A Merged
A Merged
A Merged
• A systematic,
client-centered
method for structuring the
delivery of nursing care
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Nursing Process…
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PHASES of the NURSING PROCESS
3
PURPOSES of the
NURSING PROCESS
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PURPOSES of the
NURSING PROCESS
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Characteristics of the Nursing Process
• Systematic
• client-centered
• Focuses on problem-solving
•Focuses on decision-
making
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Characteristics of the Nursing Process
• Universally applicable
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Characteristics of the Nursing Process
• Outcome- oriented
•Proactive
• Evidence-based
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Assessment
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Assessment
• a continuous process
• focuses on client’s
responses to a health
problem
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1/16/2023 NURS100
Types of Assessment:
Purpose of Type of Time Example
Assessment Assessment Performed
• collecting data
• organizing data
• validating data
• documenting data
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ASSESSMENT Activities
COLLECTING DATA
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ASSESSMENT Activities
COLLECTING DATA
DATABASE sources:
A. Nursing health history
B. Physical assessment
C. Laboratory and diagnostic tests
D. Materials contributes by other health personnel
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ASSESSMENT Activities
COLLECTING DATA
Purpose:
* identify…
-patterns of health and illness
-risk factors for health problems
-deviations from normal
-available resources for adaptation
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ASSESSMENT Activities
Health History
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ASSESSMENT Activities
Health History
Inuubo ako
Doc!
Uhu-uhu-uhu!
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ASSESSMENT Activities
Health History
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Basic Components of Health History
1. Demographic (Biographical) Data
– client’s name
– Sex
– age
– date & place of birth
– marital status
– race/nationality, religion
– address/contact number
– educational background
– other significant trainings, occupation.
– Usual source of medical care
– Source and reliability of information
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Basic Components of Health History
• Sample Statements:
– The patient was competent to provide information. She was able to speak
clearly; conscious and coherent; oriented to time, place and person.
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Basic Components of Health History
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Basic Components of Health History
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Basic Components of Health History
Chief complaint
Example:
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Basic Components of Health History
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Basic Components of Health History
6. Family History
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Basic Components of Health History
6. Family History
- Genogram or family tree
Maternal Paternal
A& W A&W
DM Accident
65 84
77 45
DM A&W
aneurysm
A&W A&W A&W
24 30
18
25 23 31
Female
A & W, 10
A & W, 9 A & W, 8 Client
Deceased
Basic Components of Health History
36
Basic Components of Health History
8. Psychosocial Assessment
• (Specific for the current developmental stage of
the client)
• (Use Erik Erikson’s Psychosocial Development
Theory)
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Basic Components of Health History
9. Functional Assessment
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Basic Components of Health History
7. Functional Assessment
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Basic Components of Health History
7. Functional Assessment
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Basic Components of Health History
7. Functional Assessment
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Basic Components of Health History
7. Functional Assessment
b. Nutrition-Metabolic pattern
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Basic Components of Health History
7. Functional Assessment
b. Nutrition-Metabolic Pattern
-person’s nourishment
-person’s food choices in comparison with recommended
food intake
-any disease that affects nutritional-metabolic function
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Basic Components of Health History
7. Functional Assessment
c. Elimination Pattern
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Basic Components of Health History
c. Elimination Pattern
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Basic Components of Health History
7. Functional Assessment
d. Activity-Exercise pattern
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Basic Components of Health History
7. Functional Assessment
d. Activity-Exercise Pattern
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Basic Components of Health History
7. Functional Assessment
e. Sleep-rest pattern
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1/16/2023 NURS100
Basic Components of Health History
7. Functional Assessment
e. Sleep-Rest Pattern
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Basic Components of Health History
7. Functional Assessment
f. Cognitive-Perceptual pattern
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Basic Components of Health History
7. Functional Assessment
f. Cognitive-Perceptual Pattern
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Basic Components of Health History
7. Functional Assessment
g. Self-Perception-Self-Concept pattern
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Basic Components of Health History
7. Functional Assessment
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Basic Components of Health History
7. Functional Assessment
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Basic Components of Health History
7. Functional Assessment
h. Role-Relationship Pattern
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Basic Components of Health History
7. Functional Assessment
i. Sexuality-Reproductive pattern
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Basic Components of Health History
7. Functional Assessment
i. Sexuality-Reproductive Pattern
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Basic Components of Health History
7. Functional Assessment
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Basic Components of Health History
7. Functional Assessment
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Basic Components of Health History
7. Functional Assessment
k. Value-Belief pattern
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Basic Components of Health History
7. Functional Assessment
k. Value-Belief Pattern
- subjective responses
- head-to-toe approach
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Basic Components of Health History
8. Review of Systems
a. General survey
• usual weight
• recent weight changes
• weakness
• fatigue
• fever
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Basic Components of Health History
8. Review of Systems
b. Skin/Integument
• rashes
• lumps
• sores
• itching
• dryness
• color change
• changes in hair or nails
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Basic Components of Health History
8. Review of Systems
c. Head
• Headache
• Head injury
• Dizziness
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Basic Components of Health History
8. Review of Systems
d. Eyes
• Vision
• glasses or contact lenses
• last eye examination
• pain redness
• excessive tearing
• double vision
• Spots
• Flashing lights
• glaucoma and cataracts
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Basic Components of Health History
8. Review of Systems
e. Hearing
• Tinnitus
• Vertigo
• Earaches
• Infection
• Discharge
• use of hearing aids
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Basic Components of Health History
8. Review of Systems
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Basic Components of Health History
8. Review of Systems
g. Mouth and Throat
• condition of teeth and gums
• bleeding gums
• dentures if any and how they fit
• last dental examination
• sore tongue
• dry mouth
• frequent sore throat
• hoarseness
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Basic Components of Health History
8. Review of Systems
h. Neck
• lumps
• swollen glands
• Goiter
• pain or stiffness
in the neck
• Limitation of motion
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Basic Components of Health History
8. Review of Systems
i. Breast
• lumps
• pain or discomfort
• nipple discharge
• History of breast disease
• Any surgery of the breast
• BSE including frequency and method
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Basic Components of Health History
8. Review of Systems
8. Review of Systems
k. Heart (Cardiac)
• Precordial or retrosternal pain
• Heart trouble
• high blood pressure
• rheumatic fever
• heart murmurs
• chest pain or discomfort
• palpitations
• dyspnea
• orthopnea
• edema
• past ECG or other heart test results
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Basic Components of Health History
8. Review of Systems
l. Gastrointestinal
• dysphagia • rectal bleeding or black tarry
• heartburn stools
• appetite • hemorrhoids
• nausea • constipation
• vomiting • diarrhea
• regurgitation • abdominal pain
• vomiting of blood • food intolerance
• Indigestion • excessive belching or
• Frequency of BM passing of gas
• color and size of stools • jaundice
• change in bowel habits • liver or gallbladder trouble
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Basic Components of Health History
8. Review of Systems
m. Urinary
• Frequency of urination
• polyuria
• nocturia
• burning or pain on urination
• hematuria
• urgency
• reduced force of the urinary stream
• hesitancy, dribbling, incontinence
• urinary infections
• stones 75
Basic Components of Health History
8. Review of Systems
n. Genitalia
– Male
• Hernias
• discharge from or sores on the penis
• testicular pain or masses
• history of sexually transmitted infections and their
treatments
• Sexual preference, interest, function, satisfaction and
problems
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Basic Components of Health History
8. Review of Systems
n. Genitalia
– Female –
• Age @ menarche • menopausal symptoms
• regularity • discharge, itching
• frequency and duration of periods • sores, lumps
• amount of bleeding • Number of pregnancies
• bleeding between periods or after • # of deliveries
intercourse • complications of pregnancy
• last menstrual period, • birth control methods (for married
• dysmenorrhea women).
• premenstrual tension • Sexual preference, interest, function,
• age of menopause satisfaction, any problems 77
Basic Components of Health History
8. Review of Systems
o. Peripheral Vascular
• Coldness, numbness and tingling
• swelling of legs
• discoloration of hands or feet,
• varicose veins or complications,
• intermittent claudication, thrombophlebitis, ulcers
• Does the occupation of the client involve long-term sitting or standing?
• Does the client avoid crossing legs at the knees?
• Does the client wear support hose?
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Basic Components of Health History
8. Review of Systems
p. Musculoskeletal
• Joints: pain, stiffness, swelling (location, migratory nature), deformity,
limitation of motion, noise with joint motion
• Muscles: Pain, cramps, weakness, gait problems or problems with
coordinated activities
• Back: Pain (location and radiation to extremities) stiffness, limitation
of motion, or history of back pain or disease
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Basic Components of Health History
8. Review of Systems
q. Neurologic
• History of seizure disorder and stroke
• Sensory function: Memory disorders (recent or
distant, disorientation)
• Motor function: tics or tremors, paresis –
weakness, fainting, blackouts
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Basic Components of Health History
8. Review of Systems
r. Hematologic
• Anemia
• easy bruising or bleeding
• past transfusion
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Basic Components of Health History
8. Review of Systems
s. Endocrine
• Thyroid trouble
• heat or cold intolerance
• excessive sweating
• diabetes
• excessive thirst/hunger
• polyuria
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Basic Components of Health History
8. Review of Systems
t. Psychiatric
• Nervousness
• Tension
• Mood including depression
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ASSESSMENT Activities
COLLECTING DATA
DATABASE sources:
A. Health history
B. Physical assessment
C. Laboratory and diagnostic tests
D. Materials contributes by other health personnel
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PHYSICAL ASSESSMENT
• As a source of database, this will be discussed
under data gathering methods.
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ASSESSMENT Activities
COLLECTING DATA
Types of Data:
A. Subjective
» symptoms or covert data
» e.g.: pain, itching, health history
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ASSESSMENT Activities
COLLECTING DATA
• Types of Data:
b. Objective
» signs or overt data
» can be measured or tested against an accepted
standard
» can be seen, heard, felt, or smelled
» obtained by observation or PE
» e.g.: color of the skin, characteristic of breath
sounds
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ASSESSMENT Activities
COLLECTING DATA
Sources of DATA
1. Primary
- the client
- “the best source”
2. Secondary
- all sources other than the client
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ASSESSMENT Activities
COLLECTING DATA
a. Observing
b. Interviewing
c. Examining
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ASSESSMENT Activities
COLLECTING DATA
a. Observing
– conscious,deliberate use of the
physical senses
- e.g.: overall appearance, body or
breath odors, lung sounds, skin
temperature
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ASSESSMENT Activities
COLLECTING DATA
Approaches to Interviewing:
1. Directive
• highly structured
• elicits specific information
• nurse controls subject matter
• used when time is limited
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ASSESSMENT Activities
COLLECTING DATA
2. Non-Directive/rapport-building
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ASSESSMENT Activities
COLLECTING DATA
Types of Interview
Questions:
Closed Open-ended
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ASSESSMENT Activities
COLLECTING DATA
Types of Interview
Questions:
Closed Open-ended
-generally require yes or no -specify broad topics to be
or short factual answers discussed & invite longer
giving specific information answers
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ASSESSMENT Activities
COLLECTING DATA
Types of Interview
Questions:
Closed Open-ended
e.g.: “How old are you?” - e.g.: “How have you been
“What medication did you feeling lately?” “What
take?” would you like to talk about
today?”
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ASSESSMENT Activities
COLLECTING DATA
Types of Interview
Questions:
Neutral Leading
-can be answered by the client - direct the client’s answer
without direction or pressure from
the nurse
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ASSESSMENT Activities
COLLECTING DATA
Types of Interview
Questions:
Neutral Leading
-open-ended - closed; used in a directive interview
-used in nondirective interview - give client less opportunity to decide
-- e.g.: “How do you feel about whether the answer is true or not
that?” -can create problems if client gives
inaccurate response just to please the
nurse
-- e.g.: “You will take your medicine,
won’t you?”
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ASSESSMENT Activities
COLLECTING DATA
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ASSESSMENT Activities
COLLECTING DATA
100
ASSESSMENT Activities
COLLECTING DATA
Approaches:
a. cephalocaudal
b. body systems approach
Upon Admission:
– Perform complete physical
examination
During on-going assessment:
– examine specific body areas,
systems or functions
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ASSESSMENT Activities
Physical Examination
OBJECTIVES
obtain baseline data about client’s functional
abilities
supplement, confirm, refute data obtained in
health history
obtain data that will help in establishing plan of
care
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ASSESSMENT Activities
Physical Examination
OBJECTIVES
evaluate physiologic outcomes of health care and
progress of health problem
make clinical judgments about a clients health
status
identify areas for health promotion & disease
prevention
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ASSESSMENT Activities
Physical Examination
PRINCIPLES / GUIDELINES
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ASSESSMENT Activities
Physical Examination
PRINCIPLES / GUIDELINES
105
ASSESSMENT Activities
Physical Examination
PRINCIPLES / GUIDELINES
106
ASSESSMENT Activities
Physical Examination
PRINCIPLES / GUIDELINES
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ASSESSMENT Activities
Physical Examination
PRINCIPLES / GUIDELINES
108
ASSESSMENT Activities
Physical Examination
PRINCIPLES / GUIDELINES
109
ASSESSMENT Activities
Physical Examination
PRINCIPLES / GUIDELINES
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ASSESSMENT Activities
Physical Examination
PRINCIPLES / GUIDELINES
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ASSESSMENT Activities
Physical Examination
Positioning for Assessment
- Posture
- body contours &
alignment
-muscles &
extremities
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1. STANDING POSITION
ASSESSMENT Activities
Physical Examination
2. Supine Position
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ASSESSMENT Activities
Physical Examination
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ASSESSMENT Activities
Physical Examination
Lithotomy Position
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ASSESSMENT Activities
Physical Examination
PRONE POSITION
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ASSESSMENT Activities
Physical Examination
Sims position
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ASSESSMENT Activities
Physical Examination
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ASSESSMENT Activities
Physical Examination
a. Inspection
120
ASSESSMENT Activities
Physical Examination
What to inspect:
* body features & symmetry
* general appearance
* nutritional state
* hair distribution
* color & shape
* posture & gait
* manner of speaking
* gross deviation 121
ASSESSMENT Activities
Physical Examination
b. Palpation
Dorsal portion
Fingertips
123
Index-thumb / grasping Palmar/ ulnar surfaces
fingers
ASSESSMENT Activities
Physical Examination
Guidelines/Approaches to Client
1. Palpate suspected tender areas last.
2. Keep fingernails short.
3. Warm hands before touching the client.
4. Use a gentle approach. Gradually increase
pressure from light to deep.
5. The sensation of touch is best preserve
with light, intermittent pressure.
124
TYPES ASSESSMENT Activities
Physical Examination
Light
palpation
125
Deep palpation ASSESSMENT Activities
Physical Examination
Bimanual
126
Fluid wave Ballottement
ASSESSMENT Activities
Physical Examination
What to Palpate:
1. Size
2. Temperature
3. Texture
4. Tenderness
5. Vibration
6. Pulsation
7. Swelling
8. Moisture
9. Consistency of any body parts under the 127
skin
ASSESSMENT Activities
Physical Examination
c. Percussion
Methods of Percussion
1. Direct / Immediate
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ASSESSMENT Activities
Physical Examination
2. Indirect / mediate
* Using plexor & pleximeter
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ASSESSMENT Activities
Characteristics of Percussion Sound Physical Examination
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ASSESSMENT Activities
Physical Examination
Characteristics of Sounds
1. Frequency / pitch
2. Loudness / intensity (amplitute)
3. Quality
4. Duration
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ASSESSMENT Activities
Physical Examination
Types:
1.Immediate / Direct
2.Mediate / Indirect
134
ASSESSMENT Activities
Physical Examination
Parts of the stethoscope:
bell
tubing
diaphragm
135
ASSESSMENT Activities
Physical Examination
COLLECTING DATA
Organizing Data
• nurse uses a written (or electronic) format that
organizes the assessment data systematically
Models
140
ORGANIZING DATA
Models
Self-esteem Needs
Models
Review of Systems
142
ORGANIZING DATA
Models
P.E.R.S.O.N.
• P - sychological
• E - limination
• R - est & activity
• S - afe environment
• O - xygenation
• N - utrition 143
ORGANIZING DATA
HENDERSON’S 14 Models
FUNDAMENTAL NEEDS
1. Breathe normally.
2. Eat & drink adequately.
3. Eliminate body waste.
4. Move & maintain desirable posture.
5. Sleep & rest.
6. Select suitable clothing.
7. Maintain body temperature.
8. Keep the body clean and well groomed to protect the 144
integument.
ORGANIZING DATA
HENDERSON’S 14 Models
FUNDAMENTAL NEEDS
9. Avoid dangers in the environment & avoid injuring others.
10. Communicate with others.
11. Worship according to one’s faith.
12. Work in such a way that there is a sense of
accomplishment.
13. Play or participate in various forms of recreation.
14. Learn, discover or satisfy the curiosity that lead to normal
development & health & use available health facilities. 145
ORGANIZING DATA
ABDELLAH’S 21
Models
ACTIVITIES OF DAILY
LIVING
1. To maintain good hygiene & physical comfort
2. To achieve optimal activity, exercise, rest & sleep
3. To prevent accident, injury or other trauma &
prevent the spread of infection
4. To maintain good body mechanics & prevent &
correct deformities
146
ORGANIZING DATA
ABDELLAH’S 21
Models
ACTIVITIES OF DAILY
LIVING
5. To facilitate supply of oxygen to all body cells
6. To facilitate the maintenance of nutrition to all body
cells
7. To facilitate the maintenance of elimination
8. To facilitate the maintenance of fluid & electrolyte
balance
9. To recognize the physiological responses of the body
to disease conditions- pathological, physiological &
compensatory 147
ORGANIZING DATA
Models
ABDELLAH’S 21 ACTIVITIES OF
DAILY LIVING
10. To facilitate the maintenance of regulatory
mechanics and functions
11. To facilitate the maintenance of sensory
functions
12. To identify & accept positive & negative
expressions, feelings & reactions
13. To identify & accept the interrelatedness of
emotions& organic illness 148
ORGANIZING DATA
Models
ABDELLAH’S 21 ACTIVITIES
OF DAILY LIVING
14. To facilitate the maintenance of effective
verbal & non verbal communication
15. To facilitate the development of productive
interpersonal relationships
16. To facilitate progress toward achievement
of personal spiritual goals
17. To create &/or maintain a therapeutic
environment 149
ORGANIZING DATA
Models
ABDELLAH’S 21 ACTIVITIES OF
DAILY LIVING
18. To facilitate awareness of the self as an
individual with varying physical and
emotional & development needs
19. To accept the possible optimum goals in
light of limitations- physical & emotional
150
ORGANIZING DATA
Models
ABDELLAH’S 21 ACTIVITIES OF
DAILY LIVING
20. To use community resources as an aid in
resolving problems arising from illness
COLLECTING DATA
Organizing Data
Validating Data
• act of double-checking or verifying data to
confirm that it is accurate & factual
152
ASSESSMENT ACTIVITIES
COLLECTING DATA
Organizing Data
Validating Data
Documenting Data
153
NURSING PROCESS
Funda 2019-2020
Edited_by_jmdamian
PHASES Assessment
Evaluation Diagnosing
Implementation Planning
DIAGNOSING
DIAGNOSTIC LABELS
Standardized NANDA (North American Nursing
Diagnosis Association) names for the diagnoses
NURSING DIAGNOSIS
The client’s problem statement, consisting of the
diagnostic label plus etiology (causal relationship
between a problem and its related or risk factor)
Examples:
Constipation r/t prolonged laxative use
Severe anxiety r/t threat to physiologic integrity: possible
CA diagnosis
Formulating Diagnostic Statements
2. Basic three-part statement (PES format)
- applicable for actual nursing diagnosis
Problem (P) – statement of the client’s response
Etiology (E) – factors contributing to or probable causes of
the responses
Signs and symptoms (S) – defining characteristics manifested
by the client
Evaluation Diagnosing
Implementation Planning
THE PLANNING PROCESS
Setting priorities
Examples :
1. The patient will pass out flatus within 24
hours post operatively.
2. Patient’s temperature will decrease from
38.5 C to 37 C within one hour.
Classification of Goals
2. Long term goals
➢ Give direction for nursing care over time,
usually more than a week.
➢ Often used for clients who have chronic health
problems
Example: The patient will demonstrate the
ability to care for his colostomy within one
month after surgery.
Long Term Goal Short Term Goal
VAGUE GOAL: The patient’s breathing will improve within the shift.
OBSERVABLE/MEASURABLE GOAL:
The patient will be able to breathe without using his accessory
muscles for breathing by tomorrow.
EXAMPLE:
Doctor’s order: Complete bed rest with bathroom
privileges.
INCORRECT GOAL:
Patient will ambulate along the corridors within the
shift.
MORE APPROPRIATE GOAL:
Patient will be able to ambulate from bed to bathroom
within the shift.
Guidelines for Writing Goals
3. Whenever possible, the goal is important and
valued by the patient, the nurses and the
physician.
➢ Patient – will be more motivated to reach
the goal
➢ Nurse – will be more likely to carry out the
care
➢ Physician – understanding and support of
nursing goals will help to assure
congruence with medical treatment
Guidelines for Writing Goals
4. Write goals in terms of patient outcomes,
NOT nurse activities.
➢ Avoid statements that start with enable,
facilitate, allow, let, permit, or similar verbs
followed by the word client.
EXAMPLE:
INCORRECT: Promote urinary elimination.
CORRECT: Patient will void at least once within 6
hours.
INCORRECT: Maintain client hydration.
CORRECT: Client will drink 100 mL of water/hour.
Guidelines for Writing Goals
5. Derive each goal from only one nursing
diagnosis.
➢ Keeping the goal statement related to
only one nursing diagnosis facilitates
evaluation of care by ensuring that planned
nursing interventions are clearly related to
the diagnosis.
Patient’s
behavior
Criteria of
Performance
Goal
Statement
Time
Conditions
(if needed)
Formula for Writing a Goal Statement
Patient’s behavior – an observable activity that
the patient will demonstrate
Goal:
Before discharge, the patient will ambulate
length of hallway independently
Examples of Goal Statements
Goal:
Before discharge, the patient will ambulate length
of hallway independently
Goal:
Body temperature will decrease from 38.50C to
37.50C within 2 hours after administering
TSB.
Body temperature will decrease from 38.50C to 37.50C
within 2 hours after administering TSB.
Goal:
Verbalization of decreased pain from a scale of
2 to 1(where 3=severe, 2=moderate, 1=mild,
0=no pain) within the shift.
Verbalization of decreased pain from a scale of 2 to 1(where
3=severe, 2=moderate, 1=mild, 0=no pain) within the shift.
Goal:
Will not manifest any sign of infection during
hospitalization
Will not manifest any sign of infection during
hospitalization
b. Nurse variables
➢level of expertise, creativity, willingness to
provide care, and available time
Variables that Influence Goal
Outcome Achievements
c. Resources
➢adequate staff, equipment and supplies
➢the financial resources of the patient
➢adequacy of community-based resources
Nursing Interventions
❖activities the nurse plans and implement to
help a patient achieve identified goal
b. PTx (Therapeutic)
ex: Administering of Paracetamol 500 mg. 1tab. q4H as
ordered by the physician, enforce fluid intake
Dependent:
Objective:
Short Term:
Collaborative
:
PHASES
Assessment
Evaluation Diagnosing
Implementation Planning
IMPLEMENTATION
Putting the nursing care plan into action to
achieve the expected outcome;
Purposes:
Involves:
a. Care aspects
b. Curative
c. Protective
d. Teaching
e. Patient advocate
Principles in Implementation of
Nursing Care
a. maintaining the individuality of man
b. consideration for the patient’s safety,
comfort and privacy
c. considering economy of time, effort and
materials
d. neatness of the finished product
Delegating Care
If care has been delegated to other health
care personnel, the nurse responsible for
the client’s overall care must ensure that
the activities have been implemented
according to the care plan.
Documenting Nursing Activities
Completion of the implementing phase
The nurse records the interventions
carried out and client responses and/or
changes in the client’s health status in the
nursing progress notes.
To be able to record client responses
and/or changes in the client’s status,
continuing data collection is
necessary.
Documenting Nursing Activities
Routine or recurring activities may be
recorded at the end of a shift.
In some instances, certain nursing
interventions should be recorded
immediately after it is implemented, i.e.
administration of medications and
treatments. This helps safeguard the
client, for example, from receiving a
duplicate dose of the drug.
PHASES
Assessment
Evaluation Diagnosing
Implementation Planning
EVALUATION
• a planned, ongoing, purposeful activity
Goal statement: Will ambulate half the length of hallway w/ assistance 3x daily
Evaluative Statement:
Goal partially met: Patient refused to ambulate in the morning but walked
(Conclusion) to the bathroom once in the afternoon w/ the
assistance of one nurse (supporting data)
Evaluation Statement
Goal statement: Body temperature will decrease from 38.50C to 37.50C
within 2 hours after administering TSB.
Evaluative statement:
Goal met. Body temperature went down to 37.20C within 2 hours after TSB
administration.
Evaluative statement:
Goal not met. Patient verbalized that the pain intensity remained the same
.
PHASES
Assessment
Evaluation Diagnosing
Implementation Planning