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Nursing Process

Nursing Process

  1. 1. Descriptive Number: N 101Descriptive Name: Health AssessmentCourse Description: The course deals with concepts, principles and techniques of history taking using various tools, physical examination (head to toe), psychosocial assessment and interpretation of laboratory findings to arrive at a nursing diagnosis on the client across the lifespan in varied settings.<br />
  2. 2. Course Outline:<br />I. Conceptual Overview of the Nursing Health Assessment<br /> - review of the phases of the Nursing Process<br /> A. Nurse’s Role in Health Assessment:<br /> Collecting and Analyzing Data<br /> Evolution of nurse’s role in health assessment<br />B. Critical Thinking in Health Assessment<br />II. Data Collection Documentation and Analysis<br /> A. Data Collection Process<br /> - General Survey<br /> - Interview Techniques<br /> B. Collecting Subjective Data<br /> - COLD SPA<br />
  3. 3. - Health History<br /> a. Biographical data<br /> b. Chief Complaints<br /> c. Present Health History<br /> d. Past Health History<br /> e. Family History<br /> f. Psychosocial History<br /> g. Activities of Daily Living (ADLs)<br /> h. Review of Systems<br />
  4. 4. C. Collecting Objective Data<br /> - Vital signs (TPR, BP)<br /> - Physical Assessment (IPPA)<br /> - Diagnostic Procedures<br />D. Validation/ Rationalization of Subjective/ ObjectiveData<br />E. Documentation of Data<br /> - Purposes of Assessment Documentation<br /> - Guidelines for Documentation<br /> - Assessment forms used for documentation<br />
  5. 5. INTERMEDIATE COMPETENCIES<br />Given a hypothetical case, the student will be able to:<br />1. Analyze the different phases of the nursing process<br />2. Utilize the nursing process in health assessment<br />3. Describe the critical thinking process with relevance to health assessment<br />4. Demonstrate critical thinking skills in health assessment<br />5. Collect relevant data<br />6. Classify subjective from objective data<br />7. Utilize interview techniques<br />
  6. 6. 8. Conduct health history<br />9. Perform accurately<br /> a. Vital signs<br /> b. Physical Examination (IPPA)<br />10. Assist client before, during and after diagnostic procedures <br />11. Differentiate normal from abnormal findings<br />12. Explain deviations from normal results<br />13. Demonstrate legal practices in documentation<br />
  7. 7. NURSING PROCESS<br />&quot;the cornerstone of the nursing profession&quot;<br />
  8. 8. What is a Process?<br />It is a series of planned actions or operations directed towards a particular result or goal.<br />
  9. 9. Nursing Process<br />It is a systematic, rational method of planning and providing individualized nursing care.<br />
  10. 10. Characteristics of the Nursing Process<br />Dynamic<br />Client-centered<br />Planned<br />Interpersonal and collaborative<br />Universally applicable<br />Can focus on problems or strengths<br />
  11. 11. Open, flexibe<br /> Humanistic and individualized<br /> Cyclical<br /> Outcome focused ( results oriented)<br /> Emphasizes feedback and validation<br />
  12. 12. Purpose of Nursing Process<br />To identify a client’s health status, actual or potential health care problems or needs, to establish plans to meet the identified needs, and to deliver specific nursing interventions to meet those needs. <br />It helps nurses in arriving at decisions and in predicting and evaluating consequences.<br />It was developed as a specific method for applying a scientific approach or a problem solving approach to nursing practice.<br />
  13. 13. Nursing Process...<br />Systematic<br />Organized<br />Goal-Oriented<br />Humanistic Care<br />Efficient Effective<br />
  14. 14. PHASES OF THE NURSING PROCESS<br />Assessment<br />Diagnosis<br />Outcome Identification<br />Planning<br />Implementation<br />Evaluation<br />
  15. 15. Nursing Diagnosis<br />Assessment<br />Evaluation<br />Planning<br />Implementation<br />Nursing Process<br />Outcome identification<br />
  16. 16. Benefits of using the nursing process<br />Continuity of care<br />Prevention of duplication<br />Individualized care<br />Standards of care<br />Increased client participation<br />Collaboration of care<br />
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  19. 19. ASSESSMENT<br />
  20. 20. Assessing is a continuous process carried out during all phases of nursing process. All phases of the nursing process depend on the accurate and complete collection of data.<br />Assessing is the systematic and continuous collection, organization, validation and documentation of data.<br /> - Potter and Perry( 2006)<br />
  21. 21. Assessment is the deliberate and systematic collection of data to determine a clients current and past health status and to determine the clients present and past coping patterns<br /> - Carpenito 2004<br />Assessment is the systematic and continuous collection, validation and communication of patient data.<br /> - Carol Taylor<br /> <br />
  22. 22. To establish baseline information on the client.<br />To determine the client’s normal function.<br />To determine the client’s risk for diagnosis function.<br />To determine presence or absence of diagnosis function.<br />To determine client’s strengths.<br />To provide data for the diagnostic phase.<br />
  23. 23. Activities of Assessment<br />COLLECT DATA<br />VALIDATE DATA<br />ORGANIZE DATA<br />RECORDING DATA<br />Assessment involves reorganizing and collecting CUES:<br />Objective (overt) Subjective (covert)<br />
  24. 24. Assessment<br />ASESSMENT<br />Collect data<br />Organize data<br />Validates Data<br />Document data<br />DIAGNOSIS<br />PLANNING<br />EVALUATION<br />IMPLIMENTATION<br />
  25. 25. Types of Assessment<br /><ul><li>1.Initial Assessment: Performed within specified time after admission to a health care agency</li></ul>Eg. Nursing Admission Assessment<br /><ul><li>2. Problem Focused Assessment: Ongoing process integrated with nursing care to determine specific problem identified in an earlier assessment and to identify new or overlooked problems.</li></ul>E.g.. Assessment of clients ability to perform self-care while assisting client to bathe.<br /><ul><li>3. Emergency Assessment: Done during psychiatric or physiological crisis of the client to identify life threatening problems</li></ul>Eg. Rapid assessment of airway, breathing and circulation during cardiac arrest<br /><ul><li>4. Time lapsed-Reassessment: Done several months after initial assessment to compare the clients status to baseline data previously obtained.</li></li></ul><li>Clinical Skills used in Assessment<br />Observation – act of noticing client cues.<br /> *looking, watching, examining, scrutinizing, surveying, scanning, appraising.<br /> *uses different senses: vision, smell, hearing, touch.<br />Interviewing – interaction and communication.<br />Physical Examination<br />INSPECTION<br />PALPATION<br />PERCUSSION<br />AUSCULTATIONTUITION<br />- defined as insights, instincts or clinical experiences to make judgment about client care.<br />
  26. 26. 1.COLLECTION OF DATA<br />Data Collection is the process of gathering information about a clients health status.<br />
  27. 27. Collection of Data:<br /> <br /><ul><li>Data base: A data base is all information about a client. It includes the nursing health history, physical assessment, the physician’s history, physical examination, results of laboratory and diagnostic tests and material contributed by other health personnel.</li></ul> <br /> <br /> <br />
  28. 28. Medical vs. Nursing Assessments<br />Medical assessments<br />Target data pointing to pathologic conditions<br />Nursing assessments<br />Focus on the patient’s response to health problems<br />
  29. 29. Types of Data: <br />SUBJECTIVE DATA: Also referred to as symptoms or covert data are apparent only to the person affected and can be described or verified only by that person<br /> Eg. Itching, Pain, Feelings of worry<br />OBJECTIVE DATA: Also referred to as signs or overt data. These are detectable by an observer or can be measured or tested against an accepted standard.<br /> They can be seen, heard, felt or smelled and they are obtained by observation or physical examination<br /> Eg. A Blood Pressure Data<br /> Discolouration of the Skin<br /> <br />
  30. 30. Objective Data vs. Subjective Data<br />Objective data<br />Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them<br />E.g., elevated temperature, skin moisture, vomiting<br />Subjective data<br />Information perceived only by the affected person<br />E.g., pain experience, feeling dizzy, feeling anxious<br />
  31. 31. COMPARING SUBJECTIVE AND OBJECTIVE DATA<br />Data elicited and verified by the client<br />Client Family and significant others.<br />Client record<br />Other health care professionals<br />Client interview<br />Interview and therapeutic communication skills.<br />Caring ability and empathy.<br />Listening skills.<br />“I have a headache.”<br />“It frightens me.”<br />“I am not hungry.”<br />Data directly or indirectly observed through measurement<br /> <br />Observation and Physical examination<br />Inspection<br />Palpation<br />Percussion<br />Auscultation<br />Respiration is 16 per minute.<br />BP 180/100 mmhg, apical pulse 80 bpm and irregular<br />X-ray film reveals fractured ribs<br /><ul><li>Description
  32. 32. Sources
  33. 33. Methods used to obtain data
  34. 34. Skills needed to obtain data
  35. 35. Examples</li></li></ul><li>Sources of Data:<br />Primary Source (Direct Source<br />client:Usually BEST source<br />
  36. 36. Secondary Source (Indirect Source)<br /><ul><li>Family Members
  37. 37. Client’s records</li></ul> 1. Medical Records<br /> Eg. Medical History, Physical Examination,<br /> Operation notes, Progress notes, <br /> Consultation done by Physicians<br /> 2. Records of therapies done by other health professionals<br /> Eg. Social Workers, Dieticians, Physical Therapist<br /> 3. Laboratory Records<br /><ul><li> Other health care professionals Verbal reports</li></li></ul><li>Data Collection<br />Consider <br />time<br />needs of patient<br />developmental stage<br />physical surroundings<br />past and present coping patterns<br />
  38. 38. Data Characteristics<br /><ul><li>Complete
  39. 39. Factual
  40. 40. Accurate
  41. 41. Relevant</li></li></ul><li>Data collection methods<br />OBSERVATION<br />INTERVIEWING <br />PHYSICAL ASSESSMENT<br />
  42. 42. Observation<br />To gather data using senses<br />Eg: laboured breathing, pallor or flushing,pain<br /> a lowered side rail ,functioning of an equipment , pt environment and people in it etc…<br />
  43. 43. Interviewing<br />An interview is a planned communication or a conversation with a purpose<br />Collection of Health History<br />
  44. 44. Four Phases of a Nursing Interview<br /><ul><li>Preparatory phase
  45. 45. Introduction
  46. 46. Working phase
  47. 47. Termination</li></li></ul><li>Interview Phases<br /><ul><li>Preparatory
  48. 48. Nurse collects background info from previous charts
  49. 49. Ensure environment is conducive
  50. 50. Arrange seating
  51. 51. 3 – 4 ft apart
  52. 52. Interviewer at 45° angle to patient
  53. 53. Allow adequate time </li></li></ul><li>Introduction<br /><ul><li>Nurse introduces self
  54. 54. Identifies purpose of interview
  55. 55. Ensure confidentiality of information
  56. 56. Provide for patient needs before starting</li></li></ul><li>Working<br /><ul><li>Nurse gathers info for subjective data
  57. 57. Excellent communication skills are needed
  58. 58. Active listening
  59. 59. Eye contact
  60. 60. Open-ended questions </li></li></ul><li>Termination<br /><ul><li>Inform patient when nearing end of interview
  61. 61. Ensure patient knows what will happen with info
  62. 62. Offer patient chance to add anything</li></li></ul><li>
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  90. 90. DIAGNOSTIC PROCEDURE</li></li></ul><li>Physical assessment<br /><ul><li>Appraisal of health status
  91. 91. Usually by Review of Systems
  92. 92. Overview of symptoms
  93. 93. Observable, measurable data</li></li></ul><li><ul><li>Possible approaches—body systems, head to toe, or functional health patterns</li></li></ul><li>Methods of physical assessment<br /><ul><li>Inspection
  94. 94. Percussion
  95. 95. Palpation
  96. 96. Auscultation</li></li></ul><li>DIAGNOSTIC PROCEDURES<br /><ul><li>URINE ANALYSIS
  97. 97. STOOL EXAM
  98. 98. SPUTUM
  100. 100. CHEST X-RAY
  101. 101. ULTRASOUND</li></li></ul><li>Chest x-ray film (radiograph)<br />1. Description: provides information regarding the anatomical location and appearance of the lungs.<br />2. Preprocedure<br /> a. Remove all jewelry and other metal objects from the chest area.<br /> b. Assess the client’s ability to inhale and hold breath.<br /> c. Question females regarding pregnancy or the possibility of pregnancy.<br />3. Postprocedure: <br /> Assist the client to dress.<br />
  102. 102. Ultrasound<br />Imaging, medical diagnostic technique in which very high frequency sound is directed into the body. The tissue interfaces reflect the sound, and the resulting pattern of sound reflection is processed by a computer to produce a photograph or a moving image on a television. Ultrasound can be used to examine many parts of the body, but its best known application is the examination of the fetus during pregnancy.<br />
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  105. 105. You will be given a scenario, that you would analyze as CUES for your nursing assessment.<br />Identify subjective to objective data.<br />You will be given points to every correct assessment.<br />
  106. 106. W.T. a 22 year old male, presented to ER with a chief complaint “bad” abdominal pain. The generalized abdominal pain started 24 hours ago but seem to “ease up” after he vomited. Several hours later the pain returned but had shifted to the RLQ and has remained there. The pain is steadily getting worse that he is guarding that area, maintaining a fetal position, profusely sweating and BP when up to 150/100 mmhg from the baseline 120/70 mmhg. <br />
  107. 107. W.T. reports marked nausea and “dry heaves” and he has no appetite. He has also had diarrhea for the last day. VS are 150/100mmhg, 92 bpm, 25 breaths/min, 38.8C temp. Started to have chills, weakness, trembling toes and redness of the face and neck. He vomited again to a greenish gastric secretions with undigested foods. The patient states “dawmapataynagidkosakasakit” appears to anxious and uneasy.<br />
  108. 108. Ana-physio. What organ(s) are located in the RLQ?<br />Priority problem identified?<br />Based on the scenario, identify the subjective data<br />Based on the scenario, identify the objective data<br />Given the scenario, how are you going to approach the patient?<br />State all the cues that can be collected by means of observation. <br />
  109. 109. ACTIVITY<br /> G.S. a 36 year old secretary, was having difficulty of breathing a few hours after eating a green salad tossed in tartar sauce with grilled shrimp. She developed a mild urticaria, peri-orbital edema, generalized itchiness. Patient states she had never experienced this before,very anxious and diaphoretic thinks that she may die. RR= 24 breaths/min laboured, cyanotic nailbeds, cold clammy skin,<br />
  110. 110. ACTIVITY<br /> Bilateral wheezing sounds upon auscultation, and pulse rate of 106bpm. She is crying she cant breath deeply. She had an oxygen at 2lpm, nebulization every 4 hours and on steroid therapy.<br />
  111. 111. ACTIVITY<br />Priority problem identified?<br />Based on the scenario, identify the subjective data<br />Based on the scenario, identify the objective data<br />Given the scenario, how are you going to approach/communication technique to the patient?<br />State all the cues that can be collected by means of observation. <br />
  112. 112. Kindly bring your Nursing Care Plan Book, Nursing Process, and any pocket guide to nursing diagnosis or nursing process.<br />
  113. 113. ORGANISING DATA<br /><ul><li> Nurses uses a written or computerized format for arranging he data systematically
  114. 114. Clustering facts into groups of information.</li></li></ul><li>VALIDATING DATA<br /><ul><li>VALIDATING -THE ACT OF DOUBLE CHECKING
  115. 115. Verifies understanding of information
  116. 116. Comparison with another source</li></ul> -patient or family member<br /> -record<br /> -health team member<br />
  117. 117. DOCUMENTING DATA<br /><ul><li>Record in permanent record ASAP
  118. 118. Use patient’s own words in subjective data – enclose in “ ___” (quotation marks)
  119. 119. Avoid generalizations – be specific
  120. 120. Don’t make summative statements</li></li></ul><li> Document what you saw the patient doing or what you believe he’s doing.<br />
  121. 121. SIX PHASES<br />NURSING <br />PROCESS<br />
  122. 122. ASSESSMENT<br /><ul><li>To establish data base.</li></ul>Sources of Data:<br />Primary: Patient / Client<br />Secondary: Family members, SOs, Record/Chart, Health team members, Related Lit.<br />
  123. 123. Approaches to Collecting Data for Assessing Client’s Health:<br />ABDELLAH’S 21 Nursing Problems<br />DOROTHEA OREM’S Components of Universal Self-Care<br />GORDON’S Functional Health Patterns<br />Correlating a Body Systems Physical Examination with Data Gathered by Functional Health Area.<br />
  124. 124. DIAGNOSING<br />Nursing Diagnosis- terminology used for a clinical judgment by the professional nurse that identifies the client’s actual, risk, wellness, or syndrome responses to a health state, problem, or condition.<br />
  125. 125. Purposes of Nursing Diagnosis<br />Identifies areas that nurses can resolve or enhance.<br />Demonstrates professional judgment.<br />Organizes decision making as part of the nursing process.<br />Promotes accountability.<br />Provides communication among nurses and other health care personnel.<br />Promotes use of standardized language and process.<br />A means to individualize care.<br />Provides a mechanism for conducting nursing research.<br />
  126. 126. Categories of Nursing Diagnoses<br />Actual Diagnoses<br />Risk Diagnoses<br />Wellness Diagnoses<br />
  127. 127. Categories of Nursing DiagnosesWELLNESS RISK ACTUAL<br />Human responses that may develop in a vulnerable individual, family, or community (NANDA,2003-2004)<br />“Risk for…”<br />-Risk for Disturbed Body Image.<br />-Risk for Interrupted Family processes.<br />-Risk for Ineffective Breast-feeding.<br />-Risk for impaired Skin integrity<br />Human responses to health conditions/life processes that exist (NANDA,2003-2004)<br />“Nursing diagnoses and related to cause”<br />-Disturbed Body Image related to wound on hand that is not healing.<br />-Dysfunctional Family Processes: Alcoholism.<br />-Ineffective Breast-feeding related to poor mother-infant attachment.<br />-Impaired Skin Integrity related to immobility<br />
  128. 128. Developing a Nursing Diagnosis<br />Critical thinking is essential to the synthesis and interpretation of information when developing a nursing diagnosis.<br />Assessing the Data Base <br />Cues are small amounts of data gathered during assessment.<br />Cues raise suspicion.<br />Cues stimulate further observation.<br />Cues stimulate further data collection.<br />Validating Cues- Verifying subjective and objective data for accuracy and completeness<br />Interpreting Cues- Assigning meaning to data cues<br />Clustering Cues- Grouping related data together<br />Consulting NANDA List of Nursing Diagnoses<br />Writing the Nursing Diagnosis Statement<br />
  129. 129. Nursing diagnosis statement<br />Actual Health Problem: PE Format<br />Potential Health Problem: PER Format<br />P- Problem statement;<br />E- Etiology;<br />R- Risk Factor<br />
  130. 130. Classification of NURSING DIAGNOSIS:<br />High – priority<br /> - life threatening and requires immediate attention.<br />Medium – priority<br /> - resulting to unhealthy consequences.<br />Low – priority<br /> - can be resolve with minimal interventions.<br />
  131. 131. Outcome Identification<br />refers to formulating and documenting measurable, realistic, client-focused goals.<br />PURPOSES:<br />To provide individualized care<br />To promote client participation<br />To plan care that is realistic and measurable<br />To allow involvement of support people<br />ESTABLISH PRIORITIES!!!<br />
  132. 132. Characteristics ofOutcome Criteria:<br />S - SPECIFIC<br />M - MEASURABLE<br />A - ATTAINABLE<br />R - REALISTIC<br />T - TIME – FRAMED<br />CAN BE SHORT TERM OR LONG TERM GOAL.<br />
  133. 133. PLANNING<br />Involves determining beforehand the strategies or course of actions to be taken before implementation of nursing care. <br />To be effective, involve the client and his family in planning!<br />
  134. 134. IMPLEMENTATION<br />Putting nursing care plan into ACTION!<br />To help client attain goals and achieve optimal level of health.<br />Requires: Knowledge, Technical skills, Communication skills, Therapeutic Use of Self.<br />…..SOMETHING THAT IS NOT WRITTEN IS CONSIDERED AS NOT DONE!!!<br />
  135. 135. Planning Nursing InterventionsCategories of Nursing Interventions<br />Independent Nursing Interventions:<br />-Actions initiated by the nurse<br />-Do not require direction or an order from another health care professional.<br />-Sanctioned by professional nurse practice acts.<br />
  136. 136. Planning Nursing InterventionsCategories of Nursing Interventions<br />Interdependent Nursing Interventions:<br /><ul><li>Collaboration
  137. 137. Consultation </li></li></ul><li>Planning Nursing InterventionsCategories of Nursing Interventions<br />Dependent Nursing Interventions:<br />-Require an order from another health care professional.<br />
  138. 138. Nursing intervention activities<br /><ul><li>Reassessing
  139. 139. Set priorities
  140. 140. Perform nursing intervention
  141. 141. Record actions</li></li></ul><li>Requirements of implementing:<br />KNOWLEDGE- include intellectual skills like problem solving, decision making, and teaching.<br />TECHNICAL SKILLS- to carry out treatments and procedures.<br />COMMUNICATION SKILLS- use of verbal and non-verbal communication to carry out planned nsg. Intervention.<br />THERAPEUTIC USE OF SELF- being willing and being able to care.<br />
  142. 142. EVALUATION<br />IS ASSESSING THE CLIENT’S RESPONSE TO NURSING INTERVENTIONS.<br />COMPARING THE RESPONSE TO PREDETERMINED STANDARDS OR OUTCOME CRITERIA.<br />FOUR POSSIBLE JUDGMENTS:<br />The goal was completely met.<br />The goal was partially met.<br />The goal was completely unmet.<br />New problems or nursing diagnoses have developed.<br />
  143. 143. ACTIVITY<br /> G.S. a 36 year old secretary, was having difficulty of breathing a few hours after eating a green salad tossed in tartar sauce with grilled shrimp. She developed a mild urticaria, peri-orbital edema, generalized itchiness. Patient states she had never experienced this before,very anxious and diaphoretic thinks that she may die. RR= 24 breaths/min laboured, cyanotic nailbeds, cold clammy skin,<br />
  144. 144. ACTIVITY<br /> Bilateral wheezing sounds upon auscultation, and pulse rate of 106bpm. She is crying she cant breath deeply. She had an oxygen at 2lpm, nebulization every 4 hours and on steroid therapy.<br />
  145. 145. ACTIVITY<br />Priority problem identified?<br />Based on the scenario, identify the subjective data<br />Based on the scenario, identify the objective data<br />Make an actual and risk nursing diagnosis with rationale.<br />
  146. 146. Characteristics of NURSING PROCESS…<br />Problem-oriented.<br />Goal oriented.<br />Orderly, planned, step by step.<br /> (systematic)<br />Open to new information.<br />Interpersonal.<br />Permits creativity.<br />Cyclical.<br />
  149. 149. HEART OF THE NURSING PROCESS…<br />KNOWLEDGE<br />SKILLS<br />- manual, intellectual, interpersonal.<br />CARING<br />- willingness and ability to care.<br />
  150. 150. Willingness to CARE<br />Keep the focus on what is best for the patient.<br />Respect the beliefs / values of others.<br />Stay involved.<br />Maintain a healthy lifestyle.<br />
  151. 151. CARING BEHAVIORS<br />Inspiring someone / instilling hope and faith.<br />Demonstrating patience, compassion, and willingness to persevere.<br />Offering companionship.<br />Helping someone stay in touch with positive aspect of his life.<br />
  152. 152. Demonstrating thoughtfulness.<br />Bending the rules when it really counts.<br />Doing the “little things”<br />Keeping someone informed.<br />Showing your human side by sharing “stories”<br />
  153. 153. Any Questions???<br />
  154. 154. COLLECTING SUBJECTIVE DATA<br />by: CMG<br />
  155. 155. CHIEF COMPLAINT/REASON FOR SEEKING HEALTH CARE:<br />Guide Questions: <br />“what is your major health problem or concern at this time?”<br />“why are you here?”<br />“how can I help you?”<br />Subjective: <br />Translation:<br />by: CMG<br />CLIENT’S HEALTH HISTORY<br />
  156. 156. ADMITTING IMPRESSION : Physicians initial findings (No Abbreviations)<br />by: CMG<br />
  157. 157. BIOGRAPHICAL DATA<br /> <br /> Name:(use initials) <br /> Age:<br /> Sex:<br />Marital Status: <br /> Religion/Spiritual practices: <br /> Address:<br /> Birth date:<br />Birthplace:<br />by: CMG<br />
  158. 158. Race or ethnic background:<br />Who lives with the client:<br />Significant others:<br />Educational Level:<br />Occupation: (active/laid off/retired)<br />Nationality:<br />Physician:<br />Date of interview:<br />Time of interview:<br />Date of admission:<br />Time of admission:<br />Room/ Ward:<br />by: CMG<br />
  159. 159. Provider of history: <br /> Primary: <br /> Secondary:<br />Vital Signs upon Admission:<br />by: CMG<br />
  160. 160. HISTORY OF PRESENT ILLNESS<br />Character ( How does it feel, look, smell, sound, etc.?)<br />Onset( When did it begin; is it better, worse, or the same since it began?)<br />Location (Where is it? Does it radiate?)<br />Duration (How long it last? Does it recur?)<br />Severity ( How bad is it on a scale 1 [barely noticeable] to 10 [worst pain ever experienced])?<br />Pattern ( What makes it better? What makes it worse?)<br />Associated factors (What other symptoms do you have with it? Will you be able to continue doing your work or other activities? <br />by: CMG<br />
  161. 161. (In chronological order, include specifications for signs and symptoms, interventions or treatment done, response and compliance. For medications, include the name of the drug, dosage, frequency, time).<br />by: CMG<br />HISTORY OF PRESENT ILLNESS<br />
  162. 162. Problems at birth<br />Childhood Illnesses<br />Immunizations to date<br />Adult illnesses (physical, emotional, mental)<br />Surgeries<br />Accidents<br />Prolonged pain or pain patterns<br />Allergies<br />by: CMG<br />PAST HEALTH HISTORY<br />
  163. 163. Purpose: More health problems that seem to run in the families and that are genetically based; the family history assumes greater importance.<br />by: CMG<br />FAMILY HISTORY<br />
  164. 164. (Focused Interview based on the chief complaint and the admitting impression of the patient).<br />Purpose: How the client views herself and investigation of all behaviors that a person does to promote her health. This will help to point out clients strengths and needs for health maintenance and determine client’s level of social development.<br />by: CMG<br />SOCIO-CULTURAL HISTORY<br />
  165. 165. (Focused Interview based on the chief complaint and the admitting impression of the patient).<br />Purpose: Questions regarding the client’s environment to assess health hazards unique to the clients living situation and lifestyle that may put the client at risk. They may be controllable or uncontrollable<br />by: CMG<br />ENVIRONMENTAL HISTORY<br />
  166. 166. MEDICATION AND SUBSTANCE USE<br />Purpose: The information gathered about medication and substance use provides the nurse with information concerning lifestyle and a client’s self care ability. Medication and substance use can affect the client’s health and cause loss of function or impaired senses and can increase the client’s risk for a disease.<br />by: CMG<br />
  167. 167. OBSTETRICAL HISTORY (For Ob-Gyne Cases)<br />GROWTH AND DEVELOPMENT<br />(For Pediatric Patients, significance must be indicated if the growth and development of a child is delayed, advanced or normal. State the reason for the abnormalities.)<br />by: CMG<br />
  168. 168. Using GORDON’S functional Health Pattern with comparison to Home and Hospital<br />by: CMG<br />PATTERNS OF FUNCTIONING<br />
  169. 169. Example:<br />CBC, Blood studies<br />Urine analysis<br />Stool Exam<br />Sputum Exam<br />Chest x-ray<br />Ultrasound<br />by: CMG<br />DIAGNOSTIC EXAMINATION<br />
  170. 170. General Appearance<br />-Vital statistics, vital signs, Contraptions like tubings (IVF, 02 catheter, Wound dressing, Urinary catheter, Nasogastric tubes and etc.) consciousness, coherence and orientation, hygiene/dress, mood and affect, gait obvious signs of discomfort, body build, speech, <br />by: CMG<br />PHYSICAL EXAMINATION<br />
  171. 171. Ht.: 5 foot 5 inches; Wt: 145 lbs; Radial pulse: 71; respiration:16; BP: Right arm= 120/70 mmHg, Left arm= 120/70 mmhg; Temp: 36.7 C(date and time taken) Client alert and cooperative. Sitting comfortably on the table with arms crossed and shoulder slightly slouched forward. Smiling with mild anxiety. Dress is neat and clean. Walks steadily with posture slightly stooped.<br /> <br />by: CMG<br />General AppearanceExample:<br />
  172. 172. Physical Assessment <br />(Cephalo-caudal Approach with emphasis on the specific area which is related to the chief complaint/ admitting impression. Highlight the abnormal findings). <br />by: CMG<br />
  173. 173. TRANSFUSIONS<br />-Blood and blood products transfusions (if any)<br /> <br />by: CMG<br />
  174. 174. TREATMENT AND NURSING CARE with specific Rationale<br />by: CMG<br />
  175. 175. A. Overview of the System (Anatomy and Physiology)<br />B. Definition (of the specific case)<br />C. Epidemiology<br />D. Etiology<br />E. Clinical Manifestations <br />by: CMG<br />TEXTBOOK DISCUSSION<br />
  176. 176. F. Pathogenesis<br />G. Complications<br />H. Interventions<br /> 1. Medical <br /> 2. Surgical<br /> 3. Nursing<br /> Levels of Care: <br />Promotive, <br /> Preventive,<br />Curative, <br /> Rehabilitative<br />by: CMG<br />
  177. 177. References<br />Title of the book<br />Author<br />Edition<br />Copyright<br />Pages<br />For electronic source: website and location of topic<br /> <br />by: CMG<br />
  178. 178. Actual Health Problem: PE Format<br />Potential Health Problem: PER Format<br />P- Problem statement;<br />E- Etiology;<br />R- Risk Factor<br /> Each Goal should have a set of independent, dependent, and collaborative nursing interventions.<br />Definition of the problem statement should be under the column of Nursing Diagnosis with the REFERENCE.<br />ALL rationales should have a reference.<br />by: CMG<br />NURSING CARE PLAN<br />
  179. 179. GOD BLESS<br />
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