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Process
RN
THE NURSING PROCESS
Nondirective Interview
Aka. Rapport building interview
Nurse allows the client to control the purpose, subject
matter and pacing
Rapport is an understanding between two or more people
Methods of Data Collection:
A. Interview
Types of Interview Questions:
Closed questions
Used in directive interview
Require only yes or no or short factual answers giving
specific information
Open-ended questions
Associated with the nondirective interview
Invite clients to discover and explore, elaborate, clarify or
illustrate their feelings or thoughts
Invite answers longer than one or two words
B. Observation
use to gather data by using the 5 senses and instruments
Sense of vision, smell, hearing and tourch
Is a conscious, deliberate skill that is developed through
effort and with an organized approach
C. Physical Examination
systematic data collection to detect health problems using
unit of measurements, physical examination techniques
inspection, palpation, percussion, auscultation (IPPA), and
interpretation of laboratory results.
should be conducted systematically:
Cephalocaudal approach head-to-toe assessment, begins assessment of
the head, neck, thorax, abdomen, extremities
Body System approach examine all the body system individually
Review of System approach examine only particular area affected
Source of data:
Primary source
data directly gathered from the client using
interview and physical examination
client is the primary source of data
Secondary source
data gathered from clients family members,
significant others, clients medical
records/chart, other members of health team,
and related care literature/journals.
NURSING HEALTH HISTORY
a structured interview designed to collect specific data and to
obtain a detailed health record of a client.
The objective in taking the nursing health history is to identify
patterns of health and illness, risk factors, physical and
behavioral problems and deviations from normal
Its components include:
Biographical data
Chief complaint
History of present illness
Family History
Past Health History
Lifestyle
Social Data
Psychological Data
Patterns of Health Care
Components of a Nursing Health History
1. BIOGRAPHIC DATA
Clients name , address, age, sex, marital status,
occupation, religious preferences, health care
financing and usual source of medical care
3. Accuracy
chart objective facts, not your interpretations or
opinion
e.g.
Correct ate 50% of the food served.
Incorrect ate with poor appetite
Correct refused medications.
Incorrect uncooperative.
Correct seen crying.
Incorrect depressed.
Place complaint of the client in quotation marks to
indicate that it is statement.
E.g. complained of chest pain radiating down the left arm
5. Completeness and
Chronology/organization/sequence/timing
notes should appear on each succeeding line
continuous charting is done for each entry unless a time
change occurs. No need for a new line for each new idea
or entry
date is entered in the date column on the first line of every
page of nurses notes and whenever the date changes
time is entered in the time column whenever a new time
entry occurs
7. Signed
affix signature, place at the end of the charting, at
the right hand margin of the nurses notes
sign each entry with your full name and status e.g.
SN for student nurse. RN for registered nurse
script, not printing is used for the signature
8. In case of ERROR
9. Confidentiality
12. Legibility
writing must be clear and easily read by the others
If writing is not legible, then print
a horizontal line is drawn to fill up a partial line. This
is to prevent other persons from adding information
in the nurses notes.
DIAGNOSING
is the 2nd step of the nursing process.
Is a process which results to a diagnostic
statement or nursing diagnosis
Purpose: To identify clients health care needs
and to prepare diagnostic statements
To diagnose in nursing: it means to analyze
assessment information and derive meaning
from this analysis.
Nursing Diagnosis
is a statement of a clients potential or actual health
problem resulting from analysis of data.
is a statement of clients potential or actual
alterations/changes in his health status.
A statement that describes a clients actual or
potential health problems that a nurse can identify
and for which she can order nursing interventions to
maintain the health status, to reduce, eliminate or
prevent alterations/changes.
Nursing Diagnosis
Is the problem statement that the nurse
makes regarding a clients condition which she
uses to communicate professionally.
It uses the critical-thinking skills analysis and
synthesis in order to identify client strengths &
health problems that can be
resolve/prevented by collaborative and
independent nursing interventions.
Nursing Diagnosis
Analysis separation into components or the
breaking down of the whole into its parts.
Synthesis the putting together of parts into
whole
3 activities in Diagnosing:
DIAGNOSING = Data Analysis + Problem
Identification + Formulation of Nursing
Diagnosis
Characteristics of Nursing
Diagnosis:
It states a clear and concise health problem.
It is derived from existing evidences about the
client.
It is potentially amenable to nursing therapy.
It is the basis for planning and carrying out
nursing care.
Components of a nursing
diagnosis: PES format
Problem statement/diagnostic label/definition
=P
Etiology/related factors/causes = E
Defining characteristics/signs and symptoms =
S
Types of Nursing Diagnosis:
1. 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:
Imbalanced Nutrition: Less than body requirements r/t decreased appetite
nausea.
Disturbed Sleep Pattern r/t cough, fever and pain.
Constipation r/t long term use of laxative.
Ineffective airway clearance r/t to viscous secretions
Noncompliance (Medication) r/t unknown etiology
Noncompliance (Diabetic diet) r/t unresolved anger about Diagnosis
Acute Pain (Chest) r/t cough 2 to pneumonia
Activity Intolerance r/t generalize weakness.
Anxiety r/t difficulty of breathing & concerns over work
Types of Nursing Diagnosis:
2. 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 of job
Possible altered thought processes r/t unfamiliar
surroundings
Types of Nursing Diagnosis:
3. 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
indicates that a problem is only 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 is the etiology of
a risk nursing diagnosis.
Examples:
Risk for Impaired skin integrity (left ankle) r/t decrease peripheral circulation in
diabetes.
Risk for interrupted family processes r/t mothers illness & unavailability to provide
child care.
Risk for Constipation r/t inactivity and insufficient fluid intake
Risk for infection r/t compromised immune system.
Risk for injury r/t decreased vision after cataract surgery.
Formula in writing nursing
diagnosis: PES or PE
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
Qualifiers
Qualifiers words added to the diagnostic
label/problem statement to gain additional
meaning.
deficient - inadequate in amount, quality,
degree, insufficient, incomplete
impaired made worse, weakened, damaged,
reduced, deteriorated
decreased lesser in size, amount, degree
ineffective not producing the desired effect
Activities during diagnosis:
Compare data against standards. Standards are accepted
norms, measures, or patterns for purposes of comparison. E.g
the standard color of the sclera is white; the standard color of
urine is amber
Cluster or group data e.g. pallor, dyspnea, weakness, fatigue,
RBC=4 M/cu.mm, Hgb=10g/dl,,pertains to problems with
oxygenation
Data analysis after comparing with standards
Identify gaps and inconsistencies in data
Determine the clients health problems, health risks, strengths
Formulate Nursing Diagnosis prioritize nursing diagnosis
based on what problem endangers the clients life
Situation: Functional Health
Pattern Activity/Exercise
Aling Sylvia,35 years as a laundry woman seeks consultation at
the Ospital ng Sampaloc due to fever 2 days PTA. She
verbalizes: Bigla na lang ako giniginaw, masakit ang ulo at
mainit ang pakiramdam pagkatapos kong maglaba sa kabilang
kanto. She has 3 children she walks off to school everyday
before she goes to work
VS: T=39.2C RR = 35 P = 96; With flush skin and warm to
touch, teary eyed and with dry lips and mucous membrane.
Nsg Dx: Hyperthermia r/t environmental condition as
manifested by T = 39C, flush skin, warm to touch, teary eyed
and dry lip and mucous membrane.
Situation: Functional Health
Pattern = Nutritional/Metabolic
States, No appetite since having cough
Has not eaten today; last fluids at noon today
Has lost 8 lbs in past 2 weeks
Nauseated x 2 days
Nsg. Dx: Imbalanced Nutrition: Less than body
Requirements r/t decreased appetite and
nausea 2ndary to disease process/cough
Situation: Functional Health
Pattern = Activity/Exercise
Difficulty sleeping because of cough
States, Cant breath lying down
Report pain on chest when coughing
Nsg Dx: Disturbed Sleep Pattern r/t a disease
process, orthopnea and pain.
Acute Pain (chest) r/t pathologic condition
2ndary to pneumonia
O-U-T-C-O-M-E I-D-E-N-T-I-F-I-C-A-T-I-O-N
Short Term Goal can be met in a short period (days/ less than a week)
Long Term Goal require more time (several weeks/months)
Outcome Criteria are specific, measurable, realistic statements goal attainment.
Therefore the characteristic of well-stared outcome criteria are:
S = pecific
M =easurable
A = ttainable
R = ealistic
T = ime bounded
Example of Goals and Outcome
Criteria
Goal The client will report a decreased anxiety level
regarding Surgery.
Possible Outcome Criteria
The client discusses fears & concern regarding
surgical procedure after client teaching.
After client teaching, the client verbalizes decreased
anxiety.
The client identifies a support system and strategies
to use to reduce stress and anxiety related to the
surgical experience.
Example of Goals and Outcome
Criteria
2. Goal The client will demonstrate safety habits when
performing activities of daily living.
Possible Outcome Criteria:
Immediately after instruction by the nurse, the client uses call
light system for assistance when needs to use the bathroom.
The client demonstrates safety practices when dressing and
doing personal hygiene.
The client uses over-the-bed lights, non-skid slippers when
transferring to chair or getting out of bed.
The client identifies modification for home safety (removal of
throw pillows, installation of hand rails in hallway, better
lighting of hallway and stairway), 12 hours after nurses
instruction about home safety.
Example of Goals and Outcome
Criteria
3. Goal The client will mobilize lung secretions.
Possible Out come Criteria:
After teaching session, the client demonstrates
proper coughing techniques.
The client drinks at least 6 glasses of water per day
while in the hospital.
The caregiver or significant other demonstrates
proper technique of chest physiotherapy including
percussion, vibration and postural drainage before
discharge.
Classification of Nursing
Diagnoses:
1. High priority Nursing Diagnosis
are those that are potentially life-threatening
and require immediate action.
E.g. include impaired gas exchange, ineffective
breathing pattern, self-directed risk for
violence
Classification of Nursing
Diagnoses:
2. Medium Priority Nursing Diagnosis
are those that could result in unhealthy
consequences such as physical or emotional
impairment, but are not life threatening.
E.g include fatigue, activity intolerance,
ineffective coping and dysfunctional grieving
Classification of Nursing
Diagnoses:
3. Low priority Nursing Diagnosis
involve problems that usually can be resolved
easily with minimal intervention and are
unlikely to cause significant dysfunction.
E.g include sensation of hunger in a client who
is on NPO in preparation for diagnostic
procedure, minimal pain on the third
postoperative day related to ambulation
P-L-A-N-N-I-N-G
involves determining beforehand the strategies or
course of actions to be taken before implementation
of nursing care. To be effective, the client and his
family should be involve in planning.
Purpose:
To determine the goals of care and the course of
actions to be undertaken during the implementation
phase.
To promote continuity of care.
To focus charting requirements.
To allow for delegation of specific activities.
Activities during Planning:
1. Establish/Set priorities
Priority is something that takes precedence in position, and
considered the most important among several items.
Guideline for setting priorities:
Life-threatening situations should be given highest priority.
Use the principle of ABCs (airway, breathing, circulation)
Use Maslows hierarchy of needs.
Consider something that is very important to the client.
Actual problems take precedence over potential concerns.
Clients with unstable condition should be given priority over
those with stable conditions. Ex: attend to client with fever
before attending to client who is scheduled for physical
therapy in the afternoon.
Activities during Planning:
Consider the amount of time, materials,
equipment required to care for clients. Ex:
attend to client who requires dressing change
for postop wound before attending to client
who requires health teachings & is ready to be
discharged late in the afternoon.
Attend to client before equipment. Ex: assess
the client before checking IV fluids, urinary
catheter, drainage tube.
Activities during Planning:
2. Plan nursing interventions/nursing orders to direct
activities to be carried out in the implementation phase.
to direct activities to be carried out in the implementation
phase
nursing interventions are any treatment, based upon clinical
judgment and knowledge, that a nurse performs to enhance
client outcomes
they are used to monitor health status; prevent, resolve or
control a problem; assist with activities of daily living; or
promote optimum health and independence
nursing interventions are also called nursing orders
nursing interventions are independent, dependent and
interdependent activities that nurses carry out to provide
client care
Activities during Planning:
3. Write a Nursing Care Plan or NCP
NCP
a written summary of the care that a client is to receive.
It is nursing centered in that the nurse remains in the scope of nursing
practice domain in treating human responses to actual or potential health
problems.
It is s step-by-step process as evidence by:
Sufficient data are collected to substantiate nursing diagnosis.
At least one goal must be stated for each nursing diagnosis.
Outcome criteria must be identified for each goal.
Nursing interventions must be specifically designed to meet the identified
goal.
Each intervention should be supported by a scientific rationale, which is
the justification or reason for carrying out the intervention.
Evaluation must address whether each goal was completely met, partially
met or completely unmet.
I-M-P-L-E-M-E-N-T-A-T-I-O-N
Is putting nursing care plan into action
Purpose: To carry out planned nursing interventions to help the
client attain goals and achieve optimal level of health.
Activities:
Reassessing ensure prompt attention to emerging problems
Set priorities determine the order in which nursing
interventions are carried out
Perform nursing interventions these may be independent.
Dependent or collaborative measures.
Record actions to complete nursing interventions, relevant
documentation should be done. Remember: Something that is
NOT written is considered as NOT done at all.
Requirements of Implementation:
Cognitive Skills (Knowledge)
include intellectual skills like problem solving,
decision making, critical thinking, creativity and
teaching
Technical skills
Hands on skills to carry out treatment and
procedures such as manipulating equipment, giving
injections and bandaging, moving, lifting and
repositioning clients
Interpersonal (Communication) skills
use of verbal and non verbal communication to carry
out planned nursing interventions