Nursing as a Science

A.PROBLEM SOLVING PROCESS- solving is an important skill for today’s

healthcare workers. Knowing the types of problem that can arise and planning for
them in case they do happen will help them deal with problems effectively.

B. NURSING PROCESS- a systemic guide to client-centered care

LYDIA HALL – is one who originated the term Nursing Process in 1995, and
introduced Three-Steps of Nursing Process: note observation, ministration of care,
validation

Step of Nursing Process

A – ASSESSMENT
D – DIAGNOSIS
P – PLANNING
I – IMPLEMENTING
E – EVALUATING
1.ASSESSMENT:   the first step in NP it is the process of gathering, verifying and
communicating data about a client.

Purpose: To establish a data base.

During assessment:
Collection of data by gathering information about the client, physical, psychological,
emotional, socio-cultural, and spiritual factors that may affect his/or her health
status.

Types of Data:

Subjective data (symptoms) – those can be described only by the person

experiencing it.  E.g.  vertigo (dizziness), pain, tinnitus (ringing of the ears),
feeling anxious

Objective data (signs) – those that can be observed and measured. E.g., pallor,
sweating, BP=120/80, reddish urine, cyanosis. elevated temperature, skin
moisture.

Methods of Data Collection 

a. Interview – planned purposeful conversation.

Focused interview – asking specific questions
Directive interview – limited questions especially in emergency situation.

b. Observation – use of senses, units of measure, physical examination

techniques, interpretation of laboratory results.
c. Physical examination techniques: - inspection, palpation, percussion,
auscultation

2. DIAGNOSIS:  Analyzing and synthesizing data, the second phase of the nursing
process, use critical thinking skills to interpret assessment data and identify
client strength and problems A causal relationship between a problem and
its related or risk factors.

Purpose: 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

Differentiating Nursing Diagnoses from Medical Diagnoses

A nursing diagnosis is a statement of nursing judgment and refers to a

condition that nurses, by virtue of their education, experience, and
expertise, are licensed to treat. Nursing diagnoses describe the human
response, a client’s physical, sociocultural, psychological, and spiritual
responses to an illness or a health problem.  

A medical diagnosis is made by a physician and refers to a condition that

only a physician can treat.
refer to the disease processes—specific pathophysiologic responses that
are fairly uniform from one client 

Based on the data collected identify a nursing diagnosis from NANDA

International Consult evidence practice literature (North American Nursing
Diagnosis Association)

Purpose of NANDA International

 To define
 Refine
 Promote a taxonomy of nursing diagnostic terminology of general use to
professional nurses.
 taxonomy is a classification system or set of categories arranged based on
a single principle or set of principles. 
 
Status of the Nursing Diagnoses

actual diagnosis / problem focused diagnosis - is a client’s problem that is

present at the time of the nursing assessment.  
        Example- Ineffective Breathing Pattern and Anxiety.  

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.
         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 higher risk than others, therefore, the nurse would appropriately
use the label Risk for Infection to describe the client’s health status.

health promotion diagnosis- relates to clients’ preparedness to implement

behaviors to improve their health condition
        Example- Readiness for Enhanced Nutrition

Components of a NANDA Nursing Diagnosis:

P – problem
E / R – etiology / related to
S – signs and symptoms

 the problem and its definition- describes the client’s health problem or
response for which nursing therapy is given 
 the etiology- identifies one or more probable causes of the health problem,
gives direction to the required nursing therapy, and enables the nurse to
individualize the client’s care the defining characteristics
 signs and symptoms – defining characteristics of the client

Formulating Diagnostic Statements

 BASIC TWO-PART STATEMENTS

 1. Problem (P): statement of the client’s response (NANDA label)
 2. Etiology (E): factors contributing to or probable causes of the responses 
                : two parts are joined by the words related to

 BASIC THREE-PART STATEMENTS

       1. Problem (P): statement of the client’s response (NANDA label)
       2. Etiology (E): factors contributing to or probable causes of the responses.
       3. Signs and symptoms (S): defining characteristics manifested by the
client.
           : list the signs and symptoms on the care plan below the nursing diagnosis,
grouping the subjective (S) and objective (O) data

ONE -PART STATEMENTS

diagnostic statements, such as health promotion 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.
E.g. Readiness for Enhanced Parenting

Types of Nursing Interventions

I. 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

II. Dependent interventions are activities carried out under the orders or
supervision of a licensed physician or other health care provider authorized to
write orders to nurses.

III. Collaborative interventions are the actions the nurse carries out in
collaboration with other health team members, such as physical therapists,
social workers, dietitians, and primary care providers.
 Collaborative nursing activities reflect the overlapping responsibilities of, and
collegial relationships among, health personnel.

 NURSING CARE PLAN FORMAT

NURSING DESIRED OUTCOME/ NURSING RATIONAL EVALUATIO

DEFINING DIAGNOSIS GOALS INTERVENTION E N
CHARCTERISTICS (Problems)

Subjective cues NANDA        

Objective cues          

           

3.PLANNING:
Planning is a deliberative, systematic phase of the nursing process that involves
decision making and problem solving. In planning, the nurse refers to the
 client’s assessment data and diagnostic statements for direction in formulating
client goals and designing the nursing interventions required to prevent, reduce,
or eliminate the client’s health problems.
- begins with the first client contact and continue until the nurse–client
relationship ends, usually when the client is discharged from the health care
agency
Steps
 Prioritize problems/diagnoses
 Formulate goals/desired outcomes
 Select nursing interventions
 Write nursing interventions

Purpose: Identify the patients problem

TYPES OF PLANNING
 Initial Planning
The nurse who performs the admission assessment usually develops the initial
comprehensive plan of care. This nurse has the benefit of seeing the client’s
body language and can also gather some intuitive kinds of information that are
not available solely from the written database. Planning should be initiated as
soon as possible after the initial assessment.

 Ongoing Planning
All nurses who work with the client do ongoing planning. As nurses obtain new
information and evaluate the client’s 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. Using ongoing
assessment data, the nurse carries out daily planning for the following purpose:
 To determine whether the client’s health status has changed
 To set priorities for the client’s care during the shift
 To decide which problems to focus on during the shift
 To coordinate the nurse’s activities so that more than one problem can
be addressed at each client contact

  Discharge Planning
Discharge planning, the process of anticipating and planning for needs after
discharge, is a crucial part of a comprehensive health care plan and should be
addressed in each client’s care plan

The end product of the planning phase of the nursing process is a formal or informal
plan of care

a. informal nursing care plan is a strategy for action that exists in the nurse’s
mind.

b. formal nursing care plan is a written or computerized guide that organizes

information about the client’s care
 i. 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 infarction
 ii. individualized care plan is tailored to meet the unique needs of a
specific client—needs that are not addressed by the standardized plan

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.

NURSING OUTCOMES CLASSIFICATION(NOC)

Standardized or common 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, describing client outcomes that respond
to nursing interventions

PURPOSE OF GOALS/DESIRED OUTCOMES

a. Provide direction for planning nursing interventions
b. Serve as criteria for evaluating client progress
c. Enable the client and nurse to determine when the problem has been
resolved.
d. Help motivate the client and nurse by providing a sense of
achievement

Goals may be short term or long term

TYPES OF NURSING INTERVENTIONS

I. Independent interventions are those activities that nurses are licensed to
initiate on the basis of their knowledge and skills, include physical care,
ongoing assessment, emotional support and comfort, teaching, counseling,
environmental management 

II. Dependent interventions are activities carried out under the orders or
supervision of a licensed physician or other healthcare provider authorized to
write orders to nurses. Primary care providers’ orders commonly direct the
nurse to provide medications, intravenous therapy, diagnostic tests,
treatments, diet, and activity.
 
III. Interdependent interventions are the actions the nurse carries out in
collaboration with other health team members, such as physical therapists,
social workers, dietitians, and primary care providers

HEALTH EDUCATION -I s defined as “developing and providing instruction and

learning experiences to facilitate voluntary adaptation of behavior conducive
to health in individuals, families, groups, or communities” (Iowa Intervention
Project, 2000). 
         -a higher level nursing skill that requires education to efficiently and
effectively accomplish goals

5.EVALUATING/EVALUATION
 To evaluate is to judge or to appraise. Evaluating is the fifth phase of the
nursing process. the final phase of the nursing process. In this phase the nurse
determines the client’s progress toward goal achievement and the
effectiveness of the nursing care plan. The plan may be continued, modified, or
terminated. Determine if goals and expected outcomes are achieved.
Evaluating is a planned, ongoing, purposeful activity in which clients and
health care professionals determine:
(a)the client’s progress toward achievement of goals/ outcomes and 
(b) the effectiveness of the nursing care plan.

Evaluation is an important aspect of the nursing process because conclusions drawn

from the evaluation to determine whether the nursing interventions should be
terminated, continued, or changed.

 Collect data related to outcomes 

 Compare data with outcomes 
 Relate nursing actions to client goals/outcomes
 Draw conclusions about problem status
 Continue, modify, or terminate the client’s care plan

Purpose: To determine where to continue, modify or terminate the plan of care

TYPES OF EVALUATION

I. PLANNED- detailed scheme, program or method worked out beforehand for the
accomplishment of an object, a systematic arrangement of details

II. ON-GOING- assesses whether the relevance is still as expected, or if there are
changes in the program or its context which influence its relevance.

III. PURPOSEFUL- Purposeful assessment practices help teachers and students

understand where they have been, where they are, and where they might go
next

6.DOCUMENTATION
The interactions between and among health professionals, clients, their
families, and health care organizations. The results of, or client’s response to,
diagnostic tests and interventions. Serves as a permanent record of client
information and care. The process of making an entry on a client record is also
called charting or documenting.

 Reporting

PURPOSES OF CLIENT RECORDS/DOCUMENTATION

1. Communication - record serves as the vehicle by which different health
professionals who interact with a client communicate with each other

2. Planning Client Care - uses data from the client’s record to plan care for that
client. Nurses use baseline and ongoing data to evaluate the effectiveness of
the nursing care plan

3. Auditing Health Agencies - a review of client records for quality assurance

purposes

4. Education - Students in health disciplines often use client records as

educational tools.

5. Reimbursement-helps a facility receive reimbursement from the federal

government.

6. Legal Documentation-client’s record is a legal document and is usually

admissible in court as evidence

7. Health Care Analysis-Information from records may assist health care planners
to identify agency needs, such as over utilized and underutilized hospital
services.

DOCUMENTATION SYSTEMS
Source-Oriented Record
           -traditional client record, each person or department makes notations
in a separate section or sections of the client’s chart. For example, the
admissions department has an admission sheet; the primary care provider
has a physician’s order form, a physician’s history sheet, and progress notes;
nurses use the nurses’ notes; and other departments or personnel have their
own records.

Narrative charting
           -consists of written notes that include routine care, normal findings,
and client problems. There is no right or wrong order to the information,
although chronological order is frequently used.

“Problem-Oriented Medical Record

                -established by Lawrence Weed in the 1960s, the data are
arranged according to the problems the client has rather than the source of
the information. Members of the health care team contribute to the problem
list, plan of care, and progress notes. Plans for each active or potential
problem are drawn up, and progress notes are recorded for each problem.

POMR four basic components

1.Database
2.Problem list
3.Plan of care
4.Progress notes
5.with additional forms
Flow sheets
Discharge notes

Advantage of POMR
 it encourages collaboration
 the problem list in the front of the chart alerts caregivers to the client’s needs
and makes it easier to track the status of each problem

Disadvantage of POMR
 caregivers differ in their ability to use the required charting format
 it takes constant vigilance to maintain an up-to-date problem list
 it is somewhat inefficient because assessments and interventions that apply to
more than one problem must be repeated

1. Database
-consists of all information known about the client when the client first enters the
health care agency, it includes the nursing assessment, the primary care provider’s
history, social and family data, and the results of the physical examination and
baseline diagnostic tests. Data are constantly updated as the client’s health status
changes.

2. Problem list
- derived from the database, it is usually kept at the front of the chart and serves as
an index to the numbered entries in the progress notes. 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. All caregivers may contribute to the
problem list, which includes the client’s physiological, psychological, social, cultural,
spiritual, developmental, and environmental needs. Primary care providers write
problems as medical diagnoses, surgical procedures, or symptoms; nurses write
problems as nursing diagnoses.

3. Plan of care
-initial list of orders or plan of care is made with reference to the active problems.
Care plans are generated by the individual who lists the problems. Primary care
providers write physician’s orders or medical care plans; nurses write nursing orders
or nursing care plans. The written plan in the record is listed under each problem in
the progress notes and is not isolated as a separate list of orders.

4. Progress notes
-chart entry made by all health professionals involved in a client’s 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. 

 SOAP format is frequently used. SOAP is an acronym for subjective data,

objective data, assessment, and planning. with additional forms
S- Subjective data consist of information obtained from what the client says.
O- Objective data consist of information that is measured or observed by use of
the senses (e.g., vital signs, laboratory and x-ray results).
A- Assessment is the interpretation or conclusions drawn about the subjective
and objective data. During the initial assessment, the problem list is created
from the database, so the “A” entry should be a statement of the problem. “A”
should describe the client’s condition and level of progress rather than merely
restating the diagnosis or problem.
P- Plan is the plan of care designed to resolve the stated problem. The initial plan
is written by the person who enters the problem into the record. All
subsequent plans, including revisions, are entered into the progress notes.

Modifications

The acronyms SOAPIE and SOAPIER refer to formats that add interventions,
evaluation, and revision:
I-Interventions refer to the specific interventions that have actually
   been performed by the caregiver.

E-Evaluation includes client responses to nursing interventions and

medical treatments. This is primarily reassessment data.

R-Revision reflects care plan modifications suggested by the

    evaluation.
Changes may be made in desired outcomes, interventions, or target dates.
PIE documentation:
Newer versions of this format eliminate the subjective and objective PIE
documentation model groups information into three categories.
PIE is an acronym for problems, interventions, and evaluation of nursing care.
This system consists of a client care assessment flow sheet and progress notes. The
flow sheet uses specific assessment criteria in a particular format, such as human
needs or functional health patterns. The time parameters for a flow sheet can vary
from minutes to months

Advantage
Eliminates the traditional care plan and incorporates an ongoing care plan into the
progress notes.

Disadvantage
The nurse must review all of the nursing notes before giving care to determine
which problems are current and which interventions were effective.

Focus Charting
-intended to make the client and client concerns and strengths the focus of care.
Three columns for recording are usually used: date and time, focus, and progress
notes. The focus may be a condition, a nursing diagnosis, a behavior, a sign or
symptom, an acute change in the client’s condition, or a client strength. The
progress notes are organized into:
(D) data, (A) action, and (R) response, referred to as DAR. 

The data category reflects the assessment phase of the nursing process and
consists of observations of client status and behaviors, including data from flow
sheets (e.g., vital signs, pupil reactivity). The nurse records both subjective and
objective data in this section. 

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. 

The response category reflects the evaluation phase of the nursing process and
describes the client’s response to any nursing and medical care.
Advantage
 Focus charting system provides a holistic perspective of the client and the
client’s needs.
  It also provides a nursing process framework for the progress notes (DAR)
  The three components do not need to be recorded in order and each note does
not need to have all three categories. Flow sheets and checklists are frequently
used on the client’s chart to record routine nursing tasks and assessment data

Charting by Exception (CBE)

a documentation system in which only abnormal or significant findings or
exceptions to norms are recorded, CBE incorporates three key elements (Guido,
2010):

 Flow sheets-include graphic records of a vital sign sheet

 Standards of nursing care-documentation by reference to the agency’s printed
standards of nursing practice eliminates much of the repetitive charting of
routine care.
 Bedside access to chart forms- all flow sheets are kept at the client’s bedside
to allow immediate recording and to eliminate the need to transcribe data from
the nurse’s worksheet to the permanent record.

Advantage
 Eliminates lengthy, repetitive notes and it makes client changes in condition
more obvious. Inherent in CBE is the presumption that the nurse did assess
the client and determined what responses were normal and abnormal

Computerized Documentation

 Electronic health records (EHRs) are used to manage the huge volume of
information required
 in contemporary health care. That is, the EHR can integrate all pertinent
client information into one record. Nurses use computers to store the client’s
database, add new data, create and revise care plans, and document client
progress

PROS

• Computer records can facilitate a focus on client outcomes.

• Bedside terminals can synthesize information from monitoring equipment.
• Such systems allow nurses to use their time more efficiently.
• The system links various sources of client information.
• Client information, requests, and results are sent and received quickly.
• Links to monitors improve accuracy of documentation.
• Bedside terminals eliminate the need to take notes on a worksheet   before
recording.
 • Bedside terminals permit the nurse to check an order immediately before
administering treatment or medication.
• Information is legible.
• The system incorporates and reinforces standards of care.
• Standard terminology improves communication.

CONS

• Client’s privacy may be infringed on if security measures are not used.

• Breakdowns make information temporarily unavailable.
• The system is expensive.
• Extended training periods may be required when a new or update system is
installed