NURSING PROCESS ASSESSMENT Flashcards
A systematic, client-centered method for structuring the delivery of nursing care.
Nursing Process
What is the difference of Shamans to People who practiced medicine?
Shamans don’t do documentations
- Goal oriented method of caring.
- Provides structure for nursing practice.
- Entails gathering and analyzing data and in order to identify client strengths and potential or actual problem.
Nursing Process
NANDA stands for?
North American Nursing Diagnosis Association
ACTUAL OR POTENTIAL PROBLEM
- This refers to a health condition that is currently present and observed in the patient.
- It is supported by defining characteristics (signs and symptoms).
- Nursing interventions aim to manage, treat, or resolve the issue.
Example: Acute Pain related to surgical incision as evidenced by verbal complaints of pain, facial grimacing, and guarding behavior.
Actual Problem
ACTUAL OR POTENTIAL PROBLEM
- This refers to a condition that has not yet occurred but the patient is at risk of developing.
- It is identified based on risk factors rather than existing symptoms.
- Nursing interventions focus on prevention to reduce the likelihood of the problem occurring.
Example: Risk for Infection related to invasive procedure and compromised immune response. (No current signs of infection, but the patient is at risk due to a wound or surgery.)
Potential Problem
The Nursing Process is a structured, scientific method used by nurses to provide patient care.
Give 4 Characteristics of the Nursing Process.
Systematic
- The nursing process follows a logical and organized sequence to assess, diagnose, plan, implement, and evaluate care.
- Each step builds on the previous one, ensuring consistency and accuracy in patient care.
Cyclic and Dynamic
- It is continuous and ever-changing based on the patient’s condition and response to interventions.
- If a nursing intervention is not effective, the process loops back to reassessment and modifications are made accordingly.
Client-Centered
- The nursing process is tailored to the individual patient rather than following a one-size-fits-all approach.
- It considers the patient’s needs, preferences, values, and participation in their own care.
Interpersonal and Collaborative
- Nursing care requires effective communication with the patient, family, and healthcare team.
- Collaboration with doctors, physical therapists, dietitians, and other professionals ensures holistic and coordinated care.
FAMILIARIZE ONLY!
“Purposes of the Nursing Process”
- To identify client’s health status.
- To identify actual or potential health care problems or needs.
What are the 5 Phases of the Nursing Process?
- Assessment
- Diagnosis
- Planning
- Implementation / Intervention
- Evaluation
REMEMBER THE ACRONYM ADPIE
WHAT IS THIS?
- Systematic & continuous collection, organization, validation, & documentation of data.
- A continuous process.
- Focuses on client’s responses to a health problem.
Assessment
What are the 2 components of Assessment?
Subjective and Objective Data
A type of data that is elicited or directly quoted by the patient.
Subjective Data
A type of data that is measured and observed.
Objective Data
What are the 4 Types of Assessment?
- Initial or Comprehensive Assessment
- Problem-focused assessment
- Emergency Assessment
- Time-lapsed reassessment
WHAT TYPE OF ASSESSMENT IS THIS?
Purpose:
- To establish a complete database for problem identification, reference, & future comparison.
Time Performed:
- Within a specified time after admission to a health care agency.
Example:
- Nursing admission assessment
Initial Assessment or Comprehensive Assessment
WHAT TYPE OF ASSESSMENT IS THIS?
Purpose:
- To determine the status of a specific problem identified in an earlier assessment.
Time Performed:
- Ongoing process integrated with nursing care.
Example:
- Hourly assessment of a client’s I&O in an ICU.
Problem-focused assessment
WHAT TYPE OF ASSESSMENT IS THIS?
Purpose:
- To identify life-threatening problems
- To identify new or overlooked problems
Time Performed:
- During any physiologic or psychologic crisis
Example:
- Rapid ABC assessment during a cardiac arrest
Emergency Assessment
WHAT TYPE OF ASSESSMENT IS THIS?
Purpose:
- To compare the client’s current status to baseline data previously obtained.
Time Performed:
- Several months after initial assessment.
Example:
- Reassessment of a client’s functional health patterns in a home care.
Time-lapsed reassessment
What are the 4 Related Activities done during assessment?
- Collecting data
- Organizing data
- Validating data
- Documenting data
WHAT IS THIS?
- This is getting a client’s DATA BASE.
Collecting Data
In Collecting Data, what are the DATABASE sources?
Give 4.
- Health History
- Physical assessment
- Laboratory and diagnostic tests
- Materials contributed by other health personnel
WHAT IS THIS?
The FF are the PURPOSE of this:
Identify…
- Patterns of health and illness
- Risk factors for health problems
- Deviations from normal
- Available resources for adaptation
Health History
FAMILIARIZE ONLY!
“Guidelines in Health History Taking”
- Sources of Information:
- Client, family or significant others, health team members & client’s health record.
- Most of the data are SUBJECTIVE.
- Focus on data/information from all the client’s dimensions.
- Record data using clear, concise and appropriate terminology.
FAMILIARIZE ONLY!
“Basic Components of Health History”
- Source and Reliability of Information
- Reasons for seeking care or Chief Complaint
- Present Health or History of Present Illness
- Past Medical History/Past Health
- Family History
- Socio-economic Data or Social History
- Psychosocial Assessment
- Functional Assessment
- Health Perception - Health Management Pattern
- Nutritional - Metabolic Pattern
- Elimination Pattern
- Activity - Exercise Pattern
- Sleep - rest Pattern
- Cognitive - Perceptual Pattern
- Self - Perception - Self - Concept Pattern
- Role Relationship Pattern
- Sexuality - Reproductive Pattern
- Coping - Stress Tolerance Pattern
- Value - Belief Pattern
- Review of Systems
- General Survey
- Skin/Integument
- Head
- Eyes
- Hearing
- Nose and Sinuses
- Mouth and Throat
- Neck
- Breast
- Thorax and Lungs (Respiratory)
- Heart (Cardiac)
- Gastrointestinal
- Urinary
- Genitalia (Male or Female)
- Peripheral Vascular
- Musculoskeletal
- Neurologic
- Hematologic
- Endocrine
- Psychiatric
Under BASIC COMPONENTS OF HEALTH HISTORY
Should be in narrative form (describe specifically according to the patient’s manifestation or capability).
Sample Statements:
- The patient was competent to provide information. She was able to speak clearly; conscious and coherent; oriented to time, place and person.
Source and Reliability of Information
Under BASIC COMPONENTS OF HEALTH HISTORY
Recorded as direct quotes.
Examples:
- “I am going to college and I need to get a physical check-up; the college is requiring me to get a hepatitis B vaccine…”
- “I need to find a new health care provider to treat my asthma because it is starting to bother me again…”
Reasons for seeking care or Chief Complaint
Under BASIC COMPONENTS OF HEALTH HISTORY
It is a crucial component of a health history assessment, helping nurses and healthcare providers understand a patient’s current health status.
Present Health or History of Present Illness (HPI)
BASIC COMPONENTS OF HEALTH HISTORY
Under the Present Health or History of Present Illness (HPI)
The ff is for __________:
- The focus is on the general state of health and any health maintenance behaviors.
- Example: “The patient describes himself as a healthy male without any significant medical problems.”
- Includes lifestyle factors such as diet, exercise, sleep, and stress management.
For a Well Person
BASIC COMPONENTS OF HEALTH HISTORY
Under the Present Health or History of Present Illness (HPI)
The ff is for __________:
- A chronological account of how the illness developed, structured to gather detailed information about the chief complaint (CC).
- Timing
- Location
- Quality (Character)
- Quantity (Severity, Volume, Number)
- Setting in which symptoms occur
- Associated Phenomena/Manifestations
- Aggravating/Alleviating Factors
- Meaning and Impact of Chief Complaint (CC) on the Client
For an Ill Person
FAMILIARIZE ONLY!
“KEY Elements of HPI (History of Present Illness)”
- Timing
- Onset: When did the symptoms start?
- Frequency: How often do they occur?
- Duration: How long do they last?
- Location
- Where is the symptom felt? (E.g., chest pain, abdominal pain)
- Quality (Character)
- How does the symptom feel? (E.g., sharp, dull, burning, throbbing pain)
- Quantity (Severity, Volume, Number)
- How severe is the symptom? (E.g., rating pain on a scale of 1-10)
- How much is present? (E.g., amount of sputum in a cough)
- Setting in which symptoms occur
- What was the patient doing when symptoms appeared?
- Does it occur at a specific time of day or during specific activities?
- Associated Phenomena/Manifestations
- Are there any other symptoms that occur alongside the main complaint? (E.g., fever with a cough, nausea with a headache)
- Aggravating/Alleviating Factors
- What makes the symptoms worse? (E.g., movement, eating, stress)
- What makes them better? (E.g., rest, medications, home remedies)
- Meaning and Impact of Chief Complaint (CC) on the Client
- How does the illness affect the patient’s daily life?
- How does the patient perceive the illness? (E.g., Is the patient anxious, scared, or dismissive?)
FAMILIARIZE ONLY!
“History of Present Illness (a sample):”
“The patient was in their usual state of good health until one week ago, when they developed shortness of breath (SOB) accompanied by mild wheezing and chest tightness. The patient has been using albuterol MDI (2 inhalations qid), which usually improves breathing. No other medications have been taken. The patient, who typically runs 5 miles daily, has not felt well enough to do so this past week. Yesterday, the patient recorded a temperature of 37.0°C and reported a sore throat and fatigue. However, the patient denies sputum production, cough, sinus pressure, tooth pain, nasal discharge, or nasal polyps. The patient noticed that symptoms began the day after performing yard work before a recent storm.”
Analysis of the HPI Sample:
- Timing (Onset, Frequency, Duration):
- Symptoms began one week ago.
- Shortness of breath (SOB) has persisted, affecting daily activities.
- Location:
- Chest tightness is mentioned, indicating the symptom’s location.
- Quality (Character):
- SOB is described along with mild wheezing and chest tightness.
- Quantity (Severity, Volume, Number):
- Severity is implied as significant enough to require albuterol inhaler four times daily (qid).
- The patient usually runs 5 miles daily but has been unable to due to symptoms.
- Setting:
- Symptoms started the day after doing yard work before a storm.
- Associated Phenomena/Manifestations:
- Positive symptoms:
→ Sore throat
→ Fatigue
→ Mild fever (37.0°C) yesterday - Negative symptoms (denials):
→ No sputum, cough, sinus pressure, tooth pain, nasal discharge, or nasal polyps.
- Aggravating/Alleviating Factors:
- Albuterol MDI (2 inhalations qid) helps ease breathing.
- No other medications taken.
- Impact on Client’s Life:
- Unable to continue his usual 5-mile daily run due to symptoms.
Under BASIC COMPONENTS OF HEALTH HISTORY
The FF are referring to what?
- Review of previous illness
- Injuries & hospitalizations
- Obstetric history (female)
- Surgeries/operations
- Allergies
- Immunizations
- Use of medications
Past Medical History/Past Health
Under BASIC COMPONENTS OF HEALTH HISTORY
The FF are referring to what?
- Health status of the immediate family members & other blood relations (age, cause of death, or present state of health)
- Genogram or family tree
Family History
Under BASIC COMPONENTS OF HEALTH HISTORY
The FF are referring to what?
- Information about patient’s lifestyle that can affect health.
Socio-economic Data or Social History
Under BASIC COMPONENTS OF HEALTH HISTORY
The FF are referring to what?
- Evaluation of mental health, social status, and functional capacity.
- Specific for the current developmental stage of the Client
- Use Erik Erikson’s Psychosocial Dvelopment Theory
Psychosocial Assessment
Under BASIC COMPONENTS OF HEALTH HISTORY
The FF are referring to what?
- Includes a person’s ability to perform activities of daily living and physical self-maintenance activities.
- Assists the nurse in collecting, organizing and categorizing data.
Functional Assessment
BASIC COMPONENTS OF HEALTH HISTORY
Under Functional Assessment
The FF are referring to what?
- Person’s description of his current health
- Activities that the person does to improve or maintain his health
- Person’s knowledge about links between lifestyle choices and health
- Extent of person’s problem on financing health care, if any
- Person’s knowledge of the names of current medications he is taking and their purpose/s
- Activities that the person does to prevent problems related to allergies, if any
- Person’s knowledge about medical problems in the family
- Any important illnesses or injuries in this person’s life
Health Perception - Health Management Pattern
BASIC COMPONENTS OF HEALTH HISTORY
Under Functional Assessment
The FF are referring to what?
- Person’s nourishment
- Person’s food choices in comparison with recommended food intake
- Any disease that affects nutritional - metabolic function
Nutritional - Metabolic Pattern
BASIC COMPONENTS OF HEALTH HISTORY
Under Functional Assessment
The FF are referring to what?
- Person’s excretory pattern
- Any disease of the digestive system, urinary system or skin
Elimination Pattern
BASIC COMPONENTS OF HEALTH HISTORY
Under Functional Assessment
The FF are referring to what?
- Person’s description of his weekly pattern of activities, leisure, exercise and recreation
- Any disease that affects his cardio-respiratory and/or musculoskeletal system
Activity - Exercise Pattern
BASIC COMPONENTS OF HEALTH HISTORY
Under Functional Assessment
The FF are referring to what?
- Description of the person’s sleep-wake cycle
- Person’s physical appearance (rested and relaxed?)
Sleep-rest Pattern
BASIC COMPONENTS OF HEALTH HISTORY
Under Functional Assessment
The FF are referring to what?
- Any sensory deficit and if corrected
- Person’s ability to express himself clearly and logically
- Person’s education
- Any disease that affects mental or sensory function
- Person’s pain description & causes, if any
Cognitive - Perceptual Pattern
BASIC COMPONENTS OF HEALTH HISTORY
Under Functional Assessment
The FF are referring to what?
- Anything unusual about the person’s appearance
- If person is comfortable with his appearance
- Description of the person’s feeling state.
Self - Perception - Self - Concept Pattern
BASIC COMPONENTS OF HEALTH HISTORY
Under Functional Assessment
The FF are referring to what?
- Person’s description of his various roles in life
- Positive role models of his roles, if any
- Important relationships at present
- Any big changes in role or relationship
Role Relationship Pattern
BASIC COMPONENTS OF HEALTH HISTORY
Under Functional Assessment
The FF are referring to what?
- Person’s satisfaction with his situation related to sexuality
- How have the person’s plans and experiences matched regarding having children?
- Any disease/dysfunction of the reproductive system
Sexuality - Reproductive Pattern
BASIC COMPONENTS OF HEALTH HISTORY
Under Functional Assessment
The FF are referring to what?
- Person’s means/actions of coping with problems
- If coping actions help or make things worse
- Any treatment for emotional distress
Coping - Stress Tolerance Pattern
BASIC COMPONENTS OF HEALTH HISTORY
Under Functional Assessment
The FF are referring to what?
- Principles that the person learn as a child which are still important to him
- Person’s identification with any cultural, ethnic, religious, regional or other groups
- Support systems that the person has
Value - Belief Pattern
Under BASIC COMPONENTS OF HEALTH HISTORY
The FF are referring to what?
- Subjective responses to a series of body system - related questions
- Head - to - toe approach
- Include sign or symptom - related and disease - related questions
Review of Systems
BASIC COMPONENTS OF HEALTH HISTORY
Under REVIEW OF SYSTEMS
The FF are referring to what?
- Usual weight
- Recent weight changes
- Weakness
- Fatigue
- Fever
- Sweats
General Survey
BASIC COMPONENTS OF HEALTH HISTORY
Under REVIEW OF SYSTEMS
The FF are referring to what?
- Rashes
- Lumps
- Sores
- Itching
- Dryness
- Color change
- Changes in hair or nails
Skin/Integument
BASIC COMPONENTS OF HEALTH HISTORY
Under REVIEW OF SYSTEMS
The FF are referring to what?
- Headache
- Head injury
- Dizziness
Head
BASIC COMPONENTS OF HEALTH HISTORY
Under REVIEW OF SYSTEMS
The FF are referring to what?
- Vision
- Glasses or contact lenses
- Last eye examination
- Pain and redness
- Excessive tearing
- Double vision
- Spots
- Flashing lights
- Glaucoma and cataracts
Eyes
BASIC COMPONENTS OF HEALTH HISTORY
Under REVIEW OF SYSTEMS
The FF are referring to what?
- Tinnitus
- Vertigo
- Earaches
- Infection
- Discharge
- Use of hearing aids
Hearing
BASIC COMPONENTS OF HEALTH HISTORY
Under REVIEW OF SYSTEMS
The FF are referring to what?
- Frequent colds
- Nasal stuffiness
- Discharge or itching
- Nosebleeds
- Sinus trouble
Nose and Sinuses
BASIC COMPONENTS OF HEALTH HISTORY
Under REVIEW OF SYSTEMS
The FF are referring to what?
- Condition of teeth and gums
- Bleeding gums
- Dentures if any and how they fit
- Last dental examination
- Sore tongue
- Dry mouth
- Frequent sore throat
- Hoarseness
Mouth and Throat
BASIC COMPONENTS OF HEALTH HISTORY
Under REVIEW OF SYSTEMS
The FF are referring to what?
- Lumps
- Swollen glands
- Goiter
- Pain or stiffness in the neck
- Limitation of motion
Neck
BASIC COMPONENTS OF HEALTH HISTORY
Under REVIEW OF SYSTEMS
The FF are referring to what?
- Lumps
- Pain or discomfort
- Nipple discharge
- History of breast disease
- Any surgery of the breast
- BSE including frequency and method
Breast
BASIC COMPONENTS OF HEALTH HISTORY
Under REVIEW OF SYSTEMS
The FF are referring to what?
- Cough
- Sputum (color, quantity)
- Hemoptysis
- Wheezing
- Asthma
- Dyspnea
- History of respiratory diseases
- Toxin or pollution exposure
- Last x-ray film
Thorax and Lungs (Respiratory)
BASIC COMPONENTS OF HEALTH HISTORY
Under REVIEW OF SYSTEMS
The FF are referring to what?
- Precordial or retrosternal pain
- Heart trouble
- High blood pressure
- Rheumatic fever
- Heart murmurs
- Chest pain or discomfort
- Palpitations
- Dyspnea
- Orthopnea
- Edema
- Past ECG or other heart test results
Heart (Cardiac)
BASIC COMPONENTS OF HEALTH HISTORY
Under REVIEW OF SYSTEMS
The FF are referring to what?
- Dysphagia
- Heartburn
- Appetite
- Nausea
- Vomiting
- Regurgitation
- Vomiting of blood
- Indigestion
- Frequency of BM
- Color and size of stools
- Change in bowel habits
- Rectal bleeding or black tarry stools
- Hemorrhoids
- Constipation
- Diarrhea
- Abdominal pain
- Food intolerance
- Excessive belching or passing of gas
- Jaundice
- Liver or gallbladder trouble
Gastrointestinal
BASIC COMPONENTS OF HEALTH HISTORY
Under REVIEW OF SYSTEMS
The FF are referring to what?
- Frequency of urination
- Polyuria
- Nocturia
- Burning or pain on urination
- Hematuria
- Urgency
- Reduced force of the urinary stream
- Hesitancy, dribbling, incontinence
- Urinary infections
- Stones
Urinary
BASIC COMPONENTS OF HEALTH HISTORY
Under REVIEW OF SYSTEMS
The FF are referring to what?
- Hernias
- Discharge from or sores on the penis
- Testicular pain or masses
- History of sexually transmitted infections and their treatments
- Sexual preference, interest, function, satisfaction and problems
Male genitalia
BASIC COMPONENTS OF HEALTH HISTORY
Under REVIEW OF SYSTEMS
The FF are referring to what?
- Age @ menarche
- Regularity
- Frequency and durations of periods
- Amount of bleeding
- Bleeding between periods or after intercourse
- Last menstrual period
- Dysmenorrhea
- Premenstrual tension
- Age of menopause
- Menopausal symptoms
- Discharge, itching
- Sores, lumps
- Number of pregnancies
- # of deliveries
- Complications of pregnancy
- Birth control methods (for married women)
- Sexual preference, interest, function, satisfaction, any problems
Female genitalia
BASIC COMPONENTS OF HEALTH HISTORY
Under REVIEW OF SYSTEMS
The FF are referring to what?
- Coldness, numbness and tingling
- Swelling of legs
- Discoloration of hands or feet
- Varicose veins or complications
- Intermittent claudication, thrombophlebitis, ulcers
- Does the occupation of the client involve long-term sitting or standing?
- Does the client avoid crossing legs at the knees?
- Does the client wear support hose?
Peripheral Vascular
BASIC COMPONENTS OF HEALTH HISTORY
Under REVIEW OF SYSTEMS
The FF are referring to what?
- Joints: Pain, stiffness, swelling (location, migratory nature), deformity, limitation of motion, noise with joint motion.
- Muscles: Pain, cramps, weakness, gait problems or problems with coordinated activities
- Back: Pain (location and radiation to extremities) stiffness, limitation of motion, or history of back pain or disease
Musculoskeletal
BASIC COMPONENTS OF HEALTH HISTORY
Under REVIEW OF SYSTEMS
The FF are referring to what?
- History of seizure disorder and stroke
- Sensory function: Memory disorders (recent or distant, disorientation)
- Motor function: tics or tremors, paresis — weakness, fainting, blackouts
Neurologic
BASIC COMPONENTS OF HEALTH HISTORY
Under REVIEW OF SYSTEMS
The FF are referring to what?
- Anemia
- Easy bruising or bleeding
- Past transfusion
Hematologic
BASIC COMPONENTS OF HEALTH HISTORY
Under REVIEW OF SYSTEMS
The FF are referring to what?
- Thyroid trouble
- Heat or cold intolerance
- Excessive sweating
- Diabetes
- Excessive thirst/hunger
- Polyuria
Endocrine
BASIC COMPONENTS OF HEALTH HISTORY
Under REVIEW OF SYSTEMS
The FF are referring to what?
- Nervousness
- Tension
- Mood including depression
- Hx of mental dysfunction or hallucination
Psychiatric
In collecting Data,
What are the 2 Type of Sources of data?
Primary and Secondary
What type of Sources of Data is this?
- The client
Primary
What type of Sources of Data is this?
- All sources other than the client
Secondary
Who is the best source of information?
The client
FAMILIARIZE ONLY!
“Basic Categories of Diagnostic Tests”
1️⃣ Tests that Measure Body Function & Performance
- Evaluate how well an organ or system is working.
Examples:
→ Heart Rate Monitoring – ECG, pulse oximetry
→ Lung Function Tests – Spirometry
→ Vision Tests – Visual acuity, color blindness test
2️⃣ Tests that Use Hollow Tubes & Fiber Optics to View Inside the Body
- Uses cameras to examine internal structures directly.
Example:
→ Endoscopy – Gastroscopy, colonoscopy, bronchoscopy
3️⃣ Tests that Use Imaging (Film or Sound) to Look at the Body
- Provides internal views without invasive procedures.
Examples:
→ X-rays – Chest X-ray, bone fracture imaging
→ Scans – CT scan, MRI
→ Ultrasound (UTZ) – Obstetric UTZ, Doppler UTZ
4️⃣ Tests that Collect & Analyze Specimens from the Body
- Requires bodily fluids or tissues for laboratory analysis.
Examples:
→ Blood Tests – CBC, blood glucose test
→ Urinalysis – Checks kidney function, infections
→ Fecalysis – Detects parasites, GI infections
→ CSF Analysis – Diagnoses meningitis, neurological conditions
WHAT IS THIS?
- A test that examines urine to detect infections, kidney disease, diabetes, or other medical conditions.
- Common Parameters: Color, pH, glucose, protein, ketones, WBC, RBC, bacteria.
Urinalysis
WHAT IS THIS?
- The process of drawing blood from a vein using a needle for laboratory testing.
- Common Blood Tests: CBC, blood glucose, cholesterol levels, electrolyte panel.
Venipuncture
WHAT IS THIS?
- A small sample of tissue is removed from the body for microscopic examination.
- Purpose: Diagnose cancer, infections, or other abnormal tissue growth.
Biopsy
WHAT IS THIS?
- Uses radiation (X-rays) to capture images of bones and internal structures.
- Common Uses: Bone fractures, pneumonia, lung diseases, dental imaging.
Radiography (X-ray)
WHAT IS THIS?
- Uses high-frequency sound waves to create real-time images of organs and tissues.
- Common Uses: Pregnancy monitoring, heart (echocardiography), abdominal organs.
Ultrasonography (UTZ)
WHAT IS THIS?
- Uses powerful magnets and radio waves to generate detailed images of organs, soft tissues, and joints.
- Common Uses: Brain scans, spinal cord injuries, ligament tears, tumors.
Magnetic Resonance Imaging (MRI)
WHAT IS THIS?
- Records the electrical activity of the heart to assess heart rhythm and function.
- Common Uses: Detects arrhythmias, heart attacks, heart enlargement.
Electrocardiogram (ECG/EKG)
