The nursing process is a systematic method for planning and providing nursing care to patients. It involves five interrelated phases: assessment, diagnosis, planning, implementation, and evaluation. Assessment is the first phase and involves collecting subjective and objective data about the patient's health status through various techniques like inspection, palpation, percussion, and auscultation. The data is then organized, validated, and documented to form the patient's database which provides the basis for determining the patient's diagnoses, developing a care plan, and evaluating outcomes.
Florence nightingaleâs environment theoryShrooti Shah
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The foundation of Nightingaleâs theory is the environment- all the external conditions and forces that influence the life and development of an organism.
According to her, external influences and conditions can prevent, suppress, or contribute to disease or death.
Her goal was to help the patient retain his own vitality by meeting his basic needs through control of the environment.
Florence nightingaleâs environment theoryShrooti Shah
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The foundation of Nightingaleâs theory is the environment- all the external conditions and forces that influence the life and development of an organism.
According to her, external influences and conditions can prevent, suppress, or contribute to disease or death.
Her goal was to help the patient retain his own vitality by meeting his basic needs through control of the environment.
The first step for assessing a person's health and disease status. A detailed comprehension of health assessment can enable health care professionals to work more confidently in the clinical setting.
Health assessment By - Jitendra Bokha.pptxJitendra Bokha
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Health assessment is defined as systematic and dynamic process by which nurse through interaction with client, significant others and health care providers, collect data about the client.
A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
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NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
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As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Departmentâs official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Recomendaçþes da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS â Objetivos do Desenvolvimento SustentĂĄvel e a EstratĂŠgia Global para a SaĂşde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pĂłs-natais devem expandir-se para alĂŠm da cobertura e da simples sobrevivĂŞncia, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pĂłs-natais essenciais e de rotina prestados Ă s mulheres e aos recĂŠm-nascidos, com o objetivo final de melhorar a saĂşde e o bem-estar materno e neonatal.
Uma âexperiĂŞncia pĂłs-natal positivaâ ĂŠ um resultado importante para todas as mulheres que dĂŁo Ă luz e para os seus recĂŠm-nascidos, estabelecendo as bases para a melhoria da saĂşde e do bem-estar a curto e longo prazo. Uma experiĂŞncia pĂłs-natal positiva ĂŠ definida como aquela em que as mulheres, pessoas que gestam, os recĂŠm-nascidos, os casais, os pais, os cuidadores e as famĂlias recebem informação consistente, garantia e apoio de profissionais de saĂşde motivados; e onde um sistema de saĂşde flexĂvel e com recursos reconheça as necessidades das mulheres e dos bebĂŞs e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendaçþes novas e jĂĄ bem fundamentadas sobre cuidados pĂłs-natais de rotina para mulheres e neonatos que recebem cuidados no pĂłs-parto em unidades de saĂşde ou na comunidade, independentemente dos recursos disponĂveis.
Ă fornecido um conjunto abrangente de recomendaçþes para cuidados durante o perĂodo puerperal, com ĂŞnfase nos cuidados essenciais que todas as mulheres e recĂŠm-nascidos devem receber, e com a devida atenção Ă qualidade dos cuidados; isto ĂŠ, a entrega e a experiĂŞncia do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendaçþes da OMS de 2014 sobre cuidados pĂłs-natais da mĂŁe e do recĂŠm-nascido e complementam as atuais diretrizes da OMS sobre a gestĂŁo de complicaçþes pĂłs-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências Ê contemplada.
Recomendamos muito.
Vamos discutir essas recomendaçþes no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação sĂł estĂĄ disponĂvel em inglĂŞs atĂŠ o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
New Drug Discovery and Development .....NEHA GUPTA
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The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Report Back from SGO 2024: Whatâs the Latest in Cervical Cancer?bkling
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Are you curious about whatâs new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Womenâs Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2â3 criteria; moderate AUD: 4â5 criteria; severe AUD: 6â11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowmanâs Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Knee anatomy and clinical tests 2024.pdfvimalpl1234
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This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
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Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
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2. Introduction to Nursing:
Nursing is an art of applying scientific principles
in a humanitarian way to care of people
The nursing process serves as the
organizational framework for the practice of
nursing.
3. Nursing process:
Is a systematic method by which nursing :plans
and provides care for patients.
This involves a problem-solving approach that
enables the nurse to identify patient problems
and potential at-risk needs (problems) and to
plan, deliver, and evaluate nursing care in an
orderly, scientific manner.
4. Components of nursing process:
The nursing process consists of five dynamic
and interrelated phases:
2. assessment
3. diagnosis
4. planning
5. implementation
6. evaluation.
7. Assessment
Is the systematic and continuous:
⢠collection
⢠organization
⢠validation
⢠documentation of data.
8. Assessment
Documenting
Collect data Organize data Validate data
data
9. The nurse gathers information to identify the health
status of the patient.
Assessments are made initially and continuously
throughout patient care.
The remaining phases of the nursing process
depend on the validity and completeness of the initial data
collection.
10. Purposes of assessment
To establish Database: all the information about a client: it
includes:
⢠The nursing health history
⢠Physical examination
⢠The physician's history
⢠Results of laboratory and diagnostic tests
11. PURPOSE:
Assessment is part of each activity the nurse does for
and with the patient.
The purposes is
4. To validate a diagnosis
5. To provide basis for effective nursing care.
6. It helps in effective decision making
7. Basis for accurate diagnosis
8. It promote holistic nursing care
1. To provide effective and innovative nursing care
1. To collecting data for nursing
research
2. To evaluation of nursing care
13. Initial comprehensive assessment
An initial assessment, also called an admission assessment, is
performed when the client enters a health care from a health care
agency. The purposes are to evaluate the clientâs health status, to
identify functional health patterns that are problematic, and to
provide an in-depth, comprehensive database, which is critical
for evaluating changes in the clientâs health status in subsequent
assessments.
14. Problem-focused assessment
A problem focus assessment collects data about a problem that
has already been identified. This type of assessment has a
narrower scope and a shorter time frame than the initial
assessment. In focus assessments, nurse determine whether the
problems still exists and whether the status of the problem has
changed (i.e. improved, worsened, or resolved). This assessment
also includes the appraisal of any new, overlooked, or
misdiagnosed problems. In intensive care units, may perform
focus assessment every few minute.
15. Emergency assessment
Emergency assessment takes place in life-threatening
situations in which the preservation of life is the top priority. Time
is of the essence rapid identification of and intervention for the
clientâs health problems. Often the clientâs difficulties involve
airway, breathing and circulatory problems (the ABCs). Abrupt
changes in self-concept (suicidal thoughts) or roles or relationships
(social conflict leading to violent acts) can also initiate an
emergency. Emergency assessment focuses on few essential health
patterns and is not comprehensive.
16. Time-lapsed assessment or Ongoing
assessment
Time lapsed reassessment, another type of assessment,
takes place after the initial assessment to evaluate any changes
in the clients functional health. Nurses perform time-lapsed
reassessment when substantial periods of time have elapsed
between assessments (e.g., periodic output patient clinic visits,
home health visits, health and development screenings)
17. Steps Of Assessment
1. Collection of data
ďą Subjective data collection
ďą Objective data collection
2. Validation of data
3. Organization of data
4. Recording/documentation of data
18. Collection of data
ďŽ gathering of information about the client
ďŽ includes physical, psychological, emotion, socio-cultural, spiritual
factors that may affect clientâs health status
ď§ includes past health history of client (allergies, past surgeries,
chronic diseases, use of folk healing methods)
ď§ includes current/present problems of client (pain, nausea, sleep
pattern, religious practices, medication or treatment the client is
taking now)
19. Types of data:
When performing an assessment the nurse gathers subjective and
objective data.
Subjective data (symptoms or covert data):
are the verbal statements provided by the Patient.
Statements about nausea and descriptions of pain and
fatigue are examples of subjective data.
20. Objective data (signs or overt data):
are detectable by an observer or can be measured or tested
against an accepted standard. They can be seen, heard, felt, or
smelt, and they are obtained by observation or physical
examination. For example: discoloration of the skin
21. Data collection methods:
1. Observing: to observe is to gather data by using the senses.
2. Interviewing: an interview is a planned communication or
conversation with a purpose.
3. Examining: Performance of a physical examination. The
physical examination is often guided by data
provided by the patient. A head-to-toe approach is
frequently used to provide systematic approach
that helps to avoid omitting important data
24. Head-to-toe Assessment
Physical Assessment using head toe approach
General Test hearing
General health status Cranial nerves
Vital signs and weight Inspect lymph nodes
Nutrional status Inspect neck veins
Mobility and self care Chest
Observe posture Inspect and palpate breast
Assess gait and balance Inspect and auscultate lungs
Evaluate mobility Auscultate heart
Activities of daily living Abdomen
Head face and neck Inspect, auscultate, palpate four
Evaluate cognition quadrants
LOC Palpate and percuss liver, stomach,
Orientation bladder
Mood Bowel elimination
Language and memory Urinary elimination
Sensory function
Test vision
Inspect and examine ears
25. ContâŚ..
Extremities
Skin, hair and nails Palpate arterial pulses
Inspect scalp, hair & nails Observe capillary refill
Evaluate skin turgor Evaluate edema
Observe skin lesion Assess joint mobility
Assess wounds Measure strength
Genitalia Assess sensory function
Inspect female client Assess circulation, movement, &
Inspect male client sensation
Deep tendon reflexes
Inspect skin and nails
26. Body System approach
Review Of Systems
â˘General presentation of symptoms: Fever, chills, malaise, pain, sleep
patterns, fatigability
â˘Diet: Appetite, likes and dislikes, restrictions, written dairy of food intake
â˘Skin, hair, and nails: rash or eruption, itching, color or texture change,
excessive sweating, abnormal nail or hair growth
â˘Musculoskeletal: Joint stiffness, pain, restricted motion, swelling, redness,
heat, deformity
â˘Head and neck:
Eyes: visual acuity, blurring, diplopia, photophobia, pain, recent change in
vision
Ears: Hearing loss, pain, discharge, tinnitus, vertigo
Nose: Sense of smell, frequency of colds, obstruction, epistaxis, sinus
pain, or postnasal discharge
Throat and mouth: Hoarseness or change in voice, frequent sore throat,
bleeding o swelling, of gums, recent tooth abscesses or extractions, soreness
of tongue or mucosa.
27. ⢠Endocrine and genital reproductive: Thyroid enlargement or
tenderness, heat or cold intolerance, unexplained weight change, polyuria,
polydipsia, changes in distribution of facial hair; Males: Puberty onset,
difficulty with erections, testicular pain, libido, infertility; Females:
Menses {onset, regularity, duration and amount}, Dysmenorrhea, last
menstrual period, frequency of intercourse, age at menopause, pregnancies
{number, miscarriage, abortions} type of delivery, complications, use of
contraceptives; breasts {pain, tenderness, discharge, lumps}
⢠Chest and lungs: Pain related to respiration, dyspnea, cyanosis, wheezing,
cough, sputum {character, and quantity}, exposure to tuberculosis (TB), last
chest X-ray
⢠Heart and blood vessels: Chest pain or distress, precipitating causes,
timing and duration, relieving factors, dyspnea, orthopnea, edema,
hypertension, exercise tolerance
28. ⢠Gastrointestinal: Appetite, digestion, food intolerance, dysphagia,
heartburn, nausea or vomiting, bowel regularity, change in stool
color, or contents, constipation or diarrhea, flatulence or
hemorrhoids
⢠Genitourinary: Dysuria, flank or suprapubic pain, urgency,
frequency, nocturia, hematuria, polyuria, hesitancy, loss in force of
stream, edema, sexually transmitted disease
⢠Neurological: Syncope, seizures, weakness or paralysis,
abnormalities of sensation or coordination, tremors, loss of memory
⢠Psychiatric: Depression, mood changes, difficulty concentrating
nervousness, tension, suicidal thoughts, irritability.
⢠Pediatrics: along with systemic approach in case of
pediatrics, measure anthropometric measurement and
neuromuscular assessment.
30. Assessment techniques - Cont.
Inspection
ďŽ Close and careful visualization of the person
as a whole and of each body system
ďŽ Ensure good lighting
ďŽ Perform at every encounter with your client
31. Assessment techniques - Cont.
Palpation
Palpation Techniques
ďŽ Temperature, Texture,
Moisture ďą Light
ďŽ Organ size and location
ďŽ Rigidity or spasticity ďą Deep
ďŽ Crepitation & Vibration
ďŽ Position & Size
ďŽ Presence of lumps or
masses
ďŽ Tenderness, or pain
32. Assessment techniques - Cont.
Percussion
ďŽ assess underlying structures
for location, size, density of
underlying tissue.
ďŽ Direct
ďŽ Indirect
ďŽ Blunt percussion
33. Percussion Sounds
ďŽ Resonance: A hollow sound.
ďŽ Hyper resonance: A booming sound.
ďŽ Tympany: A musical sound or drum sound like
that produced by the stomach.
ďŽ Dullness: Thud sound produced by dense
structures such as the liver, and enlarged spleen,
or a full bladder.
ďŽ Flatness: An extremely dull sound like that
produced by very dense structures such as muscle
or bone.
34. Percussion sounds
Sound Intensit Pitch Length Quality Example of
y origin
Resonance (heard Loud Low Long Hollow Normal lung
over part air and
part solid
Hyper-resonance Very Low Long Booming Lung with
(heard over loud emphysema
mostly air
Tympany (heard Loud High Moderate Drum like Puffed-out
over air) cheek, gastric
bubble
Dullness (heard Medium Medium Moderate Thud like Diaphragm,
over more solid pleural
tissue effusion
Flatness (heard Soft High short Flat Muscle,
over very dense Bone, Thigh
tissue
35. Assessment techniques - Cont.
Auscultation
ďŽ Listening to sounds
produced by the body
ďŽ Instrument: stethoscope (to
skin)
ďŽ Diaphragm âhigh pitched
sounds
Heart
Lungs
Abdomen
ďŽ Bell â low pitched sounds
Blood vessels
36. Assessment techniques - Cont.
Setting Technique
ďŽ General survey
ďŽ Environment & ďŽ Head to toe or systems
Equipment
approach
ďŽ Minimize exposure
ďŽ Areas to assess first â
unaffected areas, external
before internal parts
37. Physical Health Exam-General Survey
ďŽ Appearance
ďą Age, skin color, facial features
ďą Body Structure - Stature, nutrition, posture, position, symmetry
ďą Mobility - Gait, ROM
ďŽ Behavior
ďą Facial expression, mood/affect, speech, dress, hygiene
ďŽ Cognition
ďą Level of Consciousness and Orientation (x4)
ďŽ Include any signs of distress- facial grimacing, breathing
problems
38. Complete Health History
ďŽ Biographical data
ďŽ Reason for Seeking Care
ďŽ History of Present Illness
ďŽ Past Health
ďŽ Accidents and Injuries
ďŽ Hospitalizations and Operations
ďŽ Family History
ďŽ Review of Systems
ďŽ Functional Assessment ( Activities of Daily Living)
ďŽ Perception of Health
39. Sources of data:
Data can be obtained from primary or secondary sources.
The primary source of data is the patient. In most
instances the patient is considered to be the most accurate
reporter. The alert and oriented patient can provide information
about past illness and surgeries and present signs, symptoms,
and lifestyle.
When the patient is unable to supply
information because of deterioration of mental
status, age, or seriousness of illness, secondary
sources are used.
40. The Secondary sources of data include family members,
significant others, medical records, diagnostic procedures, âŚ.
Members of the patient's support system may be able to
furnish information about the patient's past health status,
current illness, allergies, and current medications.
Other health team professionals are also helpful secondary
sources (Physicians, other nurses.)
41. Validating data:
The information gathered during the assessment
phase must be complete, factual, and accurate
because the nursing diagnosis and interventions are
based on this information.
Validation is the act of "double-checking" or
verifying data to confirm that it is accurate
and factual.
42. Purposes of data validation:
⢠ensure that data collection is complete
⢠ensure that objective and subjective data agree
⢠obtain additional data that may have been overlooked
⢠avoid jumping to conclusion
⢠differentiate cues and inferences
43. Data Requiring Validation
Not every piece of data you collect must be verified. For
example: you would not need to verify or repeat the clientâs pulse,
temperature, or blood pressure unless certain conditions exist.
Conditions that require data to be rechecked and validated include:
â˘Discrepancies or gaps between the subjective
and objective data. For example, a male client
tells you that he is very happy despite
learning that he has terminal cancer.
44. Data Requiring Validation
⢠Discrepancies or gaps between what the client says at one time and
then another time. For example, your female patient says she has
never had surgery, but later in the interview she mentions that her
appendix was removed at a military hospital when she was in the
navy
⢠Findings those are very abnormal and inconsistent with
other findings. For example, the client has a temperature
of 104oF degree. The client is resting comfortably. The
clientâs skin is warm to touch and not flushed.
45. Methods of validation
⢠Recheck your own data through a repeat assessment. For example, take the
clientâs temperature again with a different thermometer.
⢠Clarify data with the client by asking additional questions. For example: if a
client is holding his abdomen the nurse may assume he is having abdominal
pain, when actually the client is very upset about his diagnosis and is
feeling
⢠Verify the data with another health care
professional. For example, ask a more
experienced nurse to listen to the abnormal heart
sounds you think you have just heard.
⢠Compare you objective findings with your
subjective findings to uncover discrepancies. For
example, if the client state that she ânever gets
any time in the sunâ yet has dark, wrinkled,
46. Organizing data
The nurse uses a written or computerized format that
organizes the assessment data systematically. The format
may be modified according to the client's physical status.
47.
48. Body System Model
The Body systems model (also called the medical model
or review of systems) focuses on the clientâs major anatomic
systems. The framework allows nurses to collect data about
past and present condition of each organ or body system and
to examine thoroughly all body systems for actual
and potential problems.
49. Gordonâs Functional Health Patterns:
The clientâs strengths, talents and functional health patterns are an
integral part of the assessment data. An assessment of functional health
focuses on clientâs normal function and his or her altered function or
risk for altered function.
⢠Health perception-health management pattern.
⢠Nutritional-metabolic pattern
⢠Elimination pattern
⢠Activity-exercise pattern
⢠Sleep-rest pattern
⢠Cognitive-perceptual pattern
⢠Self-perception-concept pattern
⢠Role-relationship pattern
⢠Sexuality-reproductive pattern
⢠Coping-stress tolerance pattern
⢠Value-belief pattern
50. Documenting data:
To complete the assessment phase, the nurse records
client's data.
Accurate documentation is essential and should include
all data collected about the client's health status.
Data are recorded in a factual manner and not interpreted
by the nurse.
E.g.: the nurse record the client's breakfast intake
as" coffee 240 mL. Juice 120 mL, 1 egg". Rather
than as "appetite good".
51. Purposes of documentation
⢠Provides a chronological source of client assessment
data and a progressive record of assessment findings
that outline the clientâs course of care.
⢠Ensures that information about the client and family is
easily accessible to members of the health care team;
provides a vehicle for communication; and prevents
fragmentation, repetition, and delays in carrying out
the plan of care.
⢠Establishes a basis for screening or validation
proposed diagnoses.
⢠Acts as a source of information to help diagnose new
problems.
52. Purposes of documentation contâŚ
⢠Offers a basis for determining the educational needs
of the client, family, and significant others.
⢠Provides a basis for determining eligibility for care
and reimbursement. Careful recording of data can
support financial reimbursement or gain additional
reimbursement for transitional or skilled care needed
by the client.
⢠Constitutes a permanent legal record of the care that
was or was not given to the client.
⢠Provides access to significant epidemiologic data for
future investigations and research and educational
endeavors.
53. Guidelines for documentation
⢠Document legibly or print neatly in unerasable ink
⢠Use correct grammar and spelling
⢠Avoid wordiness that creates redundancy
⢠Use phrases instead of sentences to record data
⢠Record data findings, not how they were obtained
⢠Write entries objectively without making premature
judgments or diagnosis
54. Guidelines for documentation
⢠Record the clientâs understanding and perception of
problems
⢠Avoid recording the word ânormalâ for normal
findings
⢠Record complete information and details for all
client symptoms or experiences
⢠Include additional assessment content when
applicable
⢠Support objective data with specific observations
obtained during the physical examination
55.
56. Nursing Assessment
⢠Assessment is the first stage of the nursing process in which
the nurse should carry out a complete and holistic nursing
assessment of every patient's needs, regardless of the reason
for the encounter. Usually, an assessment framework, based
on a nursing model is used.
⢠The purpose of this stage is to identify the patient's nursing
problems. These problems are expressed as either actual or
potential. For example, a patient who has been rendered
immobile by a road traffic accident may be assessed as
having the "potential for impaired skin integrity related to
immobility".
57. Components of a nursing
assessment
⢠Biographic data â name, address, age, sex, martial
status, occupation, religion.
⢠Reason for visit/Chief complaint â primary reason why
client seek consultation or hospitalization.
⢠History of present Illness â includes: usual health
status, chronological story, family history, disability
assessment.
⢠Past Health History â includes all previous
immunizations, experiences with illness.
⢠Family History â reveals risk factors for certain disease
diseases (Diabetes, hypertension, cancer, mental
illness).
58. Components of a nursing
assessment
⢠Review of systems â review of all health problems by
body systems
⢠Lifestyle â include personal habits, diets, sleep or rest
patterns, activities of daily living, recreation or hobbies.
⢠Social data â include family relationships, ethnic and
educational background, economic status, home and
neighborhood conditions.
⢠Psychological data â information about the clientâs
emotional state.
⢠Pattern of health care â includes all health care
resources: hospitals, clinics, health centers, family
doctors.
59. Psychological And Social
Examination
⢠Clientâs perception (why they think they have been referred/are
being assessed; what they hope to gain from the meeting)
⢠Emotional health (mental health state, coping styles etc)
⢠Social health (accommodation, finances, relationships, genogram,
employment status, ethnic back ground, support networks etc)
⢠Physical health (general health, illnesses, previous history,
appetite, weight, sleep pattern, diurinal variations, alcohol,
tobacco, street drugs; list any prescribed medication with
comments on effectiveness)
60. Psychological And Social
Examination
⢠Spiritual health (is religion important? If so, in what way?
What/who provides a sense of purpose?)
⢠Intellectual health (cognitive functioning, hallucinations,
delusions, concentration, interests, hobbies etc
61. Physical examination
⢠A nursing assessment includes a physical examination: the
observation or measurement of signs, which can be
observed or measured, or symptoms such as nausea or
vertigo, which can be felt by the patient.
⢠The techniques used may include Inspection, Palpation,
Auscultation and Percussion in addition to the "vital signs"
of temperature, blood pressure, pulse and respiratory rate,
and further examination of the body systems such as the
cardiovascular or musculoskeletal systems.
62. Documentation of the
assessment
The assessment is documented in the
patient's medical or nursing records, which
may be on paper or as part of the electronic
medical record which can be accessed by all
members of the healthcare team.
63. Assessment tools
The index of independence in activities of daily living
⢠Activities of daily living (ADLs) are "the things we
normally do in daily living including any daily activity we
perform for self-care (such as feeding ourselves, bathing,
dressing, grooming), work, homemaking, and leisure."
64. The Barthel index
The Barthel Index consists of 10 items that measure a person's
daily functioning specifically the activities of daily living and
mobility. The items include feeding, moving from wheelchair to
bed and return, grooming, transferring to and from a toilet,
bathing, walking on level surface, going up and down stairs,
dressing, continence of bowels and bladder.
65. Patient Name: __________________ Rater: ____________________
Date: / / :
Activity Score
Feeding
0 = unable
5 = needs help cutting, spreading butter, etc., or requires 0 5 10
modified diet
10 = independent
Bathing
0 = dependent 0 5
5 = independent (or in shower)
Grooming
0 = needs to help with personal care 0 5
5 = independent face/hair/teeth/shaving (implements provided)
Dressing
0 = dependent
0 5 10
5 = needs help but can do about half unaided
10 = independent (including buttons, zips, laces, etc.)
Bowels
0 = incontinent (or needs to be given enemas)
0 5 10
5 = occasional accident
10 = continent
66. Bladder
0 = incontinent, or catheterized and unable to manage alone
0 5 10
5 = occasional accident
10 = continent
Toilet Use
0 = dependent
0 5 10
5 = needs some help, but can do something alone
10 = independent (on and off, dressing, wiping)
Transfers (bed to chair and back)
0 = unable, no sitting balance
5 = major help (one or two people, physical), can sit 0 5 10 15
10 = minor help (verbal or physical)
15 = independent
Mobility (on level surfaces)
0 = immobile or < 50 yards
5 = wheelchair independent, including corners, > 50 yards 0 5 10 15
10 = walks with help of one person (verbal or physical) > 50 yards
15 = independent (but may use any aid; for example, stick) > 50 yards
Stairs
0 = unable
0 5 10
5 = needs help (verbal, physical, carrying aid)
10 = independent
TOTAL (0 - 100) ________
67. ContâŚ..
⢠The general health questionnaire
⢠Mental health status examination
The Mental Status Exam (MSE) is a series of questions and
observations that provide a snapshot of a client's current mental,
cognitive, and behavioural condition.
69. Conclusion
Assessment is the first and most critical step of
nursing process. Accuracy of assessment data affects all
other phases of the nursing process. A complete data
base of both subjective and objective data allows the
nurse to formulate nursing diagnosis, develop client goals,
and intervenes to promote heath and prevent disease.