MODULE 1

• Formulate Nursing Goals/Client Outcome Criteria

  1. Specific, Measurable, Attainable, Realistic, Time-bound goals

  2. Short-term and Long-term goals
• Objective data


  Data directly or indirectly observed through measurement
• Initial Comprehensive Assessment


  1. Performed within specified time after admission to a health care agency

  2. To establish a complete database for problem identification, reference, and future comparison

  3. Involves collection of subjective and objective data
• Nursing Diagnosis


  • Statement of a client’s potential or actual health problem resulting from analysis of data
  • Statement that describes a client’s actual or potential health problems that a nurse can identify and perform nursing interventions
• Nursing Process Overview

  1. Assessment/Assessing

  2. Diagnosis

  3. Formulate Nursing Goals/Client Outcome Criteria

  4. Implementing
• Implementing

  1. To give an appropriate, wholistic, and prompt quality healthcare service to the client

  2. Types of Nursing Interventions: Independent, Dependen
• Subjective data

  Data elicited and verified by the client
• Examples of Nursing Diagnosis

  • Ineffective Airway Clearance related to the presence of thick, tenacious secretions AEB rales on the right upper
• Assessment/Assessing

  1. Systematic and continuous collection, organization, validation, and documentation of data

  2. Four types of assessment: Initial Comprehensive Assessment, Ongoing or Partial Assessment, Focused or Problem Oriented Assessment, Emergency Assessment
• Example of a Nursing Goal

  • After 2 hours of nursing intervention, the patient will attain a normal temperature AMB
  • Temp- 36.5-37.4C, Absence of facial flushes, Skin is no longer warm to touch, No excessive sweating (diaphoresis)
• Diagnosis

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

  2. To analyze assessment information and derive meaning from this analysis
• Advantages of open-ended questions
• Method of collecting data

  Interviewing
• Current Health Information/Lifestyle

  • Allergies
  • Habits
  • Medications taken regularly
  • Exercise pattern
• Nursing Intervention

  1. Independent

  2. Dependent

  3. Collaborative
• Components of Health History

  • Biographic data
  • Chief complaint or reason for visit
  • History of present illness
  • Past history
  • Family history of illness
  • Review of systems
  • Lifestyle
  • Social data
  • Psychological data
  • Pattern of health care
• Purpose of Health History

  1. To elicit information about all the variables that may affect the client’s health status

  2. To obtain data that help the nurse understand and appreciate the client’s life experience

  3. To initiate a nonjudgemental, trusting interpersonal relationship
• Family History

  • Family history of communicable diseases
  • Heredity factors associated with causes of some diseases
  • Strong family history of certain problems
  • Health of family members
  • Cause of death of family members
• Disadvantages of open-ended questions
• Types of interview questions

  Open-ended questions
• Evaluating

  1. Ongoing evaluation

  2. Intermittent evaluation

  3. Terminal evaluation
• Types of Nursing Health History

  • Complete health history
  • Interval health history
  • Problem-focused health history
• Environmental History


  • Gather information about surroundings of the client including physical, psychological, social environment, presence of hazards, pollutants, and safety measures
• Biographical Data


  • Full name
  • Address and telephone numbers
  • Birth date and birth place
  • Sex
  • Religion and race
• Preparing Oneself

  1. Assessing own feelings and anxieties before examining the client

  2. Ensuring self-confidence

  3. Preventing the transmission of infectious agents
• Physical Systems Assessment

  1. General review of skin, hair, head, face, eyes, ears, nose, sinuses, mouth, throat, neck nodes, and breasts

  2. Assessment of respiratory and cardiovascular system

  3. Assessment of gastrointestinal system

  4. Assessment of urinary system
• Psychosocial History


  1. How client and his family cope with disease or stress, and how they responses to illness and health

  2. Assessment of psychological or social problems affecting general health of the client

  3. Major stressor

  4. Communication

  5. Self-concept

  6. Mood

  7. Usual coping mechanism
• Key elements for documentation in nursing assessments include nursing history and physical assessment (subjective & objective data)
• Objective data in examination includes IPPA (Inspection, Palpation, Percussion, Auscultation)
• Review of Systems (ROS)

  1. Collection of data about the past and present of each of the client systems

  2. Assessment of physical, sociologic, and psychological health status

  3. Identification of hidden problems and indication of client strength and liabilities
• Approaching and Preparing the Client


  1. Establishing nurse-client relationship before the physical examination

  2. Alleviating tension or anxiety in the client

  3. Explaining the purpose of the procedure

  4. Starting with less intrusive procedures

  5. Respecting client's desires and requests

  6. Describing the examination to the client

  7. Using nonthreatening/nonintrusive procedures

  8. Continuing to communicate throughout the examination
• Preparing the Physical Setting


  The nurse ensures the examination setting meets specific conditions such as comfortable room temperature, private area, quiet area, adequate lighting, firm examination table or bed, bedside table/tray for equipment
• Current Health Information/Lifestyle

  1. Allergies: environmental, ingestion, drug, other

  2. Habits "alcohol, tobacco, drug, caffeine"

  3. Medications taken regularly prescribed by doctors or self-prescription

  4. Exercise patterns

  5. Sleep patterns (daily routine)

  6. The pattern life (sedentary or active)
• Subjective data includes biographic data, present health concern review, past health history data, family history, lifestyle and health practices information
• The major concern during Emergency Assessment is to determine the status of the client’s life-sustaining physical functions
• Ensuring Confidentiality in Computerized Record
• Focused or Problem-Oriented Assessment


  1. Performed when a comprehensive database exists for a client with a specific health concern

  2. Thorough assessment of a particular client problem without covering unrelated areas

  3. Avoids repeating all system examinations
• Assessment Forms Used for Documentation

  1. Initial Assessment Form

  2. Frequent or Ongoing Assessment Form

  3. Focused or Specialty Area Assessment Form
• Contents of The Chart

  • Patient record
  • Proof of client’s condition and care in legal proceedings
  • Admission record
  • Consent for hospitalization
  • Discharge summary
  • Medical history
  • ECG form
  • X-ray results
  • Ultrasound results
  • CT Scan results
  • Laboratory results
  • TPR Sheet
  • I and O Sheet
  • IVF Sheet
  • Medication Sheet
  • Doctor’s order and progress Notes
  • Nurses notes and treatment record
  • Charge slips
• Assessment Forms are used for documentation purposes