HA PRELIMS WEEK 1

NURSING PROCESS

-        is a circular, ongoing, and continuous process used to make professional judgments and provide client care. (A.D.P.I.E)

ASSESSMENT

o   Collecting subjective and objective data.

DIAGNOSIS

o   Analyzing subjective and objective data to make a professional nursing judgment (nursing diagnosis, collaborative problem, or referral).

PLANNING

o   Determining outcome criteria and developing a plan.

IMPLEMENTATION

o   Carrying out the plan.

EVALUATION

o   Assessing whether outcome criteria have been met and revising the plan as necessary.

PROBLEM + ETIOLOGY + SIGNS/SYMPTOMS

Nursing Diagnosis Format

SUBJECTIVE DATA
OBJECTIVE DATA

2 Types of Assessment

SUBJECTIVE DATA

Information reported by the client; cannot be directly observed or measured

Client, family, or significant others

Symptoms, feelings, perceptions

Cannot be independently verified

“I have a headache.”“I feel dizzy.”“I am anxious.”

OBJECTIVE DATA

Information observed or measured by the nurse

Nurse through physical examination or instruments

Signs, measurable findings

Can be validated by others

Blood pressure: 150/90 mmHgTemperature: 38.5°CRedness noted on skin

WELLNESS DIAGNOSIS
RISK DIAGNOSIS
ACTUAL NURSING DIAGNOSIS
SYNDROME DIAGNOSIS

4 Types of Nursing DIagnosis

WELLNESS DIAGNOSIS (HEALTH PROMOTION)

Client is motivated and ready to improve well-being or health behaviors; used to move from a healthy level to a higher level of wellness. -         When no problem is present and the client verbalizes readiness for enhancement

Readiness for enhanced sleep

RISK DIAGNOSIS

Problem is not present yet but client is highly likely to develop it due to risk factors (vulnerability). -         No signs and symptoms present

Risk for impaired skin integrity related to immobility, poor nutrition, and incontinence

ACTUAL NURSING DIAGNOSIS

Client is currently experiencing a problem or has a dysfunctional pattern validated by the nurse. -         Has defining signs and symptoms

Impaired skin integrity manifested by a reddened area on the right buttocks

SYNDROME DIAGNOSIS

Cluster of nursing diagnoses occurring together and best addressed as one group. -         Mix of symptoms that leads to a syndrome

Example depends on symptom cluster

SHORT-TERM PLANNING
LONG-TERM PLANNING

2 Types of Planning

SHORT-TERM PLANNING

Hours to days (within the shift or day)

Immediate or urgent problems

Stabilize the client and manage acute conditions

Immediate, specific outcomes

High priority / acute needs

Specific, Measurable, Achievable

Pain score will decrease from 8/10 to ≤3/10 within 8 hours

LONG-TERM PLANNING

Weeks to months

Ongoing problems, rehabilitation, and wellness

Maintain balance, promote recovery, and prevent complications

Broad, sustained outcomes

Lower priority once client is stable

Realistic, health-maintaining, preventive

Client will demonstrate independent mobility within 4 weeks

INDEPENDENT
DEPENDENT
INTERDEPENDENT

3 Types of Nursing Intervention

INDEPENDENT

Nurse-initiated; no doctor’s order needed

Positioning, health teaching

DEPENDENT

Requires doctor’s order

Medications, IV therapy

INTERDEPENDENT

Done with the healthcare team

PT referral, diet planning

GOAL MET
PARTIALLY MET
NOT MET

3 Types of Evaluation Result

EVALUATION

EVALUATION RESULT	MEANING	CRITERIA / INDICATORS	NURSING ACTION
GOAL MET	Outcome achieved as planned	All outcome criteria are fully attained	Discontinue or maintain the current plan
PARTIALLY MET	Outcome achieved but not completely	Some criteria met; others unmet	Modify interventions or extend time
NOT MET	Outcome not achieved	Criteria not attained	Reassess client, revise diagnosis and care plan

HEALTH ASSESSMENT IN NURSING

-        involves the collection of holistic subjective and objective data to determine a client’s overall level of functioning.

o   Goal: To make a professional clinical judgment.

-        Unlike medical assessments which focus primarily on physiologic status, ________collects physiologic, psychological, sociocultural, developmental, and spiritual data. It focuses on how the client’s health status affects their activities of daily living (ADL) and vice versa.

INITIAL COMPREHENSIVE ASSESSMENT
ONGOING OR PARTIAL ASSESSMENT
FOCUSED OR PROBLEM-ORIENTED ASSESSMENT
EMERGENCY ASSESSMENT

4 Types of Health Assessment in Nursing Practice

INITIAL COMPREHENSIVE ASSESSMENT

Collection of subjective and objective data assessing the whole client; used as a baseline for comparison after interventions

Upon first contact / admission

ONGOING OR PARTIAL ASSESSMENT

Mini-overview performed after interventions to monitor if the client’s condition improves or worsens

Ongoing care

FOCUSED OR PROBLEM-ORIENTED ASSESSMENT

In-depth assessment of a specific problem only; does not cover unrelated areas

When a particular issue is identified

EMERGENCY ASSESSSMENT

Rapid assessment focusing on ABC (Airway, Breathing, Circulation) with priority on the airway

Life-threatening situations / triage

COLLECTION OF SUBJECTIVE DATA
COLLECTION OF OBJECTIVE DATA
VALIDATION OF DATA
DOCUMENTATION OF DATA

4 Steps in Health Assessment

PRE INTRODUCTORY PHASE
INTRODUCTORY PHASE
WORKING PHASE
SUMMARY AND CLOSING PHASE

Phases in the Collection of Subjective Data

PRE INTRODUCTORY PHASE

Nurse reviews medical records and history before meeting the client to prepare for the interview

INTRODUCTORY PHASE

Nurse introduces self, explains purpose, type of questions, note-taking, ensures privacy and confidentiality, and builds trust

WORKING PHASE

Nurse gathers biographic data, health history, present illness, pain assessment, lifestyle, and development level; uses critical thinking

SUMMARY AND CLOSING PHASE

Nurse summarizes information, validates problems and goals, and discusses possible plans of care

HEALTH HISTORY TAKING

COMPONENT	DESCRIPTION
Biographic Data	Name, age, religion, occupation, etc.
Reason for Seeking Health Care	Chief complaint and feelings about seeking care
History of Present Health Concern	Detailed problem description using COLDSPA (Character, Onset, Location, Duration, Severity, Pattern, Associated factors)
Personal Health History	Childhood illnesses, immunizations, adult illnesses, surgeries, accidents, allergies, medications
Family Health History	Health status of parents, grandparents, siblings to identify genetic risks
Review of Systems (ROS)	Symptoms related to each body system (e.g., skin, head, eyes, lungs)
Lifestyle & Health Practices	Nutrition, activity/exercise, sleep, substance use, self-concept, social and environmental risks
Developmental Level	Psychosocial, cognitive, and moral development (e.g., Young Adult: intimacy vs. isolation)

CHARACTER
ONSET
LOCATION
DURATION
SEVERITY
PATTERN
ASSOCIATED FACTORS

COLDSPA (PAIN ASSESSMENT GUIDE)

INSPECTION
PALPATION
PERCUSSION
AUSCULTATION

Techniques in Collection of Objective Data

OBJECTIVE DATA

-        Objective data are directly observed by the examiner.

-        Physical Examination:

o   Preparation: Gather equipment (stethoscope, otoscope, etc.) and ensure privacy and comfort

o   Techniques: Inspection, Palpation, Percussion, Auscultation

INSPECTION

ASPECT	DESCRIPTION
Definition	Uses vision, smell, and hearing to detect normal or abnormal findings
When Performed	Begins at first contact and continues throughout the examination
Technique	Ensure good lighting, observe before touching, expose area appropriately, compare bilateral parts
What to Observe	Color, size, shape, location, consistency, symmetry, movement, behavior, odors, sounds
Important Note	Inspection is done first to avoid altering findings

PALPATION

ASPECT	DESCRIPTION
Definition	Using hands to feel specific characteristics
Fingerpads	Pulses, texture, size, consistency, shape, crepitus
Ulnar/Palmar Surface	Vibrations, thrills, fremitus
Dorsal Hand Surface	Temperature
Light Palpation	< 1 cm; pulses, tenderness, skin texture, moisture
Moderate Palpation	1–2 cm (0.5–0.75 in); organs and masses
Deep Palpation	Presses 2.5–5 cm (1–2 in) to feel deep organs or masses hidden by thick muscle
Bimanual Palpation	Uses two hands on each side of a body part (e.g., uterus, breasts) to assess size, shape, consistency, and mobility

LIGHT PALPATION
MODERATE PALPATION
DEEP PALPATION
BIMANUAL PALPATION

Types of Palpation

LIGHT PALPATION

< 1 cm; pulses, tenderness, skin texture, moisture

MODERATE PALPATION

1–2 cm (0.5–0.75 in); organs and masses

DEEP PALPATION

Presses 2.5–5 cm (1–2 in) to feel deep organs or masses hidden by thick muscle

BIMANUAL PALPATION

Uses two hands on each side of a body part (e.g., uterus, breasts) to assess size, shape, consistency, and mobility

PERCUSSION

-        It involves tapping body parts to produce sound waves or vibrations that enable the examiner to assess underlying structures.

-        Uses:

USES	PURPOSE / DESCRIPTION
Eliciting Pain	Detects inflamed or underlying structures (e.g., kidneys)
Determining Location	Identifies position of organs
Determining Size & Shape	Notes changes in organ borders
Determining Density	Identifies whether a structure contains air, fluid, or solid matter
Eliciting Reflexes	Uses percussion (reflex) hammer to assess tendon reflexes

DIRECT PERCUSSION
BLUNT PERCUSSION
INDIRECT PERCUSSION

3 Types of Percussion

DIRECT PERCUSSION

Tapping directly with fingers (e.g., sinuses)

BLUNT PERCUSSION

One hand flat, struck by the fist of the other hand (e.g., kidneys)

INDIRECT PERCUSSION

Middle finger tapped by dominant hand (most common)

RESONANCE
TYMPANY
DULLNESS

3 Types of Percussion Sounds

RESONANCE

Normal lung tissue (hollow sound)

TYMPANY

Air-filled areas (stomach/abdomen)

DULLNESS

Solid organs (e.g., liver)

AUSCULTATION

ASPECT	DETAILS
Definition	Listening to body sounds using a stethoscope
Sounds Heard	Heart sounds, breath sounds, bowel sounds, blood flow
Diaphragm	High-pitched sounds; press firmly
Bell	Low-pitched sounds (e.g., bruits); hold lightly
Key Rule	Do not auscultate over clothing

INSPECTION
AUSCULTATION
PERCUSSION
PALPATION

ABDOMINAL ORDER FOR COLLECTION OF OBJECTIVE DATA

REASON	EXPLANATION
Altered bowel sounds	Touching increases peristalsis and causes false sounds
Pain prevention	Palpation first may cause guarding and inaccurate findings

VALIDATION OF DATA

-        Definition: The process of confirming or verifying that the data collected is reliable and accurate.

-        Purpose: To prevent errors in judgment and ensure data is consistent.
-        When to Validate:

o   When there are discrepancies between subjective and objective data.

o   When there are discrepancies in what the client says at different times.

o   When findings are highly abnormal or inconsistent.

DOCUMENTATION OF DATA

-        forms the database for the entire nursing process and facilitates communication among the health care team.

-        Guidelines:

o   Objective: Record only what is observed or stated, not interpretations
(e.g., record “Client crying” instead of “Client is depressed”).

Be Specific:Avoid “normal” or “good”; use descriptive terms
(e.g., “Bilateral lung sounds clear”).

NARRATIVE NOTES

Free-text documentation of observations, assessments, interventions, and patient responses.

CHECKLIST FORMS

Pre-set items to check/tick to ensure completeness and consistency.

SOAPIE

Subjective, Objective, Assessment, Plan, Intervention, Evaluation — a structured method of documentation.

FDAR

Focus, Data, Action, Response — centers on patient concerns or events and nursing action taken.

SBAR

Situation, Background, Assessment, Recommendation — used for clear, concise communication, especially during handoff.

ELECTRONIC HEALTH RECORD

Computer-based documentation system that reduces errors, streamlines data collection, and improves safety.