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UNIT II - Processes in Nursing Care

1. Nursing Process
1.1 Overview of the Nursing Process

Collect data
Organize data
Validate data
Document data



Analyze data



risk, and strengths
Formulate diagnostic



Prioritize problems/diagnoses
Formulate goals/desired outcomes
Select nursing interventions
Write nursing orders
Reassess the client
Determine the nurses need for
Implement the nursing interventions
Supervise delegated cases
Document nursing activities
Collect data related to outcome
Compare data with outcomes
Relate nursing actions to client
Draw conclusions about problem status
Continue, modify, or terminate the
clients care plan

The nursing process in Action.

Overview of the Nursing Process

Phase and Description
validating, and documenting
client data


To establish a database about Establish a database:

the clients response to health Obtain a nursing health
concerns or illness and the
ability to manage health care Conduct a physical
Review client records
Consult support persons
Update data as needed
Organize data
Validate data

Analyzing and synthesizing To identify client strengths
and health problems that can
be prevented or resolved by
collaborative and independent
nursing interventions
To develop a list of nursing
and collaborative problems

Determining how to prevent,
reduce, or resolve the
identified client problems;
how to support client
strengths; and how to
organized, individualized,
and goal-directed manner


To develop an individualized
care plan that specifies client
goals/desired outcomes, and
related nursing interventions

Interpret and analyze data.

Compare data against
Cluster or group data
Determine clients strengths,
Formulate nursing diagnoses
and collaborative problem
Document nursing diagnoses
on the care plan.
Set priorities and goals/
outcomes in collaboration
with client
Write goals / desired
Select nursing strategies /
Write nursing orders and
nursing care plan
Communicate care plan to

Phase and Description

Carrying out the planned To assist the client to meet
nursing interventions
desired goals / outcomes;
promote wellness; prevent
illness and disease; restore
health; and facilitate coping
with related functioning

Measuring the degree to To determine whether to
which goals/outcomes have continue, modify, or terminate
and the plan of care
identifying factors that
positively or negatively
influence goal achievement

Reassess the client to update
the database.
Determine need for nursing
Perform planned nursing
Communicate what nursing
actions were implemented
Document care and
client responses to care
Give verbal reports as
Collaborate with client and
collect data related to
desired outcomes
goals/outcomes have been
Relate nursing actions to
client outcomes
problem status
Review and modify the care
terminate nursing care
Document achievement of
outcomes and modification
of the care plan.

2. Four (4) Related Activities of the Assessment Process

2.1 Collecting Data data can be subjective or Objective.
2.1.1 Types of data
1. Subjective data - also referred to as symptoms or covert data, are
apparent only to the person affected and can be described or verified
only by that person. Subjective data include the clients sensations,
feelings, values, beliefs, attitudes, and perception of personal health
status and life situation.
2. Objective data - also referred to as signs or overt data, are detectable
by an observer or can be measured or tested against an accepted
standard. They can be seen, heard, felt, or smelled, and they are obtained
by observation or physical examination.
2.1.2 Sources of data
The client is the primary source of data. Family members or other support
persons, other professionals, record s and reports, laboratory and diagnostic
analyses, analyses, and relevant literature are secondary or indirect sources.
In fact, all sources other than the client are considered secondary sources.

2.1.3 Methods of data collection

1. Observing
To observe is to gather data by using the senses. Observation is a
conscious, deliberate skill that is developed through effort and with
organized approach.
2. Interviewing
An interview is a planned communication or a conversation with a
purpose, for example, to get or give information, identify problems of
mutual concern, evaluate change, teach, provide, support, or provide
counseling or theory.
3. Examining
The physical examination or physical assessment is a systematic datacollection method that uses observation (i.e., the senses of sight, hearing,
smell, and touch) to detect health problems. To conduct the examination
the nurses uses techniques of inspection, auscultation, palpation, and
The physical examination is carried out systematically. It may be
organized according to the examiners preference, in a head-to-toe
approach or a body system approach.
The cephalocaudal or head-to-toe approach begins the examination at the
head, progresses to the neck, thorax , abdomen, and extremities, and ends
at the toes. The nurse using a body systems approach investigates each
system individually, that is, the respiratory system, the circulatory system,
the nervous system, and so on.
Alternatively, the nurse may perform a screening examination. A
screening examination, also called a review of systems, is a brief review of
essential functioning of various body parts or systems. An example of a
screening examination is the nursing admission assessment form.
2.2 Organizing data
2.2.1 Gordons Typology of 11 Functional Health Patterns
1. Health-perception/health-management pattern. Describes the clients
perceived pattern of health and well-being and how health is managed.
2. Nutritional/Metabolic pattern. Describes the clients pattern of food and
fluid consumption relative to metabolic need and pattern indicators of
local nutrient body.
3. Elimination pattern. Describes the patterns of excretory function (bowel,
bladder, and skin).
4. Activity/exercise pattern. Describes the 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 the clients selfconcept pattern and perceptions of self (e.g., self-conception,/worth,
comfort, body image, feeling state).
8. Role/relationship pattern. Describes the clients pattern of role
participation and relationships.

9. Sexuality/reproductive pattern. Describes the clients pattern of
satisfaction and dissatisfaction with sexuality pattern; describes
reproductive patterns.
10. Coping/stress tolerance pattern. Describes the clients general coping
pattern and the effectiveness of the pattern in terms of stress tolerance.
11. Value/belief pattern. Describes the patterns of values, beliefs (including
spiritual), and goals that guide the clients choices or decisions.
2.2.2 Orems Self-Care model
Universal Self-Care Requisites
1. The maintenance of a sufficient intake of air
2. The maintenance of a sufficient intake of water.
3. The maintenance of a sufficient intake of food.
4. The provision of care associated with elimination processes and
5. The maintenance of a balance between activity and rest.
6. The maintenance of a balance between solitude and social interaction.
7. The prevention of hazards to human life, human functioning, and human
8. The promotion of human functioning and development within the social
groups in accord with human potential, known human limitations, and
human desire to be normal. (Normalcy is used in the sense of that which
is essentially human and that which is in accord with the generic and
constitutional characteristics and the talents of individuals.)
2.2.3 Roys Adaptation Model
Adaptation Modes
1. Physiologic needs
Activity and rest
Fluid and Electrolytes
Regulation: Temperature
Regulation: the senses
Regulation: endocrine system
2. Self-concept
Physical self
Personal self
3. Role function
4. Interdependence

Data for Amanda Aquilini, Organized According to Functional Health

1. Health Perception/Health Management
Aware/understands medical diagnosis
Gives thorough history of illnesses and surgeries
Complies with Synthroid regimen
Relates progression of illness in detail
Expects to have antibiotic therapy and go home in a day or two
States usual eating pattern 3 meals a day
2. Nutritional/Metabolic
158 cm (5 ft, 2 in) tall; weighs 56 kg (125 lb)
Usual eating pattern 3 meals a day
No appetite since having cold
Has not eaten today; last fluids at noon

Oral temp 39.4 C (103 F)
Decreased skin turgor
3. Elimination
Usually no problem
Decreased urinary frequency and amount x 2 days
Last bowel movement yesterday, formed, states was normal
4. Activity/Exercise
No musculoskeletal impairment
Difficulty sleeping because of cough
Cant breathe lying down
States I feel weak
Short of breath on exertion
Exercises daily
5. Cognitive/Perceptual
No sensory deficits
Pupils 3 mm, equal, brisk reaction
Oriented to time, place, and person
Responsive but fatigued
Responds appropriately to verbal and physical stimuli
Recent and remote memory intact
States short of breath on exertion
Reports pain in lungs, especially when coughing
Experiencing chills
Reports nausea
6. Roles/Relationships
Lives with husband and 3-year-old daughter
Husband out of town; will be back tomorrow afternoon
Child with neighbor until husband returns
States good relationships with friends and coworkers
Working mother, attorney
7. Self-Perception/Self-Concept
Expresses concern and worry over leaving daughter with
neighbors until husband returns
Well-groomed, says, Too tired to put on makeup.
8. Coping/Stress
Anxious: I cant breathe
Facial muscles tense; trembling
Expresses concerns about work: Ill never get caught up
9. Value/Belief
No special practices desired except anointing of the sick
Middle-class, professional orientation
No wish to see chaplain or priest at present
10. Medication/History
Synthroid .1 mg per day
Client has history of appendectomy, partial thyroidectomy
11. Nursing Physical Assessment
28 years old
Height 158 cm (5 ft., 2 in); weight 56 kg (125 lb)
TPR 39.4C, 92,28
Radial pulses weak, regular
Blood pressure 122/80 sitting
Skin hot and pale, cheeks flushed
Mucous membranes dry and pale
Respirations shallow; chest expansion < 3 cm
Cough productive of small amounts of pale pink sputum

Inspiratory crackles auscultated throughout right upper and lower
Diminished breath sounds on right side
Abdomen soft, not distended
Old surgical scars; anterior, RLQ abdomen
2.2.5 Wellness Models
Nurses use wellness models to assist clients to identify health risks and to
explore lifestyle habits and health behaviors, beliefs, values, and attitudes
that influence levels of wellness. Such models generally include the
1. Health history
2. Physical fitness evaluation
3. Nutritional assessment
4. Life-stress analysis
5. Lifestyle and health habits
6. Health beliefs
7. Sexual health
8. Spiritual health
9. Relationships
10. Health risk appraisal
2.2.6 Nonnursing Models
Frameworks and models from other disciplines may also be helpful for
organizing data. These frameworks are narrower than the model required in
nursing; therefore, the nurse usually needs to combine these with other
approaches to obtain a complete history.
1. Body System Model. The body system model focuses on abnormalities
of the following anatomic systems:
Integumentary system
Respiratory system
Cardiovascular system
Nervous system
Musculoskeletal system
Gastrointestinal system
Genitourinary system
Reproductive system
Immune system
2. Maslows Hierarchy of Needs. Maslows hierarchy of needs clusters
data pertaining to the following:
Physiologic needs (survival needs)
Safety and security needs
Love and belonging needs
Self-esteem needs
Self-actualization needs
3. Developmental Theories. Several physical, psychosocial, cognitive, and
moral developmental theories may be used by the nurse in specific
Examples include the following:
Havighursts age periods and developmental tasks
Freuds five stages of development
Eriksons eight stages of development
Piagets phases of cognitive development
Kohlbergs stages of moral development

2.3 Validating Data

Definition of Terms:
Validation is the act of double-checking or verifying data to confirm
that it is accurate and factual. Validating data helps the nurse complete the
Cues are subjective or objective data that can be directly observed by
the nurse ; that is, what the client says or what the nurse can see, hear, feel,
smell, or measure.
Inferences are the nurses interpretation or conclusions made based on
the cues (e.g., a nurse observes the cues that an incision is red, hot, and
swollen ; the nurse makes the inference that the incision in infected).
2.4 Documenting Data
Accurate documentation is essential and should include all data collected about
the clients health status. Data are recorded in a factual manner and not
interpreted by the nurse.
3. Diagnosing
3.1 Definition
The term diagnosis is a statement or conclusion regarding the nature of
phenomenon. The standardized NANDA names for the diagnoses are called
diagnostic labels; and the clients problem statement, consisting of the diagnostic
label plus etiology (causal relationship between a problem and its related or risk
factors), is called a nursing diagnosis.
Nursing diagnosis a clinical judgment about individual, family, or community
responses to actual and potential health problems/life processes. Nursing diagnoses
provide the basis for selection of nursing interventions to achieve outcomes for
which the nurse is accountable.
3.2 Types of Nursing Diagnoses
The five types of nursing diagnoses are actual, risk, wellness, possible, and
An actual diagnosis is a client problem that is present at the time of the
nursing assessment. Examples are Ineffective Breathing Pattern and Anxiety.
An actual nursing diagnosis is based on the presence of associated signs and
3.2.2 A risk nursing diagnosis is a clinical judgment that a problem does not exist,
but the presence of risk factors indicates that a problem is likely to develop
unless nurses intervene. For example, all people admitted to a hospital have
some possibility of acquiring an infection; however a client with diabetes or
a compromised immune system is at high risk than others. Therefore, the
nurse would appropriately use the label Risk for Infection to describe the
clients health status.
3.2.3 A wellness diagnosis Describes human responses to levels of wellness in an
individual, family or community that have a readiness for enhancement.
Example of wellness diagnosis would be Readiness for Enhanced Spiritual
Well-Being or Readiness for Enhanced Family Coping.

3.2.4 A possible nursing diagnosis is one in which evidence about a health

problem is incomplete or unclear. A possible diagnosis requires more data
either to support or to refute it. For example, an elderly widow who lives
alone is admitted to the hospital. The nurse notices that she has no visitors
and is pleased with attention and conversation from the nursing staff. Until
more data are collected, the nurse may write a nursing diagnosis of Possible
Social Isolation related to unknown etiology.
3.2.5 A syndrome diagnosis is a diagnosis that is associated with a cluster of other
diagnoses. Currently six syndrome diagnoses are on the NANDA
International list. Risk for Disuse Syndrome, for example, may be
experienced by long-term bedridden clients. Clusters of diagnosis associated
with this syndrome include Impaired Physical Mobility, Risk for Impaired
Tissue Integrity, Risk for Activity Intolerance, Risk for Constipation, Risk for
Infection, risk for Injury, Risk for Powerlessness, Impaired Gas Exchange,
and so on.
3.3 Components of a NANDA Nursing Diagnosis
A nursing diagnosis has three components:
3.3.1 Problem (Diagnostic Label) and Definition
The problem statement, or diagnostic label, describes the clients health
problem or response for which nursing therapy is given. It describes the
clients health status clearly and concisely in a few words. The purpose of the
diagnostic label is to direct the formation of client goals and desired
outcomes. It may also suggest some nursing interventions.
3.3.2 Etiology (Related Factors and Risk Factors)
The etiology component of a nursing diagnosis identifies one or more
probable cause of the health problem, gives direction to the required nursing
therapy, and enables the nurse to individualize the clients care.
3.3.3 Defining Characteristics
Defining Characteristics are the cluster of signs and symptoms that indicate
the presence of a particular diagnostic label. For e actual nursing diagnoses,
the defining characteristic are the clients signs and symptoms. For risk
nursing diagnoses, no subjective and objective signs are present. Thus, the
factors that cause the client to be more than normally vulnerable to the
problem from the etiology of a risk nursing diagnosis.
3.4 Formulating Diagnostic Statements
3.4.1 Basic Two-Part Statements
The basic two-part statement includes the following:
1. Problem (P) : statement of the clients response (NANDA Label)
2. Etiology (E): factors contributing to or probable causes of the responses
The two parts are joined by the words related to rather than due to. The
phrase due to implies that one part causes or is responsible for the other
part. By contrast, the phrase related to merely implies a relationship.
Some examples of two-part nursing diagnoses are shown below:
Basic Two-Part Diagnostic Statement

Related to
Related to

Prolonged laxative use

Ineffective Breastfeeding

Related to

breast engorgement

Basic Three-Part Statements

The basic three-part nursing diagnosis statement is called the PES format
and includes the following:
1. Problem (P): statement of the clients response (NANDA Label)
2. Etiology (E): factors contributing to or probable cause of the response
3. Signs and Symptoms (s): defining characteristics manifested by the
Actual nursing diagnoses can be documented by using the three-part
statement because the signs and symptoms have been identified. This
format cannot be used for risk diagnoses because the signs and
symptoms of the diagnosis.
Basic Three-Part Statement


Related to
related to(r/t)



As manifested


Signs and Symptoms

criticism; states : I
dont know if I can dont
know if I can manage by
and rejects
positive feedback

The PES format is especially recommended for beginning diagnosticians

because the signs and symptoms validate why the diagnosis was chosen and
make the problem statement mores descriptive.
The disadvantage of the EPS format is that it can create very long problem
statements, thereby making the problem and etiology unclear.
3.4.3 One-Part Statements
Some diagnostic statements, such as wellness diagnoses and syndrome
nursing diagnoses, consist of a NANDA label only. As the diagnostic labels
are refined they tend to become more specific, so that nursing interventions
can be derived from the label itself. Therefore, an etiology may not be
needed. For example, adding an etiology to the label Rape-Trauma Syndrome
does not make the label any more descriptive or useful.
3.5 Ongoing Development of Nursing Diagnoses
The diagnoses are no longer grouped by Gordons pattern but by seven axes:
diagnostic concept, time, unit of care, age, health status, descriptor, and topology.
In addition, diagnoses are now listed alphabetically by concept, not by first word.
In 1997, NANDA changed the name of its official journal from Nursing Diagnosis
to Nursing Diagnosis: The International Journal of Nursing Language and
Classification./ The subtitle emphasizes that nursing diagnosis is part of a larger,
developing system of standardized nursing language. This system includes
classifications of nursing interventions (NIC) and nursing outcomes (NOC) that are
being developed by other research groups and linked to the NANDA diagnostic


The Seven axes:

Taxonomy II


Dimension of the Human

Diagnostic Concept

N = 99


Unit of care
Health status

N = 12
N = 26


N = 17 body

Anxiety, falls, nutrition, walking
Acute, chronic, intermittent,
Individual, family, group, community
Infant, adolescent, young old adult
Wellness, sick, actual
Anticipatory, deficient, imbalanced,
Cerebral, gustatory, renal, visual

4. Planning
4.1 Definition
Planning is a deliberate, systematic phase of the nursing process that involves
decision making and problem solving. In planning, the nurse refers to the clients
assessment data and diagnostic statements for direction in formulating client goals
and designing the nursing interventions required to prevent, reduce, or eliminate the
clients health problems.
4.2 Types of Planning
4.2.1 Initial Planning
The nurse who performs the admission assessment usually develops the initial
comprehensive plan of care. Planning should be initiated as soon as possible
after the initial assessment, especially because of the trend toward shorter
hospital stays.
4.2.2 Ongoing Planning
Ongoing planning is done by all nurses who work with the client. As nurses
obtain new information and evaluate the clients responses to care, they can
individualize the initial care plan further. Ongoing planning also occurs at the
beginning of a shift as the nurse plans the care to be given that day.
4.2.3 Discharge Planning
Discharge planning, the process of anticipating and planning for needs after
discharge, is a crucial part of a comprehensive health care and should be
addressed in each clients care plan.
4.3 Developing nursing Care Plan
4.3.1 An Informal nursing care plan is a strategy for action that exists in the nurses
mind. For example, the nurse may think, Mrs. Phan is very tired. I will need to
reinforce her teaching after she is rested.
4.3.2 A formal nursing care plan is a written or computerized guide that organizes
information about the clients care.
4.3.3 A standardized care plan is a formal plan that specifies the nursing care for
groups of clients with common needs (e.g., all clients with myocardial
4.3.4 An individualized care plan is tailored to meet the unique needs of a specific
client needs that are not addressed by the standardized plan.


4.4 Standardized Approaches to Care Planning

4.4.1 Standards of Care describe nursing actions for clients with similar medication
conditions rather than individuals, and they describe achievable rather than ideal
nursing care. They defines the interventions fore which nurse are held
accountable, they do not contain medical interventions. Standards of care are
usually agency records and not part of the clients care plan, but they may be
referred to in the plan (e.g., a nurse might write see unit standards of care for
cardiac catheterization).
4.4.2 Standardized care plans are reprinted guides for the nursing care of the client
who has a need that arises frequently in the agency (e.g., a specific nursing
diagnosis or all nursing diagnoses associated with a particular medical
condition). They are written from the perspective of what care the client can
expect. They should not be confused with standards of care. Although the two
have some similarities, they have important differences.
4.4.3 Protocols are reprinted to indicate the actions commonly required for a particular
group of clients. For example, an agency may have a protocol for admitting a
client to the intensive care unit, for administering magnesium sulfate to a client
with preeclampsia, or for caring for a client receiving continuous epidural
analgesia. Protocols may include both physicians order and nursing
4.4.4 Policies and Procedures are developed to govern the handling of frequently
occurring situations. For example, a hospital may have a policy specifying the
number of visitors a client may have.
4.4.5 A standing Order is a written document about policies, rules, regulations, or
orders regarding client care. Standing orders give nurses the authority to carry
out specific actions under certain circumstances, often wen a physician is not
immediately available.
4.5 Formats for Nursing Care Plans
Although formats differ from agency to agency, the care plan is often organized into
four columns or categories:
4.5.1 nursing diagnoses
4.5.2 goals/desired outcomes
4.5.3 nursing orders
4.5.4 evaluation
Some agencies use a three-column plan in which evaluation is done in the goals
column or in the nurses notes; others have a five-column plan that adds a column for
assessment data preceding the nursing diagnosis column.
4.6 The Planning Process
The nurse engages in the following activities:
4.6.1 Setting Priorities
Priority setting is the process of establishing preferential sequence for
addressing nursing diagnoses and interventions. Nurses frequently use Maslows
hierarchy of needs when setting priorities.
4.6.2 Establishing Client Goals (Desired Outcomes)
Goals/desired outcomes describe, in terms of observable client responses, what
the nurse hopes to achieve by implementing the nursing interventions. The term

goal/desired outcome are used interchangeably. Some references also use the
terms expected outcome, predicted outcome, outcome criterion, and objective.
Some nursing literature differentiates the terms by defining goals as broad
statements about the clients status and desired outcomes as the more
specific, observable criteria used to evaluate whether the goals have been
met. For example:
Goal (broad)
Improved nutritional status
Desired outcome (specific) Gain 5 lb. by April 25
1. The Nursing Outcomes Classification
Standardized nursing language is required in all phases of the nursing
process if nursing data are to be included in computerized databases that
are analyzed and used in nursing practice. Working toward this end,
researchers have developed a taxonomy, the Nursing Outcomes
Classification (NOC), for describing client outcomes that respond to
nursing interventions (Johnson, Maas, & Moorhead, 2002). In the
taxonomy, outcomes belong to one of seven domains.
A NOC outcome is similar to a goal in traditional language. It is a
measurable patient or family caregiver state, behavior, or perception that
is conceptualized as a variable and is largely influenced by and sensitive
to nursing interventions. The NOC outcomes are broadly stated and
conceptual. To be measured an outcome must be made more specific by
identifying the specific indicators that apply to a client. An indicator is
concrete, an observable patient state, behavior, or self-reported
perception or evaluation and is similar to desired outcomes in
traditional language. Indicators are also stated in neutral terms, but each
outcome includes a five-point scale ( a measure) that is used to rate the
clients status on each indicator.
2. Purpose of Desired Outcomes/Goals
Desired outcomes/goals serve the following purposes:
Provide direction for planning nursing interventions. Ideas for
interventions come more easily if the desired outcomes state clearly
and specifically what the nurse hopes to achieve.
Serve as criteria for evaluating client progress. Although developed in
the planning step of the nursing process, desired outcomes serve as
the criteria for judging the effectiveness of nursing interventions and
client progress in the evaluation step.
Enable the client and nurse to determine when the problem has been
Help motivate the client and nurse by providing a sense of
achievement. As goals are met, both client and nurse can see that their
efforts have been worthwhile. This provides motivation to continue
following the plan, especially when difficult lifestyle changes need to
be made.
3. Long-Term and Short-Term Goals
Short-term goal are useful for:
clients who require health care for a short time
those who are frustrated by long-term goals that seem difficult to
attain and who need the satisfaction of achieving a short-term goal.
Long - term goal are often used for clients who live at home and have
chronic health problems and for clients in nursing homes, extended

care facilities, and rehabilitation centers.
4. Components of Goal(Desired Outcome Statements)
Subject. The subject, a noun, is the client, any part of the client, or
some attribute of the client, such as the clients pulse or urinary
output. The subject is often omitted in goals; it is assumed that the
subject is the client unless indicated otherwise.
Verb. The verb specifies an action the client is to perform , for
example, what the client is to do, learn, or experience. Verbs that
denote directly observable behaviors, such as administer, show,
walk, must be used.
Conditions or modifiers. Conditions or modifiers may be added to
the verb to explain the circumstances under which the behavior is to
be performed. They explain what, where, when, or how. For
Walks with the help of a cane (how)
Criterion of desired performance. The criterion indicates the
standard by which a performance is evaluated or the level at which
the client will perform the specified behaviors. Examples are:
Weighs 75 kg by April (time).
Lists five out of six signs of diabetes (accuracy)
Walks one block per day ( time and distance)
Administers insulin using aseptic technique (quality)
5. Guidelines for Writing Goals / Desired Outcomes
Write goals and outcomes in terms of client responses, not nurse
activities. Beginning each goal statement with the client will may
help focus the goal on client behaviors and responses.
Correct: Client will drink 100 cc of water per hour (client
Incorrect: Maintain client hydration (nursing action)
Be sure that desired outcomes are realistic for the clients
capabilities, limitations, and designated time span, if it is indicated.
Ensure that the goals and the desired outcomes are compatible with
the therapies of other professionals.
Make sure that each goal is derived from only one nursing
Use observable, measurable, terms for outcomes.
Make sure the client considers the goals/desired outcomes
important and values them.
4.6.3 Selecting Nursing Interventions and Activities
Nursing interventions and activities are the actions that a nurse performs to
achieve client goals.
Types of Nursing Interventions
1. Independent Interventions are those activities that nurses are licensed to
initiate on the basis of their knowledge and skills. They include physical
care, ongoing assessment, emotional support and comfort, teaching,
counseling, environmental management, and making referrals to other
health care professionals. McCloskey and Bulechek (2000) refer to these
as nurse-initiated treatment


2. Dependent Intervention are activities carried out under the physicians

orders or supervision, or according to specified routines. McCloskey and
Bulechek (2000) call these physician-initiated treatments. Physicians
orders commonly include orders for medications, intravenous therapy,
diagnostic tests, treatments, diet, and activity. The nurse is responsible
for explaining, assessing the need for, and administering the medical
3. Collaborative Interventions are actions the nurse carries out in
collaboration with other health team members, such as physical
therapist, social workers, dietitians, and physicians. Collaborative
nursing activities reflect the overlapping responsibilities of, and
collegial relationship between health personnel.

Writing Nursing Orders

Nursing orders are instructions for the specific individualized activities the
nurse performs to help the client meet established health care goals. The term
order connotes a sense of accountability for the nurse who gives the order and
for the nurse who carries it out. Components of a nursing order are the
1. Date. Nursing orders are dated when they are written and reviewed
regularly at intervals that depend on the individuals needs.
2. Action Verb. The action verb starts the order and must be precise.
3. Content Area. The content is the what and the where of the order.
4. Time Element. The time element answers when, how long, or how often
the nursing action is to occur.
5. Signature. The signature of the nurse prescribing the order shows the
nurses accountability and has legal significance.
Types of nursing orders
1. Observation orders include assessments made to determine whether a
complication is developing, as well as observation of the clients
responses to nursing and other therapies. Some examples are
Auscultate lungs q8h, Observe for redness over sacrum q2h. and
Record intake and output hourly.
2. Prevention orders prescribe the care needed to prevent complications or
reduce risk factors. They are needed mainly for potential nursing
diagnoses and collaborative problems. Examples of prevention orders
are Turn, cough, and deep breathe q2h.
3. Treatment orders include teaching, referrals, physical care, and other
care needed to treat an actual nursing diagnosis. Some orders accomplish
either prevention or treatment functions, depending on the status of the
problem. If fundus is boggy, massage until firm can also be intended
to treat an actual postpartum hemorrhage.
4. Health promotion orders are appropriate when the client has no health
problems or when the nurse makes a wellness nursing diagnosis.

Discuss the importance of daily exercises and Explore infantstimulation techniques.
4.6.5 Delegating Implementation
The American Nurses Association defines delegation as the transfer of
responsibility for the performance of an activity from one person to another
while retaining accountability for the outcome. This differs from assignment
which is a downward or lateral transfer of both the responsibility and
accountability of an activity from one individual to another.
The nurse has two responsibilities in delegating and assigning:
1. appropriate delegation of duties (that is, giving people duties within their
scope of practice)
2. adequate supervision of personnel to whom work is delegated or assigned.
4.7 The Nursing Interventions Classifications it describes the efforts of the North
American Nursing Diagnosis Association (NANDA) to standardize the language for
describing problems that require nursing care and to create a taxonomy of standardized
client outcome labels. A group of nurse researchers also recognized the need for
standardized language to describe the interventions that nurses perform. A taxonomy
of nursing interventions referred to as the Nursing Interventions Classification
(NIC) taxonomy has been developed by the Iowa Intervention Project (McCloskey &
Bulechek, 2000). This taxonomy consists of three levels:
4.7.1 Level I, domains
4.7.2 Level 2, classes
4.7.3 Level 3, interventions

NIC Taxonomy
Level I: Domains
Domain 1
Physiological: Basic
Care that supports physical

Level 2: Classes (lettered for cross-referencing)

A. Activity and Exercise Management: Interventions to organize or
assist with physical activity and energy conservation and
B. Elimination Management: Interventions to establish and maintain
regular bowel and urinary elimination patterns and manage
complications due to altered patterns
C. Immobility Management: Interventions to manage restricted body
Movement and the sequelae
D. Nutrition Support: Interventions to modify or maintain nutritional
E. Physical Comfort Promotion: Interventions to promote comfort
using physical techniques
F. Self-Care Facilitation: Interventions to provide or assist with
routine activities of daily living
Domain 2
G. Electrolyte and Acid-Base Management: Interventions to regulate
Physiological: Complex
electrolyte/acid-base balance and prevent complications
supports H. Drug Management: Interventions to facilitate desired effects of
homeostatic regulation
pharmacological agents
I. Neurologic Management: Interventions to optimize neurologic
J. Perioperative Care: Interventions to provide care before, during,
and immediately after surgery
K. Respiratory Management: Interventions to promote airway
patency and gas exchange
L. Skin/Wound Management: Interventions to maintain or restore
tissue integrity

M. Thermoregulation: Interventions to maintain body temperature
within a normal range
N. Tissue Perfusion Management: Interventions to optimize
circulation of blood and fluids to the tissue
Level I: Domains
Level 2: Classes (lettered for cross-referencing)
Domain 3
O. Behavior Therapy: Interventions to reinforce or promote
desirable behaviors or alter undesirable behaviors
Care that supports psychoP. Cognitive Theory: Interventions to reinforce or promote desirable
Social functioning and
cognitive functioning or alter undesirable cognitive functioning
facilities lifestyle changes
Q. Communication Enhancement: Interventions to facilitate
delivering and receiving verbal and non verbal messages
R. Coping Assistance: Interventions to assist another to build on own
strength, to adapt to a change in function, or to achieve a higher
level of function
S. Patient Education: Interventions to facilitate learning
T. Psychological Comfort Promotion: Interventions to promote
comforts using psychological techniques
Domain 4
U. Crisis Management: Interventions to provide immediate shortSafety
term help in both psychological and physiological crisis
supports V. Risk Management: Intervention s to initiate risk-reduction
protection against harm
activities and continue monitoring risk over time
Domain 5
W. Childbearing Care: Interventions to assist in understanding
and coping with the psychological and physiological changes
Care that supports the
during the childbearing period
family unit
Z. Childbearing Care: Interventions to assist in child rearing
X. Lifespan Care: Interventions to facilitate family unit functioning
and promote the health and welfare of family members through
out the lifespan
Domain 6
Y. Health System Medication: Interventions to facilitate the inter Health System
Face between patient/family and the health care system
Care that supports effective a. Health System Management: Interventions to provide and
use of the health care
enhance support services for the delivery of care
delivery system
b. Information Management: Interventions to facilitate communi cation among health care providers
Domain 7
c. Community Health Promotion: Interventions that promote the
health of the whole community
Care that supports the d. Community Risk Management: Interventions that assist in
health of the community
detecting or preventing health risks to the whole community

Implementing and Evaluating

5.1 Definition
Implementing consists of doing and documenting the activities that are specific
nursing actions needed to carry out the interventions (or nursing orders).
5.2 Implementing Skills
5.2.1 The cognitive skills (intellectual skills) include problem solving, decision
making, critical thinking, and creativity. They are crucial to safe intelligent
nursing care.
5.2.2 Interpersonal skills are all of the activities, verbal and nonverbal, people uses
when interacting directly with one another.
5.2.3 Technical skills are hands-on skills such as manipulating equipment, giving
injections and bandaging, moving, lifting, and repositioning clients. These skills
are also called tasks, procedures, or psychomotor skills. The term psychomotor
includes the interpersonal component, for example, the need to communicate
with the client.
5.3 Process of Implementing
5.3.1 Reassessing the client
5.3.2 Determining the nurses need for assistance

5.3.3 Implementing the nursing interventions
5.3.4 Supervising the delegated care
5.3.5 Documenting nursing activities
5.4. Definition of Evaluation
Evaluating is a planned, ongoing, purposeful activity in which clients and health
care professionals determine:
5.4.1 the clients progress toward achievement of goals/outcomes
5.4.2 the effectiveness of the nursing process because conclusions drawn from the
evaluation determine whether the nursing interventions should be terminated,
continued, or changed.
5.5 Five Components of the Evaluation Process
5.5.1 Collecting data related to the desired outcomes (NOC indicators)
5.5.2 Comparing the data with outcomes
5.5.3 Relating nursing activities to outcomes
5.5.4 Drawing conclusions about problem status
5.5.5 Continuing, modifying, or terminating the nursing care plan
5.6 Evaluating the Quality of Nursing Care
5.6.1 Quality Assurance
A quality assurance (QA) program is an ongoing, systematic process
designed to evaluate and promote excellence in the health care provided to
clients. Quality assurance frequently refers to evaluation of the level of care
provided in a health care agency, but it may limited to the evaluation of the
performance of one nurse or more broadly involve the evaluation of the
quality of the care in an agency, or even in a country.
Quality assurance requires evaluation of three components of care:
1. Structure evaluation focuses on the setting in which care is given. It
answers this question: What affects does the setting have on the quality of
care? Structural
standards describe desirable environmental and
organizational characteristics that influence care, such as equipment and
2. Process evaluation focuses on how the care was given. It answers
questions such as these: Is the care relevant to the clients needs? Is the
care appropriate, complete, and timely? Process standards focus on the
manner in which the nurse uses the nursing process.
3. Outcome evaluation focuses on demonstrable changes in the clients
health status as a result of nursing care. Outcome criteria are written in
terms of client responses or health status, just as they are for evaluation
within the nursing process. For example, How many clients undergoing
hip repairs develop pneumonia? or How many clients who have a
colostomy experience an infection that delays discharge?
5.6.2 Quality Improvement
Quality improvement (QI) is also known as continuous quality
improvement (CQI), total quality management (TQM), performance
improvement (PI), or persistent quality improvement (PQI). According to
Schroeder , QI is the commitment and approach used to continuously
improve every process in every part of an organization, with the intent of
meeting and exceeding customer expectations and outcomes.
Unlike quality assurance, QI follows client care rather than organizational
structure, focuses on process rather than individuals, and uses a systematic
approach with the intention of improving the quality of care rather than
ensuring the quality of care. QI studies often focus on identifying and

correcting a systems problems, such as duplication of services in a hospital
or improving services.
5.6.3 Nursing Audit
An audit means the examination or review of record. A retrospective audit is
the evaluation of a clients record after discharge from agency. Retrospective
means relating to past events. A concurrent audit is the evaluation of a
clients health care while the client is still receiving care from the agency.
These evaluation use interviewing, direct observation of nursing care, and
review of clinical records to determine whether specific evaluative criteria
have been met.
Another type of evaluation of care is the peer review. In nurse peer review,
nurses functioning in the same capacity, that is, peers, appraise the quality of
care or practice performed by other equally qualified nurses. The peer
review is based on preestablished standards or criteria.
There are two types of peer reviews: individual and nursing audits. The
individual peer review focuses on the performance of an individual nurse.
The nursing audit focuses on evaluating nursing care through the review of
records. The success of these audits depends on accurate documentation;
auditors assume that if the data have been recorded, the care has not been

6. Documenting and Reporting

6.1 Definition of Terms
A report is oral, written, or computer-based communication intended to convey
information to others. For instance, nurses always report on clients at the end of a
hospital work shift.
A record is written or computer-based. The process of making an entry on a client
record is called recording, charting, or documenting.
6.2 Purposes of Client Records
6.2.1 Communication. This prevents fragmentation, repetition, and delays in
client care
6.2.2 Planning Client Care. Nurses use baseline and ongoing data to evaluate the
effectiveness of the nursing care plan.
6.2.3 Auditing Health Agencies. An audit is a review of client records for quality
assurance purposes.
6.2.4 Research The treatment plans for a number of clients with the same health
problems can yield information helpful in treating other clients.
6.2.5 Education. A record can frequently provide a comprehensive view of the
client, the illness, effective treatment strategies, and factors that affect the
outcome of the illness.
6.2.6 Reimbursement. This is not only facilitates reimbursement from the federal
government, but also from insurance companies and other third-party
6.2.7 Legal Documentation. The clients record is a legal document and is
usually admissible in court as evidence.
6.2.8 Health Care Analysis. Records can be used to establish the costs of various
services and to identify those services that cost the agency money and those
that generate revenue.


6.3 Documentation Systems

6.3.1 Source-Oriented Record
The traditional client record is a source-oriented record. Each person or
department makes notations in a separate section or sections of the clients
chart. For example, the admission department has an admission sheet; the
physician has a physicians order sheet, a physicians history sheet, and
progress notes; nurses use the nurses notes; and other departments or
personnel have their own records.
Narrative charting is a traditional part of the source oriented record. It
consists of written notes that include routine care, normal findings, and client
6.3.2 Problem-Oriented Medical Record
In the problem-oriented medical record (POMR), or problem-oriented
record (POR), established by Lawrence Weed in the 1960s, the data are
arranged according tot the problems the client has rather than the source of the
The advantage of POMR is that:
it encourages collaboration
the problem list in the front of the chart alerts caregivers to the
needs and makes it easier to tract the status of each problem
The disadvantages are that:
caregivers differ in their ability to use the required charting format
it is somewhat inefficient because assessment s and interventions that
to more than one problem must be repeated.
Four basic components of POMR
1. Database it includes the nursing assessment, the physicians history,
social and family data, and the results of the physical examination and
baseline diagnostic tests. Data are constantly updated as the clients
health status changes.
2. Problem list problems are listed in the order in which they are
identified, and the list is continually updated as new problems are
identified and others resolved.
3. Plan of care physician write physicians orders or medical care plans;
nurses write nursing orders or nursing care plans.
4. Progress notes is a chart entry made by all health professionals
involved in a clients care; they all use the same type of sheet for notes.
Progress notes are numbered to correspond to the problems on the
problem list and may be lettered for the type of data. For example, the
SOAP format is frequently used. SOAP is acronym for subjective data,
objective data, assessment, and planning.
S - Subjective data consist of information obtained from what the
client says. It describes the clients perceptions of and experience
with the problem. Subjective data are included only when it is
important and relevant to the problem.

O - Objective data consist of information that is measured or
observed by use of the senses (e.g., vital signs, laboratory and xray results)
A - Assessment is the interpretation or conclusions drawn about
the subjective and objective data.
P - The plan is the plan of care designed to resolve the stated
Over the years, the SOAP format has been modified. The acronyms
SOAPIE and SOAPIER refer to formats that add interventions,
evaluation and revision.

- Intervention refer to the specific interventions that have

actually been performed by the caregiver.
E - Evaluation includes the client responses to
interventions and medical treatments. This is primarily
reassessment data.
R - Revision reflects care plan modifications suggested by the
Evaluation. Changes may e made in desired outcomes,
interventions, or target dates.
6.3.3 PIE
The PIE documentation model groups information into three categories.
PIE is an acronym for problems, interventions, and evaluation of nursing
6.3.4 Focus Charting
Focus charting is intended to make the client and the client concerns and
strengths the focus of care. Three columns for recording are usually used:
date and time, focus, progress notes. The focus maybe a condition, a
nursing diagnosis, a behavior, a sign or symptom, an acute change in the
clients condition, or a client strength. The progress notes are organized
1. (D) Data
Data category reflects the assessment phase of the nursing process and
consist of observations of client status and behaviors including data flow
2. (A) Action
The action category reflects planning and implementation and includes
immediate and future nursing actions. It may also include any changes
to the plan of care.
3. (R) Response
The response category reflects the evaluation phase of the nursing
process and describes the clients response to any nursing and medical
6.3.5 Charting by Exception
Charting by Exception (CEB) is a documentation system in which only
abnormal or significant findings or exceptions to norms are recorded.
CBE incorporates three key elements:
1. Flow sheet. Examples of flow sheets include a graphic record, fluid
balance record, daily care record, client teaching record, client
discharge record, and skin assessment record.

2. Standards of nursing care. An agency using CBE must develop its own
specific standards of nursing practice that identify the minimum criteria
for client care regardless of clinical area.
3. Bedside access to chart forms. In the CBE system, all flow sheets are
kept at the clients bedside to allow immediate recording and to
eliminate the need to transcribe data from the nurses worksheet to the
permanent record.

6.3.6 Computerized Documentation

Computerized clinical record system are being developed as a way to
manage the huge volume of information required in contemporary health
care. Computers make care planning and documentation relatively easy.
6.3.7 Case Management
The case management model emphasizes quality, cost-effective care
delivered within an established length of stay. This model uses a
multidisciplinary approach to planning and documenting client care, using
critical pathways. These forms identify the outcomes that certain groups of
clients are expected to achieve on each day of care, along with the
interventions necessary for each day.
Along with critical pathways, the case management model incorporates
graphics and flow sheets. Progress notes typically use some type of charting
by exception. For example, if goals are met, no further charting is required.
A goal that is not met is called a variance. Variations are deviations to what
is planned on the critical pathway unexpected occurrences that affect the
planned care or the clients responses to care.
6.4 Reporting
The purpose of reporting is to communicate specific information to a person or
group of people. A report, whether oral or written, should be concise, including
pertinent information but no extraneous detail.
A change-of-shift-report is a report given to all nurses on the next shift.
6.4.2 Telephone Report
The nurse receiving a telephone report should document the date and time,
the name of the person giving the information, and the subject of the
information received and signs the notation. Telephone reports usually
include the clients name and medical diagnosis, change in nursing
assessment, vital signs related to baseline vital signs, significant laboratory
data, and related nursing interventions.
6.4.3 Telephone Orders
Physician often order a therapy (e.g., a medication) for a client by telephone.
Most agencies have specific policies about telephone orders. Many agencies
allow only registered nurses to take telephone orders.
While the physician gives the order, write it down and repeat it back to the
physician to ensure accuracy. Question the physician about any order that is
ambiguous, unusual (e.g., an abnormally high dosage of a medication), or
contraindicated by the clients condition.

6.4.4 Care Plan Conference
A care plan conference is a meeting of a group of nurses to discuss possible
solutions to certain problems of a client, such as inability to cope with an
event or lack of progress toward goal attainment.
6.4.5 Nursing Rounds
During round, the nurse assigned to the client provides a brief summary of
the clients nursing needs and the interventions being implemented.
2. Communication
2.1 Definitions
2.1.1 The basic element of human interactions that allows people to establish,
maintain and improve contacts with others
2.1.2 A complex, multifaceted , dynamic series of events involving behaviors and
relationships and allows individuals to associate with others through meanings
which are generated and transmitted
2.1.3 Verbal and nonverbal behavior with a social context and includes all symbols
and clues used by persons in giving and receiving meaning
2.1.4 Do not only refers to content but also to feelings and emotions that people may
convey in relationship
2.1.5 An act of sharing because it influences a relationship
2.1.6 An active process between sender and receiver
2.2 Levels of Communication
2.2.1 Intrapersonal occurs within the individual. It is self-talk or an internal
dialogue that occurs constantly and consciously. The goal is self-awareness,
which is influenced by self-concept and feelings of self worth.
2.2.2 Interpersonal interaction that occurs between 2 people or in a small group. It
is often face-to-face and is the most frequently used type in nursing situations.
It allow problem-solving, sharing of ideas, decision-making and personal
2.2.3 Public Communication interaction with large groups of people, e.g. giving a
lecture to a class of reviewees
2.3 Elements
2.3.1 Referent a stimulus which motivates a person to communicate with another.
May be an object, experience, emotion, idea or act.
2.3.2 Sender or encoder the person who initiates the interpersonal communication
or message
2.3.3 Message the information sent or expressed by the sender
2.3.4 Channels means of conveying messages, e.g., visual (facial expression),
auditory (spoken word) or tactile (touching) senses
2.3.5 Receiver or decoder person to whom the message is sent. To be effective, the
receiver must perceive or become aware of he message.
2.3.6 Feedback verbal and nonverbal response to the message. To be effective, the
sender and the receiver must be sensitive and open to each others message,
clarify the message and modify behavior accordingly
2.4 Modes
2.4.1 Verbal Communication involves spoken or written words
A. Language the words, their pronunciation and method or combining them
that is used and understood by a community
B. Effective verbal communication is simple, short and direct. Clarity is
achieved by speaking slowly and enunciating clearly

C. A message spoken in terms the client understands makes communication
more effective. Do not use medical terms when giving health teachings to
clients; if you must translate them to laymans terms
D. Denotative meaning one shared by individuals who use a common
language. A word that means the same to everyone.
E. Connotative meaning thoughts, feelings or ideas that people have about a
word. They are shades or interpretations of a words meaning rather its
definite definition

2.4.2 Nonverbal Communication transmission of message without the use of

words. Actions speak louder than words. One of the most powerful ways to
convey messages to others.
A. Metacommunication a message within a message that conveys the
senders attitude toward the self and the message, as well as the attitudes,
feelings and intentions toward the listener. Maybe verbal or nonverbal
B. Personal appearance of the first things noticed during an intrapersonal
encounter. People form an impression about another within 20 seconds to 4
minutes and 84% of this impression is based on appearance. Physical
characteristics, dress, grooming as well as jewelry and other adornment
provide clues to the persons physical well-being, personality, social status,
occupation, religion, culture and self concept. Physical characteristics, e.g.,
condition of hair, nails, skin or teeth, weight, energy level, etc. also
communicate information about the level of health, in fact, even
socioeconomic status
C. Intonation voice tone can be a clue to a clients emotional tone or energy
D. Facial expression the face and eyes send overt and subtle cues that assist
in interpretation of messages. Studies show that the face reveals 6 primary
emotions: surprise, fear, anger, disgust, happiness and sadness
E. Posture and Gait reflect attitudes , emotions, self-concept and physical
F. Gestures - a wave of a hand, a salute or shifting of feet are visual italics
which may emphasize, punctuate or clarify the spoken word. Three
functions of gestures: illustrate an idea; express an emotional state; or make
a signal
G. Touch a personal form of nonverbal communication. Affection,
emotional, support, encouragement, tenderness and personal attention can
be conveyed through touch. Touch, however, must be used with caution
because strong social norms govern its use. Who, when, why and where
people touch are determined by unwritten sociocultural guidelines
2.5 Characteristics of Communication
2.5.1 Credibility includes cognitive skills, interpersonal skills and right attitudes
2.5.2 Clarity messages should b clear and direct
2.5.3 Brevity brief and direct use few words
2.5.4 Simplicity use laymans term. Avoid medical terms
2.5.5 Timing and Relevance - information to be given, to the client should be
relevant to the clients health condition
2.5.6 Adaptability and Flexibility use various technique in communication with
client to adjust to the age or educational attainment of the client
2.5.7 Intonation the tone of voice may affect the interaction process. It provides
information about the persons mood
2.5.8 Pacing speak slow enough to convey the message clearly

2.6 Factors Influencing Communication
2.6.1 Development the environment provided by parents affects the ability to
2.6.2 Perception a personal view of events
2.6.3 Values standards that influence behavior, what a person considers important
in life and, therefore, influence expression of thoughts and ideas
2.6.4 Emotions a persons subjective feelings about events. They influence the
ability to successfully receive a message

2.6.5 Sociocultural background communication style is highly dependent on

cultural factors. e.g. a nurse can ask an American client directly without the
latter feeling offended., Are you gong to commit suicide? With a Filipino
suicidal patient, however, a nurse tends to diversional therapy rather than
confront the client
2.6.6 Gender men and women have different communication styles
2.6.7 Knowledge a common language is important when communicating across
different knowledge levels.
2.6.8 Roles and Relationships e.g., students talk with friends in a different way
than with teachers or parents.
2.6.9 Environment people tend to communicate more effectively in a comfortable
2.6.10 Space and Territoriality
A. Territoriality the drive to gain, maintain and defend an exclusive right to
an area or space. It provides people with a sense of identity, security and
B. Proxemics (Hall, 169) use of space in interpersonal relationships or the
distance between communicators. During social interactions, people
consciously maintain a distance between themselves (personal space).
When personal space is threatened, a defensive response occurs, thus
preventing effective communication
2.7 Functions of Communication in Nursing
2.7.1 To gather information
A. Collect assessment information on which to base diagnosis and decisionmaking
B. Use methods to provide information that promotes client understanding,
retention and comprehension
2.7.2 To expert influence use communication techniques when helping clients to
change attitudes, beliefs and actions
2.7.3 To provide comfort
A. Interact with clients to provide reassurance, support and comfort
B. Reduce a clients uncertainty during stressful times to alleviate or
moderate emotional distress
2.7.4 To promote relations
A. Interact to define control and modify the relationship between nurse and
B. Establish, maintain, repair and end relationships
2.7.5 To establish identity
A. Establish self-identities to present oneself in ways that build credibility
and produce friendliness, respect and nurturing
B. Present oneself in a way that reflects competency
2.8 Methods of effective Nursing Communication
2.8.1 Listen attentively

2.8.2 Convey acceptance do not judge another person and demonstrate
willingness to listen to the clients beliefs, values and practices
2.8.3 Ask related questions
2.8.4 Paraphrase restate clients messages in order to convey to the client that you
understood his message
2.8.5 Clarify repeat the message or admit you did not understand and then let the
client repeat his message
2.8.6 Focus eliminates vagueness in communication y limiting the area of
2.8.7 State conversation share with the client observations regarding their
2.8.8 Offer information as a means to provide additional data or insight
2.8.9 Maintain silence allows the nurse and client to organize thoughts as well as
observe each others behavior
2.8.10Be assertive express feelings and emotions confidently, spontaneously and
2.8.11Summarize a concise review of main ideas that have been discussed, it sets
the tone for further interactions
2.9 Barriers Effective Communication
2.9.1 Giving an opinion takes decision-making away from the client, inhibits
spontaneity, stalls problem-solving and creates doubt
2.9.2 Giving false reassurance can discourage open communication. Genuine
truthful reassurance is what is important is validating a clients self-worth and
sense of hope
2.9.3 Being defensive when a nurse becomes defensive, the clients concerns are
often ignored
2.9.4 Showing approval or disapproval offering excessive praise implies that the
behavior is the only acceptable one. But disapproval also implies that the
client must meet the nurses expectations or standards
2.9.5 Stereotyping inhibits communication and threatens
a client-nurse
relationship. e.g., People from depressed areas have very poor hygiene.
2.9.6 Asking why can cause resentment, insecurity and mistrust
2.9.7 Changing the topic inappropriately definitely rude and shows a lack of
3. Client Education
3.1 Purposes of Client Education the goal of client education is to assist individuals,
families, or communities in achieving optimal levels of health (Edelman and Mandle,
3.2 Domains of Learning
3.2.1 Cognitive Learning includes all intellectual behaviors such as the acquisition
of knowledge, comprehension (ability to understand), application (using
abstract ideas in concrete situations) analysis (relating ideas in an organized
way), synthesis (recognizing parts of information as a whole), and evaluation
(judging the worth of a body of information)
3.2.2 Affective learning deals with the expression of feelings related to attitudes,
opinions, or values.
3.2.3 Psychomotor learning involves acquiring skills that require the integration
of mental and motor activity such as the ability to walk, to use an eating
utensil, or to give an insulin injection
3.3 Teaching Methods Based on clients Developmental Capacity
3.3.1 Infant
Keep routines 9e.g., feeding, bathing) consistent


Hold infant firmly while smiling and speaking softly to convey sense of
Have infant touch different textures (e.g., soft fabric, hard plastic)
3.3.2 Toddler
Use play to teach procedure or activity (e.g., handling, examination
equipment, applying bandage to doll)
Offer picture books that describes story of children in hospital r clinic
Use simple words such as cut instead of laceration to promote

3.3.3 Preschooler
Use role playing, imitation, and play to make it fun for preschoolers to
Encourage questions and offer explanations. Use simple explanations and
Encourage children to learn together through pictures and short stories about
how to perform hygiene
3.3.4 School-Age Child
Teach psychomotor skills needed to maintain health. (Complicated skills
such as learning to use syringe, may take considerable practice)
Offer opportunities to discuss health problems and answer questions
3.3.5 Adolescent
Help adolescent learn about feelings and need for self-expression
Use teaching as collaborative activity
Allow adolescents to make decisions about health and health promotion
(safety, sex education, substance abuse)
Use problem solving to help adolescents make choices
3.3.6 Young or Middle Adult
Encourage participation in teaching plan by setting mutual goals
Encourage independent learning
Offer information so that adult can understand effects of health problem
3.3.7 Older Adult
Teach when client is alert and rested
Involve the adult in discussion or activity
Focus on wellness and the persons strength
Use approaches that enhance sensorially impaired clients reception stimuli
Keep teaching session short
3.4 Teaching Methods Based on Clients Learning Needs
3.4.1 Cognitive
Discussion (One-on-One or Group)
May involve nurse and client or nurse with several clients
Promotes active participation and focuses on topics of interest o client
Allows peer support
Enhances application and analysis for new information
Is more formal method of instruction because it is controlled by teacher
Helps learner acquire new knowledge and gain comprehension

Question-and-Answer Session
Is designed specifically to address clients concerns
Assists client in applying knowledge
Role Play, Discovery
Allows client to actively apply knowledge in controlled situation
Promotes synthesis of information and problem solving
Independent Project (Computer-Assisted Instruction), Field Experience
Allows client to assume responsibility for completing learning activities at
own pace
Promotes analysis, synthesis, and evaluation of new information and skills
3.4.2 Affective
Role Play
Allows expression of values, feelings, and attitudes
Discussion (Group)
Allows client to acquire support from others in group
Permits client to learn from others experiences
Promotes responding, valuing, and organization
Discussion (One-on-One)
Allows discussion of personal, sensitive, topics of interest or concern
3.4.3 Psychomotor
Provides presentation of procedures or skills by nurse
Permits client to incorporate modeling of nurses behavior
Allows nurse to control questioning during demonstration
Gives client opportunity to perform skills using equipment
Provides repetition
Return Demonstration
Permits client to perform skills as nurse observes
Is excellent source of feedback and reinforcement
Independent Project, Game
Requires teaching method that promotes adaptation and origination of
psychomotor learning
Permits learner to use new skills
UNIT III - Principles for Nursing Practice
1. Vital Signs
1.1 Temperature
1.1.1 Sites and normal values
Oral = 37 C = 98. F
1. The nurse should wait for 20-30 minutes before taking the temperature of
a client who has taken hot or cold drinks or food, has been smoking or
has been through strenuous exercise
2. Approximately 1F higher than the bodys core temperature (temperature
of deep tissues)
Rectal = 37.5C = 99.6 F
1. Considered to be the most reliable because few factors can alter the
2. Should not be taken in newborns because the thermometer can cause
rectal trauma

3. Usually a few tenths higher than the oral temperature
Axilla = 36.4C (97.6F). Safest site for temperature measurement,
especially with newborns but is less convenient and accurate and requires
longer time (5 minutes)
Tympanic membrane
1. Excellent site because of its highly vascular nature and easy accessibility
2. Directly reflects core temperature
1.1.2 Factors affecting body temperature
1. An infants temperature may change drastically with changes in the
environment because temperature-control mechanisms are not yet fully
1.1 Clothing must be adequate and exposure to extreme temperatures
must be avoided
1.2 30% of body heat of newborns is lost through the head, that is why
a cap is to be worn to prevent heat loss
2. Temperature regulation stabilizes during puberty
3. The elderly are sensitive to extremes in temperature because of:
3.1 Deterioration in thermoregulation
3.2 Poor vasomotor control
3.3 Reduced amount of subcutaneous tissues
3.4 Reduce sweat gland activity
3.5 Reduced metabolism
Exercise muscle activity requires increased body supply increase in
carbohydrate and fat breakdown for more energy increased metabolism
increased heat production increased temperature
Hormone level
1. Progesterone increases body temperature. When progesterone levels are
low, just before ovulation, the temperature falls a few tenths of a degree
below the baseline; during ovulation, greater amounts of progesterone
raises the body temperature to previous baseline or higher.
2. Menopausal women may experience periods of intense body heat and
sweating lasting from 30 seconds to 5 minutes due to the instability of
the vasomotor control
3. The amount of thyroxine, epinephrine and norepinephrine in the body
can also affect temperature
Circadian rhythms body temperature changes 0.5 C to 1C during a 24
hour period
1. Temperature is usually lowest between 1:00 and 4:00 a.m.
2. During the day, body temperature rises, steadily until 6:00 p.m. then
declines to early morning levels
Stress physical and emotional stress increase body temperature through
hormonal and neural stimulation
1.1.3 Fever rectal temperature above 38C (100.4F) that is measured under resting
conditions. Common fever patterns:
Sustained little fluctuation, e.g., pneumococcal pneumonia
Intermittent wide temperature variations with return to normal at least
once daily, e.g., malaria, bacterial or viral infections
Remittent fluctuations less than intermittent, with no return to normal;
e.g., measles, Dengue fever
Recurrent duration of few days, returns to normal for 1 day or more, then
recurs; e.g., Hodgkins disease, leptospirosis

Night e.g. , tuberculosis
1.1.4 Body temperature disorders
Heat exhaustion occurs when a person loses excessive amounts of water
and sodium because of profuse diaphoresis
Heat Stroke very high temperatures of 105F or more produces tissue
damage to the cells of all body organs; has a high fatality rate
1. Suddenly becomes giddy, confused or delirious
2. Extreme thirst, nausea, muscle cramps and visual disturbances
3. Hot, dry skin most important sign
4. Does not sweat because of severe electrolyte loss and impaired
hypothalamic function
5. Tachycardia and hypotension
6. Becomes unconscious incontinent, with blotchy redness of the skin and
fixed, unreactive pupils
1. Skin temperature drops to 35C (95F) and uncontrolled shivering begins
2. Loss of memory, depression and signs of poor judgment
3. If temperature falls below 34.4 C (94 F), heat and respiratory rates and
blood pressure fall an skin becomes cyanotic
4. May have cardiac dysrhythmias, lose consciousness and becomes
unresponsive to painful stimuli
5. Frostbites are frozen surface areas of the skin, e.g, earlobes, fingers, toes
6. Formula
6.1 to convert Fahrenheit to centigrade, subtract 32 from the Fahrenheit
reading and multiple the result by 5/9
Example : (104 F - 32 F) x 5/9 = 40 C
6.2 To convert centigrade to Fahrenheit, multiple the centigrade reading
by 9/5 and add 32 to the product
Example: (9/5 x 40 C) + 32 = 104 F
1.2. Pulse The pulse is the palpable bounding of the blood flow in a peripheral artery.
1.2.1 Pulse Sites




Over temporal bone of head, above

and lateral to eye

Easily accessible site used to assess

pulse in children


Along medial edge of sternocleidomastoid muscle in neck

Easily accessible site used during

physiological shock or cardiac arrest
when other sites are not palpable


Fourth to fifth intercostal space at left

mid clavicular line

Site used to auscultate for heart sounds;

site used for infants and young children


Groove between biceps and triceps

muscles at antecubital fossa

Site used to assess pulse rate; site used

to auscultate blood pressure


Radial or thumb side of forearm at


Common site used to assess character

of pulse peripherally and assess status
of circulation to hand


Ulnar side of forearm at wrist

Site used to assess status of circulation

to hand


Below inguinal ligament, midway

between symphysis pubis and anterior

Site used to assess character of pulse

during physiological shock or cardiac

superior iliac spine

arrest when other pulses are not



Behind knee in politeal fossa

Site used to auscultate lower extremity

blood pressure

Posterior tibial

Inner side of ankle, below medial


Site used to assess status of circulation

to foot

Dorsalis pedis

Along top of foot, between extension

tendons of great and first toe

Site used to assess status of circulation

to foot


Stethoscope - to assess the apical rate.

5 major parts of the stethoscope

earpieces - should follow the contour of the ear canal pointing toward your face
when the stethoscope is in place
polyvinyl tubing should be 30-40 cm (12-18 in. long)
bell chestpiece transmit low-pitched sounds created by the low-velocity
movement of blood like heart and vascular sounds
diaphragm chestpiece transmits high-pitched sounds created by high velocity
movement of air and blood. Bowel, lung and heart sounds are auscultated using the
1.2.3 Acceptable Ranges of heart Rate for Age

Heart Rate (beats/min)

120 160
90 140
80 110
75 100
60 90
60 - 100

1.3. Respiration
1.3.1 Definition
Respiration is the mechanism the body uses to exchange gases between the atmosphere
and the blood and the cells.
1.3.2 Processes
ventilation - the mechanical movement of gases into and out of the lungs
diffusion the movement of oxygen (0 2) and carbon dioxide (CO2)between the
alveoli and the red blood cells
perfusion the distribution of red blood cells to and from the pulmonary
1.3.3. Factors Influencing Character of Respirations
a. Exercise
Exercise increases respiration rate and depth to meet the bodys need for
additional oxygen and to rid the body of CO2
b. Acute Pain
Pain alters rate and rhythm of respirations, breathing becomes shallow.
Client may inhibit or splint chest wall movement when pain is in ara of chest or
c. Anxiety

Anxiety increases respiration rate and depth as a result of sympathetic
d. Smoking
Chronic smoking changes the lungs airways, resulting in increased rate of
respiration at rest when not smoking
e. Body Position
A straight, erect posture promotes full chest expansion
A stooped or slumped position impairs ventilatory movement
Lying flat prevents full chest expansion
f. Medications
Narcotic analgesic, general anesthetics, and sedative hypnotics depress
respiration rate and depth
Amphetamines and cocaine may increase rate and depth
Bronchodilators slow rate by causing airway dilation
g. Neurological Injury
Injury to the brainstem impairs the respiratory center and inhibits respiratory rate
and rhythm

h. Hemoglobin Function
Decreased hemoglobin levels (anemia) reduce oxygen-carrying capacity of the
blood, which increases respiratory rate
Increased altitude lowers the amount of saturated hemoglobin, which increases
respiratory rate and depth
Abnormal blood cell function (e.g., sickle cell disease) reduces ability of
hemoglobin to carry oxygen, which increases respiratory rate and depth
4. Acceptable Range of Respiratory Rates for Age
Infant (6 months)
Toddler (2 years)

Rate (breaths/min)
35 40
30 50
25 32
20 30
16 19
12 - 6

1.4 Blood Pressure

1. Definition of Terms
1.1 Blood Pressure is the force exerted on the walls of an artery created by the pulsing
blood under pressure from the heart.
1.2 The peak of maximum pressure when ejection occurs is the systolic blood pressure
1.3 When the heart relaxes, the blood remaining in the arteries exerts a minimum or
diastolic pressure. Diastolic pressure is the lowest pressure exerted against the arterial
walls at all times.
1.4 The difference between systolic and diastolic pressure is the pulse pressure. For a
blood pressure of 120/80,, the pulse pressure is 40
2. Factors Influencing Blood Pressure
2.1 Age
Blood pressure tends to rise with advancing age:
Arterial Pressure (mm Hg)
Newborn (3000 g (6.6 lb)
40 (mean)

1 month
1 year
6 years
10-13 years
14-17 years
Middle-age adult
Older adult


Level of a childs or adolescents blood pressure is assessed with respect to body

size and age. Larger children have higher bloods that smaller children of the same
age. Larger children have higher blood pressures than smaller children of the same
age. Older adults have a rise in systolic pressure related to decreased elasticity.
2.2 Stress
Anxiety, fear, and pain can initially increase blood pressure because of increased
heart rate, increased cardiac output, and increased peripheral vascular resistance
2.3 Gender
There is no clinically significant difference in blood pressure levels between boys
and girls
After puberty, males have higher readings
With menopause, women tend to have higher levels of blood pressure than men of
the same age