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NCM 100 SKILLS Nursing Process Handouts
NCM 100 SKILLS Nursing Process Handouts
Types of Data:
a. Subjective Data (Symptoms)
- Those that can be described only by the person experiencing it, e.g. vertigo is dizziness,
tinnitus is ringing in the ears.
C. OUTCOME IDENTIFICATION
- ___________________________________________________________.
- It provides the basis for evaluating nursing diagnosis.
Purposes:
o To provide individualized care.
o To promote client participation.
o To plan care that is realistic and measurable.
o To allow involvement of support people.
o Nursing diagnoses are classified as high – priority, medium – priority and low -
priority:
a. High – priority nursing diagnoses – are those that are potentially life – threatening and
require immediate action. Examples include Impaired Gas Exchange, Ineffective
Breathing Pattern, Self – Directed Risk for Violence.
b. Medium – priority nursing diagnoses – are those that could result in unhealthy
consequences, such as physical or emotional impairment, but are not life – threatening.
Examples include Fatigue, Activity Intolerance, Ineffective Coping, and Dysfunctional
Grieving.
c. Low – priority nursing diagnoses – involve problems that usually can be resolved easily
with minimal interventions and are unlikely to cause significant dysfunction. Examples
include sensation of hunger in a client who is on NPO (nothing by mouth), I preparation for
a diagnostic procedure; minimal pain on the third postoperative day, related to
ambulation.
ESTABLISH CLIENT’S GOALS AND OUTCOME CRITERIA:
2. Goal
The client will demonstrate safety habits when performing ADL’s (activities of daily
living) and injury prevention.
Possible outcome criteria
The client uses call light system for assistance at each need to use bathroom
immediately after instruction by the nurse.
The client demonstrates safety practices in dressing and hygiene.
The client uses over – the – bed – lights, non – skid slippers when transferring to chair
or out of bed.
The client identifies modification for home safety (removal of throw rugs, installation of
hand rails in hallway, better lighting of hallway and stairway) 12 hours after nurse’s
instruction about home safety.
3. Goal
The client will mobilize pulmonary secretions
Purposes:
To identify the client’s goals and appropriate nursing interventions.
To direct client care activities.
To promote continuity of care.
To focus charting requirements.
To allow for delegation of specific activities.
Client Goal
(One or more client goals established from nursing diagnosis . A broadly stated
objective that indicates an overall picture of the state of the client if the problem is
resolved.)
Client will demonstrate safety habits when performing ADL’s and injury prevention.
Client Outcome Criteria
(Specific, measurable, realistic statements, that can be evaluated to judge goal
attainment. Stated as behavioral objectives, they include a verb, a short phase
describing the specific measure to be accomplished, and a time reference.)
Client uses call light system for assistance for each need to use the bathroom
immediately after instruction by the nurse.
Client demonstrates safety practices in dressing and hygiene.
Client uses over – the – bed lights, nonskid slippers each time when transferring to
chair or out of bed.
Client identifies modification for home safety (removal of throw rugs, installation of
hand rails in hall way, better lighting of hallway and stairway) 12 hours after nurse’s
instruction about home safety.
Purpose: To carry out planned nursing interventions to help the client attain goals and achieve
optimal level of health.
Activities:
Reassessing. To ensure prompt attention to emerging problems.
Set Priorities. To determine the order in which the nursing interventions are carried
out.
Perform Nursing Interventions. These may be independent, dependent, or
collaborative measures.
REQUIREMENTS OF IMPLEMENTATION
1. Knowledge. Include intellectual skills like problem – solving decision – making and
teaching.
2. Technical skills – To carry out treatments and procedures.
3. Communication Skills – Use of verbal and non – verbal communication to carry out
planned nursing interventions.
4. Therapeutic Use of Self. It is being willing and being able to care.
F. EVALUATION
- Is assessing the client’s response to nursing interventions and then comparing the
response to predetermined standards or outcome criteria.
Purpose: To appraise the extent to which goals and outcome criteria of nursing care have been
achieved.
Activities:
Collect data about the client’s response.
Compare the client’s response to goals and outcome criteria.
The four possible judgments that may be made are as follows:
The goal was completely met.
The goal was partially met.
The goal was completely unmet.
New problems or nursing diagnoses have developed.