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INTERVENTION
 Are the action steps of the nursing process,
the time when the nurse intervenes or
provides varying types of care for the
Patient.
 Nursing interventions include anything that
nurses directly do to patients and the
things done on behalf of patients,
improving patient outcomes.
 Nursing interventions are actions that
nurses perform to provide direct or
indirect care to patients
NURSING INTERVENTIONS CLASSIFICATION
 Independent: interventions that can be
performed by the nurse without assistance
or input from others, such as checking
vital signs or administering medication;
such as checking vital signs or
administering medication.
 Dependent: interventions that require
instructions or permission from a doctor,
such as prescribing medication
 Interdependent: interventions that require
collaboration with a medical team across
disciplines, such as managing a complex
wound.
Some examples of health education in nursing
interventions:
Nursing intervention health education is a
critical component of patient care. As nurses, we
play a pivotal role in empowering individuals with
the knowledge they need to make informed
decisions about their health and manage their
conditions effectively
 Providing patient education on topics such
as disease prevention, nutrition, hygiene,
and self-care.
 Administering medication and explaining
its purpose, dosage, and side effects.
 Maintaining a safe environment and
following procedures to reduce the risk of
infection and injury.
 Monitoring vitals and recovery progress
and providing feedback and
encouragement.
EVALUATION
-helps the whole organization to identify how we could
improve what we are achieving, take action to build on
successes, and avoid repeating failures.
Evaluating is the fifth phase of the nursing
process. In this context, evaluating is a
planned, ongoing, purposeful activity in which
clients and healthcare professionals
determine:
 The client’s progress toward achievement of
goals/ outcomes
 The effectiveness of the nursing care plan.
Evaluation is an important aspect of the
nursing process because conclusions drawn
from the evaluation determine whether the
nursing interventions should be terminated,
continued, or changed. Evaluation is the
sixth standard of the ANA standards of
practice and states that “the registered nurse
evaluates progress towards attainment of
outcomes”
TYPES OF EVALUATION:
PLANNED Involves setting specific criteria and
goal at the beginning of patient care to assess
progress and outcomes systematically.
ONGOING a type of evaluation performed at
specified intervals shows the extent of progress
toward achievement of outcomes and enables the
nurse to correct any deficiencies and modify the
care plan as needed.
PURPOSEFUL a type of evaluation where nurse
collects data for the purpose of comparing it to
preselected goals/outcomes and judging the
effectiveness of the nursing care
DOCUMENTATION
 Is anything written or printed that is
relied on as a record of proof for
authorized person
 Documentation and reporting in
nursing are needed for continuity of
care it is also a legal requirement
showing the nursing care performed or
not performed by a nurse. The
purpose of documentation in nursing is
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multifaceted and includes the
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following:
1. Communication
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2. Planning Client Care
3. Auditing Health Agencies
4. Research
5. Education
6. Reimbursement
7. Legal Documentation
8. Health Care Analysis
Guidelines for Good Documentation
Fact – information about clients and their care
must be factual. A record should contain
descriptive, objective information about what a
nurse sees, hears, feels and smells
Accuracy – information must be accurate so that
health team members have confidence in it
Completeness – the information within a record
or a report should be complete, containing
concise and thorough information about a client’s
care. Concise data are easy to understand
Currentness – ongoing decisions about care
must be based on currently reported
information. At the time of occurrence include the
following:
a. Vital signs
b. Administration of medications and treatments
c. Preparation of diagnostic tests or surgery
d. Change in status
e. Admission, transfer, discharge, or death of a
client
f. Treatment for a sudden change in status
Organization – the nurse communicates in a
logical format or order
Confidentiality – a confidential communication is
information given by one person to another with
trust and confidence that such information will not
be disclosed
• Review and revise the plan of care every 3
months or whenever the client’s health status
changes.
• Document and report any change in the client’s
condition to the primary care provider and the
client’s family within 24 hours.
• Document all measures implemented in
response to a change in the client’s condition.
• Make sure that progress notes address the
client’s progress about the goals or outcomes
defined in the plan of care.
HOME CARE DOCUMENTATION
• Complete a comprehensive nursing assessment
and develop a plan of care to meet Medicare and
other third-party payer requirements. Some
agencies use the certification and plan of
treatment form as the client’s official plan of care.
• Write a progress note at each client visit, noting
any changes in the client’s condition, nursing
interventions performed (including education and
instructional brochures and materials provided to
the client and home caregiver), client responses
to nursing care, and vital signs as indicated.
• Provide a monthly progress nursing summary to
the attending primary care provider and to the
reimbursement to confirm the need to continue
services.
• Keep a copy of the care plan in the client’s
home and update it as the client’s condition
changes.
• Report changes in the plan of care to the
primary care provider and document that these
were reported. Medicare and Medicaid will
reimburse only for the skilled services provided
that are reported to the primary care provider.
• Encourage the client or home caregiver to
record data when appropriate.

LONG-TERM CARE DOCUMENTATION
• Complete the assessment and screening forms
(MDS) and plan of care within the period specified
by regulatory bodies.
• Keep a record of any visits and phone calls from
family, friends, and others regarding the client.
• Write a discharge summary for the primary care
provider to approve the discharge and to notify
the reimbursement that services have been
discontinued. Include all services provided, the
client’s health status at discharge, outcomes
achieved, and recommendations for further care.
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• Write nursing summaries and progress notes Date and Time

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that comply with the frequency and standards

required by regulatory bodies.
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Document the date and time of each recording.
This is essential not only for legal reasons but
also for client safety
Timing
Follow the agency’s policy about the frequency of
documenting, and adjust the frequency as a
client’s condition indicates; for example, a client
whose blood pressure is changing requires more
frequent documentation than a client whose blood
pressure is constant. As a rule, documenting
should be done as soon as possible after an
assessment or intervention. No recording should
be done before providing nursing care
Legibility
All entries must be legible and easy to read to
prevent interpretation errors. Hand printing or
easily understood handwriting is usually
permissible. Follow the agency’s policies about
handwritten recording
Permanence
All entries on the client’s record are made in dark
ink so that the record is permanent and changes
can be identified. Dark ink reproduces well on
microfilm and in duplication processes.
Accepted Terminology
Abbreviations are used because they are short,
convenient, and easy to use. People are often in
a hurry and use abbreviations when texting or text
paging. Abbreviations are convenient; however,
they are often ambiguous
Correct Spelling
Correct spelling is essential for accuracy in
recording. If unsure how to spell a word, look it up
in a dictionary or other resource book
Accuracy
The client’s name and identifying information
should be stamped or written on each page of the
clinical record. Before making an entry, check that
the chart is the correct one. Do not identify charts
by room number only; check the client’s name.
Special care is needed when caring for clients
with the same last name
Signature
Each recording on the nursing notes is signed by
the nurse making it. The signature includes the
name and title; for example, “Susan J. Green,
RN” or “SJ Green, RN.” Some agencies have a
signature sheet and after signing this signature
sheet, nurses can use their initials. With
computerized charting, each nurse has his or her
code, which allows the documentation to be
identified
Sequence
Document events in the order in which they
occur; for example, record assessments, then the
nursing interventions, and then the client’s
responses. Update or delete problems as
needed.
Appropriateness
Record only information that pertains to the
client’s health problems and care. Any other
personal information that the client conveys is
inappropriate for the record
Completeness
Not all data that a nurse obtains about a client
can be recorded. However, the information that is
recorded needs to be complete and helpful to the
client and health care professionals.
Conciseness
Recordings need to be brief as well as complete
to save time in communication. The client’s name
and the word client are omitted. For example,
write “Perspiring profusely. Respirations shallow,
28/min.” End each thought or sentence with a
period
Legal Prudence
Accurate, complete documentation should give
legal protection to the nurse, the client’s other
caregivers, the healthcare facility, and the client.
Admissible in court as a legal document, the
clinical record provides proof of the quality of care
given to a client
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 A universal phenomenon influencing how
people think, feel, and behave about one
another.
HEALTHCARE ELECTRONIC DATABASE
 It includes all of the client's known
information,
upon the patient's initial arrival at the
healthcare facility, includes primary care
and nurse assessment
 Provider's past, as well as social and
familial information, and
physical examination findings and
baseline
Diagnostic tests.
Nursing as an Art
 Emerged suggesting that the art of
nursing is the intentional creative use of
oneself, based upon skill and expertise,
to transmit emotion and meaning to
another. It is a process that is subjective
and requires interpretation, sensitivity,
imagination, and active participation.
 Caring is
Caring central to
nursing
practice,
but it is even more important in today’s
hectic healthcare environment. The
demands, pressure, and time constraints
in the healthcare environment leave little
room for caring practice, which results in
nurses and other health professionals
becoming dissatisfied with their jobs and
cold and indifferent to patient needs
CARING PRACTICE MODEL
Leininger’s Transcultural Caring
 From a transcultural perspective,
Madeleine Leininger (1991) describes the
concept of care as the essence and
central, unifying, and dominant domain
that distinguishes nursing from other
health disciplines. Care is an essential
human need, necessary for the health and
survival of all individuals.
 Stresses the importance of nurses’
understanding cultural caring behaviors.
Watson’s Transpersonal Caring
 Patients and their families expect a high
quality of human interaction from nurses.
Unfortunately, many conversations
between patients and their nurses are very
brief and disconnected. Watson’s theory of
caring is a holistic model for nursing that
suggests that a conscious intention to care
promotes healing and wholeness
 In Watson’s view caring becomes almost
spiritual. It preserves human dignity in the
technological, cure-dominated healthcare
system
 the model is transformative because the
relationship influences both the nurse and
the patient for better or for worse (Watson,
2006, 2010). Caring-healing
consciousness promotes healing.
Application of Watson’s caring model in
practice enhances nurses’ caring
practices
Swanson’s Theory of Caring
 Kristen Swanson (1991) studied patients
and professional caregivers in an effort to
develop a theory of caring for nursing
practice. This middle-range theory of
caring was developed from three perinatal
studies that interviewed women who
miscarried, parents and health care
professionals in a newborn intensive care
unit, and socially at-risk mothers who
received long-term public health
intervention.
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Patients’ Perceptions of Caring
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 Leininger’s, Watson’s, and Swanson’s
theories provide an excellent beginning to
understanding the behaviors and
processes that characterize caring.
Nursing as Caring (Boykin and Schoenhofer)
 suggest that the purpose of the discipline
and profession of nursing is to know
people and nurture them as individuals
living and growing in caring
Caring, the Human Mode of Being (Roach)
 visualizes caring to be unique in nursing,
however, because caring is the center of
all attributes she uses to describe nursing
6 C’s CARING
Compassion
 Awareness of one’s relationship to
others, sharing their joys, sorrows,
pain, and accomplishments.
Participation in the experience of
another.
Competence
 having the “knowledge, judgment,
skills, energy, experience and
motivation required to respond
adequately to the demands of
one’s professional responsibilities”
Confidence
 Comfort with self, client, and
others that allows one to build
trusting relationships.
Conscience
 Morals, ethics, and an informed
sense of right and wrong.
Awareness of personal
responsibility.
Commitment
 The deliberate choice to act by
one’s desires as well as
obligations, resulting in an
investment of self in a task or
cause.
Comportment
 Appropriate bearing,
demeanor, dress, and
language that are in
harmony with a caring
presence. Presenting
oneself as someone who
respects others and
demands respect.
COMMUNICATING
 For nurses, good communication in
healthcare means approaching every
patient interaction with the intention to
understand the patient's concerns,
experiences, and opinions. This includes
using verbal and nonverbal
communication skills, along with active
listening and patient teach-back
techniques.
PROCESS AND MODELS:
Sender
 a person or group who wishes to
communicate a message to another, can
be considered the source encoder
 Encoding: involves the selection of
specific signs or symbols (codes) to
transmit the message, such which
language and words to use, how to
arrange the words, and what tone of voice
and gestures to use
Message
 what is actually said or written, the body
language that accompanies the words,
and how the message is transmitted
Receiver
 The listener, who must listen, observe,
and attend. This person is the decoder,
who must perceive what the sender
intended
 Decode: relate the message perceived to
the receiver’s storehouse of knowledge
and experience and to sort out the
meaning of the message.
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Response
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 The message that the receiver returns to  Termination phase: the end of the helping
the sender. It is also called feedback.
relationship, the nurse and the client evaluate
the outcomes and say goodbye.

THERAPEUTIC
COMMUNICATION

Promotes understanding and can help establish a

constructive relationship between the nurse and
the client.
Researchers explored nursing care behaviors as
perceived by patients

1. EMPATHY – an emotional linkage between

two or more people through which feelings
are communicated; involves trying to imagine
what it must be like to be in another person’s
situation.
2. TRUST – the client’s belief that the nurse will
behave predictably and competently while
respecting the client’s needs
3. HONESTY – the ability to be truthful, frank
and sincere
4. VALIDATION – listening to the client and
responding congruently to be sure that the
nurse and client have the same understanding
of a problem or issue
5. ACTIVE LISTENING – the level of emotional
involvement between the nurse and the
client.
6. CARING – the level or emotional involvement
between the nurse and client.

HELPING RELATIONSHIP

 Pre-interaction phase: before meeting the

client, the nurse prepares for the encounter
and gathers information.
 Orientation phase: the nurse and the client
meet and establish the parameters, goals, and
expectations of the relationship.
 Working phase: the nurse and the client work
together to achieve the goals and address the
client's needs and problems.
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REFERENCES:

Mozafaripour, S. (2023, December 20). The

Importance of Effective Communication in
Nursing. University of St. Augustine for Health
Sciences.
https://www.usa.edu/blog/communication-in-
nursing/#:~:text=For%20nurses%2C%20good
%20communication%20in,and%20patient
%20teach%2Dback%20techniques.

Phases of Helping Relationships – LevelUpRN

Audrey T Berman, Shirlee Snyder, Geralyn Frandsen -

Kozier & Erb's Fundamentals of Nursing-Prentice Hall
(2015)(Z-Lib.io).pdf

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