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FIVE (5) PHASES OF NURSING CARE


(American Nurses Association (ANA) Standards of Clinical Nursing Practice)

I.ASSESING – is the systematic and continuous collection, organizing,


validation, and documentation of data.

PURPOSE: To establish a database about client’s response to


health concerns or illness and the ability to manage health care needs.

TYPES OF ASSESSMENT:
TYPE TIME PURPOSE EXAMPLE
PERFORMED
Initial Within specified To establish a Nursing
Assessment time after complete data admission
admission base for problem assessment
identification,
reference and
future
comparison
Problem-focused Ongoing To determine I & O q 1 hr in
assessment process status of specific ICU
integrated with problem
nursing care identified in an
earlier
assessment Assess client’s
To identify new ability to perform
or overlooked self care while
problems assisting to
bathe
Emergency During any To identify life- Rapid
Assessment physiologic threatening assessment of
and problems ABC during
psychologic cardiac arrest
crisis of the Assessment for
client suicidal
tendencies and
potential for
violence
Time-lapsed Several months To compare Reassessment of
reassessment after initial client’s current client’s
assessment status to functional health
baseline data patterns.
previously
obtained
A. DATA COLLECTION – is the process of gathering info about a client’s
health status.

DATABASE – is all info about the client; includes nursing health history,
physical assessment, doctor’s history and physical exam, results of lab and
diagnostic tests, and material contributed by other health personel.

CLIENT DATA – past history and current problems.

TYPES OF DATA:

1. SUBJECTIVE DATA – symptoms or covert (secret) data. It is described or


verified only by the affected person.

Examples: itching, pain, worry, sensations, feelings, values, attitudes,


perception of personal status and life situation.

2. OBJECTIVE DATA – signs or overt (obvious) data. It is detectable by the


observer, can be measured or tested against accepted standard. They
can be seen, heard and felt, or smelled, can be obtained by
observation or physical exam.

SOURCES OF DATA:

1. PRIMARY DATA – from the CLIENT, it is the best source of data unless
too ill, young, confused to communicate clearly.

2. SECONDARY DATA – are SUPPORT PEOPLE(family members, friends,


caregivers), CLIENT RECORD, HEALTH CARE PROFESSIONALS(doctors,
nurses, physiotherapist, social workers), LITERATURE
(standards/norms,cultural and health practices, spiritual beliefs)

DATA COLLECTION METHODS


1. OBSERVATION – is a conscious, deliberate skill that is developed
through effort and with an organized approach.
2. INTERVIEW – is planned communication or a conversation with a
purpose.
TWO APPROACHES:
a. DIRECTIVE INTERVIEW. The nurse establishes the purpose and
controls the interview. The client responds to questions but may
limited opportunity to ask questions or discuss concerns
b. NONDIRECTIVE INTERVIEW – rapport-building interview. The nurse
allows the client to control the purpose, subject matter, and pacing.
RAPPORT- is the understanding b/w 2 or more people.
TYPES OF INTERVIEW:
a. CLOSED QUESTION – (directive interview) restrictive and answered
by YES/NO, questions begin by WHEN, WHERE, WHO, WHAT, DO or
IS.
b. OPEN-ENDED QUESTIONS – (indirective interview) invite clients to
discover, explore, elaborate, clarify, or illustrate their thoughts and
feelings. It may begin with WHAT/HOW.
c. NEUTRAL QUESTION – (open ended and indirective) is a question a
client can answer without direction or pressure from the nurse
( regarding feelings and point of views)
d. LEADING QUESTIONS – (closed and directive) directs the client’s
answer. It gives the client less opportunity to decide whether the
answer is true or not. (Ex. You’re stressed about the surgery
tomorrow, aren’t you?)
PLANNING AND SETTING OF INTERVIEW
a. Time. comfortable and unhurried
b. Place. Well lighted, well ventilated, moderate sized room, free from
noise, movements and interruptions.
c. Seating arrangement.
• Two parties are seated on two chairs placed at right angles to a
desk or table / few feet apart without table between.
• A horseshoe or circular chair arrangements
• When a client in bed, sit at a 45 degrees angle to bed, not
standing and looking down the client who is in bed.
d. Distance. Maintaining a distance of 2 to 3 feet.
PROXEMICS – term for the study of human use and perception of
social and personal space.
• INTIMATE ZONE (0-18 inches) –use for comforting, protecting,
counseling and preserved for people who feel close.
• PERSONAL ZONE (18 inches to 3 feet) – maintained with
friends or in some counseling interactions
• SOCIAL/PUBLIC ZONE (3 – 6 feet) – used when impersonal
business is conducted or with people who are working
together.
e. Language. Failure to communicate is a form of discrimination.
• Translate medical terminologies into common English
understandable to both client and family members.
STAGES OF INTERVIEW
1. The Opening – most important part.
Purpose: to establish rapport (process of creating a goodwill and trust)
and orient the interviewee.
• begin with a greeting, self intro accompanied by smile or
handshake
• Explain the purpose and nature of interview
• Tell the client how the info will be used and usually states
the client’s right not to provide the info.
2. The Body – the client communicates what he feels or thinks.
Knows, and perceives in response to questions from the
nurse.
3. The Closing – the termination is important for maintaining
rapport and trust and for facilitating future interactions.
TECHNIQUES:
a. Offer to answer questions. Do u have any questions?
b. Conclude by saying “Well, ….” , that generally signals that the need
of interactions
c. Thank the client.
d. Express concern for person’s welfare and future. “Take care of
urself….”
e. Plan for the next meeting, if there’s a need.
f. Provide summary to verify accuracy and agreement.
3. EXAMING – a physical exam/ assessment is the systematic data-
collection method used observation (the senses) to detect health
problems.
APPROACHES:
a. CEPAHALOCAUDAL / HEAD-TO-TOE APPROACHES – begins the
examination at the head, progresses to the neck, thorax, abdomen,
and extremities, and ends at the toes.
b. BODY SYSTEMS APPROACH – investigates each systems individually.
That is, respiratory, circulatory, nervous systems, and so on.
c. SCREENING EXAMINATION/ REVIEW OF SYSTEMS – is a brief review
of a screening examination measured against norms/standards, such
as ideal wt & ht for body tem / BP.

B. ORGANIZING DATA – the nurse uses a written/computerized format


that organizes the assessment data systematically.
OTHER TERM: Nursing Health History, Nursing Assessment, Nursing
Database Form
NURSING CONCEPTUAL MODELS
1. Gordon (2000) –provides a framework of 11 functional health
patterns. It collects data about dysfunctional as well as functional
behavior.
2. Orem, Taylor, and Renpenning (2000) – delineate 8 universal self
care requisites of humans.
3. Roy and Andrews (1998) – classify observable behavior into 4
categories: self concept, role function and interdependence.
4. Others
WELLNESS MODELS – to assist clients to identify health risks and to
explore lifestyle habits and health behaviors, beliefs, beliefs, values,
and attitudes that influence levbels of wellness.
NONNURSING MODELS
1. BODY SYSTEMS MODEL – focuses on abnormalities in anatomic
systems of the body.
2. MASLOW’S HIERARCHY OF NEEDS
3. DEVELOPMENTAL THEORIES – for physical, psychosocial, cognitive
and moral developmental theories.

C. VALIDATING DATA – is verifying data to confirm that it is accurate and


factual
CUES – are subjective or objective data that can be directly observed
by the nurse.
INFERENCES – nurse’s interpretation or conclusions made based on the
cues.
D. DOCUMENTING DATA – the nurse records the data.
ACCURATE DOCUMENTAION – is essential and should include all data
collected about the client’s health status.

II. DIAGNOSING – is analyzing data; identification of health problems, risks


and strengths; and formulation of diagnostic statement.
Diagnostic Labels – are standardized NANDA names for diagnoses
Diagnosis – is the statement or conclusion regarding the nature of
phenomenon.
Nursing Diagnosis – the client’s problem statement, consisting of the
diagnostic label plus the etiology (casual relationship b/w a problem and
its related or risk factors)

TYPES OF NURSING DIAGNOSES

1. ACTUAL DIAGNOSIS is a client problem that is present at the time of


nursing assessment.

2. RISK NURSING DIAGNOSIS is a clinical judgment that a problem does


not exist, but the presence of risk factors indicates a problem is likely
to develop unless nurse intervenes.

3. WELLNESS DIAGNOSIS – describe a human response to level of


wellness that have a readiness for enhancement.

4. POSSIBLE NURSING DIAGNOSIS is one in which evidence about a health


problem is incomplete or uncler.
5. SYNDROME DIAGNOSIS is a diagnosiss that is associated with a cluster
of other diagnosis.

THREE COMPONNETS OF NURSING DIAGNOSIS

1. PROBLEM and its definition – describes the client’s health problem or


response for hich nursing therapy is given.

QUALIFIERS – are words that have been added to some NANDA labels to give
additional meaning to the diagnostic statement.

• Deficient – inadequate, incomplete

• Impaired – made worse, weakened, damaged, reduced,


deteriorated

• Decreased – lesser

• Ineffective – not producing a desired effect

• Compromised – to make vulnerable to threat

2. EtTOLOGY (Related factors/Risk factors) – identifies one/more probable


causes of the health problem, gives direction to the required nursing
therapy, and enables the nurse to individualized the client’s care.

3. DEFINING CHARACTERISTICS – are the cluster of signs and symptoms


that indicate the presence of a particular diagnostic label.

THREE STEPS OF DIAGNOSTIC PROCESS

1. Analyzing data- a. compare data against standards/ norms (generally


acceptable measure, rule, model or pattern)

b. cluster cues

c. identify gaps and inconsistencies

2. Identify health problems, risks, and strengths – decision making


process

3. Formulation diagnostic statements

• BASIC TWO-PART STATEMENTS (Problem + Etiology)


• BASIC THREE-PART STATEMENTS – PES format

(Problem + Etiology + Signs and Symptoms)

• ONE-PART STATEMENTS – NANDA LABEL ONLY


(Wellness/Syndrome diagnosis)

BASIC FORMATS VARIATIONS:

a. Writing unknown etiology when the defining characteristics are


present but the nurse does not know the cause or contributing
factors.

Ex: Noncompliance (medication Regimen) r/t unknown etiology

b. Using the phrase complex factors when there are too many
etiologic factors or when they are too complex to state in a brief
phrase.

Ex: Chronic Low Self-Esteem r/t complex factors

c. Using word possible to describe either the problem of etiology.

Ex: Possible low self esteem r/t loss of job

Altered thought process possibly r/t unfamiliar surroundings

d. Using secondary to divide the etiology into two parts, thereby


making the statements more descriptive and useful. The part
following the secondary to is often the pathophysiology/disease
process.

Ex: Risk for impaired skin integrity r/t decreased peripheral


circulation secondary to diabetes.

e. Adding a second part to the general response or NANDA label to


make it more precise.

Ex: Impaired skin integrity (Left lateral ankle) r/t decreased


peripheral circulation
III.PLANNING – is a deliberative, systematic phase that involves decision
making and problem solving. It begins with the first client contact and
continues until the nurse-client relationship ends, usually when client is
discharged from the health care agency.

• Prioritize problems/diagnosis

• Formulate goals/desired outcomes

• Select nursing interventions

• Write nursing orders

NURSING INTERVENTION- is any treatment, based upon clinical judgment and


knowledge that a nurse performs to enhance patient’s outcomes.

TYPES OF PLANNING

• Initial Planning. Planning is initiated as soon as possible after initial


assessment

• Ongoing Planning. Planning occurs at the beginning of a shift to the


end of the shift.

• Discharge Planning. The process of anticipating and planning for the


needs after discharge.

NURSING CARE PLAN. Is the end product of the planning phase of the
nursing process

• Informal nursing care plan. Is a strategy of action that exists in the


nurse’s mind.

• Formal nursing care plan. A written/computerized guide that


organizes info about the client’s care.

• Standardized care plan. A formal plan that specifies the nursing


care fro groups of clients with common needs.
• Individualized care plan. Is tailored to meet the unique needs of a
epecific client – needs that are not addressed by the standardized
plan.

STANDARDS OF CARE. It describes nursing actions forclients with similar


medical conditions rather than individuals, and they describe achievable
rather than ideal nursing care.

PROTOCOLS. They are preprinted to indicate actions commonly required for


a particular group of clients.

STANDARDIZED CARE PLANS. They are preprinted guides for the nursing
care of a client who has a need that arises frequently in the agency. They
written from the perspective of what care the client can expect.

POLICIES AND PROCEDURES. They are developed to govern a handling of


frequent occurring situations.(institutional records)

STANDING ORDER. Is a written document about policies, rules, regulations,


or orders regarding client care. It gives nurses the authority to carry out
specific actions under certain circumstances, often when a physician is not
immediately available.

• STUDENT CARE PLANS – plan of care made by the students with a”


rationale” column.

RATIONALE - is the scientific principle given as the reason for selecting a


particular nursing intervention.

CONCEPT MAP – is a visual tool in which ideas or data are enclosed in


circles or boxes of some shape and relationships b/w these are indicated by
connecting lines and arrows.

• COMPUTERIZED CARE PLANS – computer are used to create and store


NCP.
• MULTIDISCIPLINARY (Collaborative) CARE PLAN – standardized paln
outlines the care required for clients with common, predictable – usually
medical – conditions.

THE PLANNING PROCESS

1. PRIORITY SETTING is the process of establishing a preferential


sequence for addressing nursing diagnoses and interventions

2. ESTABLISHING CLIENT GOALS/DESIRED OTCOMES – what the nurse


hopes to achieve by implementing the nursing interventions.

COMPONENTS

a. Subject. Is the client, any part of the client, or some attributes such
as BP/ Temp.

b. Verb. It specifies an action the client is to perform.

c. Conditions/ modifiers. It may be added to the verb to explain the


circumstances under which the behavior is to be performed. They
explain what, where, when and how.

d. Criterion of desired outcome. It indicates the standard by which a


performance is evaluated or at the level at which the client will
perform the specified behavior. It specifies time or speed, accuracy,
distance and quality.

3. SELECTING NURSING INTERVENTIONS.

• INDEPENEDENT INTERVENTIONS - are those activities that


nurses are licensed to initiate on the basis of their knowledge
and skills.

• DEPENDENT INTERVENTIONS - are activities carried out


under the physician’s orders or supervision, or according to
specified routines.
• Collaborative interventions – are actions the nurse caries out
in collaboration with other health team members, such as PT,
SW, Dietitians, and physicians.

IV.IMPLEMENTING – consist of doing and documenting the activities


that are the specific nursing actions needed to carry out the
interventions.

IMPLEMENTING SKILLS

• COGNITIVE (intellectual) SKILLS – includes problem solving, decision


making. Critical thinking and creativity

• INTERPERSONAL SKILLS -

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