HEALTH ASSESSMENT Subjective – from the client (symptom)
- Health Assessment is an essential nursing function Objective – observable data (sign)
which provides foundation for quality nursing care THE FOUR BASIC TYPES OF ASSESMENT
and interventions. - Initial comprehensive assessment
- The first step of the Nursing Process - Focused or problem-oriented assessment
- The most important because it DIRECTS the rest of - Time-lapsed assessment
the process. - Emergency assessment
- A thinking, doing, and feeling process – THINK as you INITIAL COMPREHENSIVE ASSESSMENT
ACT and interact with patients. - Also called as triage, the initial assessment’s purpose
- Think critically as you go with the process is to determine the origin and nature of the problem
- Learning the normal and to use that information to prepare for the next
- Identify the normal and differentiate it from the assessment stages.
abnormal. - It usually consists of getting the patient’s medical
- Will USE in every area of nursing. history and performing a physical exam on them.
NURSING PROCESS - May include recording the patient’s vital signs and
- Is a systematic, organized method of planning, and look for symptoms that may be sign of an underlying
providing quality and individualized nursing care. condition.
- Specific to the nursing profession FOCUSED ASSESSMENT
- A framework for critical thinking (A.D.P.I.E.) - After the initial assessment, the medical issue is fully
- Its purpose is to: “Diagnose and treat human exposed and treated in the focused assessment
responses to actual or potential health problems” phase.
- Organized framework to guide practice - The focused assessment also involves relieving the
- Problem solving method patient from pain and stabilizing their condition,
- Systematic when needed.
- Goal oriented TIME-LAPSED ASSESSMENT
- Dynamic-always changing, flexible - After the medical condition is properly diagnosed and
- Utilizes critical thinking processes a treatment plan is implemented, the time-lapsed
- Universally applicable assessment is conducted to evaluate how the patients
- Client-centered reacts to the agreed treatment plan and how their
- Interpersonal and collaborative condition is evolving.
ADVANTAGES OF NURSING PROCESS EMERGENCY ASSESSMENT
- Provides individualized care - The emergency assessment is performed during
- Clients is an active participant emergency procedures, when it is crucial to evaluate
- Promotes continuity of care the patient’s airway, breathing and circulation, as well
- Provides more effective communication among as the exact cause of the problem.
nurses and healthcare professionals SCIENTIFIC METHOD OF PROBLEM SOLVING
- Develops a clear and efficient plan of care - ID problem
- Provides personal satisfaction as you see client - Collect data
achieve goals - Form hypothesis
- Professional growth as you evaluate effectiveness of - Plan of action
your interventions - Hypothesis testing
NURSING PROCESS INVOLVED: - Interpret results
CRITICAL THINKING - must use with logical thinking - Evaluate findings
PROBLEM SOLVING - analyze ASSESMENT- COLLECTING DATA
DECISION MAKING - make choices - Nursing interview (history)
PHASES OF NURSING PROCESS - Health assessment – review of systems
Assessment (A) - Physical exam: Inspection, Palpation, Percussion,
Nursing Diagnosis (D) Auscultation
Planning (P) - Make sure information is complete and accurate
Implementing (I) - Organize and cluster data
Evaluating (E) - Interpret and analyze data compare to “standard
ASSESSMENT norms”
- Gather information about the client’s condition. - Validate prn (if/when necessary)
- The most important step 10 COMPONENTS OF NURSING HEALTH HISTORY
- Identifies your patient’s strengths and limitations and - Biographic data
is performed not just once, but continuously. - Chief complaint / Reason for visit
- First step of the nursing process. - History of present illness
- Gather information/collect data. - Past history / Past illness
Primary Source – client / family - Family history of illness
Secondary Source – physical exam, nursing history, team - Lifestyle
members, lab reports, diagnostic tests… - Social data
RMPM
, - Psychologic Data NURSING DIAGNOSIS
- Patterns of Healthcare - Second step of the nursing process
- Review of Systems - Interpret and analyze clustered data
BIOGRAPHIC DATA - Identify client’s problems and strengths
- Client’s name - Formulate Nursing Diagnosis (NANDA: North
- Age American Nursing Diagnosis Association) –
- Sex statement of how the client is RESPONDING to an
- Marital status actual or potential problem that requires nursing
- Occupation intervention.
- Religious affiliation DIAGNOSE
- Others (e.g. address, income, area, etc.) - Identify the client’s problems (through nursing
CHIEF COMPLAINT diagnosis NOT MEDICAL DIAGNOSIS).
- Why patient seek consultation DIFFERENCE BETWEEN NURSING DIAGNOSIS
- Chief complaint should be recorded in the client’s AND MEDICAL DIAGNOSIS
own words. NURSING DIAGNOSIS MEDICAL DIAGNOSIS
HISTORY OF PRESENT ILLNESS Within the scope of nursing Within the scope of medical
- Use CHRONOLOGIC story practice. practice.
- When the symptoms started
- Whether the onset of symptom was sudden or Identify responses to health Focuses on curing
gradual and illness. pathology.
- How often the problem occurs
- Exact location of distress Can change from day to day. Stays the same as long as
- Character of complaint the disease is present.
- Activity in which the client was involved when the
problem occurred TYPES OF NURSING DIAGNOSIS
- Aggravating factors - Problem-focused (actual) Nursing diagnosis
PAST HISTORY - Risk Nursing diagnosis
- Childhood illness - Syndrome Nursing diagnosis
- Immunization - Health Promotion Nursing Diagnosis
- Allergies PROBLEM-FOCUSED NURSING DIAGNOSIS
- Accidents and injuries - AKA “actual diagnosis”
- Hospitalization - Is a client problem that is present at the time of the
- Medication nursing assessment.
FAMILY HISTORY OF ILLNESS - P.E.S. FORMULA (Problem, Etiology, Signs &
MOTHER FATHER Symptoms)
(+) HPN (-) HPN BASIS FOR STANDARD NURSING DIAGNOSIS
(-) DM (-) DM (NANDA-I)
(-) PTB (+) PTB - North
- American
LIFESTYLE - Nursing
- Personal habits - Diagnosis
- Diet - Association-International
- Sleep/rest patterns FORMULATING A NURSING DIAGNOSIS
- Activities of daily living (ADL) Composed of 3 parts: PED/PES format
- Recreation/hobbies Problem Statement
SOCIAL DATA - The client’s response to a problem.
- Family relationship Etiology
- Ethnic affiliation - What’s causing/contributing to the client’s problem.
- Education history
- Occupational history Defining Characteristics or S/S
- Economic status - What’s the evidence of the problem.
- Home and neighborhood conditions GUIDELINES FOR WRITING A NURSING DIAGNOSTIC
PSYCHOLOGIC DATA STATEMENT
- Major stressors - State in terms of problem, not a need or intervention.
- Usual coping patterns - Non-self incriminating.
- Communication style - Use non-judgmental statements.
PATTERNS OF HEALTH CARE - Both elements of the statement do not say the same
- The patient undergoes regular annual check-up thing.
through his HMO and he consults first his family - Cause and effect are correctly stated.
physician concerning his health. - Use nursing terminology rather than medical
terminology to describe the client’s response.
RMPM
, RISK NURSING DIAGNOSIS - The nurse uses clinical judgement and professional
- These are clinical judgement that a problem does not knowledge to select appropriate interventions that
exist, but the presence of risk factors indicates that a will aid the client in reaching their goal.
problem is likely to develop unless nurses intervene. - Interventions should be written clearly and
HEALTH PROMOTION DIAGNOSIS specifically.
- AKA “Wellness diagnosis” Other factors in prioritizing your planning:
- Is a clinical judgement about motivation and desire to - Client’s health status
increase well - being. - Client’s priorities
SYNDROME NURSING DIAGNOSIS - Availability of resources
- Is used when a cluster of assessment findings or - Urgency of the health problem
nursing diagnosis occur together, showing a specific - Medical treatment plan
clinical pattern. INTERVENTION
- It can be actual or risk diagnosis - Perform the nursing actions identified in planning.
NANDA-I APPROVED SYNDROME DIAGNOSIS - - defined as any treatment based on clinical
- Disuse syndrome judgement and knowledge that a nurse performs to.
- Impaired environmental interpretation syndrome - Enhance patient outcomes
- Post-trauma syndrome - Putting the plan of care into action
- Relocation stress syndrome - Also called IMPLEMENTATION
- Rape trauma syndrome - Involves carrying out your plan to achieve goals and
- Sudden infant death syndrome outcomes
PLANNING - The “doing” phase
- Set goals of care and desired outcomes and identify TYPES OF INTERVENTIONS
appropriate nursing actions. INDEPENDENT
- Set the goal TOGETHER with the client. - (Nurse initiated) any action that the nurse can initiate
- If the client is unconscious set the goal with the or do without direct supervision.
clients significant other/family. DEPENDENT
Types of Goals: - (Physician initiated) nursing actions requiring doctors
LONG-TERM GOALS order.
- Objective behavior or response that you expect a COLLABORATIVE
patient to achieve over a more extended period, - Nursing action performed jointly with other health
usually over several days, weeks, or months. care team members.
SHORT-TERM GOALS NURSING INTERVENTION SHOULD BE:
- Objective behavior or response that you expect the - Safe and appropriate for the client’s age, health, and
patient to achieve in short time usually few hours or condition.
less than a week. - Achievable with the resources and time available.
PLANNING SHOULD BE: - In line with the client’s values, culture, and beliefs.
- Specific - In line with other therapies.
- Measurable - Based on nursing knowledge and experience or
- Attainable knowledge from relevant sciences.
- Realistic EVALUATION
- Time-bound - Determine if goals met and outcomes achieved.
PLANNING DEVELOPING - Evaluating is a planned, ongoing, purposeful activity
A GOAL AND OUTCOME STATEMENT in which the client’s progress towards achieving goals
- Goal and outcome statements are client focused or desired outcomes and the effectiveness of the
- Worded positively nursing care plan (NCP).
- Measurable, specific, observable, time-limited and - Evaluation is an essential aspect of the nursing
realistic process because conclusions drawn from this step
- Goal = broad statement determine whether the nursing intervention should
- Expected outcome = objective criterion for be terminated, continued, or changed.
measurement of goal - GOAL MET, GOAL PARTIALLY MET, GOAL UNMET
Types of Planning: COLLECTING SUBJECTIVE DATA
INITIAL - Is an integral part of interviewing the client to obtain
- Upon admission a nursing health history.
ONGOING Consist of:
- During confinement - Sensations or Symptoms
DISCHARGE - Feeling, Perceptions
- Before going home (MGH – may go home) - Desires, Preferences
PLANNING – SELECT INTERVENTION - Beliefs, Ideas
- Interventions are selected and written - Values
- Personal Information
RMPM
- Health Assessment is an essential nursing function Objective – observable data (sign)
which provides foundation for quality nursing care THE FOUR BASIC TYPES OF ASSESMENT
and interventions. - Initial comprehensive assessment
- The first step of the Nursing Process - Focused or problem-oriented assessment
- The most important because it DIRECTS the rest of - Time-lapsed assessment
the process. - Emergency assessment
- A thinking, doing, and feeling process – THINK as you INITIAL COMPREHENSIVE ASSESSMENT
ACT and interact with patients. - Also called as triage, the initial assessment’s purpose
- Think critically as you go with the process is to determine the origin and nature of the problem
- Learning the normal and to use that information to prepare for the next
- Identify the normal and differentiate it from the assessment stages.
abnormal. - It usually consists of getting the patient’s medical
- Will USE in every area of nursing. history and performing a physical exam on them.
NURSING PROCESS - May include recording the patient’s vital signs and
- Is a systematic, organized method of planning, and look for symptoms that may be sign of an underlying
providing quality and individualized nursing care. condition.
- Specific to the nursing profession FOCUSED ASSESSMENT
- A framework for critical thinking (A.D.P.I.E.) - After the initial assessment, the medical issue is fully
- Its purpose is to: “Diagnose and treat human exposed and treated in the focused assessment
responses to actual or potential health problems” phase.
- Organized framework to guide practice - The focused assessment also involves relieving the
- Problem solving method patient from pain and stabilizing their condition,
- Systematic when needed.
- Goal oriented TIME-LAPSED ASSESSMENT
- Dynamic-always changing, flexible - After the medical condition is properly diagnosed and
- Utilizes critical thinking processes a treatment plan is implemented, the time-lapsed
- Universally applicable assessment is conducted to evaluate how the patients
- Client-centered reacts to the agreed treatment plan and how their
- Interpersonal and collaborative condition is evolving.
ADVANTAGES OF NURSING PROCESS EMERGENCY ASSESSMENT
- Provides individualized care - The emergency assessment is performed during
- Clients is an active participant emergency procedures, when it is crucial to evaluate
- Promotes continuity of care the patient’s airway, breathing and circulation, as well
- Provides more effective communication among as the exact cause of the problem.
nurses and healthcare professionals SCIENTIFIC METHOD OF PROBLEM SOLVING
- Develops a clear and efficient plan of care - ID problem
- Provides personal satisfaction as you see client - Collect data
achieve goals - Form hypothesis
- Professional growth as you evaluate effectiveness of - Plan of action
your interventions - Hypothesis testing
NURSING PROCESS INVOLVED: - Interpret results
CRITICAL THINKING - must use with logical thinking - Evaluate findings
PROBLEM SOLVING - analyze ASSESMENT- COLLECTING DATA
DECISION MAKING - make choices - Nursing interview (history)
PHASES OF NURSING PROCESS - Health assessment – review of systems
Assessment (A) - Physical exam: Inspection, Palpation, Percussion,
Nursing Diagnosis (D) Auscultation
Planning (P) - Make sure information is complete and accurate
Implementing (I) - Organize and cluster data
Evaluating (E) - Interpret and analyze data compare to “standard
ASSESSMENT norms”
- Gather information about the client’s condition. - Validate prn (if/when necessary)
- The most important step 10 COMPONENTS OF NURSING HEALTH HISTORY
- Identifies your patient’s strengths and limitations and - Biographic data
is performed not just once, but continuously. - Chief complaint / Reason for visit
- First step of the nursing process. - History of present illness
- Gather information/collect data. - Past history / Past illness
Primary Source – client / family - Family history of illness
Secondary Source – physical exam, nursing history, team - Lifestyle
members, lab reports, diagnostic tests… - Social data
RMPM
, - Psychologic Data NURSING DIAGNOSIS
- Patterns of Healthcare - Second step of the nursing process
- Review of Systems - Interpret and analyze clustered data
BIOGRAPHIC DATA - Identify client’s problems and strengths
- Client’s name - Formulate Nursing Diagnosis (NANDA: North
- Age American Nursing Diagnosis Association) –
- Sex statement of how the client is RESPONDING to an
- Marital status actual or potential problem that requires nursing
- Occupation intervention.
- Religious affiliation DIAGNOSE
- Others (e.g. address, income, area, etc.) - Identify the client’s problems (through nursing
CHIEF COMPLAINT diagnosis NOT MEDICAL DIAGNOSIS).
- Why patient seek consultation DIFFERENCE BETWEEN NURSING DIAGNOSIS
- Chief complaint should be recorded in the client’s AND MEDICAL DIAGNOSIS
own words. NURSING DIAGNOSIS MEDICAL DIAGNOSIS
HISTORY OF PRESENT ILLNESS Within the scope of nursing Within the scope of medical
- Use CHRONOLOGIC story practice. practice.
- When the symptoms started
- Whether the onset of symptom was sudden or Identify responses to health Focuses on curing
gradual and illness. pathology.
- How often the problem occurs
- Exact location of distress Can change from day to day. Stays the same as long as
- Character of complaint the disease is present.
- Activity in which the client was involved when the
problem occurred TYPES OF NURSING DIAGNOSIS
- Aggravating factors - Problem-focused (actual) Nursing diagnosis
PAST HISTORY - Risk Nursing diagnosis
- Childhood illness - Syndrome Nursing diagnosis
- Immunization - Health Promotion Nursing Diagnosis
- Allergies PROBLEM-FOCUSED NURSING DIAGNOSIS
- Accidents and injuries - AKA “actual diagnosis”
- Hospitalization - Is a client problem that is present at the time of the
- Medication nursing assessment.
FAMILY HISTORY OF ILLNESS - P.E.S. FORMULA (Problem, Etiology, Signs &
MOTHER FATHER Symptoms)
(+) HPN (-) HPN BASIS FOR STANDARD NURSING DIAGNOSIS
(-) DM (-) DM (NANDA-I)
(-) PTB (+) PTB - North
- American
LIFESTYLE - Nursing
- Personal habits - Diagnosis
- Diet - Association-International
- Sleep/rest patterns FORMULATING A NURSING DIAGNOSIS
- Activities of daily living (ADL) Composed of 3 parts: PED/PES format
- Recreation/hobbies Problem Statement
SOCIAL DATA - The client’s response to a problem.
- Family relationship Etiology
- Ethnic affiliation - What’s causing/contributing to the client’s problem.
- Education history
- Occupational history Defining Characteristics or S/S
- Economic status - What’s the evidence of the problem.
- Home and neighborhood conditions GUIDELINES FOR WRITING A NURSING DIAGNOSTIC
PSYCHOLOGIC DATA STATEMENT
- Major stressors - State in terms of problem, not a need or intervention.
- Usual coping patterns - Non-self incriminating.
- Communication style - Use non-judgmental statements.
PATTERNS OF HEALTH CARE - Both elements of the statement do not say the same
- The patient undergoes regular annual check-up thing.
through his HMO and he consults first his family - Cause and effect are correctly stated.
physician concerning his health. - Use nursing terminology rather than medical
terminology to describe the client’s response.
RMPM
, RISK NURSING DIAGNOSIS - The nurse uses clinical judgement and professional
- These are clinical judgement that a problem does not knowledge to select appropriate interventions that
exist, but the presence of risk factors indicates that a will aid the client in reaching their goal.
problem is likely to develop unless nurses intervene. - Interventions should be written clearly and
HEALTH PROMOTION DIAGNOSIS specifically.
- AKA “Wellness diagnosis” Other factors in prioritizing your planning:
- Is a clinical judgement about motivation and desire to - Client’s health status
increase well - being. - Client’s priorities
SYNDROME NURSING DIAGNOSIS - Availability of resources
- Is used when a cluster of assessment findings or - Urgency of the health problem
nursing diagnosis occur together, showing a specific - Medical treatment plan
clinical pattern. INTERVENTION
- It can be actual or risk diagnosis - Perform the nursing actions identified in planning.
NANDA-I APPROVED SYNDROME DIAGNOSIS - - defined as any treatment based on clinical
- Disuse syndrome judgement and knowledge that a nurse performs to.
- Impaired environmental interpretation syndrome - Enhance patient outcomes
- Post-trauma syndrome - Putting the plan of care into action
- Relocation stress syndrome - Also called IMPLEMENTATION
- Rape trauma syndrome - Involves carrying out your plan to achieve goals and
- Sudden infant death syndrome outcomes
PLANNING - The “doing” phase
- Set goals of care and desired outcomes and identify TYPES OF INTERVENTIONS
appropriate nursing actions. INDEPENDENT
- Set the goal TOGETHER with the client. - (Nurse initiated) any action that the nurse can initiate
- If the client is unconscious set the goal with the or do without direct supervision.
clients significant other/family. DEPENDENT
Types of Goals: - (Physician initiated) nursing actions requiring doctors
LONG-TERM GOALS order.
- Objective behavior or response that you expect a COLLABORATIVE
patient to achieve over a more extended period, - Nursing action performed jointly with other health
usually over several days, weeks, or months. care team members.
SHORT-TERM GOALS NURSING INTERVENTION SHOULD BE:
- Objective behavior or response that you expect the - Safe and appropriate for the client’s age, health, and
patient to achieve in short time usually few hours or condition.
less than a week. - Achievable with the resources and time available.
PLANNING SHOULD BE: - In line with the client’s values, culture, and beliefs.
- Specific - In line with other therapies.
- Measurable - Based on nursing knowledge and experience or
- Attainable knowledge from relevant sciences.
- Realistic EVALUATION
- Time-bound - Determine if goals met and outcomes achieved.
PLANNING DEVELOPING - Evaluating is a planned, ongoing, purposeful activity
A GOAL AND OUTCOME STATEMENT in which the client’s progress towards achieving goals
- Goal and outcome statements are client focused or desired outcomes and the effectiveness of the
- Worded positively nursing care plan (NCP).
- Measurable, specific, observable, time-limited and - Evaluation is an essential aspect of the nursing
realistic process because conclusions drawn from this step
- Goal = broad statement determine whether the nursing intervention should
- Expected outcome = objective criterion for be terminated, continued, or changed.
measurement of goal - GOAL MET, GOAL PARTIALLY MET, GOAL UNMET
Types of Planning: COLLECTING SUBJECTIVE DATA
INITIAL - Is an integral part of interviewing the client to obtain
- Upon admission a nursing health history.
ONGOING Consist of:
- During confinement - Sensations or Symptoms
DISCHARGE - Feeling, Perceptions
- Before going home (MGH – may go home) - Desires, Preferences
PLANNING – SELECT INTERVENTION - Beliefs, Ideas
- Interventions are selected and written - Values
- Personal Information
RMPM
