NP

• Initial Comprehensive Assessment


  Performed within specified time after admission to a health care agency to establish a complete database for problem identification and future comparison
• Assessment/Assessing


  Establish a data base through systematic and continuous collection, organization, validation, and documentation of data
• Objective data


  Data directly or indirectly observed through measurement
• Focused or Problem-Oriented Assessment


  Thorough assessment of a particular client problem, not covering areas not related to the problem
• Nursing Process

  • Phases: Assessment, Diagnosing, Planning, Implementation, Evaluation
• Assessment

  Four types: Initial Comprehensive Assessment, Ongoing or Partial Assessment, Focused or Problem-Oriented Assessment, Emergency Assessment
• Emergency Assessment


  Done during any physiological or psychological crisis of the client
• Ongoing-Partial Assessment


  Data collection after the comprehensive database is established, mini-overview of the client's body systems and holistic health patterns
• Subjective data


  Data elicited and verified by the client
• Nursing Diagnosis

  1. Statement of a client’s potential or actual health problem resulting from analysis of data

  2. Statement of client’s potential or actual alterations/changes in health status

  3. Problem statement that the nurse makes regarding a client’s condition to communicate professionally
• Preparing for the Assessment


  1. Review client’s record, if available

  2. Know the client’s basic biographical data(age, sex, religion, and occupation)

  3. Review client’s status with other health care team members

  4. Keep an open mind and validate information with the client

  5. Use this time to educate yourself about the client’s diagnoses or tests performed

  6. Reflect on your feelings regarding your initial encounter with the client

  7. Obtain and organize materials needed for the assessment
• Emergency Assessment


  1. Done during any physiological or psychological crisis of the client

  2. Done to identify life-threatening problems like choking, cardiac arrest, drowning

  3. Done when an immediate diagnosis is needed to provide prompt treatment

  4. Done to identify new or overlooked problems

  5. Example: Evaluation of the client’s airway, breathing, and circulation when cardiac arrest is suspected

  6. The major concern during this type of assessment is to determine the status of the client’s life-sustaining physical functions
• Steps of Health Assessment

  1. Collection of subjective data

  2. Collection of objective data

  3. Validation of data

  4. Documentation data
• Diagnosis


  1. To identify the client’s healthcare needs and prepare diagnostic statement

  2. To analyze assessment information and derive meaning from this analysis
• Components of Nursing Diagnosis

  • Problem
  • Etiology
  • Defining Characteristics
• Planning


  To identify the client’s goal and appropriate nursing interventions
• Types of Planning

  • Initial Planning
  • Ongoing Planning
  • Discharge Planning
• Establishing Priorities

  1. Life-threatening situations

  2. Use of the CAB principles

  3. Maslow’s hierarchy of needs

  4. Consider something that is very important to the client ex. Pain, anxiety

  5. Clients unstable condition

  6. Resources

  7. Actual problems take precedence over potential concerns

  8. Attend to the client before the equipment
• Types of Evaluation

  • Ongoing Evaluation
  • Intermittent Evaluation
  • Terminal Evaluation
• Types of Nursing Goals

  • SHORT TERM- GOAL- most common in acute care facilities, outcome that can be attained in an hour to days (may vary)
  • LONG-TERM GOAL- most common in nursing homes, rehabilitative centers and extended facilities, outcome that can be met in weeks-months (may vary)
• ONGOING PLANNING


  Performed with all nurses who work with the client
• Types of Nursing Interventions

  • Independent
  • Dependent
  • Collaborative
• Classifications

  • High-priority- potentially life-threatening and required immediate action
  • Medium-priority- problems that can result in unhealthy consequences but not life-threatening
  • Low-priority- problems that can be resolved easily with minimal interventions
• PLANNING

  1. To identify the client’s goal and appropriate nursing interventions

  2. To direct client care activities

  3. To promote continuity of care

  4. To focus charting requirements

  5. To allow for delegation of specific activities
• INITIAL PLANNING


  Admission assessment, initial comprehensive plan of care
• Factors when assigning priorities

  • Clients health values and beliefs
  • Clients priorities
  • Resources available to the nurse and client
  • Urgency of the health problem
  • Medical treatment plan
• DISCHARGE PLANNING


  Anticipating and planning for needs after discharge
• FORMULATE NURSING GOALS/ CLIENT-OUTCOME

  1. SPECIFIC

  2. MEASURABLE

  3. ATTAINABLE

  4. REALISTIC

  5. TIME-BOUND
• Components of Goals/ Desired Outcome Statements

  • Subject
  • Verb
  • Conditions or modifiers
  • Criterion of desired performance
• EVALUATING


  To determine the client’s response with regards to the interventions rendered
• IMPLEMENTING


  To give an appropriate, wholistic and prompt quality healthcare service to the client
• Four Possible Judgment/Evaluation of the Outcome

  • Completely met/ Goal met
  • Partially met
  • Completely unmet/ Goal not met- New problems or nursing diagnoses have emerged or developed