1.-Assessment-NCP.pdf

NURSING PROCESS  What is Nursing Process? a systematic, patient-centered approach used by nurses to ensure high-quality care  It involves five interrelated steps: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE)  These steps guide the nurse in delivering effectiv...

NURSING PROCESS  What is Nursing Process? a systematic, patient-centered approach used by nurses to ensure high-quality care  It involves five interrelated steps: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE)  These steps guide the nurse in delivering effective, holistic, individualized, and evidence-based care to patients. 1. Assessment  Definition:The systematic collection of data about a patient’s health status  Purpose: To gather comprehensive information about the patient’s physical, psychological, social, and spiritual health.  Components v Subjective Data: Information provided by the patient, such as symptoms and personal experiences. v Objective Data: Observable and measurable data, such as vital signs, lab results, and physical examination findings. 2. Diagnosis  Definition: The nurse’s clinical judgment about the patient’s health conditions or needs, based on the assessment data  Purpose:To identify the patient’s health problems that can be addressed by nursing care.  Components v NANDA-I Diagnosis (Problem): Use standardized language to describe the nursing diagnosis. v Related Factors (Etiology): The causes or contributing factors of the problem. v Defining Characteristics (Signs/symptoms): Signs and symptoms that validate the diagnosis. Example of Nursing Diagnosis Nursing Diagnosis: Impaired Gas Exchange related to alveolar-capillary membrane changes as evidenced by low SpO2 and shortness of breath. 3. Planning Ø Definition: The development of goals and outcomes, and the selection of nursing interventions to address the nursing diagnoses. Ø Purpose: To create a plan of care that is individualized to the patient’s needs. Ø Components: v Goals/Outcomes: Specific, measurable, attainable/achievable, realistic/relevant, and time-bound (SMART) statements that define what the patient should achieve. v Interventions: Specific actions the nurse will take to help the patient meet the goals. Example of Planning Goal: After 8 hours of nursing intervention, the patient will be able to improve SPO2 to 92% or above on room air. Intervention: Administer oxygen at 2 L/min via nasal cannula. 4. Implementation Ø Definition: The execution of the nursing care plan, including carrying out the planned interventions. Ø Purpose: To perform the actions that will help the patient achieve the desired outcomes Ø Components: vDirectCare: Hands-on care, such as administering medications or assisting with mobility. vIndirectCare: Actions that support patient care, such as documentation and collaboration with other healthcare professionals. Example of implementation Direct Care: Administer oxygen therapy and monitor the patient’s respiratory status. Indirect Care: Document the patient’s response to the intervention and communicate any changes to the healthcare team. 5. Evaluation Ø Definition: The assessment of the patient’s response to the nursing interventions and progress toward achieving the goals. Ø Purpose: To determine the effectiveness of the care plan and whether modifications are needed. Ø Components: vGoal Achievement: Determine if the patient met the expected outcomes. vReassessment: Review the patient’s condition and revise the care plan if necessary. Example of Evaluation Evaluation: Goal Met! After 8 hours of nursing intervention, the patient was able to improve SPO2 to 93% on room air, and respiratory rate decreased to 20 breaths per minute. The care plan will continue with a focus on maintaining oxygenation. PREPARED BY: CHARLEMAGNE B. PULGAN, RN Nursing Assessment  the first step of the nursing process, where the nurse collects comprehensive information about a patient's health status  this step is crucial as it lays the foundation for creating an individualized care plan  the assessment involves gathering both subjective and objective data through various methods like observation, interviews, physical examinations, and reviewing medical records Components of Nursing Assessment 1. Subjective Data Ø Informationprovided by the patient or their family members is based on personal perceptions, feelings, and experiences. Examples: üSymptoms: “I have a headache,” “I feel short of breath,” “I’ve been feeling anxious. üHistory: Past medical history, family history, lifestyle habits, and social factors  General and health history Subjective – what the patient says 1. Health history 2. Family history 3. Chief complaint 2. Objective Data Ø Observable and measurable information is collected by the nurse through physical examination, diagnostic tests, and observations. Examples: üVital Signs: Blood pressure, heart rate, respiratory rate, temperature üPhysicalFindings: Skin color, lung sounds, level of consciousness, edema üLaboratoryResults: Blood glucose levels, hemoglobin, electrolyte levels  Objective – what you see/measure  Behavior and mode  Appearance  Hygiene and nourishment level  Posture and mobility  Level of consciousness  Collecttheir vital signs ( it’s encouraged to ask permission before touching a patient)  Objective – what you see/measure  Measure blood pressure  Check heart rate  Take body temperature  Pulse oximetry  Respiratory rate  Check pain levels  Check height and weight with BMI Types of Nursing Assessments A. Initial (Comprehensive) Assessment üWhen:Conducted upon admission or first encounter with the patient üPurpose: To establish a baseline and gather detailed information about the patient’s overall health. üComponents: Complete health history, review of systems, and a thorough physical examination. B. Focused Assessment üWhen: Performed when a patient presents with a specific complaint or issue üPurpose: To gather data about a specific problem or body system üComponents: Detailed examination of the area or system of concern (e.g., assessing respiratory function in a patient with shortness of breath) C. Ongoing (Follow-Up) Assessment üWhen: Conducted at regular intervals during patient care. üPurpose: To monitor changes in the patient’s condition and evaluate the effectiveness of interventions. üComponents: Reassessing vital signs, pain levels, wound healing, etc. D. Emergency Assessment üWhen: Conducted during a crisis or emergency situation üPurpose: To quickly identify life-threatening conditions and initiate immediate interventions üComponents: Rapid assessment of airway, breathing, circulation (ABCs), level of consciousness, etc. Methods of Data Collection 1. Observation üVisual: Observing the patient’s overall appearance, mobility, behavior, and interactions üAuditory: Listening to the patient’s speech, breath sounds, and any distress signals üOlfactory: Detecting any unusual odors (e.g., fruity breath in diabetic ketoacidosis) 2. Interview üOpen-Ended Questions: Encouraging the patient to describe their symptoms and concerns in their own words (e.g., “Can you tell me more about your pain?”). üClosed-Ended Questions: Asking specific, direct questions to obtain precise information (e.g., “Have you had any surgeries in the past?”). 3. Physical Examination ü Inspection: Visually examining the patient’s body for any abnormalities. ü Palpation:Feeling the body with hands to assess texture, temperature, moisture, and the presence of lumps or tenderness. ü Percussion:Tapping on body parts to determine the underlying structure’s density (e.g., checking for fluid in the lungs). ü Auscultation: Listening to body sounds, such as heart, lung, and bowel sounds, using a stethoscope. What are the 4 methods of clinical assessment?  When you perform a physical assessment, you’ll use four techniques: 1. Inspection – look and smell 2. Palpation – feel texture and consistency with palms and fingertips 3. Percussion – tap to assess for dullness/tympany 4. Auscultation – listen for sounds 4. Review of Records üMedical History: Reviewing past medical records, treatment plans, and diagnostic results. üProgress Notes: Checking previous documentation for any changes in the patient’s condition. üLab and Imaging Reports: Evaluating recent test results for any abnormalities. Nursing Assessment Frameworks 1. Head-to-Toe Assessment: Systematic evaluation starting from the head and moving down to the toes, covering all body systems. 2. Focused Assessment: Concentrated on a particular body system based on the patient’s presenting symptoms. 3. Functional Health Patterns (Gordon’s): A holistic approach assessing areas like nutrition, sleep, elimination, activity, and stress. Head to toe assessment  Before the examination ØEnsure privacy and keep the room at a comfortable temperature ØSit/stand at eye level and make good eye contact Øuse open-ended questions to gather unbiased information Documentation of Nursing Assessment ü Accuracy: Record precise and factual information. ü Timeliness: Document findings immediately or as soon as possible after the assessment. ü Completeness: Ensure that all relevant data are included. ü Confidentiality: Protect patient information as per HIPAA or other relevant regulations. Example of a Nursing Assessment v Patient: 68-year-old female, admitted for shortness of breath. v Subjective Data: The patient reports worsening shortness of breath over the past two days, especially when lying flat. Complaints of fatigue and a persistent dry cough. Denies chest pain. v Objective Data: Vital Signs: BP 150/90 mmHg, HR 98 bpm, RR 28 breaths/min, Temp 98.6°F, SpO2 88% on room air. Physical Exam: Wheezing heard in all lung fields, jugular venous distention observed, 2+ pitting edema in lower extremities. Lab Results: Elevated BNP (Brain Natriuretic Peptide), suggestive of heart failure. Mental Status Level of consciousness is a term used to describe a person’s awareness and understanding of what is happening in his/her surroundings. Level of consciousness description: v Awake – Alert, responds immediately and fully to commands, may or may not be fully oriented. vConfused – The inability to think rapidly and clearly. There is impaired judgement and decision-making. v Disorientated–There is disorientation in place, impaired memory, and a loss of recognition of self which is the last to deteriorate. v Lethargic– Drowsy, sleeps a lot, but is easily aroused with minimal stimuli, i. e. voice, and then responds, but may not be oriented in time, place, or person. v Obtundation – Can be aroused by stimuli; (not pain) i. e shaking and will then respond to questions or commands. Remains aroused as long as stimulation is applied. If not will fall asleep, and questions are aroused with minimal response. During the arousal, the patient responds but may be confused. v Stuporous – This is a condition of deep sleep or unresponsiveness. The patient can only be aroused or caused to make a motor or verbal response by vigorous and repeated external stimulation (painful). The response initiated is often withdrawal or grabbing at stimulus. v Comatose – There is no motor response to the external environment or to any stimuli, even deep pain or suctioning. There is no arousal to any stimulus. Reflexes may be present, and abnormal (posturing) to pain may be present. What does the Glasgow Coma Scale? The Glasgow Coma Scale (GCS) is used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients. The scale assesses patients according of three aspects of responsiveness:  Eye-opening  Motor Response  Verbal Response Practical Example Ø Confused Question: "What day is it today?" Response: "It’s Tuesday, and I have to go to work," (but it’s actually Saturday and the patient is in the hospital). Ø Inappropriate Words Question: "What day is it today?" Response: "Apple tree...running fast...,” (words are unrelated and do not answer the question). 1. Localizes to Pain (Score: 5 on GCS) Ø The patient purposefully moves their hand or arm towards the source of pain in an attempt to stop it. This indicates a higher level of brain function because the patient can recognize the pain and attempt to address it. Ø Ifa painful stimulus is applied (e.g., pressure on the nail bed or supraorbital ridge), the patient brings their hand or arm toward the area where the pain is being applied to push it away or stop it. Ø Example: If you apply pressure to the nail bed on the right hand, the patient might use their left hand to reach across and try to push your hand away 2. Withdrawal from Pain (Score: 4 on GCS) Ø the patient pulls the limb away from the source of pain, but this response is more reflexive than purposeful. It indicates a lower level of brain function compared to localization. Ø Ifa painful stimulus is applied, the patient’s arm or leg will pull back or flex away from the stimulus, but there is no directed movement toward the site of the pain to stop it Ø Example: If you apply pressure to the nail bed on the right hand, the patient might pull their hand away from the pressure but does not try to move their other hand toward the painful area. Head & Eyes  Inspect and palpate hair, scalp, and face.  Test CN VII – have the patient smile, frown, show teeth, and puff cheeks.  Inspect sclera, iris and conjunctiva for any discoloration/abnormalities  Test vision – Snellen chart  Check pupils are equal, round, and reactive to light and accommodation Neurological and mental Status  Assess speech pattern  Orientation to person, place, time, and situation  Assess immediate, recent and remote memory  Ensure the client’s thought process is logical and coherent  Assess mode and facial expression ; if it’s is inappropriate Ears 1. Test hearing  There are components of hearing screening: ØOtoscopic inspection 2. Inspect pinna and inner ear  Mouth 1. Inspect lips/mucosa 2. Assess teeth and gums 3. Check soft palate Nose 1. Assess patency 2. Ensure a sense of smell 3. Inspect septum and turbinates Throat 1. Inspect uvula 2. Test CN IX “say ahhh” v The glossopharyngeal nerve (CN IX) It provides motor, parasympathetic and sensory information to your mouth and throat vAmong its many functions, the nerve helps raise part of your throat, enabling swallowing. Throat 3. Test CN XI The Spinal Accessory Nerve - The muscles innervated directly by the CN XI nerve are the trapezius and the sternocleidomastoid in addition to the laryngeal musculature such as the palatal, pharyngeal, laryngeal muscles. 4. Test CN XII-or Hypoglossal “movement of tongue side by side Integuments  Inspect Skin 1. Color 2. Moisture 3. Texture 4. Turgor 5. Lesions Lungs and Cardiovascular  Inspect anterior and posterior chest  Palpate apical pulse (pigeon chest vvvv.  Auscultate lung sounds  What are abnormal lung sounds you may hear? 1. Stridor - or noisy breathing, is caused by a narrowed or partially blocked airway, the passage that connects the mouth to the lungs. (higher-pitched noisy) 2. Rhonchi – “harsh sound” This is a low-pitched sound that resembles snoring. This will occur when air tries to pass through bronchial tubes that contain fluid or mucus. 3. Wheezes- This high-pitched whistling noise can happen when you’re breathing in and out. 4. Rales – you can have fine crackles, which are lower. Either can be a sign that there’s fluid in your air sacs. They can be caused by Pneumonia. “slurping a straw” 5. Crackles are short interrupted breath sounds usually associated with pulmonary disorders. Auscultate heart sounds How do you auscultate heart sounds?  Listen over the mitral valve area with the bell of the stethoscope. Ask the patient to sit forward and fully exhale as they hold their breath in expiration. Listen over the second left intercostal space at the left sternal border with the diaphragm of the stethoscope. There are two normal heart sounds that should be elicited in auscultation:  S1 (Lub)  S2 (dub) Listen for normal heart sounds:  The1st heart sound, S1(lub) marks the beginning of systole Related to the closure of the mitral and tricuspid valves. Loudest at the apex.  The 2nd hear sound, S2 (dub) marks the end of systole (beginning of diastole). Related to the closure of the aortic and pulmonic valves.  Loudest at the base. Four main heart valves areas: 1. Aortic 2. Pulmonary 3. Tricuspid 4. Mitral Abnormal Heart Sounds Are called Heart Murmurs  such as whooshing or swishing made by rapid, choppy (turbulent) blood flow through the heart.  Abdomen Gastrointestinal and Genitourinary 1. Inspect contour, symmetry 2. Auscultate for bowel sounds 3. Percuss all 4 quadrants 4. Palpate all 4 quadrants 5. Assess bladder and voiding habits Extremities and Musculoskeletal 1. Assess ROM and muscle strength 2. Check for + grade any edema 3. Inspect posture and gait 4. Test deep tendon reflex The chapter you’re learning today is going to save someone’s life tomorrow. Pay attention!!!  NURSING CARE PLAN  is a comprehensive document that outlines the nursing care to be provided to a patient.  It is developed based on the patient's individual needs, nursing diagnoses, and desired outcomes.  The care plan guides the nursing team in delivering consistent and effective care, ensuring that all aspects of the patient’s condition are addressed. PES format a structured approach used to write nursing diagnoses within a Nursing Care Plan (NCP) vP (Problem): The specific nursing diagnosis or problem identified vE (Etiology): The cause or contributing factors related to the problem vS (Signs and Symptoms): The evidence or manifestations that support the diagnosis. How to Write a PES Nursing Diagnosis? 1. Problem (P) ØIdentify the nursing diagnosis based on the patient’s assessment. ØUse standardized nursing diagnosis terminology, such as those found in NANDA-I (North American Nursing Diagnosis Association International). ØExample: Impaired Gas Exchange 2. Etiology (E) ØIdentify the underlying cause or contributing factors related to the problem. ØThis is often phrased as “related to” or “r/t”. ØExample: related to alveolar-capillary membrane changes 3. Signs and Symptoms (S) ØList the defining characteristics or clinical manifestations that validate the diagnosis. ØThis is often phrased as “as evidenced by” or “AEB”. ØExample: as evidenced by SpO2 of 88% on room air, respiratory rate of 26 breaths/min, and use of accessory muscles for breathing. Example of PES Statement Nursing Diagnosis ØImpaired Gas Exchange (P) related to alveolar-capillary membrane changes (E) as evidenced by SpO2 of 88% on room air, respiratory rate of 26 breaths/min, and use of accessory muscles for breathing (S).  Steps to Create a Nursing Care Plan Using PES 1. Assessment ØCollect subjective and objective data to identify the patient’s problems. 2. PES Nursing Diagnosis ØUse the PES format to formulate a clear, concise nursing diagnosis that guides the care plan. 3. Goals/Outcomes Ø Based on the PES statement, set SMART goals that aim to resolve or mitigate the identified problem. 4. Interventions Ø Plan and implement nursing interventions to address the etiology (E) and signs/symptoms (S) in the PES statement. 5. Evaluation Ø Assessthe patient’s response to the interventions and whether the goals were achieved. Adjust the care plan as needed.  Example of a Nursing Care Plan Using PES A. Patient Information Ø Age: 70 years old Ø Diagnosis: Pneumonia B. Assessment Ø Subjective: Patient reports difficulty breathing and fatigue. Ø Objective:SpO2 is 86% on room air, respiratory rate 28 breaths/min, bilateral crackles noted on auscultation. C. PES Nursing Diagnosis Ø Impaired Gas Exchange (P) related to alveolar-capillary membrane changes due to inflammation and infection (E) as evidenced by SpO2 of 86% on room air, respiratory rate of 28 breaths/min, and bilateral crackles (S). D. Goals/Outcomes Ø After 3 hours of nursing intervention, the patient will be able to: a. improve SPO2 to 95% or above in room air b. report reduced shortness of breath and exhibit a respiratory rate of 16-20 breaths per minute within 3hours of initiating oxygen therapy c. demonstrate effective deep breathing and coughing techniques Goal Writing Tips Specific: Clearly define what is to be achieved (e.g., "SpO2 will improve to 95%"). Measurable: Include quantifiable indicators (e.g., "SpO2 levels at or above 95%"). Attainable/Achievable: Ensure the goal is realistic given the patient's condition (e.g., improving oxygenation). Realistic/Relevant: The goal should directly address the problem identified in the nursing diagnosis (e.g., improving gas exchange). Time-bound: Specify a timeframe for achieving the goal (e.g., "within the next 3 hours"). E. Interventions Ø Administer oxygen at 2 L/min via nasal cannula to maintain SpO2 ≥ 92%. Ø Administerprescribed antibiotics to treat the underlying infection. Ø Positionthe patient in a high Fowler’s position to facilitate lung expansion. Ø Monitorrespiratory status and lung sounds every 4 hours and prn. Ø Encourage deep breathing and coughing exercises to clear secretions. F. Evaluation Ø Goal Met! Ø After 3 hours of nursing intervention, the patient was able to: a. improve SPO2 to 95% in room air b. report reduced shortness of breath and exhibit a respiratory rate of 16 breaths per minute after initiating oxygen therapy c. demonstrate effective deep breathing and coughing techniques Charlemagne B. Pulgan, SN  How to prioritize nursing care plans? Ø Prioritizing nursing care plans involves determining the most important and urgent needs of the patient and organizing care interventions accordingly. Ø Prioritization ensures that the most critical issues are addressed first, which can improve patient outcomes and overall care efficiency. Here are steps and strategies for prioritizing nursing care plans: 1. Assess Patient Needs ü Identify Critical Issues: Determine which problems are most urgent or life-threatening. This involves assessing the severity and immediacy of each issue. üConsider Patient Safety: Prioritize care interventions that address immediate risks to patient safety and well-being. 2. Use the ABCs (Airway, Breathing, Circulation) üAirway: Ensure that the patient’s airway is clear and functioning. üBreathing: Address issues related to the patient’s ability to breathe effectively. üCirculation: Focus on problems related to blood flow and cardiovascular health. 3. Apply Maslow’s Hierarchy of Needs ü Physiological Needs: Prioritize interventions that address basic physiological needs like oxygen, hydration, nutrition, and elimination. ü SafetyNeeds: Ensure the patient is in a safe environment and address any potential hazards. ü Love and Belonging: Consider emotional support and social needs once basic physiological and safety needs are met. ü Esteem and Self-Actualization: Address higher-level needs once more immediate needs are stabilized. 4. Use the Nursing Process ü Assessment:Prioritize based on the assessment data, including patient complaints, vital signs, and diagnostic results. ü Diagnosis: Address the most pressing nursing diagnoses first. ü Planning: Develop care plans that target the highest priority needs. ü Implementation:Focus on implementing interventions that address the most critical issues. ü Evaluation:Continuously reassess priorities based on the patient’s response to interventions and changes in their condition. 5. Consider Urgency and Impact ü High Priority: Problems that are life-threatening or require immediate action (e.g., severe bleeding, airway obstruction). üMedium Priority: Issues that affect patient comfort or recovery but are not immediately life- threatening (e.g., pain management). üLow Priority: Problems that are less urgent or can be addressed once more critical issues are managed (e.g., patient education on discharge). 6. Utilize Frameworks and Tools üNANDA-I Taxonomy: Use standardized nursing diagnoses to help categorize and prioritize care. üThe Nursing Care Plan Framework: Follow a structured framework that guides prioritization based on patient needs and conditions. Example of Prioritizing Nursing Care Plans Scenario: A patient is admitted with chronic obstructive pulmonary disease (COPD) exacerbation, exhibiting shortness of breath, elevated blood pressure, and signs of dehydration. 1. Immediate Priorities ü Airway and Breathing: Administer oxygen therapy and assess lung sounds. Address any immediate respiratory distress. ü Circulation: Monitor blood pressure and initiate fluid replacement if dehydration is severe. 2. Secondary Priorities ü Comfort and Pain Management: Address any reported pain or discomfort related to the COPD exacerbation. ü Patient Education: Provide information about COPD management, but this can be done once the immediate symptoms are stabilized. 3. Tertiary Priorities ü Long-Term Planning: Plan for follow-up care, lifestyle modifications, and continued education once acute issues are resolved. Summary üPrioritizing nursing care plans involves assessing the patient’s immediate and long-term needs, focusing on critical issues first, and using frameworks like the ABCs and Maslow’s Hierarchy of Needs. üBy applying these strategies, nurses can ensure that they provide timely and effective care that addresses the most pressing concerns and promotes the best possible patient outcomes. Nursing Care Plan Scientific Assessment Diagnosis Objective Intervention Rationale Evaluation basis