Fundamentals of Nursing

What is nursing?

Assist and coordinates care for individuals, families and communities to attain, recover, and maintain optimum health and function from birth to old age.  Nurses act as a bridge between an often extremely vulnerable public and the health care resources that can literally make the difference between life, death, health and disease/disability and well being and discomfort.  It involves a wide range of activities from carrying out complicated technical procedures to something as simple as holding a hand.  Nursing is a bleed of science and art.  It is knowledge base for the care that is given, and the art of skilled application to help others maximum health and quality of life.

The theory of animism attempted to explain the cause of mysterious changes in bodily functions.  Good spirits brought health & evil spirits brought sickness and death.  The roles of the physician and the nurse were separate and distinct.  Physician-medicine man.  The nurse usually was the mother who cared for her family during sickness by providing physical care and herbal remedies.

With the Ancient Greeks, the temples became the centers for medical care because of the belief that illness was caused was caused by sin and the god’s displeasure.  Nurse cared for sick in the home & community and as nurse-midwives.

During the early Christian period, nurses had a more formal and more clearly defined roles.  Women were deaconess visited the sick and members of male religious orders gave nursing orders.  Nursing had developed a purpose, direction, and leadership.

In the 16th century, western societies shifted from religious orientation to warfare exploration and expansion of knowledge.  They used female criminals as nurses in lieu to jail time.  This gave nursing a poor reputation.

During the 19th to 21st centuries, schools of nursing, founded in connection with hospitals were established on the belief of Florence Nightingale.  Hospitals saw an economic advantage in having their own schools, and most hospital schools, were organized to provide more easily controlled and less expensive staff.  Female nurses were under the control of male hospital administrators and physicians.

WWII had an effect on nursing.  The first time, large numbers of women worked outside the home.  They became more independent and assertive.  This led an increase role of education which broadened the role of nurses.  After WWII education was upgraded.

Nursing has broadened in all areas, including practice in a wide variety of health care setting the development of a specific body of knowledge, the conduct, and publication of nursing research, and recognition of the role of nursing in promoting health.  Evidence based discipline has led to the growth of nursing as a professional discipline.

The American Nursing Association defines nursing as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, and communities, and population.”  (ANA, 2010)  Nurses primary roles are caregiver, communicator, teacher and educator, counselor, leaders, researchers, advocate, and collaborator.

The nursing aims and competencies to promote health, to prevent illness,  to restore health, and to facilitate coping with disability or death.  The method to promote health is by making referral for homecare for young women with newborn.  To prevent illness by means literature or internet info on  diet (healthy).  The method of restoring health is by referring an abnormal finding to other healthcare provider.

To achieve those aims, nursing blends cognitive, technical, interpersonal, and ethical/legal.  (QSEN = Quality & Safely Education for Nursing) competencies = patient centered care teamwork & collaboration, quality improvement, safety EBP and informatics.

Health literacy is the ability of patients to obtain, process, and understand the basic information needed to make appropriate decisions about health.

Nursing as a Professional Discipline:

  1. Well-defined body of specific and unique knowledge
  2. Strong service orientation
  3. Recognized authority by a professional group
  4. Code of ethics
  5. Professional organization that set standards
  6. Ongoing research
  7. Autonomy and self-regulation

Health is a state of optimal functioning or well being.  It is motivated by the desire to increase a person’s well-being and health potential.  Prevention is “anticipatory action taken to prevent the occurrence of an event or to minimize its effects after it has occurred.  Restore health encompass those traditionally considered to be the nurse’s responsibility.  These focus on the individual with an illness and range from early detection of a disease to rehabilitation and teaching during recovery.

Nursing as a professional discipline

  • well-defined body of specific and unique knowledge
  • strong service orientation
  • recognized authority by a professional group
  • code of ethics
  • professional organization that sets standards
  • ongoing research
  • autonomy and self-regulation

Educational preparation for Nursing practice

  1. Practical & vocational nursing education
  2. Registered Nursing education
    1. Diploma nursing, associates, bachelor
  3. Graduate education in nursing
    1. Master’s or doctoral
  4. Continuing education
    1. In service education

Practical and vocational nursing education were established to teach graduates to give bedside nursing care to patients.  They take the NCLEX as LPN.  LPN works under direction of physician or RN to give direct care to patients, focusing on meeting health care needs in hospitals, long-term facilities, and home health agencies.

Three types of RNs: Diploma, Associates, and Baccalaureate in Nursing.  All of them will have to take NCLEX-RN.

  • Diploma work in acute, long-term and ambulatory health care facilites.
  • Associates (ADN) work in hospitals, long-term care facilities, home health care and other community settings.
  • Baccalaureate (BSN) is required for many administrative, managerial, and community health positions.

The two levels of Graduate Nursing are:  Master’s and Doctoral.  Nurses who have Masters usually work in educational settings, in managerial roles, as clinical specialists and in various advanced practice areas.  Doctoral nurses usually work in academic advancement and organizational management research.

Additional education can be acquired via continuing education credits and in-service education.  Continuing education are those professional experiences designed to enrich the nurse’s contribution to health.  Many employers offer what is called in service credit which is education and training for their employees.

Guidelines for Nursing Practice

  • Standards of Nursing Practice defines activities that are specific and unique to nursing
  • Standards allow nurses to carry out professional roles, serving as protection for the nurse, the patient and the institution where health care is provided.

Nursing Practice Acts are laws established in each state in the USA to regulate the practice of nursing.  State board of nursing is responsible for regulating nursing practice.

Traditional knowledge (subjective) is pass down from generation to generation.  Authoritative knowledge (subjective) comes from an expert and is accepted as truth based on the person’s perceive expertise.  Scientific knowledge is knowledge obtained through scientific method (implying thorough research).  New ideas are tested and measured systematically using objective criteria.

Types of Knowledge

  • Science is observing, identifying, describing investigating, and explaining events and occurrences that are perceived in word.
  • Philosophy is the study of wisdom, fundamental knowledge, and the processes used to develop and construct one’s perception of life.
  • Process is a series of actions, changes, or functions, intended to bring about a desired result.

Historical Influences

Florence Nightingale’s influenced nursing knowledge and practice by demonstrating efficient and knowledgeable nursing care, defining nursing practice as separate and distinct from medical practice and differentiating between health nursing and illness nursing.

Nursing theory is composed of a group of concepts that describe a pattern of reality.  Theories can be tested, changed, or used to guide research or to provide a base for evaluation.  They are derived from deductive and inductive reasoning.  Concepts, like ideas, are abstract impressions organized into symbols of reality.  Describe objects, properties, and events and relationships among them.

Benefits of Nursing Theory directs nurses toward a common goal, with ultimate outcome being improved patient care.  It provides rational and knowledgeable reasons for nursing interventions, based on descriptions of what nursing and what nurses do.  It gives nurses the knowledge base necessary for acting and responding appropriately in nursing care situations, provides a base for discussing ideally, helps resolve current nursing issues.  In addition, it prepares nurses to question assumptions and values in nursing, thus further defining nursing and increasing the knowledge base, and identifies and defines interrelated concepts important in nursing and clearly states the relationship between and among these concepts.  Finally, it helps resolve current nursing issues as well as serves research, education, and practice.

Common concepts in Nursing theories are person (patient), environment, health and nursing.  The most important is the person.

Jean Watson (1979) developed theory of Human Caring/Theory of Transpersonal Caring. Nursing is concerned with promoting and restoring health, preventing illness, and caring for the sick.  Application – Clinical nursing care is holistic to promote, humanism, health, and quality of living.  Caring is universal and is practiced through interpersonal relationships.

Dorothea Orem (1971) developed Self-Care Deficient Theory.  Self care is a human need, self-care deficits require nursing actions.  Application-Nursing is a human service, and nurses design interventions to provide or to manage self-care actions for sustaining health or recovering from illness or injury.

Nursing Research encompasses research to improve the care of people in the clinical setting as well as the broader study of people and the nursing profession, including studies of education, policy and development, ethics, and nursing history.  It is fundamental to the recognition of nursing as a profession, and develop greater autonomy and strength as a profession.  It develop greater autonomy and strength as a profession evidence based and helps find solutions to problems.

Methods of Conducting Nursing Research

  • Quantitative – involves the concepts of basic and applied research.
  • Qualitative – is a method of research conducted to gain insight by discovery meanings – Reality is based on perceptions, which differ for each person & change over time.

Concepts of Health & Wellness

  • Health is a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity.  (WHO 1974)
  • Wellness is a term often used interchangeably with health – is an active state of being healthy, including a lifestyle that promotes good physical, mental, and emotional health.

Classifications of illness

  1. Acute
  2. Chronic
  3. Illness behaviors
    1. stage 1 Experiences symptoms
    2. stage 2 Assuming the sick role
    3. stage 3 Assuming dependent role
    4. stage 4 Achieving recovery & rehabilitation

Assessing Chapter 11

Assessing is the systematic and continuous collection, analysis, validation, and communication of patient data, or information

Assessment – getting the fact

Data reflect health functioning is enhanced by health promotion or comprised by illness/injury.  A database includes all the pertinent patient info collected by the nurse and other health care professionals.

Make judgment about the individual’s health state, ability to manage his or her own need for self-care and need for nursing care.

Plan and deliver thoughtful, person-centered nursing care that draws on the individual’s strength & promotes optimum functioning, independence, and well-being.

Refer the patient to a physician or other health care professional, if indicated.

The nurse makes ongoing assessments.

Nursing history identifies the patient’s health status, strengths, health problems, health risks, and need for nursing care.  The nurse may also perform a nursing physical examination to collect data.

Other sources of patient info used by the nurse include the patient’s family and significant others, the patient record, other health care literature.

It is imperative to use excellent critical thinking and clinical reasoning skills when gathering, analyzing, validating, and communicating data.  Among the critical thinking activities linked to assessment are:

Assessing systematically and comprehensively, using a nursing framework to identify nursing concerns and a body systems framework to identify medical concerns.

Detecting bias and determining the credibility of information sources

Distinguishing normal from abnormal findings and identifying the risks for abnormal findings

Making judgments about the significance of data, distinguishing relevant from irrelevant.

Identifying assumptions and inconsistencies checking accuracy, and reliability, and recognizing missing information

Your nursing assessments should have the following characteristics:  purposeful, prioritized, complete, systematic, factual & accurate, relevant, recorded in a standard manner.

Assessment & Interpersonal Competence

Make a lasting impression

Show respect

Have a genuine concern


Professionalism & care

The patient’s initial impression of the nurse is crucial, especially with patients who are new to the healthcare environment.  When the nurse communicates respect and genuine concern for the patient, the patient is encouraged to discuss health concerns and problems freely.  The nurse’s competence and professionalism as well as the interpersonal qualities of being respectful and caring invite the patient’s confidence and assure the patient that help is available.

Nursing assessments include the comprehensive initial assessment, the focused assessment, emergency assessment, and the time-lapsed assessment.

The initial assessment is performed shortly after the patient is admitted to a health care agency or service.

In a focused assessment, the nurse gathers data about a specific problem that has already been identified.  Focused assessment is to identify new or overlooked problems.

Emergency Assessment to identify life-threatening problems.

Time-lapsed Assessment is scheduled to care a patient’s status to the baseline data obtained earlier.  Can be comprehensive or focused?

Medical vs. Nursing Assessments

Medical = pathologic conditions
Nursing = client’s response to health problems

Establishing Assessment Priorities

Health orientation, development stage, culture, need for nursing

Structuring Assessment

Data must be structured systematically.  Helps ensure the assessment is comprehensive and holistic.

Makes it easier with identifying nursing diagnosis.

A minimum data set – used by schools of Nursing.  Gordon’s framework identifies 11 functional health patterns and organizes patient data within these patterns

Collecting Data

Objective what you see
Subjective what you say

Objective = observable and measurable data that can be sources:  client, family & significant others, patient record, assessment technology, other healthcare professionals & nursing & other healthcare literature

Methods of Data Collection

Nursing history

            Physical assessment = head to toe

Physical assessment is the examination of the patient for objective data that may better define the patient’s condition and help the nurse plan car

Identifying cues and making inferences

A cue is something that may be wrong.  The judgment about the cue is an inference.

Clarify inference by:

Physical exam

Clarifying statements

Checking your findings with research reports, textbooks, or journals sharing your inferences with other respected members of the team & seeking consensus-comparing cues to your knowledge base of normal function.  Checking consistencies of cues.

Validation is the act of confirming or verifying.  It is an important part of assessment because invalid information can lead to inappropriate nursing care.  Data needs to be verified when there are discrepancies between what the person is saying and what you are observing.  Data also need verification when they lack objectivity.  You should validate the data before proceeding and should determine whether the patient does indeed have a problem.

Documentation of Data

Data should be reported verbally immediately whenever assessment findings reveal a critical change in the patient’s health status that necessitates the involvement of the other nurses or healthcare professionals.

The patient’s initial database is entered into the computer or recorded in ink, using the designated agency protocol or the same day the patient is admitted to the agency.

Avoid the tendency to record data using nonspecific terms with different meanings or interpretations – words like adequate, good average, normal, poor, small, large.  Always be specific.


Diagnosing Chapter 12

Diagnosing – the second step in the nursing process – begins after the nurse has collected and recorded the patient data.  The purposes of diagnosing are to

  1. Identify how a person, group, or community responds to actual or potential health and life processes;
  2. Identify factors that contribute to or cause health problem (etiologies); and
  3.   Identify resources or strengths that the person, group, or community can draw onto prevent or resolve problems

Need Critical thinking skills to assess

Health problem is a condition that necessitates intervention to prevent or resolve disease or illness or t promote coping and wellness

  1. Assessment consists of collecting data identifying cues and make inferences validating (verifying data), clustering related data, identifying patterns) testing final impressions, reporting and recording data
  2. Clinical reasoning is analyzing, synthesizing, reflecting, drawing conclusions
  3. Creating a list of suspected problems/diagnoses Ruling out similar problems/diagnoses, naming actual and potential problems, diagnoses and clarifying what’s causing or contributing to them determining risk factors, that must be managed, and identifying resources, strengths, and areas of health promotion.

Alfaro-Lefebvre lists the following as concerns that are central to your role as a nurse:

Recognizing safety and infection-transmission risks and addressing these immediately

Identifying human responses – how problems, signs, and symptoms, and treatment regimens impact on patients’ lives – promoting optimum function, independence, and quality of life

Anticipating possible complications and taking steps to prevent them

Initiating urgent interventions – you do not want to wait to make a final diagnoses if there are signs and symptoms indicating the need for immediate treatment.


Predict, Prevent, Manage, and Promote (PPMP)


1)    In the presence of known problems, predict the most common and most dangerous complications and take immediate action to

  1. a) Prevent them, and
  2. b) Manage them in case they cannot be prevented

2)    Whether problems are present or not, look for evidence of risk factors (things the evidence of risk factors, you aim to reduce or control them, thereby preventing the problems themselves

3)    In all situation, ensure that safety and learning needs are met, and promote optimum function & independence

Types of Diagnoses

Nursing diagnoses are written to describe patient problems or issues that nurses can treat independently, such as activity, pain, and comfort, and to issue integrity and perfusion problems.

Medical diagnosis:  Describe problems for which the physician directs the primary treatment collaborative problems managed by using Physician – prescribed & nursing – prescribed interventions.

Medical vs. Nursing Diagnosis

Medical => indentify diseases, treated primarily by physician; diagnosis remains the same for as long as the diseases is present.

Nursing => focus on unhealthy responses to health & illness treated by nurses within scope of practice.  It can change from day-to-day


Examples of medical vs. nursing

Medical diagnoses – myocardial infarction (heart attack)
Nursing diagnosis – fear, altered health maintenance, deficient knowledge, pain, altered tissue perfusion

Diagnostic Reasoning & Clinical Reasoning

Be familiar with nursing diagnoses and other health problems, read professional literature, and keep reference guides handy

Trust clinical experience and judgment, but be willing to ask for help when the situation demands more than your and experience can provide.

Respect your clinical intuition, but before writing a diagnosis without evidence, increase the frequency of your observations and intuition.

Recognize personal biases and keep an open mind.

Diagnostic Reasoning & Interpersonal Competency

Build trust, respect opinions, listen objectively

Recognizing significant data

Recognizing patterns or clusters

Identifying strengths & problems

Identifying potential complications

Reaching Conclusions

Reaching Conclusions

1)    No problem

2)    Possible problem

3)    Actual or potential nursing diagnosis

4)    Clinical problem other than nursing diagnosis

Formulating and validating nursing diagnosis

Problem – identifies what is unhealthy about the patient, indicating the need for change (clear, concise, statement of the patient’s health problem)

Etiology – identifies the factors that are maintaining the unhealthy state or response (contributing or causative factors)

Defining characteristics – identify the subjective and objective data that signal the existence of the problem (cues that reflect the existence of a problem)

Types of Nursing Diagnosis

Actual nursing diagnoses represent problems that have been validated by the presence of major defining characteristics

1)    Label – title

2)    Definition – a concise description of the problem

3)    Defining characteristics – subjective or objective data

4)    Related factors – something known to be associated with a specific health problem

Stating a Nursing Diagnosis

1)    State the problem

2)    Use “related to” to link the problem & its etiology (the cause or related (risk) factors)

3)    Give the signs & symptoms that show evidence that the diagnoses is present, using the words “as evidenced by”

Problem:  Impaired Communication
Reliable factor:  not bathing

Validating Nursing Diagnoses

Is my patient database (assessment data) sufficient, accurate, and supported by nursing research?

Does my synthesis of data (significant cues) demonstrate the existence of a pattern?

Are they subjective and objective data I used to determine the existence of a pattern characteristic of the health problem I defined?

Is my tentative nursing diagnosis based on scientific nursing knowledge and clinical expertise?

Is my tentative nursing diagnosis able to be prevented, reduced, or resolved by independent nursing action?

Is my degree of confidence above 50% that other qualified practitioners would formulate the same the same nursing diagnosis based on my data?

Documenting Nursing Diagnoses

1)    View the patient’s ongoing risks and problems that others have identified and documented

2)    Decide on and document new nursing diagnoses based on the patient assessment findings

3)    Facilitate communication of the patient’s actual problems with nurses and others on the care team

4)    Use nursing diagnosis to make decisions about what mutual goals the patient desires (patient outcomes) and what can be done (nursing interventions)

5)    Determine and document when the nursing diagnoses (risks, health promotion, or actual problem) are resolved

Benefits of Nursing Diagnosis

The primary benefit of nursing diagnosis for the patient is the individualization of patient care.

Among the other benefits of nursing diagnoses for the profession is help in defining the domain of nursing for health care administrators, legislators, and other health care providers.  This is important for seeking funding for nursing & reimbursements for nursing services

Limitations of Nursing Process

If used incorrectly, patient might be misdiagnosed and nursing practice might be restricted.


Common Errors in Writing Nursing Diagnosis

Writing the diagnosis in terms of needs and not response

Making legally inadvisable statements

Identifying as a problem a patient response that is not necessarily unhealthy

Identifying as a patient problem or etiology what cannot be changed

Identifying environmental factors as a problem

Reversing clauses

Having both clauses say the same thing

Including value judgments in the nursing diagnosis

Including the medical diagnosis in the diagnostic statement


Sources of Errors When Writing Nursing Diagnosis

Premature diagnose based on an incomplete database

Erroneous diagnoses resulting from an inaccurate database or a faulty data analysis

Routine diagnoses resulting from the nurse’s failure to tailor data collection & analysis to the unique needs of the patient

Errors of omission

Outcome Identification & Planning

Chapter 13

Goal of Outcome Identification and Planning Step

During the outcome identification and planning steps of the nursing process, the nurse works in partnership with the patient and family to:

Establish priorities

Identify and write expected patient outcomes

Select evidence-based nursing interventions

Communicate the plan of nursing care

Standards to Apply to Outcome Identification & Planning

The law – the state’s nursing practice act

National practice standards – Outlined by the ANA

Specialty professional organization

The Joint Commission – accrediting agency

The Agency for Healthcare Research and Quality (AHRQ)

Your employer

Formal plan allows the nurse to:

Individualize care that maximizes outcome achievement

Set priorties

Facilitate communication among nursing personnel and their colleagues

Promote continuity of high-quality., cost effective care

Coordinate care

Evaluate the patient’s responses to nursing care

Create a record that can be used for evaluation, research, reimbursement, and legal purposes

Promote the nurse’s professional development

Outcome Identification, Planning, and Clinical Reasoning

Be familiar with standards and agency policies for setting priorities, identifying and recording expected patient outcomes, selecting evidence-based nursing interventions, and recording the plan of care

Remember that the goal of person-centered care is to keep the patient and the patient’s interest and preferences central in every aspect to planning and outcome identification

Keep the “big picture” in focus:  What are the discharge goals for this patient, and how should this direct each shift’s interventions?

Trust clinical experience and judgment but be willing to ask for help when the situation demands more than your qualifications and experience can provide; value collaborative practice

Respect your clinical intuitions, but before establishing priorities, identifying outcomes, and selecting nursing interventions, be sure that research supports your plan

Recognize your personal biases and keep an open mind

Three elements of Comprehensive Planning’s

1)    Initial planning is performed by the nurse with the admission nursing history and physical assessment.  This comprehensive plan addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care.  This may be done before the initial database is complete

2)    Ongoing planning is carried out by any nurse who interacts with the patient.  Its chief purpose is to keep the plan up to date to facilitate the resolution of health problems, manage risk factors, and promote function.  Its chief purpose is to keep the plan up to date to facilitate the resolution of health problems, manage risk factors, and promote function.  States nursing diagnoses more clearly and develop new diagnoses.  Makes outcomes more realistic and develops new outcome identifier

3)    Discharge planning is best carried out by the nurse who has worked most closely with the patient and family, possibly in conjunction with a nurse or social worker with a broad knowledge of existing community resources.  Careful planning ensures that the nurse uses teaching and counseling skills effectively to help the patient and family develop sufficient knowledge of the health problem and the therapeutic regimen to carry out necessary self-care behaviors at home competently.

Prioritizing Nursing Diagnoses

High–priority diagnoses pose the greatest threat to the patient.
Medium-priority diagnoses are not rank as life threatening.
Low-priority diagnoses are not specifically related to the current level of health or well-being


Maslow’s Hierarchy of Human Needs

1)    Physiologic needs

2)    Safety needs

3)    Love and belonging needs

4)    Self-esteem needs

5)    Self-actualization needs

Clinical Reasoning and Establishing Priorities

1)    What problems need immediate attention and which ones can wait?

2)    Which problems are your responsibilities and which do you need to refer to someone else?

3)    Which problems can be dealt with by using standard plans (critical paths, standards of care)?

4)    Which problems aren’t covered by protocols or standard plans but must be addressed to ensure a safe hospital stay and timely discharge (or simply safe care of high quality)?

When planning nursing care for each day, consider the following:

  • Have changes in the patient’s health status influenced the priority of nursing diagnoses?
  • Have changes in the way the patient is responding to health and illness or the plan of care affected those nursing diagnoses that can be realistically addressed?
  • Are there relationships among diagnoses that require that one be worked on before another can be resolved?
  • Can several patient problems be dealt with together?

Long Term vs. Short Term Outcomes

Long-term outcomes require a longer period (usually more than a week) to be achieved than do short-term outcomes.  They need discharge goals

Short term usually completed within a day

Institute of Medicine (IOM) six aims to be met by Health Care Systems

Ensuring Quality Outcomes

Safe: avoiding injury

Effective:  avoiding overuse and underuse

Patient-centered: responding to patient preferences, needs, and values

Timely:  reducing waits and delays

Efficient:  avoiding waste

Equitable:  providing care that does not vary in quality to all recipients

Using Cognitive, psychomotor, and affective outcomes

Cognitive outcomes describe increases in patient knowledge or intellectual behavior.
Psychomotor outcomes describe a patient’s achievement of new skills.
Affective outcomes describe changes in patient values, beliefs, and attitudes.

Identifying clinical, functional, and quality-of-life outcomes
Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete.
Functional outcomes describe the person’s ability t function in relation to the desired usual activities
Quality-of-life outcomes focus on key factors that affect someone’s ability to enjoy life and achieve personal goals.

The ANA direct the nurse to derive culturally appropriate expected outcomes from the diagnoses

Remember that nurses nurse people, not their problems.  All goals should make sense in terms of the overall goals for the patient.

Writing Patient-Centered Measurable Outcomes

Outcomes should have the following:

Subject:  patient or some part of the patient

Verb:  indicates the action the patient will perform

Conditions:  specifies the particular circumstances in or by which the outcome is to be achieved.

Performance criteria:  describe in observable, measurable terms the expected patient behavior or other manifestations

Target time:  specifies when the patient is expected to be able to achieve the outcome.

It is often helps to include special conditions when writing an outcome if this information is important for other nurses.

Memory jog:  SMART

S – Specific
M – measurable
A – attainable
R – realistic
T – timebound

Avoiding Common Errors in Outcomes

Expressing the patient outcome as a nursing intervention

Using verbs that are not observable and measurable

Including more than one patient behavior/manifestation in short-term outcomes

Writing outcomes that are so vague that other nurses are unsure of the goal of nursing care.

o   Describe two new coping strategies he is will to try

o   Demonstrate decreased incidence of previously observed ineffective coping behaviors

Nursing Interventions Classification (NIC) Identifies nursing interventions as “any treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes

Nurse-Initiated Interventions

1)    Indentifying and selecting Appropriate Nurse-Initiated Interventions

2)    Individualizing Evidence-Based Interventions

3)    Recording Nurse-Initiated Interventions in the Patient Record

Nurse-initiated intervention is an autonomous action based on scientific rationale that a nurse executes to benefit the patient in a predictable way related to the nursing diagnosis and projected outcomes.

1)    Monitor patient health status and response to treatment

2)    Reduce risks

3)    Resolve, prevent, or manage a problem

4)    Promote independence with activities of daily living

5)    Promote optimum sense of physical, psychological, and spiritual well-being

6)    Give patients the information they need to make informed decisions and be independent

Identifying and selecting appropriate nurse-initiated interventions

Nursing Intervention Classification (NIC), the first comprehensive, validated list of nursing interventions applicable to all settings that can be used by nurses in multiple specialties, greatly facilitates the work of identifying appropriate interventions.  13-2

Guidelines for selecting nursing interventions

  • Appropriate in terms of the nursing diagnosis and related patient outcomes, safe, and efficient
  • Consistent with research findings and standards of care
  • Realistic in terms of the abilities, time, and resources available to the nurse and patient
  • Compatible with the patient’s values, beliefs, and cultural and psychosocial background
  • Valued, whenever possible, by the patient and family
  • Compatible with other planned therapies

Four key questions when determining individualized evidence-based interventions:

1)    What can be done to prevent or minimize the risks or causes of this problem?

2)    What can be done to manage the problem?

3)    How can I tailor interventions to meet expected outcomes?

4)    How likely are we to get desired versus adverse responses to the interventions, and what can we do to reduce the risks and increase the likelihood of beneficial responses?

Well-written nursing interventions accomplish the following:

  • Assist the patient to meet specific outcomes that are related directly to one outcome
  • Clearly and concisely describe the nursing action to be performed (answer the questions who, what, where, when, and how)
  • Are dated when written and when the plan of care is reviewed
  • Are signed by the nurse prescribing the order or intervention
  • Use only those abbreviations accepted in the institution
  • Use only those abbreviations accepted in the institution
  • Refer the nurse to the agency’s procedure manual or other literature for the steps of routine, lengthy procedures

Chapter 15 Evaluating

Evaluating allows achievement of outcomes; directs nurse-patient interactions; measures patient outcomes achievement; identifies factors to achieve outcomes; modifies the plan of care, if necessary.

The purpose of evaluation is to allow the patient’s achievement of expected outcomes to direct future nurse-patient interactions.  Based on the patient’s responses to the plan of care, the nurse decides to:

  • Terminate the plan of care when each expected outcome is achieved
  • Modify the plan of care if there are difficulties achieving the outcomes
  • Continue the plan of care if more time is needed to achieve the outcomes


Four types of Outcomes

  • Cognitive – increase in patient knowledge
  • Psychomotor – patient’s achievement of new skills
  • Affective – changes in patient values, beliefs, and attitudes
  • Physiologic – physical changes in the patient


  • Cognitive – asking patient for information or to apply new knowledge
  • Psychomotor – asking patient to demonstrate new skill
  • Affective – observing patient behavior and conversation
  • Physiologic – using physical assessment skill to collect or compare data

The five classic elements of evaluation are:

  1. Identifying evaluative criteria and standards (what you are looking for when you evaluate)
  2. Collecting data to determine whether these criteria and standards are met,
  3. Interpreting and summarizing findings;
  4. Documenting your judgment, and
  5. Terminating, continuing, or modifying the plan.

Identifying Evaluative Criteria and Standards

Criteria are measurable qualities, attributes, or characteristics that specify skills, knowledge, or health status.  They describe acceptable levels of performance by stating expected behavior of nurse or patient

Standards are the levels of performance accepted by and expected of nursing staff or other health team members.  They establish authority, custom, or consent.

Variables Affecting Outcome Achievement

Patient- Ex Patient gives up & refuses treatment
Nurse- Ex nurse is suffering from burnout
Healthcare system- Ex inadequate staffing

Evaluative statements decide how well outcome was met (met, partially met, or not met); lists patient data or behaviors that support this decision.

Revisions in the plan of care

  1. Delete or modify the nursing diagnosis.
  2. Make the outcome statement more realistic.
  3. Adjust time criteria in outcome statement
  4. Change nursing interventions

IOM’s 10 New Rules to redesign and improve care:

  1. Care based on continuous healing relationships
  2. Customization based on patient needs and values
  3. The patient as the source of control
  4. Shared knowledge and the free flow of information
  5. Evidence-based decision making
  6. Safety as a system priority
  7. The need for transparency
  8. Anticipation of patient’s needs
  9. Continuous decrease in waste
  10. Cooperation among clinicians

The four steps for continuous improvement

  1. Discover a problem
  2. Plan a strategy using indicators
  3. Implement a change
  4. Assess the change; if the outcome is not met, plan a new strategy

Improving professional performance

  • Peer review
  • Quality-assurance programs
  • Structure evaluations
  • Process evaluations
  • Outcome evaluations
  • Quality improvement
  • Nursing audit
  • Concurrent vs. Retrospective evaluation

The major premises of quality improvement are as follow

  • Focus on organizational mission
  • Continuous improvement
  • Customer orientation
  • Leadership commitment
  • Empowerment
  • Collaboration/crossing boundaries
  • Focus on process
  • Focus on data and statistical thinking

Determining Adequacy of Evaluation Step

  • Evaluate patient achievement of desired outcomes
  • Review how the process is used
  • Revise the plan of care if necessary
  • Participate in quality assurance programs

Elements of Healthy Work Environments

  • Skilled communication
  • True collaboration
  • Effective decision making
  • Appropriate staffing
  • Meaningful recognition
  • Authentic leadership

Crucial Conversations in Healthcare

  • Broken rules
  • Mistakes
  • Lack of Support
  • Incompetence
  • Poor teamwork
  • Disrespect
  • Micro management

Chapter 21 Teacher and Counselor

Aims of teaching & counseling

  1. Maintaining & promoting health
  2. Preventing illness
  3. Restoring health
  4. Facilitating coping

Teaching Outcomes

  • High level wellness & related self-care practices
  • Disease prevention & early detection
  • Quick recovery from trauma or illness with minimum or no complications
  • Enhanced ability to adjust to developmental life changes and acute, chronic, and terminal illness
  • Family acceptance of life style necessitated by illness or disability

Patient education focuses on three critical areas:

  • Preparation of receiving care
  • Preparation before discharge from health care
  • Documentation of patient education activity


Tune into the patient
Edit patient information
Act on every teaching moment
Clarify often
Honor the patient as partner in the education process

Three domains of learning

Cognitive-storing and recalling of new knowledge in the brain
Psychomotor-learning physical skill
Affective-charging attitudes, values, & feelings

Ask me three questions.
What is my main problem?
What do I need to do?
Why is most important for me to do this?

Factors Affecting Patient Learning
Age & development level
Family Support Networks
Financial resources
Cultural influences
Language deficits
Health literacy levels

Critical Developmental Areas
Physical maturation & abilities, psychosocial development, cognitive capacity, emotional maturity, moral, and spiritual development

COPE Model

Expert Information

Assessment Parameters
Knowledge, attitudes, and skills needed for the patient and family to manage health care independently
Readiness to learn
Ability to learn
Learning strengths

Promoting Patient and Family Compliance
Be certain that health care instructions are understandable and designed to support patient goals.
Include the patient and family as partners in the teaching-learning process.
Use interactive teaching strategies
Remember that teaching and learning are processes that rely on strong interpersonal relationships with patients and their families

Providing Culturally Competent Patient Education

Develop an understanding of the patient’s culture.
Work with the multicultural team in developing educational programs
Be aware of personal assumptions, biases, and prejudices.
Understand the core cultural values of the patient or group.
Develop written materials in the patient’s native language
Use testimonials of people with the same cultural background as the patient

Knowles four assumptions about learners

  1. As people mature, their self-concept is likely to move from dependence to independence.
  2. The previous experience of the adult rich resource for learning
  3. An adult’s readiness to learn is often related to a developmental task or a social role.
  4. Most adults’ orientation to learning is that material should be useful immediately, rather than at some time in the future.

Teaching Plans for Older Adults
Identify learning barriers
Allow extra time
Plan short teaching sessions
Accommodate for sensory deficit
Reduce environmental distractions
Relate new information to familiar activities

Suggested teaching strategies for the three learning domains

Cognitive domain=lecture or discussion, panel discussion, discovery, audiovisual materials, printed materials, programmed instruction, computer-assisted instruction programs

Affective domain=role modeling, discussion, panel discussion, audiovisual materials, role playing, printed materials

Psychomotor domain=demonstration, discovery, audiovisual materials, printed materials

Key Points of Effective Communication

Be sincere & honest
Avoid too much detail & stick to the basics
Ask for questions
Be a cheerleader for the patient
Use simple vocabulary
Vary the tone of voice
Keep content clear
Listen and don’t interrupt
Ensure that the environment is conducive to learning and free of interruptions
Be sensitive
Promote Interpersonal Relationships

Sources of information are the patient as primary and all others as secondary (medical records, patient’s family)

Considerations for successful patient teacher
Forming a contractual agreement
Considering time constraints
Group versus Individual teaching
Formal versus informal teaching
Manipulating the physical environment

Nursing Coaching Process
Establishing relationships and identifying readiness for change
Identifying opportunities, issues, and concerns
Establishing patient-centered goals
Creating the structure of the coaching interaction
Empowering and motivating patients to reach goals
Assisting the patient to determine progress toward goals

Evaluating Methods-Obtaining Feedback about Learning

Evaluating Teaching
Reinforcing & Celebrating Learning
Revising the plan

Documentation of the teaching-learning process includes a summary of the learning need, the plan, the implementation of the plan, and the evaluation results.

Make everyone feel comfortable in the situation and surroundings
Counseling may be formal or informal
Use interpersonal skills of warmth, friendship, openness, & empathy
Caring is fundamental

Types of Counseling

Short, long, and motivational interviewing

Cultural diversity is the differences among people.  As nurses, one must be sensitive to provide care which crosses racial classification, national origin, religion, language, physical size, gender, sexual orientation, age, and disability.  In addition, it crosses socioeconomic and occupational status and geographic location.