Name: Zhyrra R.

Gracia
BSN II
ASSESSMENT
(Also known as Data collection)
Initial phase in the nursin process.
Is the systematic collection an! anlysis o" !ata culminatin in a nursin !ianosis.
(it is a continuous aspect of the nursing process and involves collaboration with patients,
caregivers and healt providers who contribute to the patients care.)
#e are alrea!y aware that we ha$e % types o" !ata& which are:
objective data - are datas gathered thru observation.
subjective data - are information that are given verball b the client.
Sources of Assessment Information
'. (he client ) !rovides the subjective data, !rimar source of info regarding past and
present illnessess health belief and practices and health care needs.
%. (he "amily or Sini"icant others.) source of objective data when client are unable to
participate,disoriendted or unconscious.
*. +e!ical recor!s an! nurses, notes. ) provide reliable and pertinent info regarding the
clints past medical histor and current health status.
-. Nursin sta"" an! other mem.ers o" the health team.
/. 0hane o" shi"t reports& nursin roun!s& 1ar!e2 an! nursin notes. ) communication in
other health team care provides important sources of assessment data.
3. 0on"errin with colleaues. ) contribute to a wealth of "nowledge and e#perience
which the nurse can use in assessing the clients health needs.
Methods of data collection
) Assessment !ata is athere! .y se$eral techni4ues an! metho!s to ather the necessary
in"ormation "or creatin a nursin care plan.
5. Inter$iew - process which involved tal"ing to people, as"ing $uestions to gather facts.
6. 7.ser$ation ) using of diff senses li"e sight, hearing, touch and etc.
8. 9hysical assessment ) will ield necessar objective data %what ou observed& as well
as subjective data %what the client states regardin his health status)
Documentation of assessment data
In!icate su.:ecti$e in"ormation "rom the client or other persons .y 4outation marks. )
'm stomach is burning;
a$oi! enerali<ation. ) li"e (ood, normal or fair
Recor! !ata completely& o.:ecti$ely& an! concisely o.ser$in correct rammar an!
spellin.
ASSESSMENT )* +)MM,N-T. /EA0T/ NEE1S
Needs Assessment
) Is a process o" lookin at many kin!s o" in"ormation a.out a taret roup or community.
%this includes review of census2demographic data,surves ad intervews of the population&
Health needs assessment
) is process o" systematically collectin in"ormation to ena.le the practitioner& team an! policy
makers to i!enti"y& analy<e& prioriti<e an! meet the heath nee! o" an in!i$i!ual& "amily or
population.
Community Health Needs Assessment
!escri.es the state o" health o" local people.
=na.les the i!enti"ication o" ma:or risks "actors an! causes o" ill health an! i!enti"ication
o" actions or inter$entions that are nee!e!. it is a wa of using info to plan healthcare
and public health care program in the future&
Purpose of Community Health Needs Assessment
) #ill ena.le the health practitioners& NG7s& ci$ic)oriente! societies& an! policy makers to
i!enti"y the mem.ers o" the population who nee! the health care ser$ices. -t is a ver important
process in health care planning to identif priorit health needs, utili3e the internal and
e#ternal resources)
Steps in community Health Needs Assessment to identif major health issues.
'>. 9ro"ilin. ) collection of relevent info that will inform the nurse about the state of
health and health needs of the population
''. Deci!in on priorities "or action.) nurses must "now what to prioriti3e first. from
most to least priorities.
'%. 9lannin pu.lic health an! health care prorams to a!!ress the priority issues.
'*. Implementin the planne! acti$ities. ) in this phase, the plans are now bein e#ecuted.
'-. =$aluation ) health outcomes are evaluated to see if implemented actions are
effective.
Data to be Included in the Assessment
'/. 0haracteristics o" the population %- geograph -numbers -age2gender distribution
-ethnicit2reliion -population trends&
'3. ?ealth status o" the population () mortaliit2morbidit rate -commu.diseases -low
birth weights -breastfeeding2immuni3ation rate -health behavior such as smo"ing-
health service used&
'5. @ocal "actors a""ectin health
-wor" and emploment -povert and income -environment -social support
-destabiliing factors -resources,formal and informal&
+)M!)NENTS )* +)MM,N-T. /EA0T/ NEE1S ASSESSMENT
A. /ealth Status
) (he health stan!in or con!ition o" the population as in!icate! .y the mor.i!ity& mortality an!
"etility rates (++A)
- a set of factors li"e povert,pollution,racism,income ine$ualities plas sinificant role in
determining commu. health stat&
'. Mortality Data ) Descri.es patterns o" !eath in relation to ae& en!er an! cause o" !eath.
) it is a basic measure of epidemiolog w2c is the stud of disease in populations.
- info is collected nationall, regionall and sometimes local level,usuall from death
cerificate.
- it indicates death from disease, accidents,suicides and homicides.
2. Morbidity Data ) (his in"ormation is on the types o" illness an! !isa.ility& their inci!ence an!
pre$alence.
- can be ta"en from sources li"e hospital records, sic"ness record and other surves.
- it is a reflection of illness not health
3. eha!ior Measures ) 7"ten use! as in!icators o" health
- smo"ing is the best e#ample
- smo"ing cause ill health, if a lot of people smo"e it shows a large potential for illness in the
population.
". #uality of life measures ) a means o" assessin physical health& "unctional a.ility an!
psycholoical well.ein.
- the assessment scales are based on an individuals own assessment.
$. %se of ser!ice information ) this in"ormation i$es an account o" mor.i!ity status o" the
community& the hospital a!missions an! use o" pre$enti$e ser$ices.
-li"e immuni3ation and screening
- not be reliable source of info as indicator of public health in countries where people ate too
poor to gain access to health the health services.
&. Health ine'ualities ) most !isease an! illness pattern are closely associate! to economic
circumstances.
- where there is a high rate of death and illness among the poor sectors of societ.
4. /ealth resources
) are assets& means& strenth an! skills that are contri.utory to the promotion o" health an! well)
.ein that e2ist within communities to meet the nee!s o" in!i$i!uals& "amilies or social roups.
'. Informal ) Aamilies !eli$er the reatest part o" all care ser$ices in the community.
- burden of care normall falls primaril to women and can affect their health status
2. (ormal ) can .e pro$i!e! at a $ariety o" le$els an! .y any aencies. (eiB ?ealth ser$ices)
-political ng religious organi3ations li"e medical missions b -N+s
5inds of 6esources a communit will have, include7
'. knowle!e an! skills in carin "or an! promotin health.
%. health careers ("amily an! "rien!s)
*. social support networks (commu. .ase! oraniations)
-. resources ( money& shop& "oo!& tranpo)
/.a.ility to cope in an o"ten $ery !i""icult circumstances
+. /ealth action potential
) comple2 acti$ity that shoul! .e un!ertaken where the more local people are in$ol$e! in action
plannin.
- there must also be collaboration with others li"e groups of health care professionals,
wor"ers from other agencies and other people who can serve as partners in health planning.
Action plannin stages
'. preparation stae
%. areein to aims set .y the roup
*. !escri.in the o.:ecti$es o" the proram
-. !etailin the acti$ities nee!e to meet the o.:ecti$es.
/. e$aluation o" the outcomes.
N,6SiN( 1iA(N)SiS
) (he statement o" client,s current health status an! concern which were o.taine! "rom the
assessment !ata an! can .e resol$e! or minimi<e! throuh nursin inter$entions.
importance of nsg d#
) allows nurse in!i$i!uali<e! plan o" care.
- distinguishes the role of the nurse from the phsician
Elements of Nursing 1ianosis Statement
'6. Actual nursin !ianosis ) problem statement that describes the client8s response to
an actual or potential health prob.
'8. =tioloy ) related cause or contributor to the problem (R=@A(=D (7)
%>. De"inin characteristics.) is the clinical manifestation. %AS MAN-*ESTE1 4.&
Tpes of Nursing !roblem
%'. Actual ) prob being currentl2presentl e#perience or percieved b the patient.2
validated b defining characteristics.
%%. RiskC?ih Risk ) a problem which has the potential of developing in the future due to
the presence of ris" factor. -ma develop into a new illness, unless a specific nursin
action are applied. -this tpe of problem is validated b 6-S5 *A+T)6S.
%*. 9ossi.le ) a problem which ma e#ist, but additional data is neede to confirm its
presence
%-. #ellness ) a change from a certain level of wellness to a higher lever of wellness.
%/. Syn!rome ) a combination or a group of actual or high ris" nursing diagnosis that
all relate to a serious event or situation.
Community Dia)nosis
) statement o" the health an! health)relate! pro.lems o" the community.
) the en!)result o" !ata collection an! analysis.
- in short it is a nursin diagnosis with the communit as its client.
Tpes of +ommunit 1iagnosis
'. Comprehensi!e ) aims to o.tain eneral in"ormation a.out the community. %li"e illness
pattern,health resources)
%. Problem oriented or (ocused dia)nosis ) responds to a particular problem or need.
/ealth !roblem
a situation where there is a demonstrated health need combined with actual or potential
resource and to appl remedial measures.
+ategories of health problem
'. Health threat ) con!itions that are con!uci$e lea! to !isease& acci!ent or "ailure to reali<e one,s
potential.
- famili histor of hereditar disease - threat of cross infection -aaccidental ha3ards
-fault eating habits
- poor evironmental condition, -unhealth life stle.
%. Health deficit ) when their is a ap .etween actual an! achie$a.le health status which may .e
!ue to "ailures in health maintenance. )brought about b histor of repeated
infection,miscarriages 9 absence of reg /. chec"up
*. (oreseeable crisis ) anticipate! perio!s o" unusual !eman! on the in!i$i!ual or "amily in terms
o" a!:ustmentC"amily resources. -marriage, pregnanc, parenthood, divorce, separation,loss of
job,menopause,death.
Magnitude of problem
- refers to the : percentage of population that has been affected.
- ma be categori3ed as
;<-=>>: affected -- ?pts
<>-;?: affected -- @pts
A<-?B: affected -- Apts
lessthan A<: - =pt
!0ANNiN(
also "nown as the blueprint of the nursing process
after data has been collected and nsg d# have been formulatedn ne#t step is the planning
phase.
) !eterminin the approach to .e use! in assistin the client towar! optimal wellness.
) !eci!in which actions will .e use! to help sol$e!& lessen& or minimie! the e""ects o" the
i!enti"ie! pro.lems& or to pre$ent potential pro.lems.
!lanning +cle %; steps&
'. Sur!eyin) the en!ironment ) in$ol$es e2tensi$e in"ormation atherin to !etermine the health
or illness pro"iles an! e2periences o" the population o" interest. meant to identif the current
state of issue under consideration
A Settin) Direction ) in$ol$es settin oal an! o.:ecti$es . meant to identif desirable future
state for issue.
3. Problems and challen)es ) i!enti"yin an! 4uanti"yin the short"alls .etween what is an! what
ouht to .e.
". *an)e of solutions ) i!enti"yin the rane o" solutions to each i!enti"ie! pro.lem or challene.
re$uires creativit on how to address the problem, using of alternative solutions.
$. est solution+s, ) choice o" solution or sets o" solutions that shoul! .e implemente! to a!!ress
the pro.lems.
in choosing the best solution, financial,political and other consideration must be considered.
%6eligion&
&.Implementation ) implementation o" the chosen solutions
plan must be developed before implementation.
-. .!aluation ) e$aluation o" the results o" implementation to !etermine whether the
implemente! solutions are e""ecti$e in achie$in thier oals.
Essential steps in the !lanning !rocess
%3. 9rioriti<in the i!enti"ie! pro.lem.
%5. De$elopin oalsC outcome statements.
%6. 9lannin nursin actions.
%8. Documentation o" the Nursin 0are 9lan.
!lanning the interventions
%fear r2t upcoming Surger as manifested b urinar fre$uenc,irritabilit, rapid pulse.
'CCCCCCCCCC'
the "irst step in plannin nursin inter$entions is to e2amin the secon! element o" the
nursin !ianosis statement. that pertains to the cause factor.
once the etioloical "actors ha$e .een i!enti"ie!& procee! to how these are reconi<e! .y
the nurse .y statin the ;as e$i!ence! .y; or as mani"este! .y part o" the statement.
i!enti"ies sins an! symptoms present.
a"ter etioloical "actors ha$e .een i!enti"ie!& !etermine nursin inter$entions which
woul! eliminate the "actors or minimi<e! their e""ects.
(uidelines in formulating nursing interventions
'. !ut safet first, remember that nursing actions must be safe
A. individuali3e the nursing actions for each client %ever client is uni$ue, interventions
are not same&
@. base nursing actions on rationale %ever intervention has its purpose& e#ample. TS4
?. nursing action must be stated clearl so that other health team members can interpret
it in dsame wa
<.ma"e nursin actions realistic. %SMA6T&specific -Measurable -Attainable -6ealistic
-Time bound
-M!0EMENTAT-)N
A step in nursin process that "ocuses on nurse workin with the patient an! "amily to
carry out the plan o" care.
its primary component is i$in care to the patient.
) Durin implementation& all the pre$ious phases o" the nursin process are interate!.
) #hile i$in the actual care& you must continue to assess& $ali!ate concerns& mo!i"y the plan
an! i!enti"y priorities as nee!e!.
+omponents of !rogram -mplementation
*>. 0oor!inatin the health prorams. (we have diff health sectors such as 1)/ 9
sentrong sigla monv8t
*'. +onitorin health proram (prorams are constantly monitore!&chanes miht occur
!urin implementation)
*%. super$isin the proram sta"". ( for the effectivit of the program, health team
members must wor" hand in hand, the wor" as a team not individuall to "eep
things organi3ed&
EDA0,AT-)N
7ccurs continuously while care is .ein i$en&shi"t .y shi"t as the health team e$aluate
proress towar! interme!iate outcomes.
#hile i$in care the patient the nurse will continually e$aluate the patient,s response to
the inter$entions.
Evaluating The effectiveness of -ntervention %E that can as" to evalute intervemtions&
**. @anuae .arrier (was there a language barrier between the nure and the client that
reduced the effectiveness of intervention& !angasinan dialect in communit, N,6SE
onl spea" tagalog
*-. Skills are m s"ills enoughF do i need more s"ill ensure the effectivit of our
actionsD
*/. Di""erent approaches did i approached the problem in diff anglesF or i onl used =
intervention. for e#ample giving analgesic as re$uested b the patient vs. e#ploration
of the pain management stategies in addition to medication.
*3. In$ol$ement o" others (ei&Aamily) would m intervention be more effective if the
famil is more involvedF less involvedF
*5. 9atient, In$ol$ement ) did i share the plan with the client to promote understanding
and participation
*6. Seekin suestions - do i need to as" for e#pertise of the other nurseF
*8. (imin o" Inter$ention ) !i! the patient,s con!ition chane!& makin the type an! timin
o" inter$ention less appropriate an! there"ore less e""ecti$e.

1eciding how well an outcome was metG
->. 7utcome met if the pt was able to demonstrate behavior b the specific time or date
stated in the outcome statement.
-'. 7utcome 9artially +et ) i" the pt was a.le to !emonstrate .eha$ior .ut not as well as
what is speci"ie! in the outcome statement.
-%. 7utcome Not +et ) i" the pt was una.le or unwillin to !o the .eha$ior.
Tools used in communit 1iagnosis
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/EA0T/ STAT-ST-+S
- used as indicators of health status for a group or a communit.
Re"ers to the !ata athere! "rom the systematic stu!y o" $ital e$ents such as .irths&
!eaths& illness& marriaes& !i$orces& separations& a!options& an! annulment patterns.
) Statistic o" !isease Morbidit an! !eath Mortalit in!icate the state o" health o" community
an! the success or "ailure o" health work.
) Birth an! !eaths are reistere! in the o""ice o" the @ocal 0i$il Reistrar o" the municipality.
(hese statistics are collecte! .y the D7? throuh it,s reional& pro$incial an! municipal
aencies.
%6/,& Rural Health Units ) are responsi.le "or collectin an! reportin !ata o" $ital
statistics !ealin with .irths&!eath an! all reporta.le !iseases in municipalities.
%NS)& National Statistics office ) pro$i!es statistics on population an! its characteristics
like ae& se2 an! !istri.ution.
0ocal civil 6egistrar2+it /ealth department ) Reistration o" .irths an! !eaths an!
correction o" errors in names are .ein !one here.

+ommon Dital and /ealth Statistical -ndicators
*ertilit rates - !ata relate! to the "ecun!ity or capacity to procreate.
-*. general fertility rate (GFR) - Measure of one characteristic or natural growth
compared to the fertility age group.
--. Birth rate - Measure the number of live birth for any given population.
-/. Crude Birth Rate (CR) - a measure of one characteristic of the natural growth or
increase in population.
Mortality rates - !ata related to analysis of death trends.
-3. Crude mortality rate - number of death in an entire population.
-5. Specific mortality rates - for a particular group of poplulation (e.i" children)
-6. Standardized mortality ratios (#MRs) - the age and se$ structure of the population
has been ta%en account of (standardi&ed) so that rates can be compared
between geographical areas.
-8. Crude Death Rate (C!R) - a measure of one's mortality from all causes which may
result in a decrease in the population.
/>. Specific Death Rate (#!R) - !escribes more accurately the ris% of e$posure of
certain classes of groups to particular diseases.
/'. Age specific death rate - measures the total number of deaths in a specific age
group.
/%. Sex Specific Death Rate - measures the total number of deaths of a certain se$.
/*. Cause Specific Death Rate - measures the total number of deaths of a certain
cause.
/-. Infant Mortality Rate ((MR) - measures the ris% of dying during the )st year of life a
good inde$ of a general health of a community.
//. Maternal Mortality Rate (MMR) - measures the ris% of dying from causes related to
pregnancy" childbirth and puerperium.
/3. Fetal Death Rate (F!R) - measures pregnancy wastage.
/5. Neonatal Death Rate (*!R) -measures the ris% of dying the first month of life.
/6. Saroops Index (#() - measures the ris% of dying for +, yrs. old and up.
/8. !roportionate Mortality Rate (-MR) - show the numerical relationship between
deaths from a cause" age etc.
Morbidity Rates - data describing the e$tent and distribution of illness.
3>. Incidence Rate ((R) - measures the fre.uency of occurrence of the phenomenon
during a given period of time. deals only with new cases
3'. !re"alence Rate (-R) - measures the proportion of the population which e$hibits a
particular disease at a particular time. deals with old and new cases
3%. Case Fatality Rate (CFR) - inde$ of a %illing power of a disease. it is influenced
by by incomplete reportind and poor morbidity data.
3*. Attac# Rate (/R) - a more accurate measure of the ris% of e$posure. is usefull in
epidemiological investigation.
EPIDEMIOLOGY
also !nown as the bac!bone of disease pre"ention.
- 0he study of factors that affect the health and cause diseases and conditions in a
population for the purpose of promoting wellness and preventing diseases or disease
causing conditions.
Multiple #ausation $heory also !nown as ecolo%ic concept of disease
states that heath conditions result from a multitude of factors which must be
analy&ed and understood.
alteration in any of the 1 components will cause disease or illness. if components
are altered it will also alter the internal or2and internal e.uilibrium.
&eb of #ausation
cause is a condition' reason that plays a si%nificant role in the uccorence of a
disease.
it is often difficult to find causes for healthrelated e"ents or chronic disease as
they are multiple and hetero%eneous.
these factors collecti"ely will form the &E( #)*+)$IO,'
where e"ery cause is interconected -ust li!e spiderweb.
3-. Microorganisms
3/. Genetic /bnormalities
33. #ocio-economic factors
35. 3nvironmental Factors
Ecolo%ic $riad
- /lso %nown as the 3pidemiologic triangle (is a model of how infectious disease is
spread)
- $riad tal!s about the . compoents of the disease process which are the...
1. Host any organism that harbors and provides nourishment for another person.
- it is the or%anism that is infected by the a%ent.
human is the host or%anism and others li!e animals.
2. Agent the cause" source or vihicle by which infectious organisms are transmitted.
- it is an or%anism that does the infectin% such as "irus or a parasite.
3. Environment the sum total of all e$ternal conditions and influences that affect the
development of an organism.
Physical en"ironment - composed of non-living things li%e climate and weather.
(iolo%ical En"ironment - composed of all livin things li%e plants
animals"microorganisms.
+ocioeconomic En"ironment li!e presecse or absence of economic
opportunities within the community' problem li!e prostitution and dru%
addiction.
-presence of tires in the bac%yard that accumulate stagnant water increasin the
possibility of children contractin disease.
/ #lassifications
Descriptive Epidemiology - attempts to describe patterns of disease according to
spatial and temporal information about the members of a population. these
patterns are describes by tabulations and summaries or sur"eys and polls.
Analytical Epidemiology - attempts to e$plain and predict the state of a
populations health. a typical goal is to summari&e the relationship between the
e$posure and disease incidence by comparing two measures of disease
fre.uency.
)pproaches to Epidemiolo%y the ff approaches to are used to analy0e and
determine factors that affects rate of a particular disease.
36. Case control studies - individuals with or w2o the disease of interest are recruited
systimatically from the same population and their histories of e$posure to
potential causative and and protective factors and measured and compared.
(short term /1years'less e2pesi"e3
38. Cohort studies -a population with a %nown level of e$posure to potential
causative and and protective factors is recruited and follwed over time to
determine who gets and who does not get the disease(#). (longer term +-4,
years" more e$pensive)
5>. meta-analysis - the results of several studies can be compared or even combined
to determine the strength of the association.
Patterns of Disease Occurrence
sporadic - intermitent occurrence or onandoff presence of disease
3ndemic - continuous or constant occurrence of disease in a certain area
3pidemic - sudden increase in the number of cases in a short period of time.
-oint source epidemic - there is a common vihicle in the transmission of disease.
propagated epidemic - trans of disease from person to person
vector propagated epidemic - number of cases is based mainly on the number of
vectors
-andemic - worlwide epidemic or global outbrea%
Epidemiolo%ic Process
5'. !etermine the nature" e$tent and scope of the problem.studying the
characteristic of epidemic in terms of distribution pattern person- age se$" place -
using the spot map of community" $ime onset of outbrea%
5%. Formulate a tentative hypothesis - this is a temporary hypothesis.
5*. 0estin the hypothesis - conducting of the diagnostic e$am to prove the source of
the disease.
5-. Ma%in conclusion and recommendations - emphasi&ing the significant result of
investigation.
5/. -lan for control of spread of disease - includes suggestions on what can be done
to stop the epidemic.
53. (mplementation - of control proram
55. evaluate - evaluation of controlprogram
56. Ma%ing report as basis for dianostic purposes. includes preventive actions to
prevent the reccurrence of the same disease.
4erd Immunity
Refers to the general immunity of a population against a particular disease.
this is usually represented by terms of 5 and is used in ma%ing public health decisions.