDIC)

D-eficient (inadequate in amount, quality or degree; not sufficient; incomplete)

I- mpaired (made worse, weakened, damaged, reduced, deteriorated)
D- ecreased ( lesser in size, amount, degree)
I- neffective ( not producing the desired effect)
C- ompromised ( to make vulnerable to threat)

E-tiology (related factors/ risk factors)

-identifies one or more probable causes of health problem, gives direction to the required nursing therapy and
enables the nurse to individualized nursing care.

D-efining Characteristics
-cluster of signs and symptoms that indicate the presence of a particular diagnostic label
 • P-problem
• R-related to factors
• S-signs and symptoms
• P-problem
• E –etiology
• S-signs and symptoms

***DIAGNOSTIC PROCESS
-uses critical thinking skills of analysis and synthesis
*Critical Thinking- cognitive process during which a person reviews data and considers explanation before
forming an opinion.
*Analysis- separation into components; breaking down of the whole into its parts ( deductive reasoning)
*Synthesis- putting together parts into whole (inductive reasoning)

3 STEPS OF DIAGNOSTIC PROCESS ( AIF)

1. A-nalyze Data
2. I-dentifying health problems, risk, strengths
3. F-ormulating Diagnostic Statements

1. A-nalyzing Data
A) Compare data against standards
B) Cluster Cues
C) Identify gaps and inconsistencies

A) Compare data against standard and norms

TYPE OF CUE CLIENT CUES STANDARD/NORM

Deviation from population F- 5’2 in height, 240 lbs F- 5’2 in height -108-121 lbs
norms (ideal weight)
Dysfunctional behavior Teen (16 y/o) not left the room Adolescents usually liked to be
for 2 days as verbalized by the with their peers
mother
Developmental Delay Child 17 months old, still cannot Children usually speak their first
speak as verbalized by the parent word by 10-12 months
Changes in usual health status States “I’m not hungry these Client usually eats three balanced
days” meals per day
Changes in usual behavior Reports that his husband angers Husband usually relaxed and
easily easygoing

B) Cluster Cues
- combining data from different assessment areas to form a pattern and organizing subjective and objective data
into appropriate categories
- nurse interprets meaning of cues, label the cue clusters with tentative diagnostic hypothesis
C) Identifying Gaps and Inconsistencies in Data
- Final check to ensure that data are complete and correct.
Possible sources: measurement error, expectations, and inconsistent or unreliable reports.
E.g. Nursing history- not seen doctor in 15 years, stated my doctor takes my BP every year

2. I-dentifying Health Problems, Risk and Strengths

*Determining Health Problem and Risk
- after grouping and clustering data, nurse- client together identify problem
Ex. 1. Decreased urinary frequency and amount for two days
à possible urinary problem
2. Deficient Fluid Volume (urinary problem- eliminated)
*Determining Strengths
-when problem is already identified, taking inventory of strengths promotes self-concept and self-image.
-this strengths aid in mobilizing health and regenerative process
Ex. normal weight/ height, absence of allergies, being a non-smoker

3. F-ormulating Diagnostic Statements

a) One- part statement (Problem)
-consist of NANDA label only
-Wellness diagnosis, Syndrome diagnosis
e.g. Rape-Trauma Syndrome, Readiness for Enhanced Spiritual Well Being

b) Two- part statement (Problem + Etiology)

-are joined by the words Related to
e.g. Constipation related to prolonged laxative use, Severe anxiety related to threat to physiologic integrity;
possible cancer

c) Three- part statement (Problem + Etiology + Signs/ Symptoms)

-are joined by the word related to; and manifested by for the signs/ symptoms
e.g. Non Compliance ( Diabetic Diet) related to unresolved anger about diagnosis as manifested by:
S- “ I forget to take my pills”
“ I can’t live without sugar in my food”
O- Weight 98 kg (215 lbs)
BP- 190/ 100
VARIATIONS OF BASIC FORMAT
1. Unknown Etiology- does not know the cause
e.g. Noncompliance (Medication Regimen) related to unknown etiology

2. Complex Factors- too many etiologic factors

e.g. Chronic Low Self- Esteem related to complex factors

3. Possible- nurse believes more data are needed about clients problem/ needs
e.g. Possible Low Self-Esteem related to loss of job and rejection by family

4. Secondary to-divide etiology in 2 parts; more descriptive, useful; often pathophysiologic or disease process
or medical diagnosis
e.g. Risk for Impaired skin integrity related to decreased peripheral circulation secondary to diabetes

Outcome Identification - Refers to formulating and documenting measurable, realistic, client - focused goals. It
provides the basis for evaluating nursing diagnosis.
o Purposes:
• To provide individualized care.
• To promote client participation.
• To plan care that is realistic and measurable.
• To allow involvement of support people.

o Activities During Outcome identification:

• Establish priorities.
 • A priority is something that takes precedence in position, deemed the most important among several
items. Priority setting is a decision-making process that ranks the order of nursing diagnoses in terms
of importance to the client.
• Establishing priorities involve the following:
a. Life - threatening situations should be given highest priority, E.g., difficulty in breathing,
hemorrhage, suicidal tendencies.
b. Use the principle of ABC's (airway, breathing, circulation); airway should always be given the
highest priority.
c. Use Maslow's hierarchy of needs; Physiologic needs are given priority over psychosocial needs.
d. Consider something that is very important to the client, e.g. pain, anxiety.
e. Clients with unstable condition should be given priority over those with stable conditions. E.g.
attend to the client with fever before attending to the client who is scheduled for physical therapy
in the afternoon.
f. Consider the amount of time, materials, equipment required to care for clients, E.g., attend to the
client who requires dressing change for postop wound before attending to the client who requires
health teachings and is ready to be discharged late in the afternoon.
g. An actual problem takes precedence over potential concerns.
h. Attend to the client before equipment, E.g., assess the client before checking contraptions like IV
fluids, urinary catheter, drainage tubes.
• Nursing diagnoses are classified as high - priority, medium - priority, and low-priority.
• High - priority nursing diagnoses are those that are potentially life - threatening and require immediate
action. Examples include Impaired Gas Exchange, Ineffective Breathing Pattern, Self-Directed Risk for
Violence.
• Medium - priority nursing diagnoses are those that could result in unhealthy consequences, such as
physical or emotional impairment, but are not life -threatening. Examples include Fatigue, Activity
Intolerance, ineffective Coping, and Dysfunctional Grieving.
• Low - priority nursing diagnoses involve problems that usually can be resolved easily with minimal
interventions and are unlikely to cause significant dysfunction. Examples include sensation of hunger in
a client who is on NPO (nothing by mouth), in preparation for a diagnostic procedure; minimal pain on
the third postoperative day, related to ambulation.

3. PLANNING
- A deliberative, systematic phase of nursing process that involves decision making and problem solving.
NURSE refers à client’s assessment data and diagnostic statementsàformulating client’s goals àdesigning
interventionsà prevent, reduce or eliminate the client’s health problem
-productà NCP “blueprint of nursing process

***TYPES OF PLANNING (IOD)

I- NITIAL PLANNING
- admission assessment
-initial comprehensive plan of care
O-NGOING PLANNING
- done by all nurses who work with the client, occurs at the beginning of the shift as the nurse plans the care to
be given that day.
PURPOSES:
1. To determine whether the client’s health status has changed
2. To set priorities for the client’s care during the shift
3. To decide which problems to focus on during the shift
4. To coordinate the nurse’s activities so that more than one problem can be addressed at each client contact

D-ISCHARGE PLANNING
- the process of anticipating and planning for the needs after discharge

THE PLANNING PROCESS (SESI)

1. S-etting Priorities
2. E-stablishing Client’s Goal
3. S-electing Nursing Intervention
4. I-ndividualized Nursing Care Plan Writing

1. S-etting priorities
-a process of establishing a preferential sequence for addressing nursing diagnosis and intervention.
*High Priority- life- threatening
*Medium Priority- delayed development or causes physical and emotional changes
*Low Priority-arises from normal developmental needs or that requires minimal nursing support
Ex. Loss of cardiac function, Loss of respiratory function
Acute illness, Decreased coping ability

à Often use HIERARCHY OF NEEDS of Abraham Maslow

FACTORS TO CONSIDER:
1. Client’s Values and Beliefs- values concerning health may be more important to the nurse than to the client.
2. Client’s Priorities- involving client in prioritizing and care planning enhances cooperation.
3. Resources Available
4. Urgency of Health problem

2. E-stablishing Client’s Goal

GOAL (broad) Improve nutritional status
DESIRED OUTCOME (specific) Gain 5 lbs by Dec. 15, 2021

GOAL (broad) Improve knowledge regarding disease (Hypertension)

DESIRED OUTCOME (specific) Be able to discuss the factors that affect the disease
(Hypertension)
2 TYPES OF GOALS
1. SHORT TERM GOAL- can achieve in a short period of time (days/ less than a week)
(useful: pts that require healthcare for short time,pts frustrated with long term
goals)

2. LONG TERM GOAL- can achieve for weeks or months

(useful: who lives at home, with chronic problems, pts in nursing extended care
facilities, rehabilitation centers)

COMPONENTS OF GOAL/ DESIRED OUTCOME STATEMENT

1. Subject- a noun ( client, any part of client)
2. Verb- specifies an action the client is to perform
3. Conditions/ Modifiers- added to verb to explain –what, where, when, how?
4. Criterion of Desired Outcome- level at which client will perform specified behavior (time, speed, accuracy,
distance, quality)

Client walks the length of the hall without cane by date of discharge.
(December 1, 2009)

Client performs leg ROM exercises as taught every 8 hours

3. S-electing Nursing Intervention

-nurse perform to achieve client’s goals

***3 TYPES OF NURSING INTERVENTIONS

1. Independent or nurse-initiated interventions - are autonomous actions based on scientific rationale that
is executed to benefit the client in a predicted way related to the nursing diagnosis and client-centered goals.
These can solve the client’s problems without consultation or collaboration with physicians or other health
care professionals.
Example: the nurse gives health teachings on the ill effects of cigarette smoking, alcohol abuse and drug
abuse.

2. Dependent or physician-initiated interventions - are based on physician’s response to a medical diagnosis.

The doctor intervenes by carrying out physician’s written orders, but requires nursing judgment or decision
making.
Example: The nurse administers antibiotics to the client with infection

3. Interdependent or collaborative interventions - are therapies that require the knowledge, skill and
expertise of multiple health care professionals.
Example: The nurse assists the client in walking using crutches after conferring with the physical therapist.
CRITERIA FOR CHOOSING NURSING INTERVENTIONS

I- ndividual’s age, health, condition

T- herapies
S- afe Intervention
S- how respect (values/ beliefs)
A- chievable with resources available
F- irm adherance
E- evidenced based

4. Individualized NCP Writing

4. IMPLEMENTATION – action phase

-is putting the nursing care plan into action.
-an action phase in which nurse performs nursing intervention.
Purpose: To carry out planned nursing interventions to help the client attain goals and achieve optimal level of
health.

***Implementing Skills
1. Cognitive- include intellectual skills like problem solving, decision-making, critical thinking and creativity.
à Crucial to safe, intelligent nursing care
2. Interpersonal- nurse ability to communicate with others.
à caring, comforting, advocacy, referring, counseling/ supporting
3. Technical skills- hands on skills, tasks, procedures, and psychomotor skills.
à manipulating equipment, giving injections, bandaging, moving, lifting
4. Therapeutic use of self – is being willing and being able to care.

PROCESS IN IMPLEMENTING (RIDDS)

R- eassessing client
I- mplementing nursing intervention
D- etermine nurse’s need for assistance
D- ocumenting nursing activities
S- upervising nursing activities

1. Reassessing the client- to ensure prompt attention to emerging problems.

>just before implementing an intervention, nurse must reassess the client to make sure the intervention is still
needed.
Ex. Diagnosis ( Disturbed Sleep Pattern r/t Anxiety) à during rounds you see that the pt is sleeping à (X)
relaxation strategy
2. Implementing nursing intervention- it is important to explain the client the ff:
• What interventions will be done?
• What sensation to expect?
• What the expected outcome is?
***Always ensure patient’s privacy!!!

>>>When implementing nursing intervention, nurses should follow these guidelines. (ABC RE HIP).
A- dapt activities to the individual client
- client’s beliefs, values, age, health status and environment that can affect the success of a nursing action.
B- ased on scientific knowledge, research and professional standard of care
-rationale, possible side effects or complications
C- learly understand interventions to be implemented
-intelligent implementation of medical and nursing plan
R- espect dignity of client and enhance client’s self- esteem
-providing pricay and encouraging clients to make their own decision
E- ncourage patient to participate actively
-enhances client sense of independence and control but it varies (because
some patient may want total or little involvement.
***Amount of desired involvement may be related to:
• Severity of illness
• Client’s culture
 • Client’s fears
• Client’s understanding of the illness/ intervention
H- olistic
-nurse must view client as a whole and consider client’s responses in that context
I- mplement safe care
P-rovide teaching, support and comfort
-should explain purpose of intervention, what client will experience, how the client can participate
à increase responsibility for self-care
3. Determining nurse’s need for assistance- when implementing nursing intervention, nurse may need assistance
for one or more of the following reasons:
NURSE: Unable to implement
Assistance decreases stress of clients
Lacks knowledge/ skills
4. Documenting nursing activities-part of the agency’s permanent record for the client
-after carrying outà DOCUMENT!
*not done before implementation

5. Supervising nursing activities-if care is delegated to other healthcare personnel, the nurse is responsible for
client’s overall care and must ensure that activities have been implemented according to the care plan.
COMMUNICATE- documenting the client’s record
- reporting verbally
- filling out a written form
5. EVALUATION
-assessing client’s response to nursing progress toward healthcare and effectiveness of nursing care plan.

TYPES OF EVALUATION

1. Ongoing Evaluation- continuous

2. Initial Evaluation- specific intervals

3. Terminal Evaluation- evaluation at discharge

TYPES OF OUTCOMES

• The goal was completely met.

• The goal was partially met.
• The goal was completely unmet.
RACE MODEL

Recognize what information is in the stem. à TOPIC?

Recognize the key words in the stem. à X NEVER, ALL, ALWAYS, ONLY
Recognize who the client is in the stem. -à PATIENT FIRST!
ADPIE à FIRST/PRIORITY à ABC, UNSTABLE BEFORE STABLE, UNEXPECTED VS
EXPECTED, PAIN/ANXIETY,
Recognize what the topic is about.
Ask what is the question asking? à EXCEPT!, FIRST, PRIORITY, MOST, LESS, NOT
Ask what are the key words in the stem that indicate the need for a response?
Ask what is the question asking the nurse to implement? à ASSESS
Critically analyze the options in relation to the question asked in the stem. à
CONTRASTING; WHAT?; VERIFY, NEVER LEAVE YOUR PATIENT
Critically scrutinize each option in relation to the information in the stem. à SATA à
TRUE OR FALSE, YES OR NO
Critically identify a rationale for each option.
Critically compare and contrast the options in relation to the information in the stem
and their relationships to one another. à UMBRELLA EFECT
Eliminate as many options as possible.
Eliminate one option at a time.