The nursing process document describes the steps of the nursing process which includes assessment, nursing diagnosis, planning, implementation, and evaluation. It defines assessment as the systematic collection of data and identifies the main components and purposes of assessment. The key types of assessment are also outlined which include initial, problem-focused, emergency, and time-lapsed assessments.
The document provides an overview of the nursing process, which is defined as a systematic, organized method of planning and providing quality, individualized nursing care. It discusses the evolution of the nursing process from a 3-step model to the currently used 6-step model of assessment, diagnosis, outcome identification, planning, implementation, and evaluation. Each step is then described in more detail, with assessment discussed as the first step of collecting both subjective and objective data on the client. Diagnosis is defined as identifying the client's health problems based on the assessment data. Outcome identification involves formulating measurable goals for the client.
The series of questions provided would likely occur during the "Gathering information about the patient's chief concerns" phase of a patient-centered interview. The questions are gathering specific details about the patient's diet and weight, which are important concerns to assess. Setting the stage would involve introducing oneself and explaining the purpose of the interview. Collecting the assessment involves gathering additional assessment data through physical exam or tests. Termination involves concluding the interview.
The nursing process is a systematic, evidence-based framework for planning and providing nursing care. It consists of 5 interrelated phases: assessment, diagnosis, planning, implementation, and evaluation. During assessment, nurses collect comprehensive patient data through health histories, physical exams, and diagnostic tests. This data forms the basis for nursing diagnoses, which identify actual or potential patient problems. Goals and interventions are then planned and implemented to address these diagnoses. Implementation involves providing planned care and ongoing reassessment of patient responses and needs. The nursing process allows nurses to deliver holistic, individualized care through problem-solving and evaluation.
The document discusses health assessment and the nursing process. It defines health using the WHO definition and describes the health triangle consisting of physical, social, and mental health. It then explains the nursing process as a 5 step problem-solving approach and notes that assessment is the first step where nurses collect data through observation, interviewing, and examination to identify client needs and problems. Finally, it outlines the importance of health assessment for establishing a baseline, identifying issues, planning care, and evaluating outcomes.
The document provides information on health assessment in nursing. It defines health assessment as a systematic process by which a nurse collects and analyzes subjective and objective data on a client's health status through interaction with the client and other providers. The data collection involves observation, interviews, physical exams, and intuition. The purposes of assessment include establishing a health baseline, identifying health issues and needed care/treatments, and developing a holistic understanding of the client. The nursing process framework is also described, which involves assessment, nursing diagnosis, planning, implementation, and evaluation steps to provide individualized client care.
nursing process is the base or heart of complete nursing and nursing process gives the framework for the nurses in giving care to the patient the knowledge of nursing process is must to become a licensed nurse or to practice nursing this ppt give nurses a brief idea what all thing are including in nursing process and to determine efficiency, knowledge, skills and attitude of personnel and can make best use of their skills into clinical practice.
Critical thinking in nursing involves using a systematic nursing process of assessment, nursing diagnosis, planning, implementation, and evaluation. Nurses collect and analyze data to identify client health problems and formulate diagnoses. Goals and interventions are then planned and implemented, with outcomes evaluated to determine if goals were met and care should be continued, modified, or discontinued. This nursing process framework guides nursing practice and requires ongoing critical thinking.
The document provides an overview of the nursing process, which is defined as a systematic, organized method of planning and providing quality, individualized nursing care. It discusses the evolution of the nursing process from a 3-step model to the currently used 6-step model of assessment, diagnosis, outcome identification, planning, implementation, and evaluation. Each step is then described in more detail, with assessment discussed as the first step of collecting both subjective and objective data on the client. Diagnosis is defined as identifying the client's health problems based on the assessment data. Outcome identification involves formulating measurable goals for the client.
The series of questions provided would likely occur during the "Gathering information about the patient's chief concerns" phase of a patient-centered interview. The questions are gathering specific details about the patient's diet and weight, which are important concerns to assess. Setting the stage would involve introducing oneself and explaining the purpose of the interview. Collecting the assessment involves gathering additional assessment data through physical exam or tests. Termination involves concluding the interview.
The nursing process is a systematic, evidence-based framework for planning and providing nursing care. It consists of 5 interrelated phases: assessment, diagnosis, planning, implementation, and evaluation. During assessment, nurses collect comprehensive patient data through health histories, physical exams, and diagnostic tests. This data forms the basis for nursing diagnoses, which identify actual or potential patient problems. Goals and interventions are then planned and implemented to address these diagnoses. Implementation involves providing planned care and ongoing reassessment of patient responses and needs. The nursing process allows nurses to deliver holistic, individualized care through problem-solving and evaluation.
The document discusses health assessment and the nursing process. It defines health using the WHO definition and describes the health triangle consisting of physical, social, and mental health. It then explains the nursing process as a 5 step problem-solving approach and notes that assessment is the first step where nurses collect data through observation, interviewing, and examination to identify client needs and problems. Finally, it outlines the importance of health assessment for establishing a baseline, identifying issues, planning care, and evaluating outcomes.
The document provides information on health assessment in nursing. It defines health assessment as a systematic process by which a nurse collects and analyzes subjective and objective data on a client's health status through interaction with the client and other providers. The data collection involves observation, interviews, physical exams, and intuition. The purposes of assessment include establishing a health baseline, identifying health issues and needed care/treatments, and developing a holistic understanding of the client. The nursing process framework is also described, which involves assessment, nursing diagnosis, planning, implementation, and evaluation steps to provide individualized client care.
nursing process is the base or heart of complete nursing and nursing process gives the framework for the nurses in giving care to the patient the knowledge of nursing process is must to become a licensed nurse or to practice nursing this ppt give nurses a brief idea what all thing are including in nursing process and to determine efficiency, knowledge, skills and attitude of personnel and can make best use of their skills into clinical practice.
Critical thinking in nursing involves using a systematic nursing process of assessment, nursing diagnosis, planning, implementation, and evaluation. Nurses collect and analyze data to identify client health problems and formulate diagnoses. Goals and interventions are then planned and implemented, with outcomes evaluated to determine if goals were met and care should be continued, modified, or discontinued. This nursing process framework guides nursing practice and requires ongoing critical thinking.
The document discusses the nursing process and standards of practice in mental health nursing. It describes the six steps of the nursing process as assessment, diagnosis, outcome identification, planning, implementation, and evaluation. It outlines the six standards of practice for psychiatric-mental health nurses and what they entail, such as collecting comprehensive health data, analyzing data to determine diagnoses, identifying expected outcomes, developing a plan to achieve outcomes, implementing interventions, and evaluating progress. The nursing process is used to provide quality client care through critical thinking and problem solving.
Nursing process (fundamental of nursing)romanajavaid
Nursing process is systematic frame work to provide quality care to patients in which nurses learned how to assess,make nursing diagnose,plan ,implementation and evaluation.
The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective
The nursing process document describes the steps of the nursing process and how it is used to plan and provide individualized patient care. It outlines the 6 main steps as assessment, diagnosis, planning, implementation, evaluation, and reassessment. Assessment involves collecting both subjective and objective patient data to develop an understanding of their health status. This data is then analyzed during diagnosis to identify any health problems or needs. The following steps of planning, implementation, and evaluation are used to create a care plan and provide nursing interventions to address the identified needs and problems. The nursing process is cyclic and repeated to allow for continuous reassessment and adaptation of the care plan based on the patient's changing condition.
The Nursing Process is a framework that helps organize and deliver nursing care through five main steps: assessment, nursing diagnosis, planning, implementation, and evaluation. It provides an orderly and systematic method for planning and providing care, enhances nursing efficiency, and increases care quality. During the assessment step, nurses gather both subjective and objective data on the client's health history, current status, and potential problems through various sources like interviews, examinations, and record reviews. This comprehensive data collection helps identify client needs and priorities to guide the development of the subsequent nursing diagnosis and care plan.
1. The document discusses the nursing process and its key steps: assessment, nursing diagnosis, planning, implementation, and evaluation. It emphasizes that critical thinking is essential for each step.
2. Key aspects of critical thinking discussed include reflection, intuition, problem-solving, decision-making, and developing critical thinking skills and attitudes.
3. The nursing process provides a systematic framework for nurses to gather data, analyze it, identify issues, design goals and interventions, take action, and evaluate outcomes. It requires ongoing assessment, modification of the care plan as needed, and reevaluation until goals are met.
nursing process . In nursing management.TulsiDhidhi1
The document discusses the nursing process, which is a problem-solving framework used by nurses to provide patient-centered care. It includes assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment involves collecting subjective and objective data about a patient. Nursing diagnosis identifies patient problems/needs. Planning develops goals and interventions. Implementation puts the plan into action. Evaluation assesses progress towards goals and effectiveness of the nursing process. The nursing process provides structure for delivering care and problem-solving to achieve optimal patient outcomes.
The course deals with concepts, principles and techniques of health assessment, including history taking, physical examination, psychosocial assessment and interpreting laboratory findings to determine nursing diagnoses across the lifespan. The course outline covers the nursing process, data collection, documentation, assessment techniques, vital signs, physical exams and diagnostic procedures. Students will learn to analyze health assessments, utilize the nursing process, demonstrate critical thinking and accurately collect, classify and document subjective and objective data.
The document introduces the nursing process, which includes assessment, nursing diagnosis, planning, implementation, and evaluation. It is a systematic approach to providing nursing care. The nursing process allows nurses to identify patient health problems, plan and provide interventions, and determine the effectiveness of the care.
The document discusses the nursing process, which is a systematic, client-centered method for structuring nursing care. It consists of five phases - assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment involves collecting client data, nursing diagnosis analyzes the data to identify client problems or strengths, planning develops goals and interventions, implementation carries out the interventions, and evaluation assesses outcome achievement. The nursing process provides an organized framework to guide nursing practice and ensure quality care.
The document defines and describes the nursing process, which includes assessment, nursing diagnosis, planning, implementation, and evaluation. It is a systematic, critical thinking process used by nurses to provide individualized care. Assessment involves collecting client data through various methods. Nursing diagnosis involves analyzing the data to identify actual or potential health problems. Planning establishes goals and selects interventions. Implementation involves applying the interventions. Evaluation assesses client progress and intervention effectiveness.
The document discusses the key concepts and steps of the nursing process, including assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment involves collecting, organizing, validating, and documenting data about the client's health concerns. Nursing diagnosis identifies actual, risk, wellness, possible, or syndrome diagnoses by analyzing data and formulating diagnostic statements. Planning determines how to prevent, reduce, or resolve identified client problems by developing an individualized care plan with goals and nursing interventions.
The document outlines the nursing process, which consists of assessment, planning, implementation, and evaluation. It describes the assessment phase in detail. Assessment involves collecting both subjective and objective data through various methods like observation, interview, and examination. The nurse organizes, validates, and documents the collected data to identify the patient's health status, problems, and needs in order to develop an appropriate care plan.
The document discusses the nursing process and assessment. It describes assessment as the first step of the nursing process, which involves systematically collecting, organizing, validating, and documenting data about a patient's physical, psychological, and functional status. This includes both subjective data obtained from the patient and objective data obtained through examination. The key aspects of assessment are data collection through methods like observation, interviewing, and examination; organizing and analyzing the data; validating its accuracy and completeness; and documenting the findings in the patient's record.
The document discusses the nursing process, which is a systematic method for planning and providing nursing care. It outlines the key steps as assessment, diagnosis, planning, implementation, and evaluation. Assessment involves collecting both subjective and objective data from various sources like the client, family, and medical records. This data is then organized, interpreted, and documented. The nursing diagnosis phase further analyzes the collected data to identify any actual or potential health problems nurses can address. The overall nursing process provides structure to nursing care and allows for continuity and quality of care.
The document discusses the nursing process, which includes 5 components: assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment involves systematically collecting client data through various methods like observation, interviews, and examinations. This data is then organized using frameworks like Gordon's functional health patterns or Orem's self-care model. The data is validated by double checking for accuracy and documented in the client's record. The nursing process provides a systematic approach to planning and delivering nursing care.
PART A - ASSESSMENT Nursing foundation I semSuji236384
This document provides an overview of the nursing process and assessment phase. It defines the nursing process as a systematic method of planning and providing individualized care through identifying health needs, establishing care plans, and evaluating outcomes. Assessment is the first phase and involves systematically collecting subjective and objective data about a client's health status and needs. Various methods of data collection are described, including observation, interviews, physical exams, and documentation in the client's record. The assessment phase aims to gather complete and accurate information to identify client problems and needs to inform the following phases of the nursing process.
The document discusses the nursing process, which is a systematic, cyclic framework for providing quality nursing care. It consists of 5 steps: assessment, diagnosis, planning, implementation, and evaluation. Assessment involves collecting client data from various sources. Diagnosis identifies actual or potential nursing problems. Planning establishes goals and interventions. Implementation carries out planned interventions. Evaluation determines if goals were met and identifies need for re-planning. The nursing process framework guides nursing practice across all settings and specialties.
The document discusses the nursing process, which consists of 5 phases - assessment, diagnosis, planning, implementation, and evaluation. Assessment involves collecting client data through various methods. Diagnosis involves analyzing the data to identify client health problems or risks. Planning develops goals and interventions. Implementation involves carrying out the planned interventions. Evaluation assesses client outcomes and the effectiveness of the nursing care. The nursing process provides a systematic way for nurses to problem solve and provide individualized care for clients.
This document discusses strategies for preventing infections in the neonatal intensive care unit (NICU). Neonates are at high risk of infection due to prematurity, low birth weight, and frequent invasive procedures. Common infections include central line-associated bloodstream infections, pneumonia, and neonatal sepsis. Infections can lead to longer hospital stays, higher treatment costs, and neurological impairments. The document recommends proper location and design of the NICU, strict hand hygiene, limiting visitors and following isolation procedures. Other strategies include optimizing staffing, following infection control policies, judicious antibiotic use, proper catheter and skin care, and promoting breast milk feeding which prevents infections. Regular environmental monitoring and staff education are also important to prevent infections
The document discusses the nursing process and standards of practice in mental health nursing. It describes the six steps of the nursing process as assessment, diagnosis, outcome identification, planning, implementation, and evaluation. It outlines the six standards of practice for psychiatric-mental health nurses and what they entail, such as collecting comprehensive health data, analyzing data to determine diagnoses, identifying expected outcomes, developing a plan to achieve outcomes, implementing interventions, and evaluating progress. The nursing process is used to provide quality client care through critical thinking and problem solving.
Nursing process (fundamental of nursing)romanajavaid
Nursing process is systematic frame work to provide quality care to patients in which nurses learned how to assess,make nursing diagnose,plan ,implementation and evaluation.
The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective
The nursing process document describes the steps of the nursing process and how it is used to plan and provide individualized patient care. It outlines the 6 main steps as assessment, diagnosis, planning, implementation, evaluation, and reassessment. Assessment involves collecting both subjective and objective patient data to develop an understanding of their health status. This data is then analyzed during diagnosis to identify any health problems or needs. The following steps of planning, implementation, and evaluation are used to create a care plan and provide nursing interventions to address the identified needs and problems. The nursing process is cyclic and repeated to allow for continuous reassessment and adaptation of the care plan based on the patient's changing condition.
The Nursing Process is a framework that helps organize and deliver nursing care through five main steps: assessment, nursing diagnosis, planning, implementation, and evaluation. It provides an orderly and systematic method for planning and providing care, enhances nursing efficiency, and increases care quality. During the assessment step, nurses gather both subjective and objective data on the client's health history, current status, and potential problems through various sources like interviews, examinations, and record reviews. This comprehensive data collection helps identify client needs and priorities to guide the development of the subsequent nursing diagnosis and care plan.
1. The document discusses the nursing process and its key steps: assessment, nursing diagnosis, planning, implementation, and evaluation. It emphasizes that critical thinking is essential for each step.
2. Key aspects of critical thinking discussed include reflection, intuition, problem-solving, decision-making, and developing critical thinking skills and attitudes.
3. The nursing process provides a systematic framework for nurses to gather data, analyze it, identify issues, design goals and interventions, take action, and evaluate outcomes. It requires ongoing assessment, modification of the care plan as needed, and reevaluation until goals are met.
nursing process . In nursing management.TulsiDhidhi1
The document discusses the nursing process, which is a problem-solving framework used by nurses to provide patient-centered care. It includes assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment involves collecting subjective and objective data about a patient. Nursing diagnosis identifies patient problems/needs. Planning develops goals and interventions. Implementation puts the plan into action. Evaluation assesses progress towards goals and effectiveness of the nursing process. The nursing process provides structure for delivering care and problem-solving to achieve optimal patient outcomes.
The course deals with concepts, principles and techniques of health assessment, including history taking, physical examination, psychosocial assessment and interpreting laboratory findings to determine nursing diagnoses across the lifespan. The course outline covers the nursing process, data collection, documentation, assessment techniques, vital signs, physical exams and diagnostic procedures. Students will learn to analyze health assessments, utilize the nursing process, demonstrate critical thinking and accurately collect, classify and document subjective and objective data.
The document introduces the nursing process, which includes assessment, nursing diagnosis, planning, implementation, and evaluation. It is a systematic approach to providing nursing care. The nursing process allows nurses to identify patient health problems, plan and provide interventions, and determine the effectiveness of the care.
The document discusses the nursing process, which is a systematic, client-centered method for structuring nursing care. It consists of five phases - assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment involves collecting client data, nursing diagnosis analyzes the data to identify client problems or strengths, planning develops goals and interventions, implementation carries out the interventions, and evaluation assesses outcome achievement. The nursing process provides an organized framework to guide nursing practice and ensure quality care.
The document defines and describes the nursing process, which includes assessment, nursing diagnosis, planning, implementation, and evaluation. It is a systematic, critical thinking process used by nurses to provide individualized care. Assessment involves collecting client data through various methods. Nursing diagnosis involves analyzing the data to identify actual or potential health problems. Planning establishes goals and selects interventions. Implementation involves applying the interventions. Evaluation assesses client progress and intervention effectiveness.
The document discusses the key concepts and steps of the nursing process, including assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment involves collecting, organizing, validating, and documenting data about the client's health concerns. Nursing diagnosis identifies actual, risk, wellness, possible, or syndrome diagnoses by analyzing data and formulating diagnostic statements. Planning determines how to prevent, reduce, or resolve identified client problems by developing an individualized care plan with goals and nursing interventions.
The document outlines the nursing process, which consists of assessment, planning, implementation, and evaluation. It describes the assessment phase in detail. Assessment involves collecting both subjective and objective data through various methods like observation, interview, and examination. The nurse organizes, validates, and documents the collected data to identify the patient's health status, problems, and needs in order to develop an appropriate care plan.
The document discusses the nursing process and assessment. It describes assessment as the first step of the nursing process, which involves systematically collecting, organizing, validating, and documenting data about a patient's physical, psychological, and functional status. This includes both subjective data obtained from the patient and objective data obtained through examination. The key aspects of assessment are data collection through methods like observation, interviewing, and examination; organizing and analyzing the data; validating its accuracy and completeness; and documenting the findings in the patient's record.
The document discusses the nursing process, which is a systematic method for planning and providing nursing care. It outlines the key steps as assessment, diagnosis, planning, implementation, and evaluation. Assessment involves collecting both subjective and objective data from various sources like the client, family, and medical records. This data is then organized, interpreted, and documented. The nursing diagnosis phase further analyzes the collected data to identify any actual or potential health problems nurses can address. The overall nursing process provides structure to nursing care and allows for continuity and quality of care.
The document discusses the nursing process, which includes 5 components: assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment involves systematically collecting client data through various methods like observation, interviews, and examinations. This data is then organized using frameworks like Gordon's functional health patterns or Orem's self-care model. The data is validated by double checking for accuracy and documented in the client's record. The nursing process provides a systematic approach to planning and delivering nursing care.
PART A - ASSESSMENT Nursing foundation I semSuji236384
This document provides an overview of the nursing process and assessment phase. It defines the nursing process as a systematic method of planning and providing individualized care through identifying health needs, establishing care plans, and evaluating outcomes. Assessment is the first phase and involves systematically collecting subjective and objective data about a client's health status and needs. Various methods of data collection are described, including observation, interviews, physical exams, and documentation in the client's record. The assessment phase aims to gather complete and accurate information to identify client problems and needs to inform the following phases of the nursing process.
The document discusses the nursing process, which is a systematic, cyclic framework for providing quality nursing care. It consists of 5 steps: assessment, diagnosis, planning, implementation, and evaluation. Assessment involves collecting client data from various sources. Diagnosis identifies actual or potential nursing problems. Planning establishes goals and interventions. Implementation carries out planned interventions. Evaluation determines if goals were met and identifies need for re-planning. The nursing process framework guides nursing practice across all settings and specialties.
The document discusses the nursing process, which consists of 5 phases - assessment, diagnosis, planning, implementation, and evaluation. Assessment involves collecting client data through various methods. Diagnosis involves analyzing the data to identify client health problems or risks. Planning develops goals and interventions. Implementation involves carrying out the planned interventions. Evaluation assesses client outcomes and the effectiveness of the nursing care. The nursing process provides a systematic way for nurses to problem solve and provide individualized care for clients.
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This document discusses strategies for preventing infections in the neonatal intensive care unit (NICU). Neonates are at high risk of infection due to prematurity, low birth weight, and frequent invasive procedures. Common infections include central line-associated bloodstream infections, pneumonia, and neonatal sepsis. Infections can lead to longer hospital stays, higher treatment costs, and neurological impairments. The document recommends proper location and design of the NICU, strict hand hygiene, limiting visitors and following isolation procedures. Other strategies include optimizing staffing, following infection control policies, judicious antibiotic use, proper catheter and skin care, and promoting breast milk feeding which prevents infections. Regular environmental monitoring and staff education are also important to prevent infections
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2. • Nursing process is a systematic method of
providing care to clients.
• The nursing process is a systematic
method of planning and providing
individualized nursing care.
NURSING PROCESS
3. NURSING PROCESS
Purposes of nursing process
• To identify a client’s health status and
actual or potential health care
problems or needs.
• To establish plans to meet the
identified needs.
• To deliver specific nursing
interventions to meet those needs.
4. Components of nursing process:
The nursing process consists of five dynamic and
interrelated phases:
1. Assessment
2. diagnosis
3. planning
4. implementation
5. evaluation.
7. Definition
Assessment is the systematic and
continuous collection, organization,
validation, and documentation of
data (information).
NURSING ASSESSMENT
Assessment – First Step in the Nursing Process
8. The purposes of Assessment is
• To validate a diagnosis
• To provide basis for effective nursing care.
• It helps in effective decision making
• Basis for accurate diagnosis
• It promote holistic nursing care
• To collecting data for nursing research
• To evaluation of nursing care
PURPOSE OF
ASSESSMENT
9. The four different types of assessments
are;
1. Initial nursing assessment
2. Problem-focused assessment
3. Emergency assessment
4. Time-lapsed reassessment
Types of assessment
10. 1. Initial nursing assessment:
Performed within specified time after admission,
To establish a complete database for problem
identification.
EG:-
• Patient history
• General appearance
• physical examination
• Vital signs (HR, TEMP, RR, BP, AND PAIN).
Types of assessment
11. Problem Focus 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
Types of assessment
12. Emergency Assessments
• During emergency procedures, a nurse is focused
on rapidly identifying the root causes of concern
for the patient and assessing the airway,
breathing and circulation (ABCs) of the patient.
• Once the ABCs are stabilized, the emergency
assessment may turn into an initial or focused
assessment, depending on the situation.
Types of assessment
13. Time-Lapsed Assessment
• Time-lapsed assessment – reassessment of
client’s functional health pattern done
several months after initial assessment to
compare the client’s current status to
baseline data previously obtained
• The time-lapsed assessment may also
include lab work, X-rays or other diagnostic
medical testing
Types of assessment
16. Collect Data
Data collection is the process of gathering
information about a client’s health status.
Includes:
• physical, psychological, emotion, socio-cultural,
spiritual factors that may affect client’s health
status
• includes past health history of client (allergies,
past surgeries, chronic diseases, use of folk
healing methods)
• includes current/present problems of client
(pain, nausea, sleep pattern, meds or treatment
the client is taking now)
17. 1.Subjective data
• also referred to as Symptom/Covert data
• Information from the client’s point of view or are
described by the person experiencing it.
• Information supplied by family members, significant
others; other health professionals are considered
subjective data.
• Example: pain, dizziness, Itching and feelings of
worry
2.Objective data
• also referred to as Sign/Overt data
• Those that can be detected observed or
measured/tested using accepted standard or norm.
• Example: diaphoresis, BP=150/100, yellow
discoloration of skin
Types of Data Collection
18. 1.Interview
• A planned, purposeful conversation/communication with the client
to get information, identify problems, evaluate change, to teach,
or to provide support or counseling.
• it is used while taking the nursing history of a client
2.Observation
• Use to gather data by using the 5 senses and instruments.
3.Examination
• Systematic data collection to detect health problems using unit of
measurements, physical examination techniques (IPPA),
interpretation of laboratory results.
• should be conducted systematically:
a. Cephalocaudal approach – head-to-toe assessment
b. Body System approach – examine all the body system
c. Review of System approach – examine only particular area
affected
Methods of Data Collection
19. A.Primary source – data directly gathered from
the client using interview and physical
examination.
B.Secondary source – data gathered from client’s
family members, significant others, client’s
medical records/chart, and other members of
health team.
• In the Assessment Phase, obtain a Nursing
Health History – a structured interview
designed to collect specific data and to obtain
a detailed health record of a client.
SOURCE OF DATA
20. COMPONENTS OF A NURSING HEALTH HISTORY:
• Biographic data – name, address, age, sex, martial status,
occupation, religion.
• Reason for visit/Chief complaint – primary reason why client seek
consultation or hospitalization.
• History of present Illness – includes: usual health status,
chronological story, family history, disability assessment.
• Past Health History – includes all previous immunizations,
experiences with illness.
• Family History – reveals risk factors for certain disease diseases
(Diabetes, hypertension, cancer, mental illness).
• Review of systems – review of all health problems by body systems
• Lifestyle – include personal habits, diets, sleep or rest patterns,
activities of daily living, recreation or hobbies.
• Social data – include family relationships, ethnic and educational
background, economic status, home and neighborhood conditions.
• Psychological data – information about the client’s emotional state.
• Pattern of health care – includes all health care resources: hospitals,
clinics, health centers, family doctors.
23. 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.
26. Validation of Data
• The act of “double-checking” or verifying data to
confirm that it is accurate and complete.
Purposes of data validation
1.ensure that data collection is complete
2.ensure that objective and subjective data agree
3.obtain additional data that may have been overlooked
4.avoid jumping to conclusion
Validation of Data
27. • Recheck your own data through a repeat assessment. For example,
take the client’s 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,
• 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
“never gets any time in the sun” yet has dark, wrinkled, suntanned
skin, you need to validate the client’s perception of never getting
any time in the sun
METHODS OF VALIDATION
30. • 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.
DOCUMENTING DATA
33. • Nursing Diagnosis is the second Step of
nursing process.
• In this phase, nurses use critical thinking skills
to interpret assessment data to identify client
problems.
• North American Nursing Diagnosis Association
(NANDA) define or refine nursing diagnosis.
NURSING DIAGNOSIS
Purpose
•To identify health care needs and prepare a
Nursing Diagnosis.
•It means to analyze assessment
information and derive meaning from this
analysis
34. Three Activities in Diagnosing:
1.Data Analysis
2.Problem Identification
3.Formulation of Nursing Diagnosis
Characteristics of Nursing Diagnosis
1. It states a clear and concise health
problem.
2. It is derived from existing evidences
about the client.
3. It is potentially amenable to nursing
therapy.
4. It is the basis for planning and carrying
out nursing care.
35. COMPONENTS OF A NANDA
NURSING DIAGNOSIS
A nursing diagnosis has three components:
(1) The problem and its definition
(2) The etiology
(3) The defining characteristics.
36. • The problem statement describes the
client’s health problem.
• The etiology component of a nursing
diagnosis identifies causes of the health
problem.
• Defining characteristics are the cluster
of signs and symptoms that indicate the
presence of health problem.
COMPONENTS OF A NANDA NURSING
DIAGNOSIS
37. Types of Nursing Diagnoses
Actual Nursing Diagnosis – a client problem that is
present at the time of the nursing assessment. It is
based on the presence of signs and symptoms
Examples:
1.Imbalanced Nutrition: Less than body requirements r/t
decreased appetite nausea.
2.Disturbed Sleep Pattern r/t cough, fever and pain.
3.Constipation r/t long term use of laxative.
4.Ineffective airway clearance r/t to viscous secretions
5.Noncompliance (Medication) r/t unknown etiology
6.Noncompliance (Diabetic diet) r/t unresolved anger
about Diagnosis
7.Acute Pain (Chest) r/t cough 2nrdary to pneumonia
8.Activity Intolerance r/t general weakness.
9.Anxiety r/t difficulty of breathing & concerns over work
38. 1. Potential Nursing diagnosis – one in which
evidence about a health problem is incomplete or
unclear therefore requires more data to support or
reject it; or the causative factors are unknown but a
problem is only considered possible to occur
Examples:
• Possible nutritional deficit
• Possible low self-esteem r/t loss job
• Possible altered thought processes r/t unfamiliar
surroundings
Types of Nursing Diagnoses
39. 1. Risk Nursing diagnosis – is a clinical judgment that a
problem does not exist, therefore no S/S are present, but
the presence of RISK FACTORS is indicates that a problem is
only is likely to develop unless nurse intervene or do
something about it. No subjective or objective cues are
present therefore the factors that cause the client to be more
vulnerable to the problem are the etiology of a risk nursing
Diagnosis Examples:
a. Risk for Impaired skin integrity (left ankle) r/t decrease
peripheral circulation in diabetes.
b. Risk for interrupted family processes r/t mother’s illness &
unavailability to provide child care.
c. Risk for Constipation r/t inactivity and insufficient fluid
intake
d. Risk for infection r/t compromised immune system.
e. Risk for injury r/t decreased vision after cataract surgery.
Types of Nursing Diagnoses
40. Formulating a Nursing
Diagnosis
1. Actual nursing diagnosis = Patient problem +
Etiology – replace the (+) symbol with the
words “RELATED TO” abbreviated as r/t. =
Problem + Etiology + S/S
2. Risk Nursing diagnosis = Problem + Risk
Factors
3. Possible nursing diagnosis = Problem +
Etiology
41. Acute pain related to abdominal surgery
as evidenced by patient discomfort and
pain scale.
Problem Etiology Signs and
symptoms
Pain Surgery of
abdomen
Pain scale
and
discomfort of
patient
42. Situation: Functional Health Pattern –
Activity/Exercise
• fadumo, 35 years of laundry woman seeks
consultation at the Manhal Hospital due to fever
2 days prior to admission She verbalizes: “(“I
suddenly felt cold, headache and warm after I
done laundry”). She has 3 children she walks off
to school everyday before she goes to work
43. Vital Signs
• Temperature (T) =39.2°C Respiratory Rate (RR)
= 35 P = 96; with flush skin and warm to touch,
teary eyed and with dry lips and mucous
membrane.
Nursing Diagnosis
• Hyperthermia [related to (r/t)] environmental
condition AMB T = 39°C, flush skin, warm to touch,
teary eyed and dry lip and mucous membrane.
44. Situation: Functional Health Pattern = Nutritional
1. States, “No appetite since having cough”
2. Has not eaten today; last fluids at noon today
3. Has lost 8 lbs in past 2 weeks
4. Nauseated x 2 days
Nursing Diagnosis
• Imbalanced Nutrition: Less than body Requirements
r/t decreased appetite and nausea 2ndary to disease
process/cough
45. Situation: Functional Health Pattern Activity/Exercise
1. Difficulty sleeping because of cough
2. States, “Can’t breath lying down”
3. Report pain on chest when coughing
Nursing Diagnosis
• Disturbed Sleep Pattern r/t a disease process,
orthopnea and pain.
• Acute Pain (chest) r/t pathologic condition 2ndary
to pneumonia
46. Situation: Functional Health Pattern = Stress
1. Anxious
2. State, “I can’t breath”
3. Facial muscles tense, trembling
4. Expresses concern and worry over leaving
daughter with neighbors
5. Husband out of town, will be back next
week.
Nursing Diagnosis
• Anxiety r/t difficulty of breathing and
concerns over parenting roles.
47.
48.
49. Mang Teban is a 73-year old patient diagnosed with
pneumonia. Which data would be of greatest concern to the
nurse when completing the nursing assessment of the
patient?
A.Alert and oriented to date, time, and place
B. Buccal cyanosis and capillary refill greater than 3 seconds
C. Clear breath sounds and nonproductive cough
D.Hemoglobin concentration of 13 g/dl and leukocyte count
5,300/mm3
50. 1.Nursing diagnosis is the
A.First step of Nursing process
B.Last step of Nursing process
C.Second step of Nursing process
D.Third step of Nursing process
The correct answer is C
51. 1.Components of nursing process include
except
A.Nursing diagnosis
B.Nursing planning
C.Nursing evaluation
D.Medical diagnosis
The correct answer is D
52. 1.If the first method of Nursing Process is
nursing assessment, what is the second
method?
A.Nursing diagnosis
B.NR planning
C.NR Evaluation
D.Nursing intervention
The correct answer is A
53. 1.Components of a Nursing Diagnosis. Select all that
apply
A. planning
B. Data clustering
C. Contributing, etiologic or related factors
D. None of the above
The correct answer is C
54. 1.Which of the following are true regarding nursing
diagnosis?
A. Nurses Use Critical Thinking Skills To
Interpret Assessment Data To Identify
Client Problems.
B. First Step Of Nursing Process
C. A Nursing Diagnosis Is The Planning Of Pts
Care
D. Nursing Diagnosis And Nursing Intervention
Are Same
The correct answer is A
55. 1.Assessment is the
A.first step of nursing process
B.last step of nursing process
C.second step of nursing process
D.third step of nursing process
The correct answer is A