NCMA111: HEALTH ASSESSMENT PRELIMS

01
Mr. Francis Vasquez III / Second Semester
Transcriber: K. Venus 23

THE NURSING PROCESS

3. Decision Making
OUTLINE o Sometimes when you take care of the
I. THE NURSING PROCESS patient, there are instances that you need
A. THE NURSING CARE PLAN to decide
B. ASSESSMENT BACKGROUND OF THE NURSING PROCESS
i. SOURCES OF DATA - Organized framework to guide practice
ii. TYPES OF DATA - Problem-solving method
iii. METHODS OF COLLECTING DATA - Systematic
iv. COMPONENTS OF NURSING HEALTH - Goal-oriented
iiiiiiiiiiiiiiHISTORY - Dynamic-always changing, flexible
C. DIAGNOSIS - Utilizes critical thinking processes
i. TYPES OF NURSING DIAGNOSIS - Universally applicable
ii. DOMAINS OF NANDA - Client-centered
iii. FORMULATING A NURSING DIAGNOSIS - Interpersonal and collaborative
iv. COMPONENT OF NURSING DIAGNOSIS ADVANTAGES OF NURSING PROCESS
v. GUIDELINES FOR WRITING A NURSING - Provides individualized care
iiiiiiiiiiDIAGNOSTIC STATEMENT - Client is an active participant
D. PLANNING - Promotes continuity of care
i. DEVELOPING A GOAL AND OUTCOME - Provides more effective communication among
iiiiiSTATEMENT nurses and healthcare professionals
ii. TYPES OF PLANNING - Develops a clear and efficient plan of care
iii. TYPES OF GOALS - Provides personal satisfaction as you see client
iv. INTERVENTIONS achieve goals
a. TYPES OF INTERVENTIONS - Professional growth as you evaluate effectiveness
v. SETTING PRIORITIES of your interventions
E. IMPLEMENTATION
i. KEY COMPONENTS IN INTERVENTION THE NURSING CARE PLAN
Goals
F. EVALUATION Cues
Nursing
diagnosis
Background
Knowledge
of Interventions Rationale evaluation
Care
i. EVALUATING

THE NURSING PROCESS

Subjective

- A systematic, rational, dynamic and cyclic process Objective

for planning and providing care for the client
- It refers to a series of phases describing the
practice of nursing. ASSESSMENT
- Is a systematic, chronological, step by step -To establish data base
procedure of ADPIE -First step of the Nursing process
o Assessment -It is the collection, organization, validation and
o Diagnosis documentation of data
o Planning - It begins during the first meeting of the nurse and
o Implementation the client
o Evaluation - There are four types of assessment:
- “To diagnose and treat human responses to actual INITIAL ASSESSMENT
or potential health problems” Time performed Purpose Sample
Establish Nursing
A D P I E Performed after
complete data admission
Prioritize Collect admission
Collect Analyze Reassess base assessment
Problem data
Identify
Formulate PROBLEM-FOCUSED ASSESSMENT
Organize the Implement Compare
Goals
problem Time performed Purpose Sample
Formulate Select Relate to Ongoing process To determine
Validate Supervise Hourly
Nsg Dx Interventions Goals integrated with status of a
Write assessment of
Document Assist Conclude nursing care specific problem
Interventions client’s intake
identified in an
Document Continue and output, or
Period of earlier
Modify vital signs
Terminate
confinement assessment

PROCESSES INVOLVED TIME-LAPSED ASSESSMENT

1. Critical-thinking Time performed Purpose Sample
o Since you are trying to analyze the Reassessment of
problem of the patient To compare the a client’s
2. Problem Solving Several months client’s current functional health
o Since you are going to identify what are after initial status to baseline patterns in a
assessment data previously home care or
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the different nursing care that are needed

to solve the problem of the patient. obtained outpatient
settings
[NCMA111] 2.01 THE NURSING PROCESS – Mr. Francis Vasquez III
PAST HISTORY
EMERGENCY ASSESSMENT - Childhood illness
Time performed Purpose Sample - Immunization
Rapid - Allergies
assessment of - Accidents and injuries
To identify life- individual’s - Hospitalization
threatening airway, breathing - Medication
During any FAMILY HISTORY OF ILLNESS
problems and circulation
physiological or MOTHER FATHER
during a cardiac
psychological
To identify new arrest (+) HPN (-) HPN
crisis of the client
or overlooked (-) DM (-) DM
problems Assessment of (-) PTB (+) PTB
suicidal LIFESTYLE
tendencies - Personal habits
o Amount, frequency and duration of
SOURCES OF DATA substance use
PRIMARY SOURCE - Diet
- Client or Family o Description of typical daily diet
SECONDARY SOURCE - Sleep or Rest patterns
- Physical exam, nursing history, team members, lab - Activities of Daily Living (ADL)
reports, diagnostic tests - Recreation or Hobbies
SOCIAL DATA
TYPES OF DATA - Family Relationship
- Ethnic Affiliation
SUBJECTIVE OBJECTIVE
- Education History
From the client Observable Data
- Occupational History
Symptom Sign
- Economic Status
“I have a headache” Blood Pressure 130/80 - Home and Neighborhood conditions

METHODS OF COLLECTING DATA DIAGNOSIS

- Make sure information is complete & accurate - Second step of the nursing process
- Validate prn - Interpret and analyze clustered data
- Interpret and analyze data and compare to - Identify client’s problems and strengths
“Standard norms” - Formulate Nursing Diagnosis (NANDA: North
- Organize and cluster data American Nursing Diagnosis Association)
- Methods: o Statement of how the client is responding
NURSING INTERVIEW to an actual or potential problem that
Open-ended question Close-ended question requires nursing intervention
not answerable by yes or
Answerable by yes or no
no THE DIFFERENCE OF NURSING AND MEDICAL DX
“Tell me how you feel NURSING DIAGNOSIS MEDICAL DIAGNOSIS
“Does it hurt?”
today” Within the scope of nursing Within the scope of medical
HEALTH ASSESSMENT practice practice
- Review of systems Identify responses to Focuses on curing
PHYSICAL EXAM health and illness pathology
- Inspection
Can change from day to Stays the same as long as
- Palpation
- Percussion day the disease is present
- Auscultation
COMPONENTS OF NURSING HEALTH HISTORY TYPES OF NURSING DIAGNOSIS
BIOGRAPHIC DATA ACTUAL
- Client’s Name - One of the commonly used type of diagnosis
- Age - Based on the actual problem of the patient
- Sex - The problem is already existing
- Marital status RISK
- Occupation - Also one of the commonly used type of diagnosis
- Religious affiliation - Similar to POSSIBLE
- Others - The causes that can make the problem become
CHIEF OF COMPLAINT present are already there
- The reason why the patient is seeking consultation - Can be based on the actual problem
- Chief complaint should be recorded in the client’s WELLNESS
own words - The patient is not ill, the patient is well
o “What brought you to the hospital?” POSSIBLE
HISTORY OF THE PRESENT ILLNESS - Similar to RISK
- Use chronologic story - The patient has the tendency to develop the
o When the symptoms started problem
o Whether the onset of symptom was SYNDROME
sudden or gradual - This is composed of two or more problem
o How often the problem occurs
o Exact location of distress
o Character of complaint
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▪ Intensity of pain
▪ Quality of sputum
[NCMA111] 2.01 THE NURSING PROCESS – Mr. Francis Vasquez III
DOMAINS OF NANDA
DOMAIN 1: HEALTH PROMOTION
- Class 1: Health awareness
o Decreased diversional activity engagement
o Readiness for enhanced health literacy
o Sedentary lifestyle
- Class 2: Health management
o Frail elderly syndrome
o Risk for frail elderly syndrome
o Deficient community health
DOMAIN 2: NUTRITION
- Class 1: Ingestion
o Insufficient breast milk
o Ineffective breastfeeding
o Imbalanced nutrition: less than body
requirements
- Class 2: Digestion
o This class does not currently contain any
diagnoses
- Class 3: Absorption
o This class does not currently contain any
diagnoses
- Class 4: Metabolism
o Risk for unstable blood glucose level
o Neonatal hyperbilirubinemia
o Risk for neonatal hyperbilirubinemia
- Class 5: Hydration
o Risk for electrolyte imbalance
o Risk for imbalanced fluid volume
o Deficient fluid volume
DOMAIN 3: ELIMINATION AND EXCHANGE
- Class 1: Urinary Function
o Impaired urinary elimination
o Functional urinary incontinence
o Overflow urinary incontinence
- Class 2: Gastrointestinal Function
o Constipation
o Risk for constipation
o Perceived constipation
- Class 3: Integumentary Function
o This class does not currently contain any
diagnoses
- Class 4: Respiratory Function
o Impaired gas exchange
DOMAIN 4: ACTIVITY/REST
- Class 1: Sleep/Rest
o Insomnia
o Sleep deprivation
o Readiness for enhanced sleep
- Class 2: Activity/Exercise
o Risk for disuse syndrome
o Impaired bed mobility
o Impaired physical mobility
- Class 3: Energy Balance
o Imbalanced energy field
o Fatigue
o Wandering
- Class 4: Cardiovascular/pulmonary responses
o Activity intolerance
o Risk for activity intolerance
o Ineffective breathing pattern
- Class 5: Self-care
o Impaired home maintenance
o Bathing self-care deficit
o Dressing self-care deficit
DOMAIN 5: PERCEPTION/COGNITION
- Class 1: Attention
o Unilateral neglect
- Class 2: Orientation
o This class does not currently contain any
diagnoses
- Class 3: Sensation/Perception
o This class does not currently contain any
diagnoses
- Class 4: Cognition
o Acute confusion
o Risk for acute confusion
o Chronic confusion
- Class 5: Communication
o Readiness for enhanced communication
o Impaired verbal communication
DOMAIN 6: SELF-PERCEPTION
- Class 1: Self-concept
o Hopelessness
o Readiness for enhanced hope
o Risk for compromised human dignity
- Class 2: Self-esteem
o Chronic low self-esteem
o Risk for chronic low self-esteem
o Situational low self-esteem
- Class 3: Body image
o Disturbed body image
DOMAIN 7: ROLE RELATIONSHIPS
- Class 1: Caregiving roles
o Caregiver role strain
o Risk for caregiver role strain
o Impaired parenting
- Class 2: Family Relationship
o Risk for impaired attachment
o Dysfunctional family processes
o Interrupted family processes
- Class 3: Role Performance
o Ineffective relationship
o Risk for ineffective relationship
o Readiness for enhanced relationship
DOMAIN 8: SEXUALITY
- Class 1: Sexual Identity
o This class does not currently contain any
diagnoses
- Class 2: Sexual Dysfunction
o Sexual dysfunction
o Ineffective sexuality pattern
- Class 3: Reproduction
o Ineffective childbearing process
o Risk for ineffective childbearing process
o Readiness for enhanced childbearing
process
DOMAIN 9: COPING/STRESS TOLERANCE
- Class 1: Post-Trauma responses
o Risk for complicated immigration transition
o Post-trauma syndrome
o Risk for post-trauma syndrome
- Class 2: Coping Responses
o Ineffective activity planning
o Risk for ineffective activity planning
o Anxiety
- Class 3: Neurobehavioral Stress
o Acute substance withdrawal syndrome
o Risk for acute substance withdrawal
syndrome
o Autonomic dysreflexia
DOMAIN 10: LIFE PRINCIPLES
- Class 1: Values
o This class does not currently contain any
diagnoses
- Class 2: Beliefs
o Readiness for enhanced spiritual well-
being
- Class 3: Value/Belief/Action congruence
o Readiness for enhanced decision-making
o Decisional conflict
o Impaired emancipated decision-making
DOMAIN 11: SAFETY/PROTECTION
- Class 1: Infection
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o Risk for infection
[NCMA111] 2.01 THE NURSING PROCESS – Mr. Francis Vasquez III
o Risk for surgical site infection
- Class 2: Physical Injury
o Ineffective airway clearance
o Risk for aspiration
o Risk for bleeding
- Class 3: Violence
o Risk for female genital mutilation
o Risk for other-directed violence
o Risk for self-directed violence
- Class 4: Environmental Hazards
o Contamination
o Risk for contamination
o Risk for occupational injury
- Class 5: Defensive Processes
o Risk for adverse reaction to iodinated
contrast media
o Risk for allergy reaction
o Latex allergy reaction
- Class 6: Thermoregulation
o Hyperthermia
o Hypothermia
o Risk for hypothermia
DOMAIN 12: COMFORT
- Class 1: Physical Comfort
o Impaired comfort
o Readiness for enhanced comfort
o Nausea
- Class 2: Environmental Comfort
o Impaired comfort
o Readiness for enhanced comfort
- Class 3: Social Comfort
o Impaired comfort
o Readiness for enhanced comfort
o Risk for loneliness
DOMAIN 13: GROWTH/DEVELOPMENT
- Class 1: Growth
o This class does not currently contain any
diagnoses
- Class 2: Development
o Risk for delayed development
FORMULATING A NURSING DIAGNOSIS
- Composed of three parts: PED/PES FORMAT
o Problem Statement
▪ The client’s response to a
problem
o Etiology
▪ What’s causing/contributing to the
client’s problem
o Defining Characteristics or S/S
▪ what’s the evidence of the
problem
EXAMPLE
Problem: Activity Intolerance
Etiology: Imbalance between oxygen supply / demand
S/Sx: a.m.b. abnormal HR and BP in response to light
activity
COMPONENT OF NURSING DIAGNOSIS
ONE-PART STATEMENT
- Consist of NANDA label only
TWO-PART STATEMENT
- Problem + Etiology
THREE-PART STATEMENT
- Problem + Etiology + Signs and Symptoms
GUIDELINES FOR WRITING A NURSING
DIAGNOSTIC STATEMENT
1. State in terms of problem, not a need or intervention
WRONG: Fluid replacement r/t fever
CORRECT: Deficient fluid volume r/t fever
2. Non-self incriminating
WRONG: Impaired skin integrity r/t improper positioning
CORRECT: Impaired skin integrity r/t immobility
3. Use non-judgemental statements
WRONG: Spiritual distress r/t strict rules necessiting church
attendance
CORRECT: Spiritual distress r/t inability to attend church
services secondary to immobility
4. Both elements of the statement do not say the same
thing
WRONG: Impaired skin integrity r/t ulceration of sacral area
CORRECT: Risk for impaired skin integrity r/t immobility
5. Cause and effect are correctly stated
WRONG: Pain r/t to severe headache
CORRECT: Severe headache r/t fear of addiction to
narcotics
6. Use nursing terminology rather than medical
terminology to describe the client’s response
WRONG: Risk for ineffective airway clearance related to
pneumonia
CORRECT: Risk for ineffective airway clearance r/t to
accumulation of secretions in lungs
PLANNING
- Third step of the nursing process
- This is when the nurse organizes a nursing care
plan based on the nursing diagnosis
- Nurse and client formulate goals to help the client
with their problems
- Expected outcomes are identified
- Interventions (nursing orders) are selected to aid
the client reach these goals
- Begin by prioritizing client problems
- Prioritize list of client’s nursing diagnosis using
Maslow’s Hierarchy of Needs
- Rank as high, intermediate or low
- Client specific
- Priorities can change
DEVELOPING A GOAL & OUTCOME STATEMENT
- Goal and outcome statements are client focused
- Worded Positively
- Must be SMART
o Specific
o Measurable
o Attainable
o Realistic
o Time-bounded
- Goal
o Broad statement
o Sometimes we call the goal as
EXPECTED OUTCOME
o Expected Outcome
▪ Objective criterion for
measurement of goal
TYPES OF PLANNING
INITIAL PLANNING
- Admission
- It answers initial assessment
- Short and quick
ONGOING PLANNING
- Confinement
- Day to day planning depending to the type of
problem the patient is presenting
DISCHARGE PLANNING
- Before discharge
- A discharge plan that will guide the patient on the
things that he must perform to himself at home to
be able to maintain recovery
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[NCMA111] 2.01 THE NURSING PROCESS – Mr. Francis Vasquez III
TYPES OF GOALS KEY COMPONENTS IN INTERVENTION
SHORT-TERM GOALS M – Monitoring
- We can use this if the patients problem will last no - Monitor the vital signs
longer than 6 months - Monitor urine output
LONG-TERM GOALS T – Teach
- We can use this if the patient’s problem will last for - Teach the patient about take home medication
more than 6 months A – Administer
GOAL - Administer medication to the client
DIAGNOSIS
STATEMENT P – Perform
Ineffective airway Within 48-72 hours, pt’s
clearance r/t tenacious lungs will be clear on EVALUATION
secretions auscultation - Final step of the nursing process but also done
Within 24-48 hours, client concurrently throughout client care
will show fluid balance as - A comparison of client behavior and/or response to
Fluid volume deficit related
evidenced by urine output the established outcome criteria
to diarrhea
of greater than 30ml/hr and - Continuous review of the nursing care plan
good skin turgor - Examines if nursing interventions are working
- Determines changes needed to help client reach
INTERVENTIONS stated goals
- Interventions are selected and written
- The nurse uses clinical judgement and professional EVALUATING
knowledge to select appropriate interventions that - An appraisal whether expected outcomes are met
will aid the client in reaching their goal - An appraisal of the effectiveness of nursing care
- Interventions should be examined for feasibility and plan
acceptability to the client POSSIBLE RESULT
- Interventions should be written clearly and GOAL is MET
specifically - Problem resolved
CRITERION OF GOAL is PARTIALLY MET
SUBJECT VERB CONDITIONS/MODIFIERS DESIRED
PERFORMANCE - Continue plan of care – ongoing
Using GOAL is NOT MET
Correct insulin
CLIENT Administers aseptic - Review each step of NCP and determine of
dose
technique modification of the NCP is needed
Leg ROM
Every 8
Client Performs exercise as
hours
taught
Client Drinks 2500 ml fluid daily

TYPES OF INTERVENTIONS
INDEPENDENT (NURSE INITIATED)
- Any action the nurse can initiate without direct
supervision
DEPENDENT (PHYSICIAN INITIATED)
- Nursing actions requiring MD orders
COLLABORATIVE
- Nursing actions performed jointly with other health
care team members
SETTING PRIORITIES
USE:
- Maslow’s Hierarchy of Human Needs
- ABC of Life
o Airway
o Breathing
o Circulation
OTHER FACTORS IN PRIORITIZING:
- Client’s health status and belief
- Client’s priorities
- Available resources
- Urgency of the health problem
- Medical treatment plan

IMPLEMENTATION
- The fourth step in the nursing process
- This is the “doing” step
- Carrying out nursing interventions (Orders) selected
during the planning step
- This includes monitoring, teaching, further
assessing, reviewing NCP, Incorporating
physician’s orders and monitoring cost
effectiveness of interventions
- Utilize NIC as standard
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- It is putting the plan into actions

o (Go back to types of intervention)