Escolar Documentos
Profissional Documentos
Cultura Documentos
and validation.
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it is a G O S H approach (goal-oriented,
health needs.
Humanistic care
2
• plan to care is developed and implemented taking into
condition/illness)
time, money/cost)
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problem. She must make decisions whenever several
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
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- First Step in the Nursing Process
is standard/norm.
and lifestyles.
the client):
• physical assessment
4 Types of Assessment:
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Ex: nursing admission assessment
assessment
output hourly
threatening problems.
Activities:
1. Collection of data
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2. Validation of data
3. Organization of data
4. Analyzing of data
5. Recording/documentation of data
of medical record
I. Collection of data
status
methods)
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• current/present problems of client (pain, nausea, sleep
Types of Data:
a. Subjective data
subjective data.
b. Objective data
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Example: pallor, diaphoresis, BP=150/100, yellow
discoloration of skin
a. Interview
counseling.
c. Examination
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c.2. Body System approach – examine all the body system
area affected
Source of data:
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• Reason for visit/Chief complaint – primary reason
assessment.
mental illness).
body systems
neighborhood conditions.
emotional state.
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• Pattern of health care – includes all health care
doctors.
is what the client says, or what the nurse can see, hear, feel,
smell or measure.
on the cues.
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Example: red, swollen wound = infected wound
2. Nutritional-metabolic pattern
3. Elimination pattern
4. Activity-exercise pattern
5. Sleep-rest pattern
6. Cognitive-perceptual pattern
7. Self-perception-concept pattern
8. Role-relationship pattern
9. Sexuality-reproductive pattern
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IV. Analyze data – compare data against standard and
development pattern
V. Communicate/Record/Document Data
health status
meaning.
Process
Diagnosing
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• the process of reasoning or the clinical act of identifying
problems
Nursing Diagnosis.
Nursing Diagnosis
alterations/changes.
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• Is the problem statement that the nurse makes
communicate professionally.
3 activities in Diagnosing:
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4. It is the basis for planning and carrying out nursing
care.
2. Etiology/related factors/causes = E
Examples:
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• Noncompliance (Medication) r/t unknown etiology
about Diagnosis
possible to occur.
Examples:
surroundings
problem does not exist, therefore no S/S are present, but the
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presence of RISK FACTORS is indicates that a problem is only
about it.
Examples:
intake
surgery.
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1. Actual nursing diagnosis = Patient problem + Etiology –
abbreviated as r/t.
insufficient, incomplete
reduced, deteriorated
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3. Data analysis after comparing with standards
strengths
client’s life
Activity/Exercise
touch, teary eyed and with dry lips and mucous membrane.
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Nsg Dx: Hyperthermia r/t environmental condition AMB T =
39C, flush skin, warm to touch, teary eyed and dry lip and
mucous membrane.
Nauseated x 2 days
process/cough
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Nsg Dx: Disturbed Sleep Pattern r/t a disease process,
pneumonia
Anxious
neighbors
parenting roles.
Process
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• involves determining before and the strategies or
Purpose:
phase.
1. Establish/Set priorities
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1. Life-threatening situations should be given highest
priority.
circulation)
concerns.
tube.
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2. Plan nursing interventions/nursing orders to direct
Nursing interventions
outcomes.
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Interdependent/Collaborative – those activities the nurse
NCP
receive.
diagnosis.
diagnosis.
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4. Nursing interventions must be specifically designed to
into action.
Activities:
problems.
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3. Perform nursing interventions – these may be
done at all.
Requirements of Implementation:
procedures.
interventions.
to care
Process
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• is assessment the client’s response to nursing
Activities:
criteria.
follows:
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MATERNAL DATA BASE ASSESSMENT GUIDE
Personal Data
Name of Patient : R. A.
Age : 32 y/o
Nationality : Filipino
of Christ
Menstrual History
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Maternal History
a. Family History
drinker.
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Before Pregnancy:
During Pregnacy:
heavy ADL’s.
Nutrition-Metabolic Pattern
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Before Pregnancy:
During Pregnancy:
Elimination Pattern
Before Pregnancy:
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• She urinates 4-5 times a day with the amount of at
stool softeners.
During Pregnancy:
stool softeners.
Activity-Exercise Pattern
Before Pregnancy:
her usual time. She prepares their breakfast and did all
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the household chores. Her ADL’s serves as her exercise
During Pregnancy:
activities.
Sleep-Rest Pattern
Before Pregnancy:
her to get her sleep. She is not using sleeping pills. She
During Pregnancy:
Cognitive-Perceptual Pattern
Before Pregnancy:
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her. She is able to answer questions immediately. She
During Pregnancy:
Before Pregnancy:
said.
During Pregnancy:
• The patient stated that she will take good care of her
as she stated.
Before Pregnancy:
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• She is a loving housewife and a mother. She loves to
During Pregnancy:
Sexuality-Reproductive Pattern
Before Pregnancy:
During Pregnancy:
pregnancy go through.
Before Pregnancy:
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just turns on their television to watch her favorite
During Pregnancy:
Value-Belief Pattern
Before Pregnancy:
During Pregnancy:
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Date Assessed: February 22, 2009
Vital Signs:
Temperature: 36.50C
General Appearance:
easily.
AREA TECHNIQ
NORMAL ACTUAL ANALY
ASSESSE UES
FINDINGS FINDINGS SIS
D USED
SKIN
soft soft
Turgor Palpation Skin snaps Skin snaps Normal
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back back
immediately immediatel
when y when
pinched pinched
Hair Inspection Evenly Evenly Normal
n
Temperatu Palpation Warm to Warm to Normal
re touch touch
Moisture Palpation Dry, skin Dry, skin Normal
normally normally
moist moist
NAILS
curvature curvature
Nail Base Inspection Firm Firm Normal
Capillary Blanch 2-3 seconds 2-3 seconds Normal
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(varies)
Distributio Inspection Evenly Evenly Normal
n distributed distributed
Moisture Inspection Neither Neither Normal
excessively excessively
resilient resilient
HEAD
Symmetry l
Skull Size Inspection Normoceph Normoceph Normal
alic alic
Shape Inspection Round Round Normal
and
Palpation
Nodules/ Palpation Absence of Absence of Normal
masses masses
FACE
l
Facial Inspection Symmetrical Symmetrica Normal
Movement l
Skin color Inspection Tan Tan Normal
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EYES
equal equal
movement movement
Eyelashes Inspection Slightly Slightly Normal
curved curved
upward upward
Eyelids Inspection Smooth, Smooth, Normal
as sclera, as sclera,
close close
symmetrical symmetrical
ly ly
Ability to Inspection Blinks Blinks Normal
and and
bilaterally bilaterally
Frequency Inspection 20 blinks 20 blinks Normal
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movement freely freely
Position Inspection Drawn from Drawn from Normal
angle
Size Inspection Medium Medium Normal
Texture Palpation Mobile, firm Mobile, firm Normal
tender tender
Conjuncti
color color
Texture Inspection Shiny and Shiny and Normal
smooth smooth
Presence Inspection No lesions No lesions Normal
of lesions
Lacrimal
Apparatu
Clarity
Texture Inspection Shiny, Shiny, Normal
smooth, smooth,
transparent transparent
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Pupils
React to React to
Light Light
Accommoda Accommoda
tion tion
(PERRLA) (PERRLA)
Size Inspection Equal Equal Normal
Shape Inspection Round and Round and Normal
constrict constrict
briskly briskly
Symmetry Inspection Equal in size Equal in Normal
size
Visual Inspection Able to real Able to read Normal
straight straight
ahead, ahead,
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see objects see objects
in periphery in periphery
Ocular Inspection Eyes move Eyes moves Normal
freely freely
NOSE
Septum
symmetrical symmetrical
Nasal Inspection No No Normal
Lips
slightly slightly
brown brown
Symmetry Inspection Symmetrical Symmetrica Normal
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l
Texture Palpation Soft, moist, Soft, moist, Normal
smooth smooth
Moisture Palpation Soft and Soft and Normal
moist moist
Gums
Mucosa
pink pink
Texture Palpation Soft Soft Normal
Moisture Palpation moist moist Normal
Tongue
l
Mobility Inspection Moves Moves Normal
freely freely
Uvula
midline midline
Symmetry Inspection Symmetrical Symmetrica Normal
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l
Tonsils
discharges discharges
Teeth
sh
NECK
Centered Centered
Movement Inspection Moves Moves Normal
freely freely
Range of Inspection Full range Full range Normal
Motion
Consistenc Inspection No No Normal
y Enlargemen Enlargemen
t t
HEART
Heart Auscultati Clear, Clear, Normal
crackles crackles
Lung Field Auscultati Resonant Resonant Normal
on
THORAX
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AND
LUNGS
Posterior
Symmetry l
aligned backward(lo cy
rdosis)
Anterior
Thorax
and and
effortless, effortless,
produces no
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noise.
Lung/ Auscultati Broncho- Broncho- Normal
sounds
ABDOME
Contour
Texture Palpation Smooth Smooth Normal
Frequency Auscultati Audible; soft Audible; Normal
minutes
UPPER
EXTREMI
Skin color
Size Inspection Equal Equal Normal
(arms)
Symmetry Inspection Symmetrical Symmetrica Normal
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l
Hair Inspection Evenly Evenly Normal
n
LOWER
EXTREMI
Skin color
Size (legs) Inspection Equal Equal Normal
Symmetry Inspection Symmetrical Symmetrica Normal
l
Hair Inspection Evenly Evenly Normal
n
NEUROLO
GIC
commands commands
Behavior Interview Makes eye Makes eye Normal
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e examiner examiner
Mood Interview Expresses Expresses Normal
feelings feelings
which which
correspond correspond
to situation to situation
Manneris
ms and
actions
inflection
Tone Interview Fluent and Fluent and Normal
articulated articulated
Manner Interview Can give Can give Normal
questions questions
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Mental
person person
Time
recall of recall of
remote remote
information information
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