NCM116 PRELIM
Care of CLIENTS WITH PROBLEM L
E
IN
C
By: Ronamae Grace S. Demafelis
NURSING DATA COLLECTION, DOCUMENTATION,
ASSESMENT
AND ANALYSIS
4 TYPES OF ASSESSMENT
NURSE’S ROLE IN HEALTH ASSESSMENT: COLLECTING & Initial collection of subjective data about the
ANALYZING DATA Comprehensive client’s perception of her health of all
Assessment body parts or systems, past health
NURSING history, family history, and lifestyle
“Protection, promotion, and optimization of health and and health practices as well as
abilities, prevention of illness and injury, alleviation of objective data gathered during a step-
by-step physical examination.
suffering through the diagnosis and treatment of human
Ongoing or consists of data collection that occurs
responses and advocacy in the care of individuals, family,
Partial after the comprehensive database is
communities and population”
Assessment established.
HOW? consists of a mini-overview of the
Collect data in a systematic and ongoing process client’s body systems and holistic
Involve the patient, family and other health care health patterns as a follow-up on his
provider health status
Uses evidence-based assessment techniques and Focused or It is performed when a comprehensive
instruments Problem- database exists for a client who
Uses analytical models and problem-solving tools oriented comes to the health care agency with
Synthesizes available data, available information Assessment a specific health concern.
and knowledge consists of a thorough assessment of
Documents relevant data in retrievable format a particular client problem and does
not cover areas not related to the
HEALTH ASSESSMENT IN NURSING problem.
Purpose: is to collect subjective and objective data Emergency a very rapid assessment performed in
Assessment life-threatening situations.
situations like choking, cardiac arrest,
FOCUS:
drowning, an immediate diagnosis is
how the client’s health status affects his activities of daily needed to provide prompt treatment.
living and how the client’s activities of daily living affect
his health
STEPS OF HEALTH ASSESSMENT
how clients interact within their family, culture, and
The assessment phase of the nursing process has four major
community and how the clients’ health status affects the
steps:
family and community
1. Collection of subjective data
assesses how family and community affect the individual
2. Collection of objective data
client’s health status.
3. Validation of data
4. Documentation of data
PHASES OF THE NURSING PROCESS
Phas Title Description
SUBJECTIVE DATA VS. OBJECTIVE DATA
e
I Assessment Collecting subjective and SYMPTOMS: subjective concerns, or what the patient tells you
objective data
SIGNS: considered as one type of objective information, or
II Diagnosis Analyzing subjective and
what you observed.
objective data to make a
professional nursing judgement Objective Data Subjective Data
(nursing diagnosis, collaborative What you detect during the What the patient tells you
problem, or referral) examination, laboratory
III Planning Determining outcome criteria information, and test data
and developing a plan All physical examination The symptoms and
IV Implementatio Carrying out the plan findings, or signs history, from Chief
n Complaint through Review
V Evaluation Assessing whether outcome of Systems
criteria have been met and Example: Example:
revising the plan as necessary Mrs. G. is an older, overweight Mrs. G. is a 54-year-old
white female, who is pleasant hairdresser who reports
and cooperative. Height 5’4’, pressure over her left
The end result of a nursing assessment is the formulation of
weight 150lbs, BMI: 26, BP chest “like an elephant
NURSING DIAGNOSES 160/80, HR 96 and regular, sitting there,” which goes
respiratory rate 24, into her left neck and
temperature 97.5°F arm.
Collecting Subjective Data
• Subjective data are sensations or symptoms, feelings,
perceptions, desires, preferences, beliefs, ideas, values,
and personal information that can be elicited and verified
NCM116 PRELIM
Care of CLIENTS WITH PROBLEM L
E
IN
C
By: Ronamae Grace S. Demafelis
only •
N
by o
the client n-directive Interview: rapport building interview and
• Physical symptoms related to each body part or system the nurse allows the client to control the interview
• Past health history and Family history
• Health and lifestyle practices Collecting Subjective Data: INTERVIEWING
a. Establishing rapport and a trusting relationship with the
Collecting Objective Data client
• Directly observed by the examiner b. Gathering information on the client’s developmental,
• Physical characteristics psychological, physiologic, sociocultural, and spiritual
• Body functions status
• Appearance
• Behavior Phases:
• Measurements • Introductory Phase
• Results of laboratory testing • Working Phase
• Summary and Closing Phase
Subjective Objective
Description Data elicited and Data directly or indirectly Communication
verified by the observed through - is a process in which people affect one another
client measurement through exchange of information, ideas and feelings
Sources Client Observations and
Family and physical assessment
significant findings of the nurse Modes of Communication
others or other health care a. Verbal Communication: uses spoken or written words
Client record professionals b. Non-verbal Communication: uses gestures, facial
Other health Documentation of
expression, posture or gait, body movement, physical
care assessments made
professionals in client record appearance, body language, eye contact and tone of
Observations made voice.
by the client’s family
or significant others
Nonverbal
Verbal Communication Communication
Methods used Client interview Observation and physical
to obtain data examination • Open-ended questions • Appearance
Skills needed Interview and Inspection • closed-ended questions • Demeanor
to obtain data therapeutic Palpation • Laudrylist • Facial expression
communication Percussion • Rephrasing
skills Auscultation
• Attitude
• Well-placed phrases • Silence
Caring ability
and empathy • Inferring • Listening
Listening skills • Providing Information
Examples “I have a Respirations 16 per
headache” min
“It frightens BP 180/100, apical
me” pulse 80 and Collecting Objective Data
“I am not irregular - To become proficient with physical assessment skills,
hungry” X-ray fil reveals the nurse must have basic knowledge in three areas:
fractured pelvis
• Types of and operation of equipment needed for the
particular examination
NURSING DIAGNOSIS
• Preparation of the setting, oneself, and the client for the
“a clinical judgment about individuals, family or community
physical assessment
responses to actual and potential health problems and life
• Performance of the four assessment techniques:
processes”
inspection, palpation, percussion, and auscultation
also mean analysis of data
goes hand in hand with the rationale for performing a
PLANNING
nursing
• involves determining beforehand the strategies or course
needs to analyze and synthesize data to determine
of actions to be taken before implementation of nursing
whether the data reveal a nursing concern (nursing
care
diagnosis), a collaborative concern (collaborative
• planning involves decision making and problem solving
problem), or a concern that needs to be referred to
another discipline (referral).
Types:
a. Initial planning
COLLECTING SUBJECTIVE DATA AND OBJECTIVE DATA
b. b.Ongoing planning
c. Discharge planning
Methods of Data Collection
Interview
Planning Process
Observation: gathering of data thru the use of senses:
1. Setting Priority
vision, smell and hearing
2. Establishing client’s goal and desire outcomes
Examination
Short term: used for client who require health care
for the short time
Long term: applicable to client who stay at home
2 approaches to Interviewing
and have a chronic problem
• Directive Interview: is a highly structured and directly
ask the questions and the nurse control the interview
NCM116 PRELIM
Care of CLIENTS WITH PROBLEM L
E
IN
C
By: Ronamae Grace S. Demafelis
NURSING INTERVENTION
- is any treatment that a nurse performs to improve
client’s health
Categories of Nursing Interventions:
Independent Interventions: activities that nurses are
licensed to initiate on the basis of their knowledge and
skills
Collaborative Interventions: aka Interdependent
Interventions
Dependent Interventions: activities carried out under
the orders or supervision of a licensed physician
IMPLEMENTATION
the 4th steps in the nursing process
the performance of the nursing interventions identified
during the planning phase
consist of doing and documenting the activities.
Process of implementation:
1. Reassessing the client
2. Determine the client’s need for assistance
3. Implementing the nursing intervention
4. Supervising delegated care
5. Documenting nursing activities
EVALUATION
5th step in the nursing process
final phase of the nursing process that measures the
effectiveness of nursing care plan in promoting the
achievement of client’s goal
Gauges the extent to which goal of care plan have been
achieved
3 possible conclusions:
goal was met
goal was partially met
goal was not met
