Initial - A.k.

a admission assessment
COURSE COURSE UNIT WEEK Comprehensive Purposes:
MODULE assessment ● Evaluate the client’s health status
● Identify functional health patterns that
are problematic
○ According to Gordon’s
ADPIE functional health pattern
○ Cephalocaudally assessment
NURSING ● Provide an in-depth comprehensive
“ The protection, promotion, and optimization of health and database, w/c is critical for evaluation
abilities, prevention of illness and injury, alleviation of suffering changes in the client’s status
through the diagnosis and treatment of human responses and
advocacy in the care of individuals, families, communities, and Problem/ - Collects data about a problem that has
populations. ” Focused already been identified
- American Nurses Association, 2010 - Narrower scope and shorter time-frame
Nursing is an art of applying scientific principles in a - Nurse determines w/e the problem still exists
humanitarian way to care of people and w/e the status of the problem has changed
NURSING PROCESS I.e. improved / worsened / resolved
● Ida Jean Orlando - May also include appraisal of any new,
● This involves a problem-solving approach that overlooked, or misdiagnosed problems
enables the nurse to identify pt problems and
potential at risk needsm (problems) and to plan, Emergency - Takes place in life-threatening situations in w/c
deliver, and evaluate nursing care in an orderly, assessment preservation of life is top priority
scientific manner. - Often the client;s difficulties involve
● Components of nursing process: ADPIE ● Airway
● Assessment, Diagnosis, Planning, ● Breathing
Implementation, Evaluation ● Circulation
ASSESSMENT - Focuses on few essential health patterns and
❖ Collection of Data is not comprehensive
❖ Three types: Subjective, Objective, and - Life threatening
Measurements - Top priority
❖ Systematic and continuous collection, organization,
validation, and documentation of data
Time-lapsed or - Takes place after the initial assessment to
ASSESSMENT PROCESS:
Ongoing evaluate any changes in the client’s functional
Collect d > Organize d > Validate findings > Document the
health
gathered data
- Nurses perform time-lapsed reassessment
★ The nurse gather information to identify the health
when substantial periods of time have elapsed
status of the pt
between assessment
★ Assessments are made initially and continuously
● Check if there is improvement
throughout pt care
● If worsen, go back to assessment
★ The remaining phases of the nursing process depend
on the validity & completeness of the initial data
collection
★ Initial = assessment SUBJECTIVE OBJECTIVE MEASUREMENTS
VALIDATION OF FINDINGS: Pt might malinger : exaggerate
or feign illness in order to escape duty or work - Verbalizations of - Observations - Vital signs:
● someone might pretend to be injured so they can patient - Validate the ● BP
collect an insurance settlement or obtain prescription “Nahihirapan akong subjectives stated ● RR
medication. huminga ● PR
PURPOSES OF ASSESSMENT ● Temp
➔ Establish the nurse-pt relationship ● Pain scale
◆ Trust of the pt to health provider ● Oxygen
◆ Pt might not be verbal if there is no trust saturation
➔ Gather data-physiological, psychological, cognitive, ● Facial
sociocultural, developmental, spiritual grimace
◆ Respect the pt’s decision with documentation DYSPNEA Difficulty of breathing / DOB
◆ Document and ask the pt’s family to sign the TACHYPNEA: More than 20 breaths pm
refusal form BRADYPNEA: Less than 12 breaths pm
● Refusal form are renewed every ACHMEA: Absence of breathing
24hrs EUPNEA: Normal range
➔ Identify pt strengths DIAGNOSIS
➔ Identify actual and potential health problems ❖ Analyzing data to make professional nursing
➔ Establish a base for the nursing process judgment
(assessment) ❖ NANDA
TYPES OF ASSESSMENT ➢ Ineffective airway clearance related to to
thick cupus phlegm
TYPES OF NURSING DIAGNOSIS
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1. PROBLEM/FOCUSED ➔ Document relevant data in a retrievable format
2. RISK NURSING DIAGNOSIS ◆ No documentation, nothing happened
- Possible na mangyari s/a risk for fall ◆ Document everything
3. HEALTH PROMOTION
- Educate the pt to promote lifestyle
4. SYNDROME ND COURSE COURSE UNIT WEEK
- Cluster of nursing diagnosis together with similar MODULE
nursing intervention
PLANNING
❖ Determining outcome and developing plan
❖ Two types of planning: short and long term goal COLLECTION OF SUBJECTIVE DATA HEALTH HISTORY
STEPS OF HEALTH ASSESSMENT
SHORT TERM LONG TERM 1. Subjective Data
● Sensations or symptoms, feelings,
- perceptions, preferences, beliefs, ideas,
values, and personal information that can be
elicited and verified by the client
IMPLEMENTATION ● Verbalizations of clients
❖ Carrying out the plan 2. Objective Data
❖ Independent, Dependent, and Collaborative ● Obtained by general information and by
❖ Independent: does not require doctor’s orders using physical examination techniques and
➢ I.e. place the pt in semi/fowler's position by reviewing medical records.
❖ Dependent: requires doctor’s orders ● This may also include observations noted by
➢ I.e Medication the family/significant others
➢ Nebulization ● Physical examination
➢ Antibiotics (bacteria) 3. Validation
❖ Collaborative: collaboration with other paramedical ● Serves to ensure that the assessment
courses process is not ended before all relevant data
➢ Laboratory tests, diagnostic tests, and have been collected, and helps to prevent
pharmacy inaccurate data.
➢ ABG = Arterial Blood Gas ● Avoid false data
❖ Needs RATIONALE 4. Documentation
➢ The purpose/objectives of your nursing ● Forms the database for the entire nursing
intervention process and provides data for all other
EVALUATION members of the health care team
❖ Check if plans are meant ANALYSIS OF ASSESSMENT DATA
❖ If not meant, go back to assessment - Data was analyzed and synthesized to determine
In doing ADPIE you need to be SMART: whether the data reveal a nursing concern (nursing
S: Specific diagnosis), a collaborative concern (collaborative
M: Measurable problem), or a concern that needs to be referred to
A: Attainable another discipline
R: Realistic NURSING DIAGNOSIS
T: Time bounded ● This is a clinical judgment concerning human
NURSES’ RESPONSIBILITIES IN HEALTH ASSESSMENT response to health condition/s life processes or
➔ Collects data in a systematic ongoing process vulnerability for that response by an individual, family,
◆ Subjective, objective, and measurements or community that a nurse is licensed and competent
➔ Involves the pt, family, other health care providers to treat
(hcp), and environment, as appropriate, in holistic
data collection
◆ If pt is unconscious: consult the next keen MEDICAL DIAGNOSIS NURSING DIAGNOSIS
➔ Prioritizes data collection activities based on pt’s
immediate health condition, or anticipated needs of - Identification of a diseases - Clinical judgment concerning a
the pt or situation condition based on a physical human response to health
◆ Prioritize pt’s concern/ chief concern signs and symptoms, a pt conditions/life processes, or
◆ REMEMBER ABC: medical history, and the results of vulnerability for that response by
● Airway diagnostic tests and procedures and individual, family, or
● Breathing - Stays constant as condition community that a nurse is
● Circulation remains licensed and competent to treat
➔ Uses appropriate evidence- based assessment NANDA (North American Nursing Diagnosis Association)
techniques and instruments in collecting pertinent ● Provides a precise definition of pt’s responses to
data. health problems that gives nurses and other members
➔ Uses analytical models and problem-solving tools of the health care team a common language for
➔ Synthesizes available data, information, and understanding a pt’s needs
knowledge relevant to the situation to identify patterns ● Allows nurses to communicate what they do among
and variances themselves w/other healthcare professionals and the
◆ Focus on both subjective and objective data public
◆ And assess other available data

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 ● Distinguishes nurse’s role from that of other c. Fingernails should be short and neat
healthcare providers d. Minimal jewelry
● Helps nurses focus on the scope of nursing practice 2. Demeanor
● Fosters the development of nursing knowledge a. Professional and poise
● Promotes creation of practice guidelines that reflect b. Greet client calmly and w/proper references
the essence of nursing c. Do not be overwhelmingly friendly or touchy
DIAGNOSTIC REASONING PROCESS d. Maintain professional distance
- Data clustering 3. Facial expression
- Data interpretation a. Closely monitor facial expressions
- Formulation of nursing diagnosis b. Display a NEUTRAL expression
4. Attitude
a. Non-judgmental attitude
b. All clients should be accepted, regardless of
beliefs, ethnicity, lifestyle, and healthcare
practices
5. Silence
a. Allows the nurse and the client to reflect
organize thoughts, w/c facilitate more
accurate reporting and data collections
6. Listening
a. Demonstrate active listening
b. Maintain good eye contact
c. Appropriate facial expression
COLLECTION OF SUBJECTIVE DATA d. Open body positions (arms, hands)
MAJOR AREAS of SUBJECTIVE DATA: e. Lean forward
● Biographical information NON VERBAL COMMUNICATION: TO AVOID
○ Name - Excessive or insufficient eye contact
○ Age, gender - Distraction and distance
● History of present health concern - Standing
○ Anong ginagawa nung naramdaman yung VERBAL COMMUNICATION
chief complaint OPEN ENDED QUESTIONS
● Personal health history - Used to elicit the client;s feelings and perceptions
● Family history CLOSED ENDED
● Health and lifestyle practices - Used to obtain facts and to focus on specific
● Review of systems information
PHASES OF THE INTERVIEW LAUNDRY LIST
PRE-INTRODUCTORY PHASE - Providing clients with a list of words to choose from in
● The nurse prepare himself for the interview describing symptoms, conditions, or feelings
● The nurse reviews the medical record before meeting WELL-PLACED PHRASES
the pt INTERFERING
○ Basahin ang chart ng pt PROVIDING INFORMATION
INTRODUCTORY PHASE VERBAL COMMUNICATION TO AVOID
● The nurse introduces himself/ to the client ● Biased or leading question
● She explains the purpose of the interview and the ● Rushing through the interview
types of questions, reasons for taking notes ● Reading the questions
● N assures the client that all the information of the pt is ○ Familiarize yourself with the questions
confidential SPECIAL CONSIDERATIONS DURING INTERVIEW
WORKING PHASE Gerontologic variations
● The n elicit the pt’s comments about major Communicating the elderly
biographical data, reasons for seeking care, health ● Consider the hearing ability of the client
history, review of body systems for current health ● Speak clearly
problem, lifestyle, and health ● Use straightforward language
○ Inaalam lahhat ● Speak clearly
○ 30 y/o na pero 20 y/o nang nainom ng alak ● Uses straightforward language
SUMMARY AND CLOSING ● If the old client is confused or forgetful interview the
● The n summarizes information obttainend during client with significant others
working phases and validates problems and goals ○ Face the elderly to do lip reading
with pt CULTURAL VARIATIONS
● Nurse identifies and discusses possible plans for her Communicating with people of different culture
chief complaint ● Reluctance to reveal personal info to stranger for
○ Validate the problems to the assessment you various culturally-based reasons
did ● Variation in meaning conveyed by language
COMMUNICATION DURING INTERVIEW ● Variation in use and meaning of nonverbal
Non-verbal communication: eyecontact, stance gestures,
1. Appearance demeanor
a. Comfortable and neat uniform ● Variations in disease/illness perception
b. Hair should be neat and pulled back ● Variations in family roles
● Variations in health practices
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EMOTIONAL VARIATIONS iv. No known allergies
- Clients’ emotions varyu for a number of reasons i.Physical, emotional, social, or spiritual
- Clients may have some sensitive issues with which strengths, and weaknesses
they are grappling 5. Family health history
- Educate a. Presented in the form of a genogram
i. Schematic diagram
b. Age of parents (Living, deceased? Cause,
date)
COURSE COURSE UNIT WEEK c. Parent’s illnesses and longevity
MODULE d. Grandprarent’s illnesses and longevity
e. Children’s age, illnesses and longevity
1 1 3 6. Review of systems
a. Each body system is addressed and the
COMPLETE HEALTH HISTORY clients is asked specific questions to draw
1. Biographical data out current health problems or problems
a. Complete name from the recent past that may still affect
i. Ask for ID 7. Lifestyle and health practices
b. Address a. Description of a typical day
c. Contact information i. Daily activities
d. Gender b. Nutrition and weight management
e. Provider of information (pt/family) c. Activity level and exercise
f. Birthdate and place of birth d. Sleep and rest
g. Race or ethnicity, languages spoken i. Gano katagal natutulog?
h. Marital status e. Substance use
i. Religious practices f. Self-consent and self-care responsibilities
j. Educational level i. Self-care
i. Layman's term g. Social activities
k. Occupation h. Relationships
l. Significant others i. Friends, families, etc
2. Reasons for seeking health care ii. No below the belt q’s
a. “What is your major health problem or i. Values and belief system
concern at this time?” j. Education and work
b. “How do you feel about having to seek k. Stress level and coping styles
health care?” l. Environment
c. Ask the chief complaint 8. Developmental level
d. Reasons: Feelings about seeking healthcare COLLECTION OF OBJECTIVE DATA
3. History of present concern: USE COLDSPA - Naoobserve ng healthcare provider
- Character MAJOR AREAS OF OBJECTIVE DATA:
- Onset 1. Physical characteristics
- Kelan nag start? 2. Body functions: nakakataas ba to pag nilalabanan
- Location 3. Appearance: dry lips/ nail bed test
- Specific location in body a. Anemia
- Naggradiate or stable? 4. Behavior
- Duration a. Hyper/matamlay
- Gano katagal nag last yung pain? 5. Measurements
- Severity a. Nalaki ang tiyan
- 1-10 b. Edema
- Pattern 6. Results of laboratory testing
- Direretso? Nawawala? Palala nang GENERAL GUIDELINES
palala? ❖ Instrumentation
- Associated Factor/ Alleviating ❖ Positioning
factor/aggravating factor ❖ Draping
- Ano yung ginagawa ng pt nung ❖ Preparation of the environment
naramadaman niya yung pain? ❖ Patient preparation
- May ginawa ba to lessen the pain? ❖ Techniques of physical assessment
4. Past health history POSITIONING
a. Problems at birth ● Sitting: used in an upright chair or dangling off exam
b. Childhood illnesses table
c. Immunizations ● Supine: lie flat on your back
d. Adult illnesses ● Dorsal recumbent: lie back with knees bent
e. Surgeries ● Sim’s: lies on either right or left side lower arm behind
f. Accidents the body and the upper arm is bent at the shoulder
g. Prolonged pain or pain patterns and elbow and knees are both bend
h. Allergies
i. After negative skin test
ii. Antibiotics
iii. ATS

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 ● Note for the ff characteristics: color, pattern, size,
location, consistency, symmetry, movement, behavior,
odors, or sounds
● Compare the appearance of symmetric body part
PALPATION
- Technique using the sense of touch
- The hands and fingers are sensitive tools:

Things to consider:
● Temperature (warm/cold)
● Texture (rough/smooth)
● Moisture (dry/wet)
● Mobility (fixed/ movable/ still/ vibrating)
● Consistency (soft/hard/fluid-filled)
● Strength (strong/weak/thread/bounding)
● Size (small/medium/large/cm)
● Shape (well-defined/irregular)
● Degree of tenderness
Types:
● Light: placing of dominant hand lightly on the surface
DRAPING: of the structure
● Prevents unnecessary exposure ● Moderate: depressing the skin surface with the
○ Data privacy act dominant hand using a circular motion in feeling fore
○ Provide linen or towel size, consistency, and mobility of structure
● Provides privacy ● Deep: uses of non-dominant hand on top of the
● Keeps the pt warm during the physical exam (P.E.) dominant hand to apply pressure
PREPARATION THE ENVIRONMENT ● Bimanual: use of two hand of each side of the body
● Temperature: preserve the warm environment part
● Noise: Avoid distractions ○ Leopold maneuvers: used to palpate the
● Ambiance: gravid uterus systematically
TECHNIQUES FOR EXAMINATION ○ This method of abdominal palpation is of low
IPAPEA cost, easy to perform, and non-invasive. It is
● Inspection: observing, listening, or smelling to gather used to determine the position, presentation,
data and engagement of the fetus in utero
● Palpation: assessment that uses sense of touch
● Percussion: act of striking one object against
another to produce a sound
● Auscultation: act of listening with a stethoscope to
sounds produced within the body
○ Uses stethoscope
EXANIMATION TECHNIQUES
Inspection
- Deliberate, purposeful, observations in a systematic
manner
- Cephalocaudal
- Nurse use the physical sense: visualizing, hearing,
and smelling
- Close and careful visualization of the person as a
whole and of each body system
- Ensure good lighting PERCUSSION
- Perform at every counter of your pt Act of striking one object against another to produce a
Instrumentation of equipment: sound
● Ophthalmoscope: exams the eyes - Percussion tones are used to assess location, shape,
● Otoscope: examines the ears, mouth, an nostrils size, and density of tissue
● Tuning fork: hearing - Flat
● Nasal speculum: visualized - Dul
● Snellen chart: used to check eyesight - Resonance
THINGS TO CONSIDER: - Hyper resonance
● Comfortable temp - Tympany
● Good lighting, preferably sunlight
● Look and observe before touching’
● Complete exposure of the part to be examined
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ASSIGNMENT: CHECK THESE SOUNDS
PURPOSES
● Eliciting pain
● Determining loc, size, and shape VALIDATING AND DOCUMENTING
● Determining density VALIDATION
● Detecting density - Process of confirming or verifying the that the
● Detecting abnormal masses subjective data and objective data you have collected
● Eliciting reflexes are reliable and accurate
- Validate subjective data with objective data, and
TYPES objective data with measurements
● Direct: direct tapping of the body part w/ one or two DATA REQUIRING VALIDATION:
fingertips ● Discrepancies or gaps between the subjective and
● Blunt: one hand flat on the body surface and using objective data
the fist to strike the back of the hand ○ Magkaiba yung sinabi ni pt sa pinapakita
● Indirect: use of a plexor and pleximeter niya
● Discrepancies or gaps between what the client says
at one time vs another time
● Findings that are highly abnormal and/or inconsistent
with other findings
○ Recheck lab tests

DOCUMENTING DATA
PURPOSES:
- Provides a chronologic source of client assessment
data and a progressive record of assessment findings
that outline the pt’s course of care
- Ensures that gathered information is easily accessible
to other members of the healthcare team
- Establishes a basis for screening or validating
proposed diagnoses
- Acts a source of information to help diagnose new
problems
- Offers basis for determining the educational need of
the pt, family, and so
- Provides a basis for eligibility for care and
reimbursement
- Constitutes a permanent legal record of care that was
or was not given to the client

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 - Provides access to significant epidemiologic data for
future investigations and researches
- Promotes compliance w legal, accreditation,
reimbursement, and professional standards
SUBJECTIVE DATA DOCUMENTATION
- Statements must be verbatim
- Compare data prior and upon admission/assessment
- BE sure to include all data including negative
statements
OBJECTIVE DATA DOCUMENT
- Make notes as you perform the assessments and
document as concisely as possible
- Avoid documenting w genera;l non descriptive or
non-measurable terms
- Instead, use specific descriptive and measurable
terms
GUIDELINES FOR DOCUMENTATION
● Keep confidential all documented information in the
client record
● Document legibly or print neatly in a non erasable ink
● Use correct grammar and spelling
● Avoid wordiness that creates redundancy
○ Avoid abbreviations
● Use phrases instead of sentence
● Record data finding, not how they were obtained
● Write entries objectively w/o making premature
judgments or diagnoses
● Make line if there's space
● Record pt’s understanding and perception of
problems
● Avoid recording the word normal
● Record complete info
● Include additional assessment content when
applicable
● Support objective data
ABDOMEN:
Inspection
Auscultate
P • Document legibly or print neatly in non erasable ink
P • Use correct grammar and spelling
A • Avoid wordiness that creates redundancy
Purpose of Validation
- Is the process of confirming or verifying that the
subjective and objective data the nurse have collected are
reliable and accurate
The steps of validation include:
Data Requiring Validation
● Conditions that require data to be rechecked and
validated include:
○ Discrepancies or gaps between the
subjective and objective data
○ Discrepancies or gaps between the client
says at one time versus another time
○ Findings that are highly abnormal and/or
inconsistent with other findings
Methods of Validation
▪ There are several ways to validate your data:
● Recheck your own data through a repeat assessment
● Clarify with the client by asking additional questions
● Verify the data with another health care professional
● Compare your objective findings with your
subjective findings to uncover discrepancies
Identification of Areas for Which Data are Missing
▪ Once an initial database is established, identify areas for
which more data are needed
▪ Examine data in a grouped format
DOCUMENTING DATA
• another crucial part of the first step in the nursing process
• categories of information on the forms are designed to ensure
that the nurse gathers pertinent information needed to meet
the standards and guidelines of the specific institutions
mentioned previously and to develop a plan of care for the
client
Purpose of Documentation
➔ Promote effective communication among
multidisciplinary health team members to facilitate
safe and efficient client care
➔ Provides the health care team with a database that
becomes the foundation for care of the client
➔ Helps to identify health problems, formulate nursing
diagnosis, and plan immediate and ongoing
interventions
➔ The use of electronic health records (EHRs) also
increases the likelihood that clients received
life-saving treatments and may lower the risk of
hospital acquired infections
Things to Consider on Documentation
❖ Legal record of patient encounter
❖ May be used by many professionals
❖ Document in a professional and legally acceptable
manner
❖ FOLLOW INSTITUTION’S SYSTEM
❖ Ensure accuracy
❖ Ensure correct patient record or chart
➢ Record information immediately upon
completion of patient encounter
➢ Avoid distractions while documenting
➢ Date and time each entry
Guidelines for Documentation
• Keep confidential all documented information in the client
record
• Use phrases instead of sentences to record data
• Record data findings, not how they were obtained
•Write entries objectively without making premature
judgments or diagnoses
• Record the client’s understanding and perception of
problems
• Avoid recording the word “normal” for normal findings
• Record complete information and details for all client
symptoms or experiences
• Include additional assessment content when applicable
• Support objective data with specific observations obtained
during the physical examination
Assessment Specific Documentation Guidelines
➢ Record pertinent positive and negative assessment
data
➢ Document any parts of the assessment that are
omitted or refused by patient
➢ Avoid using judgmental language
➢ Avoid evaluative statements; cite specific statements
or actions you observe
➢ State time intervals precisely
➢ Use specific measurements
➢ Draw pictures when appropriate
➢ Refer to findings using anatomic landmarks
➢ Use the face of a clock to describe findings that are in
a circular pattern
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 ➢ Document any change in patient’s condition during a ● Assessment includes the inference
visit or from previous visits made by the nurse from the two
➢ Describe what you observed, not what you did types of data. This is the part
wherein the problem is stated. The
Examples of Vague versus Clear and Concise Documentation nursing problem is stated in a form
of Data of nursing diagnoses using the
NANDA.
◆ P
● Plan this includes the nursing
actions to be made in order to solve
the stated problem. This part can
be revised.
★ Additional entries
CHARTING ◆ SOAPIE or SOAPIER
★ the common term used in the field of nursing when it ● I Intervention
comes to documentation ○ This is the part wherein
Purpose of Charting specific nursing actions
➢ It is a permanent record of patient’s information. are stated
➢ Tracks the progress of the patient’s condition during ● E – Evaluation
the hospitalization as well as the status upon ○ This is the part wherein
discharge. It serves as an information sheet of the the nurse evaluates the
medications and procedures rendered to the patient. reaction of the patient or
➢ Legal evidence for cross-examination whenever progress of the problem
complaints or malpractice claims have been being solved.
sighted out. ● Revision
➢ It serves as the evidence of continuity of care. ○ This is the section that
➢ It serves as a research material for retrospective states the changes made
study. in order to further resolve
Types of Charting the problem. Example:
➔ Narrative Charting Case: A patient with hypersensitivity reaction secondary to
◆ traditional form of charting food intake.
◆ source-oriented record ➔ •S
◆ advantage is that it provides organized ◆ “My skin is so itchy, especially on the
section for each member of the healthcare skinfolds.”
team ➔ O
◆ disadvantage in using this type of recording ◆ Skin appears to be flushed with bumps.
is that the information is scattered Irritation noted on the armpit and inner
throughout the chart thighs.
◆ Example: ➔ A
● Treatment Chart ◆ Altered comfort secondary to food intake
● Admission sheet ➔ P
● Initial Nursing Assessment ◆ Inform the patient not to scratch the skin.
● Graphic Record ◆ Apply cold compress on the hot spots
◆ Cut nails in order to prevent skin scratches
➔ Problem-oriented record ◆ Refer to the physician
◆ give focus on the problems that patients face ◆ Assess for progress of skin rash
◆ each medical personnel can contribute and
collaborate on the plan of care Intervention Evaluation Revision
◆ advantage seen in this type of charting is
collaboration among medical personnel
o Instructed not to “I feel more Give antihistamine
◆ the disadvantage here is that it takes
scratch the skin. comfortable and I do (Antamin) 1mg/mL
complete and on time assessment of
o Cut the fingernails not have the urge to as deep
problem lists
short scratch my intramuscular
➔ SOAP formats
o Applied cold skin.” injection to left
◆ usually used since it gives a quick look at the
compress deltoid muscle.
observation of each nurse as well as the
o Referred to the
nursing action on each observation.
physician
◆ S
● Subjective data includes the
patient’s complaints or perception of
the present problem cited. ➔ Focus Charting (FDAR)
◆ O ◆ This type of charting involves Data, Action
● Objective data includes the nurse’s and Response categories.
observation using his or her clinical ◆ This is a client-focused charting
eye ◆ Since it is the client being talked about most
◆ A of the documentation, this is a form of
holistic perspective of the client's needs.

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 Example ★ Can integrate all pertinent client information into one
➔ F (Focus) record
◆ Nursing Dx, Client Concern, S&S, ★ Nurse’s responsibilities include storing client’s
Event database, add new data, create and revise care plans
➔ D (Data) and document client progress
◆ Facial grimacing, graded the nape ★ Makes care planning and documentation relatively
pain as 7 in the scale of 1 to 10 with easy
10 as severe pain ★ Transmit information from one care setting to another
➔ A (Action) OTHER FORMS OF DOCUMENTATION
◆ Given Norgesic Forte per orem as Kardex
now dose. ★ Widely used, concise method of organizing and
➔ R (Response) recording data about a client, making information
◆ Rated pain as 2 and able to walk on accessible to all health professionals
her own. ★ Consists of series of cards kept in a portable index file
★ The SBAR which is particular for a client
★ Can be quickly accessed to reveal specific data
★ May or may not become a part of the client’s
permanent record
Flow sheets
★ Graphic record
★ Intake and Output Record
★ Medication Administration Record (MAR)
★ Skin Assessment Record
Nursing Discharge / Referral Summaries
• Completed when the client is being discharged and
transferred to another institution or to a home setting where a
visit by a community health nurse is required

REMEMBER:
When reporting over a telephone, ask the receiver to read back
what he or she heard in your report and document the phone
call with time, receiver, sender, and information shared.

○ Situation, Background, Assessment,

Recommendation COURSE COURSE UNIT WEEK
○ a model of communication MODULE
○ one of the most common handover
mnemonic models used in health care 1 4 4
○ improve quality and patient safety outcomes
when used by health team members to HOLISTIC NURSING ASSESSMENT
communicate or hand-off client information
ASSESSMENT FORMS USED FOR DOCUMENTATION Observations lead to clues about health status of the client
Initial Assessment Form The general survey includes observation of the client;s
● called a nursing admission or admission database
● 4 types B. VITAL SIGNS
○ Open – Ended Forms (Traditional form) ● Indicators of health
○ Cued or Checklist Forms ● A.k.a. Cardinal signs
○ Integrated Cued Checklist ● Common, noninvasive physical assessment
○ Nursing Minimum Data Set procedure that most clients are accustomed
Frequent or Ongoing Assessment Form ○ First step in physical assessment
● Flowcharts that help staff record and retrieve data for ● Provide data that reflect the status of several body
frequent reassessments systems, including butt not limited to cardiovascular,
● Examples neurologic, peripheral vascular,m and respiratory
○ Vital signs sheet systems
○ Assessment flowchart WHEN TO ASSESS VITAL SIGNS
● Emphasis is placed on quality, not quantity of ● Upon admission
documentation ● A change in health status
Focused or Specialty Area Assessment Form ● Prea and post Op/Procedure
● Focused on one major area of the body for clients ● Pre and POst medication administration
who have a particular problem ● Before and after any nursing intervention that could
● o Examples affect the vital signs
○ Cardiovascular assessment forms ○ Activity, talking, gum - chewing, and anxiety
○ Neurologic assessment forms affect pulse, respirations, and blood pressure
COMPUTERIZED DOCUMENTATION ■ ALLOW 5 minutes of REST before
Electronic Health Records (EHRs) beginning to take VS
★ Used to manage the huge volume of information Temperature
required in contemporary health care
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CLINICAL ONSET OF FEVER
● ONSET / CHILL
● COURSE / PLATEAU
○ After the core temp has reach a new
● DEFERVESCENCE
○ Occurs when the cause of fever is suddenly
removed
○ The hypothalamus attempts to normalize
NURSING INTERVENTIONS DURING FEVER
1. Monitor VS and skin color
2. Monitor ab values
3. Provide adequate nutrition and fluids
4. Oral hygiene
5. Tepid sponge bath
● Measured in degrees 6. Dry clothing and linens
● Body tempoeratrure is 7. Antipyretics
○ Lowest early iun the morning 4-6 am a. Medications
○ Higghest late in the evening 8-12 mn b. Needs doctor’s order
○ Regulated by hypothalamus
Purpose:
● To establish baseline data for subsequent evaluation
● To identify
● To determine
● To monitor
Factors that Affect Heat Production
● BMR (bASAL METABOLIC RATE
○ Tate energy utilization body required to
maintain
● Muscle activity
● Thyroxine (T4) Output
○ A thyroid hormone for regulation of (BMR)
○ Increased thyroxine output increases PULSE
metabolism (Chemical thermogenesis) ● A shock wave produced by the contraction of the
○ HYPER = ALL ARE INCREASED EXCEPT heart and forceful pumping of blood out of the
○ HYPO =- ALL ARE DECREASED EXCEPT ventricles into the aorta
WEIGHT AND MENSTRUATION ● Commonly called as the arterial or peripheral pulse
● Epinephrine, Norepinephrine, and Sympathetic ● Is an indirect measurement of cardiac output obtained
stimulation by counting the number of apical or peripheral pulse
● Fever waves over a pulse point
○ Increase in the body temperature’s set point ● A normal pulse rate for adult is between 60 and 100
○ Increases cellular metabolic rate bpm
○ Increase in set point triggers increased Arterial or Peripheral Pulse Sites
muscle contractions ● Temporal
■ Viral ● Carotid
■ Bacteria ● Apical
■ Parasitic infections ● Brachial
○ Pyrexia ● Radial
TYPES OF HEAT TRANSFER ● Femoral
● Conduction ● Popliteal
● Radiation ● Posterior tibialis
● Convection ● Dorsalis pedis
● Vaporization / Evaporation Asessing the Pulse Rate
FACTORS AFFERCTING BODY TEMPERATURE 1. The nurse should begin the assessment by speaking
● Age with the client about normal pulse rate
● Diurnal variations 2. Palpate a peripheral pulse by placing the forest two
● Exercise fingers on the pulse point with moderate pressure
● Hormones 3. Count the rate for a full minute, noting the regularity
● Stress (rhythm)
● Environment a. When an irregular peripheral pulse is
TYPES OF FEVERS present, the nurse needs to assess for pulse
● Intermittent deficit
● Remittent b. Pulse deficit
○ Wide range of temperature i. J
● Relapsing ii. A deficit
○ Short febrile periods of a few days are c. When a discrepancy exists ,,,,,,
interspersed with Pulse characteristics
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 ● A normal pulse has defined characteristics: quality, ● A
rate, and volume (strength of amplitude), and ● A
elasticity C. MENTAL STATUS
● Pulse quality refers to the “feel” of the pulse, its Refers to a client’s level of cognitive functioning (thinking,
rhythm and forcefulness knowledge, rp
● Normally, pulsation is equally strong in both wrists ASSESSMENT TECHNIQUES
● Amplitude can be quantified as follows: ● Positioning
○ 0- absent ● Observe the patient
● Pulse rhythm ● Note the pt’s speech and language abilities
● Dysrhythmia ● Assess pt’ sensorium
● Pulse volume ● Assess the pt’s memory
● Arterial elasticity ● Assess the pt’s ability to calculate problems
● Bradycardia ● Assess the pt’s ability to think abstractly
● Tachycardia ● Assess the pt;s mood and emotional state
Respirations ● Assess perceptions and thought processes
● The act opf breathing ● Assess the pt’s ability to make judgments
● Rate and character are additional clues to the client;s D. PSYCHOSOCIAL, COGNITIVE, AND MORAL
overall health status DEVELOPMENT
Process of Respirations * Freud Theory of Psychosexual
● External E. PAIN: THE 5TH VITAL SIGNS
● Internal
● Inhalation
● Exhalation
● Ventilation
TYPES OF BREATHING
● Costal / Thoracic
● Abdominal / Diaphragmatic
Normal breathing is accomplished by:
1. The downward and upward movement of the
diaphragm to lengthen or shorten the chest cavity
2. The e
Major Physical Functions
1. Ventilation
2. Circulation
3. Diffusion
4. Transport
Assessing Respiuration
● Normal breathing is slightly observable, effortless,
quiet, automatic, and regular
● It can be assessed by observing chest wall expansion
and bilateral symmetrical movement of the thorax
● Sites
○ Chest wall
○ Thorax
○ Nose and mouth
How to do it?
● Place your hand over the client's wrist and observe
one complete respiratory cycle.
● Start to count with first inspiration while looking at the
second hand sweep of watch
● Nursing consideration
○ Aa
Altered Breathing Pattern /.Sounds
● Rate
● Volume
● Effort
● Sounds
● Chest movement
○ Intercostal retractions
○ Substernal retractions
○ Suprasternal retractions
● Secretions
BLOOD PRESSURE
● Blood pressure is the measure of pressure exerted as
blood flows through the artery
● Measurement of the pressure of the blood in the
arteries when ventricles are contracted (Systolic blood
pressure - SBP
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