MODULE 4

Nursing as a Science
LEARNING OBJECTIVES:
At the end of the lesson, the students will be able to:
a. Identify the different components of the nursing process
b. Discuss the importance of documentations and reporting.

INTRODUCTION

Nursing has a specific body of knowledge; it is essential to socialize

within the profession and practice to fully understand and apply, develop
professional expertise. Nursing practice requires a blend of the most
current knowledge and practice standards with an insightful and
compassionate approach of care.

Time allotment/ duration:

3hrs per session

Core-Related values and Biblical Reflection:

Service: Compassionate
1 Peter 4:10: As every man hath received the gift, even so minister the same one to another,
as good stewards of the manifold grace of God.

LEARNING CONTENT

Topic Content

Unit 1 Nursing Process

a. Assessment
b. Diagnoses
c. Planning
d. Implementation
e. Evaluation

Unit 2 Documentation\ Reporting

Purpose of Client Chart\ Record
Types of Record
Characteristic of Good Recording
Advantages of Referral Case
Key Points to Effective Referral System
 Unit 3 Guidelines\ Protocols\ Tools in Documentation Related
To Client Care
Subjective \ Objective Information, Assessment
Plan, Implementation, Evaluation -SOAPIE
Focus, Data, Action, Response – FDAR
Electronic Health Record – EHR
Problem Oriented Medical Record – POMR

Unit 4 Guidelines\ Protocols\ Tools in Reporting Related to Client

Care
Identify, Situation, Background, Assessment,
Recommendation, Read Back – ISBARR
Change of Shift Report
Incidental Report
Referral System

Nursing Process – a systematic method of planning and providing care

to clients
*Basis for accurate, complete documentation required to meet
legal standard

Purpose of the Nursing Process

To achieve scientifically based, holistic, individualized care for the client.
To achieve the opportunity to work collaboratively with clients.
To achieve continuity of care.

Characteristics of the Nursing Process

Systematic
Dynamic
Interpersonal
Goal – oriented
Universally Applicable

Five Steps of the Nursing Process

A. ASSESSMENT – first step of the nursing process that includes the

systematic collection, verification, organization,
interpretation and documentation of client data.
 Steps in Assessment
Collection of data from variety of source
*Subjective data
*Objective data
Validating of data
prevents omission, misunderstanding and incorrect inferences
and conclusions if data source is unreliable.
Organizing the data
putting data together in order to identify areas of the client’s
problems and strengths
Interpreting the data
after collecting data, the nurse begins to develop impressions or
inferences about the meaning of the data. When data is clusters
the nurse can: a. distinguishes relevant and irrelevant data
b. determines if there are gaps in the data
c. identifies patterns of cause and effect
Documenting of data
* Assessment data must be recorded and reported.
* Data to be immediately reported or data need only to be recorded.
*Accurate and complete recording of assessment data is essential
for communicating information to other health care team.
*Documentation is the basis for determining quality of care and have
data to support identified problems

Types of Assessment
Comprehensive Assessment
*Gathers client’s information through* complete health history
* Physical examination
* Review of psychosocial aspects of client’s health
* client’s perception of health
* Presence of health factors
* Clients coping patterns
*Usually completed upon admission to the health care agency.
Focused Assessment
*Assessment is limited to concentrate on particular need
that is limited in scope
*Emergency department
Ongoing Assessment
systematic monitoring and observation related to specific.
problems.
systematic monitoring allows the nurse to determine the
response of nursing g interventions ad to identify any
emergency problems.
 Source of Data
PRIMARY SOURCE - client is the major provider of information
using interview and physical examination
SECONDARY SOURCE – family members, significant others,
laboratory and diagnostic test, other HCP and records.

Types of Data
Subjective Data (symptoms)
information from the client’s sometimes family’s point of
view that includes feelings, perceptions and concern thru
interview
Objective Data (signs)
are observable and measurable information obtained thru
laboratory and diagnosing testing’s.

B. NURSING DIAGNOSIS
Involves analysis (breaking the whole parts that can be examined)
and synthesis (putting data together in a new way) of the data
that have been collected
Nursing diagnosis is a clinical judgement about individual, family, or
community responses to actual and potential health problems \
life process, the basis for selection of nursing intervention to
achieve outcomes for which nurse is accountable.

Benefits of Nursing Diagnosis

ND is unique that focuses on client’s response to a health problem
rather than on the problem itself, it provides a structure through
which nursing care can be delivered.
ND provides a means for effective communications.
Holistic client, family, and community-focused care are facilitated with
the use of nursing diagnosis.

COMPONENTS OF NURSING DIAGNOSIS

1. Actual Nursing Diagnosis
a problem statement or diagnostic label that describes the client’s
response to an actual or potential health problems or a wellness
condition.

[Link] – related cause or contributor to the problem

diagnostic label and etiology are linked by the term
related to (R\T)
 Example of 2 parts ND statement

Feeding self-care deficit R\T perceptual \ cognitive impairment.

Delayed growth and development R\T separation from significant
others.

3. Three Part Statement

ND can be expressed as three-part statement.
As in two-part statement, the two first components are the
diagnostic label and the etiology.
The third component consists of defining characteristics (consist
of signs and symptoms, subjective and objective data or
clinical manifestations.
The third is joined to the first two components with the
connecting phrase as evidenced by (AEB).

Example of the three-part ND statement

Impaired gas exchange R\T ventilation perfusion imbalance
AEB respiratory rate of 40

Types of Nursing Diagnosis

Actual Nursing Diagnosis
-indicates problem exists, compose of the diagnostic label,
related factors, and signs and symptoms
Example
Low self-esteem R\T loss of chair trumpet in a band AEB
self-negating verbalization “I’m no good anymore.”

Risk Nursing Diagnosis (potential problem)

-indicates that a problem does not yet exist but that special risk
factor is present.
-risk diagnosis is composed of the phrase RISK for followed by
diagnostic label and the list of the specific risk factors

Example
Risk for situational low self-esteem R\T unrealistic self-expectations
AEB receiving “B” in two college courses while working full time
(expected “A”)
Wellness Nursing Diagnosis –indicates the client’s expression of a
desire to attain a higher level of wellness in some area
of functions.

Example: A wife who has been caring for her husband who had stroke
two months’ age ask a nurse about meeting with other wives
who are have the same similar situations. The nurse would
make a wellness diagnosis of Readiness for enhanced
family coping.

C. PLANNING
establishing of client goals\outcomes by the providers, working
with the clients, that prevent, reduce or reduce problems and
the determination of related nursing interventions most likely to
assist client in achieving goals.

During the planning, the provider should:

a. establish priorities
b. write client-centered goal (long and short term goals and
outcome)
c. select\develop nursing interventions
d. communicates and plan and records entire nursing care plan
in the client’s record

Prioritizing the Nursing Diagnoses

Three level of approaches in prioritizing problems

[Link] Level Priority Problem (immediate)

*Airway problems
*Breathing problems
*cardia\circulation problems
*Signs (vital signs)

2 Second Level Priority Problems – immediate, after TX for the 1 st

level problems
*Mental status change
*Acute pain
*Acute urinary elimination problems
*Untreated medical problems requiring immediate attention
(ex-diabetes who has not had insulin
*Abnormal lab values
*Risk for infection, safety, or security – for clients
 Third Level Priority Problems
Health problems that do not fit in the first and second level.

Goals- is an aim, intent, or end. Goals are broad statement that

describe the intended or desired change in the client’s condition
Client-centered goals are established in collaboration with the client
whenever possible.

TYPES OF GOALS
SHORT-TERM GOAL is an objective statement that outlines the desired
resolution of nursing diagnosis, over a short period of time,
usually, a few hours or days. (less than a week)

LONG-TERM GOAL is an objective statement that outlines the desire

resolutions of the nursing diagnosis over a longer period of
time, usually a few weeks or months.

CATEGORIES OF NURSING INTERVENTIONS

[Link] Nursing Intervention
are nursing actions are initiated by the nurse and do not require
direction or an order from another health care professional, this
includes daily living, health education, health promotion and
counseling.

Example: elevating client’s edematous extremity

[Link] – are those actions that are implemented in a

collaborative manner by the nurse in conjunction with other health
care professionals.

Example: Nurse may assist a client to perform an exercise thought

by the physical therapist.

[Link] Nursing Intervention – are those actions that require an

order from a physician or another health care professional.

Example: administration of medicines

[Link]
involves the execution of the nursing care plan derived during the
planning phase. It consists of performing nursing activities
(interventions) that has been planned to meet the goals. It also
involves delegation (process of transferring a selected nursing task
to a licensed individual who is competent to perform the specific task.
Types of Nursing Interventions

[Link] Order- is an order written in a client medical record or nursing

care plan by a physician or a nurse especially for that
individual.

[Link] Order – is a standardized intervention written, approved and

signed by the physician that is kept in on the file within the
the health care agencies to be used in predictable situations
or in circumstances requiring immediate attentions.

[Link] is a series of standing orders or procedures that should be

followed under specific conditions. The protocol defines
interventions that are permissible and those circumstances
under the nurse is allowed to implement the measures.

EVALUATION
Final phase of nursing process that measures of effectiveness of
nursing care in promoting the achievement of client’s goal, used
to determine the extent to which goals of care plan have been
achieved.
Consists of:
a. comparing client responses to expected outcome
b. analyzing reason for results and conclusions
c. modifying care

Documentation and Reporting

DOCUMENTATION – serves as a permanent record of client information

and care.

REPORTING – takes place when two of more people share information

about client care, either face to face or by telephone

Purpose of Client’s Record \ Chart

a . Communication
- provides efficient and effective method of sharing information
-it allows to convey meaningful data about the client.
b Legal Documentation
-it is admissible as evidence in a court of law.
c. Research
provides valuable health-related data for research
d. Statistics
provides statistical information that can be utilized for planning
people’s future needs.
e. Education
serves as an educational tool for students in health discipline.
f. Audit and Quality
monitor the quality of care received by client and competence
of health care givers
g. Planning Client Care
provides data which the entire team uses to plan care for client
h. Reimbursement
provides the basis for decision regarding care to be provided and
subsequent reimbursement to the agency, to cover health related
expenses.

TYPES OF RECORDS

[Link] Oriented Medical Record

Five Basic Components
a. admission sheet
b. physician’s order sheet
c. medical history
d. nurse’s notes
e. special records and reports
that includes a. referrals
b. laboratory findings
c. anesthesia record
d. flow sheet
e. vital signs sheet
f. Intake and output
g. medications

POMR-Problem-oriented medical record

data about the client are recorded and arranged according to source
of the information.

the record integrates all data about the problem gathered by the
members of the health team.
 Basic Components of POMR
a. Data Base – contains all the initial information about the client.
b. Problem List – contains all the aspects of the person’s life requiring
health care.
c. Initial list of orders or care plan
d. progress notes
nurse’s narrative notes - SOAPIE Format
S – subjective data
O- objective data
A – assessment
P –planning
I – intervention
E- evaluation

KARDEX
provides concise method of organizing and recording date
about the client making information readily accessible to all
members of the health team.

*it is a series of flip cards usually kept in portable file

*it is a way to ensure continuity of care from shift to other shift
*it is a tool for change-of-shift report, a primary basis for an
endorsement.
*is the planning and communication purposes.

Characteristics of Good Recording

[Link]
entries are concise, complete sentences are not required
start each entry with a capital letter and end the with a period.
[Link] of Ink\permanence
different colors of pen to use (blue, black, red) to signify shifting
of duty (7-3, 3-11, 11-7)
[Link]
write the objective and subjective data
describe behavior rather than feeling
refusal of medications and treatment must be documented
and let the client signed 3x
[Link]
only information that pertains to the client’s health problems and
care is recorded.
[Link] and chronological/ organizational\ sequential\ timing
* Continuous charting for each entry unless,
 * Date is entered in the date column on the first line of every page
of nurse’s note
* Avoid double charting
**information should be charted
-physician’s visit
-time client leaves and return if for special procedure to
be done outside the hospital.
-medications should be charted immediately after given
- treatment should be charted immediately after given.
-unstable condition of the client
[Link] of standardized terminology
use abbreviations and symbols approved by the institution
spell correctly and use proper grammar
[Link]
affix signature, place at the end of the charting at the right
hand margin of the nurse’s notes
sign each entry with your full name and status e.g. SN for
student nurse, RN for registered nurse
8. In case of error
* Correct error by drawing single –horizontal line through the
error.
* Write the word error above the line, sign your signature
*Avoid erasure for it is a legal document
9. Confidentiality
only the health personnel who participated in the care of the
client is allowed to read the chart
[Link] Awareness
* chart only what you personally have done, observed, heard,
smelled or felt
*do not discard any part of the client record
11 Legible
writing must be clear, easily read by others, if writing is not
legible then print
12. Do not use the word “patient” or “pt.” in the chart’ the chart belongs
to the patient. All information in the chart pertains to the patient.
13. A horizontal line drawn to fill up a partial line.
this is to prevent other persons from adding information in the
nurse’s notes.
 REPORTING – takes place when two or more people share information
about client’s care either face to face or by telephone.
Types of Reporting
[Link] of shift reports or endorsement
-it is a communication between two shifts the outgoing and the
incoming nursing staff in a certain unit assigned about up-to date
information of client’s condition.
-for continuity of care
- it is based on health care needs of the client
- it is not mere reciting the content of the Kardex
2. Telephone Report
-provide clear, accurate and concise information
-the nurse document telephone report including the following
information- when the call was made
-who made the call\ report
-who was called
- to whom information was given
-what information was given
- what information was received
3 Telephone Order
-only RN’’s receives telephone orders
- orders need to be verified by reporting it clearly and precisely
-the order must be countersigned by the physician who made
the order within prescribed period of time (within 24 hours)

[Link] Reports
this is done when transferring a client from one unit to
another

5. Nursing Referral System

a system of transferring cases which is beyond the technical
competence of one infrastructure to a higher level infrastructure
or institution having technical competency and all other resources
to provide desired health services.
.
Advantages of Referral Cases
*Beneficial on the part of the client
-they receive effective care at the primary level
*Beneficial to health workers
- able to take care of clients which are within their level of
competence and are not frightened to handle difficult
cases because they can refer them to higher level center
and referral units.
 Key Points to Effective Referral System
*mutual understanding of each other role
*mutual respect
*mutual cooperation