ASSESSING  Record and reports, laboratory and diagnostic analyses

 Other health professionals

(First phase of nursing process)  Relevant literature
Data Collection Method:
INTERVIEWING: ORGANIZING DATA:
 Planning interview and setting arrangement  This is often referred to as a nursing health history, nursing assessment, or nursing database form
1. Time  Uses a format that organizes the assessment data systematically

2. Place FORMATS:

3. Distance 1. Conceptual models/Frameworks

4. Seating arrangement 2. Wellness Models

5. Language 3. Non nursing models

 Stages of an interview CONCEPTUAL MODEL AND FRAMEWORKS:

1. Opening (Establish rapport and orientation)  Gordon’s functional health pattern framework
 Orem’s self-care model.
2. Body  Roy’s adaptation model.
3. Closing WELLNESS MODELS:
EXAMINING: Such models generally include the following:
 The Physical examination or physical assessment is a systematic data collection method that uses  Health history
observation (i.e., the senses of sight, hearing, smell, and touch) to detect health problems  Physical fitness evaluation
 Techniques of Inspection, Auscultation, Palpation and Percussion  Nutritional assessment
 The cephalocaudal or head to toe approach  Life-stress analysis
 Body systems, screening examination, or also called review of systems approach.  Lifestyle and health habits
 Health beliefs
 Sexual health
TYPES OF DATA:  Spiritual health
 Relationships
SUBJECTIVE DATA
 Health risk appraisal
 Also referred to as symptoms or covert data NON-NURSING MODELS:
 Are apparent only to the person affected and can be described or verified only by that person
 Body System model
OBJECTIVE DATA
 Maslow’s hierarchy of need
 Also referred to as signs or overt data  Developmental theories
 Are detectable by, in observer or can be measured or tested again an accepted standard

VALIDATING DATA:
SOURCES OF DATA:
 Validation is the act of “double-checking” or verifying data to confirm that it is accurate and factual
PRIMARY SOURCE
Validating data helps the nurse complete these tasks:
 The client is the primary source of data
 Ensure that assessment information is complete.
SECONDARY SOURCE  Ensure that objective and related subjective data agree.
 Obtain additional information that may have been overlooked.
 Family members or other support persons
  Differentiate between cues and inferences
 Avoid jumping to conclusions and focusing in the wrong direction to identify problems. The Problem and its definition
DOCUMENTING DATA: The problem statement, or diagnostic label describes the client’s health problem or response
 It is the recording of all data collected in a factual manner for which nursing therapy is given
 To complete the assessment phase, the nurse record client data.
 Accurate documentation is essential and should include all data collected about the client’s health status. Qualifiers are words added/used to diagnostic statement
 Data are recorded in a factual manner and not interpreted by the nurse eg. Deficient, Impaired, Decreased, Ineffective compromised
 Documentation may be narrative form, a summary, detailed information as necessary, use of checklist and
others. The etiology
 Method of documentation depends on health condition of patient, resources available, and the like The etiology component of a nursing diagnosis identifies one or more probable causes of the
health problem, gives direction to the required nursing therapy, and enables the nurse to
individualize the client’s care.
DIANOSING
(Second phase of the nursing process) The defining characteristics
Defining characteristics are the cluster of signs and symptoms that indicate the presence of a
North American Nursing Diagnosis Association (NANDA) particular diagnostic label.
The members of NANDA include staff nurses, clinical specialists, faculty, directors of nursing, deans, theorists,
and researchers. FORMULATING DIANOSTIC STATEMENTS
The purpose of NANDA international is to define, refine, and promote a Taxonomy of nursing diagnostic Basic 2 Part Statement (PE) Basic 3 Part Statement (PES) One Part Statement
terminology of general use to professional nurses 1. Problem (P): statement of 1. Problem (P): statement of Statement comprises of
the client’s response the client’s response health promotion or risk
DEFINITONS AND CONCEPTS
(NANDA label) (NANDA label) diagnoses to desired higher
 Diagnosing refers to the reasoning process level of wellness
 Diagnosis is a statement or conclusion regarding the nature of a phenomenon. 2. Etiology (E): factors 2. Etiology (E): factors
contributing to or probable contributing to or probable
 Diagnostic labels are the standardized NANDA names for the diagnoses.
causes of the responses. causes of the response
 Nursing diagnosis is the client’s problem statement consisting of the diagnostic label plus 3. Signs and symptoms (S):
etiology (causal relationship between a problem and its related or risk factors). defining characteristics
manifested by the client
The official NANDA definition of a nursing diagnosis EXAMPLE:
“ a clinical judgement concerning a human response to health conditions/life processes, or a
vulnerability for that response, by an individual, family, group, or community” Basic 2 Part Statement (PE) Basic 3 Part Statement (PES) One Part Statement
P – Imbalanced nutrition, less P – ineffective breathing Risk for Activity Intolerance
KINDS OF NURSING DIAGNOSIS than body requirement pattern
 Risk nursing diagnosis is a clinical judgement that a problem does not exist, but the presence of risk LINK – related to LINK – related to Chronic pain syndrome
factors indicates that a problem is likely to develop unless nurses intervene. E- poor nutrition intake E- decreased lung expansion Risk for impaired Tissue
 Syndrome diagnosis is assigned by a nurse’s clinical judgement to describe a cluster of nursing diagnoses integrity
that have similar interventions S – as evidenced by dyspnea, Readiness for enhanced
coughing, and difficulty of parenting
THREE (3) COMPONENTS OF NURSING DIAGNOSIS breathing.
1. The problem and its definition
2. The etiology
3. The defining characteristics
  A Concept Map is another method of organizing and representing care plan information, a visual tool in
which ideas or data are enclosed in circles or boxes of some shape, and relationships between these are
PLANNING indicated by connecting lines or arrows
(Third Phase of Nursing Process) FORMAT OF A NURSING CARE-PLAN- FOUR COLUMNS
 Prioritize problems/diagnoses Example:
 Formulate goals/desired outcomes
 Select nursing interventions FORMAT OF A NURSING CARE PLAN- FIVE COLUMS
 Write nursing interventions Example:
Planning – is a deliberative, systematic phase of the nursing process that involves decision making and problem
solving
THE PLANNING PROCESS
The nurse refers to the client’s assessment data and diagnostic statements for direction in formulating client
goals and designing the nursing interventions, required to prevent, reduce, or eliminate the client’s health ACTIVITIES
problem.
 Setting priorities
 Establishing client goals/desire outcomes
 Selecting nursing interventions and activities
TYPES OF PLANNING
 Writing individualized nursing interventions on care plans.
Initial Planning
A. Setting priorities is the process of establishing a preferential sequence for addressing nursing diagnoses and
 Initial/admission assessment interventions.
 Observe client’s body language
Life-threatening problems Health-threatening problems Low priority problems
 Obtain Intuitive kinds of information
Ongoing Planning
B. Establishing Client Goals/Desired Outcomes the goals/desired outcomes describe, in terms of observable
 Obtain new information client responses, what hopes to achieve by implementing the nursing interventions.
 Evaluate the client’s responses to care
- Goal and desired outcome are used interchangeably
Discharge Planning
- Uses terms like expected outcome, predicted outcome, outcome criterion, and objective.
 Anticipating and planning for needs after discharge
 Coming up with a comprehensive health care plan - Defining goals as broad statements and desired outcomes as the more specific

DEVELOPING A CARE PLAN

 The end product of the planning phase of the nursing process is a formal or informal plan of care Purposes of Goal and/Desired Outcome
 A standardized care plan is a formal plan that specifies the nursing care for groups of client’s with Provide direction for planning nursing interventions Enable the client and nurse to determine when the
common needs problem has been resolved
 An individualized care plan is tailored to meet the unique needs of a specific client-needs that are not
addressed by the standardized plan. Serve as criteria for evaluating client progress Help motivate the client and nurse by providing a sense

FORMAT OF A NURSING CARE PLAN Of achievement

 The care plan is often organized into four sections LONG-TERM GOAL AND SHORT-TERM GOAL
1. Problem/nursing diagnoses Long-Term Goal are set to guide planning for client’s discharge home or in a managed care environment
2. Goals/desired outcomes
3. Nursing interventions Short-Term Goal are set for clients who require health care for a short time or address immediate needs
4. Evaluation
 Assessment data preceding problem/nursing diagnosis for a five-section nursing care plans
 Adding “Rationale” after the nursing interventions, as it is the evidence-based principle given as the
reason for selecting a particular nursing intervention
COMPONENT OF GOAL AND/ DESIRED OUTCOME  Client’s overall care must be implemented according to the care plan and the nurse is responsible in
supervising the delegated care done by other health care personnel or caregivers, validates and
*SUBJECT *CONDITIONS AND MODIFIERS
responds to adverse findings and client’s responses
*VERB *CRITERION OF DESIRED PERFORMANCE  Documenting the nursing activities after carrying it out, completes the implementing phase by recording
the interventions and client nursing progress notes.

C. Selecting Nursing Interventions and Activities Evaluating

 These are nursing actions chosen with focus on eliminating or reducing the etiology of the nursing (Fifth Phase of the Nursing Process)
diagnosis Definition and Concepts
 Choosing interventions to treat the signs ans symptoms, the defining characteristics in NANDA
International terminology, or focusing on measure to reduce client’s risk factors To evaluate is to judge or to appraise
EVALUATING is a planned, ongoing, purposeful activity in which clients and health care professionals
determine;
TYPES OF NURSING INTERVENTIONS
(a) the client’s progress toward achievement of goals/outcomes and
Nursing intervention include both direct and indirect care, as well as nurse-initiated, physician initiated and other
provider-initiated treatments. (b) the effectiveness of the nursing care plan.

 Dependent Interventions EVALUATION IS CONTINUOUS and done while or immediately after implementing a nursing order that will
 Independent Interventions enables nurse to do on the spot modifications in an intervention and continues until health goals are archived
 Collaborative or Interdependent Interventions Successful evaluation depends on the effectiveness of the steps that precede it;
a) Accurate and complete assessment data
IMPLEMENTING b) Appropriate nursing diagnosis

is the action phase in which the nurse performs the nursing interventions c) Desired outcomes stated concretely using behavioral terms

The nurse performs or delegates the nursing activities for the interventions and then concludes the d) Plan is put into action
implementing step by recording nursing activities and the resulting client responses.
THE EVALUATING PROCESS
Implementing Skills
The evaluation phase o=has five components:
1. Cognitive skills (intellectual skills) include problem solving, decision making, critical thinking, clinical reason,
 Collecting data related to desired outcomes
and creativity
 Comparing data with desired outcomes
2. Interpersonal Skills are all of the activities, verbal and nonverbal, people use when interacting directly with  Relating nursing activities to outcomes
one another  Drawing conclusions about problem status
3. Technical Skills require knowledge and frequently, manual dexterity  Continuing, modifying, or terminating the nursing care plan

THE IMPLENMENTING PROCESS

Salient Points

 Do reassessment on the client just before implementing an intervention because the client’s condition
may have changed.
 The Nurse may also require assistance when implementing nursing intervention for reasons such as;
unable to implement activity safety or efficiently alone, it would reduce stress on the client if with
assistance, and the nurse lacks the knowledge and skills to implement a particular nursing activity
 Explain to client what the interventions to be done, what sensations to expect, what the client is expected
to do, and what the expected outcome is when implementing interventions
COMMUNICATION- central to successful caring relationships. Listening is important for effective understanding
and communication

 Is the interchange information between two or more people; in other words, the exchange of ideas or Indicated the patient has been
thoughts. Accepting understood. It does not indicate Uh-hmm. Yes, I’m following you,
agreement and is nodding.
METHODS: talking and listening or writing and reading, painting, dancing, and storytelling, gestures and body non-judgemental.
actions
INTENT of communication is to obtain a response. Thus, communication is a process. Giving Indicated awareness of change in Good morning, Mr. Jones I see you have
recognition personal efforts. Does not Imply put in your jewelry today.
TWO MAIN PURPOSES: to influence others and to gain information. good or bad, right or wrong.
Offering self Offers presence, interest, and a I’ll sit with you her for a while, I would
SEVEN C’S OF COMMUNICATION desire to listen to the patient. like to spend sometime with you. I’m
available if you need to talk.
CONTENT
Making Calls attention to the patient’s You appear intense. I noticed that you
CONTUINITY AND CONSISTENCE Observations physical behavior or emotional are biting you lip.
state. Verbalizing what the nurse
CLARITY perceives.
Acknowledgin To help patient know that feelings Patient: “I hate it here. I wish I could go
CONTEXT
g feelings are understood and accepted. home.
CHANNELS (empathy) Nurse: It must be difficult to stay in a
place you hate.
CREDIBILITY Reflecting Directing questions, feelings and Patient: what do you think I should do
ideas back to the patient. about telling my employer about my
CAPABILITY Acknowledges the patient’s right illness?
CONTENT to have opinions and make Nurse: What have you been thinking
decisions about this situation?
MODES OF COMMUNICATION Patient: “Everyone ignores me”
Nurse: Ignores you?
VERBAL- uses the spoken or written word Proving Makes facts available in order to This medication is for you high blood
NON-VERBAL – uses other forms, such as gestures or facial expressions, and touch. information assist in decision-making or pressure. This test will determine your
drawing conclusions. treatment options.
ELECTRONIC – uses technological means such as email, others My purpose for being here is….
Clarifying To make clear what which is vague I am not sure I follow you. What would
THERAPEUTIC COMMUNICATION TECHNIQUES or maximize understanding you say the main point of what you said
between the nurse and patient. was?
TECHNIQUE DESCRIPTION EXAMPLE
Can you give me an example?
Broad opening To allow the patient to pick the Where would you like to begin? What is
Seeking Searching for mutual Tell me whether my understanding of it
statements topic, take the initiative to express on your mind today?
consensual understanding especially when agrees with yours. Are you using this
self, and set the direction of the
validation slang term have been used. word to convey that…?
conversation
Offering Encourages the client to continue Go on. And then? Tell me about it.
general leads and that the nurse is interested in
what comes next.
Exploring Examines certain ideas, Tell me more about that. What kind of Verbalizing To voice what the patient has Patient: I can’t talk to you or anyone else
experiences, or relationships more relationship do u have with your implied implied. To verify impressions to because it’s a waste of time
fully. children? Could you talk about how you thoughts and help the patient more fully aware Nurse: Do you feel that no one
felt when you learned you had cancer? feelings of feelings expressed. understand?
Focusing Helps the patient focus on a certain Let’s stop and look more closely at your Sharing Humor Discharge of energy through comic This gives a whole new meaning to “just
point when they are jumping from feelings about managing your enjoyment of the imperfect. Can relax”
topic to topic. medications. reduce the tension and promote
Silence Provides time for the patient to put Maintain an interested expectant silence. mental well-being. Must be used
thoughts or feelings into words, carefully and sparingly
regain composure or continue Encouraging Brings out recurrent themes by Was it something like….? Have you had
talking.
comparison looking at similarities or
differences
Encouraging Assists the patient In considering
evaluation things from their own set of values
or perspective.
Encouraging of Asking the patient to verbalize
description of things from their own perspective.
perception
Placing the To help the patient see cause and
event in time or effect or identify patterns of events
in sequence and actions.
Presenting Indicated what is real without
reality arguing. Presenting facts of a
situation
Voicing Doubt Expressing uncertainty about the
reality of the patient’s perceptions.
The patient can become aware that
others do not necessarily perceive
things in the same way. This is not
an attempt to get the patient to
change their point of view.
Attempting to Seeking to verbalize the patient’s
translate into feelings that are expressed only
feelings indirectly.
TECHNIQUE DESCRIPTION
Sharing hope Communication a sense of
possibility to achieve their
potential. Commenting on the
positive aspects of the patients
behavior, performance, and
response
Encouraging Asking patient to consider kinds of
formulation of behavior likely to be appropriate in
an action plan future situations
Summarizing Concise review of the key aspects
of the interaction to bring a sense
of satisfaction and closure.
Self-disclosure Generalized sharing of personal
experiences about the self to
benefit the patient.
Confrontation Helping the patient become aware
of inconsistencies in feelings,
attitudes, beliefs or behaviors
Recommend or Allows patient to consider options
suggest options they may not have previously
(do not advise) considered
a similar experience? Has this ever PROBLEM SOLVING
happened before?
What did it mean to you when he said PROBLEM SOLVING – is a mental activity in which a problem is identified that represents an unsteady state.
her couldn’t stay? How do you feel  It requires the nurse to obtain information that clarifies the nature of the problem and suggests possible
about your recovery this time in the
solutions.
hospital?
APPROACHES TO PROBLEM SOLVING
Tell me what is happening right now?
Tell me what you are thinking when you 1. TRIAL AND ERROR – a number of approaches are tried until a solution is found.
feel anxious
2. INTUITION- Relies on a nurse’s inner sense
When did this happen? What seemed to
lead up to..? Was it before or after? 3. RESEARCH PROCESS- a formalized, logical, systematic approach to problem solving.
Your mother is not here, I am the nurse, I PROBLEM SOLVING PROCESS
see no else in this room.
 Identify the issues
Really? That’s hard to believe, isn’t that  Understand everyone’s concern
unusual.  List possible solutions
 Evaluate the options
 Select an option or options
 Document the agreements
 Agree on contingencies, monitoring, and evaluation
Patient: I’m dead inside.
Nurse: Are you saying you feel lifeless?
THE NURSING PROCESS
EXAMPLE
I believe you will find a way to face your - Is a systematic, rational method of planning and providing individualized nursing care.
situation because I have seen your PURPOSES ARE:
courage and creativity.
1. identify a client’s health status and actual or potential health care problems or needs
2. To establish plans to meet the identifies needs
What could you do to let your anger our DISTINCTIVE CHARACTERISTICS OF THE NURSING PROCESS
harmlessly? Next time this comes up,
how might you handle it? what are other  Client Centeredness
ways you could approach your boss?  Focus on problem solving and decision making
During the past hour, you and I have  Its cyclic and dynamic nature
discussed…. We have discussed many
ways to deal with your anger toward  Universal applicability
your mother. You have agreed to try a  Interpersonal and collaborative style
few and let me know how it works out  The use of critical thinking and clinical reasoning
That happened to me once, it was
devastating, and I had to face some
things about myself that I didn’t like.
You say you have already decided what
to do, yet you are still talking a lot about
your options.
Have you thought about…? Here are
some things other people in your
situation have considered..?