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Subject: advance nursing


Mr. ShreyasWalvekar
Mrs. ManishaGholap.
M.Sc.(N) 1st Year Student
Assistant Professor
KINS, Karad.
KINS, Karad
Sr. no. Content

1. Introduction

2. Methods of data collection

3. Analysis of data

4. Utilization of data relevant to nursing process

5. Summary

6. Conclusion

7. Bibliography

At the end of this seminar, the post-graduate students will be able to understand the methods of data
collection, analysis, utilization of data related to nursing process.


At the end of this seminar the post-graduate students will be able to:

1) Describe various methods of data collection in nursing process.

2) Discuss analysis of data collected in nursing process.

3) Explain utilization of data relevant to nursing process
The nursing process is a systematic, rational method of planning and providing individualized nursing care.
Its purpose is to identify a client’s health status and 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.
Methods of Data Collection:
 The principal methods used to collect data are observing, interviewing, and examining.Observing
occurs whenever the nurse is in contact with the client or support persons. Interviewing is used
mainly while taking the nursing health history. Examining is the major method used in the physical
health assessment.
 In reality, the nurse uses all three methods simultaneously when assessing clients. For example,
during the client interview the nurse observes, listens, asks questions, and mentally retains
information to explore in the physical examination.


Observation is an assessment tool that relies on the use of the five senses (sight, touch, hearing, smell, and
taste) to discover information about the client. This information relates to characteristics of the client’s
appearance, functioning, primary relationships, and environment.

Visual Observation:

Sight provides an abundance of clues that you must continually process when assessing the client. A few
examples to consider are body movements, general appearance, mannerisms, facial expressions, mode of
dress, nonverbal communication, interaction with others, use of space, skin color and appearance, and
cleanliness. You use visual observation to collect subjective data, such as when noting the client’s facial
expression and body language. You also use visual observation to collect objective data, such as when you
inspect the client’s skin for rashes or irritation and note the cleanliness and level of safety of the client’s
immediate environment.

Tactile Observation.

The sense of touch provides valuable information about the client. For example, touch or palpation of the
skin assesses factors such as muscle strength, temperature, moisture, edema, rash, or swelling.

Auditory Observation.

Hearing allows you to listen actively to the client and family as they interact with you and other members of
the healthcare team. You may also use specialized equipment to listen for information. For example, data
collected by auscultation (listening to the heart, lung, or bowel sounds with a stethoscope) depend on your
sense of hearing and level of skill in interpreting such sounds. Similarly, you must be able to hear the sounds
of the pulse when measuring blood pressure with a sphygmomanometer and stethoscope.
Olfactory or Gustatory Observation.

The sense of smell identifies odors that can be specific to a client’s condition or state of health. Some
microorganisms’ infections have specific, identifiable odors. Olfactory observation includes noting body and
breath odors, which might indicate alcohol intoxication, poor hygiene, or metabolic acidosis. The senses of
smell and taste may also help you to detect harmful chemicals in the air. It should be noted that a client
wholacks a sense of smell often is anorexic (lacks an appetite

 To observe is to gather data by using the senses. Observing is aconscious, deliberate skill that is
developed through effort andwith an organized approach. Although nurses observe mainlythrough
sight, most of the senses are engaged during carefulobservations.
 Observing has two aspects: (a) noticing the data and (b) selecting, organizing, and interpreting the
 A nurse who observesthat a client’s face is flushed must relate that observation to findings such as
body temperature, activity, environmental temperature, and blood pressure.
 Nurses often need to focus on specific data in order not to be overwhelmedby a multitude of data.
Observing, therefore, involves distinguishing data in a meaningful manner.
 The experienced nurse is often able to attend to an intervention (e.g., give a bed bath or monitor an
intravenous infusion) andat the same time make important observations (e.g., note a changein
respiratory status or skin color).
 Nursing observations must be organized so that nothing significant is missed.
 Most nurses develop a particular sequencefor observing events, usually focusing on the client first.
Forexample, a nurse walks into a client’s room and observes, in thefollowing order:
1. Clinical signs of client distress (e.g., pallor or flushing, labored breathing, and behavior indicating
pain or emotionaldistress)
2. Threats to the client’s safety, real or anticipated (e.g., alowered side rail)
3. The presence and functioning of associated equipment (e.g., intravenous equipment and oxygen)
4. The immediate environment, including the people it.


 An interview is a planned communication or a conversation with a purpose, for example, to get or
give information, identify problems of mutual concern, evaluate change, teach, provide support, or
provide counseling or therapy. One example of the interview is the nursing health history, which is a
part of the nursing admission assessment.
 There are two approaches to interviewing: directive and nondirective.
 The directive interview is highly structured and elicits specific information. The nurse establishes the
purpose of the interview and controls the interview, at least at the outset.
 The client responds to questions but may have limited opportunity to ask questions or discuss
concerns. Nurses frequently use directive interviews to gather and to give information when time is
limited (e.g., in an emergency situation).
 By contrast, during a nondirective interview, or rapport building interview, the nurse allows the
client to control thepurpose, subject matter, and pacing. Rapport is an understanding between two or
more people.
 A combination of directive and nondirective approaches isusually appropriate during the
information-gathering interview.
 The nurse begins by determining areas of concern for theclient.
 If, for example, a client expresses worry about surgery,the nurse pauses to explore the client’s worry
and to provide support.
 Simply noting the worry, without dealing with it, can leave the impression that the nurse does not
care about the client’s concerns or dismisses them as unimportant.
 Types of interview questions they are often classified as closed or open ended, and neutral or
 Closed questions, used in the directive interview, are restrictive and generally require only “yes” or
“no” or short factual answers giving specific information.
 Closed questions often beginwith “when,” “where,” “who,” “what,” “do (did, does),” or “is(are,
 Examples of closed questions are “What medication did you take?” “Are you having pain now?
Show me whereit is.” “How old are you?” “When did you fall?”
 Closed questions are often used when information is needed quickly, suchas in an emergency
 The highly stressed person and theperson who has difficulty communicating will find closed
questions easier to answer than open-ended questions.
 Open-ended questions, associated with the nondirective interview, invite clients to discover and
explore, elaborate, clarify,or illustrate their thoughts or feelings.
 An open-ended questionspecifies only the broad topic to be discussed, and invites answers longer
than one or two words.
 Such questions give clientsthe freedom to divulge only the information that they are readyto disclose.
 The open-ended question is useful at the beginningof an interview or to change topics and to elicit
 Open-ended questions may begin with “what” or “how.”
 Examples of open-ended questions are “How have you been feeling lately?” “What brought you to
the hospital?” “How did youfeel in that situation?” “Would you describe more about how yourelate
to your child?” “What would you like to talk about today?”
 The type of question a nurse chooses depends on the needsof the client at the time.
 Nurses often find it necessary to use acombination of closed and open-ended questions throughout
aninterview to accomplish the goals of the interview and obtainneeded information.
 A neutral question is a question the client can answer without direction or pressure from the nurse,
is open ended, and isused in nondirective interviews.
 Examples are “How do you feel about that?” “What do you think led to the operation?”
 A leading question, by contrast, is usually closed, used in a directive interview, and thus directs the
client’s answer. Examples are “You’re stressed about surgery tomorrow, aren’t you?”
1. They let the interviewee do the talking.
2. The interviewer is able to listen and observe.
3. They reveal what the interviewee thinks is important.
4. They may reveal the interviewee's lack of information,
5. Misunderstanding of words, frame of reference, prejudices, or stereotypes.
6. They can provide information the interviewer may not ask for.
7. They can reveal the interviewee's degree of feeling about an issue.
8. They can convey interest and trust because of the freedom they provide.


1. They take more time.
2. Only brief answers may be given.
3. Valuable information may be withheld.
4. They often elicit more information than necessary.
5. Responses are difficult to document and require skill in recording.
6. The interviewer requires skill in controlling an open-ended interview.
7. Responses require insight and sensitivity from the interviewer.
1. Questions and answers can be controlled more effectively.
2. They require less effort from the interviewee.
3. They may be less threatening, since they do not require explanations or justifications.
4. They take less time.
5. Information can be asked for sooner than it would be volunteered.
6. Responses are easily documented.
7. Questions are easy to use and can be handled by unskilled interviewers.
1. They may provide too little information and require follow up questions.
2. They may not reveal how the interviewee feels.
3. They do not allow the interviewee to volunteer possibly valuable information.
4. They may inhibit communication and convey lack of interest by the interviewer.
5. The interviewer may dominate the interview with questions.

Planning the interview and setting
 Before beginning an interview, the nurse reviews available information, for example, the operative
report, information about the current illness, or literature about the client’s health problem.
 Both nurses and clients are made comfortable in order to encourage an effective interview by
balancing several factors.
 Each interview is influenced by time, place, seating arrangement or distance, and language.
Time :
 Nurses need to plan interviews with clients when theclient is physically comfortable and free of pain,
and when interruptions by friends, family, and other health professionalsare minimal.
 Nurses should schedule interviews with clients intheir homes at a time selected by the client.
 A well-lighted, well-ventilated room that is relativelyfree of noise, movements, and distractions
encourages communication. In addition, a place where others cannot overhear orsee the client is
Seating Arrangement:
 By standing and looking down at aclient who is in bed or in a chair, the nurse risks intimidating
theclient. When a client is in bed, the nurse can sit at a 45-degreeangle to the bed.
 During an initial admission interview, a client may feel less confronted ifthere is an overbed table
between the client and the nurse. Sitting on a client’s bed hems the client in and makes staring
difficult to avoid.
 The distance between the interviewer and interviewee should be neither too small nor too great,
because people feel uncomfortable when talking to someone who is too closeor too far away.
Proxemics is the study of use of space.
 As aspecies, humans are highly territorial but we are rarely awareof it unless our space is somehow
violated. Most people feel comfortable maintaining a distance of 2 to 3 feet during an interview.
 Failure to communicate in language the client canunderstand is a form of discrimination.
 The nurse must convertcomplicated medical terminology into common English usage,and
interpreters or translators are needed if the client and thenurse do not speak the same language or
dialect (a variation ina language spoken in a particular geographic region).
 Translating medical terminology is a specialized skill because not allpersons fluent in the
conversational form of the language arefamiliar with anatomic or other health terms.
 Interpreters, however, may make judgments about precise wording but alsoabout subtle meanings
that require additional explanation orclarification according to the specific language and ethnicity.
 They may edit the original source to make the meaning cleareror more culturally appropriate.
Stages of an interview
 An interview has three major stages: the opening or introduction, the body or development,and the
The Opening:
 The opening can be the most important part of the interview because what is said and done at that
time sets the tone for the remainder of the interview. The purposes of the opening are to establish
rapport and orient the interviewee.
 Opening are to establish rapport and orient the interviewee. Establishing rapport is a process of
creating goodwill andtrust.
 It can begin with a greeting (“Good morning,) or a self-introduction (“Good morning. I’m,a nursing
student”) accompanied by nonverbal gestures such asa smile, a handshake, and a friendly manner.
 In orientation, the nurse explains the purpose and nature ofthe interview, for example, what
information is needed, howlong it will take, and what is expected of the client.
 The nurse tells the client how the information will be used and usuallystates that the client has the
right not to provide data.
The following is an example of an interview introduction:
Step 1—Establish Rapport

Nurse: Hello, Ms. Goodwin, I’m Ms. Fellows. I’m a nursing student, and I’ll be assisting with your
care here today.
Client: Hi. Are you a student from the college?
Nurse: Yes, I’m in my final year. Are you familiar with thecampus?
Client: Oh, yes! I’m an avid football fan. My nephew graduated in 2008, and I often attend football
games with him.
Nurse: That’s great! Sounds like fun.
Client: Yes, I enjoy it very much.
Step 2—Orientation
Nurse: May I sit down with you here for about 10 minutesto talk about your care while you’re here?
Client: All right. What do you want to know?
Nurse: Well, to plan your care after your operation, I’d liketo get some information about your usual
daily activities andwhat you expect here in the hospital. I’ll take notes while wetalk to get the
important points and have them available to the other staff who will also look after you.
Client: OK. That’s all right with me.
Nurse: If there is anything you don’t want to talk about, please feel free to say so. Everything you
tell me will beconfidential and only be shared with others who have the legal right to know it.
Client: Sure, that will be fine
The Body
 In the body of the interview, the client communicates what he or she thinks, feels, knows, and
perceives in response to questions from the nurse.
 Effective development of the interview demands that the nurse use communication techniques that
make both parties feel comfortable and serve the purpose of the interview.

The Closing

 The nurse terminates the interview when the needed information has been obtained. In some cases,
however a client terminates it, for example, when deciding not to give any more information or when
unable to offer more information for some other reason—fatigue, for example.
 The closing is important for maintaining rapport and trust and for facilitating future interactions.

The following techniques are commonly used to close an interview:

1. Offer to answer questions: “Do you have any questions?” “I would be glad to answer any questions you
have.” Be sure to allow time for the person to answer, or the offer will be regarded as insincere.

2. Conclude by saying “Well, that’s all I need to know for now” or “Well, those are all the questions I have
for now.” Preceding a remark with the word “well” generally signal that the end of the interaction is near.

3. Thank the client: “Thank you for your time and help. The questions you have answered will be helpful in
planning your nursing care.” You may also shake the client’s hand.

4. Express concern for the person’s welfare and future: “I hope all goes well for you.”

5. Plan for the next meeting, if there is to be one, or state what will happen next. Include the day, time,
place, topic, and purpose: “Let’s get together again here on the fifteenth at nine a.m. to see how you are
managing then.” Or “Ms. Goodwin, I will be responsible for giving you care three mornings perweek while
you are here. I will be here each Monday, Tuesday, and Wednesday between eight o’clock and noon. At
those times, we can adjust your care as needed.”

6. Provide a summary to verify accuracy and agreement.

 Summarizing serves several purposes:It helps to terminate the interview, it reassures the client that
the nurse has listened, it checks the accuracy of the nurse’s perceptions, it clears the way for new
ideas, and it helps the client to note progress and a forward direction.

Client's name, address, age, sex, marital status, occupation, religious preference, health care financing,
and usual source of medical care.
The answer given to the question "What is troubling you?" or "Describe the reason you came to the
hospital or clinic today: The chief complaint should be recorded in the client's own words.

 When the symptoms started
 Whether the onset of symptoms was sudden or gradual
 How often the problem occurs
 Exact location of the distress
 Character of the complaint (e.g., intensity of pain or quality of sputum, emesis, or discharge)
 Activity in which the client was involved when the problem occurred
 Phenomena or symptoms associated with the chief complaint
 Factors that aggravate or alleviate the problem

 Illnesses, such as chickenpox, mumps, measles, rubella (German measles), rubeola (red measles),
streptococcal infections, scarlet fever, rheumatic fever, hepatitis, polio, and other significant
 Immunizations and the date of the last tetanus shot
 Allergies to drugs, animals, insects, or other environmental agents, the type of reaction that occurs,
and how the reaction is treated
 Accidents and injuries: how, when, and where the incident occurred, type of injury, treatment received,
and any complications
 Hospitalization for serious illnesses: reasons for the hospitalization, dates, surgery performed, course
of recovery, and any complications
 Medications: all currently used prescription and over-the. counter medications, such as aspirin, nasal
spray, vitamins, or laxatives

To ascertain risk factors for certain diseases, the ages of siblings, parents, and grandparents and their current
state of health or, if they are deceased, the cause of death are obtained. Particular attention should be given
to disorders such as heart disease. cancer, diabetes, hypertension, obesity, allergies, arthritis,
tuberculosis, bleeding, alcoholism, and any mental health disorders.

 Personal habits: the amount, frequency, and duration of substance use (tobacco, alcohol, coffee, cola,
tea, and illegal or recreational drugs)
 Diet: description of a typical diet on a normal day or any special diet, number of meals and snacks
per day, who cooks and shops for food, ethnic food patterns, and allergies
 Sleep patterns: usual daily sleep/wake times, difficulties sleeping, and remedies used for difficulties
 Activities of daily living (ADLs): any difficulties experienced in the basic activities of eating,
grooming, dressing, elimination, and locomotion
 Instrumental ADLs: any difficulties experienced in food preparation. shopping. transportation,
housekeeping, laundry, and ability to use the telephone. handle finances, and manage medications
 Recreation/hobbies: exercise activity and tolerance, hobbies and other interests, and vacations

 Family relationships/friendships: the client's support system in times of stress (who helps in time of
need?), what effect the client's illness has on the family, and whether any family problems are
affecting the client.
 Ethnic affiliation: health customs and beliefs; cultural practices that may affect health care and
 Educational history: Data about the client's highest level of
education attained and any past difficulties with learning.
 Occupational history: current employment status, the number of days missed from work because of
illness, any history of accidents on the job, any occupational hazards with a potential for future
disease or accident, the client's need to change jobs because of past illness, the employment status
of spouses or partners and the way child care is handled, and the client's overall satisfaction with
the work.
 Economic status: information about how the client is paying for medical care (including what kind of
medical and hospitalization coverage the client has), and whether the client's illness presents
financial concerns.
 Home and neighborhood conditions: home safety measures and adjustments in physical facilities that
may be required to help the client manage a physical disability. activityintolerance, and activities of
daily living; the availability of neighborhood and community services to meet the client's needs.

 Major stressors experienced and the client's perception of them
 Usual coping pattern for a serious problem or a high level of stress
 Communication style: ability to verbalize appropriate emotion; nonverbal communication—such as
eye movements, gestures, use of touch, and posture; interactions with support persons; and the
congruence of nonverbal behavior and verbal expression

All health care resources the client is currently using and has used in the past. These include the
primary care provider, specialists (e.g.. ophthalmologist or gynecologist), dentist, folk practitioners (e.g.,
herbalist or curandero), health clinic, or health center; whether the client considers the care being
provided adequate; and whether access to health care is a problems
 The physical examination or physical assessment is a systematic data collection method that uses
observation (i.e., the senses of sight, hearing, smell, and touch) to detect health problems.
 To conduct the examination the nurse uses techniques of inspection, auscultation, palpation, and
 The physical examination is carried out systematically. It maybe organized according to the
examiner’s preference, in a head-to-toe approach or a body systems approach.
 Usually, the nurse first records a general impression about the client’s overall appearance and health
status: for example, age, body size, mental andnutritional status, speech, and behavior.
 Then the nurse takessuch measurements as vital signs, height, and weight.
 The cephalo-caudal or head-to-toe approach begins the examination at the head; progresses to the
neck, thorax, abdomen, and extremities; and ends at the toes.
 The nurse uses a body systems approach to investigates each system individually, that is, the
respiratory system, the circulatory system, the nervous system, and so on.
 During the physical examination, the nurse assesses all body parts and compares findings on each
side of the body (e.g., lungs).
 Instead of giving a complete examination, the nurse may focus on a specific problem area noted from
the nursing assessment, such as the inability to urinate.
 On occasion, the nurse may find it necessary to resolve a client complaint or problem(e.g., shortness
of breath) before completing the examination.
 Alternatively, the nurse may perform a screening examination.A screening examination, also called a
review of systems, isa brief review of essential functioning of various body parts orsystems.
Data organization:
 The nurse uses a written (or electronic) format that organizesthe assessment data systematically.
 This is often referred to asa nursing health history, nursing assessment, or nursing database form.
 The format may be modified according to the client’s physical status such as one focused on
musculoskeletal data for orthopedic clients.
 Three examples are Gordon’s functional health pattern framework, Orem’s self-care model, and
Roy’s adaptation model
 Gordon (2010) provides a framework of 11 functional health patterns Gordon uses the word pattern
to signify a sequence of recurring behavior.
 The nurse collects data about dysfunctional as well as functional behavior. Thus, by using Gordon’s
framework to organize data, nurses are able to discern emerging patterns.
 Orem (2001) delineates eight universal self-care requisitesof humans.
 Roy (2008) outlines the data to be collected according to the Roy adaptation model and classifies
observable behavior into four categories: physiological,
Self-concept, role function, and interdependence.

Gordon’s framework:
 Health perception health-management pattern. Describes the client's perceived pattern of health
and well-being and how health is managed.
 Nutritional-metabolic pattern. Describes the client's pattern of food and fluid consumption
relative to metabolic need and pattern indicators of local nutrient supply.
 Elimination pattern. Describes the patterns of excretory function (bowel, bladder, and skin).
 Activity-exercise pattern. Describes the pattern of exercise, activity, leisure, and recreation.
 Sleep pattern. Describes patterns of sleep and relaxation.
 Cognitive-perceptual pattern. Describes sensory-perceptual and cognitive patterns.
 Self-perception-self-concept pattern. Describes the client's self-concept pattern and perceptions
of self (e.g., self-conception worth, comfort, body image, feeling state).
 Role-relationship pattern. Describes the client's pattern of role participation and relationships.
 Sexuality-reproductive pattern. Describes the client's patterns of satisfaction and dissatisfaction
with sexuality pattern; describes reproductive patterns.
 Coping-stress-tolerance pattern. Describes the client's general coping pattern and the effectiveness
of the pattern in terms of stress tolerance.
 Value-belief pattern. Describes the patterns of values, beliefs (including spiritual), and goals that
guide the client's choices or decisions.
Orem’s self -care model
1. The maintenance of a sufficient intake of air.
2. The maintenance of a sufficient intake of water.
3. The maintenance of a sufficient intake of food.
4. The provision of care associated with elimination processes and excrement.
5. The maintenance of a balance between activity and rest.
6. The maintenance of a balance between solitude and social interaction.
7. The prevention of hazards to human life, human functioning, and human well-being.
8. The promotion of human functioning and development within social groups in accord with human
potential, known human limitations, and human desire to be normal. (Normalcy is used in the sense of that
which is essentially human and that which is in accord with the genetic and constitutional characteristics and
the talents of individuals.)
Roy’s adaptation model:
1. Physiological needs
 Activity and rest
 Nutrition
 Elimination
 Fluid and electrolytes
 Oxygenation
 Protection
 Regulation: temperature
 Regulation: the senses
 Regulation: endocrine system
2. Self-concept
 Physical self
 Personal self
3. Role function
4. Interdependence

Functional health problem:
 Aware/understands medical diagnosis
 Gives thorough history of illnesses and surgeries
 Complies with Synthroid regimen
 Relates progression of illness in detail
 Expects to have antibiotic therapy and "go home in a day Or two"
 States usual eating pattern "3 meals a day"
 158 cm (5 ft, 2 in.) tall; weighs 56 kg (125 Ib)
 Usual eating pattern "3 meals a day"
 "No appetite" since having "cold"
 Has not eaten today; last fluids at noon
 Nauseated
 Oral temperature 39.4°C (103°F)
 Decreased skin turgor

 Usually no problem
 Decreased urinary frequency and amount x 2 days
 Last bowel movement yesterday, formed, states was "normal"

 No musculoskeletal impairment
 Difficulty sleeping because of cough
 "Can't breathe lying down"
 States "I feel weak"
 Short of breath on exertion
 Exercises daily
 No sensory deficits
 Pupils 3 mm, equal, brisk reaction
 Oriented to time, place, and person
 Responsive, but fatigued
 Responds appropriately to verbal and physical stimuli
 Recent and remote memory intact
 States "short of breath" on exertion
 Reports "pain in lungs," especially when coughing
 Experiencing chills
 Reports nausea
 Lives with husband and 3-year-old daughter
 Husband out of town; will be back tomorrow afternoon
 Child with neighbor until husband returns
 States "good" relationships with friends and coworkers
 Working mother, attorney

 Expresses "concern" and "worry" over leaving daughter with neighbors until husband returns
 Well-groomed; says, "Too tired to put on makeup"

 Anxious: "I can't breathe"
 Facial muscles tense; trembling
 Expresses concerns about work: "I'll never get caught up"

 Catholic
 No special practices desired except anointing of the sick
 Middle-class, professional orientation
 No wish to see chaplain or priest at present

 Synthroid 0.1 mg per day
 Client has history of appendectomy, partial thyroidectomy
 28 years old
 Height 158 cm (5 ft, 2 in.); weight 56 kg (125 Ib)
 TPR 39.4°C (103°F). 92, 28
 Radial pulses weak, regular
 Blood pressure 122/80 sitting
 Skin hot and pale, cheeks flushed
 Mucous membranes dry and pale
 Respirations shallow; chest expansion < 3 cm
 Cough productive of small amounts of pale pink sputum
 Inspiratory crackles auscultated throughout right upper and lower chest
 Diminished breath sounds on right side
 Abdomen soft, not distended
 Old surgical scars: anterior neck, RLQ abdomen
 Diaphoretic

Analyzing Data
 In the diagnostic process, analyzing involves the following steps:
 Compare data against standards (identify significant cues).
 Cluster the cues (generate tentative hypotheses).
 Identify gaps and inconsistencies.
Comparing Data with Standards:
 Nurses draw on knowledge and experience to compare client data to standards and norms and
identify significant and relevant cues.
 A standard or norm is a generally accepted measure, rule, model, or pattern. The nurse uses a wide
range ofstandards, such as growth and development patterns, normalvital signs, and laboratory
 A cue is considered significant if it does any of the following:
 Points to negative or positive change in a client’s health status or pattern. For example, the client
states: “I have recently experienced shortness of breath while climbing stairs” or “I have not smoked
for three months.”
 Varies from norms of the client population. The client may consider a pattern—for example, eating
very small meals and having little appetite—to be normal. This pattern, however, may not be healthy
and may require further exploration
Comparing cues to standards and norms:

Clustering Cues:
 Data clustering or grouping of cues is a process of determining the relatedness of facts and
determining whether any patterns are present, whether the data represent isolated incidents,and
whether the data are significant. This is the beginning of synthesis.
 Experienced nurses may cluster data as they collect and interpret it, as evidenced in remarks or
thoughts such as “I’m getting a sense of . . .” or “This cue doesn’t fit the picture.”

 The novice nurse does not have the knowledge base or the clinicalexperience that aids in recognizing
 Thus, the novice must take careful assessment notes, search data for abnormal cues,and use textbook
resources for comparing the client’s cues withthe defining characteristics and etiologic factors of the
accepted nursing diagnoses.
 Data clustering involves making inferences about the data.
 The nurse interprets the possible meaning of the cues, and labels the cue clusters with tentative
diagnostic hypotheses.
Identifying Gaps and Inconsistencies in Data:
 Skillful assessment minimizes gaps and inconsistencies indata. However, data analysis should
include a final check to ensure that data are complete and correct.
 Inconsistencies are conflicting data. Possible sources ofconflicting data include measurement error,
expectations, andinconsistent or unreliable reports.
 For example, a nurse may learn from the nursing history that the client reports not having seen a
doctor in 15 years, yet during the physical health examination he states, “My doctor takes my blood
pressure everyyear.”
 All inconsistencies must be clarified before a valid pattern can be established.
Utilization of data relevant to nursing process:

While providing nursing care the nursing process can be used & followed. In all settings nursing care
can be provide through above elaborated steps of nursing process as

Any example can be take to get familiar with the concept of nursing care using nursing process
Vijay Singh is a 39-year-old secretary who was admitted to the hospital with an elevated
temperature, fatigue, rapid, labored respirations; and mild dehydration. The nursing history reveals
that Ms. Singh has had a “bad cold” for several weeks that just wouldn’t go away. She has been
dieting for several months and skipping meals. Ms. Singh mentions that in addition to her fulltime
job as a secretary she is attending college classes two evenings a week. She has smoked one package
of cigarettes perday since she was 18 years old. Chest x-ray confirms pneumonia.
Physical Examination
o Height: 167.6 cm (5′6′′)
o Weight: 54.4 kg (120 lb)
o Temperature: 39.4°C (103°F)
o Pulse: 68 BPM
o Respirations: 24/minute
o Blood pressure:
o 118/70 mm Hg
o Skin pale; cheeks flushed;
o chills; use of accessory muscles; inspiratory crackles with
o diminished breath sounds
o right base; expectorating thick,
o yellow sputum

Diagnostic Data

o Chest x-ray: right lobarinfiltration
o WBC: 14,000
o pH: 7.49
o PaCO2: 33 mm Hg
o HCO3–: 20 mEq/L
o PaO2: 80 mm Hg
o O2 sat: 88%
Then here we will see how the nursing care is provided using nursing process
The first step is assessment:
o In the above mentioned case whole data of Ms. Singh is collected in the sense with
(subjective , objective data).
o Also detailed nursing history including lifestyle, habits etc.
o Organizing data according to needs.
Second is diagnosis:
o In this phase whatever information collected during assessment phase is compared with
o Then identify the problem that is patient is badly affected by Cough.
o Formulate a diagnosis statement
o i.e. Ineffective Airway Clearance related to thick sputum, secondary to pneumonia
(asevidenced by rapid respirations,diminished and adventitiousbreath sounds, thick
Third is Planning :
o This phase starts with setting priorities.
o In this Ms. Singh suffers from bad cough and the first priority is given to it.
o She also is taken into confidence and along with her implementation is done.
o This phase has long term & short term outcome.
o Respiratory Status: Airway Patency as evidenced by
o not compromised
o Respiratory rate
o Moves sputum out of airway
o No adventitious breathsounds
Fourth is implementing:
o This phase has implementations like independent, dependent, collaborative type.
o Firstly asses the condition of Ms. Singh (the rate and depth of respirations and chest
o (Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath
sounds: crackles, wheezes.)
o Then Assist Ms. Singh to a sitting position with head slightly flexed,shoulders relaxed, and
knees flexed.
o Teach and assist patient with proper deep-breathing exercises. Demonstrate proper splinting
of chest and effective coughing while in upright position. Encourage him to do so often.
o Assist and monitor effects of nebulizer treatment and other respiratory physiotherapy:
incentive spirometer, IPPB, percussion, postural drainage. Perform treatments between
meals and limit fluids when appropriate.
o Administer medications as indicated: mucolytics, expectorants, bronchodilators, analgesics.
o Urge all bedridden and postoperative patients to perform deep breathing and coughing
exercises frequently.
o At last reassess client’s condition after all interventions are provided.
Fifth is evaluation:
o The last phase is evaluation of all care provided throughout the phases.
o The evaluation statement has measures were taken to meet outcome partially met. Ms. Singh
coughs and deep breathes purposefully q1–2h during the day. Her fluid intake is
approximately1,500 mL each day.
o Cough continues to be productive of moderately thick, rusty-colored sputum. Inspiratory
crackles remain present in right lower lobe.
1. Berman, Audrey, Barbara Kozier, And Glenora Lea Erb. Kozier And Erb's Fundamentals Of Nursing.
Frenchs Forest, N.S.W.: Pearson Australia, 2012. Print.

2. Anne-Marie Brady, Catherine McCabe, Margaret McCann November 2013, ©2012, Wiley-Blackwell
Fundamentals of Medical-Surgical Nursing: a Systems Approach