Your SlideShare is downloading. ×
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Nursing Process
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Nursing Process

25,588

Published on

4 Comments
20 Likes
Statistics
Notes
No Downloads
Views
Total Views
25,588
On Slideshare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
0
Comments
4
Likes
20
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Descriptive Number: N 101Descriptive Name: Health AssessmentCourse Description: The course deals with concepts, principles and techniques of history taking using various tools, physical examination (head to toe), psychosocial assessment and interpretation of laboratory findings to arrive at a nursing diagnosis on the client across the lifespan in varied settings.
  • 2. Course Outline:
    I. Conceptual Overview of the Nursing Health Assessment
    - review of the phases of the Nursing Process
    A. Nurse’s Role in Health Assessment:
    Collecting and Analyzing Data
    Evolution of nurse’s role in health assessment
    B. Critical Thinking in Health Assessment
    II. Data Collection Documentation and Analysis
    A. Data Collection Process
    - General Survey
    - Interview Techniques
    B. Collecting Subjective Data
    - COLD SPA
  • 3. - Health History
    a. Biographical data
    b. Chief Complaints
    c. Present Health History
    d. Past Health History
    e. Family History
    f. Psychosocial History
    g. Activities of Daily Living (ADLs)
    h. Review of Systems
  • 4. C. Collecting Objective Data
    - Vital signs (TPR, BP)
    - Physical Assessment (IPPA)
    - Diagnostic Procedures
    D. Validation/ Rationalization of Subjective/ ObjectiveData
    E. Documentation of Data
    - Purposes of Assessment Documentation
    - Guidelines for Documentation
    - Assessment forms used for documentation
  • 5. INTERMEDIATE COMPETENCIES
    Given a hypothetical case, the student will be able to:
    1. Analyze the different phases of the nursing process
    2. Utilize the nursing process in health assessment
    3. Describe the critical thinking process with relevance to health assessment
    4. Demonstrate critical thinking skills in health assessment
    5. Collect relevant data
    6. Classify subjective from objective data
    7. Utilize interview techniques
  • 6. 8. Conduct health history
    9. Perform accurately
    a. Vital signs
    b. Physical Examination (IPPA)
    10. Assist client before, during and after diagnostic procedures
    11. Differentiate normal from abnormal findings
    12. Explain deviations from normal results
    13. Demonstrate legal practices in documentation
  • 7. NURSING PROCESS
    "the cornerstone of the nursing profession"
  • 8. What is a Process?
    It is a series of planned actions or operations directed towards a particular result or goal.
  • 9. Nursing Process
    It is a systematic, rational method of planning and providing individualized nursing care.
  • 10. Characteristics of the Nursing Process
    Dynamic
    Client-centered
    Planned
    Interpersonal and collaborative
    Universally applicable
    Can focus on problems or strengths
  • 11. Open, flexibe
    Humanistic and individualized
    Cyclical
    Outcome focused ( results oriented)
    Emphasizes feedback and validation
  • 12. Purpose of Nursing Process
    To identify a client’s health status, actual or potential health care problems or needs, to establish plans to meet the identified needs, and to deliver specific nursing interventions to meet those needs.
    It helps nurses in arriving at decisions and in predicting and evaluating consequences.
    It was developed as a specific method for applying a scientific approach or a problem solving approach to nursing practice.
  • 13. Nursing Process...
    Systematic
    Organized
    Goal-Oriented
    Humanistic Care
    Efficient Effective
  • 14. PHASES OF THE NURSING PROCESS
    Assessment
    Diagnosis
    Outcome Identification
    Planning
    Implementation
    Evaluation
  • 15. Nursing Diagnosis
    Assessment
    Evaluation
    Planning
    Implementation
    Nursing Process
    Outcome identification
  • 16. Benefits of using the nursing process
    Continuity of care
    Prevention of duplication
    Individualized care
    Standards of care
    Increased client participation
    Collaboration of care
  • 17. ASSESSMENT
    DIAGNOSIS
    OUTCOME &
    PLANNING
    IMPLIMENTATION
    EVALUATION
    INTER RELATIONSHIP BETWEEN THE STEPS OF NURSING PROCESS
  • 18.
  • 19. ASSESSMENT
  • 20. Assessing is a continuous process carried out during all phases of nursing process. All phases of the nursing process depend on the accurate and complete collection of data.
    Assessing is the systematic and continuous collection, organization, validation and documentation of data.
    - Potter and Perry( 2006)
  • 21. Assessment is the deliberate and systematic collection of data to determine a clients current and past health status and to determine the clients present and past coping patterns
    - Carpenito 2004
    Assessment is the systematic and continuous collection, validation and communication of patient data.
    - Carol Taylor
     
  • 22. To establish baseline information on the client.
    To determine the client’s normal function.
    To determine the client’s risk for diagnosis function.
    To determine presence or absence of diagnosis function.
    To determine client’s strengths.
    To provide data for the diagnostic phase.
  • 23. Activities of Assessment
    COLLECT DATA
    VALIDATE DATA
    ORGANIZE DATA
    RECORDING DATA
    Assessment involves reorganizing and collecting CUES:
    Objective (overt) Subjective (covert)
  • 24. Assessment
    ASESSMENT
    Collect data
    Organize data
    Validates Data
    Document data
    DIAGNOSIS
    PLANNING
    EVALUATION
    IMPLIMENTATION
  • 25. Types of Assessment
    • 1.Initial Assessment: Performed within specified time after admission to a health care agency
    Eg. Nursing Admission Assessment
    • 2. Problem Focused Assessment: Ongoing process integrated with nursing care to determine specific problem identified in an earlier assessment and to identify new or overlooked problems.
    E.g.. Assessment of clients ability to perform self-care while assisting client to bathe.
    • 3. Emergency Assessment: Done during psychiatric or physiological crisis of the client to identify life threatening problems
    Eg. Rapid assessment of airway, breathing and circulation during cardiac arrest
    • 4. Time lapsed-Reassessment: Done several months after initial assessment to compare the clients status to baseline data previously obtained.
  • Clinical Skills used in Assessment
    Observation – act of noticing client cues.
    *looking, watching, examining, scrutinizing, surveying, scanning, appraising.
    *uses different senses: vision, smell, hearing, touch.
    Interviewing – interaction and communication.
    Physical Examination
    INSPECTION
    PALPATION
    PERCUSSION
    AUSCULTATIONTUITION
    - defined as insights, instincts or clinical experiences to make judgment about client care.
  • 26. 1.COLLECTION OF DATA
    Data Collection is the process of gathering information about a clients health status.
  • 27. Collection of Data:
     
    • Data base: A data base is all information about a client. It includes the nursing health history, physical assessment, the physician’s history, physical examination, results of laboratory and diagnostic tests and material contributed by other health personnel.
     
     
     
  • 28. Medical vs. Nursing Assessments
    Medical assessments
    Target data pointing to pathologic conditions
    Nursing assessments
    Focus on the patient’s response to health problems
  • 29. Types of Data: 
    SUBJECTIVE DATA: Also referred to as symptoms or covert data are apparent only to the person affected and can be described or verified only by that person
    Eg. Itching, Pain, Feelings of worry
    OBJECTIVE DATA: Also referred to as signs or overt data. These are detectable by an observer or can be measured or tested against an accepted standard.
    They can be seen, heard, felt or smelled and they are obtained by observation or physical examination
    Eg. A Blood Pressure Data
    Discolouration of the Skin
     
  • 30. Objective Data vs. Subjective Data
    Objective data
    Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them
    E.g., elevated temperature, skin moisture, vomiting
    Subjective data
    Information perceived only by the affected person
    E.g., pain experience, feeling dizzy, feeling anxious
  • 31. COMPARING SUBJECTIVE AND OBJECTIVE DATA
    Data elicited and verified by the client
    Client Family and significant others.
    Client record
    Other health care professionals
    Client interview
    Interview and therapeutic communication skills.
    Caring ability and empathy.
    Listening skills.
    “I have a headache.”
    “It frightens me.”
    “I am not hungry.”
    Data directly or indirectly observed through measurement
     
    Observation and Physical examination
    Inspection
    Palpation
    Percussion
    Auscultation
    Respiration is 16 per minute.
    BP 180/100 mmhg, apical pulse 80 bpm and irregular
    X-ray film reveals fractured ribs
    • Description
    • 32. Sources
    • 33. Methods used to obtain data
    • 34. Skills needed to obtain data
    • 35. Examples
  • Sources of Data:
    Primary Source (Direct Source
    client:Usually BEST source
  • 36. Secondary Source (Indirect Source)
    • Family Members
    • 37. Client’s records
    1. Medical Records
    Eg. Medical History, Physical Examination,
    Operation notes, Progress notes,
    Consultation done by Physicians
    2. Records of therapies done by other health professionals
    Eg. Social Workers, Dieticians, Physical Therapist
    3. Laboratory Records
    • Other health care professionals Verbal reports
  • Data Collection
    Consider
    time
    needs of patient
    developmental stage
    physical surroundings
    past and present coping patterns
  • 38. Data Characteristics
  • Data collection methods
    OBSERVATION
    INTERVIEWING
    PHYSICAL ASSESSMENT
  • 42. Observation
    To gather data using senses
    Eg: laboured breathing, pallor or flushing,pain
    a lowered side rail ,functioning of an equipment , pt environment and people in it etc…
  • 43. Interviewing
    An interview is a planned communication or a conversation with a purpose
    Collection of Health History
  • 44. Four Phases of a Nursing Interview
  • Interview Phases
    • Preparatory
    • 48. Nurse collects background info from previous charts
    • 49. Ensure environment is conducive
    • 50. Arrange seating
    • 51. 3 – 4 ft apart
    • 52. Interviewer at 45° angle to patient
    • 53. Allow adequate time
  • Introduction
    • Nurse introduces self
    • 54. Identifies purpose of interview
    • 55. Ensure confidentiality of information
    • 56. Provide for patient needs before starting
  • Working
    • Nurse gathers info for subjective data
    • 57. Excellent communication skills are needed
    • 58. Active listening
    • 59. Eye contact
    • 60. Open-ended questions
  • Termination
    • Inform patient when nearing end of interview
    • 61. Ensure patient knows what will happen with info
    • 62. Offer patient chance to add anything
  • 63.
  • 64.
  • 65.
  • 66.
  • 67.
  • 68.
  • 69.
  • 70.
  • 71.
  • 72.
  • 73.
  • 74.
  • 75.
  • 76.
  • 77.
  • 78.
  • 79.
  • 80.
  • 81.
  • 82.
  • 83.
  • 84.
  • 85.
  • 86.
  • 87.
  • 88. COLLECTING OBJECTIVE DATA
    • VITAL SIGNS
    • 89. PHYSICAL ASSESSMENT
    • 90. DIAGNOSTIC PROCEDURE
  • Physical assessment
    • Appraisal of health status
    • 91. Usually by Review of Systems
    • 92. Overview of symptoms
    • 93. Observable, measurable data
    • Possible approaches—body systems, head to toe, or functional health patterns
  • Methods of physical assessment
  • DIAGNOSTIC PROCEDURES
  • Chest x-ray film (radiograph)
    1. Description: provides information regarding the anatomical location and appearance of the lungs.
    2. Preprocedure
    a. Remove all jewelry and other metal objects from the chest area.
    b. Assess the client’s ability to inhale and hold breath.
    c. Question females regarding pregnancy or the possibility of pregnancy.
    3. Postprocedure:
    Assist the client to dress.
  • 102. Ultrasound
    Imaging, medical diagnostic technique in which very high frequency sound is directed into the body. The tissue interfaces reflect the sound, and the resulting pattern of sound reflection is processed by a computer to produce a photograph or a moving image on a television. Ultrasound can be used to examine many parts of the body, but its best known application is the examination of the fetus during pregnancy.
  • 103.
  • 104. REVIEW ACTIVITIES
    ONE WHOLE SHEET OF PAPER
  • 105. You will be given a scenario, that you would analyze as CUES for your nursing assessment.
    Identify subjective to objective data.
    You will be given points to every correct assessment.
  • 106. W.T. a 22 year old male, presented to ER with a chief complaint “bad” abdominal pain. The generalized abdominal pain started 24 hours ago but seem to “ease up” after he vomited. Several hours later the pain returned but had shifted to the RLQ and has remained there. The pain is steadily getting worse that he is guarding that area, maintaining a fetal position, profusely sweating and BP when up to 150/100 mmhg from the baseline 120/70 mmhg.
  • 107. W.T. reports marked nausea and “dry heaves” and he has no appetite. He has also had diarrhea for the last day. VS are 150/100mmhg, 92 bpm, 25 breaths/min, 38.8C temp. Started to have chills, weakness, trembling toes and redness of the face and neck. He vomited again to a greenish gastric secretions with undigested foods. The patient states “dawmapataynagidkosakasakit” appears to anxious and uneasy.
  • 108. Ana-physio. What organ(s) are located in the RLQ?
    Priority problem identified?
    Based on the scenario, identify the subjective data
    Based on the scenario, identify the objective data
    Given the scenario, how are you going to approach the patient?
    State all the cues that can be collected by means of observation.
  • 109. ACTIVITY
    G.S. a 36 year old secretary, was having difficulty of breathing a few hours after eating a green salad tossed in tartar sauce with grilled shrimp. She developed a mild urticaria, peri-orbital edema, generalized itchiness. Patient states she had never experienced this before,very anxious and diaphoretic thinks that she may die. RR= 24 breaths/min laboured, cyanotic nailbeds, cold clammy skin,
  • 110. ACTIVITY
    Bilateral wheezing sounds upon auscultation, and pulse rate of 106bpm. She is crying she cant breath deeply. She had an oxygen at 2lpm, nebulization every 4 hours and on steroid therapy.
  • 111. ACTIVITY
    Priority problem identified?
    Based on the scenario, identify the subjective data
    Based on the scenario, identify the objective data
    Given the scenario, how are you going to approach/communication technique to the patient?
    State all the cues that can be collected by means of observation.
  • 112. Kindly bring your Nursing Care Plan Book, Nursing Process, and any pocket guide to nursing diagnosis or nursing process.
  • 113. ORGANISING DATA
    • Nurses uses a written or computerized format for arranging he data systematically
    • 114. Clustering facts into groups of information.
  • VALIDATING DATA
    • VALIDATING -THE ACT OF DOUBLE CHECKING
    • 115. Verifies understanding of information
    • 116. Comparison with another source
    -patient or family member
    -record
    -health team member
  • 117. DOCUMENTING DATA
    • Record in permanent record ASAP
    • 118. Use patient’s own words in subjective data – enclose in “ ___” (quotation marks)
    • 119. Avoid generalizations – be specific
    • 120. Don’t make summative statements
  • Document what you saw the patient doing or what you believe he’s doing.
  • 121. SIX PHASES
    NURSING
    PROCESS
  • 122. ASSESSMENT
    • To establish data base.
    Sources of Data:
    Primary: Patient / Client
    Secondary: Family members, SOs, Record/Chart, Health team members, Related Lit.
  • 123. Approaches to Collecting Data for Assessing Client’s Health:
    ABDELLAH’S 21 Nursing Problems
    DOROTHEA OREM’S Components of Universal Self-Care
    GORDON’S Functional Health Patterns
    Correlating a Body Systems Physical Examination with Data Gathered by Functional Health Area.
  • 124. DIAGNOSING
    Nursing Diagnosis- terminology used for a clinical judgment by the professional nurse that identifies the client’s actual, risk, wellness, or syndrome responses to a health state, problem, or condition.
  • 125. Purposes of Nursing Diagnosis
    Identifies areas that nurses can resolve or enhance.
    Demonstrates professional judgment.
    Organizes decision making as part of the nursing process.
    Promotes accountability.
    Provides communication among nurses and other health care personnel.
    Promotes use of standardized language and process.
    A means to individualize care.
    Provides a mechanism for conducting nursing research.
  • 126. Categories of Nursing Diagnoses
    Actual Diagnoses
    Risk Diagnoses
    Wellness Diagnoses
  • 127. Categories of Nursing DiagnosesWELLNESS RISK ACTUAL
    Human responses that may develop in a vulnerable individual, family, or community (NANDA,2003-2004)
    “Risk for…”
    -Risk for Disturbed Body Image.
    -Risk for Interrupted Family processes.
    -Risk for Ineffective Breast-feeding.
    -Risk for impaired Skin integrity
    Human responses to health conditions/life processes that exist (NANDA,2003-2004)
    “Nursing diagnoses and related to cause”
    -Disturbed Body Image related to wound on hand that is not healing.
    -Dysfunctional Family Processes: Alcoholism.
    -Ineffective Breast-feeding related to poor mother-infant attachment.
    -Impaired Skin Integrity related to immobility
  • 128. Developing a Nursing Diagnosis
    Critical thinking is essential to the synthesis and interpretation of information when developing a nursing diagnosis.
    Assessing the Data Base
    Cues are small amounts of data gathered during assessment.
    Cues raise suspicion.
    Cues stimulate further observation.
    Cues stimulate further data collection.
    Validating Cues- Verifying subjective and objective data for accuracy and completeness
    Interpreting Cues- Assigning meaning to data cues
    Clustering Cues- Grouping related data together
    Consulting NANDA List of Nursing Diagnoses
    Writing the Nursing Diagnosis Statement
  • 129. Nursing diagnosis statement
    Actual Health Problem: PE Format
    Potential Health Problem: PER Format
    P- Problem statement;
    E- Etiology;
    R- Risk Factor
  • 130. Classification of NURSING DIAGNOSIS:
    High – priority
    - life threatening and requires immediate attention.
    Medium – priority
    - resulting to unhealthy consequences.
    Low – priority
    - can be resolve with minimal interventions.
  • 131. Outcome Identification
    refers to formulating and documenting measurable, realistic, client-focused goals.
    PURPOSES:
    To provide individualized care
    To promote client participation
    To plan care that is realistic and measurable
    To allow involvement of support people
    ESTABLISH PRIORITIES!!!
  • 132. Characteristics ofOutcome Criteria:
    S - SPECIFIC
    M - MEASURABLE
    A - ATTAINABLE
    R - REALISTIC
    T - TIME – FRAMED
    CAN BE SHORT TERM OR LONG TERM GOAL.
  • 133. PLANNING
    Involves determining beforehand the strategies or course of actions to be taken before implementation of nursing care.
    To be effective, involve the client and his family in planning!
  • 134. IMPLEMENTATION
    Putting nursing care plan into ACTION!
    To help client attain goals and achieve optimal level of health.
    Requires: Knowledge, Technical skills, Communication skills, Therapeutic Use of Self.
    …..SOMETHING THAT IS NOT WRITTEN IS CONSIDERED AS NOT DONE!!!
  • 135. Planning Nursing InterventionsCategories of Nursing Interventions
    Independent Nursing Interventions:
    -Actions initiated by the nurse
    -Do not require direction or an order from another health care professional.
    -Sanctioned by professional nurse practice acts.
  • 136. Planning Nursing InterventionsCategories of Nursing Interventions
    Interdependent Nursing Interventions:
    • Collaboration
    • 137. Consultation
  • Planning Nursing InterventionsCategories of Nursing Interventions
    Dependent Nursing Interventions:
    -Require an order from another health care professional.
  • 138. Nursing intervention activities
  • Requirements of implementing:
    KNOWLEDGE- include intellectual skills like problem solving, decision making, and teaching.
    TECHNICAL SKILLS- to carry out treatments and procedures.
    COMMUNICATION SKILLS- use of verbal and non-verbal communication to carry out planned nsg. Intervention.
    THERAPEUTIC USE OF SELF- being willing and being able to care.
  • 142. EVALUATION
    IS ASSESSING THE CLIENT’S RESPONSE TO NURSING INTERVENTIONS.
    COMPARING THE RESPONSE TO PREDETERMINED STANDARDS OR OUTCOME CRITERIA.
    FOUR POSSIBLE JUDGMENTS:
    The goal was completely met.
    The goal was partially met.
    The goal was completely unmet.
    New problems or nursing diagnoses have developed.
  • 143. ACTIVITY
    G.S. a 36 year old secretary, was having difficulty of breathing a few hours after eating a green salad tossed in tartar sauce with grilled shrimp. She developed a mild urticaria, peri-orbital edema, generalized itchiness. Patient states she had never experienced this before,very anxious and diaphoretic thinks that she may die. RR= 24 breaths/min laboured, cyanotic nailbeds, cold clammy skin,
  • 144. ACTIVITY
    Bilateral wheezing sounds upon auscultation, and pulse rate of 106bpm. She is crying she cant breath deeply. She had an oxygen at 2lpm, nebulization every 4 hours and on steroid therapy.
  • 145. ACTIVITY
    Priority problem identified?
    Based on the scenario, identify the subjective data
    Based on the scenario, identify the objective data
    Make an actual and risk nursing diagnosis with rationale.
  • 146. Characteristics of NURSING PROCESS…
    Problem-oriented.
    Goal oriented.
    Orderly, planned, step by step.
    (systematic)
    Open to new information.
    Interpersonal.
    Permits creativity.
    Cyclical.
  • 147. Benefits of the NURSING PROCESS: for the Client
    QUALITY CLIENT CARE
    CONTINUITY OF CARE
    PARTICIPATION BY CLIENTS IN THEIR HEALTH CARE
  • 148. Benefits of the NURSING PROCESS: for the Nurse
    CONSISTENT AND SYSTEMATIC NURSING EDUCATION.
    JOB SATISFACTION.
    PROFESSIONAL GROWTH.
    AVOIDANCE OF LEGAL ACTION.
    MEETING PROFESSIONAL NURSING STANDARDS.
    MEETING STANDARDS OF ACCREDITED HOSPITALS.
  • 149. HEART OF THE NURSING PROCESS…
    KNOWLEDGE
    SKILLS
    - manual, intellectual, interpersonal.
    CARING
    - willingness and ability to care.
  • 150. Willingness to CARE
    Keep the focus on what is best for the patient.
    Respect the beliefs / values of others.
    Stay involved.
    Maintain a healthy lifestyle.
  • 151. CARING BEHAVIORS
    Inspiring someone / instilling hope and faith.
    Demonstrating patience, compassion, and willingness to persevere.
    Offering companionship.
    Helping someone stay in touch with positive aspect of his life.
  • 152. Demonstrating thoughtfulness.
    Bending the rules when it really counts.
    Doing the “little things”
    Keeping someone informed.
    Showing your human side by sharing “stories”
  • 153. Any Questions???
  • 154. COLLECTING SUBJECTIVE DATA
    by: CMG
  • 155. CHIEF COMPLAINT/REASON FOR SEEKING HEALTH CARE:
    Guide Questions:
    “what is your major health problem or concern at this time?”
    “why are you here?”
    “how can I help you?”
    Subjective:
    Translation:
    by: CMG
    CLIENT’S HEALTH HISTORY
  • 156. ADMITTING IMPRESSION : Physicians initial findings (No Abbreviations)
    by: CMG
  • 157. BIOGRAPHICAL DATA
     
    Name:(use initials)
    Age:
    Sex:
    Marital Status:
    Religion/Spiritual practices:
    Address:
    Birth date:
    Birthplace:
    by: CMG
  • 158. Race or ethnic background:
    Who lives with the client:
    Significant others:
    Educational Level:
    Occupation: (active/laid off/retired)
    Nationality:
    Physician:
    Date of interview:
    Time of interview:
    Date of admission:
    Time of admission:
    Room/ Ward:
    by: CMG
  • 159. Provider of history:
    Primary:
    Secondary:
    Vital Signs upon Admission:
    by: CMG
  • 160. HISTORY OF PRESENT ILLNESS
    Character ( How does it feel, look, smell, sound, etc.?)
    Onset( When did it begin; is it better, worse, or the same since it began?)
    Location (Where is it? Does it radiate?)
    Duration (How long it last? Does it recur?)
    Severity ( How bad is it on a scale 1 [barely noticeable] to 10 [worst pain ever experienced])?
    Pattern ( What makes it better? What makes it worse?)
    Associated factors (What other symptoms do you have with it? Will you be able to continue doing your work or other activities? 
    by: CMG
  • 161. (In chronological order, include specifications for signs and symptoms, interventions or treatment done, response and compliance. For medications, include the name of the drug, dosage, frequency, time).
    by: CMG
    HISTORY OF PRESENT ILLNESS
  • 162. Problems at birth
    Childhood Illnesses
    Immunizations to date
    Adult illnesses (physical, emotional, mental)
    Surgeries
    Accidents
    Prolonged pain or pain patterns
    Allergies
    by: CMG
    PAST HEALTH HISTORY
  • 163. Purpose: More health problems that seem to run in the families and that are genetically based; the family history assumes greater importance.
    by: CMG
    FAMILY HISTORY
  • 164. (Focused Interview based on the chief complaint and the admitting impression of the patient).
    Purpose: How the client views herself and investigation of all behaviors that a person does to promote her health. This will help to point out clients strengths and needs for health maintenance and determine client’s level of social development.
    by: CMG
    SOCIO-CULTURAL HISTORY
  • 165. (Focused Interview based on the chief complaint and the admitting impression of the patient).
    Purpose: Questions regarding the client’s environment to assess health hazards unique to the clients living situation and lifestyle that may put the client at risk. They may be controllable or uncontrollable
    by: CMG
    ENVIRONMENTAL HISTORY
  • 166. MEDICATION AND SUBSTANCE USE
    Purpose: The information gathered about medication and substance use provides the nurse with information concerning lifestyle and a client’s self care ability. Medication and substance use can affect the client’s health and cause loss of function or impaired senses and can increase the client’s risk for a disease.
    by: CMG
  • 167. OBSTETRICAL HISTORY (For Ob-Gyne Cases)
    GROWTH AND DEVELOPMENT
    (For Pediatric Patients, significance must be indicated if the growth and development of a child is delayed, advanced or normal. State the reason for the abnormalities.)
    by: CMG
  • 168. Using GORDON’S functional Health Pattern with comparison to Home and Hospital
    by: CMG
    PATTERNS OF FUNCTIONING
  • 169. Example:
    CBC, Blood studies
    Urine analysis
    Stool Exam
    Sputum Exam
    Chest x-ray
    Ultrasound
    by: CMG
    DIAGNOSTIC EXAMINATION
  • 170. General Appearance
    -Vital statistics, vital signs, Contraptions like tubings (IVF, 02 catheter, Wound dressing, Urinary catheter, Nasogastric tubes and etc.) consciousness, coherence and orientation, hygiene/dress, mood and affect, gait obvious signs of discomfort, body build, speech,
    by: CMG
    PHYSICAL EXAMINATION
  • 171. Ht.: 5 foot 5 inches; Wt: 145 lbs; Radial pulse: 71; respiration:16; BP: Right arm= 120/70 mmHg, Left arm= 120/70 mmhg; Temp: 36.7 C(date and time taken) Client alert and cooperative. Sitting comfortably on the table with arms crossed and shoulder slightly slouched forward. Smiling with mild anxiety. Dress is neat and clean. Walks steadily with posture slightly stooped.
     
    by: CMG
    General AppearanceExample:
  • 172. Physical Assessment
    (Cephalo-caudal Approach with emphasis on the specific area which is related to the chief complaint/ admitting impression. Highlight the abnormal findings).
    by: CMG
  • 173. TRANSFUSIONS
    -Blood and blood products transfusions (if any)
     
    by: CMG
  • 174. TREATMENT AND NURSING CARE with specific Rationale
    by: CMG
  • 175. A. Overview of the System (Anatomy and Physiology)
    B. Definition (of the specific case)
    C. Epidemiology
    D. Etiology
    E. Clinical Manifestations
    by: CMG
    TEXTBOOK DISCUSSION
  • 176. F. Pathogenesis
    G. Complications
    H. Interventions
    1. Medical
    2. Surgical
    3. Nursing
    Levels of Care:
    Promotive,
    Preventive,
    Curative,
    Rehabilitative
    by: CMG
  • 177. References
    Title of the book
    Author
    Edition
    Copyright
    Pages
    For electronic source: website and location of topic
     
    by: CMG
  • 178. Actual Health Problem: PE Format
    Potential Health Problem: PER Format
    P- Problem statement;
    E- Etiology;
    R- Risk Factor
    Each Goal should have a set of independent, dependent, and collaborative nursing interventions.
    Definition of the problem statement should be under the column of Nursing Diagnosis with the REFERENCE.
    ALL rationales should have a reference.
    by: CMG
    NURSING CARE PLAN
  • 179. GOD BLESS

×