Nursing Notes

NCM 101
NOTE: PHASES OF THE NURSING PROCESS
FLORENCE NIGHTINGALE
“to change the profile of nursing”
A – assessment
NURSES D – diagnosis
“to improve”
O – outcome identification
NURSING PROCESS P – planning
I – implementation
E – evaluation
NOTE:
THEN: Assessment, Planning, Implementation,
Evaluation
NOW: ADOPIE (dynamic never a static)
IFC (Individual, Family, Community)
*it is not counted if not documented*
TAXONOMY (list)

ASSESSMENT
 What brought you to the hospital?
 Let me have a look at that.
 I’d like to listen to your lungs.
 Please describe how you are feeling.
 Lydia Hall originated -- term Nursing Process  When did the problem starts?
 Way one thinks like a nurse DIAGNOSIS
 Foundation -- the essential, enduring skill that  What is the problem?
has characterized nursing from the beginning of  What is the cause?
the profession  How do I know it?
 A framework of interrelated activities resulting  Is there additional information that I need to
in nursing care; dynamic and cyclical in verify my thinking?
nature, requiring repeated review; a scientific, OUTCOME IDENTIFICATION
problem-oriented approach to patient care;  How do I know the problem is better
 An organized approach to diagnose patient’s  This is where we hope you will be by tonight,
problematic responses to illnesses or decreased by tomorrow, by discharge.
health or provide treatment  What are the goals the patient (and family) and
NOTE: I have agreed to?
INTERRELATED ACTIVITES
-activities related to one another
 What are the results I want to achieve from the
NURSING CARE nursing interventions?
-given by nurses alone and continuous
-under patient care
 Do we have enough resources (time, energy,
PATIENT CARE money, supplies) to accomplish the goals?
-have big scope
PLANNING
NURSING DIAGNOSES
-focus on HUMAN RESPONSES not the disease  What can I do about it?
 What is most important?
 What do I want to happen and by when?
IMPLEMENTATION
 Move into action
 Carry out the plan

, NCM 101
EVALUATION
ACTIVITIES:
 Did it work?
Assessing Observation Interview
 Why or why not? (Data = of Patient + of patient, family, other
Collection) nurses
 Is the problem solved or do I need to try again? Examination Medical Record
 Revise the plan based on new information. + of patient + Review


CHARACTERISTICS OF THE NURSING
ASSESSMENT (Data Collection)
PROCESS
 DATA COLLECTION FORMAT:
1. Problem – oriented – comparable with
1. Maslow’s basic Need Format
scientific problem-solving approach
2. Henderson’s Components of Nursing Care
2. Goal-oriented - Open to accepting new
3. Gordon’s Functional Health Patterns
information during its application – flexible to
4. NANDA’s Human Response Patterns
meet the unique needs of IFC
5. Human Growth and Development
3. Interpersonal- requires that the nurse
6. Nursing Theory
communicate directly and constantly with the
client. Permits creativity among nurses and
MASLOW’S BASIC NEED FRAMEWORK
clients in devising ways to solve the health
1. Physiologic/Survival Needs
problem
> must be met or at least partially met for
4. Cyclical
survival
5. Universal NOTE:
PHYSIOLOGIC/SURVIVAL NEEDS
 Oxygen  Rest
BENEFITS OF THE NURSING PROCESS
 CLIENTS  Water  Sleep
 Food  Discomfort (broad)
1. Quality client care.  Exercise  Pain (specific)
2. Continuity of care. Pain scale
- 0 to 10
3. Participation by the clients in their health
-in child, thru facial expression
care.
 NURSE 2. Safety and security needs
1. Consistent and systematic nursing > make a person feel safe and comfortable
education. 3. Love and belonging needs
2. Job satisfaction. > need to give and receive love and
3. Professional growth. affection
4. Avoidance of legal action. 4. Esteem needs
5. Meeting professional nursing standards. > make people feel good about themselves;
6. Meeting standards of accredited hospitals. pride in abilities and accomplishments
 PURPOSE: establish a database. 5. Self-actualization needs
1. Both an initial step in the nursing process > continue to grow and change; working
and an on-going component in every other toward future goals
step in the process 6. Need to know and understand
2. Basis of the patient care plan 7. Aesthetic Needs
3. Nurse uses the five senses to assess

, NCM 101
HENDERSON’S COMPONENTS OF NURSING NOTE:
PHYSIOLOGIC/SURVIVAL NEEDS
CARE HENDERSON
1. Breathe normally  Breathe normally
 Eat and drink adequately
2. Eat and drink adequately  Eliminate body waste
3. Eliminate body waste  Move and maintain desirable posture
 Sleep and rest
4. Move and maintain desirable posture
 Maintain body temper
5. Sleep and rest GORDON
 Health-Perception-health Management
6. Select suitable clothing, dress an undress
Pattern
7. Maintain body temper  Nutritional-Metabolic Pattern
8. Keep the body clean and well groomed  Elimination Pattern
 Activity-Exercise Pattern
and protect the integument  Sleep-Rest Pattern
9. Avoid dangers in the environment and  Sexuality-Reproductive Pattern
SAFETY AND SECURITY NEEDS
avoid injuring others HENDERSON
10. Communicate with others  Select suitable clothing, dress an undress
 Keep the body clean and well groomed and
11. Worship according to one’s faith protect the integument
12. Work in such a way that there is  Avoid dangers in the environment and avoid
injuring other
accomplishment LOVE AND BELONGING NEEDS
13. Play or participate in various form of HENDERSON
 Communicate with others
recreation  Play or participate in various form of
14. Learn, discover or satisfy the curiosity recreation
GORDON
that leads to normal development and  Role-Relationship Pattern
health and use available health facilities SELF-ESTEEM NEEDS
HENDERSON
GORDON’S FUNCTIONAL HEALTH  Work in such a way that there is
PATTERNS accomplishment
GORDON
1. Health-Perception-health Management  Self-Perception-Self-Concept Pattern
Pattern SELF-ACTUALIZATION NEEDS
GORDON
2. Nutritional-Metabolic Pattern
 Cognitive-Perceptual Pattern
3. Elimination Pattern  Value-Belief Pattern
NEED TO KNOW AND UNDERSTAND
4. Activity-Exercise Pattern
 Learn, discover or satisfy the curiosity that
5. Sleep-Rest Pattern leads to normal development and health and
6. Cognitive-Perceptual Pattern use available health facilities
AESTHETIC
7. Self-Perception-Self-Concept Pattern HENDERSON
8. Role-Relationship Pattern  Worship according to one’s faith
GORDON
9. Sexuality-Reproductive Pattern  Coping-Stress Tolerance Pattern
10. Coping-Stress Tolerance Pattern
11. Value-Belief Pattern
NANDA’S HUMAN RESPONSE PATTERNS
 develop, refine and promote a taxonomy of
nursing diagnostic terminology of general
use to professional nurses

, NCM 101
HUMAN GROWTH AND DEVELOPMENT  Ability to ask questions and ability to listen
 Consideration of the individual’s level of are essential to successful interview
growth and development  eg. Nursing history or nursing admission
 Important to recognize and understand assessment obtained
variations from normal such as age-related  FORMAL INTERVIEW
development in patients individualize  Provides the opportunities and the
nursing care uninterrupted attention of the nurse
DATA COLLECTION SKILLS  Not intended to be a treatment
1. Observation NOTE:
FORMAL INTERVIEW
2. Interview -collecting comprehensive data of the client
3. Examination including the heath history
4. Medical Record Review  INFORMAL INTERVIEW
TYPES OF DATA  Conversation in the course of giving
 SUBJECTIVE DATA (symptoms) can be nursing care
described only by the person experiencing it eg.  Simultaneously focus attention on
Pain, vertigo. what the patient is saying
 Done through good communication skills and  THERAPEUTIC COMMUNICATION
interview skills.  A planned, deliberate communication
 OBJECTIVE DATA (Signs) can be observed to help identify and meet the health
and measured eg. Pallor, diaphoresis, care needs of the patient; requires
BP=120/80, reddish urine. practice to be effective
 Good observation skill – in order not to omit NOTE:
relevant information to the problem THERPEUTIC COMMUNICATION
-active listening (talking with sense and
SOURCES OF DATA listening
1. Primary – patient or client
3) EXAMINATION
2. Secondary – significant others, patient’s
 Done with advanced education and training
record/chart, health team members, related
 A skill expected of all nurses
literature
 Requirements:
DATA COLLECTION SKILLS
1) OBSERVATION 1. Establish rapport with the patient.
2. Explain procedure and ask permission
 A high level nursing skill that requires a
to proceed.
great deal of practice;
3. Provide privacy
 Can be learned with systematic study and
 Senses and skills use:
practice
1. Visualization inspection of the
 Perform nursing tasks and simultaneously
patient’s body coupled with senses of
continue the observation process
hearing, smelling and touching
 Ability to perform constant, ongoing
2. Auscultation includes listening with
observation that is essential to assessment
the use of the stethoscope
2) INTERVIEW
3. Palpation or feeling which give
 A structured form of communication used
information about organ position,
to collect data