NURSING PROCESS B.

OBJECTIVE DATA( SIGNS)

functions as a systematic guide to client
centered care with 5 sequential steps. These are
ASSESSMENT, DIAGNOSIS, PLANNING,
IMPLEMENTATION, AND EVALUATION.
PHASES OF NURSING PROCESS
COLLECTING DATA:
1. ASSESSMENT
- THIS INVOLVES GATHERING INFORMATION
ABOUT THE PATIENT, CONSIDERING THE
INVOLVES MEASURABLE FACTS AND
INFORMATION LIKE VITAL SIGNS OR THE
RESULTS OF A PHYSICAL EXAMINATION.
EXAMPLES OF OBJECTIVE DATA include but not
restricted to: pulse rate, blood pressure,
respiratory rate, ambulation, heart rate, body
temperature, weight, wound appearance,
bleeding, Full blood count, blood urea and
creatinine levels, as well as X ray or computed
tomography (CT) scans.

FOLLOWING: METHOD OF COLLECTION OF DATA:

ADMISSION OF A PATIENT TO HEALTHCARE
A. PHYSICAL FACILITY.
B. PSYCHOLOGICAL
C. EMOTIONAL A. INTERVIEW- IT IS PLANNED, PURPOSEFUL
D. SOCIO-CULTURAL CONVERSATION.
E. SPIRITUAL FACTORS
-THAT MAY AFFECT HIS/HER HEALTH STATUS. EXAMPLES:
functions as a systematic guide to client -COLLECTION OF DATA FOR HEALTH HISTORY.
centered care with 5 sequential steps. These are
assessment, diagnosis, planning, B. OBSERVATION
implementation, and evaluation. EXAMPLES: USE OF SENSES, USE OF UNITS OF
MEASURE
1. ASSESMENT
2. DIAGNOSIS C. VERIFYING/ VALIDATING DATA:
3. OUTCOME IDENTIFICATION AND -MAKING SURE YOUR INFORMATION IS
PLANNING ACCURATE
4. IMPLEMENTATION EXAMPLES:
-THE PATIENT'S URINE IS DARK IN COLOR.
TYPES OF DATA: -THE PATIENT REFUSES TO TAKE HIS/ HER
LUNCH SERVED AT 11:30AM
A. SUBJECTIVE DATA (SYMPTOMS)
THAT CAN BE DESCRIBED ONLY BY THE TYPES OF NURSING ASSESSMENT
PERSON EXPERIENCING IT.
What are the examples of subjective data? 1. INITIAL ASSESSMENT
Coughing.  ALSO CALLED A TRIAGE
Vomiting.  DETERMINE THE ORIGIN AND NATURE
Shortness of breath. OF THE PROBLEM
Dizziness.  GETTING THE PATIENT'S MEDICAL
Exhaustion. HISTORY
Itching.
  PHYSICAL EXAM ON THEM OR IN THE
CASE OF PATIENTS WITH MENTAL
ISSUES PERFORMING A
PSYCHOLOGICAL ASSESSMENT.
 RECORDING THE PATIENT'S VITAL SIGNS
AND LOOKING FOR SUBTLE SYMPTOMS
THAT MAY BE SIGNS OF AN
UNDERLYING CONDITION.
2. FOCUSED ASSESSMENT
-Given the fact that a patient's condition may
rapidly change, especially in an emergency
situation, their vital signs are constantly
monitored throughout all four assessments.
 The focused assessment also involves
Relieving the patient from pain and
stabilizing their condition, when
needed. Also, depending on the exact
nature of the issue, a long-term
treatment plan that aims to
 Resolve the root cause is implemented
during this phase.
3. TIME-LAPSED ASSESSMENT
- evaluate how the patient reacts to the agreed
treatment plan and how their condition is
evolving.
 can last from a few hours to a few
months. Throughout this time, the
patient is constantly evaluated and
their condition is compared
 Seeing if the treatment is effective.
4. EMERGENCY ASSESSMENT
-The emergency assessment is performed
during emergency procedures,
when it is crucial to evaluate the patient's
airway, breathing and circulation, as well as
the exact cause of the problem.
STEPS OF HEALTH ASSESSMENT
1. A.COLLECTION OF SUBJECTIVE DATA
2. B.COLLECTION OF OBJECTIVE DATA
3. C.VALIDATION OF ASSESSMENT DATA FOR
ACCURACY
4. D.DOCUMENTATION OF DATA
MAJOR AREAS OF SUBJECTIVE DATA
1. BIOGRAPHICAL INFORMATION
2. REASON FOR SEEKING CARE
3. HISTORY OF PRESENT HEALTH CONCERN
4. PERSONAL HEALTH HISTORY
5. FAMILY HISTORY
6. HEALTH & LIFESTYLE PRACTICES
7. REVIEW OF SYSTEM
COLLECTING OF OBJECTIVE DATA
1. PHYSICAL CHARACTERISTICS
2. BODY FUNCTIONS
3. APPEARANCE
4 BEHAVIOR
5. MEASUREMENTS
6. LABORATORY RESULTS/DIAGNOSTIC TEST
RESULTS
TYPES OF DIAGNOSIS
A. MEDICAL DIAGNOSIS
B. NURSING DIAGNOSIS
NURSING DIAGNOSIS
 is a clinical judgment about individual,
family, or community responses to
actual or potential health problems/life
processes.
 provides the basis for nursing
interventions to achieve outcomes for
which the nurse is accountable.
EXAMPLES OF ACTUAL NURSING DIAGNOSIS
  Ineffective breathing pattem related to  Anxiety related to stress as evidenced
bacterial / viral inflammatory Process by increased tension, apprehension,
and expression of concern regarding
 Ineffective breathing pattern related to upcoming surgery
Tracheo-bronchial obstruction
 Acute Pain related to decreased
 Anxiety related to changes in the myocardial flow as evidenced by
environment and routines, threat to grimacing, expression of pain, guarding
socio economic status. behavior.

 Anxiety related to change in health

2. RISK NURSING DIAGNOSIS
status and situational crisis
- These are clinical judgments that a problem
does not exist, but the presence of risk factors
 Body image disturbance related to
indicates that a problem is likely to develop
temporary presence of a visible drain
unless nurses intervene.
tube.
 The individual (or group) is more
TYPES OF NURSING DIAGNOSIS susceptible to developing the problem
than others
1. PROBLEM-FOCUSED NURSING DIAGNOSIS
 also known as actual diagnosis is a  For example, an elderly client with
client problem that is present at the diabetes and vertigo who has difficulty
time of the nursing assessment. walking refuses to ask for assistance
during ambulation may be
 based on the presence of signs and appropriately diagnosed with Risk for
symptoms. Actual nursing diagnosis Injury.
should not be viewed as more
important than risk diagnoses.
3. HEALTH PROMOTION DIAGNOSIS
also known as wellness diagnosis is a clinical
 Diagnosis with the highest priority for a
judgment about motivation and desire to
patient.
increase well-being.
 concerned with the individual, family,
 three components: (1) nursing
or community transition from a specific
diagnosis, (2) related factors, and (3)
level of wellness to a higher level of
defining characteristics
wellness.

 Ineffective Breathing Pattern related to

EXAMPLES OF HEALTH PROMOTION
pain as evidenced by pursed-lip
DIAGNOSIS:
breathing, reports of pain during
 Readiness for Enhanced Spiritual Well
inhalation, use of accessory muscles to
Being
breathe
 Readiness for Enhanced Family Coping
 Readiness for Enhanced Parenting
 4. SYNDROME DIAGNOSIS
a clinical judgment concerning a cluster of
problem or risk nursing diagnoses that are
predicted to present because of a certain
situation or event.
They, too, are written as a one-part statement
requiring only the diagnostic label.
EXAMPLES OF A SYNDROME NURSING
DIAGNOSIS ARE:
 Chronic Pain Syndrome
 Post-trauma Syndrome
 Frail Elderly Syndrome
PROCESS OF DATA ANALYSIS
A. IDENTIFY ABNORMAL DATA & STRENGTH
B. CLUSTER THE DATA
C. DRAW INFERENCES
D. PROPOSE POSSIBLE NURSING DIAGNOSIS
E. CHECK FOR DEFINING CHARACTERISTICS
F. CONFIRM A RULE OUT DIAGNOSIS
G. DOCUMENT CONCLUSION
TYPES OF GOALS
- It must be measurable and client centered.
focusing on problem prevention, resolution,
and rehabilitation.
Goals can be short-term or long-term.
SHORT-TERM GOAL – a behavior that can be
completed immediately, usually within a few
hours or days.
LONG-TERM GOAL - indicates an objective to be
completed over a longer period, usually over
weeks or months.
TYPES OF NURSING INTERVENTIONS
-Can be independent, dependent, or
collaborative:
INDEPENDENT NURSING INTERVENTIONS ARE
 activities that nurses are licensed to
initiate based on their sound judgement
and skills.
Includes: ongoing assessment, emotional
support, providing comfort, teaching, physical
care, and making referrals to other health care
professionals.
DEPENDENT NURSING INTERVENTIONS ARE
 activities carried out under the
physician's orders or supervision.
Includes orders to direct the nurse to
provide
medications, intravenous therapy, diagnostic
tests, treatments, diet, and activity or rest.
 providing explanation while
administering medical orders are also
part of the dependent nursing
interventions.
COLLABORATIVE INTERVENTIONS ARE
 Collaboration with other health team
members, such as physicians, social
workers, dietitians, and therapists.
PHASES OF INTERVIEW
- These phases are briefly explained by
describing the roles of the nurse and
client during each one.
 Pre-introductory Phase
 Introductory Phase
 Working Phase
 Summary and Closing Phase
PROCESS OF COMMUNICATION
BASIC ELEMENTS OF THE COMMUNICATION
PROCESS
SENDER- is the person who encodes and
delivers the message

MESSAGES- is the content of the
communication. It may contain verbal,
nonverbal, and symbolic language.
RECEIVER- is the person who receives the
decodes the message.
FEEDBACK - is the message returned by the
receiver. It indicates whether the meaning of
the sender's message was understood.
PURPOSE OF THE INTERVIEW
 Establishing rapport and a trusting,
relationship with the client
 Gathering information on the client's
developmental, psychological,
physiologic, sociocultural, and spiritual
statuses to identify deviations that can
be treated with nursing and
collaborative interventions or strengths
that can be enhanced through nurse
client collaboration.
 Gather to organize complete & accurate
data about the patient's health state
including the description & chronology
of any signs & symptoms of illness.
 Teach the patient about health state
Begin teaching for health promotion &
disease promotion.
TYPES OF COMMUNICATION
1. VERBAL COMMUNICATION
Examples of Verbal Communication Skills
 Advising others regarding an
appropriate course of action.
 Assertiveness
 Conveying feedback in a constructive
manner emphasizing Gestures. specific,
changeable behaviors.
 Disciplining employees in a direct and
respectful manner.
 Giving credit to others.
 Recognizing and countering objections.
2. NONVERBAL COMMUNICATION
Examples
 Facial expressions. The human face is
extremely expressive, able to convey
countless emotions without saying a
word..
 Body movement and posture....
EXTERNAL FACTORS THAT AFFECT
COMMUNICATION
 Ensure privacy
 Refuse interruptions OPhysical
Environment
 Dress
 Note-taking
 Tape / video recording
TYPE OF QUESTION USED IN INTERVIEW
OPEN-ENDED QUESTIONS
- used to elicit the client's feelings and
perceptions.
begin with the words "how" or "what."
example of this type of question is "How have
you been feeling lately?"
CLOSED-ENDED QUESTIONS
- Use closed-ended questions to obtain
facts and to focus on specific
information.
The client can respond with one or two words.
The questions typically begin with the words
"when" or "did."
An example of this type of question is "when
did your headache start?"
TECHNIQUES OF COMMUNICATION
 Facilitation of General Leads
 Silence
 Reflection
 Empathy
 Clarification
 Confrontation
 Interpretation
 Explanation
 Summary
TEN TRAPS OF INTERVIEWING
 Providing False Assurance or
Reassurrance
 Giving Unwanted
 Advise
 Using Authority
 Using Avoidance Language
 Engaging in Distancing
 Using Professional Jargon
 Using Leading or Biased Questions
 Talking too Much
 Interrupting
 Using "why" Questions
INTERVIEWING THE PARENT
 GREET THE CHILD & THE PARENT'S
NAME
 REFER TO THE CHILD BY NAME
 01-6 YEARS OLD
 FOCUS MORE ON THE PARENTS
 PROVIDE TOYS TO OCCUPY THE CHILD
AS THE NURSE & THE PARENT TALK
 AVOID QUESTIONS THAT PUT
PARENTING ABILITY IN QUESTION.
 TALK WITH THE CHILD AT EYE LEVEL
BUT AVOID CONTACT. CONSTANT EYE
INTERVIEWING THE PRE SCHOOLER (2-7 YEARS
OLD)
 USE SHORT, SIMPLE SENTENCE WITH
CONCRETE EXPLANATION.
 PRE-SCHOOLER CAN HAVE ANIMISTIC
THINKING ABOUT UNFAMILIAR
OBJECTS.
 THEY ALSO HAVE FEAR OF THEIR BODY
PARTS.
INTERVIEWING THE SCHOOL AGE (7-12YEARS
OLD)
 THEY CAN TOLERATE & UNDERSTAND
OTHER'S VIEWPOINTS MORE OBJECTIVE
& REALISTIC. LITHEY WANTS TO KNEW
FUNCTIONAL ASPECTS HOW
 THINGS WORK & WHY THINGS ARE
DONE.
INTERVIEWING THE ADOLESCENT
 COMMUNICATE WITH THE
ADOLESCENT WITH RESPECT
 EXPLAIN EVERY STEP & GIVE THE
RATIONALE.
 SILENT PERIOD ARE BEST AVOIDED.
GIVE A LITTLE TIME TO COLLECT
HIS/HER THOUGHT BUT SILENCE IS
THREATENING.
 THEY ARE SENSITIVE COMMUNICATION.
TO NON VERBAL
 REASSURE THEM OF CONFIDENTIALITY
OF ANY INFORMATION SHARE TO YOU.
 INTERVIEWING PEOPLE WITH SPECIAL
NEEDS
 ACUTELY ILL PEOPLE
 PROMPT ACTION IS REQUIRED
COMBINE INTERVIEWING WITH
PHYSICAL EXAMINATION.
 ASK BRIEF & CONCISE QUESTIONS.
 ATTEND TO THE COMFORT FIRST OF
A PATIENT.
 ESTABLISH PRIORITY.
INTERVIEWING PEOPLE WITH SPECIAL NEEDS
 PEOPLE UNDER INFLUENCE OF STRICT
DRUGS OR ALCOHOL
 ASK SIMPLY & DIRECT QUESTION.
 NO NON THREATENING QUESTIONS.
 PERSONAL QUESTIONS: NO NEED TO
ANSWER EVERY QUESTION ASK BY THE
PATIENT.
 BE SENSITIVE TO THE POSSIBILITY OF A
MOTIVE BEHIND
 THE PERSONAL QUESTIONS. USEXUALLY
AGGRESSIVE PEOPLE
 MAINTAIN PROFESSIONAL
RELATIONSHIP.
 CRYING
 LET THE PERSON CRY & EXPRESS
HIS/HER FEELINGS FREELY.OFFER A
TISSUE & WAIT TILL REGAIN CONTROL
SOON
INTERVIEWING PEOPLE WITH SPECIAL NEEDS
 THREAT OF VIOLENCE
 BE AWARE OF "RED FLAG" EX: FIST
CLENCHING, PACING BACK OF FORTH, A
VACANT STARE. STATEMENT THAT DO
NOT MAKE SENSE.
 LEAVE THE EXAMINING ROOM DOOR
OPEN POSITION YOURSELF BETWEEN
THE PATIENT & THE DOOR.
 BE CALM & TALK IN SOFT VOICE.
 ANXIETY
 ALLOW THE CLIENT TO VERBALIZE
FEELINGS, FEARS & CONCERNS.
COMPREHENSIVE HEALTH HISTORY
BIOGRAPHIC DATA
NAME,ADRESS,PHONE,GENDER VBIRTHPLACE
GENDER,MENTAL STATUS,RACE/ETHNIC
ORIGIN,OCCUPATION
A Demographic (Biographical Data)
1. Client's initials:
2 Gender:
3. Age, Birthdate and Birthplace:
4. Marital (C) Status:
5 Nationality:
6. Religion
7 Address and Telephone Number &
8.Educational Background
9. Occupation (usual and ent)
10 thual Source of Medical Care:
B. SOURCE AND RELIABILITY OF INFORMATION
C. Reasons for Seeking Care or Chief
Complaints (Preferably Top 3)
D. History of Present Illness or Present Health
PRESENT HEALTH/ HISTORY OF PRESENT
ILLNESS
 P-ROVOCATIVE
 Q-UALITY
 R-EGION/RADIATION
 S-EVERITY
 T-IMING
PAST HEALTH HISTORY
 CHILDHOOD ILLNESS
 HOSPITALIZATION
 OPERATION
 IMMUNIZATIONS
 ALLERGIES
  CURRENT MEDICATIONS
 FAMILY HISTORY
 REVIEW OF THE SYSTEM
 FUNCTIONAL ASSESSMENT
STANDARD PRECAUTIONS
A. HAND HYGIENE
- Handwashing with non antimicrobial
soap and water
- Handwashing with antiseptic soap
- Using an antiseptic hand rub (waterless
product that is usually alcohol-based)
- Performing surgical hand antisepsis
B. GLOVES
- Wear gloves (clean, non sterile gloves
are adequate) when touching blood,
body fluids, secretions, excretions, and
contaminated items.
- Put on dean gloves just before touching
mucous membranes and non intact
skin.
- Change gloves between tasks and
procedures on the same patient after
contact with material that may contain
a high concentration of
microorganisms.
- Remove gloves promptly after use,
- before touching non-contaminated
items and environmental surfaces, and
before going to another patient.
- Wash hands immediately to avoid
transfer of microrganisms to other
patients or environment
- Mask, Eye Protection, Face Shield
- Wear a mask and eye protection or a
face shield to protect mucous
membranes of the eyes, nose, and
mouth during procedures and patient
care activities that are likely to generate
splashes or sprays of blood, body fluids,
secretions, and excretions.
D. GOWN
 Wear a gown (a clean, nonsterile gown
is adequate) to protect skin and to
prevent soiling of clothing during
procedures and patient care activities
that are likely to generate splashes or
sprays of blood, body fluids, secretions,
or excretions.
 Select a gown that is appropriate for
the activity and amount of fluid likely to
be encountered.
 Remove a soiled gown as promptly as
possible, and wash hands to avoid
transfer of microorganisms to other
patients or environments
E. PATIENT CARE EQUIPMENT
F. ENVIRONMENTAL CONTROL
G. LINEN
H. OCCUPATIONAL HEALTH AND BLOODBORNE
PATHOGENS
I.PATIENT PLACEMENT
PHYSICAL EXAMINATION TECHNIQUES
PALPATION
- consists of using parts of the hand to touch
and feel for the following characteristics:
>TEXTURE (ROUGH/ SMOOTH),
 Temperature
(warm/cold)
 Moisture
(dry/wet),
 Mobility
(fixed/movable/still/vibrating),
 Consistency
(soft/ hard/fluid filled),
 strength of pulses
(strong/weak/threadv/ bounding)
 Size (small/medium/large)
 Shape (well defined/irregular)
 Three different part of the hand
POSITIONING THE CLIENT
Lithotomy Position
The client lies on his or her back with
the hips at the edge of the examination
table and the feet supported by
stirrups. The lithotomy. position is used
to examine the female genitalia,
reproductive tracts, and the rectum.
The client may require assistance
getting into this position. It is an
exposed position, and clients may feel
embarrassed.
In addition, elderly clients may no be
able to assume this position not very
long or at all. Therefore, it is best to
keep the client well draped during the
examination and to perform the
examination as quickly as possible.
PRONE POSITION
Position in which the patient lies on the
abdomen with the head turned to one side with
one small pillow under the ankle.
Prone position
Uses:
✔Examination of posterior trunk, spines and
rectum
✔Surgeries of back
✔To relieve pressure on areas such as sacrum,
scapula and boel After anesthesis to prevent
aspiration.
SUPINE POSITION
The supine position is
assumed without a pillow after lumber
puncture and also in spinal injuries. This
position is also use when examining the anterior
part of the body.
DORSAL POSITION
the client lies flat on the back with legs flexed
and feet flat on the bed. It is used For
gyanaecological examinations Insertion of
urethral catheters
SEMI-PRONE/SIM'S/RECOVERY POSITION to
assume this position, the client lies half way
between the lateraand the prone position. The
lower knee is slightly Beved and also the hip at
90".
It can be used For vaginal and rectal and vaginal
examinations
To facilitate drainage in from the mouth of
unconscious patients To provide comfort for the
pregnant woman in the last trimester of
pregnancy
THE SEMI-RECUMBENT POSITION
the patient lies on his back with two or more
pillows; the bed rest may be used in a reclining
position. It is used in nursing surgical and
medical conditions such as abdominal surgeries,
abdominal distension and in convalescents
THE KNEE-CHEST/GENU-PECTORAL POSITION
the client kneels on the bed with thighs vertical
and chest resting on a firm pillow. The head is
turned to one side and the hands are flexed
around the head or on the bed. Used for vaginal
and rectal examination, high colonic irrigation
and in replacing dropped organ in visceroptosis.
The Lateral or Side Lying Position
the client lies on his side with the upper leg
flexed and the arms in front.
It is usedFor comfort during rest and sleep To
relief pressure from the back of the head,
scapulae, sacrum and the heel
To promote drainage of saliva or secretions in
unconscious patients to prevent aspiration For
examination of the rectal, vaginal and perineal
regions Used when giving enema For insertion
of suppository and flatus tube.