HA

Health Assessment Reviewer

Nursing Process

 Is a systematic, rational method of planning and providing individualized nursing care.

Is cyclical, its components follow a logical sequence, but more than one component maybe involved at one time.

The term NURSING PROCESS was originated by Lydia Hall in 1955, and Dorothy Johnson in 1959, Ida Jean Orlando in 1961 and Ernestine Wiedenbach in 1963.

•These theorists were among the 1st to use the Nursing Process and refer to a series of phases describing the practice of nursing

PHASES/STEPS OF THE NURSING PROCESS

•Scope and Standards of Nursing Practice includes six (6) phases of nursing practice (ANA, 2010):

●Assessment

●Diagnosis

●Outcome identification

●Planning

●Implementation

●Evaluation

The national licensure examination for registered nurses (NCLEX), uses the five phases:

●Assessment

●Diagnosis

●Planning

●Implementation

●Evaluation

•These 5 phases are commonly used by most of the nurses although nurses may use different terms to describe the phases or steps of the nursing process.

ASSESSMENT/ASSESSING

is a systematic & continuous collection, organization, validation & documentation of data/information.

●Collect data

●Organize data

●Validate data

●Document data

DATA COLLECTION/ COLLECT DATA

•Is the process of gathering information about a client`s health status.

•Must be both systematic & continuous to prevent the omission of significant data & reflect a client`s changing health status.

DATA BASE contains all the information about the client

DATA COLLECTION/ COLLECT DATA

•SOURCES OF DATA COLLECTION:

1.Primary: Client is the primary source of data

2.Secondary: Family members or other support persons, other health professionals, records & reports, laboratory & diagnostic analysis, relevant literature are secondary or indirect sources.

TYPES OF DATA

•SUBJECTIVE DATA:

➢Referred to as symptoms or covert data

•OBJECTIVE DATA:

➢Referred to as the signs or overt data

COLLECTION METHODS

•Principal methods used to collect data:

•Observing/observation

•Interviewing/ interview

•Examining/Examination

•Observing occurs when the nurse is in contact with the client or support persons

•OBSERVING:

•To observe is to gather the patient`s data using the senses

INTERVIEWING:

•Is a planned communication or conversation with a purpose in order to get information, identify problems of mutual concern, evaluate change, teach, provide support, counselling or therapy.

•2 Types:

1.Directive Interview

2.Non-Directive Interview or Rapport-Building Interview

Types of Interview Questions:

1.Closed Questions: used in directive interview, are restrictive & generally require only “yes or no” or short factual answers that provide specific information

Open-Ended Questions: associated with the non-directive interview, invite clients to discover & explore, elaborate, clarify or illustrate their thoughts or feelings.

3. Neutral Question: a question the client can answer without direction or pressure from the nurse.

•EXAMINING/EXAMINATION:

•Physical examination/assessment is a systematic data collection method that uses observation (sense of sight, hearing, smell & touch) to detect health problems

ORGANIZING DATA

•Nurses uses a written or electronic format that organizes the assessment data systematically

•This is referred to as a nursing health history, nursing assessment, or nursing DATA BASE form.

VALIDATING DATA

•The act of “double checking or verifying data to confirm that it is accurate & factual.

•Cues:

•Are subjective or objective data that can be directly observed by the nurse.

•What the client says or what the nurse can see, hear, smell or measure

•Inferences:

•Are the nurse`s interpretation or conclusions made based on the cues

DOCUMENTATION/DOCUMENTING DATA

•Aims to describe the collected data to make it easier to use, retrieved or manage.

•Accurate documentation is essential & should include all data collected about the client`s health status

•Data are recorded in a factual manner & not as interpreted by the nurse.

DIAGNOSIS/DIAGNOSING

•Is the second phase of the nursing process

•Is a pivotal step in the nursing process & the nurse will use his/her critical thinking skills to interpret assessment data & identify the client`s strength & problems.

Taxonomy: Is a classification system or set of categories arranged based on a single principle or a set of principles.

DEFINITIONS

•Diagnosing: refers to the reasoning process

•Diagnosis: is a statement or conclusion regarding the nature of the phenomenon

•Diagnostic Labels: is the standardized NANDA names for the diagnosis

•Nursing diagnosis: is the client`s problem statement consisting of the diagnostic label plus the etiology (causal relationship between a problem & its related or risk factors)

•Nursing Diagnosis (official definition from NANDA):  a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response by an individual, family, group or community.

Nursing Diagnosis (NANDA-I, 2009): A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.

DEFINITIONS

•Refers to the actuality or potentiality of the problem or the categorization of the diagnosis as a health promotion diagnosis.

•Kinds of Diagnosis according to status: actual diagnosis, health promotion diagnosis, risk nursing diagnosis & syndrome diagnosis.

•Actual Diagnosis:

➢Is a client problem that is present at the time of the nursing assessment.

➢Based on the presence of associated signs & symptoms

STATUS OF NURSING DIAGNOSIS

•Health Promotion Diagnosis:

➢Relates to client`s preparedness to implement behaviors to improve their health condition

➢“Readiness for Enhanced, as in Readiness for enhanced Nutrition”

•Risk Nursing Diagnosis:

➢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.

•Syndrome Diagnosis: is assigned by a nurse`s clinical judgment to describe a cluster of nursing diagnosis that have similar interventions.

COMPONENTS OF NANDA NURSING DIAGNOSIS

•3 Components:

1.The problem and it`s definition (Diagnostic Label)

2.The etiology

3.The defining characteristics

•PROBLEM (DIAGNOSTIC LABEL) AND DEFINITION:

•Describes the client`s health problem or response for which nursing therapy is given

•Qualifiers:

•Words that are added to some NANDA labels to give meaning to the diagnostic statement

•Examples:

•Deficient (inadequate in amount, quality or degree; not sufficient; incomplete)

•Impaired (made worse, weakened, damaged, reduced, deteriorated)

•Decreased (lesser in size, amount or degree)

•Ineffective (not producing the desired effect)

•Compromised (to make vulnerable to threat)

ETIOLOGY (RELATED FACTORS & RISK FACTORS):

•Identifies one or more probable causes of the health problem, gives direction to the required nursing therapy, enables the nurse to individualize the client`s care.

•DEFINING CHARACTERISTICS:

•Are the cluster of signs & symptoms that indicate the presence of a particular diagnostic label.

DIFFERENTIATING NURSING DIAGNOSIS FROM MEDICAL DIAGNOSIS

•Nursing Diagnosis:

•Is a statement of nursing judgment & refers to a condition that nurses, by virtue of their education, experiences & expertise are licensed to treat.

•Medical Diagnosis:

•Is made by a physician & refers to a condition that only a physician can treat

•Collaborative Problems:

•Is a type of potential problem that nurses manage using both independent & physician-prescribed interventions.

•Nursing Diagnosis:

•Involves human responses which vary greatly from one person to the others.

PLANNING

•Is a deliberative, systematic of the nursing process that involves decision making & problem-solving.

•Nursing Interventions: is any treatment based upon clinical judgment & knowledge, that a nurse performs to enhance patient/client outcomes.

TYPES OF PLANNING

•INITIAL PLANNING:

•The nurse who performs the admission assessment usually develops the initial comprehensive plan of care

ONGOING PLANNING:

•All nurses who work with the client do the ongoing planning.

•As nurses obtain new information & evaluate the client`s responses to care, they can individualize the initial plan further

•DISCHARGE PLANNING:

•The process of anticipating & planning for needs after discharge, is a crucial part of a comprehensive health care plan & should be addressed in each client`s care plan.

DEVELOPING NURSING CARE PLANS

•The end product of the planning phase of the nursing process is a “formal or informal” plan of care.

•Informal Nursing Care Plan: is a strategy for actions that exists in the nurse`s mind.

•Formal Nursing Care Plan: is a written guide that organizes information about the client` care.

•Standardized Care Plan:

•Is a formal plan that specifies the nursing care for group of clients with common needs

•Individualized Care Plan:

•Is tailored to meet the unique needs of a specific client-needs that are not addressed by the standardized plan of care.

THE PLANNING PROCESS

•In the process of developing client care plans, the nurse engages in the following activities

•SETTING PRIORITIES:

•Is the process of establishing a preferential sequence for addressing nursing diagnosis & interventions

•ESTABLISHING CLIENT GOALS/DESIRED OUTCOMES:

•After establishing priorities, the nurse & the client set goals for each nursing diagnosis

•SELECTING NURSING INTERVENTIONS:

•The specific nursing interventions chosen should focus on eliminating or reducing the etiology of the nursing diagnosis, which is the second clause of the diagnostic

•WRITING INDIVIDUALIZED NURSING INTERVENTIONS:

•After choosing the appropriate nursing interventions, the nurse writes them on the care plan.

IMPLEMENTATION/ IMPLEMENTING

•Is the action phase in which the nurse performs the nursing interventions

PROCESS OF IMPLEMENTATION

1.Reassessing the client

2.Determining the nurse`s need for assistance

3.Implementing the nursing interventions

4.Supervising the delegated care

5.Documenting nursing activities

•DETERMINING THE NURSE`S NEED FOR ASSISTANCE:

•When implementing some nursing interventions, the nurse may require assistance for one or more of the following reasons

•IMPLEMENTING THE NURSING INTERVENTIONS:

•It is important to explain to the client what nursing interventions will be done, what sensations to expect, what the client is expected to do & the expected outcome.

•SUPERVISING DELEGATED CARE:

•Once care has been delegated to other health care personnel, the nurse is responsible for the client`s overall care.

•DOCUMENTING NURSING ACTIVITIES:

•After carrying out the nursing activities, the nurse has completed the implementation phase by recording the interventions & client`s responses in the progress notes.

EVALUATION

•Is a planned, on-going, purposeful activity in which clients & health care professionals determine (a) the client`s progress towards achievement of goals/outcomes and (b) the effectiveness of the nursing care plan.

•Is an important aspect of the nursing process because conclusions drawn from an evaluation determine whether the nursing interventions should be terminated, continued or changed.

Source of Data

•Primary

•Secondary 

Formulation of Nursing Diagnosis 

•Problem

•Etiology 

•Sign and Symptoms 

Types of Nursing Intervention

•

•

•

 Nursing Diagnosis Statement

•Actual Diagnosis 

• Health Promotion Diagnosis 

•Risk Nursing Diagnosis 

•Syndrom Diagnosis 

VITAL SIGNS

VITAL SIGNS (Cardinal Signs) relating to life

• They reflect the body’s physiological status and provide information about the person with current condition or state of health.

The vital signs are:

- body temperature

- pulse

- respiration

- blood pressure

- O2/oxygen saturation

Four Primary Vital Signs

•Heart Rate (Pulse)

•Blood Pressure

•Body Temperature

•Respiration Rate

•Pain

VITAL SIGNS

The most frequent measurement obtained by a health practitioner are those of temperature, pulse, O2 saturation, respiration, blood pressure.

When to Assess Vital Signs

• When a client is admitted to a health care facility.

• In a hospital or care facility on a routine schedule according to the physician’s order or the institutions standard of practice.

TEMPERATURE

Body temperature: Physiology

The body temperature is the difference between the amount of heat produced by the body processes and the amount of heat lost to the external environment;  hence

Heat produced – thermogenesis

Heat lost = thermolysis

TEMPERATURE

Body temperature is measured in heat units called degrees or Fahrenheit

2 Kinds of Body Temperature:

1. Core Temperature- temperature of the deep tissues of the body such as abdominal cavity and pelvic cavity. It remains relatively constant. 

2. Surface temperature- is the temperature of the skin, the subcutaneous tissues, and fats.

Heat Balance- when the amount of heat produced by the body equals the amount of heat lost, there is heat balance.

FACTORS AFFECTING THE BODY’S HEAT PRODUCTION:

1. Basal Metabolic Rate (BMR)- the BMR is the rate of energy utilization in the body required to maintain essential activities, such as breathing.

2. Muscle Activity

3. Epinephrine, norepinephrine, and sympathetic

stimulation/stress response

4. Fever

DIFFERENT METHODS OF HEAT LOSS:

1. Radiation- the transfer of heat from the surface of one object to the surface of another without contact between the two objects.

2. Conduction- the transfer of heat from one molecule to another molecule of lower temperature.

3.Convection- the dispersion of heat by air currents.

4.Vaporization-continuous evaporation of moisture from the respiratory tract and from the mucosa of the mouth and from the skin.

ASSESSING BODY TEMPERTAURE

Core and Surface Temp

Measurement Sites

Core Temp. 

• Rectum

• Tympanic Membrane

• Esophagus

• Pulmonary artery

• Urinary bladder

Surface Temp. 

• Skin

• Oral

• Axillae

Types of Thermometers

1. Mercury-in-glass thermometer/ Glass Thermometers- It is a glass tube sealed at one end, with a mercury-filled bulb at the other. Exposure of the bulb to heat causes the mercury to expand and rise in the enclosed tube. (2-3 mins)

2. Electronic Thermometer – consist of a rechargeable battery- powered display unit, a thin wire cord, and a temperature- processing probe covered by a disposable plastic sheath. (2 mins.-30 secs)

Another form of electronic thermometer is used exclusively for tympanic temp. An otoscope-like speculum with an infrared sensor tip detects heat radiated form the tympanic membrane. With in 2-3 seconds of placement in the auditory canal, a reading appears on the display unit. A sound signals when the peak temp reading has been measured

Disposable Thermometers- Disposable single-use thermometer are clean strips of plastic with a temp sensor at the end. They are used for oral or axillary temp , particularly with children.

Another form of disposable thermometer is a temp-sensitive patch or tape. Applied to the forehead or abdomen, the patch changes in color at different temp. These thermometers are also useful for screening clients, especially infants.

• Each device measures the temp using the Celsius or Fahrenheit scale. Electronic thermometers allows the nurse to convert scales by activating a switch. When it is necessary to convert temp readings, the following formulas can be used:

1. To convert Fahrenheit to Celsius:

C =(F- 32º F) x 5/9

2. To convert Celsius to Fahrenheit:

F= ( 9/5 x C ) + 32 º

EXAMPLE:

Convert 37.4º Celsius to Fahrenheit

Solution:

F= ( 9/5 x C ) + 32 º so F= (9/5 x 37.4º C ) + 32 º

F= 9 x 37.4º C / 5 + 32 º

F= 336.6 / 5 + 32 º

F= 67.32 + 32 º

F= 99.32 

ºConvert 102°F to Celsius

Solution:

C= (F-32°F) 5/9 so (102°F-32°F) 5/9

= 70 x 5/9

= 350 / 9

=38.9°C

Normal temp should be between 36º C (96.8 º F) to 37 º C (98.6 ºF)

Rectal temp = 0.5º C (0.9 º F) higher than oral temp

Axillary temp= 0.5º C (0.9 º F) lower than oral temp

FEVER

• FEVER Body temperature above than normal is called as fever or hyperthermia.

• The person having fever is indicated as febrile. Fevers can be categorized in different ways-

• a. Low grade fever - above 37.1oC but below 38.2oC .

• b. High grade fever - above 38.2oC. -39oC

• c. Hyperpyrexia- Higher than 40oC

• d. Intermittent fever- Alternate febrile episodes with periods of normal temperature.

• e. Remittent fever- Continuous fever but variations throughout a day

PULSE RATE

•Pulse rate is the measurement of heart rate, or the number of times the heart beats per minute. As the heart pushes blood through the arteries, the arteries expand and contract with the flow of the blood.

•the pulse reflects the heart beat; that is the pulse rate is the same as the ventricular contraction of the heart. Except for adults or patients with cardiovascular diseases.

Peripheral pulse- a pulse located away from the heart.

Apical Pulse- a central pulse, located at the apex of the heart. It is also referred to as the point of maximal impulse (PMI)

PULSE RATE

FACTORS AFFECTING THE PULSE:

1. Age

2. Gender

3. Exercise

4. Fever

5. Medications

6. Hypovolemia

7. Stress

8. Position changes

9. Pathology

Pulse Rate

1. Temporal – where the temporal artery passes over the temporal bone of the head.

2. Carotid- at the side of the neck where the carotic artery runs between the trachea and the sternocleidomastoid muscle.

3. Apical- at the apex of the heart..

4. Brachial – at the inner aspect of the biceps muscle of the arm or medially in the antecubital space.

5. Radial- where the radial artery runs along the radial bone, on the thumb side of the inner aspect of the wrist.

6. Femoral – where the femoral artery passes alongside the inguinal ligament

7. Popliteal- where the popliteal artery passes behind the knee.

8. Posterior tibial-on the medial surface of the ankle where the posterior tibial artery passes behind the medial malleolus.

9. Pedal- (dorsalis pedis) where the dorsalis pedis artery passes over the bones of the foot, on an imaginary line drawn from the middle of the ankle to the space between the big and 2nd toe.

ASSESSING THE PULSE

• A pulse is commonly assessed by palpation (feeling) and by auscultation (hearing).

WHEN ASSESSING THE PULSE, THE NURSE SHOULD TAKE NOTE OF THE FOLLOWING:

1. Rate- the number of beats per minute

Tachycardia- excessively fast heart rate (>100bpm in an adult)

Bradycardia- excessively slow heart rate (<60bpm in an adult)

2. Rhythm- the pattern of beats and the interval between each beat.

dysrhythmia or arrythmia- irregular beats

3. Volume- also called as the pulse strength of amplitude. full, bounding, weak, feeble, thready, or absent

4. Elasticity of the arterial wall- reflects an artery’s expansibility or deformities. Healthy artery-straight, smooth, soft, and palpable.

RESPIRATION

RESPIRATION- is the act of breathing.

Inhalation/Inspiration – is the intake of air into the lungs.

Exhalation/Expiration- is the breathing out movement of gases from the lungs to the atmosphere.

Ventilation- also refers to the movement of air in and out of the lungs.

2 TYPES OF BREATHING:

1. 2. Costal (thoracic) breathing- involves the external intercostal muscles and other accessory muscles (sternocleidomastoid)

Diaphragmatic (abdominal) breathing- involves the contraction and relaxation of the diaphragm and is observed by the movement of the abdomen

Respiration is the act of breathing which refers to two process-

• 1. External respiration

• 2. Internal respiration

FACTORS AFFECTING RESPIRATION:

1. Exercise- Increases depth and rate, to meet the body’s need for additional O2 supply and to rid the body of CO2.

2. Acute pain-Alters rate and rhythm, breathing becomes shallow Client may inhibit or splint chest wall movement when pain is in the area of chest or abdomen.

3. Anxiety -Increases rate and depth as a result of sympathetic stimulation.

4. Smoking- Chronic smoking changes the lung’s airway, resulting in increases rate of respirations at rest when not smoking. 

5. Body Position- straight, erect posture promotes full chest expansion. A stooped or slumped position impairs ventilatory movement, lying flat prevents full chest expansion.

6. Medication- Narcotic analgesics, gen. anesthetics, and sedative hypnotics depress rate and depth. Amphetamines and cocaine may increase rate and depth. Bronchodilators slow rate by causing airway dilation.

7. Neurological Injury- Impairs the respiratory center and inhibits the respiratory rate and rhythm.

8. Hemoglobin Function- Decreased hemoglobin level (anemia) reduce oxygen-carrying capacity of the blood, which increases respiratory rate.

ASSESSING RESPIRATION

1. When taking the client’s respiratory rate, the nurse must also take note of the following:

The depth of respiration- generally described as normal, deep, or shallow.

Deep respiration – large volume of air is inhaled and exhaled.

Shallow- involves the exchange of small volume or air and often the minimal use of lung tissue.

Normal inspiration and expiration= an adult takes in about 500mL of air. This volume is called tidal volume.

2. Rate – the number of cycles of inspiration and expiration per minute (cpm)

Hyperventilation- refers to the very deep, rapid respirations (>20 cpm)

Hypoventilation- refers to very shallow and slow respirations. (<12 cpm)

3. Respiratory rhythm- refers to the regularity of the expirations and the inspirations, it can be described as regular or irregular.

4. Respiratory quality or character- refers to those character of breathing that are different from normal, effortless breathing.

Terms of Respiration

• Tachypnea- An increased respiratory rate more than 24 breath/min.

• Bradypnea- A decreased respiratory rate less than 10 breath/min.

• Apnea- Total cessation of breathing or respiratory rate.

• Hyperapnea- Increase in the depth of respiration.

Blood Pressure

• Blood pressure (BP) is a measurement of the pressure or force exerted by the blood on the walls of the arteries in which it is contained.

• Each time the ventricles contract, blood is pushed out of the heart and into the aorta and pulmonary aorta, exerting pressure on the walls of the  arteries.

•This phase in the cardiac cycle is known as systole, and it represents the highest point of blood pressure in the body,or the systolic pressure.

•The phase of the cardiac cycle in which the heart relaxes between contractions is referred to as diastole. The diastolic pressure (recorded during diastole) is lower because the heart is relaxed.

• Contraction and relaxation of the heart result in two different pressures— systolic and diastolic

The most common condition that causes an abnormal blood pressure reading is hypertension.

Hypertension, or high blood pressure, results from excessive pressure on the walls of the arteries.

Hypertension is determined by a sustained systolic blood pressure reading of 140 mm Hg or greater, or a sustained diastolic reading of 90 mm Hg or greater.

Hypotension, or low blood pressure, results from reduced pressure on the arterial walls.

Hypotension is determined by a blood pressure reading of less than 95/60 mm Hg.

Pulse Pressure

• The difference between systolic and diastolic pressures is the pulse pressure

Factors Affecting Blood Pressure

Blood pressure does not remain at a constant value.

1.Age

2.Gender

3. Emotional states

4. Exercise

5. Body position

6. Medications, other factors

Assessment of Manual Blood Pressure

The equipment needed to measure manual blood pressure includes a stethoscope and a sphygmomanometer