A Merged

Nursing Process
• A systematic,
client-centered
method for structuring the
delivery of nursing care
1
Nursing Process…
• Provides structure for nursing practice
2
PHASES of the NURSING PROCESS
3
PURPOSES of the
NURSING PROCESS
1. To identify client’s health status

2. To identify actual or potential health care
problems or needs
4
PURPOSES of the
NURSING PROCESS
3. To establish plans to meet identified needs

4. To deliver specific nursing interventions to
meet identified needs
5
Characteristics of the Nursing Process
• Systematic
•Cyclic and dyNamic
• client-centered
• Interpersonal and collaborative 6

• Focuses on problem-solving
•Focuses on decision-
making
7
• Universally applicable
• Involves the use of critical

thinking
8
• Outcome- oriented
•Proactive
• Evidence-based
9
Assessment
• systematic & continuous

collection, organization,
validation, &
documentation of data
10
Assessment
• a continuous process
• focuses on client’s
responses to a health
problem
11
1/16/2023 NURS100
Types of Assessment:
Purpose of Type of Time Example
Assessment Assessment Performed
To establish a Initial nursing Within a Nursing

complete assessment or specified admission
assessment
database for comprehensive time after
problem assessment admission
identification, to a health
reference, & care agency
future
comparison 12
To determine Problem- Ongoing Hourly

the status of a focused process assessment
of a client’s
specific assessment integrated
I&O in an
problem with nursing ICU
identified in an care
earlier
assessment
13
To identify life- Emergency During any Rapid ABC

threatening assessment physiologic assess-
ment during
problems; or
a cardiac
To identify new psychologic arrest
or overlooked crisis
problems
14
To compare the Time-lapsed Several Reassess-

client’s current reassessment months ment of a
client’s
status to after initial
function-al
baseline data assessment health
previously patterns in
obtained a home
care
15
RELATED ACTIVITIES DONE
DURING ASSESSMENT
• collecting data
• organizing data
• validating data
• documenting data
16
ASSESSMENT Activities
COLLECTING DATA
= getting a client’s DATA BASE
17
COLLECTING DATA
DATABASE sources:
A. Nursing health history
B. Physical assessment
C. Laboratory and diagnostic tests
D. Materials contributes by other health personnel
18
COLLECTING DATA
A. Nursing health History

- gives subjective information on how
a health condition came about
- data/information to be collected:
– level of wellness
– changes in life patterns
– socio-cultural role
– mental and emotional reactions to illness
– other health conditions
19
Health History
Purpose:
* identify…
-patterns of health and illness
-risk factors for health problems
-deviations from normal
-available resources for adaptation
20
Health History
Guidelines in Health History Taking

1. Sources of information:
client, family or significant others, health team
members & client’s health record
21
Health History
2. Most of the data are SUBJECTIVE.
Inuubo ako
Doc!
Uhu-uhu-uhu!
22
Health History
3. Focus on data/information from all the client’s

dimensions.
4. Record data using clear, concise and appropriate

terminology.
23
Basic Components of Health History
1. Demographic (Biographical) Data
– client’s name
– Sex
– age
– date & place of birth
– marital status
– race/nationality, religion
– address/contact number
– educational background
– other significant trainings, occupation.
– Usual source of medical care
– Source and reliability of information
24
2. Source and Reliability of Information

– Should be in narrative form (describe specifically according to the
patient’s manifestation or capability)
• Sample Statements:
– The patient was competent to provide information. She was able to speak
clearly; conscious and coherent; oriented to time, place and person.
25
3. Reasons for seeking care or

Chief Complaint
– Recorded as direct quotes
26
Reason for seeking care

Example:
“I am going to college and I need to

get a physical check-up; the
college is requiring me to get a
hepatitis B vaccine…”
27
Chief complaint
Example:
“I need to find a new health care

provider to treat my asthma
because it is starting to bother
me again…”
28
4. Present Health or History of Present llness
✓ For well person :

General State of Health
e.g.: pt describes himself as a healthy male without any
significant medical problems.
✓ For ill person:

HPI or Chronological account of how illness came
about
29
• For ill person:

• Timing (frequency, onset and duration of symptoms)
• Location
• Quality (character)
• Quantity (Severity)
• Setting in which symptoms occur
• Associated phenomena/manifestations
• Aggravating/alleviating factors
• Meaning and impact of CC on the client
30
Please don’t copy the

contents on the next slide.
31
History of Present Illness (a sample):

Pt was in usual state of good health until one wk ago; at that time
had SOB c tightness in the chest and mild wheezing; has been
using albuterol MDI 2 inhalations qid, usually makes breathing
easier; no other meds taken; pt usually runs 5 miles daily and he
has not felt up to running the past week; describes SOB; temp
370C yesterday; (+) sore throat; (+) fatigue, denies sputum, cough,
sinus pressure, tooth pain, nasal discharge, nasal polyps; noticed
that sx started the day before he did yardwork before the recent
storm; had 2” of water in basement of house; cleared tree debris
from backyard from wind damage; pt reports that he and his wife
rescued a stray cat 2 wks ago and the cat now lives in the house
and often sleeps on his bed; pt is concerned because he has not
felt this ill in many years; he also recently started a new job and
does not want to miss time at work due to illness. 32
5. Past Medical History/Past Health

– review of previous illness
– injuries & hospitalizations
– obstetric history (female)
– surgeries/operations
– allergies
– immunizations
– use of medications
33
6. Family History
- health status of the immediate family members &

other blood relations
34
6. Family History
- Genogram or family tree
Maternal Paternal
A& W A&W
DM Accident
65 84
77 45
DM A&W
aneurysm
A&W A&W A&W
24 30
18
25 23 31
A & W – alive and well

Male
Female
A & W, 10
A & W, 9 A & W, 8 Client
Deceased
7. Socio-economic Data or Social History
- Info about pt’s lifestyle that can affect health
36
8. Psychosocial Assessment
• (Specific for the current developmental stage of
the client)
• (Use Erik Erikson’s Psychosocial Development
Theory)
37
9. Functional Assessment
- assists the nurse in collecting, organizing and

categorizing data
38
a. Health Perception-Health Management Pattern
-person’s description of his current health

-activities that the person does to improve or maintain his
health
-person’s knowledge about links between lifestyle choices and
health
39
-extent of person’s problem on financing health care, if

any
-person’s knowledge of the names of current medications

he is taking and their purpose/s
40
-activities that the person does to prevent problems related to

allergies, if any
-person’s knowledge about medical problems in the family
-any important illnesses or injuries in this person’s life
41
b. Nutrition-Metabolic pattern
42
b. Nutrition-Metabolic Pattern
-person’s nourishment
-person’s food choices in comparison with recommended
food intake
-any disease that affects nutritional-metabolic function
43
c. Elimination Pattern
44
c. Elimination Pattern
-person’s excretory pattern

-any disease of the digestive system, urinary system or
skin
45
d. Activity-Exercise pattern
46
d. Activity-Exercise Pattern
-person’s description of his weekly pattern of activities,

leisure, exercise and recreation
-any disease that affects his cardio-respiratory and/or
musculoskeletal systems
47
e. Sleep-rest pattern
48
1/16/2023 NURS100
e. Sleep-Rest Pattern
-description of the person’s sleep-wake cycle
-person’s physical appearance (rested and relaxed?)
49
f. Cognitive-Perceptual pattern
50
f. Cognitive-Perceptual Pattern
-any sensory deficit and if corrected

-person’s ability to express himself clearly and logically
-person’s education
-any disease that affects mental or sensory function
-person’s pain description & causes, if any
51
g. Self-Perception-Self-Concept pattern
52
g. Self-Perception & Self-Concept Pattern
-anything unusual about the person’s appearance

-if person is comfortable with his appearance
-description of the person’s feeling state
53
h. Role Relationship pattern
54
h. Role-Relationship Pattern
-person’s description of his various roles in life

-positive role models of his roles, if any
-important relationships at present
-any big changes in role or relationship
55
i. Sexuality-Reproductive pattern
56
i. Sexuality-Reproductive Pattern
-person’s satisfaction with his situation related to sexuality

-How have the person’s plans and experiences matched
regarding having children?
-any disease/dysfunction of the reproductive system
57
j. Coping-Stress Tolerance pattern
58
j. Coping-Stress Tolerance Pattern
-person’s means/actions of coping with problems

-if coping actions help or make things worse
-any treatment for emotional distress
59
k. Value-Belief pattern
60
k. Value-Belief Pattern
-principals that the person learn as a child which are still

important to him
-person’s identification with any cultural, ethnic, religious,
regional or other groups
-support systems that the person has
61
10. Review of Systems
- subjective responses
- head-to-toe approach
62
a. General survey
• usual weight
• recent weight changes
• weakness
• fatigue
• fever
63
b. Skin/Integument
• rashes
• lumps
• sores
• itching
• dryness
• color change
• changes in hair or nails
64
c. Head
• Headache
• Head injury
• Dizziness
65
d. Eyes
• Vision
• glasses or contact lenses
• last eye examination
• pain redness
• excessive tearing
• double vision
• Spots
• Flashing lights
• glaucoma and cataracts
66
e. Hearing
• Tinnitus
• Vertigo
• Earaches
• Infection
• Discharge
• use of hearing aids
67
f. Nose and Sinuses

• frequent colds
• nasal stuffiness
• discharge or itching
• Nosebleeds
• sinus trouble
68
g. Mouth and Throat
• condition of teeth and gums
• bleeding gums
• dentures if any and how they fit
• last dental examination
• sore tongue
• dry mouth
• frequent sore throat
• hoarseness
69
h. Neck
• lumps
• swollen glands
• Goiter
• pain or stiffness
in the neck
• Limitation of motion
70
i. Breast
• lumps
• pain or discomfort
• nipple discharge
• History of breast disease
• Any surgery of the breast
• BSE including frequency and method
71
j. Thorax and Lungs (Respiratory)

• cough
• sputum (color, quantity)
• Hemoptysis
• Wheezing
• Asthma
• Dyspnea
• History of respiratory diseases
• Toxin or pollution exposure
• last x-ray film
72
k. Heart (Cardiac)
• Precordial or retrosternal pain
• Heart trouble
• high blood pressure
• rheumatic fever
• heart murmurs
• chest pain or discomfort
• palpitations
• dyspnea
• orthopnea
• edema
• past ECG or other heart test results
73
l. Gastrointestinal
• dysphagia • rectal bleeding or black tarry
• heartburn stools
• appetite • hemorrhoids
• nausea • constipation
• vomiting • diarrhea
• regurgitation • abdominal pain
• vomiting of blood • food intolerance
• Indigestion • excessive belching or
• Frequency of BM passing of gas
• color and size of stools • jaundice
• change in bowel habits • liver or gallbladder trouble
74
m. Urinary
• Frequency of urination
• polyuria
• nocturia
• burning or pain on urination
• hematuria
• urgency
• reduced force of the urinary stream
• hesitancy, dribbling, incontinence
• urinary infections
• stones 75
n. Genitalia
– Male
• Hernias
• discharge from or sores on the penis
• testicular pain or masses
• history of sexually transmitted infections and their
treatments
• Sexual preference, interest, function, satisfaction and
problems
76
n. Genitalia
– Female –
• Age @ menarche • menopausal symptoms
• regularity • discharge, itching
• frequency and duration of periods • sores, lumps
• amount of bleeding • Number of pregnancies
• bleeding between periods or after • # of deliveries
intercourse • complications of pregnancy
• last menstrual period, • birth control methods (for married
• dysmenorrhea women).
• premenstrual tension • Sexual preference, interest, function,
• age of menopause satisfaction, any problems 77
o. Peripheral Vascular
• Coldness, numbness and tingling
• swelling of legs
• discoloration of hands or feet,
• varicose veins or complications,
• intermittent claudication, thrombophlebitis, ulcers
• Does the occupation of the client involve long-term sitting or standing?
• Does the client avoid crossing legs at the knees?
• Does the client wear support hose?
78
p. Musculoskeletal
• Joints: pain, stiffness, swelling (location, migratory nature), deformity,
limitation of motion, noise with joint motion
• Muscles: Pain, cramps, weakness, gait problems or problems with
coordinated activities
• Back: Pain (location and radiation to extremities) stiffness, limitation
of motion, or history of back pain or disease
79
q. Neurologic
• History of seizure disorder and stroke
• Sensory function: Memory disorders (recent or
distant, disorientation)
• Motor function: tics or tremors, paresis –
weakness, fainting, blackouts
80
r. Hematologic
• Anemia
• easy bruising or bleeding
• past transfusion
81
s. Endocrine
• Thyroid trouble
• heat or cold intolerance
• excessive sweating
• diabetes
• excessive thirst/hunger
• polyuria
82
t. Psychiatric
• Nervousness
• Tension
• Mood including depression
83
COLLECTING DATA
DATABASE sources:
A. Health history
B. Physical assessment
C. Laboratory and diagnostic tests
D. Materials contributes by other health personnel
84
PHYSICAL ASSESSMENT
• As a source of database, this will be discussed
under data gathering methods.
85
COLLECTING DATA
Types of Data:
A. Subjective
» symptoms or covert data
» e.g.: pain, itching, health history
86
COLLECTING DATA
• Types of Data:
b. Objective
» signs or overt data
» can be measured or tested against an accepted
standard
» can be seen, heard, felt, or smelled
» obtained by observation or PE
» e.g.: color of the skin, characteristic of breath
sounds
87
COLLECTING DATA
Sources of DATA
1. Primary
- the client
- “the best source”
2. Secondary
- all sources other than the client
88
COLLECTING DATA
Data Collection Methods
a. Observing
b. Interviewing
c. Examining
89
COLLECTING DATA
a. Observing
– conscious,deliberate use of the
physical senses
- e.g.: overall appearance, body or
breath odors, lung sounds, skin
temperature
90
COLLECTING DATA

a. Observing
b. Interviewing
- planned, structured
communication or a conversation
with a purpose
- done to attain subjective data
- focused interview – specific
questions to collect information 91
COLLECTING DATA
Approaches to Interviewing:
1. Directive
• highly structured
• elicits specific information
• nurse controls subject matter
• used when time is limited
92
COLLECTING DATA
2. Non-Directive/rapport-building
– Nurse allows patient to control the purpose, subject

matter & pacing of the interview
93
COLLECTING DATA
Types of Interview
Questions:
Closed Open-ended
-used in directive interview - associated with

nondirective interview
94
COLLECTING DATA
Types of Interview
Questions:
Closed Open-ended
-generally require yes or no -specify broad topics to be
or short factual answers discussed & invite longer
giving specific information answers
95
COLLECTING DATA
Types of Interview
Questions:
Closed Open-ended
e.g.: “How old are you?” - e.g.: “How have you been
“What medication did you feeling lately?” “What
take?” would you like to talk about
today?”
96
COLLECTING DATA
Types of Interview
Questions:
Neutral Leading
-can be answered by the client - direct the client’s answer
without direction or pressure from
the nurse
97
COLLECTING DATA
Types of Interview
Questions:
Neutral Leading
-open-ended - closed; used in a directive interview
-used in nondirective interview - give client less opportunity to decide
-- e.g.: “How do you feel about whether the answer is true or not
that?” -can create problems if client gives
inaccurate response just to please the
nurse
-- e.g.: “You will take your medicine,
won’t you?”
98
COLLECTING DATA

a. Observing
b. Interviewing
c. Examining (Physical Examination or Physical Assessment)
- systematic data collection that uses

observation to detect health problems
99
COLLECTING DATA
c. Examining (Physical Examination or Physical Assessment)
- provides objective data that can be used to:

• validate subjective data obtained
• detect any findings not reported in the history
• obtain information about the individual’s status of health
problem
100
COLLECTING DATA
Approaches:
a. cephalocaudal
b. body systems approach
Upon Admission:
– Perform complete physical
examination
During on-going assessment:
– examine specific body areas,
systems or functions
101
Physical Examination
OBJECTIVES
obtain baseline data about client’s functional
abilities
supplement, confirm, refute data obtained in
health history
obtain data that will help in establishing plan of
care
102
OBJECTIVES
evaluate physiologic outcomes of health care and
progress of health problem
make clinical judgments about a clients health
status
identify areas for health promotion & disease
prevention
103
PRINCIPLES / GUIDELINES
1. Make client relaxed & comfortable.
104
2. Provide privacy & avoid unnecessary

exposure.
105
3. Have an order for examination.

4. Follow plan of order for PE.
106
5. Maintain a well-lighted room.
107
6. Explain every step that will be

undertaken.
108
7. The body is bilaterally symmetrical.
109
8. While examining each region,

consider underlying structures.
110
9. Use all senses.
111
Positioning for Assessment
- Posture
- body contours &
alignment
-muscles &
extremities
112
1. STANDING POSITION
Head, neck, axilla,

abdomen,
anterior chest,
breast & other
accessible
structures
2. Supine Position
113
Dorsal Recumbent Position
rectum and vagina
114
Lithotomy Position
Female genitals, rectum, reproductive tract
115
PRONE POSITION
116
Sims position
117
SITTING POSITION 118

TECHNIQUES USED
IN PHYSICAL ASSESSMENT
119
a. Inspection
120
What to inspect:
* body features & symmetry
* general appearance
* nutritional state
* hair distribution
* color & shape
* posture & gait
* manner of speaking
* gross deviation 121
b. Palpation
Texture, shape, temperature, perception of

vibration or movement & consistency 122
Tools: Palpation Physical Examination
Dorsal portion
Fingertips
123
Index-thumb / grasping Palmar/ ulnar surfaces
fingers
Guidelines/Approaches to Client
1. Palpate suspected tender areas last.
2. Keep fingernails short.
3. Warm hands before touching the client.
4. Use a gentle approach. Gradually increase
pressure from light to deep.
5. The sensation of touch is best preserve
with light, intermittent pressure.
124
TYPES ASSESSMENT Activities
Light
palpation
125
Deep palpation ASSESSMENT Activities
Bimanual
126
Fluid wave Ballottement
What to Palpate:
1. Size
2. Temperature
3. Texture
4. Tenderness
5. Vibration
6. Pulsation
7. Swelling
8. Moisture
9. Consistency of any body parts under the 127
skin
c. Percussion
The act of striking certain areas/body surfaces like back,

chest, and abdomen with a finger to produce a vibration 128
that travels through body tissues
Methods of Percussion
1. Direct / Immediate
129
2. Indirect / mediate
* Using plexor & pleximeter
130
Characteristics of Percussion Sound Physical Examination
Sound Intensity Pitch Duration Quality Location
tympany loud high mod. drum-like stomach
resonance mod. to low long hollow normal lung

loud
hyperreson very loud very low longer than booming emphyse-

ance resonance ma
dullness soft to mod. high mod. thudlike liver
flatness soft high short flat muscle

131
d. Auscultation Physical Examination
132
Characteristics of Sounds
1. Frequency / pitch
2. Loudness / intensity (amplitute)
3. Quality
4. Duration
133
Types:
1.Immediate / Direct
2.Mediate / Indirect
134
Parts of the stethoscope:
bell
tubing
diaphragm
135
Guidelines when using stethoscope:

1. Tubing should not be longer than 12 – 15 inches.
2. Insert earpieces pointing toward nose.
3. Keep tubing free of contact with any surface.
4. Create a quiet environment before beginning
auscultation.
5. Warm end piece by rubbing in palm.
6. Hold stethoscope firmly and exert enough pressure to
ensure solid contact.
136
Collecting Data

a. Observing
b. Interviewing
c. Examining (Physical Examination or Physical
Assessment)
d. Using Laboratory Results

- source of objective data which is important in assessing many
health problems & conditions
137
ASSESSMENT ACTIVITIES
COLLECTING DATA
Organizing Data
• nurse uses a written (or electronic) format that
organizes the assessment data systematically
• often referred to as a nursing health history,

nursing assessment, or nursing database form
138
Organizing Data
FRAMEWORKS/MODELS USED AS BASES IN

ORGANIZING DATA
(MODELS OF ASSESSMENT):
1. Gordon’s Functional Health Pattern
2. Maslow’s Hierarchy of Needs
4. P.E.R.S.O.N.
5. Virginia Henderson’s 14 Fundamental
Needs
6. Abdellah’s 21 Activities of Daily Living 139
ORGANIZING DATA
Models
Gordon’s Functional Health Patterns
140
ORGANIZING DATA
Models
Maslow’s Hierarchy of Needs

Self-
Actualization
Self-esteem Needs
Need for love & belongingness
Safety / Security Needs
Physiologic Needs 141

ORGANIZING DATA
Models
Review of Systems
-organizes data collection

according to the organ & tissue
function in various body systems
- yields subjective data
142
ORGANIZING DATA
Models
P.E.R.S.O.N.
• P - sychological
• E - limination
• R - est & activity
• S - afe environment
• O - xygenation
• N - utrition 143
ORGANIZING DATA
HENDERSON’S 14 Models
FUNDAMENTAL NEEDS
1. Breathe normally.
2. Eat & drink adequately.
3. Eliminate body waste.
4. Move & maintain desirable posture.
5. Sleep & rest.
6. Select suitable clothing.
7. Maintain body temperature.
8. Keep the body clean and well groomed to protect the 144
integument.
ORGANIZING DATA
HENDERSON’S 14 Models
FUNDAMENTAL NEEDS
9. Avoid dangers in the environment & avoid injuring others.
10. Communicate with others.
11. Worship according to one’s faith.
12. Work in such a way that there is a sense of
accomplishment.
13. Play or participate in various forms of recreation.
14. Learn, discover or satisfy the curiosity that lead to normal
development & health & use available health facilities. 145
ORGANIZING DATA
ABDELLAH’S 21
Models
ACTIVITIES OF DAILY
LIVING
1. To maintain good hygiene & physical comfort
2. To achieve optimal activity, exercise, rest & sleep
3. To prevent accident, injury or other trauma &
prevent the spread of infection
4. To maintain good body mechanics & prevent &
correct deformities
146
ORGANIZING DATA
ABDELLAH’S 21
Models
ACTIVITIES OF DAILY
LIVING
5. To facilitate supply of oxygen to all body cells
6. To facilitate the maintenance of nutrition to all body
cells
7. To facilitate the maintenance of elimination
8. To facilitate the maintenance of fluid & electrolyte
balance
9. To recognize the physiological responses of the body
to disease conditions- pathological, physiological &
compensatory 147
ORGANIZING DATA
Models
ABDELLAH’S 21 ACTIVITIES OF
DAILY LIVING
10. To facilitate the maintenance of regulatory
mechanics and functions
11. To facilitate the maintenance of sensory
functions
12. To identify & accept positive & negative
expressions, feelings & reactions
13. To identify & accept the interrelatedness of
emotions& organic illness 148
ORGANIZING DATA
Models
ABDELLAH’S 21 ACTIVITIES
OF DAILY LIVING
14. To facilitate the maintenance of effective
verbal & non verbal communication
15. To facilitate the development of productive
interpersonal relationships
16. To facilitate progress toward achievement
of personal spiritual goals
17. To create &/or maintain a therapeutic
environment 149
ORGANIZING DATA
Models
DAILY LIVING
18. To facilitate awareness of the self as an
individual with varying physical and
emotional & development needs
19. To accept the possible optimum goals in
light of limitations- physical & emotional
150
ORGANIZING DATA
Models
DAILY LIVING
20. To use community resources as an aid in
resolving problems arising from illness
21. To understand the role of social problems

as influencing factors in the cause of
illness
151
COLLECTING DATA
Organizing Data
Validating Data
• act of double-checking or verifying data to
confirm that it is accurate & factual
152
COLLECTING DATA
Organizing Data
Validating Data
Documenting Data
recording of client’s data in a factual manner
153
NURSING PROCESS
Funda 2019-2020
Edited_by_jmdamian
PHASES Assessment
Evaluation Diagnosing
Implementation Planning
DIAGNOSING
The process of data analysis and problem

identification
Decision making nurses use to arrive at judgments

and conclusions about the patients’ responses to
actual and/or potential problems
DIAGNOSIS
A statement or conclusion regarding the nature of a
phenomenon
DIAGNOSTIC LABELS
Standardized NANDA (North American Nursing
Diagnosis Association) names for the diagnoses
NURSING DIAGNOSIS
The client’s problem statement, consisting of the
diagnostic label plus etiology (causal relationship
between a problem and its related or risk factor)
An actual or potential problem that independent

nursing intervention can prevent or resolve
Provides a basis for the selection of nursing

interventions
TYPES OF NURSING DIAGNOSES
1. Actual nursing diagnosis
2. Risk nursing diagnosis
3. Wellness diagnosis
4. Possible nursing diagnosis
5. Syndrome nursing diagnosis
Actual Nursing Diagnosis
Client’s problem that is present at the time of the nursing
assessment
represent a problem that has been validated by the presence of
major defining characteristics
based on the presence of associated signs and symptoms
Examples: Ineffective Breathing Pattern
Anxiety
Ineffective airway clearance related to excessive and
tenacious secretions
Imbalanced nutrition: more than body requirements
related to excessive intake in relation to metabolic
needs
Risk Nursing Diagnosis
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
Examples: Risk for Infection

Risk for impaired skin integrity related to
immobility secondary to fractured hip
Wellness Diagnosis
describes human responses to levels of wellness in an
individual, family or community that have readiness for
enhancement
two cues must be present for a valid wellness diagnosis:
a desire for a higher level wellness
an effective present status or function
Examples: Readiness for Enhanced Spiritual Well-being
Readiness for Enhanced Family Coping
Readiness for Enhanced Health Maintenance
Readiness for Enhanced Parenting
Readiness for Enhanced Self-Esteem
Possible Nursing Diagnosis
evidence about a problem is incomplete or unclear
requires more data either to support or to refute
statement describing a suspected problem for w/c additional
data are needed
Examples: Possible Social Isolation r/t unknown etiology
Possible self-care deficit related to impaired
ability to use left hand secondary to presence
of intravenous therapy
Syndrome Nursing Diagnosis
comprises a cluster of actual or risk nursing diagnoses that

are predicted to be present because of a certain event or
situation
Examples: Rape Trauma Syndrome
Post Trauma Syndrome
TYPES OF NURSING DIAGNOSES
1. Actual nursing diagnosis
2. Risk nursing diagnosis
3. Wellness diagnosis
4. Possible nursing diagnosis
5. Syndrome nursing diagnosis
COMPONENTS OF NURSING DIAGNOSIS
1. Problem (diagnostic label) and definition

2. Etiology (related factors and risk factors)
3. Defining characteristics
Problem (diagnostic label) and definition
Problem statement – describes the client’s health problem/status
or response for which nursing therapy is given
- its purpose is to direct the formation of client goals and desired
outcomes and it may suggest some nursing interventions
Diagnostic labels – need to be specific; when the word SPECIFY

follows a NANDA label, the nurse states the area in which the
problem occurs
Examples: Deficient knowledge (medications)
Deficient knowledge (dietary adjustments)
Problem (diagnostic label) and definition
Qualifiers – are words that have been added to some NANDA labels to
give additional 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
Example: Activity Intolerance - refers to insufficient physiological or
psychological energy to endure or complete required or desired daily
activities
Etiology (related factors and risks factors)
identifies one or more probable causes of a health problem, gives
direction to the required nursing therapy and enables the nurse to
individualize the client’s care
Example: the probable causes of activity intolerance include

sedentary lifestyle, generalized weakness, immobility or bed rest,
imbalance between oxygen supply and demand
Example: Constipation r/t (related to) long-term laxative use,

inactivity and insufficient fluid intake
Defining Characteristics
are clusters of signs and symptoms that indicate the

presence of a particular diagnostic label
for actual nursing diagnosis, the defining characteristics are

the client’s signs and symptoms
for risk nursing diagnosis, no subjective and objective signs

are present
COMPONENTS OF NURSING DIAGNOSIS
1. Problem (diagnostic label) and definition

2. Etiology (related factors and risk factors)
3. Defining characteristics
Collaborative Problems
are multidisciplinary problems with diagnostic label

potential for complication
type of potential problem that nurses manage using both

independent and physician-prescribed interventions
should include in the diagnostic statement both the possible

complication they are monitoring and the disease or
treatment that is present to produce the problem
Collaborative Problems
include disease, complication and etiology
independent nursing interventions focus mainly on monitoring
the client’s condition and preventing the development of the
potential complication
Examples: Potential Complication of Childbirth: hemorrhage r/t

uterine atony, retained placental fragments and
bladder distension
Potential Complication of Pneumonia: atelectasis,
respiratory failure, pleural effusion, pericarditis and
meningitis
STEPS OF THE DIAGNOSTIC PROCESS
• Compare data with standards
Analyzing Data • Cluster cues
• Identify gaps and inconsistencies of data
Identifying health • Determine if the client’s problem is a nursing

diagnosis or a collaborative problem
problems, risks • Establish client’s strengths, resources and abilities to
and strengths cope
Formulating • Basic two-part statement (PE format)

diagnostic • Basic three-part statement (PES format)
• One-part statement
statements
Formulating Diagnostic Statements
1. Basic two-part statement
Problem (P) – statement of the client’s response
Etiology (E) – factors contributing to or probable causes of
the responses
- joined by related to (r/t) – implies a relationship
Examples:
Constipation r/t prolonged laxative use
Severe anxiety r/t threat to physiologic integrity: possible
CA diagnosis
2. Basic three-part statement (PES format)
- applicable for actual nursing diagnosis
Problem (P) – statement of the client’s response
Etiology (E) – factors contributing to or probable causes of
the responses
Signs and symptoms (S) – defining characteristics manifested
by the client
Example: Situational low self-esteem (P) r/t feelings of rejection by

husband (E) as manifested by hypersensitivity to criticism and
rejects positive feedback (S).
3. One-part statement
- consist of a NANDA label only
- some diagnostic statements, such as wellness diagnoses
and syndrome diagnoses
Examples: Rape-Trauma Syndrome

Readiness for Enhanced Parenting
Effective breastfeeding
Variations of Basic Formats
Writing unknown etiology when Ex. Noncompliance (medication
defining characteristics are regimen) r/t unknown etiology
present but the nurse does not
know the cause or contributing
factors.
Using complex factors when there Ex. Chronic Low Self-Esteem r/t
are too many etiologic factors. complex factors
Using the word possible, to Ex. Possible Low Self-esteem r/t

describe either the problem or the loss of job and rejection by family
etiology require more data about
the client’s problem or etiology.
Variations of Basic Formats
Using secondary to to divide the Ex. Risk for impaired skin
etiology into two parts integrity r/t decreased peripheral
-(secondary to is often a circulation secondary to diabetes
pathophysiologic or disease
process or a medical
diagnosis)
Adding a second part to the Ex. Impaired Skin Integrity (left

general response or NANDA label lateral ankle) r/t decreased
to make it more precise. peripheral circulation
Nursing Diagnosis vs Medical Diagnosis
Nursing Diagnosis Medical Diagnosis

• Statement of nursing • Made by physician
judgment • Refers to a condition that
• Refers to a condition that only a physician can treat
nurses are licensed to treat • Refers to disease processes
• Describes a human • Nursing actions are
response, a client’s physical, primarily dependent
socio-cultural, psychological
and spiritual responses to an
illness or a health problem
• Nursing actions are
independent
Guidelines for Writing a Nursing Diagnosis
State in terms of a problem, not a need.
• Incorrect: Fluid replacement r/t fever

• Correct: Deficient fluid volume r/t fever
Word the statement so that it is legally

advisable.
• Incorrect: Impaired skin integrity r/t improper
positioning
• Correct: Impaired Skin Integrity r/t immobility
Use nonjudgmental statements.
• Incorrect: Spiritual distress r/t strict rules
necessitating church attendance
• Correct: Spiritual distress r/t inability to attend
church services secondary to immobility
Make sure that both elements of the statement do

not say the same thing.
• Incorrect: Impaired skin integrity r/t ulceration of
sacral area
• Correct: Risk for impaired skin integrity r/t
immobility
Be sure that cause and effect are correctly
stated.
• Incorrect: Pain r/t severe headache
• Correct: Pain: severe headache r/t fear of
addiction to narcotics
Word the diagnosis specifically and precisely to provide

direction for planning nursing intervention
• Incorrect: Impaired oral mucous membrane r/t noxious
agent (vague)
• Correct: Impaired oral mucous membrane r/t decreased
salivation secondary to radiation of neck (specific)
Use nursing terminology rather than medical
terminology to describe the client’s response.
• Incorrect: Risk for pneumonia
• Correct: Risk for ineffective airway clearance r/t
accumulation of secretions in the lungs
Use nursing terminology rather than medical
terminology to describe the probable cause of client’s
response.
• Incorrect: Risk for ineffective airway clearance r/t emphysema
• Correct: Risk for ineffective airway clearance r/t accumulation
of secretions in the lungs
PLANNING
PHASES
Assessment
THE PLANNING PROCESS
Setting priorities
Establishing client goals/ desired

outcomes
Selecting nursing interventions/

planning nursing interventions
Writing individualized nursing

interventions on care plans
Setting Priorities
Nurses can group nursing diagnoses as:
High priority problems
◦ life- threatening problems, i.e. loss of
respiratory or cardiac function
Medium priority
◦ health- threatening problems, i.e. acute illness
and decreased coping ability because they may
result in delayed development or cause
destructive physical or emotional change
Low priority
◦ arise from normal developmental needs or that
requires only minimal nursing support
Setting Priorities
Since clients may have several problems,
the nurse often deals with more than one
diagnosis at a time.
Priorities change as the client’s responses,

problems, and therapies change.
Guides for Setting Priorities
Maslow’s Hierarchy of Needs
Ex: Problems identified: dyspnea, social
isolation, and self-care deficit
ABC’s (airway, breathing, circulation) of

Life
Ex: A patient with pneumonia finds it hard
to breathe and the BP is 140/90
mmHg.
Guides for Setting Priorities
Life Preservation
Ex: Convulsion secondary to hyperthermia
Impaired nutrition: less than body
requirements
Impaired physical mobility
When setting priorities, the
following can also be considered:
the problems the patient feels are most

important if this priority does not
interfere with medical treatment
effect of potential problems
costs, resources available, personnel, time
needed to plan for and treat each of the
patient’s identified problem
Establishing Client Goals/
Desired Outcomes
A goal describes a change in the patient’s
health status or functioning
A desired outcome of nursing care that
which you hope to achieve with your
patient.
Other terms: expected outcome,
predicted outcome, outcome criterion,
objective
Classification of Goals
1. Short term goals
➢ Identify outcomes in patient’s status or
behavior that can be achieved fairly quickly
in a matter of hours or days
Examples :
1. The patient will pass out flatus within 24
hours post operatively.
2. Patient’s temperature will decrease from
38.5 C to 37 C within one hour.
Classification of Goals
2. Long term goals
➢ Give direction for nursing care over time,
usually more than a week.
➢ Often used for clients who have chronic health
problems
Example: The patient will demonstrate the
ability to care for his colostomy within one
month after surgery.
Long Term Goal Short Term Goal
The patient’s sacral Patient’s sacral pressure

area will exhibit no ulcer demonstrates
evidence of a pressure absence of purulent
ulcer within one month drainage within a week
from hospitalization. of initiating wound
care.
The client will regain The client will raise

full use of right arm in right arm to shoulder
6 weeks. level.
Guidelines for Writing Goals
1. Goals should be SMART
S – Specific
M – Measurable
A – Attainable
R – Realistic
T – Time bounded
Specific
The goal statement is a patient behavior
that demonstrates reduction of the
problem identified in the nursing
diagnosis.
Example:
Nursing Dx: Bathing self-care deficit r/t
presence of cast in the left leg
Goal: The patient will be able to bathe with
assistance within period of
hospitalization.
Measurable
Write goals in observable or measurable terms whenever
possible.
Avoid terms such as good, normal, adequate, and improve,
increase.
VAGUE GOAL: The patient’s breathing will improve within the shift.
OBSERVABLE/MEASURABLE GOAL:
The patient will be able to breathe without using his accessory
muscles for breathing by tomorrow.
VAGUE GOAL: The patient will be able to ambulate by tomorrow.

OBSERVABLE/MEASURABLE GOAL:
The patient will be able to ambulate with assistance from bed
to bathroom by tomorrow.
Attainable and Realistic
a. It is realistic for the patient’s capabilities in
the time span you designate your goal.
Ex: The patient will be able to drink fluid
amounting to 1200 mL within an 8-hour period.
b. It is realistic for the nurse’s level of skill and

experience.
Ex:
Nursing Dx: Alteration in nutrition less than
body requirement r/t refusal to eat hospital food
Time bounded
All goals include a time at which point the
patient is to be evaluated for goal
achievement .
Ex: The patient will be able to drink fluid

amounting to 1200 mL within an 8-hour
period.
2. The goal is congruent with and supportive of
other therapies. (Nursing goals for the patient
don’t contradict or interfere with the work of
other professionals caring for the patient).
EXAMPLE:
Doctor’s order: Complete bed rest with bathroom
privileges.
INCORRECT GOAL:
Patient will ambulate along the corridors within the
shift.
MORE APPROPRIATE GOAL:
Patient will be able to ambulate from bed to bathroom
within the shift.
3. Whenever possible, the goal is important and
valued by the patient, the nurses and the
physician.
➢ Patient – will be more motivated to reach
the goal
➢ Nurse – will be more likely to carry out the
care
➢ Physician – understanding and support of
nursing goals will help to assure
congruence with medical treatment
4. Write goals in terms of patient outcomes,
NOT nurse activities.
➢ Avoid statements that start with enable,
facilitate, allow, let, permit, or similar verbs
followed by the word client.
EXAMPLE:
INCORRECT: Promote urinary elimination.
CORRECT: Patient will void at least once within 6
hours.
INCORRECT: Maintain client hydration.
CORRECT: Client will drink 100 mL of water/hour.
5. Derive each goal from only one nursing
diagnosis.
➢ Keeping the goal statement related to
only one nursing diagnosis facilitates
evaluation of care by ensuring that planned
nursing interventions are clearly related to
the diagnosis.
6. Keep the goal short.

Formula for Writing a Goal Statement
Patient’s
behavior
Criteria of
Performance
Goal
Statement
Time
Conditions
(if needed)
Formula for Writing a Goal Statement
Patient’s behavior – an observable activity that
the patient will demonstrate
Criteria of performance – the level at which the

patient will perform the behavior (how well?
how long? how far? how much?)
Time – designated time or date when the

patient should be able to achieve the behavior
Condition – the circumstances, if important,

under which the behavior will be performed
Examples of Goal Statements
Nursing Diagnosis:
Impaired physical mobility r/t general muscle
weakness
Goal:
Before discharge, the patient will ambulate
length of hallway independently
Goal:
Before discharge, the patient will ambulate length
of hallway independently
Patient’s behavior – will ambulate length of

hallway
Criteria of performance (how) –
independently
Time (when) - before discharge
Condition – not stated
Nursing Diagnosis:
Hyperthermia r/t infectious process
Goal:
Body temperature will decrease from 38.50C to
37.50C within 2 hours after administering
TSB.
Body temperature will decrease from 38.50C to 37.50C
within 2 hours after administering TSB.
Patient’s behavior – body temperature will

decrease
Criteria of performance – from 38.50C to
37.50C
Time – within 2 hours
Condition – after administering TSB
Nursing Diagnosis:
Acute pain r/t post surgical incision
Goal:
Verbalization of decreased pain from a scale of
2 to 1(where 3=severe, 2=moderate, 1=mild,
0=no pain) within the shift.
Verbalization of decreased pain from a scale of 2 to 1(where
3=severe, 2=moderate, 1=mild, 0=no pain) within the shift.
Patient’s behavior - verbalization of decreased

pain
Criteria of performance – from a scale of 2 to
1 (where 3 = severe, 2 = moderate, 1 = mild, 0
= no pain)
Time – within the shift
Nursing Diagnosis:
Risk for infection r/t presence of open wound
on the right forearm
Goal:
Will not manifest any sign of infection during
hospitalization
Will not manifest any sign of infection during
hospitalization
Patient’s behavior - will not manifest

Criteria of performance – any sign of
infection
Time – during hospitalization
Variables that Influence Goal
Outcome Achievements
a. Patient variables
➢patient’s changing ability
➢willingness to participate in the plan of care
➢previous responses to nursing interventions
➢progress towards goal
b. Nurse variables
➢level of expertise, creativity, willingness to
provide care, and available time
Variables that Influence Goal
Outcome Achievements
c. Resources
➢adequate staff, equipment and supplies
➢the financial resources of the patient
➢adequacy of community-based resources
d. Ethical and legal guides to practice

➢laws and regulations that affect health care
and the ethical dimensions of clinical practice
3. Planning Nursing Interventions/
Selecting Nursing Interventions
Nursing Interventions
❖activities the nurse plans and implement to
help a patient achieve identified goal
❖any treatment based on clinical judgment and

knowledge that the nurse performs to
enhance patient outcomes
3. Planning Nursing Interventions/
Selecting Nursing Interventions
When planning nursing interventions, the
nurse should identify:
◦ what is to be done
◦ when the activity is to be done
◦ duration for each intervention
◦ any follow up activity
◦ date interventions were selected
◦ sequence in which nursing activities are to be
performed
◦ signature of the nurse writing the plan of care
Rationale of Nursing Interventions
Based on principles and theories from

various discipline (anatomy and
physiology, psychology, sociology, etc.)
Written as a part of the nursing care plan

of the students
Types of Nursing Interventions
a. Independent/ Nurse-initiated
interventions
✓ involve carrying out nurse prescribed-
interventions
✓ involve carrying out actions that nurses
initiate without the direction or
supervision of another health care
professional and that the result from their
assessment of patient needs
✓ those activities that nurses are licensed to
initiate on the basis of their knowledge
and skills
a. Independent/Nurse-initiated interventions
✓ include: physical care
ongoing assessment
emotional support and comfort
teaching, counseling
environmental management
making referrals to other health care
professionals
EXAMPLE: After identifying the patient’s problem of a distended

bladder, the nurse positions the patient to semi-Fowler’s,
places him on the bed pan, then applies slight pressure over his
hypogastric area.
b. Dependent/Physician-initiated
interventions
➢ involve carrying out physician-prescribed

orders which commonly direct the nurse
to provide medications, IV therapy,
diagnostic tests, treatments, diets, and
activity
c. Interdependent /Collaborative interventions
➢ actions that the nurse carries out in collaboration with

other health team members, such as physical therapists,
social workers, dieticians, and physicians; those
performed jointly by nurses and other members of the
health care team
➢ reflect the overlapping responsibilities of and collegial
relationships between health personnel
EXAMPLE: The physician might order PT to teach client crutch-walking.

The nurse would be responsible for informing the PT department
and for coordinating the client’s care to include the PT sessions.
When the client returns to the ward/room, the nurse would assist
with crutch-walking and collaborate with the physical therapist to
evaluate the client’s progress.
Components of Nursing Intervention
a. PDx (Diagnostics)
ex: weighing,VS, Hgt monitoring, measuring abdominal
circumference
b. PTx (Therapeutic)
ex: Administering of Paracetamol 500 mg. 1tab. q4H as
ordered by the physician, enforce fluid intake
c. PEd ( Education or Health teaching)

ex: Instruct the patient on proper wound dressing
Criteria for Selecting Nursing
Interventions
safe and appropriate for the patient
(considering his health, age, condition)
congruent with other therapies
develop the behavior described in the goal
statement
realistic
necessary to assess and monitor effect of
medical treatment which are included in the
therapeutic regimen
Some medical orders may require nursing
activities such as assessment prior to
carrying out doctor’s order.
Criteria for Selecting Nursing
Interventions
EXAMPLE:
Medical order: Lanoxin 0.125 mg QID.

Nursing actions:
1. Count apical pulse prior to giving medication.
2. Give lanoxin 0.125 mg QID if pulse is above
60 beats/min. Hold if less than 60 bpm.
3. Notify physician if drug is withheld.
4. Writing Individualized
Nursing Interventions
The nurse writes the chosen/planned

nursing interventions on the care plan.
Nursing interventions on the care plan

should be dated when they are written
and reviewed regularly at intervals that
depend on the individual’s needs.
EXAMPLES OF NURSING INTERVENTIONS
Nursing Diagnosis: Impaired urinary elimination r/t
previous indwelling catheterization
Short term goal: The patient will void at least once
6 hours after the removal of catheter.
Interventions:
Record intake and output for 24 hours.
Apply alternate hot and cold compress for 15 minutes on
hypogastric area every 2 hours.
Offer assistance to the bathroom every 2 hours.
Provide privacy for voiding attempts.
Encourage fluid intake of at least1 glass of water every
hour.
Encourage voiding attempt in sitz bath, tub bath or
shower to enable to void in 6 hour.
THE PLANNING PROCESS
Setting priorities
Establishing client goals/ desired

outcomes
Selecting nursing interventions/

planning nursing interventions
Writing individualized nursing

interventions on care plans
NURSING CARE PLAN
CUES NURSING SCIENTIFIC GOALS/ NURSING EXPECTED
DIAGNOSIS EXPLANATION OBJECTIVE INTERVEN- OUTCOME
OF THE NURSING TIONS
DIAGNOSIS
Subjective: Long Term: Independent:
Dependent:
Objective:
Short Term:
Collaborative
:
PHASES
Assessment
IMPLEMENTATION
Putting the nursing care plan into action to
achieve the expected outcome;
Doing phase of the nursing process
The nurse performs nursing interventions to

resolve or reduce the identified nursing
problem of the patient, with the patient, and
for the patient.
IMPLEMENTATION
Purposes:
✓ to assist patient in achieving desired health goals

✓ promote health
✓ prevent illness
✓ restore health
✓ facilitate coping with altered health function
IMPLEMENTATION
Involves:
✓ givingnursing care / carrying out the planned

nursing activities
✓ delegating the care to another health care
team member
✓ documenting and validating care
✓ continuing data collection
Aspects of the Nurse’s Role in
Implementation of Care
a. Care aspects
b. Curative
c. Protective
d. Teaching
e. Patient advocate
Principles in Implementation of
Nursing Care
a. maintaining the individuality of man
b. consideration for the patient’s safety,
comfort and privacy
c. considering economy of time, effort and
materials
d. neatness of the finished product
Delegating Care
If care has been delegated to other health
care personnel, the nurse responsible for
the client’s overall care must ensure that
the activities have been implemented
according to the care plan.
Documenting Nursing Activities
Completion of the implementing phase
The nurse records the interventions
carried out and client responses and/or
changes in the client’s health status in the
nursing progress notes.
To be able to record client responses
and/or changes in the client’s status,
continuing data collection is
necessary.
Documenting Nursing Activities
Routine or recurring activities may be
recorded at the end of a shift.
In some instances, certain nursing
interventions should be recorded
immediately after it is implemented, i.e.
administration of medications and
treatments. This helps safeguard the
client, for example, from receiving a
duplicate dose of the drug.
PHASES
Assessment
EVALUATION
• a planned, ongoing, purposeful activity
• determining the client’s response to nursing

interventions using the goals of care as criteria
whether they were met, partially met, or not met
goal met – the client’s response is the same as
the desired outcome
goal partially met – either the short term goal
was achieved but the long term
goal was not, or the desired
outcome was only partially attained
Who, How and When of Evaluation
Recipient of care and care giver

Terminal behavior demonstrated by the
patient
Conditions under which the behavior is
expected to occur
Criterion for determining acceptable
performance
Evaluation Statement
❖consist of 2 parts: conclusion and supporting data
EXAMPLE OF EVALUATION:
Goal statement: Will ambulate half the length of hallway w/ assistance 3x daily
Evaluative Statement:
Goal partially met: Patient refused to ambulate in the morning but walked
(Conclusion) to the bathroom once in the afternoon w/ the
assistance of one nurse (supporting data)
Evaluation Statement
Goal statement: Body temperature will decrease from 38.50C to 37.50C
within 2 hours after administering TSB.
Evaluative statement:
Goal met. Body temperature went down to 37.20C within 2 hours after TSB
administration.
Goal statement: Verbalization of decreased pain from a scale of 2 to

1(where 3=severe, 2=moderate, 1=mild, 0=no pain) within the shift
Evaluative statement:
Goal not met. Patient verbalized that the pain intensity remained the same
.
PHASES
Assessment

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Nursing Process

• Provides structure for nursing practice

1. To identify client’s health status

3. To establish plans to meet identified needs

•Cyclic and dyNamic

• Interpersonal and collaborative 6

• Involves the use of critical

• systematic & continuous

To establish a Initial nursing Within a Nursing

To determine Problem- Ongoing Hourly

To identify life- Emergency During any Rapid ABC

To compare the Time-lapsed Several Reassess-

= getting a client’s DATA BASE

A. Nursing health History

Guidelines in Health History Taking

2. Most of the data are SUBJECTIVE.

3. Focus on data/information from all the client’s

4. Record data using clear, concise and appropriate

2. Source and Reliability of Information

3. Reasons for seeking care or

– Recorded as direct quotes

Reason for seeking care

“I am going to college and I need to

“I need to find a new health care

4. Present Health or History of Present llness

✓ For well person :

✓ For ill person:

• For ill person:

Please don’t copy the

History of Present Illness (a sample):

5. Past Medical History/Past Health

- health status of the immediate family members &

A & W – alive and well

7. Socio-economic Data or Social History

- Info about pt’s lifestyle that can affect health

- assists the nurse in collecting, organizing and

a. Health Perception-Health Management Pattern

-person’s description of his current health

a. Health Perception-Health Management Pattern

-extent of person’s problem on financing health care, if

-person’s knowledge of the names of current medications

a. Health Perception-Health Management Pattern

-activities that the person does to prevent problems related to

-person’s excretory pattern

-person’s description of his weekly pattern of activities,

-description of the person’s sleep-wake cycle

-person’s physical appearance (rested and relaxed?)

-any sensory deficit and if corrected

g. Self-Perception & Self-Concept Pattern

-anything unusual about the person’s appearance

h. Role Relationship pattern

-person’s description of his various roles in life

-person’s satisfaction with his situation related to sexuality

j. Coping-Stress Tolerance pattern

j. Coping-Stress Tolerance Pattern

-person’s means/actions of coping with problems

-principals that the person learn as a child which are still

10. Review of Systems

f. Nose and Sinuses

j. Thorax and Lungs (Respiratory)

Data Collection Methods

Data Collection Methods