BASIC CONCEPTS IN NURSING
PROVIDING SAFE CLIENT
ENVIRONMENT
Physical and Biological Dimension
ADEQUATE SPACE
• Patients need for personal space, a
homely welcoming atmosphere, a
supportive environment, good
physical design, access to external
areas and provision of facilities for
recreation and leisure. Responses
suggest that patient attitudes and
perceptions to the built environment
of hospital facilities relates to
whether the hospital provides a
welcoming homely space for
themselves and their visitors that
promotes health and wellbeing.
NATURAL AND ARTIFICIAL
LIGHTING
• Light is critical to human functioning
in that it allows us to see things and
perform activities. But it is also
important because it affects human
beings psychologically and
physiologically. Several studies have
documented the importance of light
in reducing depression, decreasing
fatigue, improving alertness,
modulating circadian rhythms, and
treating conditions such as
hyperbilirubinemia among infants.
Artificial Lighting in Hospitals
• Modern healthcare architects have a
greater focus on sustainable or green
building designs that exploit natural
daylight and the views out of
windows. The designs take
advantage of the benefits of natural
light while combating the negative
impacts associated with it, such as
heat gains, the transmission of UV
rays and glare.
Benefits of Natural Light
• Reduce lengths of in-patients stay
• Faster post-operative recovery
• Greater pain relief
• Improve employee morale
TEMPERATURE AND HUMIDITY
• The usual comfort range for
environmental temperature is
between 18.3 °C - 23.9 °C (65 °F -
75°F)
• Extreme temperatures pose safety
risks for vulnerable populations
• Frequently during winter and
summer
• Exposure to severe cold for
prolonged periods causes:
✓ Frostbite - surface of the skin
freezes
✓ Hypothermia - core body
temperature is 35 °C (95 °F)
• Older adults, the young, patients
with cardiovascular conditions,
patients who have ingested drugs or
alcohol in excess, and people who
are homeless are at high risk for
hypothermia
• Exposure to extreme heat changes
the electrolyte balance of the body
and raises the core body temperature
✓ Heat Exhaustion - diaphoresis,
hypotension, changes in mental
status, muscle cramps, nausea
• Heat Stroke - severe changes in
mental status, including coma;
hyperthermia with hot dry skin;
 BASIC CONCEPTS IN NURSING
and rectal temperatures in excess
of 40.5 °C (105 °F)
• Chronically ill patients, older adults,
and infants are at greatest risk for
injury from extreme heat.
• Relative Humidity - the amount of
water vapor in the air compared
with the maximum amount of water
vapor that the air could contain at
the same temperature Comfort zone:
60% - 70%
• RH is high = skin's moisture
evaporates slowly → people feel hot
and sticky
• RH is low = skin's moisture
evaporates quickly → people feel
cooler and more comfortable
• Increasing relative humidity of
inhaled air liquefies secretions and
improves breathing.
• Children and adults with upper
respiratory tract infections may
experience some improvement in
their symptoms through placing a
humidifier in the room while they
sleep.
VENTILATION
• Ventilation moves outdoor air into a
building or a room, and distributes
the air within the building or room.
The general purpose of ventilation in
buildings is to provide healthy air for
breathing by both diluting the
pollutants originating in the building
and removing the pollutants from it
Natural Ventilation
• drive outdoor air through purpose-
built, building envelope openings.
Purpose-built openings include
windows, doors, solar chimneys,
wind towers and trickle ventilators.
Mechanical Ventilation
• Mechanical fans drive mechanical
ventilation. Fans can either be
installed directly in windows or
walls, or installed in air ducts for
supplying air into, or exhausting air
from, a room.
• An effective ventilation system
keeps stale air and odors from
lingering in the room.
• Good ventilation in patient rooms is
imperative to limit pathogens and
unpleasant odors associated with
body secretions and excretions
(urine, stool, vomitus, draining
wounds, or body odors).
Importance of Hospital Ventilation
Systems
• Maintaining air quality
• Removal and filtration of
contaminated air
• Protection of vulnerable patients
form contamination by others
• Protection of staff, patients, and
visitors from contamination by
specific disease source
COMFORTABLE SOUND LEVEL
• Sound control is critically important
in healthcare settings, and different
environmental design strategies have
proven successful in mitigating
negative effects of noise while
 BASIC CONCEPTS IN NURSING
allowing effective yet private verbal
communication.
• Noise levels can be effectively
reduced by providing single-patient
bedrooms, installing high-
performance sound-absorbing
acoustical ceiling tiles, and removing
or reducing loud noise sources on
hospital units. Also, acoustical
ceiling tiles improve speech
intelligibility by reducing sound
reverberation and increase speech
privacy by reducing sound
propagation into adjoining areas.
Another measure for increasing
patient confidentiality is providing
private rooms enclosed with walls
that go up to the ceiling, thereby
preventing voice travel through
ceilings in spaces where private
patient information is likely to be
shared. A large body of research also
shows that music therapy is effective
in reducing anxiety and distress
among patients in many different
types of healthcare settings.
FURNITURE AND CLEAN SURFACES
• Tripping over or coming into contact
with common household items, such
as doormats, small rugs on the stair
and floor, damp spots on the floor,
and clutter on side tables, closet
shelves, the top of the refrigerator,
and bookshelves, often results in
accidents in the home.
What to do to AVOID accidents?
• All obstacles should be eliminated
from halls and other highly traveled
areas to minimize the risk of injury.
Clocks, glasses, tissues, and
prescriptions, for example, should be
held on bedside tables within reach
of the client but out of reach of
children.
• Care should also be taken to ensure
that end tables are secure and have
stable, straight legs.
• To minimize clutter, non-essential
objects should be kept in drawers.
Small area rugs should be secured
with a non slip pad or skid-resistant
adhesive strips if they are used.
Carpet stacks can be used to protect
any carpeting on the stairs.
• Damp surfaces or any spillage needs
to be taken care of to avoid accidents
like slipping.
Which surfaces and objects need to be
clean and disinfect?
• To avoid the spread of infection,
clean and disinfect frequently
touched surfaces and objects on a
regular basis.
Difference between Cleaning,
Disinfecting, and Sanitizing
CLEANING
• Cleaning surfaces and objects
eliminates dirt, dust, crumbs, and
germs. When washing, you'll
probably use soap (or detergent) and
water to scrub the surfaces and
objects. This might or may not be
enough to destroy the germs.
However, now that you've eliminated
some of them, there are less germs
that might kill you.
DISINFECTING
 BASIC CONCEPTS IN NURSING
• Disinfecting kills germs on surfaces
and materials by using chemicals
(disinfectants). Bleach and alcohol
solutions are two popular
disinfectants. To destroy germs, you
normally need to leave the
disinfectant on surfaces and objects
for a certain amount of time.
Disinfecting does not always mean
cleaning or removing germs.
SANITIZING
• Cleaning, disinfecting, or both
methods may be used. When you
sanitize, you're reducing the amount
of germs to a healthy level.
• What is considered a safe level
depends on public health standards
or requirements at a workplace or
school.
How to safely clean and disinfect?
When using cleaning and disinfecting
materials, it's important to be cautious:
• Keep them in their original
containers. Always obey the
manufacturer's directions and read
the label's notices.
• If the labels suggest that combining
cleaners and disinfectants is safe, do
so. When such chemicals (like
chlorine bleach and ammonia
cleaners) are mixed together, it may
result in severe injury or even death.
• When using the item, check the label
to see if you need to wear gloves to
cover your hands and/or eye
protection.
• Store them out of the reach of
children.
• If swallowed, inhaled, or get them on
to the skin, follow the directions on
the label or get medical help.
FOOD AND WATER
Nutrients
What is Nutrition?
• Nutrition is the process of a living
being’s ability to eat foods and use
the components of those foods to
promote growth, maintenance, and
development. A poor diet may have
an injurious impact on health causing
deficiency diseases.
• The food that was broken down into
GI System into smaller substances
called nutrients.
• Nutrients are absorbed into the body
for use.
• To sustain good health, eating
different kings of foods are needed
Different Types of Nutrients
Water
• Assists in digestion and absorption
of food
Minerals
• Carries out and maintain specific
body functions (e.g., strengthen the
bones, helps the brain to function
properly)
Fats
• Source of stored energy
Carbohydrates
 BASIC CONCEPTS IN NURSING
• Provides fuel to the body for energy
use
Vitamins
• Carries out and maintain specific
body functions (e.g., heal wounds
and strengthen the immune system)
Proteins
• It builds and repairs tissue
Good Nutrition
• Eat more vegetable and fruits. Go for
its color and variety (dark green,
yellow, orange, and red)
• Eating less salt. Choosing more fresh
foods and fewer processed foods
• Choose foods with good carbs,
contains a good protein package,
healthy fats, fiber-filled diet, and
calcium
Effects of a Good Nutrition
• Aids our body in the healing process
• Provides resistance to illness (Good
Illness)
• Good physical and mental health
• Produces enough energy
Signs of a Good Nutrition
• Bright eyes
• A well-developed body
• Proper sleep patterns
• Healthy or Good Appetite
• Regular Elimination Habits
• Appropriate Body Weight
Hydration
What is Hydration?
• It's to provide someone or something
with water in order to maintain or
restore fluid imbalance.
• The required fluid we intake daily is
8 glasses of water or 64 ounces daily
• We consume fluids through: Eating,
Drinking
• We eliminate fluids through: Urine,
Perspiration, Respiration, Stool
Fluid Imbalances
Edema - excessive fluid in the body
• Caused by: Heart Failure, Kidney
Failure, Excessive salt intake
• Signs: Weight gain, Decreased urine
output, Shortness of breath
Dehydration - deficient fluid in the body
• Causes: Poor fluid intake, Diarrhea,
Bleeding, Vomiting
• Signs: Thirst, Decreased urine
output, fever, weight loss, cracked
lips
WASTE DISPOSAL
• Waste disposal is the proper
disposition or discharge material in
accordance with local environmental
guidelines or laws.
Bio-medical Waste
• It's the waste generated in the
treatment or diagnosis of a patient,
either in research or in the
production or testing of biological
products.
Hazardous Waste
• Any waste with a potential to pose a
threat to human health and life.
 BASIC CONCEPTS IN NURSING
Proper Disposal of BMW (Bio-medical
Waste)
Rules:
• It should not be mixed with other
wastes
• It should be segregated in specified
container/bag
• The container must be sealed and
labeled
• These wastes must be transported in
a specified vehicle only and away
from the patient’s units
WASTE MANAGEMENT
• Waste management is the collection,
transport, processing, recycling or
disposal, and monitoring of waste
materials.
Objectives of Waste Management:
• Decontaminate or disinfect the
infectious component of the waste
• To give awareness about the
potential hazard of medical waste
within the health care setting and
community
• To keep the waste secured and
prevent the accessed of unauthorized
person
SAFE ENVIRONMENT
Physical Hazards
• factors present in the environment
that pose a threat to a person's safety
• may lead to a physical or
psychological injury or death.
Unintentional Injuries
• harmful acts which occur without
any intention to harm the individual
affected
• the injury occurs in a fraction of
seconds or in a very short period of
time all of a sudden
• eg. motor vehicle accidents,
poisonings, falls
• One of the roles of nurses is to
educate the patients on the common
safety hazards as well as emphasis
on hazards to prevent injury.
Falls
• major public health problem
• the leading cause of both fatal and
nonfatal injuries for adults with age
65 and older (CDC, 2015a)
• put a person, especially adults and
older adults, at risk of minor to
serious injuries that result in reduced
mobility and independence and
increase the risk for premature death
• often the reason why a patient's
length of stay in the healthcare
setting extends
Factors increasing the risk of FALLS
• history of falling
• age-related physical
• changes
• sensory deficits
• orthostatic hypotension
• lower-extremity weakness
• gait and balance problems
• disease-related symptoms
• effects of various medications and
treatments
• effects of acute illness or surgery
 BASIC CONCEPTS IN NURSING
• improper use of mobility assistive
devices
• unsafe clothing
• vitamin D deficiency
Common Physical Hazards leading to
FALLS
• inadequate lighting
• unfamiliar setting
• wet surfaces
• waxed floors
• barriers along walkways and
stairways
• loose rugs and carpeting
• lack of safety devices
DIFFERENT FALL RISK-
ASSESSMENT INSTRUMENTS
• include categories on age, fall
history, elimination habits, high-risk
medications, mobility, and cognition
• need to be completed on admission,
following a change in patient's
condition, after a fall, and when
transferred.
Younger Patients
• oftentimes unaware of the effects of
medications and treatments
Roles of Family Members
• help in assessing a patient's risk for
falls
• help report on patient's level of
confusion and ability to ambulate
• help patients avoid the risks to
prevent falls
• offers appropriate assistance
NURSING INTERVENTIONS FOR
FALLS
1. Wristbands - to alert care providers
around the facility and draw extra attention
to prevent falling incident.
2. Proximity to Nurses - it is best to place
patients who are at a higher risk of falling in
rooms closer to the nurses’ station. In the
event they need assistance, they are more
likely to get quick help.
3. Mindful items placement - identify
objects are that used frequently and place
them close to the patient to avoid too much
unnecessary movement by the patient.
4. Lower Beds - keeping the bed as low as
possible for the patients to apply less effort
to get in and out of bed.
5. Nonslip padded floor mats - provide a
nonslippery surface on which to stand
6. Rails on the beds - can prevent the
patients from falling off the bed.
- let the bottom rail be left down to let the
patient quickly get out of the bed if needed
7. Adequate Lighting - to lessen the
likelihood of tripping over or bumping into
objects
- light switch should be easily accessible
from bed
8. Proper Footwear - provide shoes with a
better grip, so it does not slip on the floor
- should also fit well for comfortable and
secure walking
9. Familiarize room layout - for patients
with cognitive impairments, and those
moving into a new
 BASIC CONCEPTS IN NURSING
facility, extra care should be given to make Polypharmacy - significant risk factor for
sure that they become familiar with the falls in adults
environment.
17. Program of regular exercise and gait
10. Use of call light/bed control system training - increased physical conditioning
reduces the risk for falls and limits injury
- be sure it is accessible and within the
that is sustained when fall transpires
patient’s reach.
18. Physical and occupation therapy sessions
-provide instructions to the patient/family
- will help assist with gait techniques and
caregiver when and why use the call system
provide the patient with assistive devices for
(eg. Report pain, get out of bed, go to
transfer and ambulation
bathroom)
- routinely check the condition of rubber tips
11. Safe use of side rails - explain to patient
and the integrity of the aid.
and family members the reason for using
side rails: moving and turning self in bed Assistive Devices: canes, crutches, walkers,
wheelchairs
12. Lessen use of restraints - studies
demonstrate that regular use of restraints 19. Hip pads for high-risk patients - when
does not reduce the incidence of falls properly worn, may reduce a hip fracture
when falls happen
- use as a final option
20. Safe transport using wheelchair -
13. Use of sitters when alternatives are
determine level of assistance needed to
exhausted - a sitter is a nonprofessional staff
transfer patient to
or volunteer who stays in a patient room to
closely observe patients who are at risk for wheelchair
falling.
- place wedge cushion in chair to prevent
14. Avoid clutter on floor surface - patients patients from slipping out of the chair
having difficulty in balancing are not skilled
- secure lock brakes on both wheels when
at walking around certain objects that
transferring patients into and out of
obstruct a straight path
wheelchair
15. Security of bed and chair alarms -
- raise footplates before transfer to chair to
audible alarms can remind the patient not to
avoid tripping
get up alone.
Taking the right steps to Prevent FALLS
- can be a substitute for physical restraints.
Stay physically active
16. Examine effects of medications - review
of patient’s medications by the prescribing regular exercise improves muscles and
health care provider and pharmacist to makes a person stronger, as well as it keeps
identify the side effects and drug your joints, tendons, and ligaments flexible.
interactions that increase the patient’s fall
risk
 BASIC CONCEPTS IN NURSING
Have your eyes and hearing tested
- always wear your glasses or contacts when
you need them
- if you have a hearing aid, be sure it fits
well and wear them
Remove barriers along walkways
- this may increase the chance of tripping,
especially when there is no adequate lighting
along walkways
Know the side effects of your medicines
- if a drug makes you dizzy or sleepy, tell
the doctor or pharmacist
Limit alcohol intake
- even a small amount of alcohol can affect
your balance and reflexes
Stand up slowly
- getting up too quickly can cause blood
pressure to drop which can make you very
wobbly
Use assistive devices for steady walking
- if your doctor tells you to use a cane or
walker, make sure it is the right size and the
wheels roll smoothly
Wear non-skid soles that fully support your
feet
- do not walk on stairs or floors in socks or
in shoes and slippers with smooth soles
Always tell your history of falls
- a fall can alert the doctor to a new medical
problems or problems with medications or
eyesight that can be corrected
RESTRAINTS
• A "restraint" is defined as any
physical or chemical means or
device that restricts client's freedom
to and ability to move about and
cannot be easily removed or
eliminated by the client.
WHEN ARE RESTRAINTS USED?
• Restraints may be used to keep a
person in proper position and prevent
movement or falling during surgery
or while on a stretcher.
• Restraints can also be used to control
or prevent harmful behavior.
• Sometimes hospital patients who are
confused need restraints so that they
do not:
✓ Scratch their skin
✓ Remove catheters and tubes
that give them medicine and
fluids
✓ Get out of bed, fall, and hurt
themselves
✓ Harm other people
Types of Restraints
Physical Restraints
limit a client’s movement.
Some examples of physical restraints are:
• Lap buddies, belts, "geri" chairs, vests,
or trays, which keep the body immobile in
a wheelchair,
• Bed rails or belts, which keep people
confined to their beds, and
• Door alarms, which prevent people
 BASIC CONCEPTS IN NURSING
from walking beyond a set point
GUIDING PRINCIPLES FOR USE OF
RESTRAINTS
1. The safety and dignity of the patient
must be ensured
2. The safety and well-being of staff is
also a priority
3. Prevention of violence is key
4. De-escalation should always be tried
before the use of restraint
5. Restraint is used for the minimum
period
6. All actions undertaken by staff are
appropriate and proportional to the
patient's behavior
7. Any restraint used must be the least
restrictive, to ensure safety
8. The patient must be closely
monitored, so that any deterioration
in their physical condition is noted
and managed promptly and
appropriately. Mechanical-restraint
requires 1:1 observation
9. Only appropriately trained staff
should undertake restrictive
interventions, to ensure the safety of
patients and staff.
POTENTIAL RISKS AND SIDE
EFFECTS OF RESTRAINT USE
Psychological/Emotional Effects
• Feelings of humiliation, loss of dignity
• Diminished quality of life; increased stress,
confusion, fear
• Depression, withdrawal, isolation,
desolation; loss of hope and internal
motivation
• Anger, frustration, demoralization
• Increased agitation, hostility, and
aggression; learned dependence
• Diminished staff opinion of the resident
Physical Effects
• Pressure ulcers and skin irritation
• Bone loss from decreased weightbearing
activity
• Stiffness and muscle atrophy from lack of
use
• Increased risk of respiratory infection
• Increased risk of contractures
• Physical discomfort, increased pain
• Serious injuries from falls
• Increased risk of death from struggling to
get free
Alternative Preventive Measures
Some of the preventive, alternative measures
that can decrease the need for restraints to
prevent a fall include:
• Accurate client assessment for the risk
of falls
• The immediate initiation of special falls
risk interventions when a client is
assessed as "at risk" for falls
• More frequent monitoring
• Providing frequent reminders to the
client to call for help before arising
from the bed or chair
• Using bed and chair alarms
• Using a companion, sitter, etc.
• Reorienting the person
• Placing the client near an activity hub
such as the nursing station so that the
falls risk client gets more
 BASIC CONCEPTS IN NURSING
monitoring and observation
Some of the preventive, alternative measures
that can decrease the need for restraints in
order to prevent the dislodgment of medical
tubes, lines and catheters include:
• Discontinuing or changing the
treatment as soon as medically
possible
• More frequent monitoring
• Using a companion, sitter, etc.
• Distraction
• Providing constant reminders about
the importance of not touching the
tube, line or catheter
• Keeping the tube, line or catheter out
of view
• Reorienting the person
Some of the preventive, alternative measures
that can decrease the need for restraints in
order to prevent violent behaviors that place
self and/or others at risk for imminent harm
include:
• Behavior management techniques
• Behavior modification techniques
• Keeping the client away from
triggers
• Stress management and relaxation
techniques
• Positive and negative reinforcements
Bed Making
• nursing skill
• preparing various types of beds
• client-centered
Purpose:
1. To provide rest and sleep.
2. To eliminate irritants to the skin from the
patient’s body.
3. To dispose soiled and dirty linen properly.
4. To promote freshness and cleanliness.
5. To accommodate the patient’s needs.
6. To give a neat appearance/ look of the
unit.
7. To observe, identify, and prevent patient
complications.
8. To provide physical and psychological
comfort and security to the patient.
9. To establish an effective nurse-patient
relationship.
Principles and Precautions
It is important to learn how to make a bed in
such a way where the least amount of energy
and time is required.
• Use good body movement and make
each step purposeful.
• Keep everything ready on the
bedside before starting bed-making.
Change bed linen frequently to assure
cleanliness.
• Make the bed tight and free from
wrinkles, place all linen straight lines
on the bed.
• It should have a finished appearance.
• Observe uniformity, all bed-making
in a nursing unit should be alike for
uniformity of appearance.
After cleaning the bed, dump soap water,
and disinfectant properly.
 BASIC CONCEPTS IN NURSING
Soiled linen whether clean or dirty should
not be thrown on the floor, it should be kept
in a dirty linen box.
Ensure the patient’s needs by providing a
safe and comfortable bed.
• Prevent cross-infection of
microorganisms during bed-making.
• The uniform of the nurse should not
touch the bed while making a bed.
• Prevent complications of prolonged
bedridden patients such as pressure
sores.
• The opening of the pillowcase
should not face to the entrance of the
ward.
Types of Beds
Open Bed
• bed when it is about to be occupied
by a client.
• top sheet, blanket and bedspread are
folded back.
• wheels are locked.
• bed is in the lowest position.
Closed Bed
• empty bed ; not in use
• the linens are pulled to the top of the
bed.
• the resident will not use the bed or
the bed is ready for a new resident.
Occupied Bed
• This is to make a bed with the client
in.
• Made for a client who cannot get out
of the bed.
Special Beds
• beds adhering to the unique needs of
the patient.
Post-Operative Bed
• Prepared for a client who is
recovering from the effects of
anesthesia following a surgical
operation.
• Made for easy transfer from the
stretcher.
Cardiac Bed
• Prepared for a client with heart
cases.
• This bed is made to ease the client's
respiration.
• Bed is with extra pillows to keep the
client in prop up position for better
airflow.
Amputation Bed
• Prepared for a patient having
amputated limb.
• Amputation - the removal of a limb
by trauma, medical illnesses or
surgery.
Pediatric Bed
• Accommodate the smaller size of
young patients and account for child
risks seen in larger beds.
• Provides full side-railing support
with limited space between bed rails
to eliminate any risk of a pediatric
patient rolling out of bed.
 BASIC CONCEPTS IN NURSING
Air-Fluidized Bed
• For high-risk patients, stage III or IV
pressure ulcers or burns.
• Bed frame contains silicone coated
beads and incorporates both air and
fluid support.
Low-Air-Loss Bed

• For patients who need pressure

relief, those who cannot be
repositioned frequently, or those who
have skin breakdown on more than
one surface.
• Bed frame with a series of connected
air-filled pillows.
Kinetic Beds
• For patients in need of spinal
stabilization.
• Provides continuous passive motion
to promote mobilization of
pulmonary secretions and low air
loss
 BASIC CONCEPTS IN NURSING
NURSING
DOCUMENTATION
Documentation
• Is defined as written evidence of:
1. The interactions between and
among health professionals,
clients, their families, and
health care organizations.
2. The administration of test,
procedures, treatments, and
client education.
3. The results or client response
to these diagnostic tests and
interventions.
• It provides written records that
reflects client care provided on the
basis of assessment data and the
client’s response to interventions.
• Nurses rely on documentation tools
that support the implementation of
the nursing process.
NURSING DOCUMENTATION
• It is the record of nursing care that is
planned and delivered to individual
patients by qualifies nurses or other
caregivers under the direction of a
qualified nurse.
• It is the principal clinical information
source to meet legal and professional
requirements.
• It is vital component of safe, ethical,
and effective nursing practice
whether done manually or
electronically.
• Nursing documentation should fulfill
the legal requirements of nursing
care documentation.
RECORDING AND
DOCUMENTATION
RECORD – also called “CHART” is a
permanent legal documentation of
information relevant to the client’s health
care management
RECORDING – the act of documenting all
information relevant to patient’s care
Commonly referred to as “charting”
Examples: Nurse’s Charting or Nurse’s
Progress Notes – it is part of the patient’s
chart unique to the nurses because it is
where we document all our nursing activities
DOCUMENTATION – defined as anything
written or printed that is relied on as a
record of proof for authorized persons
Purposes of records
➢ C- ommunication
➢ A - ssessment
➢ R – esearch
➢ E - ducation
➢ F – inancial Billing
➢ aU- diting
➢ L - egal Documentation
Guidelines for quality documentation &
reporting
✓ F-ACTUAL
✓ A-CCURATE
✓ C-OMPLETE / CONFIDENTIAL
✓ T-IME BOUND OR CURRENT
✓ O-RGANIZED
 BASIC CONCEPTS IN NURSING
✓ R-ELIABLE OR TRUTHFUL
“What is not written is not done”
GENERAL DOCUMENTATION
GUIDELINES
• Ensure that you have the correct
client record or chart and that the
client’s name and identifying
information are on every page of the
record.
• Document as soon as the client
encounter is concluded to ensure
accurate recall of data.
• Date and time each entry.
• Sign each entry with your full legal
name and with your professional
credential, or per institutional policy.
• Do not leave space between entries.
• If an error is made while
documenting, use a single line to
cross out the error, then date, time,
and sign the correction.
o Avoid erasing, crossing out,
or using correction fluid.
• Never change another person’s entry,
even if it is incorrect.
• Use a quotation marks to indicate
direct client responses
o I feel dizzy.
• Document in chronological order.
• WRITE LEGIBLY
• Use permanent ink pen
o Depending on institution
policy, some use different
colors per shifting.
• Document in a complete but concise
manner by using phrases and
abbreviations as appropriate.
• Document all telephone calls that
you make or receive that are related
to a client’s case
ELEMENTS OF EFFECTIVE
COMMUNICATION
• Use of common vocabulary.
• Legibility and neatness.
o Should be easily readable,
without any chance of error
• Use of only authorized abbreviations
and symbols.
o Ex: U, IU, and the use of zero
with a decimal point (4.000)
o Should be approved by the
facility.
• Factual and time-sequenced
organization.
o Start the entry with date and
time. Should be
chronological order.
• Accurately including errors that
occurred.
o Use of factual, descriptive
terms to chart exactly what
was observed or done.
Methods of recording
There are several types of way that nurses
document, in an actual hospital setting, we
usually based our charting/recording on our
initial assessment and independent nursing
interventions and depending on the doctor’s
orders that we have to carry out.
“Carry Out” – means perform the tasks
ordered by the doctor in the doctor’s order
sheet, and then document it once done.
DISCLAIMER: ALL FORMS USE IN THIS
PRESENTATION MAY VARY FROM
DIFFERENT INSTITUTION, THE DATA
 BASIC CONCEPTS IN NURSING
ATTACHED ARE HYPOTHETICAL CASE - is part of the patient’s chart where the
ONLY AND IS USED FOR EDUCATIONAL doctor writes his assessment, and orders
PURPOSES ONLY! specific health care interventions to be
carried out not only by the nurse but also
METHODS OF DOCUMENTATION /
other members of the health care team.
RECORDING
• Documentation must reflect the
complexity of care, and it must
embody accuracy, completeness, and
evidence of a professional practice
with efficient and cost-effective
systems.
• Many methods are used for
documentation, including
o Narrative charting
o Problem oriented charting
o PIE charting
o Focus charting
o SO
o Charting by Exception

KARDEX
• It is a form or a card that is kept in
portable “flip-over” file or notebook
at the Nurse Station
• Serves as a quick reference for
activities and treatment
• Used during nursing rounds
• Eliminates the need for repeated
referral to the chart for routine
information throughout the day

SAMPLE DOCTOR’S ORDER SHEET

• Doctor’s Order Sheet/Progress
Notes
 BASIC CONCEPTS IN NURSING
TRADITIONAL CHARTING
• Free-verse style of charting in the
nurse’s notes, must be complete from
the time you received the patient
upto the time you endorsed him/her
to the next nurse on duty the
following shift.
• Must be complete & chronological
FOCUS CHARTING: FDAR
• This type of charting gives focus to
specific health problems, more direct
and concise, thus specific
interventions should be performed
for the resolution of the problem,
documentation is written in
accordance with the nursing process.
• May need to do multiple entries
within one shift depending on how
many health problems encountered
by the nurse during his/her shift
CHARTING BY EXCEPTION
• It is a charting method that requires
the nurse to document only
deviations from pre-establish norms.
• CBE was instituted in 1983 by St.
Luke Medical Center in Milwaukee
to overcome the recurring problem
 BASIC CONCEPTS IN NURSING
of lengthy, repetitive notes and to a. Derived from the database
enable the identification of trends in b. A listing of the client’s
client status. problems as identified, with
• It has three components: each problem are numbered
o Flow Sheets – highlights and labeled as acute, chronic,
significant findings and active, or inactive
define assessment parameters 3. Initial Plan
o Reference documentation – is a. Based on problem
related to the standards of identification;
nursing practice b. Starting point of care plan
o Bedside Accessibility – is development with client
related to the documentation participation in setting goals,
forms. CBE requires the expected outcomes, and
nurse to document significant learning needs.
findings and exceptions to 4. Progress Notes
predefine norms. a. Charting based on the SOAP
/ SOAPIE or SOAPIER
PROBLEM-ORIENTED CHARTING format
• Also known as Problem-oriented
medical record (POMR)
• Was introduced in 1969 by
Lawrence Weed, a physician at Case
Western Reserve University.
• The focus of documentation is on the
client’s problem, with a structured,
logical format to narrative charting
called SOAP, SOAPIE, SOAPIER
• There are four critical components of
POMR
o Database
o Problem List
o Initial Plan
o Progress Notes
1. Database
a. Assessment data,
representative of all
disciplines (hx, physical, lab PIE CHARTING
findings) which became the
• Was instituted in Craven Regional
basis for a problem list Medical Center in 1984 to streamline
evaluation of the client. documentation.
2. Problem List
 BASIC CONCEPTS IN NURSING
• The key component of this system S – Subjective Data (verbalizations of the
are assessment flow sheets and client)
nurses’ progress notes with an
O - Objective Data (data observed and
integrated plan of care that
measured by the nurse)
eliminates the need for separate plan.
• The system eliminates the traditional A – Assessment (nursing diagnosis based on
care plan by incorporating an the data)
ongoing plan of care into the daily
P – Plan (Nursing Goal with Expected
documentation.
Outcome)
P – PROBLEM (Nursing Diagnosis)
I – Interventions
I – INTERVENTIONS
E – Evaluation
E - EVALUATION
R - Revision

VITAL SIGNS GRAPHIC CHART

• It is a common part of the complete
patient’s chart where the nurse
records the vital signs of the patient
• The form may vary from different
SOAP / SOAPIE / SOAPIER institutions and may include some
CHARTING aspects of recording that the nurse
 BASIC CONCEPTS IN NURSING
monitors like I&O, Diet, Allergies,
Height and Weight
MEDICATION AND TREATMENT
RECORD
• It is a part of the patient’s complete
chart, where the nurse records all the
medications given to a patient
• Make sure in making an entry of the
medication, please indicate the
complete name of the drug
(GENERIC NAME), dosage, route
of administration and frequency
• The nurse records the time it was
given and affix his/her signature
• Note: the vary per institution
INTRAVENOUS MONITORING
SHEET
• It is used to record and monitor all
intravenous fluids administered to
the patient.
• Should be able to document the
name of the fluid (PNSS, blood,
medication infusions), the amount,
regulation of the fluid (how many
drops or ml per minute), date and
time it started and finished.
INTAKE AND OUTPUT MONITORING
• Use to record the amount of fluids
the patient received and excreted;
recorded in milliliters, usually every
shift and should be total for the 24
hours
INTAKE – amount fluid taken via IV
(including fluids, and medicines), water
drank (including soups), amount of blood
received, and other fluids given (like in
dialysis)
 BASIC CONCEPTS IN NURSING
OUTPUT – amount of fluid excreted by the
patient, thru urine, drains, vomitus, blood
loss
REPORT
• Reports can be compiled daily,
weekly, monthly, quarterly, and
annually.
• It summarizes the services of the
nurse and/or the agency.
• Reports may be in the form of an
analysis of some aspect of a service.
These are based on records and
registers and so it is relevant for the
nurses to maintain the records
regarding their daily case load,
service load and activities.
IMPORTANCE AND PURPOSES OF
REPORTS
• It saves duplication of effort and
elimination the need for investigation
to learn the facts in a situation.
• Full reports often save
embarrassment due to ignorance of
situation
• Patients receive better care when
reports are thorough and give all
pertinent data
• Complete reports give a sense of
security which comes from knowing
all factors in the situation
• It helps in efficient management of
the ward/clinical area
• It can be oral or written type of
report
END OF SHIFT REPORT/
ENDORSEMENT
• Done at the end of each shift
• Nurses report information about their
assigned clients to the nurses
working on the next shift
• Purpose is to provide continuity of
care among nurses who are caring
for a client
• Utilizes the KARDEX, and the
Patient’s Chart as reference
• Ideally, can be done during walking
endorsement or “bedside
endorsement”
TELEPHONE REPORTS
• It is done when the nurse inform the
physician of changes in a client’s
condition and communicate
information to nurses on other units
about client transfer
• Persons involved with a telephone
report need to provide clear,
accurate, and concise information
• To document a phone call, the nurse
includes when the call was made,
who made it (if other than the writer
of the information), who was called,
to whom information was given,
what information was given, and
what information was received
TELEPHONE ORDERS
• It involves a physician stating a
prescribed therapy over a phone to a
registered nurse.
• May use clarificatory questions to
avoid misunderstanding
 BASIC CONCEPTS IN NURSING
• The orders needs to be VERIFIED DOCUMENTATIONS FOR POSSIBLE
by REPEATING the order given, LEGAL PROBLEMS
should be clear and precise!
• Write the telephone order in the
physician’s order sheet in the client
permanent record and sign it, the
doctor should be able to verify later
the telephone order legally by
signing it within a set time period
(usually within 24 hours, or follow
agency’s protocol)
• The nurse will then document it on
the Nurse’s Progress notes regarding
the telephone order received,
includes date and time, the physician
who ordered, the complete telephone
order, and if it is carried out and then
signed it after.
NURSING CONFERENCE
• It is the heart of TEAM NURSING CONSENT FORM
• It is a group discussion of nurses • It is a document secured when the
working in a unit, utilizes problem patient will undergo invasive
solving techniques to determine the medical treatments (Ex: surgeries,
ways or providing care that more chemotherapy), invasive nursing
efficient where quality of care in not procedure (ex: NGT insertion, blood
compromised. transfusion, IFC insertions)
• Can be done pre-clinical rounds, to • It should be explained by the
discuss specific roles of nurses physician, make sure the patient
working together in one patient, or understand the procedure.
post-duty to determine areas of
weakness and improvement of care • The nurse will be the one to secured
the patient’s signature, and will sign
• Can be done before big emergencies as a witness plus another third party
like mass casualty incident
• Document in the nurse’s notes the
securing of the consent
 BASIC CONCEPTS IN NURSING
INCIDENT REPORT
• An incident is any event that is not
consistent with the routine operation
of health care unit or routine care of
a patient.
• It may include fall incidents,
needlestick injuries, breach of
infection control, medication errors,
accidental omission of ordered
therapies and circumstances that led
to injury or harm to patient
• Should answer WHO, WHAT,
WHERE, WHEN, and HOW
• It is an important part of the nursing
unit’s quality improvement program

HAMA (HOME AGAINST MEDICAL

ADVICE)
• Used synonymously with DAMA
(Discharge Against Medical Advice)
• It is used when a patient refuses
treatment and prompted to leave
hospital even medically the patient
needs to be treated.
• It is a protection for the hospital,
doctor and nurses that we are willing
to treat the patient, and if something
happen to the patient outside hospital
premises are result of his own
autonomy of refusing medical
management.
• The doctor should be able to explain
the implications of refusing
treatment and leaving the hospital,
the nurse will secure patient’s
signature and will attest as a witness
and should document.
 BASIC CONCEPTS IN NURSING

DNR and DNI

• DNR – “do not resuscitate” refusal
for live saving measures like CPR
during cardiac death
• DNI – “do not intubate” refusal for
an advance airway intubation in
cases of respiratory failure or arrest
• As nurses, being part of the health
care team, it is our job to respect
patient’s wishes (in cases patient is
still of sound mind) and/or next of
kin’s wishes (in cases patient is
comatose, mentally incapacitated,
unable to decide, minor) regarding
on how would they like to proceed
treatment.
• Doctor will explain the implications,
the nurse will secure the signature,
attest as witness, and will document