SALMA BEA LEDESMA

BSN – 1F
FON NURSING RPOCESS (ASSESSMENT AND DIAGNOSIS)
NURSING PROCESS
• The NP is a systematic method of giving
humanistic care that focuses on achieving
desired outcomes in a cost-effective fashion.
(Alfaro-Lefevre, 1998)
NURSING PROCESS
• The NP is a systematic method of giving
humanistic care that focuses on achieving
desired outcomes in a cost-effective fashion.
(Alfaro-Lefevre, 1998)
•The NP is an orderly systematic manner of
determining client's health status, specifying
problems identified, making plans to solve
them, implementing the plan and evaluating
the extent to which the plan was effective in
solving the problems identified.
(Yura and Walsh, 1988)
NURSING PROCESS: Characteristics
1. Cyclic & Dynamic
2. Client-centeredness (IFC)
3. Focus on problem-solving and decision-
making
4. Goal-oriented
5. Interpersonal process & collaborative
6. Use of critical thinking and clinical
reasoning
Types of Assessment
•Initial assessment
•Problem-focused assessment
•Emergency assessment
•Time-bound
Activities
•Collect data (obtain nursing health history,
conduct physical assessment, review client
records, review nursing literatures, consult
support persons, consult health professionals)
•Organize and update data as needed
•Validate data
•Document/ communicate data
Critical Thinking Activities
•Make reliable observations
•Distinguish relevant from irrelevant data/
important from unimportant data
•Categorize data according to the framework
•Recognize assumptions
•Identify gaps in the data
COLLECTION OF ASSESSMENT DATA
• Data collection is the process of gathering
information about a client's health status.

TYPES OF DATA:
ANA 2010 1. Subjective data- are apparent only to the
• Assessment person affected and can be described or
• Nursing Diagnosis (NDX) verified only by that person.
• Outcome Identification 2. Objective data- are detectable by an
• Planning observer and can be measured or tested
• Implementation against an accepted standard.
• Evaluation
SOURCES:
1. Primary source- CLIENT
ASSESSMENT 2. Secondary source- all sources other than
•Assessment is the systematic and continuous the client.
collection, organization, validation, and • SO
documentation of data. • Client Records
•Purpose: To establish a database about the • HCPs
client's response to health concerns or illness •Literature
and the ability to manage HC needs.
SALMA BEA LEDESMA
BSN – 1F
FON NURSING RPOCESS (ASSESSMENT AND DIAGNOSIS)
Confidentiality of all data collected is protected b. Nutrition
and can only be shared with persons who have a c. Elimination
legitimate responsibility to client care. d. Fluid & electrolytes
METHODS: e. Oxygenation
1. Observation- is a conscious, deliberate skill to f. Protection
gather data using the senses done in an organized g. Regulation of body processes
approach. 2. Self-concept
2. Physical Assessment- is a systematic data 3. Role function,
collection method performed through IPPA. 4. Interdependence
3. Interview- is a planned conversation with a
purpose conducted during health history taking. •Health History
4. Record Review • Physical fitness evaluation
5. Laboratory Results • Nutritional assessment
• Life-stress analysis
ORGANIZING ASSESSMENT DATA • Lifestyle and health habits
•Most healthcare agencies have developed their • Health beliefs
own structured assessment format. • Sexual health
• Frameworks: Gordon, Orem, and RAM • Relationships
•Healthrisk appr
•Marjorie Gordon (1987) proposed Functional
Health Patterns as a guide for establishing a VALIDATING ASSESSMENT DATA
comprehensive nursing database. • Validation is the act of double-checking or
verifying data to confirm that it is accurate and
1. Health Perception and Health Management factual.
2. Nutrition and Metabolism IMPORTANCE:
3. Elimination 1. Ensure that assessment information is complete.
4. Activity and Exercise 2. Ensure that objective and related subjective
5. Cognition and Perception data agree.
6. Sleep and Rest 3. Obtain additional information that may have
7. Self-Perception and Self-Concept been overlooked.
8. Roles and Relationships 4. Differentiate between cues and inferences.
9. Sexuality and Reproduction 5. Avoid jumping to conclusions and focusing in the
10 Coping and Stress Tolerance wrong direction to identify problems
11. Values and Reliefs
DOCUMENT ASSESSMENT DATA
Orem's 8 Universal Requisites of Human • Documentation is the process of making an entry
1. Sufficient intake of air on a client record.
2. Sufficient intake of water • Accurate documentation is essential and should
3. Sufficient intake of food include all data collected about the client's health
4. Adequate care and functioning of elimination status.
5. Balance between activity and rest
6. Balance between solitude and social interaction DOCUMENTING ASSESSMENT DATA
7. Prevention of hazards to human life, functioning, Narrative Notes- Narrative notes consist of
and well-being handwritten accounts in paragraph form that
8. Promotion of functioning and appropriate summarizes information obtained by general
development within social groups observation, interview, and physical examination.

Roy's Adaptation Model

1. Physiological needs
a. Activity & Rest
SALMA BEA LEDESMA
BSN – 1F
FON NURSING RPOCESS (ASSESSMENT AND DIAGNOSIS)
Open-ended notes- is the typical
"Fill-in-the-blanks" assessment form that comes
with pre-printed heading and questions. Can also be
used in a computerized documentation system
Closed-ended notes- assessment forms provide
pre-printed headings, checklists, and questions
with specific responses. The nurse will simply
check the appropriate response.
DIAGNOSIS
HISTORY OF NURSING DIAGNOSIS
• 1953 - Virginia Fry and Louise McManus introduce
"Nursing Diagnosis" as a necessary step in
preparing an NCP
• 1973-1° development of NDX sponsored by the
SLU School of Nursing Missouri USA
• 1977- First Canadian Conference in Toronto
° 1982- Acceptance of the name North American
Nursing Diagnosis Association (NANDA)
• 1987- International Nursing Conference
• 2002- NANDA-1
PURPOSE OF NANDA-I
•To define, refine and promote a taxonomy of
nursing diagnostic terminology for the general use
of professional nurses.
Impaired Physical Mobility
•267 NDX labels for clinical use and testing and
refinement.
DIAGNOSING
•Process of interpreting assessment data to
identify strengths and problems.
MEDICAL DIAGNOSIS
•Specific pathophysiologic responses that are
fairly uniform from one client to another.
NURSING DIAGNOSIS
•” A nursing judgment concerning a human response
to health conditions/life processes, or a
vulnerability for that response, by an individual,
family, group or community".
•A statement of nursing judgment and refers to a
condition that nurses, by virtue of their education,
experience, and expertise are licensed to treat.
•Human responses to an actual or potential health
problems that nurses are licensed to treat.
DIAGNOSIS
1. Actual Diagnosis- client problem that is present
at the time of diagnosis.
2. Health Promotion Diagnosis- relates to clients’
preparedness in implementing behaviors to improve
their health condition.
3. Risk Nursing Diagnosis- this is a clinical
judgment that a problem does not exist, but the
presence of risk factors indicates that a problem
is likely to develop unless nurses intervene.
4. Syndrome Diagnosis- is assigned by a nurse's
clinical judgment to describe a cluster of nursing
diagnoses that have similar interventions.
ACTIVITIES
•Analyze data
- Compare data against standards
- Identify gaps and inconsistencies
- Cluster the cues
•Identify health problems
- Critical thinking is an essential skill
needed for the identification of client
problems and the implementation of
interventions to promote effective
outcome.
•Formulate diagnostic statement
- COMPONENTS OF NANDA DX:
- Problem /Diagnostic Label
;Describes the client's health problem
or response to a health status clearly
and concisely in a few words.
• DXTIC labels need to be specific.
• Deficient Knowledge (Specify)
• Deficient Knowledge ( TB
Medications)
QUALIFIERS:
i. Deficient- inadequate
amount, quality, not
sufficient, incomplete
ii. Impaired - made worse,
weakenedamagedage,
reduced, deteriorated
iii. Decreased- lesser in size,
amount or degree
iv. Ineffective- not producing
the desired effect
SALMA BEA LEDESMA
BSN – 1F
FON NURSING RPOCESS (ASSESSMENT AND DIAGNOSIS)
- Etiology/ Related factor 8. Spiritual distress related to strict
Identifies one or more probable church rules
causes of health problem, gives 9. Impaired skin integrity related to
direction to the required nursing
ulceration of sacral area
therapy and enades the nurse to
10. Impaired skin integrity related to
individualize the client's care.
ulceration of sacral area

TIPS TO MINIMIZE DIAGNOSTIC ERROR

- S& Sx/ Defining Characteristics
o These are the cluster of
signs and symptoms that
indicate the presence of a
particular diagnostic label.
• ACTUAL NDX- client's
signs and symptoms
• RISK NDX- no subjective
and objective data
1. Verify
2. Build a good knowledge base and acquire clinical
experience
3. Have a working knowledge of what is normal
4. Consult resources
5. Base diagnosis on patterns/ behavior over time
rather than an isolated incident
6. Improve critical thinking skills

CRITICAL THINKING ACTIVITIES

•Finding patterns and relationships
among cues
•Making inference
•Suspending judgment when lacking data
•Stating the problem
•Examining assumptions
•Comparing patterns with norms
•Identifying patterns contributing to the problem

GUIDELINES FOR WRITING A NURSING

DIAGNOSIS
1. State in terms of a problem, not a need.
2. Use words that are legally acceptable.
3. Use non-judgmental statements
4. Make sure that both elements of the
statement do not say the same thing.
5. Be sure that cause and effect are
correctly stated.
6. Fluid replacement related to fever
7. Impaired skin integrity related to
improper positioning