* A series of steps that lead to accomplishing some goal or purpose. * A systematic and organizes method for providing care to clients. * Provides individualized, holistic, effective and efficient client care. * Clients of all ages and in any care setting. * Characteristics of Nursing Process * Problem solving method - client focused * Systematic- sequential steps * Goal oriented- outcome criteria * Dynamic-always changing, flexible * Utilizes critical thinking processes * ● Interpersonal – promotes nurse-client relationship● * Cyclical – continuous and promotes improvement of nursing care *
Systematic problem - solving approach toward giving individualized nursing care.
STEPS:
* Assessment * Nursing Diagnosis * Planning and outcome identification * Intervention * Evaluation *
ASSESSING PATIENT’S HEALTH STATUS
Assessment
* A systematic collection of subjective and objective data with the goal of making a clinical nursing judgment about an individual, family or community. * 1st phase of nursing process which involves systematic data collection , organization and validation, interpretation, and documentation of data. * Purpose of Nursing Assessment * To establish the client-nurse relationship. * To obtain information about the client’s health, including physiologic, socio-cultural, cognitive, developmental & spiritual aspects. * To identify actual & potential problems. * To identify health-promoting behaviors and actual and/or potential health problems. * Sources of data * Primary source–client or the major provider of information about a client. * Secondary source–sources of data other than client and include family members, other health care providers, medical records and literature. *
Types of data
Subjective data (SYMPTOMS) (STATED) * These can be gathered solely from the patient’s own account. Includes the pt. sensation, feelings, values, beliefs, attitudes & perception towards health status & life situation. * Referred to as symptoms or covert data * e.g. “I feel weak all over when I exert myself” “ I have a sharp pain on my chest”
Objective data (SIGNS) (OBSERVED) * Can be obtained through observation and verifiable * Referred as signs or overt data, these can be seen , heard, felt or smelled * Validates the subjective data * e.g. B.P. 90/50 * Apical pulse 104, abdomen is distended, skin is pale & diaphoretic. *

Methods used in Nursing Assessment * Observation * Interview * Physical Examination * Organizing the data * This is often referred as the nursing history * Data must be organized. * Data clustering is the process of putting the data together systematically in order to identify areas of the client’s problems and strengths. * Uses different models ( conceptual, non nursing, wellness, body system etc.) * VALIDATING THE DATA * Must be factual, complete and accurate because the nursing diagnosis and interventions are based on this information. * ACT OF DOUBLE CHECKING OR VERIFYING * Prevents misunderstandings, omissions, and incorrect inferences and conclusions. * Differentiates between cues= subj. and obj data * Between * Inferences- nurse’s interpretation and conclusion made based on the cues * AVOID JUMPING TO CONCLUSIONS AND FOCUSING IN THE WRONG DIRECTION TO IDENTIFY PROBLEMS * Interpreting the data * Organizing data in clusters helps to recognize patterns of response or behavior: * Distinguish between relevant, irrelevant. * Determine whether and where there are gaps in the data. * Identify patterns of cause and effect. * Documenting the data * The nurse must decide which data should be immediately reported and which data can just be recorded. * It is essential for accurate, factual and complete recording of assessment data to communicate information to other health care team members. * Methods used in Nursing Assessment * OBSERVATION * To gather data by using the 5 senses * Is a conscious deliberate skill that is developed only through effort and with organized approach

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Observational Skills * Vision * Overall appearance (body size, weight, posture); signs of distress or discomfort; facial & body gestures; skin color & lesions; abnormalities of movement; non-verbal demeanor * Smell - Body or breath odors * Hearing - Breath & heart sounds, bowel sounds, ability to communicate, language spoken, orientation to time person & place * Touch - Skin temp, pulse rate, rhythm; muscle strength; palpatory lesions * INTERVIEW * Planned communication or conversation wherein its primary purpose is to gather data. * This will give information, identify problems of mutual concern, evaluate change, teach, provide support, counseling & therapy *
APPROACHES FOR INTERVIEW * Directive Interview * Nondirective Interview
Directive Interview * Is a highly structured and elicits specific information. * The nurse establishes the purpose of the interview & controls the interview by asking closed type of questions
Nondirective Interview * This is a rapport-building interview w/c allows the client to control the purpose, subject matter, and pacing of the interview. * The nurse usually used an open-ended questions *
KINDS OF INTERVIEW QUESTIONS
Closed questions * Used in directive interview, usually restrictive & generally require only short answers giving specific information. Thus, the amount of the information gained is limited. * Often begins with 4WH.
Open-ended questions * Associated in nondirective interview. * Allow the clients to elaborate, clarify & illustrate their thoughts & feelings. (e.g. Why did you come to the hospital tonight?; How did you feel in that situation?
Neutral question * It is a question the client can answer without direction or pressure from the nurse. (e.g., How do you feel about that?; Why do you think you had an operation?)
Leading question * Directs the client’s answer. The phrasing of the question suggests what answer is expected. e. g. You are stressed about the surgery tomorrow, aren’t you?;You will take your medicine, won’t you? *
POINTS TO REMENBER IN AN INTERVIEW * Select a quiet private setting (time, place, seating arrangement, distance). * Choose terms carefully and avoid using jargon. * Use appropriate body language. * Confirm patient statements to avoid misunderstanding. * Use open-ended question. * COMMUNICATION STRATEGIES
a. Silence * - Moments of silence during the interview encourage the pt. to continue talking & give a nurse a chance to assess the clients ability to organize thoughts.
b. Facilitation * -Facilitation encourages the pt. to continue with his story. (e.g. “please continue”, “go on” and “uh-huh)
c. Confirmation * - Ensures that both the nurses & the pt. are on the same track. * (e.g. If I understand you correctly, you said…..)
d. Reflection * - Repeating something the pt. has just said can help you obtain more specific information.
e. Clarification * is used when an information given is vague. * e.g. client: I can’t stand this! * Nurse : What do you mean by I cant stand this?
f. Summarization * -restating the information that the pt. gave you. It ensures that the data collected is accurate & complete.
g. Conclusion * Signals the pt. that the nurse is ready to conclude the interview. It provides the pt. the opportunity to gather his thoughts and make any pertinent final statements. * e.g. nurse: I think I have all the information I need now. Is there anything you would like to add. * NURSING HEALTH HISTORY * One example of an interview. * 1st part of the assessment of the client’s health status. * Used to gather subjective data about the pt. & explore the past & the present health problems.
II. Physical Assessment
A. General Physical Survey utilizing the different assessment skills (IPPA)
B. Integrate the Three approaches 1. Body System 2. Cephalo-caudal 3. Problem focused
III. Diagnostic/Laboratory and procedure *
COMPONENTS OF THE NURSING HISTORY
Biographic data * Includes the client’s name, address, age, sex, telephone no., race, marital status, b-day, occupation, religion, nationality
Chief complaint or reason for visit * The c/c should be recorded in the client’s own words. (‘What is troubling you?”)
History of present illness
P-rovocative/Palliative
* ask the patient: what triggers & relieves the symptom?
Q-uality or Quantity * What the symptom feels like, look like? * Are you having the symptom right now? If so , is it more or less severe than usual?
R-egion or Radiation * Where in the body does the symptom occur? * - Does the symptom appear in other regions? If so, where? S-everity * How severe is the symptom? How would you rate it on a scale of 1-10, with 10 being the most severe. * Does the symptom seem to diminishing, intensifying, or staying about the same?
T-iming
* When did the symptom begin? * Was the onset sudden or gradual? * How often does the symptom occur? * How long does the symptom last? * Past History A. Childhood Illnesses (chicken pox, mumps, measles) B. Adult Illnesses ( HPN, DM, HD) C. Accidents and/or Injuries D. Operations E. Hospitalization F. Medications G. Allergies H. Immunization Family History * The family nursing history reveals risk factors for certain diseases * This information should include the ages of siblings, parents & grandparents & their current state of health or cause of death. * Particular attention should be given to disorders such as heart disease, cancer, diabetes, hypertension, obesity, allergies, arthritis , TB, jaundice, bleeding, ulcers, migraine & alcoholism. * Gordon (1987) devised a theoretical framework for assessment of a nursing client that allows nurses to identify obvious as well as emerging patterns of functioning. Using this framework nurses screen their client for functional as well as dysfunctional patterns . * Gordon’s Typology of 11 Functional Health Patterns * Health Perception and Health Management. Data collection is focused on the person's perceived level of health and well-being, and on practices for maintaining health. Habits that may be detrimental to health are also evaluated, including smoking and alcohol or drug use * Nutrition and Metabolism Assessment is focused on the pattern of food and fluid consumption relative to metabolic need. The adequacy of local nutrient supplies is evaluated. Actual or potential problems related to fluid balance, tissue integrity, and host defenses may be identified as well as problems with the gastrointestinal system. * Elimination. Data collection is focused on excretory patterns (bowel, bladder, skin). Excretory problems such as incontinence, constipation, diarrhea, and urinary retention may be identified. * Activity and Exercise. Assessment is focused on the activities of daily living requiring energy expenditure, including self-care activities, exercise, and leisure activities. The status of major body systems involved with activity and exercise is evaluated, including the respiratory, cardiovascular, and musculoskeletal systems. * Cognition and Perception. Assessment is focused on the ability to comprehend and use information and on the sensory functions. Data pertaining to neurologic functions are collected to aid this process. Sensory experiences such as pain and altered sensory input may be identified and further evaluated. * Sleep and Rest. Assessment is focused on the person's sleep, rest, and relaxation practices. Dysfunctional sleep patterns, fatigue, and responses to sleep deprivation may be identified. * Self-Perception and Self-Concept. Assessment is focused on the person's attitudes toward self, including identity, body image, and sense of self-worth. The person's level of self-esteem and response to threats to his or her self-concept may be identified. * Roles and Relationships. Assessment is focused on the person's roles in the world and relationships with others. Satisfaction with roles, role strain, or dysfunctional relationships may be further evaluated. * Sexuality and Reproduction. Assessment is focused on the person's satisfaction or dissatisfaction with sexuality patterns and reproductive functions. Concerns with sexuality may he identified. * Coping and Stress Tolerance. Assessment is focused on the person's perception of stress and on his or her coping strategies Support systems are evaluated, and symptoms of stress are noted. The effectiveness of a person's coping strategies in terms of stress tolerance may be further evaluated. * Values and Belief. Assessment is focused on the person's values and beliefs (including spiritual beliefs), or on the goals that guide his or her choices or decisions. * PHYSICAL EXAMINATION * It is a systematic data-collection method that uses observational skills to detect health problems. (cephalocaudal or body system approach) * Uses the following techniques: * Inspection, Palpation, Percussion, Auscultation (IPPA) * PURPOSE OF PHYSICAL ASSESMENT * To obtain baseline data about the client’s functional abilities. * To supplement, confirm or refute the data obtained in nursing history. * To obtain data that will help the nurse establish nursing dx. & plan the client’s care. * To evaluate the physiologic outcomes of healthcare & the progress of the client’s health problem. * INSPECTION * -Is a visual examination or assessing by using the sense of sight. * - Use to assess color, rashes, scars, body shape facial expressions, body structures.
Pointers in performing a General Survey * Symmetry – Are face & body symmetrical? * Old – Does he look his age? * Mental acuity – Is he alert, confused, agitated? * Expression – Does he appear ill, in pain or anxious? * Trunk – Is he lean, stocky, obese, or barrel-chested ? * Extremities – Are his fingers clubbed, joint abnormalities, edema? * Appearance – Is he clean or appropriately dressed? * Movement – Are his posture, gait & coordination normal? * Speech – Is his speech relaxed, clear, strong, Understandable, appropriate.? Does it sound stressed? * PALPATION * It is the examination of the body using the sense of touch. * It is used to determine (a) texture, (b)temperature, (c) vibration, (d) position, size, consistency, and mobility of organ or masses, (e) presence & rate of peripheral pulses. (f) distention, (g) tenderness & pain. * Types of Palpation * Light palpation - used to assess surface abnormalities; texture , tenderness, temperature, moisture, elasticity , pulsations, superficial organs, & masses. * Deep palpation – used to feel internal organs & masses for size, shape, tenderness, symmetry & mobility. * Bimanual * PERCUSSION * is an assessment method in which the body surface is struck to elicit sounds that can be heard or vibration that can be felt. * this technique helps you locate organ borders, identify organ shape & position, & determine if an organ is solid or filled with fluid or gas. * 2 Types of Percussion
Direct percussion – the nurse strikes the area to be percussed directly with the pads of two, three or four fingers or with the pad of middle finger.
Indirect percussion – is the striking of an object, usu. a finger held against the body area to be examined. * the middle finger of the non dominant hand is the pleximeter which is placed firmly on the client’s skin; using the tip of the flexed middle finger of the other hand, called the plexor , the nurse strikes the pleximeter. * AUSCULTATION * Is the process of listening to the sounds produced within the body.
4 Properties used to describe sound * Pitch – is the frequency of the vibrations (the number of vibrations per second) e.g . Low pitched sounds such as heart sounds have fewer vibrations per second than high pitched sound like the bronchial sounds. * Intensity (amplitude) – refers to the loudness or softness of a sound. e.g. trachea has a loud sound, heart sound is soft * Duration – the length of the sound * Quality – is a subjective description of sound. e.g. whistling, gurgling, snapping, blowing, squeaking, humming. * ASSESSMENT TOOLS * Sphygmomanometer * Cotton balls * Gloves * Visual acuity charts * Ophthalmoscope * Otoscope * Penlight * Percussion Hammer * Safety pins * Scale with height measurement * Skin calipers * Speculum * Stethoscope * Tape measure * Thermometer * Tuning fork * Tongue depressor *
VITAL SIGNS AND STATISTICS * Height & weight * Body Temperature * Pulse Rate * Respiratory Rate * Blood Pressure HEIGHT AND WEIGHT * Important parameters for evaluating nutritional status of the client, calculating medication dosages, and assessing fluid loss and gain.
BODY TEMPERATURE * It is the balance of between the heat produced by the body & the heat lost from the body * It is measured by degrees
Heat Production * Basal metabolism * Muscular activity (shivering) * Thyroxine & epinephrine * Fever Heat Loss * Radiation- transfer of heat from one surface to another w/o contact * Conduction- transfer of heat from one molecule to another, heat transfer to a molecule of lower temp. (w/contact) * Convection- dispersion of heat by air currents. * Vaporization- continuous evaporation of moisture from respiratory tract, oral mucosa & skin. * 2 Kinds of body Temperature
Core Temperature – is the temp. of the deep tissues of the body, such as the cranium, thorax, abdominal cavity, and pelvic cavity. (37 C, 98.6 F)
Surface Temperature – is the temp of the skin, subcutaneous tissue, & fats. It is by contrast rise & fall in response to the environment. * Variations in Body temp. * Newborn : axillary : 36.1-37.7 C : 7-10 min * 1 yr : Oral : 37.7 C : 3-5 min * 3 yrs : Oral : 37.2 C * 5 yrs : Oral : 37.0 C * Adult : Oral : 37.0 Axillary : 36.4 Rectal : 37.6 : 2 min Forehead : 34.4 Tympanic : 37.7 * Elderly Oral : 36.0 * (over 70 yr) * Factors affecting body Temperature * Age * Diurnal variations (circadian rhythm) * Exercise * Hormones * Stress, Environment * Alterations in Body Temp.
Pyrexia – A body temp above the usual range. (hyperthermia or fever)
Hyperpyrexia – High fever with a temp. of 41 c (105.8 F)
Hypothermia – is a core body temp below the lower limit of normal. * 34 C - death * 35 C - hypothermia * 36 – 37 C - normal * 38 – 40 C - pyrexia * 41 C - Hyper pyrexia * 42 C & above - death * 4 Common types of fever * Intermittent fever – The body temp. alternates regularly between a period of fever & a period of normal or subnormal temp. * Remittent fever – The body temp fluctuates several degrees, more than 2 C, above normal but does not reach normal between fluctuations. * Constant fever – The body temp remains consistently elevated & fluctuates very little, less than 2 C. * Relapsing fever – The body temp returns to normal for at least a day, but then fever recurs. * Types of thermometers * Mercury – in - glass thermometer * Electronic thermometer * Temperature-sensitive patch or tape * Chemical disposable thermometer * Infrared thermometers * Thermometers * Temperature scales
Converting Celsius to Fahrenheit :
F = ( Celsius X 9/5) + 32 or F = (C x 1.8) + 32
Converting Fahrenheit to Celsius
C = (Fahrenheit – 32) X 5/9 or C = (F – 32) / 1.8 * PULSE * The pulse is a wave of blood created by contraction of the left ventricle of the heart. * The heart pumps and the blood enters the arteries w/ each heartbeat, causing pressure pulses or pulse wave
Definition of terms * Stroke volume output (SVO) – is the amount of blood that enters the arteries w/ each ventricular contraction. (70 ml of blood in a healthy adult/contraction) * Compliance – is the ability of the arteries to contract & expand. * Cardiac output (CO) – is the result of the stroke volume times the heart rate per minute. * 4-6 L of blood that pumps by an adult heart during rest. * CO = SV x HR
Factors Affecting Pulse rate * Age - as the age increases the pulse decreases. * Sex – average male pulse rate is slightly lower than the female. * Exercise – PR normally increases with activity. * Fever – the pulse rate increases (a) in response to the lowered blood pressure that results from the peripheral vasodilation (b) because of the increased metabolic rate. * Medications – Some medications decrease the CR (digitalis) others increase it (epinephrine). * Hemorrhage – Loss of blood from the vascular system normally increases the PR. * Stress – In response to stress, sympathetic nervous stimulation increases the overall activity of the heart. (fear, anxiety, pain) * Position changes –sitting or standing position usually pools the blood in dependent vessels of the venous system. Thus venous blood return to the heart decrease resulting to subsequent reduction in BP & increase in HR. * Pulse Sites * Temporal * Carotid * Apical * Brachial * Radial * Femoral * Popliteal * Posterior tibial * Pedal *
Pulse assessment
Pulse rhythm – is the pattern of the beats & the intervals between the beats. Equal time elapses between beats of a normal pulse. * - dysrhythmia or arrythmia – a pulse with an irregular rhythm. It may consist of random, irregular beats or predictable pattern or predictable pattern of irregular beat.
Pulse volume – also called a pulse strength or amplitude, refers to the force of blood with each beat. * 0 Absent, not discernible * 1 Thready or weak, difficult to feel * 2 Normal, detected readily, obliterated by strong pressure * 3 Bounding, difficult to obliterate
Elasticity of the arterial wall * Reflects its expansiblity or its deformities. * Normal artery feels straight, smooth, soft and pliable.
Apical-Radial pulse assessment * apical and radial rates are identical * need to be assessed for client with cardiovascular disease. * Pulse deficit – the difference between the apical pulse rate & radial pulse rate. Measuring the PD allows the nurse to evaluate indirectly the ability of each cardiac contraction to eject sufficient blood to peripheral circulation. * RESPIRATION
It is the act of breathing; it includes the intake of oxygen and the output of carbon dioxide. * External Respiration – refers to the interchange of oxygen & carbon dioxide between the alveoli of the lungs & the pulmonary blood. * Internal respiration – interchange of the same gases between the circulating blood and the cells of the body tissues. * Ventilation – refer to the movement of air in & out of the lungs * 2 Types of breathing * Costal/thoracic breathing – chiefly involves the external intercostal muscles & other accessory muscles such as the sternocleidomastoid. (chest) * Diaphragmatic breathing – involves the contraction & relaxation of the diaphragm and usually observe by the movement of the abdomen. * Assessing respiration
Rate – normally described in breaths per minute. Ave. Range * Newborn 35 30 – 80 * 1 yr 30 20 – 40 * 2 yrs 25 20 – 30 * 8 yrs 20 15 – 25 * 16 yrs 18 15 – 20 * Adult 16 12 – 20
Depth – can be established by watching the movement of the chest. * Deep respirations – large volume of air is inhaled & exhaled, inflating most of the lungs. * Shallow respirations – involve the exchange of small volume of air.
Rhythm – refers to the regularity of the expirations & inspirations, * normally respirations are evenly spaced * can be described as regular or irregular
Quality or character – refers to those aspects of breathing that are different from normal, effortless breathing. (effort exert & sound) * Breathing Patterns & Sound
Rate
* eupnea – normal respiration that is quiet, rhythmic, & effortless * tachypnea – rapid respiration marked by quick, shallow breaths * bradypnea – abnormally slow breathing * apnea – absence of breathing
Volume
* Hyperventilation – an increase in the amount of air in the lungs, characterized by prolonged & deep breaths. * Hypoventilation – a reduction in the amount of air in the lungs; characterized by shallow respirations.
Rhythm
* Cheyne – Stokes breathing – a gradual increase followed by a gradual decrease in the depth of respirations & then a period of apnea; often associated with cardiac failure, increased ICP, or brain damage. * Biot’s - Respiration of the same depth followed by a period of apnea.
Ease or effort * Dyspnea – difficult & labored breathing during w/c the individual has a persistent , unsatisfied need for air & feels distressed. * Orthopnea – ability to breath only in upright sitting or standing positions. * Breath sounds
Audible without amplification * Stridor – a shrill, harsh sound heard during inspiration with laryngeal obstruction * Stertor – snoring or sonorous respiration, usually due to a partial obstruction of the upper airway * Wheeze – continuous, high – pitched musical squeak or whistling sound occurring on expiration & sometimes on inspiration when air moves through a narrowed or partially obstructed airway * Bubbling – gurgling sounds heard as air passes through moist secretions in the respiratory tract * Stethoscope
Audible by stethoscope * Crackles (rales) – dry or wet crackling sounds simulated by rolling a lock of hair near the ear. (Pneumonia, HF) * heard on inspiration as air moves through accumulated moist secretions; reflects underlying inflammation. * fine – medium crackles occur when air passes through moisture in small air passages & alveoli * medium – coarse crackles occur when air passes through moisture in bronchioles, bronchi, & the trachea. * Gurgles (rhonchi) – coarse, dry, wheezy or whistling sound more audible during expiration as the air moves through tenacious mucus or narrowed bronchi * Pleural friction rub – coarse , leathery, or grating sound produced by the rubbing together of inflamed pleura - can be imitated by rubbing the thumb & index finger * BLOOD PRESSURE * Arterial blood pressure is a measure of the pressure exerted by the blood as it flows through the arteries. * To the force of the blood against the arterial walls. * BP Apparatus
Blood Pressure Measure * Systolic pressure – is the pressure of the blood as a result of contraction of the ventricles. * Diastolic – is the pressure when the ventricles are at rest
Physiology of Blood Pressure * Pumping action of the heart – cardiac output is the volume of blood pumped into the arteries by the heart. * when the pumping action of the heart is weak, less blood is pumped into arteries, and the blood pressure decreases. * Peripheral Vascular Resistance
Factors that create resistance in AS * Size of arterioles & capillaries – the smaller the lumen of the vessel the greater the resistance. * Compliance of the arteries – ability of the vessel walls to contract & relax. * Blood volume – when the blood volume decreases the BP decreases, conversely, when the BV increases the BP increases. * Blood viscosity – BP is higher if the blood is highly viscous.
Factors affecting BP * Age * Exercise * Stress * Race * Obesity * Sex * Medications * Diurnal variations * Disease process *
PHYSICAL ASSESSMENT TECHNIQUES * Inspection * Palpation * Percussion * Auscultation
INSPECTION
* -Is a visual examination or assessing by using the sense of sight. * - Use to assess color, rashes, scars, body shape facial expressions, body structures.
Pointers in performing a General Survey * Symmetry – Are face & body symmetrical? * Old – Does he look his age? * Mental acuity – Is he alert, confused, agitated? * Expression – Does he appear ill, in pain or anxious? * Trunk – Is he lean, stocky, obese, or barrel-chested ? * Extremities – Are his fingers clubbed, joint abnormalities, edema? * Appearance – Is he clean or appropriately dressed? * Movement – Are his posture, gait & coordination normal? * Speech – Is his speech relaxed, clear, strong, Understandable, appropriate.? Does it sound stressed?
PALPATION
* It is the examination of the body using the sense of touch. * It is used to determine (a) texture, (b)temperature, (c) vibration, (d) position, size, consistency, and mobility of organ or masses, (e) presence & rate of peripheral pulses. (f) distention, (g) tenderness & pain.
2 Types of Palpation * Light palpation - used to assess surface abnormalities; texture , tenderness, temperature, moisture, elasticity , pulsations, superficial organs, & masses. * Deep palpation – used to feel internal organs & masses for size, shape, tenderness, symmetry & mobility.
PERCUSSION
* is an assessment method in which the body surface is struck to elicit sounds that can be heard or vibration that can be felt. * this technique helps you locate organ borders, identify organ shape & position, & determine if an organ is solid or filled with fluid or gas.
2 Types of Percussion
Direct percussion – the nurse strikes the area to be percussed directly with the pads of two, three or four fingers or with the pad of middle finger. * usually used in percussing an adult’s sinuses
Indirect percussion – is the striking of an object, usu. a finger held against the body area to be examined. * the middle finger of the non dominant hand is the pleximeter which is placed firmly on the client’s skin; using the tip of the flexed middle finger of the other hand, called the plexor , the nurse strikes the pleximeter.
Types of sound * Flatness – is an extremely dull sound produced by very dense tissue, such as muscle or bone. * Dullness – is a thudlike sound produced by dense tissue such as liver , spleen, or heart. * Resonance – is a hollow sound with such as that produced by lungs filled with air. * Hyperresonance – not normal, a booming sound that is usually heard over an emphysematous lungs. * Tympany – is a musical or drum like sound produced from an air filled stomach.
AUSCULTATION
* Is the process of listening to the sounds produced within the body.
4 Properties used to describe sound * Pitch – is the frequency of the vibrations (the number of vibrations per second) e.g . Low pitched sounds such as heart sounds have fewer vibrations per second than high pitched sound like the bronchial sounds. * Intensity (amplitude) – refers to the loudness or softness of a sound. e.g. trachea has a loud sound, heart sound is soft * Duration – the length of the sound * Quality – is a subjective description of sound. e.g. whistling, gurgling, snapping, blowing, squeaking, humming.

The Nursing Process
Systematic problem-solving approach toward giving individualized nursing care. * STEPS: * Assessment * Nursing Diagnosis * Planning * Intervention * Evaluation
NURSING DIAGNOSIS
A clinical judgment about an individual, family or community responses to actual or potential health/life processes.
Provides the basis for selection of nursing intervention to achieve outcomes for which the nurse is accountable.
Nursing Diagnosis
Diagnosing is a process which results to a diagnostic statement.
Nursing Diagnosis – is a statement of a client’s potential or actual alteration of health status. It results from analysis and synthesis.
Purpose: To identify the client’s health care needs and to prepare diagnostic statements.
NURSING DIAGNOSIS
Medical diagnosis * describes a disease or pathology of specific organs or body system * Provide convenient means for communicating treatment requirements
Nursing Diagnosis - describes an actual, risk or wellness human response to a health problem that nurses are responsible for treating independently.
Nursing Diagnosis
EXAMPLE:
* Medical Dx: Pneumonia * Nursing Dx: Ineffective airway clearance r/t tracheobronchial secretions * Medical Dx: Tonsillitis * Nursing Dx: Elevated body temperature related to presence of pyrogens.
NURSING DIAGNOSIS TAXONOMY
Taxonomy
* Method for ordering complex information * Classification system to provide structure for nursing practice. * Purpose: to provide vocabulary for classifying phenomena in a discipline
Components of Nursing Dx
Diagnostic Label/Problem - this describes the client’s health status clearly and concisely in a few words. - name of the nursing diagnosis as listed in the taxonomy * E.g. Impaired mobility; activity intolerance
Descriptors – words used to give additional meaning to a nursing diagnosis. They describe changes in condition, state of the client or some qualification * E.g. altered, impaired, decreased, ineffective, acute, chronic, excessive, delayed
Components of Nursing Dx
Related factors/Etiology – describes the conditions, circumstances that contribute to the problem. Terms used: associated with, related to or contributing to.
Defining characteristics/Signs and symptoms – observable cues that cluster as manifestation of an actual or wellness nursing diagnosis.
Risk factors – describe clinical cues in risk nursing diagnosis. They are environmental, physiological, psychological, genetic, or chemical factors that increase the vulnerability of pt. leading to unhealthful event.
Formulating Nursing Diagnosis A. Collect Valid and pertinent data B. Cluster the Data C. Differentiate Nursing Dx from Collaborative problems D. Formulate Nursing Dx correctly select priority diagnosis.

Use Nursing Diagnosis Decision Tree
Types of Nursing Diagnosis
A. Actual Describes a clinical judgment that the nurse has validated because of the presence of major defining characteristics. Ex. Ineffective Airway Clearance related to excessive and tenacious secretions.
B. Risk Describes a clinical judgment that an individual/group is more vulnerable to develop the problem than others in the same or similar situation Ex. Risk for Impaired Skin Integrity related to immobility secondary to fractured hip. C. Possible An option to indicate that some data are present to confirm a diagnosis but are insufficient as of this time. Ex. Possible Self Care Deficit related to impaired ability to use left hand secondary to presence of intravenous therapy.
D. Wellness Diagnostic statement that describes the human response to level of wellness. From a specific level of wellness to a higher level of wellness. Ex. Readiness for enhanced spiritual well being Diagnostic Statements
A. One-Part Just the label or the problem Ex. Readiness for enhanced parenting
B. Two-Part Problem r/t to etiology or risk factors Ex. Risk for impaired skin integrity related to immobility secondary to fractured hip
C. Three-Part Diagnostic label + contributing factors + signs and symptoms. Ex. Anxiety related to unpredictable nature of operative procedure as evidenced by statements of: “Natatakot akong hindi makahinga.”
Nursing Diagnosis
To use NANDA
Use the 2-part Diagnostic Statements Problem r/t etiology or risk factors + secondary to
Don’ts
Using medical diagnosis ex. Self care deficit related to stroke Self care deficit related to neuromuscular impairment
Relating the problem to an unchangeable situation ex. paralysis
Confusing etiology or s/sx for the problem ex. Post op lung congestion related to bedrest Ineffective airway clearance related to general weakness and immobility
Use of procedure instead of a human response ex. Catheter related to urinary retention Urinary retention related to perineal swelling
Lack of specificity ex. Constipation related to nutritional imbalance
Combining two nursing dx ex. Anxiety and fear related to separation from parents
Relating one nursing dx to another ex. Ineffective coping related to anxiety
Use of judgmental / value laden language ex. Pain related to monetary gain
Making assumptions ex. Risk for altered parenting related to inexperience
Writing a legally inadvisable statements ex. Impaired skin integrity related to not being turned 2 hourly
Case : Nursing Diagnosis
Nursing care plan
A written guide for nursing intervention which aims to assist the patient to meet health needs and coordinate care provided by the nursing staff.
To be effective, involve the client and his family in planning.
Purpose: to develop a plan of action that will reduce or eliminate patient’s problems and promote health
Priority Setting:
Setting priorities
Writing goals
Planning nursing actions
Rationale for Priority Setting:
Decision making process in which the nurse determines the order in w/c the patient’s problems are approached.
Done in order that maximum effort can be directed toward resolution of the most urgent problem.
Factors to consider in priority setting
Maslow’s hierarchy of needs
Effect of lower needs on satisfaction of higher needs and reverse
Fulfillment of patient’s preference
Potential for future problems
Medical; problems and treatment
Goal Setting
Nursing goal are: * The desired outcome of nursing care that which you hope to achieve with your patient * Statements designed to remedy or lessen the problem identified in the nursing diagnosis * Needed to identify clearly what it is the nurse strives to achieve through nursing action.
Example
Guidelines for writing goal statements:
Write goals in observable, measurable and objective terms. Avoid the use of words such as “improved”, “adequate” or “normal”.
Write goals in terms of patient responses, outcomes, and behaviors, not in terms of nursing action.
Each goal is related to one nursing diagnosis.
Include a time for the response, behavior or outcome in the goal.
PLANNING
* Set goals and objectives in collaboration with the client. Short-term goal (STG) or Long-term goal (LTG) S – Specific M – Measurable A – Attainable R – Realistic T – Time-framed
IMPLEMENTATION
Putting the nursing care plan into action
Purpose: To carry out planned nursing interventions to help the client attain goals
Requirements:
1. Knowledge 2. Technical skills 3. Communication Skills
IMPLEMENTATION
STEPS: 1. Reassess the client 2. Set priorities a. ABC b. Maslow’s hierarchy of needs 3. Implement nursing interventions 4. Documentation
IMPLEMENTATION
Implementing Nursing interventions 1. Assessment – for baseline data ex: Assess breath sounds, assess wt 2. Independent nursing interventions ex: Will position pt to high-fowlers Will encourage slow but deep breathing Will instruct to have small but frequent feeding
IMPLEMENTATION
3. Dependent nursing interventions ex: Will administer pain reliever as ordered. 4. Interdependent nursing interventions ex: Will secure specimen for urinalysis as ordered 5. Psychosocial interventions ex: Will encourage verbalization of feelings
EVALUATION
Assessing the client’s response to nursing interventions and then comparing the response to predetermined standards or outcome criteria.
Purpose: To determine the extent to which goals if nursing care have been achieved.
EVALUATION
STEPS: 1. Collect data about client’s response 2. Compare the client’s response to outcome criteria 3. Analyze the reasons for the outcomes 4. Modify care plan as needed.
EVALUATION FORMULATION
Outcome Outcome Met Actual px
Evaluation = Outcome partially+ Behavior
Statement met as evidenced Outcome not met
Example
Nursing Diagnosis: Activity intolerance r/t prolonged bed rest.
Goal: Patient will walk the length of hall and back by 2/7.
Evaluation: (done on 2/7 or earlier)
Outcome achieved: patient walked length of hall but too tired to walk back
Outcome not achieved: patient refused to walk because of nausea.
Outcome not achieved: patient un able to bear his own weight.
Characteristics . . . . .
Problem-oriented – it is comparable with scientific problem solving approach
Goal oriented
Orderly, planned, step by step
Open to accepting new information during its application
Interpersonal
Permits creativity among nurses and clients in devising ways to solve the health problems
Cyclical
Universal
Benefits for clients
Quality of care
Continuity of care
Participation by the clients in their health care
Benefits for the Nurse
Consistent and systematic nursing education
Job satisfaction
Professional growth
Avoidance of legal action
Meeting professional nursing standards
Meeting standards of accredited hospitals
A man’s heart plans his way
But the Lord directs his steps . . . . . Proverbs 16:9