II.

WEEK 1 MODULE: LEARNING CONTENT

The nursing process is a systematic and rational method of planning and

providing individualize nursing care using the following steps: assessing,
diagnosing, planning, implementing and evaluating. It aims to identify client’s
health status, actual or potential health care problems or needs and deliver
specific nursing interventions to meet those needs.

Hall originated the term nursing process in 1955, and Johnson (1959), Orlando
(1961), and Wiedenbach (1963) were among the first to use it to refer to a series
of phases describing the practice of nursing. Since then, various nurses have
described the process of nursing and organized the phases in different ways.

The use of the nursing process in clinical practice gained additional legitimacy in
1973 when the phases were included in the American Nurses Association (ANA)
Standards of Nursing Practice.

In able to carry out the nursing process successfully, it is very important that one
must “think like a nurse” as introduce by Dr. Christine Tanner in 2006, which
means that critical thinking and critical reasoning on the care of clients must be
defined and understood.

Critical thinking is the process of intentional higher level of thinking used to

define a client’s problem, examine the evidence based practice in caring for the
client and making choices in the delivery of care. Nurses used critical thinking in
the process of solving problems and decision making process for a safe, efficient
and skillful nursing intervention. Critical thinking fuels the intellectual artistic
activity of creativity. When nurses incorporate creativity , they were able to find
solutions unique to the problem.

On the other hand, , critical reasoning is the cognitive process that uses
thinking strategies to gather and analyze client information, evaluate relevance
of the information, and decide on possible nursing actions to improve
psychological and psychosocial outcomes.
Critical thinking, critical reasoning and the nursing process

Through the nursing process, the nurse is able to respond to the changing health
status of the client in a systematic and rational way. Nursing process is a cyclical
process that follow a logical sequence, but more than one component maybe
involve at one time. It is action oriented, client centered and outcome directed.

Five Phases of the Nursing Process:

I. Assessing – the systematic and continuous collection, organization,

validation and documentation of data. It is carried out in all phases of the
nursing process.

II. Diagnosing – nursing use critical thinking skills to interpret assessment

data and identify client strengths and problems.

III. Planning – deliberate and systemic process that involves decision

making and problem-solving .

IV. Implementing – is the action phase where the nurse delivers nursing
interventions.

V. Evaluating – is a planned, ongoing, purposeful activity in which the

clients and health care professionals determine the client’s progress
 toward achievement of goals and outcomes and the effectiveness of the
nursing care plan.

The Nursing Process in action.

i. ASSESSING:

Assessment is a systematic, dynamic, and continuous way of data collection,

organization, validation and documentation about a client health status or
condition. This includes physiological, psychosocial, sociocultural, spiritual,
economic and life-style factors as well. It is a continuous process that is
involve in all phases of the nursing process.

There are four (4) different types of assessment namely:

1. Initial nursing assessment

2. Problem-focused assessment
3. Emergency assessment
4. Time-lapsed assessment

Data Collection:

Data collection is the systematic and continuous process of gathering information

about a client’s health status or condition which prevent omission of significant
data and reflect a client’s changing health status. A client database contains all
the information about a client which includes nursing health history, physical
assessment, primary care provider’s history, and physical examination, results of
laboratory and diagnostics tests, and material contributed by other health
personnel.

Clients data should include past history and current problems. Past history is the
total sum of client’s health status prior to the presenting problem. For example a
history of allergic reaction to penicillin, past surgical procedures, healing
practices and chronic diseases. Current data relate to the present circumstance,
such as pain, nausea, sleep patterns and religious activities or practices.

Type of Data

Subjective data, is also known or referred to as covert data or

symptoms, which is apparent and can be described or verified only by the
person affected.

Objective data, is also known or referred to as overt data or signs, which

is detectable by an observer and can be measured or tested against an
accepted standard. These data can be seen, heard, felt, or smelled.

Sources of data

Sources of data can be primary or secondary. Client is the primary and

best source of data. All sources other than the client such as family
members, friends, caregivers, and other members of the healthcare team
are considered secondary source of data and must be validated if
possible.

1. Client – primary and best source of data unless the client is too ill,
young, or disoriented to communicate clearly. Client can provide
subjective data that no one else can offer. Most often statements made
by the client and objective data obtained by the nurse from the client
consist of primary data.

2. Support people – Family members, friends and caregivers are

considered as secondary source of data if the client is unable to provide
information. These are people who knows the client wee enough to verify
or supplement information provided by the client. They are an important
source of data for client who is very young, unconscious, or confused.
Information provided is considered subjective if it is not based on facts.

3. Client records – this include information documented by various health

care professionals involve in client’s care. This may include information
such as client’s occupation, religion and marital status. Medical records
are often a source of client’s past health and illness pattern. This can give
 nurses with information about client’s coping behaviors, health practices,
previous illness and allergies. Record of therapies provided by other
health care practitioner like physical therapists, social workers, nutritionist
and other member of the healthcare team can provide relevant data not
expressed by clients. Laboratory records also provide important health
information. Any laboratory data about a client must be compared to the
agency or performing laboratory’s norm for that particular test. The nurse
must always check the information in the client records in light of the
current situation.

4. Health Care Professionals – verbal reports from other health care

professionals serve as other potential source of information about a
client’s health. Health care professionals involve in previous client’s care
may have information from previous or current contact with the client. This
is important to ensure continuity of care when client transferred to and
from home and health care agencies.

5. Literature – review of nursing and related literature, such as

professional journals and reference texts, can provide additional
information for the database. A literature review includes but is not limited
to the following information:

i. Standard or norms against which to compare findings

ii. Cultural and social practices

iii. Spiritual beliefs

iv. Assessment data needed for specific client conditions

v. Nursing interventions and evaluation criteria relevant to client’s

health problem.

vi. Information about medical diagnosis, treatment and prognosis

vii. Current methodologies and research findings

Data collection method

Observing, interviewing and examining are the principal method used in data
collection. A nurse uses all three methods simultaneously when assessing
clients. During client interview, for example, the nurse observes, listens, ask
questions and mentally retain information to explore in the physical examination.

Observing
To observe is to use the senses in gathering data or information. It is a
conscious, deliberate skill that is developed through effort and with an
organize approach and involves distinguishing data in a meaningful
manner. Nursing observations must be organized to ensure that nothing is
missed out.

Interviewing

An interview is a planned communication or conversation with a purpose.

In a focused interview, the nurse asks specific questions to the client to
collect information related to the client’s problem.

There are two approaches to interviewing: directive and non-directive.

Directive interview is highly structured and elicits specific information. At
least at the outset, the nurse establish the purpose of the interview and
controls it. In directive interview, the client answer the questions but may
have limited time to ask questions and discuss concerns. This is usually
used by the nurse to give or get information at a limited time such as in
emergency situations. Non-directive interview on the other hand is also
known as rapport building interview as the nurse allows the client to
control the purpose, subject matter and pacing of the interview. Rapport is
an understanding between two or more people.

During information gathering interview, a combination of directive and non-

directive approaches is usually appropriate.

Types of Interview Questions

Interview questions can be classified as closed or open-ended and

neutral or leading.

Closed questions generally requires a “yes” or “no” answer or short

factual answers that provide specific information. This is usually
used in directive interview where information is needed quickly
such as in emergency situation. Closed questions often begin with
“when,” “where,” “who,” “what,” “do (did, does),” or “is (are,
was).”

For example: What medication did you take?

Open-ended questions is often associated with non-directive

interview as it allow clients to discover and explore, elaborate,
clarify or illustrate their thoughts or feelings. Open-ended question
gives client the freedom to choose what information to divulge if
 and when they are ready to disclose the information. This is very
useful at the beginning of the interview or to change topics and to
elicit attitudes. It may begin with “what,” or “how.”

For example: What would you like to talk about today?

Neutral questions is a question that the client can answer without

direction or pressure from the nurse, is open-ended and is used in
non-directive interview.

For example: How do you feel about that?

Leading question is usually closed, used in direct interview and

directs the client’s answer. This type of question can lead to
problems if the client, in an effort to please the nurse, give
inaccurate response.

For example: You will take the medicine, won’t you?

It is important to note NOT to ask questions staring with “why” as it

can be perceive as an interrogation by the client. Anything that puts
the client on the defensive will interfere with getting as much
purposeful information as possible.

Stages of the interview

The Opening can be the most important part of the interview as it

sets the tone for the remainder of the interview. The purpose is to
establish rapport and orient the interviewee.

The Body is where the clients communicate with what he or she

thinks, feels, knows and perceives in response to the question of
the nurse .Effective communication techniques must be used by the
nurse for effective development of the interview.

The Closing is where the nurse terminates the interview . It is done

once the needed information was obtained already. The closing is
important in maintaining rapport and trust and for facilitation future
interactions.

Examining
 Physical examination or physical assessment is a systematic data
collection methods that uses observation to detect health problems and
utilizing the techniques of inspection, auscultation, palpation and
percussion.

Physical examination can be done using the following approach:

Cephalocaudal or head-to-toe approach begins examination at the head,

progresses to the neck, thorax, abdomen, extremities and ends at the
toes.

Body system approach investigate each system individually, that is the

respiratory system, the circulatory system, the nervous system and so on.

A screening examination or review of systems may also be done to check

the essential functioning of the body parts and systems. An example of
this is the nursing admission assessment form.

Data gathered from this examination are measured against standard and
norms such as body temperature and blood pressure.

Organizing Data

In organizing data, the nurse uses written or electronic format that organizes the
assessment data systematically. This is referred to as a nursing health history,
nursing assessment or nursing database form.

Most nursing schools and health care agencies have developed their own
structured assessment format. Many of these are based on selected nursing
models or framework. Some of the frameworks used are as follows:

Conceptual Model or Framework:

1. Gordon’s Functional Health Pattern Framework

This provides a framework of 11 functional health patterns. Gordon uses

the word pattern to signify a sequence of recurring behavior. By using this
framework, nurses are able to discern emerging patterns by collecting
functional and dysfunctional behavior.
Validating Data

Complete, factual, and accurate information must be ensured during data

gathering or assessment phase because the nursing diagnosis and interventions
are based on this information. Validation is the act of double-checking or verifying
data to confirm that it is accurate and factual.

Validation is important as it helps the nurse complete the following:

o Ensure that assessment information is complete.

o Ensure that objective and related subjective data agree.
o Obtain additional information that may have been overlooked.
o Differentiate between cues and inferences. Cues are data that can be
observed directly by a nurse. It can be subjective or objective.
Inferences are the nurses interpretation or conclusion based on the
cues.
o Avoid jumping to conclusions and focusing in the wrong direction to
identify the problem.

To build an accurate database, nurses must validate assumptions regarding the

client’s physical and emotional behavior. Data validation is necessary if there is
discrepancies obtained in the nursing interview (subjective data) and physical
examination (objective data). However, not all data must be validated.
Information such as height, weight, birthday and most laboratory results or
studies that can be measured with an accurate scale can be accepted as factual.

Documenting Data

It is important to record the client’s data in a factual manner and not interpreted
by the nurse to complete the assessment phase. Accurate documentation is
essential and should include all the data collected about the client’s health
status. To ensure accuracy, the nurse records subjective data in the client’s own
words, using quotation marks.
ii. Diagnosing is the second phase and a pivotal step of the nursing process. Nurses
use critical thinking skills to interpret assessment data and identify client strengths and
problems. Activities during this phase are directed to formulating nursing diagnosis and
the plan of care for the clients. Nursing diagnosis relate primarily to the independent
nursing functions, that is , the areas of health care that are unique to nursing. However,
nurses are still responsible for identifying and responding to the data that indicate real
or potential medical problems Nursing diagnosis involve human responses, which vary
greatly from person to person. Therefore, the same set of nursing diagnosis cannot be
expected to occur with all persons who have that particular disease or condition.

In 1973, two faculty members of Saint Louis University, Kritine Gebbie and Mary Ann
Lavin recognized the need to identify nurse’ roles in an ambulatory care setting leading
to the identification and development nursing diagnosis. In 1977, the first international
recognition came with the first Canadian Conference in Toronto and the 1987 during the
International Nursing Conference in Calgary, Alberta, Canada. In 1982, North American
Nursing Diagnosis Association (NANDA) was accepted, recognizing the participation
and contribution of nurses in the United States and Canada. In 2002, the organization
changed the name to NANDA International to further reflect the worldwide interest in
nursing diagnosis.

NANDA International goal is to define, refine and promote a taxonomy of nursing

diagnostic terminology of general use to professional nurses. Taxonomy is a
classification or set of categories arranged based on a single principle or set of
principles.

NANDA Nursing Diagnosis

A nurse must be familiar with the definition of terms and components of nursing
diagnoses to use this concept effectively in generating and completing a nursing care
plan.

There are different kinds of nursing diagnosis according to status namely actual, health
promotion, risk and syndrome diagnosis. Status of the nursing diagnosis refers to the
actuality or potentiality of the problem/syndrome,

1. Actual Diagnosis is a client problem that is present at the time of the nursing
assessment and is associated with the presence of signs and symptoms.

Example: Ineffective breathing pattern and anxiety.

2. Health promotion diagnosis relates to the client’s preparedness to implement

behaviors to improve their health condition.

Example: Readiness for enhanced nutrition…

3. Risk nursing diagnosis is a clinical judgement that the problem does not exist,
but the presence of risk factors indicate that a problem is likely to develop unless
there is an intervention.

Example: Risk for infection…

4. Syndrome diagnosis is a clinical judgement by a nurse to describe a cluster of

nursing diagnosis that have similar intervention. Currently seven syndrome
diagnosis are on NANDA International list.

Components of NANDA Nursing Diagnosis

A nursing diagnosis has three components (1) the problem and its definition, (2)
the etiology, (3)the defining characteristics.

Problem (Diagnostic label) and definition

The problem statement or diagnostic label describes the client’s health

problem or response for which nursing therapy is given. Client’s health
status are clearly and concisely described in a few words. The purpose of
diagnostic label is to direct the formation of client goals, desired outcomes
and some nursing interventions. In formulating a problem statement,
qualifiers have been added to some NANDA labels to give additional
meaning. For example:

 Deficient (inadequate in amount, quality or degree, not sufficient

or incomplete)
 Impaired (made worse, weakened, damage, reduced,
deteriorated.
 Decrease (lesser in size, amount or degree)

Etiology (Related factors and risk factors)

This component of the nursing diagnosis identifies one or more probable

causes of health problem, gives direction to the required nursing therapy
and enables the nurse to provide an individualize client care.
Differentiating possible causes in the nursing diagnosis is essential
because each may require different nursing interventions. Note that each
diagnostic label approved by NANDA carries a definition that clarifies its
meaning.

Defining characteristics

These are the cluster of signs and symptoms that indicates the presence
of a particular diagnostic label. Risk nursing diagnosis does not have the
presence of subjective and objective signs. Thus factors that makes the
client vulnerable to the problem form the etiology for risk nursing
diagnosis.

Differentiating Nursing Diagnosis from Medical and Collaborative

Problems

A nursing diagnosis is a statement of nursing judgement and refers to

condition that nurses are license to treat. Nursing process describe the
human response, a client’s physical, sociocultural, psychological, spiritual
responses to illness or health problem. Nursing diagnosis change as the
client’s response change.

Medical diagnosis is made by the physician and refers to conditions that

only a physician can treat. Medical diagnosis refer to disease process,
meaning specific pathophysiologic responses that are fairly similar from
one client to another. Medical diagnosis is similar as long as the disease
process is present.

Collaborative problem is the type of potential problem that nurses manage

using both independent and physician-prescribed interventions. In a
collaborative problem, independent nursing interventions are focused
mainly on monitoring the client’s condition and preventing development of
potential complication. Collaborative problem is present as long as a
particular disease of treatment is present.

The Diagnostic Process

Critical thinking skills of analysis and synthesis is needed in the diagnostic

process. Review of data and considering explanations is important part of
critical thinking before making an opinion.

Analysis is the breaking down of the whole into its parts (deductive
reasoning). On the other hand synthesis is putting together of parts into
the whole (inclusive reasoning).

The diagnostic process is used continuously by nurses and has three

steps:

1. Analyzing data

2. Identifying health problems, risks and strengths

3. Formulating diagnostic statements

Analyzing Data

Analyzing in the diagnostic process involves three steps:

1. Compare data against standard (identify significant cues).

A standard or norm is a generally accepted measure, rule, model or

pattern. Nurses used wide range of standards such as growth, vital
signs, developmental pattern and laboratory findings. Nurses draw
on knowledge and experience to compare client data to standards
and norms and identify significant cues. A cue is considered
significant if it does any of the following:

- point to negative or positive change in a client health status or

pattern.

- Varies from norms of the client population.

- Indicates developmental delays.

2. Cluster cues (generate tentative hypothesis).

Clustering or grouping of cues is the process of determining the

relatedness of facts, determining if any patterns are present,
whether the data represent an isolated incidents and whether the
data is significant. This is the beginning of synthesis.

Nurses may cluster cues by combining data from different

assessment areas to form a pattern, begin with a framework such
as Gordon’s 11 Functional Health patterns and organize subjective
and objective data into appropriate categories (deductive
reasoning). Data clustering involves making inferences about the
data.

3. Identify gaps and inconsistencies.

Data analysis should include a final check to ensure that data are
complete and correct. Skillful assessment minimizes gaps and
inconsistencies in data. Conflicting data form inconsistencies.
Possible sources of conflicting data include measurement error,
expectations, and unreliable report.

Identifying health problems, risk, and strengths

 After data are analyzed, the nurse and the client together identify
strengths and problems that support tentative actual, risk, possible
diagnosis. In addition, the nurse must determine whether the client’s
problem is nursing diagnosis, medical diagnosis or collaborative problem.
This is primarily a decision-making process.

The nurse and the client also identifies the client’s strength, resources and
abilities to cope. By taking an inventory of strengths and resources, the
client can develop a more well-rounded self-concept and self-image. A
client’s strength can be found in the nursing assessment record such as
health, home life, education, recreation, exercise, friends etc.)

Formulating Diagnostic Statements

Most nursing statement are written as a two-part or three-part statement

but there are variations of these. For NANDA labels that contain the word
specify, the nurse must add words to indicate the problem more
specifically.

Basic two-part statements

Basic two-part statement includes the following:

1. Problem (P): Statement of the client’s response (NANDA label)

2. Etiology (E): factors contributing to or probable cause of the

response.

This type of statement is joined by the words related to which merely

implies a relationship rather than due to which implies that one part is
responsible for the other part.

Example:

Problem Related to Etiology

Constipation related to prolonged laxative use
Anxiety related to threat to physiological
integrity
possible cancer
diagnosis
Basic three-part statements

Because the signs and symptoms have been identified in this format, this
cannot be used for risk diagnosis. This format is specially recommended
for because the signs and symptoms validate the reason for the diagnosis
and make the problem statement more descriptive. This is also called PES
format and includes the following:

1. Problem (P): statement of the client’s response (NANDA label)

2. Etiology (E): factors contributing to or probe causes of the

response

3. Signs and symptoms (S): defining characteristics manifested by

the client

For nursing students, it is recommended to list the signs and symptoms on

the care plan below the nursing diagnosis, grouping the subjective (S) and
objective (O) data.

For example:

Noncompliance (Diabetes diet) related to unresolve anger about the

diagnosis as manifested by

(S) – “I forget to take my pills.”

“I can’t live without sugar in my food.”

(O) – Weight 98 kg (gain of 4.5 kg)

Blood pressure 190/100 mmHg

Basic three-part diagnostic statement example:

Problem Related Etiology As Manifested Signs and

to (r/t) by (a.m.b.) Symptoms
Situationa related Feeling of as manifested Hypersensitivity
l low self- to rejection by by (a.m.b.) to criticism;
esteem husband Client states “I
don’t know if I
can manage by
myself” and
rejects positive
feedback.
One-part statements

Any health promotion diagnosis will be developed a sone-part statements

beginning with the words Readiness for enhanced followed by the desired
higher level of wellness as specified by NANDA.

For example:

Readiness for enhanced parenting.

VARIATIONS OF BASIC FORMATS

Variations of the basic one-, two-, or three-part statement includes the

following:

1. Writing unknown etiology when the defining characteristics are present

but the nurse does not know the cause or contributing factors.

For example:

Non-compliance (Medication regimen) related to unknown etiology.

2. Using the phrase complex factors when there are too many etiologic
factors or when they are too complex to state in a brief phrase.

For example:

Chronic low self-esteem related to complex factors.

3. Using the word possible to describe either the problem or the etiology.
The word possible is inserted when the nurse thinks that more data are
needed about the client’s problem.

For example:

Possible low self-esteem r/t loss of job and rejection by the family.

4. Using secondary to, to divide the etiology into two parts, thereby making
the statement more descriptive and useful. The part following secondary
to is often a pathophysiologic or disease process or a medical diagnosis.

For example:

Risk for impaired skin integrity r/t decreased peripheral circulation

secondary to diabetes.
 5. Adding second part to the general response or NANDA label to make it
more precise.

For example:

Impaired skin integrity (left lateral ankle) r/t decreased peripheral

circulation.

COLLABORATIVE PROBLEM STATEMENT

All collaborative problems begin with the diagnostic label Potential

Complication (PC) as suggested by Carpenito-Moyet (2013). Nurses
should include in the diagnostic statement both the possible complication
they are monitoring and the disease or treatment that is present to
produce it.

For example:

Client has a head injury and could develop increase intracranial pressure.

Potential complication of head injury: increased intracranial pressure

In some situations, an etiology might be helpful in suggesting

interventions. Nurses should write etiology when (1) it clarifies the problem
statement, (2) it can be concisely stated, and (3) it helps to suggest
nursing actions.

For example:

Potential complication of childbirth: hemorrhage r/t retain placental

fragments.

It is important that nurses make nursing diagnosis with a high level of accuracy to
avoid some errors that is inherent in any human undertaking with no exception in
diagnosis. Errors can be avoided by recognizing and applying appropriate critical
thinking skills. In addition to the correct format, nurses must consider the content
of their nursing diagnostic statements. It should be accurate, concise, descriptive
and specific. Verifying data, building a good knowledge base and acquire clinical
experience, have a working knowledge of what is normal, consult resources,
based diagnosis on patterns that is, on behavior over time rather than on an
isolated incident and improve critical thinking skills can minimize diagnostic
errors.
Nurses must always validate the data with the client and compare client’s signs
and symptoms to the NANDA defining characteristics.

iii. Planning is a deliberative and systemic stage which involves problem solving
an decision making. Client assessment data and diagnostics statement are
important for the nurse to formulate client centered goals and the nursing
interventions that must be rendered in order to prevent, reduce, and/or eliminate
client’s health problems. Planning is a nurse responsibility. However, input from
the client ad other members of the health care team is essential in able for the
plan to be effective. Here, clients are encourage to actively participate as much
as possible in developing the plan of care as the effectiveness of the plan of care
depends largely on them. Planning begins from the first client contact and
continues until the nurse-patient relationship ends. This step of the nursing
process is multi-disciplinary and must include the client and family members to
the fullest extent possible.

Types of Planning:

Initial Planning is done upon admission of the patient. The nurse develops a
comprehensive plan of care based on the admission assessment performed.
This should be done immediately after the initial assessment is done.

Ongoing Planning allows the nurse to determine any changes in the client
health status, plan and determine priority nursing care needed. As nurse
gathered new information and evaluate the client’s responses to care, the can
modify and individualize the initial care plan further.

Discharge Planning this is the process of determining, planning and anticipating

the needs of the patient after discharge. An effective discharge planning begins
during the initial contact with the client and involves comprehensive and
continuous assessment to obtain information on client’s needs.

Planning leads to the creation of the formal nursing care plan and informal
nursing care plan.

Formal nursing care plan is a written or computerized guide that organizes

information about the client’s care.

- Standard Care plan is a formal plan that specifies the nursing care for
groups of clients with common needs. It is a pre-determined set of
interventions for a particular patient situation.
- Individualize Care plan is tailored to meet the unique needs of a specific
client—needs that are not addressed by the standardized plan.

Informal nursing care plan is a strategy for action that exists in the nurse’s
mind.

It is important that all members of the health care team and other caregivers work
towards the same outcome and use approaches shown to be effective with a
particular client.

Guidelines for Writing Nursing Care Plans

The nurse should use the following guidelines when writing nursing care plans:

1. Date and sign the plan.

The date the plan is written is essential for evaluation, review, and future
planning. The nurse’s signature demonstrates accountability to the client and to
the nursing profession, since the effectiveness of nursing actions can be
evaluated.

2. Use category headings. “Nursing Diagnoses,” “Goals/Desired Outcomes,”

“Nursing Interventions,” and “Evaluation” are the common headings.
Include a date for the evaluation of each goal.

3. Use standardized/approved medical or English symbols and key words rather

than complete sentences to communicate your ideas unless agency policy
dictates otherwise.

For example, write “Turn and reposition q2h” rather than “Turn and reposition the
client every two hours.” Or, write “Clean wound −c H2O2 bid” rather than “Clean
the client’s wound with hydrogen peroxide twice a day, morning and evening.”
See Table 15–4 on page 234 for a list of standard medical abbreviations.

4. Be specific. Because nurses are now working shifts of different lengths, with
some working 12-hour shifts and some working 8-hour shifts, it is even more
important to be specific about expected timing of an intervention. If the
intervention reads “change incisional dressing q shift,” it could mean either twice
in 24 hours, or three times in 24 hours, depending on the shift time. This
miscommunication becomes even more serious when medications are ordered to
be given “q shift.” Writing down specific times during the 24-hour period will help
clarify.

5. Refer to procedure books or other sources of information rather than including

all the steps on a written plan. For example, write “See unit procedure book for
tracheostomy care,” or attach a standard nursing plan about such procedures as
radiation- implantation care and preoperative or postoperative care.

6. Tailor the plan to the unique characteristics of the client by ensuring that the
client’s choices, such as preferences about the times of care and the methods
used, are included. This reinforces the client’s individuality and sense of control.
For example, the written nursing intervention “Provide prune juice at breakfast
rather than other juice” should indicate that the client was given a choice of
beverages.

7. Ensure that the nursing plan incorporates preventive and health maintenance
aspects as well as restorative ones. For example, carrying out the intervention
“Provide active-assistance ROM (range-of-motion) exercises to affected limbs
q2h” addresses the goal of preventing joint contractures and maintaining muscle
strength and joint mobility.

8. Ensure that the plan contains ongoing assessment of the client (e.g., “Inspect
incision q8h”).
9. Include collaborative and coordination activities in the plan. For example, the
nurse may write interventions to ask a nutritionist or physical therapist about
specific aspects of the client’s care.

10. Include plans for the client’s discharge and home care needs. The nurse
begins discharge planning as soon as the client has been admitted. It is often
necessary to consult and make arrangements with the community health nurse,
social worker, and specific agencies that supply client information and needed
equipment. Add teaching and discharge plans as addenda if they are lengthy and
complex.

THE PLANNING PROCESS

In the process of developing client care plans, the nurse engages in the
following activities:

• Setting priorities – is the process of determining the sequential priorities for

addressing nursing diagnosis and intervention. The nurse can identify nursing
problems into high, medium and low priorities.

- High priority are those life threatening problems such us impaired respiratory
and cardiac functions.
- Medium priority are those health threatening problems such as acute illness
and decrease coping abilities.
- Low priority are those that may result in delayed development or cause
destructive physical or emotional changes.

• Establishing client goals/desired outcomes – after establishing priorities, the

nurse and the client must set goals for each nursing diagnosis.

PURPOSE OF GOALS/DESIRED OUTCOMES

a. Provide direction for planning nursing interventions.

b. Serve as criteria for evaluating client progress.

c. Enable the client and nurse to determine when the problem has been
resolved.

d. Help motivate the client and nurse by providing a sense of achievement.

Goals maybe short-term or long-term.

COMPONENTS OF GOAL/DESIRED OUTCOME STATEMENTS

a. Subject – the client

b. Verb – action that the client needs to perform

c. Conditions or modifiers – explain the circumstances under which the behaviour

is to be performed.

d. Criteria of desired performance – standard by which a performance is

evaluated.

• Selecting nursing interventions and activities

• Writing individualized nursing interventions on care plans.

Kozier and Herbs Fundamentals of Nursing

iv. Implementing

This is the phase where the nurse put into action the plan of care. Nursing
interventions are delivered and carried out . The nurse also performs or
delegates the nursing activities and documents client’s responses to the nursing
interventions provided.
In this phase there are different skills that a nurse must have in order to deliver
safe and intelligent nursing care.

1. Cognitive skills is very important which include problem solving, decision

making, critical thinking, clinical reasoning and creativity which are crucial in safe
and intelligent nursing care.

2. Interpersonal Skills includes verbal and non-verbal activities that people use to
interact with each other. This is crucial in the effectiveness of nursing actions as
therapeutic communication and building trust and rapport plays an important role.

3. Technical skills are hands-on skills, tasks, procedures and/or psychomotor

skills. This require knowledge and manual dexterity or precision.

PROCESS OF IMPLEMENTING:

1. Reassessing the client

2. Determining the nurse’s needs for assistance.

3. Implementing the nursing interventions.

4. Supervising the delegated care.

5. Documenting nursing activities.

v. EVALUATING is the fifth phase of the nursing process. It is a planned,

ongoing purposeful activity to determine:

a. the clients progress towards achievement of goals and outcomes;

b. the effectiveness of the nursing care plan.

Conclusions made from the evaluation determine whether the nursing

intervention should be terminated, continued or changed. Evaluation is a
continuous process that helps the nurse make an immediate decision or
modifications in intervention. It is a process that is carried out until the client
achieve the health goals or outcome and is discharge.

FOCUS:

Assessing influences all subsequent steps of the nursing process and care plan.
Your assessment must be complete and accurate. If the data are incomplete or
inaccurate, the nurse reassess the client and record new data which may
indicate new nursing diagnosis, new desired goals or outcome and new nursing
interventions.
Diagnosing if done correctly with a complete database, the nurse must analyze
whether the problems are identified correctly and whether the nursing diagnosis
were relevant to the database.

Planning if the nursing diagnosis was appropriate, the nurse checks if the goal or
desired outcome were realistic and attainable. Unrealistic goals require
correction. The nurse should also determine whether priorities have changed and
whether the client agrees with the priority.

The nurse also check whether the nursing interventions were related to the
achievement of goal and whether the best nursing interventions were selected.

Implementing is carrying out the planned nursing interventions. The nurse must
check the manner of implementation and whether they were carried out
accordingly especially if the plan of care involves participation of other health
care personnel.

Example of complete nursing process and care plan for patient with diarrhea.

Evaluation demonstrate nurses responsibility and accountability for their actions.

Successful evaluation defends on the accuracy, effectiveness and completeness
of the first four phases of the nursing process.

Evaluating and assessing phases of the nursing process overlap. One The
differences lie on the following:

a. when the data are collected;

b. how the data are used.

Note that, during the assessing phase, data are collected for different purposes
at different phases of the nursing process such as gathering data for the purpose
of making nursing diagnosis. While on the evaluation phase, data are collected
for the purpose of comparing it to set goals and outcome and determining the
effectiveness of the nursing intervention.

The evaluation phase has 5 important components namely:

1. Collecting data related to the desired outcome or goal.

2. Comparing the data with the desired outcome.

3. Relating activities to outcome.

4. Drawing conclusion about the problem status.

5. Continuing, modifying or terminating the nursing care plan.

NURSING CARE PLAN FOR DIARRHEA

Diagnosis Desired Outcome Nursing Interventions Rationale Evaluation
Subjective (S) Data: Diarrhea r/t After 8 hours of Obseve and record the To determne if there is a After 8 hours of
Exposure to nursing care, the frequency, amount, need for hydration nursing intervention,
"My stomach cramps unsanitary food patient will be able time, and replacement and the goal is partially
and I had to go to the preparation as to re-establish and characteristics of stool. possible causative met as evidenced by
toilet for several manifested by maintain normal factors. reduction of
times." - stated by (a.m.b.) client bowel functioning. Restrict foods These foods can cause
frequency in passing
containing caffeine, too stoamch irritation
the client verbalizing "my stool to 2x from 5x
much oil, milk. which can make the
stomach cramps
condition worse.
"I ate street food, and I had to go to Encourage client to The bland nature of
adidas, then after a the toilet for severl have BRAT (banana, these food, starchy and
while I got stomach times," passing of rice, apple juice, toast) low fiber has a binding
cramps." as verbalize loose watery stool diet effect in the digestive
by the patient for 5x in the last 6 tract.
hours. Encourage to increase Hydration is very
Obhective (O) Data: fluid intake especially important in client
those containing with diarrhea.
Passes loose watery electrolytes.
stools for 5x in the
last 6 hours. Provide quiet and non- Stress can trigger
stimulating passing of stools.
environment and teach
Ate "adidas" (grilled
client relaxation
chicken feet) a day
techniques to decrease
prior to onset of
stress.
symptoms
Administer anti- To control diarrhea and
BP = 120/80 mmHg diarrheal agent/s as stop any other
prescribed. complications such as
PR = 87 bpm dehydration.
Educate on food To prevent outbreaks
Skin warm and moist preparation and and spread of infectious
importance of good disease and help client

EVALUATION:

A quiz will be given in a synchronous manner which will be given through your
LMS for online learners.

For modular learners, please accomplished the required activity below.

Create a CONCEPT MAP for this situation:

 Ms. Monstera Peru, 21 year, was brought to the hospital with chief complaint of
difficulty of breathing, chest pain, fever and diarrhea. She was admitted with the
diagnosis COVID-19 Confirmed. Upon assessment of the admitting nurse, Ms.
Peru’s vital signs are as follows: BP = 130/90, PR = 110 bpm, RR = 25 cpm
Temperature = 38.9 degrees Celsius. Ms. Peru is using accessory muscle for
breathing, have flushed skin and is holding her chest as if massaging it. Ms.
Peru, told the nurse that “nahihirapan akong huminga” and “mamatay na baa ko.”

I. APPLICATION:

For the situation given:

Ms. Monstera Peru, 21 year, was brought to the hospital with chief complaint of
difficulty of breathing, chest pain, fever and diarrhea. She was admitted with the
diagnosis COVID-19 Confirmed. Upon assessment of the admitting nurse, Ms.
Peru’s vital signs are as follows: BP = 130/90, PR = 110 bpm, RR = 25 cpm
Temperature = 38.9 degrees Celsius. Ms. Peru is using accessory muscle for
breathing, have flushed skin and is holding her chest as if massaging it. Ms.
Peru, told the nurse that “nahihirapan akong huminga” and “mamatay na baa ko.”

List 3 Nursing diagnosis, make a Nursing care plan. Present your nursing
care plan according to priority.

Submission of all you work must be done on not later than 2nd July 2021.

NOTE: PLEASE MAKE YOUR OWN ANALYSIS AND NCP’s any copying
either from your classmates or the internet will automatically merit a ZERO
“0” score.

II. WEEK 2 MODULE: LEARNING CONTENT

There are two aspects of assessing client’s health status namely (1) nursing health
history and (2) physical examination.

Obtaining health history is an excellent way to start the assessment process. It paves a
way for identifying nursing problems and gives direction to the physical examination.
This will also assist the primary care provider or the examiner in identifying the areas of
strength and limitation of an individual’s lifestyle and current health status.
Physical assessment or examination has three types: (1) a complete assessment, (2)
examination of the body system, and (3) examination of the body area. A complete
assessment may be done from head-to-toe which is a systematic manner downward.
However, the procedure can vary according to the age of the individual, the severity of
of the illness, the preference of the nurse, the location of the examination and the
agency’s priorities and procedures.

This module will focus on nursing health history.

Taking health history should begin with an explanation to the client of why the
information is being requested. The health history has 8 sections:

1. Biographic data

2. Reasons for seeking health care

3. history of present health concern

4. Personal health history

5. Family health history

6. Review of body systems for current health problems.

7. Lifestyle and health practices

8. Developmental levels

Biographic Data:

This includes information which will identify the client such as name, address, phone
number, gender, date of birth and who provided the information. Other information such
as medical data record number (if any) or any similar identifying data may be included.
Client is considered as the primary source of information and the all other sources are
considered secondary sources.

To determine the client’s culture, ethnicity and subculture, collecting information such as
date and place of birth, nationality, ethnicity, marital status, religious and spiritual beliefs
and practices, primary and secondary language spoken, written and read is important.
This will help the nurse identify special needs and practices that may affect the care
plan that will be given to the client. Gathering information about the client’s level of
understanding such as educational background and working status aids the nurse and
medical practitioner if communicating effectively.
Knowing the people or family members and/or significant others living with the client
provide information of the availability of possible caregivers and support person for the
client.

Reasons for Seeking Health Care

This may involve two basic but important question. First, “What is you major health
problem or concerns at this time?” This will also provide information of the client’s chief
complaint (CC), which is also the reason why the client is seeking medical help. A more
holistic approach in phrasing and delivering the question may lead out to further
information that goes beyond the physical complaint and stress on lifestyle changes.
Second, “How do you feel about having to seek health care?” This question encourages
the client to discuss fears and /or other feelings about having to see a heath care
provider.

History of the Present Health Concern

This takes into account several aspects of the health problem. Encouraging the client to
explain the health problem or symptom by giving as much details as possible by
focusing on the onset, progression, duration of the problem, signs and symptoms and
what the client perceives caused the problem is By assessing the Character, Onset,
Location, Duration, Severity, Pattern and Associated factors (COLDSPA) or
Provocation, Quality/Quantity, Region/Radiation, Severity Scale and Timing (PQRST)
helps the nurse complete this assessment effectively.

Note: COLDSPA and PQRST are some of the mnemonic used to help the nurse
remember the process easily.

Mnemonic Question
Character Describe the sign or symptom (feeling, appearance,
sound, smell, or taste). “What does the pain like?”
Onset When did it begin?
When did this pain start?
Location Where is it? Does it radiate? Does it occur anywhere
else?
Duration How long does it last? Does it come and go or is it
constant?
Severity How bad is it? How much does it bother you? How
intense is the pain?
Pattern What makes it better or worse?Are there any
treatment you’ve tried and relieve the pain?
Associated factors/ How it What other symptoms occur with it? How does it
affects the client affect you? What do you think caused it to start?
Components of the COLDSPA symptom analysis mnemonic. J. Weber and J. Kelly,
Health Assessment in Nursing, 5th Edition

Mnemonic Question
Provocation/ Palliation
What were you doing when the pain started? What caused
it? What makes it better or worse?
What relieves and aggravates the pain?
Region/ Radiation Where is the pain located? Does the pain radiate?
Severity scale How severe is the pain from a scale of 1-10?
Timing When or at what time does the pain start? How log did it
last?
PQRST of Pain Assessment

The client answers to the questions provide the nurse with a great deal of information
about the client’s problem and how it affects client’s lifestyle and activities od daily living
(ADL). This also helps the nurse gain insight on how the client view the problem and
his/her plan managing it.

Personal Health History

This will involve information about any childhood illnesses and immunization to date.
Adult illnesses including physical, emotional and psychological are being assessed.
Information on past surgeries and accidents, any prolonged episodes of pain, allergies
and use of over the counter medications are asked. These data provide information
related to the client’s strength and weaknesses in relation to his/her health history.

Information covered in this section also includes questions about birth, growth,
development, childhood diseases, immunization, allergies, medication use, previous
health problems, hospitalization, surgeries, pregnancy, births, previous accidents,
injuries, pain experiences, and emotional or psychiatric problems.

Not all clients will be very cooperative about providing their past health status. It will be
helpful to have a series of alternative questions for such clients and for those who may
not understand what is being asked.

Family Health History

Family health history plays an important role in a health of an individual. An increasing

number of health problems that seems to run in the families and are genetically based.
Being exposed to these problems may help in awareness and predisposition that may
have affected the client. This should include as many relatives genetically that the client
can recall. Thorough assessment may identify those diseases that may skip a
generation like autosomal recessive disorders. Family health history will include
paternal and maternal grandparents, aunts and uncles on both sides, parent’s siblings
and client’s children. A genogram may help to organize and illustrate the family health
history.

Review of Systems (ROM) for Current Health Problems

This is also called as the review of body systems. A client is asked questions that may
give information to current health problems or those experienced in the past that may
still affect the client or are recurring. Note, that in the review of body system, care must
be taken only to subjective information provided by the client. A nurse must document
the client’s descriptions of his/health status for each body system and to take note of the
client’s denial of any signs, symptoms, diseases or problems that was asked.

Here are the different body part/systems hat is involved in this assessment:

1. Skin, Hair, and Nails

2. Head and Neck

3. Eyes

4. Ears

5. Mouth, throat, nose and sinuses

6. Thorax and Lungs

7. Breast and regional lymphatics

8. Heart and Neck vessels

9. Peripheral Vascular

10. Abdomen

11. Male Genitalia

12. Female genitalia

13. Anus, rectum and prostate

14. Musculoskeletal

15. Neurologic

Lifestyle and Health Practices Profile

This section of the client’s health history deals with his/her human responses which
involves nutritional habits, activity and exercise patterns, sleep and rest patterns, self-
concept and self-care activities, social and community activities, relationship, values
and belief system, education and work, stress level, coping style and environment.

This will give a picture on how clients manage their everyday living, awareness on good
and healthy living patterns and their strength and available support system.

Description of a typical day is important to know how the client sees his usual daily
activity pattern. Note that the question should be vague enough in able for the client to
give the orientation from which the day is viewed and encourage the client to provide
information on activities during a usual day.

Q: “Please tell me what an average or typical day is for you? Start with awakening in the
morning and continue until bedtime.”

Nutrition and Weight Management involves knowing and asking the client what consist
of an average 24-hour intake and give focus on the foods eaten, snacks and fluid intake
and other substances consumed and in what amount. You may also ask depending on
the client who buys and prepares the food and when or where meals are eaten.
Whatever the client’s response is should be compared with the guidelines in the food
pyramid.
The messages this time around have changed slightly to emphasize different things.

1. Chose lower sodium foods

2. Make half your plate fruits and vegetables

3. Chose low fat or no fat dairy products

4. Eat smaller portions

5. Eat whole grains

6. Drink water over sugary drinks

7. Cut back on fatty, sugary foods

8. Balance your calorie intake with exercise

Information gathered in nutritional assessment gives an insight on the overall health

status of the patient. It identifies risk factor for obesity and is also used as a guide in
health promotion. Nutrition refers to a complex process by which nutrients are ingested,
digested, absorbed, transported, used and the excreted.

Essential nutrients includes carbohydrates, proteins, fats, vitamins, minerals, and water.

Q: What do you usually eat during a typical day? Please tell me the kind of foods you
prefer and how often you eat throughout the day and how much you eat.”

Activity level and exercise shows how active the client is during an average week either
at home or at work. Ask about client’s regular exercise and distinguish between activity
done when working and exercise which is designed to reduced stress.

Q: “What is your daily pattern of activity?”

“Do you follow a regular exercise plan? What type of exercise do you do?

Sleep and rest, will explore the client’s perception on whether he/she is getting enough
sleep and rest. It should focus on specific sleep patterns and how many hours a night a
person sleeps, interruptions, and whether the client feel rested, is there any problem
sleeping, rituals to promote sleep and any concerns the client might have regarding
sleeping habbits.

Q: “Tell me about your sleeping pattern.”

“Do you have trouble falling asleep or staying asleep?”

Substance use or abused provides information concerning lifestyle and a client’s self-
care ability as substance abuse can affect the client’s health and cause loss of function
or impaired senses.

Developmental Levels

Knowledge on the normal growth and development provides a nurse a framework for
health assessment and health promotion throughout lifespan. Growth and development
is a dynamic process and is often used interchangeably. GROWTH is a physical change
and can be measured quantitatively. Development on the other hand, is an increase in
the complexity of function and skill progression. Both are independent and interrelated
process.

Stages of Growth and Development:

Kozier & Erb’s Fundamentals of Nursing

There are different developmental theories related to growth and development. Some
of the these are:

1. Sigmund Freud contributed the Theory of Psychosexual Development with five

overlapping stages of personality development from birth to adulthood. Here the libido
changes it’s location of emphasis from one stage to another.
Kozier & Erb’s Fundamentals of Nursing

2. Erik H. Erikson adapted and expanded Freud’s developmental theory to include the
entire lifespan, believing people continue to develop throughout life and proposes that
life is a sequence of developmental stages or levels of achievement where each stage
signals a task that must be completed. Erikson’s theory has become known as
Psychosocial Development theory.
J. Weber & J. Kelly, Health Assessment in Nursing 5th Edition

Each person can be assessed as a comparison to the developmental domains

(psychosexual, psychosocial, cognitive and moral).

Psychosocial History

A cognitive level of functioning (thinking, knowledge, problem solving) and emotional

functioning (feelings, mood, behaviors, stability)also refers to client mental status.
Mental health is very important as one cannot be totally healthy without mental health
which is more than just the absence of mental disabilities and disorders.

A healthy status is needed to think clearly and respond appropriately to function

effectively in all activities of daily living. This manifest in a person’s appearance,
behavior, speech, thought patterns, decision and relationships.
Factors affecting Mental health:

There are several factors that affect mental health which include the following:

1. Economic and social factors

2. Unhealthy lifestyle choices

3. Exposure to violence

4. Personality factors

5. Spiritual factors

6. Cultural factors

7. Changes and impairment in the structure and function of the neurologic system.

8. Psychosocial developmental levels and issues.

The nurse observation of the client’s behaviors and answers to the interview questions
gives way to the assessment of his/her mental health. It is important to note for all
verbal and non-verbal ques that reflects the client mental status from the very first
interaction you have with the client. While doing the interview the nurse may encounter
a variety of emotions expressed by the client.
Appendix:

I. Nursing Health Assessment Tool Format

II. Sample Genogram

III. Mental Assessment Guide

IV. Nutritional Assessment Guide

V. Developmental Level Assessment Guide

VI. 24-Hour Diet Recall for Client

VII. Assessment Tool: Nutritional History

VIII. Assessment Tool: Speedy Checklist for Nutritional Health

 Mental Health Assessment Guide

BIOGRAPHICAL DATA
Question Rationale
What is your name, address, and
telephone number?
How old are you? What is your date of
birth? Note if the client is a male or
female
What is your marital status?
What is your educational level and where
are you employed?
HISTORY OF PRESENT HEALTH CONCERN
What is your most urgent health concern
at this time? Why are you seeking health
care?
Are you experiencing any other health
problems? Do you have headaches?
Describe. Do you ever have troubled
breathing or heart palpitations.
PERSONAL HEALTH HISTORY
Have you ever received medical treatment
or hospitalization for a mental health
problem or received any type of
counselling services? Explain.
Have you ever had any type of head
injury, meningitis, encephalitis, or a
stroke? What changes in your health did
you notice as a result of these?
Do you have headaches? Describe.
Have you ever served on an active duty in
the armed forces? Explain.
FAMILY HISTORY
Is there a history of mental health
problems (anxiety, depression, bipolar
disorder, schizophrenia or Alzheimer’s
disease in your family?

How are they treated? Was the treatment

effective?
LIFESTYLE AND HEALTH PRACTICES
Does your present health concern affect
your activities of daily living? Describe a
typical day. Describe your energy level.
Describe your normal eating habits.
Describe your daily bowel elimination
pattern.
Describe your sleep patterns.
Describe any exercise regimens.
Do you drink caffeinated beverages?
If so how many per day?
Do you take any prescribed or over-the-
counter medications?
Do you drink alcohol? If so, what type, how
much and how often?
Do you use recreational drugs such as
marijuana, tranquilizers, barbiturates, crack
or cocaine? If yes, how much do you use
and how often?
Have you been exposed to any
environmental toxins?
What religious affiliations do you have?
What religious activities are important to
you? What religious affiliated practices do
you participate in on a regular basis?
How do you feel about yourself and your
relationship with others?
Describe your support systems and how are
you using those at this times?
What do you perceive as your role in your
family or relationship with your significant
other? Who do you care for on a daily
basis?
Describe the current stressors in your life.
How do you feel about the future? Have
you ever had thoughts of hurting yourself or
doing away with yourself?
 Nutritional Assessment Guide

HISTORY OF PRESENT HEALTH CONCERN

What are your height and normal weight?
Have you lost or gained a considerable
amount of weight recently? How much?
Over what period of time?
Are you now or have you been on a
specific diet recently? How did you decide
which diet to follow?
How much fluid do you drink each day?
How much of it is water? How many of
these beverages that you consume daily
contain sugar, artificial sweetener, caffein
or alcohol?
Can you recall what you ate in the last 24
hours? In the last 72 hours?
Any recent changes in appetite, taste, or
smell? Any recent difficulty chewing or
swallowing?
Have you had any recent occurrences of
vomiting, diarrhea, or constipation?
PERSONAL HEALTH HISTORY
Do you have food allergies and/or food
that you cannot eat? If so, please explain
what they are and your symptoms.
Do you have chronic illness?
Have you experienced any recent trauma,
surgery, or serious illness?
What current medications, natural herbs,
vitamins/supplements are you taking?
FAMILY HISTORY
Are any members of your family obese?
Do any closely related family members
have chronic illness such as digestive
disorders, heart disease, or diabetes?
LIFESTYLE AND HEALTH PRACTICES
Do your religious beliefs or culture have
dietary restrictions or requirements?
What do you eat on a typical day? How
much do you drink and what type of fluids
do you drink?
Do you prepare your own meals? If not,
who in your household typically assumes
responsibility?
Describe how your food is stored, cooked,
and served. How it is dated and labeled?
How often per week do you typically eat
your breakfast, lunch, and dinner away
from home?
If you eat meals away from home, in a
typical week, where do you go and which
meals do you eat?
What type of foods do you typically
purchased?
What is your weekly monetary budget for
food purchases?
Where do you typically purchase your food?
Do you take any prescribed or over-the-
counter medications?
Do you follow an exercise regimen?

Developmental Level Assessment Guidelines

BIOGRAPHICAL DATA
Question Rationale
How old are you?
Where were you born? How long have
you been in this country?
Where is your place of birth? Tell me
about the places where you have lived.
When?
With what cultural group/s do you most
identify? What is your primary language?
When do you speak it? Are you fluent in
other languages?
What is your highest level of formal
education?
Discuss your history of employment. How
do you presently make a living and
maintain your everyday needs?
HISTORY OF PRESENT HEALTH CONCERN
Describe how you are feeling right now.
What concerns do you have about your
health? Describe any changes you have
recently experienced in your health.
Discuss any concerns you have about your
body weight.
What major stressors are you currently
experiencing? How do you cope with
stress? When you are having a problem,
how do you usually handle it? Does this
work? To whom do you turn when you are
having a conflict/crisis?
Do you have any trouble making
decisions?
Please give me some examples of recent
decisions you have had to make.
Tell me about life changes you have had
to make and/or need to make. How will
you make these changes?
PERSONAL HEALTH HISTORY
How would you describe yourself to
others?
What are your strengths and weaknesses?
What is the best method of learning for
you?
Have you ever been treated for a
psychological or psychiatric problem? If
so, please explain if this treatment helped
you deal with problems.
Please tell me about any prescribed
medications, herbs, or supplements you
are currently taking.
Please tell me about any over-the-counter
medication/herbs you are currently
taking.
Please tell me about your current medical
treatment or therapy you are undergoing.
Describe any changes you have recently
experienced concerning your weight,
eating, elimination patterns and sleep.
Please tell me about any allergies or
sensitivities you have.
Describe any chronic illness with which
you have been diagnosed. How has your
life changed since you were diagnosed?
FAMILY HISTORY
Whom do you consider to be your family?
Describe your life growing as a child.
Do you have brothers? Sisters?
Tell me about them and your relationship
with them.
Discuss any significant genetic
predisposition or characteristic trait or
disorder that you believe you have
inherited.
 EVALUATION:

1. Using the Nursing Health History Format, assess a member of your

household. Make a thorough assessment in relation to the following:

I. Biographic Data

II. Reasons for seeking health care (you can use the recent experience or
scenario why health care assistance was needed).

III. History of Present Health Concern (use COLDSPA format)

IV. Past Health History

V. Family Health History

VI. Lifestyle Practices

VII. Developmental Level

VII. Psychosocial History (Mental Assessment)

2. From your assessment data, create 3 NCP’s related to possible and

actual problems you can identify in your assessment.

Note: You will NOT be doing Review of Systems ad this will be discussed further
in your Health Assessment Laboratory.

II. APPLICATION:

1. Using the Nursing Health History Format, assess a member of your

household. Make a thorough assessment in relation to the following:

I. Biographic Data

II. Reasons for seeking health care (you can use the recent experience or
scenario why health care assistance was needed).

III. History of Present Health Concern (use COLDSPA format)

IV. Past Health History

V. Family Health History

VI. Lifestyle Practices

VII. Developmental Level

 VII. Psychosocial History (Mental Assessment)

2. Make your OWN GENOGRAM. From the genogram that you have, make
an analysis of possible and actual problems that you may get or have.

NOTE: PLEASE MAKE YOUR OWN GENOGRAM and ANALYSIS.

II. WEEK 3 MODULE: LEARNING CONTENT

Pregnant woman, newborn, children and older adults belong to the special client group.
These group are one of the major focus of the nursing practice as to have a healthy
adults, one must have a healthy children. Health assessment of a childbearing woman
helps to recognize and avoid health problems that might occur before, during and after
birth. Nurses works closely with expecting parents during pregnancy. Newborn
assessment immediately start the moment he/she is delivered. The doctor or the nurse
must immediately gently clears mucus and other material from the mouth and throat in
able for them to take a breath. As ageing cannot be prevented, care of the elderly
requires more time, resources and energy than younger patients.

Health Assessment in a Childbearing Woman:

During pregnancy, physiologic and anatomic changes occur. These changes are
influenced by estrogen and progesterone which are the hormones of pregnancy.

SKIN, HAIR and NAILS:

Hormonal changes results in different changes in the Integumentary system. Estrogen,

Progesterone and melanocyte-stimulating are the primary hormones involved in these
change. Hyperpigmentation occurs and mostly noted in the abdomen. Some of the
changes noted during pregnancy are: (1)Linea nigra, a dark streak down the midline of
the abdomen, (2) Chloasma also known as mask of pregnancy which is a blotchy
brownish hyperpigmentation, over the forehead, cheeks and nose, (3) Striae
gravidarum or the reddish purple stretch marks on the abdomen, breast, thighs and
upper arms occur.

EARS and HEARING:

Pregnant woman may experience a sense of fullness in the ears, earaches and
decreased hearing because of the increase vascularity of the tympanic membrane and
blockage of the eustachian tubes.
BREASTS:

Due to the increase in estrogen and progesterone, there is a notable changes in the
mammary glands. Breast size increases and may become tender. Nipples become
more pronounced. The areola become darker in color and superficial veins become
prominent. Hypertrophy of Montgomery’s occur and colostrum may leak from the breast.

HEART:

Cardiovascular changes also occurs, blood volume circulating in the system increases,
plasma increases and the total red blood cell volume also increases by approximately
40% to 50%. This will lead to an increase work load of the heart and will lead to an
increase in size of 1 to 1.5 cm and heart rate is elevated by 10 to 15 beats per minute.
Physiological anemia occurs and iron requirements are increased.

THORAX and LUNGS:

The client respiratory pattern changed during pregnancy. Diaphragm is elevated

because of the enlarge uterus. Shortness of breath is a common experienced. Oxygen
requirements increases by approximately 15 to 20%.

RENAL SYSTEM:

The expanding uterus exert pressure to the bladder, kidney and ureters. This lead to
frequency of urination which increases in the first and third trimester. Decreased bladder
tone may occur and is due to an increase in progesterone and estrogen levels.

GASTROINTESTINAL SYSTEM:

The enlarging uterus applies pressure and displaces the small intestines. Nausea and
vomiting may occur as a result of the secretion of human chorionic gonadotropin which
subsides typically on the third month. Increase in progesterone production or pressure
of the uterus trigger decrease gastric motility and may lead to poor appetite and
constipation. Alteration of taste and smell may also happen.

REPRODUCTIVE SYSTEM:

The uterus enlarges and increased in mass from approximately 60 to 1000 grams as a
result of hyperplasia and hypertrophy. The size and number of blood vessels also
increases. Irregular contractions occur typically beginning 16 weeks of gestation.

The cervix becomes shorter, more elastic and larger in diameter.

The ovaries secrete progesterone for the first 6 to 7 weeks of pregnancy and the
maturation of new follicles is blocked which lead to the cessation of ovum production.
There is a thickening and hypertrophy of the vaginal muscles and an increase in vaginal
secretion is experienced which is usually thick, white and acidic.

PSYCHOLOGICAL MENTAL CHANGES:

Ambivalence which is a simultaneous and contradictory attitude or feeling occur early in

pregnancy. Acceptance leads to the need of task accomplishment such as accepting
the pregnancy, identifying with the mothering role, solidifying her relationship with her
partner, establishing a relationship with her unborn infant, and preparing for her birth
experience.

HEALTH ASSESSMENT: COLLECTING SUBJECTIVE DATA

A complete health history is necessary in able to provide high quality care for the
pregnant client. The first pre-natal visit is focused on collecting baseline data about the
client and her partner, and identification of risk factors.

Childbearing Woman Assessment Guide

BIOGRAPHICAL DATA
Question Rationale
What is your name, address, and
telephone number?
How old are you? What is your date of
birth? Note if the client is a male or
female
What is your marital status?
What is your educational level and where
are you employed?
HISTORY OF PRESENT HEALTH CONCERN
What was your normal weight before
pregnancy? Has your weight changed
since a year ago? How much weight have
you gained since your last menstrual
period?
Have you ever had fever, chills, except
with cold since your last menstrual cycle?
Is your nose often stuffed up when you
don’t have cold? Have you experience
more frequent nosebleeds while
pregnant?
Do you have any trouble with your throat?
Do you have a cough that hasn’t gone
away, or do you have frequent chest
infections?
Do you have nausea or vomiting that
doesn’t go away? Is your thirst greater
than normal?
Do you ever have bloody stools? Do you
have any change in bowel habits? Do you
have difficulty when trying to have bowel
movement?
Do you experience a burning sensation
while urinating?
Do you have vaginal bleeding, leakage of
fluid or vaginal discharge?
Have you lost interest in eating? Do you
have trouble falling asleep or staying
asleep? Do you ever feel depressed or feel
like crying for no reason? Are problems at
home or work bothering you? Have you
ever thought of suicide? Have you ever
had professional counselling?
Have you noticed breast pain, lumps or
fluid leakage?
Have you thought about breast-feeding or
bottle feeding your infant?
Are there any problems or concerns you
may have that we haven’t discussed yet?
PERSONAL HEALTH HISTORY
Will you be 35 years or older when the
baby is born? Are you and the baby’s
father related to each other?
List the number of times you have been
pregnant, beginning with the first
pregnancy.
Describe your previous pregnancies
including the child’s name, birth date,
birth weight, sex, gestational age, type of
delivery (is CS, discuss the reason).
Did you experience any complication
during pregnancies?
Describe any neonatal complications such
as birth defects, jaundice, infection, or any
problems within the first 2 weeks of life.
Describe any perinatal or neonatal losses,
including when the loss occurred and the
reason for the loss, if known. Have you
ever had a child die in the first year of life?
Discuss previous abortions (spontaneous
or elective), including proce- dures
required and gestational age of fetus.
Have you had two or more pregnancies
that ended in miscarriage?
Have you ever had a hydatidiform mole
(molar pregnancy)?
Have you ever had a tubal (ectopic)
pregnancy (pregnancy outside of the
uterus)?
Do you have regular periods? When was
the first day of your last menstrual
period? Was this period longer, shorter, or
normal? Have you had any bleeding or
spotting since your last period? Are your
periods usually regular or irregular?
Describe the most recent form of birth
control used. If you’ve used birth control
pills in the past, when did you take the
last pill?
Have you had any difficulty in getting
pregnant for more than 1 year?
Have you ever had any type of
reproductive surgery? Have you ever had
an abnormal Pap smear? Have you ever
had any treatment performed on your
cervix for abnormal Pap smear results?
When was your last Pap test, and what
were the results?
Do you have a history of having any type
of sexually transmitted infections (STIs)
such as a chlamydial infection, gonorrhea,
herpes, genital warts, or syphilis? If so,
describe when it occurred and the
treatment. Does your partner have a
history of STI? If so, when was he treated?
Do you have a history of any vaginal
infections such as bacterial vaginosis,
yeast infection, or others? If so, when did
the last infection occur and what was the
treatment?
Do you know your blood type and Rh
factor? If you are Rh negative, do you
know the Rh factor of your partner?
Have you ever received a blood
transfusion for any reason? If so, explain
reason and provide date.
Do you have a history of any major
medical problem (e.g., heart trouble,
rheumatic fever, hypertension, diabetes,
lung problems, tuberculosis, asthma,
trouble with nerves and/or depression,
kidney disease, cancer, convulsions or
epilepsy, abnormality of female organs
[uterus, cervix], thyroid problems, or
hearing loss in infancy)?
Do you have diabetes?
Have you had twins or multiple gestation?
Do you have a history of medication, food,
or other allergies? If so, list the allergies
and describe the reactions.
Have you ever been hospitalized or had
surgery (not including hospitalizations or
surgery related to pregnancy)? If so,
discuss the reason for the hospitalization
or surgery, the date, and if the problem is
resolved today.
Are you currently taking any medications
(either prescription or nonprescription) or
have you taken any since you have
become pregnant? If so, list the
medication, the amount taken, the date
you started taking it, and the reason for
taking it.
Are your immunizations up to date? Have
you received the influenza immunization
this year?
FAMILY HISTORY
Do you have a child with a birth defect?
Do you have any type of birth defect or
inherited disease such as cleft lip or cleft
palate, club- foot, hemophilia, mental
retardation, or any others? Are there any
members in your family with a birth
defect, inherited disease, blood disorders,
mental retardation, or any other
problems? What is your ethnic or racial
group: Jewish, Black/African, Asian,
Mediterranean (e.g., Greek, Italian),
French Canadian?
Has anyone in your family (grandparents,
parents, siblings, children) had rheumatic
fever or heart trouble before age 50
years?
Has anyone in your family had lung
problems, diabetes, tuberculosis, or
asthma?
Has anyone in your family been diagnosed
with any type of cancer? If so, what kind?
LIFESTYLE AND HEALTH PRACTICES
Since the start of this pregnancy, have you
had drinks containing alcohol almost every
day or frequently?
Do you smoke? If so, how much do you
smoke per day?
Have you used cocaine, marijuana, speed,
or any street drug during this pregnancy?
Does anyone in your family consider your
social habits to be a problem? Do your
social habits interfere with your daily living?
If so, please explain.
What is a normal daily intake of food for
you? Are you on any special diet? Do you
have any diet intolerances or restrictions? If
so, what are they?
Do you eat lunchmeats or unpasteurized
milk products?
Do you currently take any vitamin
supplements? If so, what are they?
Do you exercise daily? If so, what do you do
and for how long?
Have your normal daily activities or exercise
ever had a negative impact on your
previous pregnancies? If so, please discuss.
Do you perform any type of heavy labor
(lifting > 20 lb) while work- ing or while at
home? If so, please describe.
Are you easily fatigued? Do you require
more sleep than 8 hours/ day? Do you get
fatigued with your daily routine of
work/family life? Do you get fatigued by
performing daily household chores, such as
cleaning, running errands, etc? If so, please
describe. What are your normal sleeping
patterns?
Do you frequently have rest periods? If so,
for how long?
Have you or your partner ever worked
around chemicals or radiation? If so, please
explain. Are you exposed to an excessive
amount of tobacco smoke daily?
Do you have a cat? If so, are you exposed to
cat litter or cat feces?
What is your occupation?
What are your typical daily activities? Who
do you interact with each day? Do you find
work, activities, and the people you
encounter in them supportive or stressful?
Discuss your feelings about this pregnancy.
Is the father of the baby involved with the
pregnancy? How does your partner feel
about the pregnancy? To what degree do
you feel that the father of the baby will be
involved with the pregnancy (e.g., not
involved, interested and supportive, full
caretaker of the pregnancy)?
What type of support systems do you have
at home? Who is your primary support
person? List the people living with you
including their names, ages, relationship to
you, and any health problems that they may
have. Are they aware of your pregnancy?
How have you introduced this pregnancy to
any siblings? What are their reactions
regarding this pregnancy? Do you plan to
involve the siblings in any type of education
program to enhance the attachment
process for the newborn?
Has anyone close to you ever threatened to
hurt you? Has anyone ever hit, kicked,
choked, or physically hurt you? Has anyone
ever forced you to have sex?
What is your partner’s highest level of
education? What is your partner’s
occupation or major activity? Does your
partner consume alcohol? If yes, how much
alcohol does your partner use daily? List
type and amount. Does your partner
smoke? If yes, how often does your partner
smoke? List amount and frequency. Does
your partner use illicit drugs? If yes, how
often does your partner use illicit drugs? List
drug type, amount, and frequency.

PHYSICAL ASSESSMENT:

Assessment Procedure Normal Findings Abnormal Findings

Blood Pressure
Pulse Rate
Temperature
Height and Weight
Breast
Abdomen
Fundal Height
Fetal Position

Assessment of the Abdomen:

https://www.youtube.com/watch?v=G-6x6Po5orc

Computation of LMP and EDC

https://www.youtube.com/watch?v=N0iqVBX5F9s

NEWBORN HEALTH ASSESSMENT:

Babies are considered neonates from birth to the end of the first month. Infants are
babies from 1 month of age to 1 year. An infants basic task involves survival, which
requires breathing, sleeping, sucking, eating, swallowing, digesting and eliminating.

At birth, most babies weight from 2.5 kg to 4.0 kg (2500g to 4000g). Infant will usually
loose 5% to 10% of their weight just after birth because of fluid loss which is normal
and regain the weight in about a week. After several days, babies usually gain 150g to
210g weekly for 6 months.

The average length of a newborn is 44cm to 55cm. Head Circumference is 33cm to 35

cm with the chest circumference of 31cm to 33cm which is 1cm to 2 cm less the head
circumference.

APGAR SCORE is used to assess babies immediately after birth. This provide a
numeric indicator of the baby’s physiologic capacities to adapt to extrauterine life. In
APGAR scoring system, each of the five signs is assigned a maximum of 2 so that a
maximum achievable score is 10. A score under 7 indicates that the babyis having
difficulty and a score of 4 indicates that the baby’s condition is critical and needs
immediate medical attention. APGAR scoring is carried out 60 minutes after birth and is
repeated in 5 minutes.
APGAR SCORING VIDEO:

https://www.youtube.com/watch?v=cQKaTCMFjwc

NEWBORN REFLEXES:

There are different reflexes present in all normal newborns and mostly disappear within
a few months after birth. Absence of reflex at birth or persistence of a reflex past a
certain age may indicate a problem with central nervous system function.

1. ROOTING REFLEX – to elicit touch the newborn’s upper or lower lip or cheek with a
gloved finger or sterile nipple and observe that the newborn should turn or move the
head toward the stimulated area an open the mouth. This disappears by 3-4 months.

2. SUCKING REFLEX – Place a gloved finger or a nipple in the newborn’s mouth and
note the strength of the sucking response. This disappears at 10-12 months.

3. PALMAR GRASP REFLEX – Press your finger against the palmar surface of the
newborn’s hand from the ulnar side. It should be a strong grasp and the newborn may
even be able to be pulled to a sitting position. This disappears in 3 - 4 months.
4. PLANTAR GRASP REFEX – When you touch the ball of the newborn’s foot,the toes
should curl downward tightly. This disappears in 8 -10 months.

5. TONIC NECK REFLEX – The newborn should be placed in a supine position. Turn
the head to one side, with the newborn’s jaw at the shoulder. This is observed when the
arm and leg on the side to which the head is turned extend and the opposite arm and
legs flexed. This reflex disappears in 4-6 months.

6. MORO / STARTLE REFLEX – this is a response to a sudden stimulation or an abrupt

change in position. This reflex disappear by 3 months.

7. BABINSKI REFLEX – Hold the newborn foot and stroke up the lateral edge and
across the ball of the foot. If fanning of the toe is exhibited a positive Babinski reflex is
noted. This disappears within 2 years.

8. STEPPING REFLEX – Hold the newborn upright from behind, provide support under
the arms and let the newborn’s feet touch the surface. The newborn will provide a
stepping in one foot and the other in a walking motion response. This disappears in 2
months.

ELDERLY HEALTH ASSESSMENT

As the person ages, a number of physical changes occurs which may or may not be
visible. In general lean body mass is reduced and fat issue increases until the age of 60.
There is an obvious changed in the integumentary system. The skin become more dry
and fragile, the hair loses color, the fingernails and toenails become thicker and brittle.
Response to these changes vary among individuals.

NORMAL PHYSIOLOGICAL CHANGES ASSOCIATED WITH AGING:

INTEGUMENTARY
Increased skin dryness
Increased skin pallor
Increased Skin fragility
Progressive wrinkling and
sagging of the skin
Brown “age spots” (lentigo
senilus on exposed body
parts
Decrease perspiraton
Thinning and graying of
scalp, pubic and axillary hair
Slower nail growth and
increased thickening with
ridges
NEUROMUSCULAR
Decreased speed and
power of skeletal muscle
contractions.
Slowed reaction time
Lost of height (stature)
Osteoporosis
Joint stiffness
Impaired balance
SENSORY/PERCEPTUAL
Loss of visual acuity
Increased sensitivity to glare
and decreased ability to
adjust to darkness
Partial or complete lossy
white circle around the
periphery of the cornea
(arcus senilis)
Progressive loss of hearing
Decreased sense of taste,
especially sweet sensation
at the tip of the tongue
Decreased sense of smell
Increased threshold for
sensations of pain, touch
and temperature
PULMONARY
Reduce cardiac output and
stroke volume
Reduced elasticity and
increased rigidity of arteries
Increase in blood pressure
Orthostatic hypertension
GSTROINTESTINAL
Delayed swallowing time
Increased tendency of
indigestion
Increased tendency of
constipation
URINARY
Reduced filtering ability of
the kidney and impaired
renal function
Less effective concentration
of the urine
Urinary urgency and urinary
frequency
Tendency for a nocturnal
frequency and retention of
residual urine
GENITALS
Prostate enlargement
(benign) in men
Multiple changes in woman

KATZ ACTIVITY OF DAILY LIVING is a tool used to detect problems in performing

Activities of Daily Living (ADL) and to plan care accordingly.
LAWTON SCALE FOR INSTRUMENTAL ACTIVITIES OF DAILY LIVING asses a
person’s ability to perform task such as using a telephone, doing laundry, shopping,
housekeeping etc.
EVALUATION:

Make an instructional video showing the different Newborn reflexes.

Quiz:

Make a table showing the abnormalities that can occur in the absence or non-
disappearance of the newborn reflexes. Kindly follow the table below:

Reflex Normal Abnormal Findings

Indication

APPLICATION:

Create your OWN assessment tool for Childbearing woman, Newborn and Elderly using
the lecture as a guide and JUSTIFY why do you think your assessment tool, if used for
assessment will be beneficial.

This will constitute 2 portion of the grading system activity and quiz.

Please DO NOT COPY from the internet or your classmate. If your work is found to be
copied, you will automatically get a zero mark for the said activity and quiz.