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Definition:
It is a systematic, client-centered method for structuring the delivery of nursing care.
Phases:
1. Assessment
2. Diagnosing
3. Planning
4. Implementing
5. Evaluating
Characteristics:
ASSESSMENT
Characteristics:
1. It focuses on a clients responses to a health problem.
2. It should include the clients perceived needs, health problems, related experience,
health practices, values and lifestyle.
3. To be most useful, the data collected should be relevant to a particular health
problem.
Activities:
1. Collecting Data 3. Validating Data
2. Organizing data 4. Documenting Data
TYPES OF DATA:
1. Subjective Data
- information given verbally by the patient
- information perceived only by the affected person
- symptoms complained by the patient
example:
Correct: I feel so nervous
Get out of my room
Sakit akong samad
Incorrect: Patient is anxious
Patient is hostile
Patient has pain
2. Objective data
- are detectable by an observe
- consists of information that is perceptible to the senses
- can be tested against an accepted standard
- factual data observed by the Nurse
example:
Correct: hair combed, make-up applied Concise
drag right leg when walking
tremors of both hands and
250 cc dark amber urine Descriptive
Sources of Data:
1. Primary- client
2. Secondary- significant others, other health personnel records and reports
- relevant literature
A. Observation
- occurs whenever the nurse is in contact with the client or support persons
- gather data by using the 5 senses
B. Interviewing
- structured form of communication that the nurse uses to collect data or a conversation
with a purpose
2 Approaches
1. Directive
2. Non- directive
Some hints to make patient comfortable before beginning the nursing history:
Stages of Interview
Examination
- major method used in the physical health assessment
- done systematically, according to examiners preference (head to toe or
body systems)
a. Cephalo-caudal- head, neck, thorax, abdomen, and extremities and ends at the
toes
b. Body System approach- respiratory, circulatory, etc.
- datas obtained are measured against norms or standards (ideal height/weight,
temperature, Blood Pressure)
PALPATION - the nurse uses the hands and sense of touch to gather data
- used to detect tenderness, temp., texture, vibration, pulsations, masess
- rules out/confirms suspicious raised during interview and inspection
PERCUSSION- is the tapping of the bodys surface to produce vibration and sound
- sounds indicates the density of the underlying tissue
Technique: place the palmar surface of one hand against the clients body while tapping with
the other.
AUSCULTATION the process of listening to sounds produced by the body
- Systems involved:
Cardiovascular System
Respiratory System
Gastro-intestinal System
- Use: Stethoscope- an instrument that amplifies sounds produced by i
nternal organs
ORGANIZING DATA
- nurse uses written format that organizes the assessment data systematically
Nursing Conceptual Models/Framework which can be used to structure the nursing admission
assessments:
1. Maslows Hierarchy of basic needs
2. Hendersons 14 components of nursing care
3. Gordon;s 11 functional health pattern
4. NANDAs response pattern
VALIDATING DATA
Purpose:
1. To elicit information about all variables that may effect that clients health
status.
2. To obtain data that help the nurse understand and appreciate the clients life
experiences
3. To initiate a non judgmental, trusting interpersonal relationship with the
client.
Components:
1. Biographic data
2. Chief complaints or reason of visit
3. History of present illness
4. Past history
5. Family history of illness
6. Review of system (ROS)
7. Life style
8. Social data
9. Psychological data
10. Patterns of health care
Advantages:
b. Ng. Dx = P + E + S
High risk for skin r/t diarrhea, age 3 years, low oral
Fluid vol. Intake, temperature
Deficit
High risk for injury r/t disorientation and division after cataract surgery
3. POSSIBLE NG.DX
NURSING MEDICAL DX
1. Organized Data
2. Compare data against standard -------- normal health patterns
-------- normal vital signs
-------- lab values
3. Cluster data
4. Identify gaps & inconsistencies in data
(/) (X)
1. State in terms of a Actual fluid volume deficit r/t Fluid replacement relate to
problem fever fever
2. State so that it is legally Impaired Skin r/t immobility Impaired skin integrity r/t
advisable improper positioning
3. Use nonjudgmental Spiritual distress r/t inability Spiritual distress r/t strict
statement to attend church services due rules necessitating church
to immobility attendance
4. Both elements of the Potential impaired skin Impaired skin integrity r/t
statement must not say integrity r/t immobility ulceration of sacral area
the same thing
6. Use statements provide Social isolation r/t loss of Social isolation r/t
guidance planning speech laryngectomy
independent nursing
interventions
10. Do not start with a Altered nutrition: less than Provide high protein diet
nursig intervention body requirements r/t because of potential altered
inadequate intake of protein. nutrition
BENEFITS:
A. Client:
1. quality client care
2. continuity of care
3. participation by the client in their health care
B. Nurse:
1. consistent and systematic nursing education
2. job satisfaction
3. professional growth
4. avoidance of legal action
5. meeting professional nursing standards
Characteristics:
1. the NCP focuses on actions which are designed to solve or alleviate an existing problem.
2. The NCP is a prodcut of a deliberate systematic process.
3. The NCP relates to the future. It utilizes events in the past and what is happening in the
present to determine trends.
4. The NCP revolves around identified healtgh and nursing problem
5. The NCP is a means to an end, not end in itself.
6. Nursing care planning is a continuous process.
NCP-Importance
ESTABLISHING GOALS:
Goal - is a general statement of purpose
- it is the end toward which all efforts are directed
S - specific
M - measurable
A - attainable
R - realistic
T - time bounded
PLANNING- inv9olves setting priorities, writing goals, and establishing a written plan for
nursing interventions designed to prevent, resolve or identify problems or potential
problems.
IMPLEMENTING- is carrying out or delegating the nursing interventions
EVALUATING- involves the nurse and the client in determining whether that clients goals
or predetermined outcomes of care have been met
- identifying factors that facilitated or inhibited goal achievement
- and modifying or terminated the care plan accordingly
F. Medication
The client will know:
Drug name
What dosage to take and when
Purpose of drug
Effect (s) the drug should have
Symptoms of possible adverse effects, and which ones to report (repeat for
each drug prescribed)
A. ENVIRONMENT
The client will be assured of:
Adequate instruction in necessary homemaking skills
Investigation and correction of any physical hazards in the home
environment
Adequate emotional support
Investigation of sources of economic support
Investigation of transportation means to appointment and/ or clients
T. Treatment
The client and family will:
Know the purpose of any treatment to be continued at home
Be able to demonstrate correct performance of treatment
H. Health Teaching
The client will:
Describe how his or her disease or condition affects body function
Describe the means necessary to maintain present level of health, or achive
a higher level of health
D. Diet
The client will be able to:
Describe the purpose of his or her prescribed diet
Plan several typical menus using prescribed diet
PLANNING
- the process in which problem solving and decision- making are carried out.
Uses:
1. data obtained during assessing
2. the diagnostic statements that present clients health problem
6 Compaonents of P:
1. setting priorities
2. establishing client goals and outcome criteia
3. planning Ng Strategies
4. writing Ng orders
5. writing the NCP
6. Consulting
I. Setting Priorities
Determined by the following factors:
Clients goal- is a desired outcome or change in client behavior in the direction of the
health
Purposes:
1. provide direction of planning nursing intervention
2. provide direction for establishing evaluation
Types of Goals
a. long term- client living at home or having chronic health problems, in NG. Homes and
rehab center.
b. short term- clients requiring short term care
- persons who are frustrated by long term goals
OUTCOME CRITERIA:
4 purposes:
1. subject
2. verb
3. condition or modifier
4. criterion
GUIDELINES:
1. Write goals and outcome criteria in term of client behavior- focus on the client not
nursing action.
2. Avoid statement that short and enable, facilitate, allow, let, permit followed by the word
client
3. Make sure the goal statement is appropriate for the NG. Dx and those outcome criteria
are appropriate for goal
4. Make sure the client considers the goals important and values them.
5. Ensure that the (goals) (client) goals and outcome criteria are compatible with the word
and therapies of other professionals
6. Make sure that each goals is derived from only on NG Dz
7. When writing outcome criteia, use observable, measurable terms (smart)
Relationship of OC Vs CG
1. OC- outcome criteria are derived from and relate to the client goals CG from 1 st clause of
the Ng Dx
V. WRITING NCP
NCP- is a guide that organizes information about a Clients health into a meaningful whole
7 steps:
Discharge Planning- the process of anticipating and planning for needs after discharge form
a Hospital or other facility.
IMPLEMENTING- Intervening
- putting the nursing strategies listed in the hrsing care plan into action
1. Independent Nursing Action- an activity that the nurse initiates as a result of the
nurses own knowledge and skill autonomous nursing practice.
Taxonomy- is a set of classification that are ordered and arranged on the basis of a
single principle or consistent set of principle.
2. Dependent Nursing Action- are those activities carried out in the order of the
physician, under the physicians supervision or according to specified routines.
6 COMPONENTS OF IMPLEMENTING
IMPLEMENTING ACTIVITIES
1. Caring
2. Communicating
3. Helping
4. Teaching
5. Counseling
6. Client advocate
EVALUATING
To evaluate- to identify whether or to what degree to clients goals have been met
6 Components
2. Collecting Data
- observation
- direct communication
- purposeful listening/ reports
3. Judging Goal Achievement
4. relating Nursing Action to Client Outcomes
5. Reexamining the clients care plan
- database
- diagnostic statement
- goal statements
- nursing strategies
6. Modifying the care plan
Example: