MODULE 3

Nursing Diagnosis
- Involves analysing health data and drawing conclusion to identify nursing
diagnosis.

UNIT 1
Common Laboratory Examination
1. Urinalysis – Chemical examination of urine, to assess characteristic of urine
(fever only last for 3 days, if so, there is already an infection going on)

Methods of urine Examination

a. Random Collection – Routine analyse
b. Timed Collection – Done over a 24 hours collection (
c. Culture and Sensitivity Test Urine

2. Stool Analysis – Assessment of bacteria, virus, malabsorption and blood

- *Place in a container with proper label then send to laboratory
- A test to determine the presence of parasites, fats, bacteria, and blood.
- Stool for Occult blood to detect bleeding or Guaiac Test (blood in the
stool)

3. Blood Test – Blood test that does not require fasting

- Complete blood count
- Hemoglobin
- Hematocrit level test
- Clotting studies
- Serum electrolyte studies

4. Fasting Blood Sugar (FBS) – Detects diabetes mellitus

5. Capillary Blood Gas (CBG) – Commonly perform for glucose analysis.
6. HBAIC- Glycosylated Hemoglobin- to determine if one is diabetic for the past
three months
7. Sputum Examination – to determine the presence of microorganism in the
sputum.
8. Electrocardiogram – ECG (EKG) – records electrical waves of the hearts.
9. Electroencephalogram – EEG – records the electrical activity of the brain, detects
intracranial hemorrhage and tumors
10. Arterial Blood Gas (ABG) – Reveals the ability of the lungs to exchanfg e gas by
measuring the partial pressure of the oxygen (PO2), carbon dioxide (PCO2) and
evaluate the Ph arterial blood.
11. Lumbar Puncture – To withdraw cerebral- spinal fluid to determine abnormalities.
12. Mammography – To detect the presence of breast tumor
13. Mantoux Text – To test to determine exposure to tuberculi bacillus
14. Papanicolau (Pap Smear) – smear method of examining stained exfoliative cells.
Direct Visualization

UNIT 2
Nursing Diagnosis

MODULE 4
Planning
- 3rd step in the nursing process.
- Involves determining beforehand the strategies or course of actions to be taken
before implementation of nursing care.
- Planning involves decision making and problem solving.
- It is the process of formulating client goals and designing the nursing interventions
required to prevent, reduce or eliminate the client’s health problems.

Types of Planning
1. Initial Planning – Planning which is done after the initial assessme
2. Ongoing Planning – It is a continuous planning
3. Discharge Planning – Planning for needs after discharge.

Planning Process
1. Setting Priority – factors to consider are :
- Client health values and beliefs
- Client priorities
- Resource available to the nurse and client
- Medical treatment plan

2. Establishing client’s goal and desires outcome

Goals may be:
a. Short Term- used for client who require health care fo the short time
and client who need immediate health care.
b. Long Term- applicable to client who stay at home and have a chronic
problem.
c. Selecting Nursing Interventions and Activities *focus on the elimination
and reduction of the etiology of the nursing diagnosis

UNIT 2
Nursing Intervention – is any treatment that a nurse performs to improve client’s health.

Categories of Nursing Interventions

 1. 1.Independent Interventions – are those activities that nurses are licensed to
initiate on the basis of their knowledge and skills
Examples: Physical care, Emotional support, Health teaching,
Environmental management, Making referral to other health care
professional, Elevating a client’s edematous extremities

Illness – Signs and symptoms

Disease – The sakit

2. Interdependent Interventions- (Collaborative Interventions) are those actions that

are implemented in a collaboration manner by the nurse in conjunction with the
other health care professionals
Examples: Nurse may assist client to perform an exercise thought by the
physical therapist

3. Dependent Interventions- are activities carried out under the orders or

supervision of a licensed physician
Examples: Physician’s order, Medication, IV therapy, Diagnostic test,
Diet, Activity
 Nursing responsibility: explaining assessing the needs
administrations of medicine as order

UNIT 3
Implementation
- 4th step in the nursing process
- The performance of the nursing interventions identified during the planning phase
- Consist of doing and documenting the activities.

The Process of Implementation

1. Reassessing the client - Ensure the need for further intervention
2. Determining the client’s need for assistance
3. Implementing the nursing intervention – Explain what will be done, expected to
do and expected outcome. Ensure client’s privacy. Coordinate client’s care
4. Supervising delegated care – Ensure all activities are implemented according to
the care plan
5. Documenting nursing activities – Implementation phase is completed in the
recording of intervention and client’s response in the nursing progress notes

Types of Nursing Interventions

 1. Specific Orders – is an order written in a client’s medical record or nursing care
plan by a physician or a nurse especially for that individual, it is not use for any
other client.
2. Standing Order – standardized intervention written, approved and signed by a
physician, kept on file to be used in predictable situations or circumstances
requiring immediate attention.
3. Protocol – series of standing orders or procedures that should be followed under
certain specific conditions. The protocol defines intervention that are permissible
and those circumstances under the nurse is allowed to implement the measures.

UNIT 4
Evaluation
- 5th step in the nursing process
- Final phase of the nursing process that measures the effectiveness of nursing
care plan in promoting the achievement of client’s goal, used to determine the
extent to which goal of care plan have been achieved.
- Refer to the determination that the goal has been achieved within the stated time
frame.
- Evaluation consist of:
a. Comparing client responses to expected outcome
b. Analyzing reason for results and conclusions
c. Modifying care

Three Possible Conclusions

1. Goal was met
2. Goal was partially met
3. Goal was not met