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-What is the Nursing Process?

It is a systematic method that directs the nurse and patient in planning patient care, and enables you to organize and
deliver nursing care
It is patient centered and outcome oriented
The steps are interrelated and dependent on the accuracy of each of the preceding steps
It is used to identify, diagnose, and treat human responses to health and illness

Together the nurse and the patient accomplish the following:
Assess the patient to determine need for nursing care
Determine nursing diagnoses for actual and potential health problems
Identify expected out comes and plan care
Implement care
Evaluate the results

Five Steps of the Nursing Process
Assessment collection of patient data
Diagnosis identifies patients strengths and potential problems
Planning develop the specific holistic desired goals and nursing interventions to assist the patient
Implementation carry out the plan of care
Evaluation determine the effectiveness of the plan of care

Assessment: Phase One of the Nursing Process
Purpose:
Establish a baseline of information on the client and develop a data base
Determine clients normal function
Determine clients risk for dysfunction
Determine presence or absence of dysfunction
Determine clients strengths
Provide data for diagnostic phase

Unique Focus of Nursing Assessment
Nursing assessments do not duplicate medical assessments
Medical assessments target data pointing to pathologic conditions
Nursing assessments focus on the patients responses to health problems or potential health problems

Assessment
The purpose is to establish a database by:
Collecting data
Subjective versus objective
Interviewing and taking a health history
Subjective and organized
Performing a physical examination
Vital signs, patients behavior, diagnostic and laboratory data, medical records

Approaches for Data Collection
Gordons 11 Functional Health Patterns
Uses a series of questions which assist in formulating a nursing diagnosis
Problem focused assessment
Focuses on the patients problem and develop you plan of care around the problem

Gordons Health Patterns
Health perception-management
Nutritional-metabolic
Elimination
Activity-exercise
Sleep-rest
Cognitive -perceptual
Self-perception-self-concept
Role-relationship
Sexuality-reproductive
Coping-stress-tolerance
Value-belief

Types of Nursing Assessments
Initial assessment
Focused assessment
Emergency assessment
Time-lapsed assessment

Types of Data
Subjective Data
Information perceived only the affected person
Cannot be perceived or verified by another person
Examples: feeling nervous, nauseated, chilly
Objective Data
Observable and measurable data
Data that can be see, heard or felt by someone other than the person experiencing it
Examples: elevated temperature (>101 F), moist skin, refusal to eat, vital signs

Characteristics of Data
Complete
Factual and accurate
Relevant

Components of Data Collection
Interview
Orientation phase
Working phase
Termination

Sources of Data
Primary
patient
Secondary
Family members
Significant other
Other healthcare professionals
Health records

Components of Data Collection
Nursing History
Biographical information
Reasons for seeking healthcare
Present illness or health concern
Health history
Environmental history
Psychosocial and cultural history
Review of systems or functional health patterns

Interpreting Assessment Data
Data interpretation and validation
Data clustering
Data documentation

HEALTH HISTORY DOCUMENTATION GUIDELINE (OUTLINE)

I. BIOGRAPHICAL DATA
A. Name, age, gender, family/marital status, religion, ethnic group
B. Date, address, occupation, HEALTH INSURANCE
C. Advance Directives
D. Referral source, informant (reliability) (document)

II. CHIEF COMPLAINT: Brief, pertinent
If annual exam, state why chose this time to come

III. PRESENT ILLNESS/PROBLEM: Or Current Health Status
A. When: Last well: Onset, duration & chronologic sequence of symptoms
B. What: Quality, intensity, related symptoms
C. Where: Location, range of symptoms
D. How: Associated factors, communicable exposure
E. Why: Possible solutions, Rx, (aggravating/alleviating)

IV. PAST MEDICAL HISTORY
A. General health & strength
B. Major childhood & adult illnesses
C. Immunizations & dates: Hep B, Hib, DTP/DTaP/Td, OPV/IPV, MMR, Varicella, Flu, TB skin tests, reactions to
immunizationsother

D. Surgery: Dates, Hospital, Dx., Complications
E. Injuries:
1. Resulting disability
2. Medical-legal relationships
F. Medications: Current, past month, past: Rx., OTC, herbs, complimentary therapies
G. Allergies: Meds, environmental, food. Must include "kind of" reaction
H. Transfusions: Reactions, date & # of units if known
I. Emotional status: Mood disorders, psychiatric attention

V. FAMILY HX
A. Any family members with patient's illness
B. Age of parents: Age & cause of death if deceased
C. Age & # of siblings: Health Status
D. Hx of heart disease, hypertension, cancer, TB, diabetes, asthma, STD's, kidney, thyroid disease
E. Major genetic disorders & health problems:
GENOGRAM TO GRANDPARENTS

VI. PERSONAL & PSYCHOSOCIAL HX
A. Personal status: Birthplace, socioeconomic group, general life satisfaction, interests, sources of stress
B. Habits: Diet, sleeping, exercise, coffee, alcohol, drugs, tobacco, safety issues (seat belts, helmets, other
precautions)
C. Sexual Hx: Satisfaction/concerns
D. Home conditions: Housing, economic conditions
E. Occupation: Work & conditions or hazards
F. Environment: Travel, milk & water supply
G. Military record: Dates & geographic location
H. Religious preference if concerns medical care
VII. ROS (REVIEW OF SYSTEMS)

GENERAL: Fever, chills, sweats, weight changes, weakness, fatigue, heat/cold intolerance, bleeding, radiation
SKIN, HAIR, NAILS: Rashes, lumps, sores, itching, color or texture changes, bruising, abnormal growths, tatoos, piercings
HEAD: Headaches, injury, dizziness, syncope, LOC, stroke
EYES: Vision/correction, blurring, diplopia, eye meds, trauma, redness, pain, glaucoma, cataracts
EARS: Hearing/loss, pain, discharge, infection, tinnitus, vertigo/"dizziness"
NOSE: Smell, obstruction, injury, epistaxis, discharge, colds, allergies, sinus pain
MOUTH & THROAT: Hoarseness, sore throats, gum problems, tooth abcess, dental care, sore tongue, taste
NECK: Lumps, "swollen glands," goiter, pain/stiffness
LYMPH NODES: Enlargement, tenderness, suppuration
RESPIRATORY: Pain, dyspnea, SOB, cyanosis, wheezing, cough, sputum (color & quantity), asthma, bronchitis, emphysema,
pneumonia, TB/BCG, last CXR & results, smoking
CARDIOVASCULAR: Chest pain/distress, palpitations, SOB, dyspnea, orthopnea (pillows needed), paroxysmal nocturnal
dyspnea, MI, rheumatic fever, murmur, exercise tolerance, ECG or other cardiac tests, hypertension, edema, leg
pains/edema/coolness/hair loss, varicose veins, thrombosis, ulcers
GASTROINTESTINAL: Appetite, digestion intolerance, heartburn, N&V, hematomesis, bowel irregularity, stool appearance,
flatulence\belching, hemorrhoids, jaundice, ulcer, gallstones, abdominal enlargement, previous X-ray
ENDOCRINE: Thyroid enlargement/tenderness, heat/cold intolerance, unexplained weight change, diabetes S/S, striae
MALE REPRODUCTIVE: Puberty onset, erections, emissions, testicular pain or masses, hernias, lesions/discharges, libido,
sexual activity, contraception, infertility, prostate, STDs, STE
FEMALE REPRODUCTIVE: Menses: Menarche, regularity, duration & amt. of flow, dysmenorrhea, LMP, last Pap AND
RESULTS, sexual activity, libido, contraception, fertility, menopause, discharge, itching, sores, STDs
Gravida/para: SAB, TAB, preg. duration, antepartum problems
BREAST: Pain, tenderness, discharge, lumps, galactorrhea, mammogram AND RESULTS, SBE
GENITOURINARY: Dysuria, pain, frequency, urgency, nocturia, hematuria, stress incontinence, hernias, STDs
MUSCULOSKELETAL: Joint stiffness, pain, motion restriction, weakness, paresthesias, cramps, deformities, back problems
HEMATOLOGIC: Anemia, lymph swelling, bruising/petechiae, fatigue, blood dyscrasia, transfusion, radiation
NEUROLOGIC: CNS disease, syncope, blackouts, dizziness, numbness, tingling, seizures, weakness/paralysis, tremors
coordination, memory, cognition, headaches, head injury
PSYCHIATRIC: Depression, mood changes, difficulty concentrating, nervousness, tension, suicidal thoughts, irritability, sleep
disturbances

VIII. CONCLUDING QUESTIONS: "Is there anything else that you think would be important for me to know?"


NURSING INTERVIEW
Is a communication process that has two focuses:
1. Establishing rapport and a trusting relationship with the client to elicit accurate and meaningful information
and
2. Gathering information on the clients developmental, psychological, physiologic, sociocultural, and spiritual
statuses to identify deviations that can be treated with nursing and collaborative interventions or strengths
that can be enhanced through nurse-client collaboration.

PHASES OF THE INTERVIEW

Introductory Phase
After introducing himself to the client, the nurse explains the purpose of the interview, discusses the types of
questions that will be asked, explains the reason for taking notes, and assures the client that confidential information
will remain confidential.

Working Phase
During this phase, the nurse elicits the clients comments about major biographic data, reasons for seeking
care, history of present health concern, past health history, family history, review of body systems for current health
problems, lifestyle and health practices, and developmental level.

Summary and Closing Phase
During the summary and closing, the nurse summarizes information obtained during the working phase and
validates problems and goals with the client.


































The test is generally done at one and five minutes after birth, and may be repeated later if the score is and remains low. Scores
7 and above are generally normal, 4 to 6 fairly low, and 3 and below are generally regarded as critically low.
A low score on the one-minute test may show that the neonate requires medical attention but is not necessarily an indication
that there will be long-term problems, particularly if there is an improvement by the stage of the five-minute test. If the Apgar
score remains below 3 at later times such as 10, 15, or 30 minutes, there is a risk that the child will suffer longer-
term neurologicaldamage. There is also a small but significant increase of the risk of cerebral palsy. However, the purpose of
the Apgar test is to determine quickly whether a newborn needs immediate medical care; it was not designed to make long-
term predictions on a child's health.
A score of 10 is uncommon due to the prevalence of transient cyanosis, and is not substantially different from a score of 9.
Transient cyanosis is common, particularly in babies born at high altitude. A study comparing babies born in Peru near sea
level with babies born at very high altitude (4340 m) found a significant difference in the first but not the second Apgar score.
Oxygen saturation (see Pulse oximetry) also was lower at high altitude.