NCM 101 (LEC): MIDTERM Notes B.

Diagnosis
Topic: Nurses Role in Health Assessment - Nursing diagnosis: 2nd phase of nursing process – according to NANDA, it is
a clinical judgement about individuals, family or community responses to actual and
Objectives:
potential health problems and life processes.
1. Explain how assessment is applicable to every situation the nurse
- Steps in diagnosis:
encounters: they are applicable at HOME, CLINIC, HOSPITAL, and COMMUNITY
1. Collecting information – data collected in the assessment phase.
2. Differentiate between a nursing assessment and a medical assessment:
PSYCHOLOGICAL, SOCIO-CULTURAL, PHYSIOLOGIC, DEVELOPMENTAL, and 2. Interpreting information
SPIRITUAL.
3. Clustering information – the data are sorted in meaningful groups according
3. List and describe the steps of the nursing process: Nursing Process – Lydia to NANADA’S HUMAN RESPONSE PATTERNS.
Hall
4. Naming a cluster or problem formulation
A. Assessment
- Types of nursing diagnosis:
- an orderly collection of information concerning the patients’ health status.
a. Actual nursing diagnosis – typically problem-oriented and describe human
- Sources of information: responses that have been validated by the nurse. NCM 101 (LEC): MIDTERM Notes
a. Health History
Topic: Nurses Role in Health Assessment
 History Taking – the means of gathering subjective data (sensations or
symptoms, feelings, perception, desires, preferences, beliefs, ideas, values and Objectives:
personal information that are elicited and verified only by the client).
1. Explain how assessment is applicable to every situation the nurse
 Relatives
 Neighbors encounters: they are applicable at HOME, CLINIC, HOSPITAL, and
 Friends COMMUNITY
 Total strangers
2. Differentiate between a nursing assessment and a medical assessment:
 Health care providers
 Old charts or medical records PSYCHOLOGICAL, SOCIO-CULTURAL, PHYSIOLOGIC,
DEVELOPMENTAL, and SPIRITUAL.
b. Physical Assessment
3. List and describe the steps of the nursing process: Nursing Process – Lydia
 2nd source of information that constitutes the objective data
-Physical characteristics Hall
-Body functions (heart rate, respiratory rate)
-Appearance
-Measurements (blood pressure, temperature, height, weight)
c. Diagnostic & Laboratory Data
A. Assessment 3. Clustering information – the data are sorted in meaningful groups
- an orderly collection of information concerning the patients’ health status. according to NANADA’S HUMAN RESPONSE PATTERNS.
- Sources of information: 4. Naming a cluster or problem formulation
a. Health History
 History Taking – the means of gathering subjective data - Types of nursing diagnosis:
(sensations or sysmptoms, feelings, perception, desires, a. Actual nursing diagnosis – typically problem-oriented and describe
preferences, beliefs, ideas, values and personal information that human responses that have been validated by the nurse.
are elicited and verified only by the client). b. Risk nursing diagnosis – human responses to health conditions/life
 Relatives processes that may develop in a vulnerable individual, family or
 Neighbors community.
 Friends c. Wellness nursing diagnosis – represent the patients striving for a
 Total strangers higher level of health and wellness.
 Health care providers
C. Outcomes Identification
 Old charts or medical records
b. Physical Assessment - Represents that 3rd phase of the nursing process – statement
 2nd source of information that constitutes the objective data of the expected change in patient behavior denoting progress toward
 Physical characteristics resolution of the altered human response over a specific period of
 Body functions (heart rate, respiratory rate) time.
 Appearance
D. Planning
 Measurements (blood pressure, temperature, height, weight)
c. Diagnostic & Laboratory Data - The 4th step of the nursing process that involves the

B. Diagnosis participation of nursing

- Nursing diagnosis: 2nd phase of nursing process – according to NANDA, it diagnoses and care and the

is a clinical judgement about individuals, family or community responses selection of nursing intervention.

to actual and potential health problems and life processes. - Ranking or prioritizing the

- Steps in diagnosis: nursing problems basing on the

1. Collecting information – data collected in the assessment phase. theoretical framework of Maslow

2. Interpreting information
C. Implementation
 - The 5th stage of the nursing process wherein the nurse executes the
interventions that were devised during planning stage.
D. Evaluation
- The final phase of the nursing process.
- N.B. Evaluate the outcome and not the intervention
NURSING PROCESS
 1st used and mentioned by Lydia Hall in 1995 introducing the 3 steps:
1. Observation
2. Administration
3. Validation
 It is a systematic, organized method of planning, and providing quality and
individualized nursing care.
 It is synonymous with the PROBLEM-SOLVING APPROACH that directs the
nurse and the client to determine the need of nursing care, to plan and
implement the care and evaluate result.
 It is a G O S H approach (goal-oriented, organized, systematic and
humanistic care) for efficient and effective provision of nursing care.
TOPIC 2:
INTERVIEWING:
o Describe the three phases of the interview.
NURSING INTERVIEW
A. Introductory Stage: Role of the Nurse
- Introduction of the nurse to the client.
- Explain the reason for taking notes.
- Ensure that the client is comfortable and has privacy.
- Develop trust and rapport.
B. Working Stage: Role of the Nurse
- Elicit the client’s comments about major biographic data, reasons for seeking
care, history of present health concern, past health history, family history, ROS,
lifestyle and health practices and developmental level.
- Listens observes cues and uses critical nursing skills to interpret and validate
information received.
- Keep the interview goal directed, refocusing the client and redefining the goals
established in the joining stage.
C. Termination Stage: Role of the Nurse
- Summarizes and validates the information.
- Identifies and discusses possible plans to resolve the problem of the client.
- Make sure to ask if anything else concerns the client and if there are further
questions.
-
o Illustrate the use of non - verbal communication during the interview.
NON-VERBAL COMMUNICATION
a. Appearance
- Professional in appearance
 - Wear comfortable, neat clothes - Smile or display an open appropriate facial expression
- Wear your name tag - Maintain an open arms and hands and lean forward
- Neat hair and not in extreme style - Avoid preconceived ideas or biases
- Fingernails are short and neat - Avoid crossing your arms, sitting back, tilting your head way from the client,
- Jewelry minimal thinking about other things or looking blank and inattentive
b. Demeanor - Keep an open mind
- No laughing out loud Explain the use of effective verbal communication during a client interview.
- Do not yell at your co-worker VERBAL COMMUNICATION
- Do not mutter under your breath Open-ended questions
- Great the client calmly and focus your full attention on her  Use to elicit the client’s feelings and perception
- Do not be overwhelmingly friendly or “touchy”  Answers HOW and WHAT
- Maintain a professional distance  Help to reveal significant data of the client’s health status
c. Facial expression Closed-ended questions
- Expression should be neutral and friendly  Use to obtain facts and to focus on specific information
- Appear understanding and concern  Questions begin with WHEN and DID
d. Attitude  Used to clarify or obtain more accurate information about issues
- Develop a non-judgmental attitude Laundry list
- Do not act superior to the client or appear shocked, disgusted or surprised at  Provide client with a choice of words to choose from in describing symptoms
what you are told  Helps the nurse to obtain specific answers and reduces the like hood of the
- Do not try “preaching” to the client or imposing your own sense of ethics or client’s perceiving or providing an expected answer
morality Rephrasing
- Avoid telling the patient that he or she is foolish or force guilt  An effective way to communication during the interview
e. Silence  Helps to clarify information the client has stated
- Period of silence allow the nurse and the client to reflect and organize  Enables the client to reflect on what was said
thoughts Well-placed phrases
f. Listening  Properly used phrase will encourage the client to continue
- Most important skill to learn and develop Providing information
- Maintain good eye contact  Answer every question well
  Explain well to the client what is being observed
Inferring
 Will elicit more data or verify existing data
 Be careful not to lead the client to answers that are not true
Describe the types of verbal communication that should be avoided in client interviews.
COMMUNICATION TO AVOID
Excessive or insufficient eye contact
Avoid extreme eye contact
 Establish eye contact when the patient is speaking to you but look down from
time to time
Distraction and distance
 Avoid being occupied of something while you are asking questions
 Avoid appearing mentally distant
 Try to avoid physical distance exceeding 2 to 3 feet during the interview
Standing
 Standing will put the nurse and the patient at different levels
Biased or leading questions
 This will cause the patient to provide answers that may or may not be true
Rushing through the interview
 Take time with client to show that you are concern about their health and
helps them to open up
Reading the questions
 Avoid reading the questions form the history form in order not to let the
client feel ill at ease opening up to formatted questions
Explain how communication should be varied to communicate with elderly clients,
ethnicity and with clients with emotional conditions.
VARIATIONS OF COMMUNICATION
Gerontologic
 Asses hearing acuity
 Establish trust, privacy and partnership with older client
 Assure your elderly client that you are concern
 Speak clearly and use straightforward language during the interview
 Ask questions in simple terms
 Avoid medical jargon and modern slang
 Do not talk down to the client
 Show respect to the client
Cultural
 Reluctance to reveal personal information
 Variations in wiliness to openly express emotional distress or pain
 Variation in ability to receive information
 Variation in meaning conveyed by language
 Variation In use and meaning of nonverbal communication: eye contact,
gestures
 Variation in disease/illness perception
 Variation in past, present, and future orientation
 Variation in the family’s role in the decision-making process
 Seek help from experts is there is misunderstanding or difficulty in
communicating with the client
Emotional
 Emotions vary for several reasons
Identify the major categories of a complete health history.
8 SECTIONS OF HEALTH HISTORY
1. Biographical data
 2. Reasons for seeking health care
3. History of present health concern
4. Past health history
5. Family health history
6. ROS
7. Lifestyle and health practices profile
8. Developmental level

o Describe the relationship of the lifestyle and health practices profile to health
Enumerate the types of biographical data to be collected status.
BIOGRAPHICAL DATA
LIFESTYLE & HEALTH PRACTICES PROFILE
- Include information that identifies the client that includes:
1. Name - Deals with the client’s human responses that include:
2. Age  Nutritional habits
3. Address  Activity and exercise patterns
4. Religion  Sleep and rest
5. Phone number  Self-concept and self-care activities
6. Gender  Social and community activity
7. Respondent  Relationship values and beliefs system
8. Birthdate  Education and work
9. SSS number  Stress level and coping style
10. Medical record number  Environment
11. Race DESCRIPTION OF THE TYPICAL DAY
12. Educational level
- Necessary to elicit an overview of how the client sees his usual pattern of daily
13. Occupation
activity. Questions you ask should be vague enough to allow the client to provide
14. Significant others
the orientation form which they are viewed (e.g., Please tell me what an average
or typical day is for you)
TOPIC 3: COLLECTING OBJECTIVE DATA
Draping: extended above the head with elbows bent. Pillow under chest may provide comfort.
Drape covers back and legs.
- Drapes are made of paper, cloth or bed linen.
 Prone position – patient lines on abdomen with hands at side, head turned to side.
- Drapes provide not only a degree of privacy but also warmth.
Examination of the spine and legs. Drape extends from shoulders to knees.
Examination and Positions & Draping:  Fowler’s position – sitting with backrest elevated at 90-degree angle. Legs extended

 Standing position – typical positions for examination of male patient’s genitals & flat on table. Examination of lower extremities/feet. May be position of comfort for

assessment for inguinal hernia. Screening test for scoliosis. respiratory patients. Drape should cover legs. Semi-fowler’s – 45-angle.

 Sitting position – auscultation of: heart & lungs. Examination of: head, eyes, ears, CONSIDERATIONS FOR OLDER ADULTS:
nose & throat; parts of the neurological examination. Drape sheet extended on lap
- Be aware of normal physiologic changes that occur with aging
ang legs.
- Be aware of stiffness of muscles and joints from aging or history of orthopedic
 Supine position – patient lies flat on back. Arms at side. Legs extended. Examination
surgery.
in front of body, breasts. Palpation of internal organs. Draping extends from under
- Expose only areas of the body to be examined.
the armpits to toes.
- Permit ample time for the client to answer your questions.
 Dorsal recumbent position – flat on back with knees bent and feet flat on exam
- Be aware of cultural differences.
table. Examination of rectum, vagina or both. drape placed in diamond-shaped
- Arrange for an interpreter if the client’s language differs from that of the nurse.
fashion.
- Ask client how they wish to be addressed, such as “Mrs.” or “Miss”.
- Cover chest and pubic area
- Adapt assessment techniques to any sensory impairment.
- Cover/wrap each leg with the corners of the drape
- If clients are older or frail, it is wise to conduct the assessment in several
 Lithotomy position – pelvic examination. Pap smears. Position patient in dorsal
segments.
recumbent position with feet on corners of table. Assist to end of table with buttocks
even with edge of table. Assist positioning of feet into stirrups – both feet/legs at PEDIATRIC CONSIDERATIONS:
same time. Drape diamond-shaped fashion. A. Infant
 Sim’s position – position on side with top leg bent sharply and lower leg bent - The parent should be present
slightly. Examination of rectum. Administration of edema. Rectal temperature. Drape - Maintain a warm environment
from shoulders to toes. - Timing should be 1-2 hours after feeding
 Knee-chest position – may be used for rectal (proctologic)examination. Patient - Use a soft, crooning voice
kneels on exam table. Buttock raised while head and chest remain flat on table. Arms - Lock eyes from time to time
- Use pacifier for crying and invasive procedures
 - Offer brightly colored toys PREPARATION ON THE PART OF THE NURSE:
B. Toddler
 Clean, professional dress
- Let the toddler sit on the parent’s lap in all the procedure
 Proper identification
- Begin by greeting the child or the accompanying parent by name
 Short fingernails
- Have the parent “undress” the child
 Warm hands and equipment
- 1-2 yr. old children like to say “NO”. Don’t offer a choice when there is none.
- Demonstrate a procedure to the parent first  Hairstyle and jewelry that will not interfere with the exam

- Praise the child when he or she is cooperative  Ensure that all necessary equipment are ready for use and within reach.

C. Pre-school  Introduce yourself to the patient.

- Use short, simple explanations  Clarify with the patient how he or she wishes to be addressed.
- Allow the child to play with equipment to lessen fears  Explain what you plan to do , how long will it take; allow the patient to ask
- A pre-school likes to help, let her hold the stet for you questions.
- Use games  Position the patient according to the body system being assessed.
- Use a slow, patient, deliberate approach  Adhere to standard precautions
- Give the pre-schooler the needed feedback  Avoid negative or crude remarks
- Compliment the child on his/her cooperation  Be cognizant of facial expressions
D. School-age child
 Perform exam in head-to-toe or other systematic manner
- Break the ice with small talk
 Stand on the right side of the patient to establish a dominant side for assessment
- Let the child undress himself
 Compare right to left sides of the body for symmetry
- Demonstrate equipment
 Proceed from least invasive to most invasive
- Comment on the body and how it works
 Use a systematic approach

Legal Issues Accurate, complete documentation:

E. Adolescence
 Ensure that the patient is properly informed of assessment procedures
- Health teaching
- Communicate with some care  Establish a trusting relationship with the patient

- Appraise the adolescent with the variation among teen-agers on growth and  Thank the patient when the physical assessment is concluded

development.  Document assessment findings

Standard Precautions Technique:  Different aromas
 Vaginal Speculum
 Hand washing
 Cotton tip applicator
 Mask
 Specimen cup
 Cap
 Gown ASSESSMENT TECHNIQUES:
 Gloves
 INSPECTION (I)
 Eye Protection
- Visual examination
COMMONLY USED EQUIPMENT AND SUPPLIES: - Use visual inspection to assess moisture, color and texture of body surfaces, as

 Pen and Paper well as shape, position, size color and symmetry of the body.

 Tape measure - Lighting must be sufficient for the nurse to see clearly.

 Clean gloves  PALPATION (P)

 Penlight
- An examination of the body using the sense of touch.
 Scale
- TIPS: warm hands, short nails.
 Thermometer
- Inform the patient of when, where and how the touch will occur
 Sphygmomanometer - FINGERPADS:
 Stethoscope  Texture (hair)
 Otoscope  Temperature (skin) – dorsum of the hand
 Ophthalmoscope  Vibration (joint) – metacarpophalangeal joint; ball of hand, ulnar
 Visual Acuity Charts surface, palmar surface
 Tuning fork  Distention (urinary bladder)
 Reflex Hammer  Position, size, shape consistency, mobility (organs or masses)
 Lubricant  Pulsations
 Nasal speculum  Tenderness or Pain
 Cotton balls
 Tongue depressors 1. Light Palpation
 - Use finger pads - Characteristics of Percussion Sounds:
- Depress 1 cm. below surface  Flatness – is an extremely dull sound produced by most dense tissue, such as
- Provide information on skin muscle or bone.
- texture, moisture, masses, muscle guarding and  Dullness – a thudlike sound produced by dense tissue such as the liver,
- tenderness spleen or heart.
2. Deep Palpation  Resonance – a hollow sound such as that produced lungs filled with air.
- Done with two hands or one hand.  Hyperresonance – is not produced in the normal body.
- Reveals information about position of organs, masses and their size, shape,  Tympany – drumlike sound produced from an air-filled stomach. Reflects
mobility and consistency. the least dense tissue.
- Depress 4 to 5 cm below skin surface - How are sounds analyze:
- Most often used in assessing abdominal and reproductive a. Intensity (Amplitude) – refers to the loudness or softness of a sound.
- Structures. b. Duration - describes the time period over which a sound is heard when
 PERCUSSION (P) elicited.
c. Pitch (Frequency) – the highness and lowness of a sound.
- Striking an object against another to cause vibration that produce sound.
d. Quality (Timbre) – how one perceived the sound.
- Any part of the body can be percussed.
e. Location – is where the sound is produced and heard.
- Most commonly used for abdomen and thorax.
- Analyze sounds by intensity, duration and pitch.
- Types of Percussion Technique:
1. Direct or immediate percussion – strikes the area to be percussed directly
with the pads of two, three or four fingers or with the pad of the middle
finger.
2. Indirect or mediate percussion – the striking of an object held against the
body area to be examined. In this technique, the middle finger of the
nondominant hand, referred to as the pleximeter, placed firmly on the client’s
skin. Using the tip of the flexed middle finger of the other hand, called
plexor, the nurse strikes the pleximeter, usually at the distal interphalangeal
joint or a point between the distal and proximal joints.
 PURPOSE OF DOCUMENTATION:
PURPOSES OF ASSESSMENT DOCUMENTATION:
TOPIC 4: Validating and DOCUMENTING Data
PURPOSE OF VALIDATION:
- Validation of data is the process of confirming or verifying that the subjective and
objective data you have collected are reliable and accurate.
DATA REQUIRING VALIDATION:
- Discrepancies or gaps between the subjective and objective data.
- Discrepancies or gaps between what the clients says at one time versus another time.
- Findings that are highly abnormal and/or inconsistent with other findings.
METHODS OF VALIDATION:
- Recheck your own data through repeat assessment
- Clarify with the client by asking additional questions.
- Verify the data with another health care provider
- Compare with your objective findings with your subjective findings to uncover
discrepancies.
- to promote effective communication among multidisciplinary health team members
to facilitate safe and efficient client care.
- It helps to identify health problems,
- formulate nursing diagnoses
- plan immediate and ongoing interventions.
- establishes a way to communicate with the multidisciplinary team members.
- eliminating repetition of similar data collection by other health team members.
- Provides a chronologic source of client assessment data and a progressive record of
assessment findings that outline the client’s course of care.
- Ensures that information about the client and family is easily accessible to members
of the health care team; provides a vehicle for communication; and prevents
fragmentation, repetition, and delays in carrying out the plan of care.
- Establishes a basis for screening or validating proposed diagnoses Acts as a source of
information to help diagnose new problems
- Offers a basis for determining the educational needs of the client, family, and
significant others.
- Provides a basis for determining eligibility for care and reimbursement.
- Constitutes a permanent legal record of the care that was or was not given to the
client.
- Provides access to significant epidemiologic data for future investigations and
research and educational endeavors.
- Promotes compliance with legal, accreditation, reimbursement and professional
standard requirements.
 - Standardized assessment forms have been developed to ensure that content in
documentation and assessment data meets regulatory requirements and provides a
INFORMATION REQUIRING DOCUMENTATION:
thorough database.
- Every institution is unique when it comes to documenting assessments. However, two - The type of assessment form used for documentation varies according to the health
key elements need to be included in every documentation: care institution.
1. nursing history
3 TYPES OF ASSESSMENT FORMS ARE USED TO DOCUMENT DATA:
2. physical assessment,
- also known as subjective and objective data. Most data collection starts with A. INITIAL ASSESSMENT FORM
subjective data and ends with objective data. - An initial assessment form is called a nursing admission or admission database.
- Four types of frequently used:
GUIDELINES FOR DOCUMENTATION:
1. initial\ assessment documentation forms are known as
- Keep confidential all documented information in the client record. 2. open-ended,
- Document legibly or print neatly in no erasable ink. Errors in documentation 3. cued or
- Use correct grammar and spelling. Use only abbreviations that are acceptable and 4. checklist, integrated cued checklist, and nursing mini- initial
approved by the institution. B. OPEN-ENDED FORMS (TRADITIONAL FORM)
- Avoid slang, jargon, or labels unless they are direct quotes - Calls for narrative description of problem and listing of topics.
- Avoid wordiness that creates redundancy. - Provides lines for comments.
- Use phrases instead of sentences to record data - Individualizes information.
- Record data findings, not how they were obtained - Provides “total picture,” including specific complaints and symptoms in the
- Write entries objectively without making premature judgments or diagnoses. client’s own words.
- Record the client’s understanding and perception of problems. - Increases risk of failing to ask a pertinent question because questions are not
- Avoid recording the word “normal” for normal findings. standardized.
- Record complete information and details for all client symptoms or experiences. - Requires a lot of time to complete the database
- Include additional assessment content when applicable. C. CUED OR CHECKLIST FORMS
- Support objective data with specific observations obtained during the physical - Standardizes data collection.
examination. - Lists (categorizes) information that alerts the nurse to specific

ASSESSMENT FORMS USED FOR DOCUMENTATION: - problems or symptoms assessed for each client.
 - Usually includes a comment section after each category to allow for
individualization.
- Prevents missed questions.
- Promotes easy, rapid documentation.
- Makes documentation somewhat like data entry because it requires nurse to place
checkmarks in boxes instead of writing narrative.
- Poses chance that a significant piece of data may be missed because the checklist
does not include the area of concern.
INTEGRATED CUED CHECKLIST
- Combines assessment data with identified nursing diagnoses.
- Helps cluster data, focuses on nursing diagnoses, assists in validating nursing
diagnosis labels, and combines assessment with problem listing in one form.
- Promotes use by different levels of caregivers, resulting in enhanced
communication among the disciplines
NURSING MINIMUM DATA SET
- Comprises format commonly used in long-term care facilities.
- Has a cued format that prompts nurse for specific criteria;
- usually, computerized.
- Includes specialized information, such as cognitive patterns, communication
(hearing and vision) patterns, physical function and structural patterns, activity
patterns, restorative care, and the like.
- Meets the needs of multiple data users in the health care system.
- Establishes comparability of nursing data across clinical populations, settings,
geographic areas, and time.
ANALYSIS OF DATA AND CRITICAL THINKING—STEP TWO OF THE
NURSING PROCESS
Elements of the diagnostic process:
- Keep an open mind.
- Use rationale to support opinions or decisions.
- Reflect on thoughts before reaching a conclusion.
- Use past clinical experiences to build knowledge.
- Acquire an adequate knowledge base that continues
- to build.
- Be aware of the interactions of others.
- Be aware of the environment.
- Before you begin analyzing data, make sure you have accurately
- performed the steps of the assessment phase of the nursing
- process (collection and organization of assessment data,
- validation of data, and documentation of data). This information
- will have a profound effect on the conclusions you reach
- in the analysis step of the nursing process.
1. STEP ONE—IDENTIFY ABNORMAL DATA AND STRENGTHS
- Identifying abnormal findings and client strengths
- the nurse should compare collected assessment data with findings in reliable
charts and reference
- the nurse should have a basic knowledge of risk factors
- the nurse needs to have access to both the data supplied by
- the client and the known risk factors for specific diseases or disorders
2. STEP TWO—CLUSTER DATA
 - During step two, the nurse looks at the identified abnormal
- findings and strengths for cues that are related.
- Cluster both abnormal cues and strength cues.
- Use a particular nursing framework as a guide when possible
3. STEP THREE—DRAW INFERENCES
- Write down hunches about each cue cluster. For example, based on the cue
cluster presented
- Your hunch about this data cluster might be: “Changes in physical appearance
- are affecting self-perception.” This is something for which the
- nurse would intervene and treat independently. Therefore,
- The nurse would move to step four: analysis of data to formulate a nursing
diagnosis
4. STEP FOUR—PROPOSE POSSIBLE NURSING DIAGNOSES
- Hypothesize and generate possible nursing diagnoses. The nursing diagnoses
may be;
 Wellness, or health promotion,
 Diagnoses; risk diagnoses; or actual diagnoses,
 Syndrome diagnoses (NANDA, 2012).
5. STEP FIVE—CHECK FOR DEFINING CHARACTERISTICS
- The nurse must check for defining characteristics for the data clusters and
hypothesized diagnoses in order to choose the most accurate diagnoses and delete
those diagnoses that are not valid or accurate for the client.
- This step is often difficult because diagnostic labels overlap, making it hard to
identify the most appropriate diagnosis.
6. STEP SIX—CONFIRM OR RULE OUT DIAGNOSES
- If the cue cluster data do not meet the defining characteristics you can rule out
that particular diagnosis.
- If the cue cluster data do meet the defining characteristics, the diagnosis should
be verified with the client and other health care professionals who are caring for
the client.
- Tell the client what you perceive his diagnosis to be. Often nursing diagnosis
terminology is difficult for the client to understand.
- It is essential that the client understand the problem so that treatment can be
properly implemented.
- If the client is not in a coherent state of mind to help validate the problem,
consult with family members or significant others, or even other health care
professionals
7. STEP SEVEN—DOCUMENT CONCLUSIONS
- Be sure to document all of your professional judgments and the data that support
those judgments.
- Nursing diagnoses are often documented and worded in different formats.
- The most useful formats for actual, wellness, health promotion, risk, and actual
syndrome nursing diagnoses
TOPIC 6: ASSESSING PAIN
DEFINE PAIN:
 - Is an unpleasant sensory and emotional experience associated with actual or - Functional activities
potential tissue damage. The fifth vital sign.  Treatment response

COLSPIA:

 Characteristic
 Onset
 Location
 Duration
 Severity
 Pattern
 Associated factor

Assessing the patient with pain:

 Onset and duration

 Location/distribution
 Quality
 Intensity
 Aggravating/relieving factors
 Associated features or secondary signs/symptoms
 Associated factors
- Mood/emotional distress
Acute vs Chronic Pain:

Characteristics Acute pain Chronic pain

Cause
Duration of pain
Treatment approach
Generally known
Short, well-characterized
Resolution of underlying
cause, usually self-limited
Often unknown
Persists after healing, more
than equal 3 months
Underlying cause and pain
disorder; outcome is often
pain control, not cure.

Domains of Chronic Pain:

Quality of Life Psychological Morbidity

 Physical functioning  Depression
 Ability to perform activities of daily  Anxiety, anger
living  Sleep disturbances
 Work  Loss of self-esteem
 Recreation
Social Consequences Socioeconomic Consequences
 Marital/family relations  Healthcare costs
 Intimacy/sexual activity  Disability
 Social isolation  Lost workdays

Nociceptive vs Neuropathic Pain:

Pain Assessment Scales:

Possible Descriptions of Neuropathic Pain: ENUMERATE THE DIFFERENT CLASSIFICATIONS OF PAIN:

Sensations: Signs/symptoms: PAIN

 numbness  allodynia – pain from stimulus that acute chronic cancer pain
 tingling does not normally evoke pain Associated with an Usually associated with a Often due to the compression of
 paresthetic  thermal injury with a recent specific cause or injury & peripheral nerves or meninges or

 paroxysmal  mechanical onset and duration of is described as a constant from the damage to these
 hyperalgesia – exaggerated less than 6 mos. pain that persist more than structures following surgery,
 lancinating
response to a normally painful usually less than a 6 mos. chemotherapy, radiation or tumor
 electriclike
stimulus month growth.
 raw skin
 shooting
 deep, dull, bonelike ache