NCM101 – HEALTH ASSESSMENT (MIDTERMS) 3. Emergency Assessment 1.

Name
NURSING PROCESS - Data gathered to determine the threatening status of a 2. Age
A deliberate problem-solving approach for meeting people’s health specific condition related to CAB (circulation, airway, 3. Gender
care breathing) system 4. Marital status
4. Ongoing Assessment of Follow Up 5. Educational level
STEPS OF THE NURSING PROCESS - Data gathering extended to the client discharge to 6. Occupation
➢ Assessment maintain his condition 7. Religion
➢ Diagnosis DATA COLLECTION 8. Birthdate
➢ Planning ➢ Process of gathering information about client health status 9. Birthplace
➢ Implementation ➢ Collection of patient data is vital steps in nursing process 10. Phone number
➢ Evaluation because the remaining steps depend on these steps 11. Phone number of significant person
12. Address
CHARACTERISTICS OF NURSING PROCESS CHARACTERISTICS OF DATA
➢ Provide the framework for care o Complete B. Past History
➢ It is client centered o Accurate 1. Previous Illness or Diseases
➢ Adapted to problem solving technique o Relevant 2. Previous surgery
➢ It is planes 3. Allergies
➢ It is cyclic and dynamic SOURSES OF DATA 4. Accident and injury
o Primary Source – Client 5. Immunization
o Secondary Source – client’s family, report, test results, 6. Medication
information in current and past medical records. 7. Previous hospitalization

TYPES OF DATA C. Present History (Pain Assessment)

o Subjective data (symptoms, covert data) – only the client can 1. C – Characteristics
describe (e.q itching, pain, feeling) 2. O – Onset
o Objective data (signs, overt data) – detectable by or can be 3. L – Location
observed, can be measured, can be seen, heard (e.g blood 4. D – Duration
pressure reading, pulse, redness, cyanosis) 5. S – Severity (0-10 pain scale)
6. P – Pattern
METHODS OF DATA COLLECTION 7. A – Associated signs and symptoms
1. Observation
o General appearance, behavior D. Family History (Genogram)
o Helps to determine the client’s status, both physical
and metal
2. Interview
I. ASSESSMENT o Preparation
o Phases/Stages of Interview
First step in the nursing process
✓ Introductory/Introduction Phase
o Include systematic collection of data through interview,
✓ Working Phase
observation, and examination to determine the patient’s
✓ Termination Phase/Closure
health status as well as any actual or potential health E. Social History
3. Physical Examination
problems 1. Alcohol use
o Assessment Techniques
✓ Inspection 2. Tobacco use
TYPES OF ASSESSMENT 3. Drug use
✓ Palpation
1. Database Assessment 4. Sleep
✓ Percussion
- Comprehensive information you gather on initial contact 5. Diet
✓ Auscultation
with the person to assess all aspects of health status 6. Exercise
4. Laboratory and Diagnostic Data
2. Focus Assessment 7. Stress
- Data gathered to determine the status of a specific 8. Stress Management
SUBJECTIVE DATA
condition 9. Economic Status
A. Biographical Data (demographic data) (ID)
 10. Hobbies and Leisure Activities WRITING DIAGNOSTIC STATEMENTS GOALS
11. Roles and Relationships o SHORT-TERM GOALS – outcomes achievable in a few days or
12. Characteristic Patterns of Daily Living 1 week
- Client centered
DAILY ACTIVITIES: - Measurable
➢ Bathing - Realistic
➢ Dressing o LONG-TERM GOALS – desirable outcomes that take weeks or
➢ Eating months to accomplish for client’s with chronic health
➢ Toileting problems
➢ Grooming
➢ Drinking COMPONENTS OF OUTCOMES
➢ Ambulating 1. Subject: who is the person expected to achieve the outcome?
2. Verb: what actions must the person take to achieve the
II. NURSING DIAGNOSIS outcome?
Secondary step of the nursing process 3. Condition: under what circumstances is the person to
o Describes clinical judgements about individual, family, or perform the actions?
community responses to actual or potential health 4. Performance criteria: how well is the person to perform the
problems/life processes that can be managed by independent actions?
nursing interventions 5. Target time: by when is the person expected to be able to
o NANDA – North America Nursing Diagnosis Associate III. PLANNING perform the actions?
Nursing Diagnosis (Nsg Dx) Medical Diagnosis (MD Dx) Third step of the nursing process
✓ Within the scope of ✓ Within the scope of o Development of measurable goals and outcomes as well as a e.g. The patient (1) will walk (2) with a walker (3) the length
nursing practice medical practice plan of care designed to assist the patient in resolving the of the hall (4) by the end of the shift (5)
✓ Identify responses to ✓ Determines a specific diagnosed problems and achieving the identified goals and
actual or potential disease, condition or desired outcomes INTERVENTIONS
health problems pathological state o INDEPENDENT (NURSE INITIATED) - any action the nurse can
✓ Can change from day ✓ Stays the same as long PLANNING PROCESS initiate without direct supervision
to day as the disease is ➢ Prioritizing problems o DEPENDENT (PHYSICIAN INITIATED) - nursing actions
present ➢ Formulate goals requiring MD orders
➢ Select nursing intervention o COLLABORATIVE - nursing actions performed jointly with
TYPES OF NURSING DIAGNOSES ➢ Write a nursing order other health care team members
o ACTUAL – a problem exists ➢ Record and modify
- Imbalance nutrition; less than body requirements RT IV. IMPLEMENTATION
chronic diarrhea, nausea, and pain AEB height 5’5” SETTING PRIORITIES Fourth step of the nursing process
weight 105 lbs o Determine problems that require immediate action o Involves carrying out the proposed plan of nursing care
o RISK – a problem does not yet exist o Maslow’s Hierarchy of Human Needs
- Risk for d=falls RT altered gait and generalized weakness PROCESS OF IMPLEMENTATION
➢ Reassessing the client.
COMPONENTS OF NURSING DIAGNOSIS (PES SYSTEM) ➢ Determine the nurse's need for assistance.
o PROBLEM ➢ Implementing.
- Identifies unhealthy response ➢ Supervising.
- Indicates what should change ➢ Document the action.
- Manifest by patient verbalization
o ETIOLOGY V. EVALUATION
- Identifies causative/contributing factors Final step of the nursing process
- Suggests nursing interventions o Determine the client progress toward goals achievement and
o SIGNS AND SYMPTOMS effectiveness of the nursing care plan
- Redness, cyanosis, loss or appetite o Comparison of client behavior and/or response to the
established outcome criteria
o Continuous review of the nursing care plan
 o Examines if nursing interventions are working
o Determines changes needed to help client reach stated goals
NURSING CARE PLAN (NCP)
Formal process that correctly identifies existing needs and recognizes
a client’s potential needs or risks
o Provide a way of communication among nurses, patients and
other healthcare providers to achieve healthcare outcomes
TYPES OF NURSING CARE PLAN
o INFORMAL
- Strategy of action that exists in the nurse’s mind
o FORMAL
- Written or computerized guide that organizes the
client’s care information
STANDARDIZED CARE PLANS
o Specify the nursing care for groups of clients with everyday
needs
o Pre-developed guides by the nursing staff and healthcare
agencies to ensure that patients with a particular condition
receive consistent care
o Used to ensure that minimally acceptable criteria are met and
to promote the efficient use of the nurse's time by removing
the need to develop common activities that are done
repeatedly for many of the clients on a nursing unit
INDIVIDUALIZED CARE PLANS
o Tailored to meet a specific client’s unique needs or needs
that are not addressed by the standardized care plan
o Allows more personalized and holistic care better suited to
the client’s unique needs, strengths, and goals
o Improve patient satisfaction
PURPOSES OF NURSING CARE PLAN
➢ Defines nurses’ role
➢ Provides direction for individualized care of the client
➢ Continuity of care
➢ Coordinate care
➢ Documentation
➢ Serves as guide for assigning a specific staff to a specific client
➢ Monitor progress
➢ Serves as a guide for reimbursement
➢ Defines client goal
COMPONENTS OF NURSING CARE PLAN
1. ASSESSMENT
- Health assessment, medical results, and diagnostic
reports
2. NURSING DIAGNOSIS STEPS IN WRITING A NURSING CARE PLAN:
- Statement that describes the patient’s health issue or 1. DATA COLLECTION OR ASSESSMENT
concern - Create client database using assessment techniques and
- Based on the information gathered about the patient’s data collection methods
health status during the assessment - Physical assessment, health history, interview, medical
3. EXPECTED CLIENT OUTCOMES records review, and diagnostic studies
- Specific goals that will be achieved through nursing - Includes all health information gathered
interventions - Critical thinking is key in-patient assessment, integrating
- May be long-term and short-term knowledge across sciences and professional guidelines
4. NURSING INTERVENTIONS to inform evaluations
- Specific actions that will be taken to address the nursing - Crucial for complex clinical decision-making
diagnosis and achieve expected outcomes - Aims to identify patients’ healthcare needs effectively,
- Based on best practices and evidence-based guidelines leveraging a supportive environment and reliable
5. RATIONALES information
- Evidence-based explanations for the nursing 2. DATA ANALYSIS AND ORGANIZATION
interventions specified - Analyze, cluster, and organize the data to formulate your
6. EVALUATION nursing diagnosis, priorities, and desired outcomes
- Plans for monitoring and evaluating a patient’s progress 3. FORMULATING YOUR NURSING
- Nursing diagnoses are a uniform way of identifying,
NURSING CARE PLAN FORMAT focusing on and healing with a specific client needs and
responses to actual and high-risk problems
- Actual or potential health problems that can be
prevented or resolved by independent nursing
intervention
4. SETTING PRIORITIES
- Establishing a preferential sequence for addressing
nursing diagnoses and interventions
- Encompasses Maslow’s Hierarchy of Needs and helps to
prioritize and plan care based on patient centered
outcomes
 5. ESTABLISHING CLIENT GOALS AND DESIRED OUTCOMES in which the nurse focuses holistically on the client-physical, c. Medical diagnosis
- Goals or desired outcomes describe what the nurse psychological, emotional, sociocultural, and spiritual. d. Assessment
hopes to achieve by implementing the nursing a. Assessment
interventions derived from the client’s nursing diagnoses b. Panning 13. In this step of the nursing process, you prioritize the diagnosis
- Provide direction for planning interventions and serve as c. Implementation in order of importance and figure out what nursing
a criterion for evaluating client progress d. Diagnosis interventions need to take place to accomplish these as well
- Enable the client and nurse to determine which as goals to achieve your care plan.
problems have been resolved, and help motivate the 6. What is the name of the assessment that focuses on past a. Planning
client and nurse by providing a sense of achievement medical history, family history, the reason for admission, b. Implementation
- Becomes part of the client’s permanent record, which medications currently taking, previous hospitalization, c. Assessment
may be reviewed by the oncoming nurse surgeries, psychosocial assessment, nutrition, and complete d. Evaluation
- Different nursing programs have different care plan physical assessment.
formats a. Focus assessment 14. Which nursing diagnosis should receive the highest priority in
- Designed so that the student systematically proceeds b. Initial assessment the case of a female patient who is diagnosed with deep vein
through the interrelated steps of the nursing process c. Comprehensive assessment thrombosis?
d. Emergency assessment a. Impaired gas exchange relating to an increased blood
PRACTICE TEST flow
NURSING PROCESS 7. Name that assessment process that collect data about a b. Fluid volume excess relating to peripheral vascular
1. During which of the five steps in the nursing process does the problem that has already been identified and determines if disease
nurse determine whether outcomes of care are achieved? the problem still exists or any changes. c. Risk of injury form edema
a. Implementation a. Initial assessment d. Altered peripheral tissue perfusion related to venous
b. Evaluation b. Focus assessment congestion
c. Planning c. Emergency assessment
d. Analysis d. Non-invasive assessment 15. From the following, which independent nursing intervention
can a nurse include in the plan of care for a patient with a
2. Which is the primary goals of the assessment phase of the 8. A _____ is performed to identify a life-threatening problem fractured tibia?
nursing process? (choking, stab wound, heart attack) a. Elevate the leg 5 inches above the heart
a. Build trust a. Critical assessment b. Apply a cold pack to the tibia
b. Establish goals b. Focus assessment c. Administer aspirin 325 mg every 4 hours as needed
c. Collect data c. Initial assessment d. Perform ROM to right leg every 4 hours
d. Validate medical diagnosis d. Emergency assessment
16. Ms. Cabacungan complain of pain in her chest, difficulty
3. The systematic problem-solving approach towards providing 9. Information verbalized or stated by the client breathing and cough. The nurse would be correct if she
individualized nursing care is known as a. Objective data documents these data as?
a. NCP b. Subjective data a. Objective data
b. Nursing process c. Holistic data b. Subjective data
c. Nursing practice act d. Integral data c. Holistic data
d. Nursing method d. Observable data
10. Observable and measurable information
4. Name of the association established to develop, refine, and a. Objective data 17. Which of the following assessment finding would be
promote the taxonomy of nursing diagnostic terminology b. Subjective data documented as objective data?
used by nurses c. Holistic data a. Leg pain and calf tenderness
a. North American Nursing Diagnosis Association d. Visible data b. Redness and swelling on arm
International c. Dizziness and headache in PM
b. American Nurse Association 11. What does PES stand for? d. Weakness and nausea
c. Ethical Nurse Association
d. Humane Nursing Association 18. A nurse is performing a physical assessment, which of the
12. This the step of the nursing process where you do the PES following would indicate a problem?
5. This is the step of the nursing process includes the systematic a. Planning 1. Clear bilateral lung sonds
collection of all subjective and objective data about the client b. Nursing diagnosis 2. Jaundice
 3. Erythema of lower extremities d. Outcome identification b. A 17 y/o patient with left arm fracture secondary to
4. Apical heart rate – 112 bpm mauling complaining of severe QA pain
5. Afebrile 24. In the nursing diagnosis “Impaired physical mobility related to c. A 58 y/o post stroke victim with left-sided paralysis with
6. Cyanosis on fingers join stiffness a evidenced by limited range of motion and bluish discoloration of nails
difficulty turning” the etiology of the problem is? d. A neonate with respiratory of 32 breaths per minute
a. 1, 3, 4, and 5 a. Limited range of motions
b. 2, 3, 4, and 6 b. Joint stiffness 30. Which of the following nursing diagnoses should be dealt
c. 3, 4, 5, 2, and 1 c. Physical mobility with immediately?
d. 3, 2, 4, 6, and 1 d. Difficulty turning a. High risk of infection
b. Anxiety/fear
19. The nurse is organizing the assessment data elicited from her 25. Which of the following in included in a client’s plan of care? c. Impaired physical mobility
patient and groups related information together. The nurse is a. Doctor’s order, demographic data, medication d. High risk for fluid volume deficit
doing what phase of the nursing process? administration and rationales
a. Evaluation b. Client’s assessment data, medical treatments with
b. Assessment rationales, diagnostic results and significance
c. Outcome identification c. Collected documentation of all team members providing
d. Implementation care for the client
d. Client’s nursing diagnosis, goals, expected outcomes and
20. Which of the following is not an activity of the nurse during nursing interventions
evaluation?
a. Measuring goal attainment 26. When establishing priorities for a client’s plan of care, the
b. Revising the care plan nurse should rank which of the following as the lowest
c. Collection of data priority?
d. Performing nursing orders a. Client’s needs regarding referrals
b. Safety related needs
21. Which of the following is incorrect regarding the c. Needs of family members involved in the plan of care
establishment of priorities in patient? d. Client’s social, love and belongingness needs
a. Airway should always be given highest priority
b. Clients with unstable condition should be given priority over 27. Which of the following are the essential components for
those who are stable outcome identification?
c. Attend to equipment and apparatus like IV fluids, IFCs and a. Target date, nursing action, measurement criteria and
drainage tubes first desired client behavior
d. Actual problems take precedence over potential problems b. Client behavior, measurement criteria, conditions under
which the behavior occurs and target date
22. Bella Flores has just undergone surgery on her right lower leg. c. Client behavior, target date and conditions under which
During the night, she required an analgesic to help her sleep. the client behavior occurs
She doesn’t have appetite to eat but she is able to take in d. Target date, nursing action, measurement criteria and
fluids without nausea. Which of the following nursing desired behavior
diagnosis should be given highest priority?
a. Impaired tissue perfusion: peripheral 28. As an intervention for controlling pain of a postoperative
b. Imbalanced nutrition: less than body requirement client, a nurse administers analgesic. This activity of the nurse
c. Pain is an example of a/an?
d. Impaired physical mobility a. Independent nursing action
b. Dependent nursing action
23. A patient is being positioned by the nurse because of c. Collaborative nursing action
complaints of difficulty of breathing. The action of the nurse d. Legal nurse action
indicates what phase of the nursing process?
a. Implementation 29. As a nurse taking the next shift, which of the following patient
b. Evaluation conditions should you prioritize?
c. Assessment a. A 29 y/o postoperative complaining of thirst