Nursing Process presentation by Rebira .pptx

NURSING PROCESS
Set by: Rebira W.

Objectives
By the end of this presentation participants will be
able to :
1. Explain historical perspective of nursing
process
2. Define nursing process
3. Explain the characteristics of the Nursing
process
4. Mention the components/steps of nursing
process

Outline
 Historical perspective of nursing process
 Definition of Nursing process
 Characteristics of Nursing Process
 Components/Steps of Nursing Process
 Summary

Historical Perspective of Nursing
Process
In 1955 by Lydia Hall
Mentioned the term
nursing process for the
first time
She introduced three
steps of nursing
process:
o Observation
o Administration of care
&
o Validation

Historical Perspective of Nursing Process…
In the late 1950th Johnson &
In the early 1960th Orlando & Wiedenbach
 They introduced three steps of nursing process
 Assessment
 Planning &
 Evaluation.
In the late 1960th Yura & Walsh identified four
steps in the nursing process
oAssessment
oPlanning
oImplementation &
oEvaluation

Process…
Nursing diagnosis was added as a separate and
distinct step in the nursing process by the
North American Nursing Diagnosis
Association (NANDA) in 1974.
Prior to this, nursing diagnosis had been
included as a natural conclusion to the first
step, assessment.

Process…
• Latter in 1991 ANA included outcome
identification as a specific part of the planning
phase making the nursing process five steps.
• Currently the nursing process consists of six
phases or steps: assessment, diagnosis,
outcome identification, planning
interventions, implementation, and evaluation.

Process…

Nursing Process
Definition of nursing process
Is a systematic problem- solving approach
toward giving individualized nursing care.
Is a systematic method that directs the nurse
and patient as together they accomplish each
steps in the nursing process.
The diagnosis and treatment of human
responses to actual and potential health
problems or illness (ANA, 1995)

Nursing Process …
 An organized and systematic process of giving
goal oriented (problem solving) and
humanistic nursing care (holistic) that is both
effective and efficient to patient/client
(individual, family or community).
 It is the “tool” and methodology of the nursing
profession and, as such, helps nurses in
arriving at decisions and in predicting and
evaluating consequences.

Nursing Process …
Definition of nurse
 Is a person who trained and experienced in
nursing profession and interested in care of
sick/well person.
 Has completed a program of basic, generalized
nursing education and is authorized by the
appropriate regulatory authority to practice
nursing (ICN 1987).

Nursing Process …
Examples of Responses
Pain and discomfort
Daily experience such as:-
Anxiety
Loss
Loneliness
Grief

Nursing Process …
Self care limitation in the area of ADL such as:
o Communicating
o Eliminating
o Maintaining body temperature
o Expressing sexuality
o Working and playing
o Sleeping

Characteristics of Nursing Process
 Within the scope of practice
 Planned
 Based on knowledge-Research based
 Patient centered
 Goal directed
 Prioritized
 Dynamic and cyclic
 Interpersonal and collaborative
 Universally applicable

Steps In Nursing Process (ADOPIE)
1) Assessment
 Data Collection
-Primary / Symptoms-Directly from the pt
-Secondary/ Signs-By health providers
2) Diagnosis
-Analysis of data
3) Outcome Identification
-Setting measurable criteria
4) Planning
-Goals Prioritized

Steps In Nursing Process (ADOPIE)…
5) Implementation
Intervention
Action
6) Evaluation
• Goal met?
• Reassessment
NB Today Outcome Identification is added as the
sixth step of nursing process

Steps In Nursing Process (ADOPIE)…
Critical Thinking
mix of inquiry, knowledge,
intuition, logic, experience, and
common sense
Assessment
-Data collection
-Data validation
-Data organization Diagnosis
Analysis
Clinical judgment
Outcome
identification
Setting
measurable
criteria
Planning
- Priority setting
- Goal setting
- Intervention
instruction
Implementation
Carry out nursing
instructions and
physician orders
Documentation
Evaluation
Measuring goal
against set
outcomes

Summary
Nursing process is a dynamic, systematic,
cyclic, client centered way of providing
individualized and holistic nursing care.
It encompasses six sequential and interlinked
steps (assessment, diagnosis, outcome
identification, planning intervention,
implementation, and evaluation).

NURSING ASSESSMENT
Set by: Rebira W.

Objectives
By the end of this presentation participants will be
able to :
 Define nursing assessment
 Describe types of assessment
 Identify the four phases of assessment
 List the sources of data
 Discriminate between subjective and objective data
 Describe how data is collected
 Describe a method of organizing data
 Assess patients using 11 Gordon’s functional health
patterns as nursing assessment tool

Outline
• Definition of assessment
• Types of assessment
• Phases of assessment
• Sources of data
• Method of data collection
• Functional health patterns
• Summary

What is Nursing
Assessment?
Breakout 1

Definition
o A systematic collection of subjective and
objective data from patients, family, or
community with the goal of making clinical
judgment about patient, family, or community.
o Is the 1st phase of nursing process.
o Is the collection of data for nursing purposes.

Note
Remains accessible to the entire health care
team during the course of patient stay
Do not duplicate medical assessments
o Medical assessments -Target pathologic
conditions
o Nursing assessments - Focus on the patient’s
responses

Breakout 2
Why we do
nursing
assessment?

Purpose
1.To establish baseline information on the client
2. To determine the client’s
o Normal function
o Abnormal function
o Risk for dysfunction &
o Strengths
3. To provide data for the diagnosis phase

PREPARING FOR ASSESSMENT
Type Aim Time Frame
1. Initial
Ass’t
-Initial ass’t of normal function,
functional status, & collection of
data concerning actual or potential
dysfunction
-Baseline for reference & future
comparison
Within the specified time frame
after admission to hospital, nursing
home, ambulatory healthcare
center
2. Focus-
Assessment
Status determination of a specific
problem identified during previous
assessment
Ongoing process, integrated with
nursing care, a few minutes to a few
hours b/n ass’t

...
… … …
3. Time- lapsed Reass’t -Comparison of ct’s current
status to baseline obtained
previously
-Detection of changes in all
functional health patterns
after an extended period of
time has passed
Several months( 3,6,9
months or more ) b/n ass’t
4. Emergency Ass’t Identification of life –
threatening situation
At any time

Phases of Assessment
1. Data collection
2. Data validation
3. Data organization /Clustering
4. Recording and reporting

Sources of data
1. Primary
 Most reliable
 From patient
2. Secondary
 Family members
 Significant others
 Other health professionals
 Health records

Types of data
1. Objective data
2. Subjective Data
Breakout 3: Describe and Give
Examples

Subjective Data
Symptoms or covert cues including patient
feeling
Information perceived only by the affected
person
Cannot be perceived or verified by another
person
Examples:
oI feel sick
oI have stomach ache
oNausea

Objective data
Sign or overt cues
Observable, perceptible/detectable and
measurable data
o Seen, validated , heard or felt by someone
other than the person experiencing it
Obtained through observation, standard
assessment techniques (physical examination,
laboratory and diagnostic testing)

Objective data…
Examples:
oPulse: Rate 100 beats per minute, strong and
regular
oDistended abdomen
oHemoglobin 9 mg/dL

Breakout 4
Ato Hailu is 51 years old admitted 2 days ago with chest
pain. The physician in charge ordered the following
studies- ECG, and complete blood counts. He states “I feel
much better today, no more pain. It is a relief to get rid of
discomfort”. You think he appears a little tired, and seems
to be talking slowly and exhale noisily more often than you
think. He denies being tired.
V/S: Tep 37oC, PR 74 bpm, RR 20 breaths pm, B/P 140/90
mmHg.
Draw subjective and objective data from the above case
history

Data Summarization
Breakout 5
CASE STUDY 1:
• W/ro Alem Kebede, 28 years old woman admitted with
Medical Diagnosis of Acute Gastroenteritis
Subjective: States…
• “I am weak and worried about my condition.”, “My stool
is very watery and frequent” and “I’m feeling very
feverish”
Objective:
• Temp = 38.0 C (oral), Pulse = 110 per minute
• Respiration rate = 32 per minute,
• Decreased PaO2 , the nurse observed that the patient had
diarrhea x 2-3 times of ½ cup per bout following
admission

Assessment …
GROUP WORK
How will you summarize the subjective data?
What other information would you collect and
record using the nursing admission assessment
form?
5 minutes!

Breakout 6
What are methods of data
collection used during patient
assessment?

Methods of data collection
1. Client interview
2. Doing physical examination
3. Reviewing charts for other diagnostic findings
Interviewing
Is a planned communication or a conversation
with a purpose
Essential skill in obtaining history

Methods of data collection…
Two approaches to interviewing
1. Direct interview: is highly structured and
elicits specific information.
2. Non-direct interview or rapport-building
interview: the nurse allows the client to control
the purpose, subject matter, and pacing

Methods of data collection…
It has four phases
1. Reparatory phase /pre interaction phase
oOccur before the nurse meet the patient
oPre collecting of some information about the
patient
2. Introductory phase/orientation phase
oEstablishing rapport
oClarifying role
oAlleviating anxiety
3. Maintenance phase /working phase
4. Concluding phase

Interviewing skills
1. Questioning: Using open-ended questions that
cannot be answered with a simple “yes” or “no’’
2. Facilitation: “Go on…I am listening.” (including
non-verbal nodding)
3. Direction: “I understand that many things are
bothering you…could we focus on the diarrhoea for
just a minute?”
4. Summarising: "So, from what I understand, you
have had a lot of nausea and some cramping, you
have taken all of the pills each day this week and
you want some help with these symptoms…do I
have it all right?

Physical examination
• Is a systematic data collection method that uses the
senses of
o Sight
o Hearing
o Smell
o touch
• Four techniques are used:
• Inspection
• Palpation
• Percussion
• auscultation

Inspection
Is concentrated watching
Begins the moment you first meet the
individual
Good to develop a “general assessment“
Start with the inspection of each body system
Compare the right and left sides of the body
Requires good lighting, adequate exposure,
and occasional use of certain instruments

Palpation
Uses the sense of touch to assess: texture,
temperature, moisture, organ location and
size, vibrations and pulsations, swelling,
masses, and tenderness
Requires a calm, gentle approach
Done systematically:
o light palpation preceding deep palpation
and
o palpation of tender areas performed last

Different parts of the hands to assess different
factors
• Fingertips- best for skin texture, swelling,
pulsation, and presence of lumps.
• A grasping action of the fingers- to detect the
position, shape, and consistency of an organ or
mass
• The dorsa (backs) of hands and fingers- best
for determining temperature
• Base of the fingers (metatarsophalangeal
joints) or ulna surface for vibration

Percussion
o Uses short, tapping strokes on the surface of
the skin to create vibrations of underlying
organs.
o It is used for assessing the density of
structures or determining the location and the
size of organs in the body.

The Five Percussion notes and their
characteristics

Auscultation
o Involves listening to sounds in the body that
are created by movement of air or fluid
o Areas most often Auscultated include :
• Lungs
• Heart
• Abdomen
• blood vessels.

Equipment and Supplies Used for
a Physical Examination

Equipment and Supplies Used for a
Physical Examination

Equipment and Supplies Used for a Physical
Examination…

Data validation
o Double -checking of the information
o Verifying and clarifying cues and inference
o Confirm the accuracy of data
Methods of validation
o Comparing cues to normal function
o Referring text books, journals & research report
o Rechecking cues
o Clarifying the patient statement (ask closed end question)
o Seeking consensus with colleagues about inferences

Organization of data
o This process is known as data clustering.
o How data are organized depends on the
assessment model used.
o One of these models is head – to – toe model.

Data interpretation
Is important to identify cues and reach at
inferences
Helps make clinical judgments about the client

Identifying Cues and Making
Inferences
Cues are hints, or reminders, that prompt you to reach
a conclusion about a patient needs.
Subjective and objective data that you have identified
act as cues
Cues
Subjective Data
Patient states, “generalized body weakness following
three days of passing loose stool in average four
times a day”

Inferences…
• Inference: how you interpret or perceive a cue:
Generalized body weakness following
passage of loose stool, dry oral mucosa, PR:
120 beats per minute, BP: 80/50 mmHg, skin
pinch going back slowly
Dehydration
• Cues and correct inferences need:
observational skills, nursing knowledge and
clinical expertise

Inferences…
Examples of cues and inferences
Group of cues client has
oBlurry vision or visual defect, headache
oTingling and numbness in extremities,
dizziness
Possible inferences
o Client has a brain tumor
o Client is having warning signals of a stroke
o Client may be diabetic, client is anxious

Inferences…
Cues
 Persistent vomiting
 Diarrhea 4 times per day
 Taking nothing per os
 Dry oral cavity
 PR: 140 beats per min
 PB: 80/50 mmHg
 Wt: loss of 0.5 kg

Inferences…
Possible inferences
 Imbalanced body nutrition: less than body
requirement
 Fluid volume deficit
 Risk for electrolyte imbalance
 Diarrhea
 Dysfunctional gastrointestinal motility

Functional health pattern/
FHP approach

Functional health pattern/ FHP
approach

Functional Health Pattern
• Using nursing assessment format discuss
each of the pattern separately considering its
practicality at patient assessment level
• Present discussion output
Breakout 7: Make a group of 5
members

Group Reflection
Health Perception-Health Management

1. Health Perception-Health
Management

Group Reflection
Nutrition and Metabolism

2. Nutrition and metabolism pattern
o Focuses on the pattern of food and fluid
consumption relative to metabolic need.
Subjective data
Typical daily food: compare previous and
current
Special diet
Appetite: as usual, increased or decreased)
Average fluid intake per day

2. Nutrition and metabolism pattern…
Subjective data…
o Difficulty in chewing
o Nausea ,vomiting
o Abdominal pain
o Antacid
o Use of supplements, vitamins, types of snacks
o Weight loss/gain
o Sore tongue ,sore throat
o Dental problem

Objective data
Skin, oral mucous membranes, teeth, abdominal assessment
• Wt: __Ht:___BMI: ___MUAC ___
• Skin
o Colour: jaundice, Pallor or Cyanosis
o Lesion:
o Texture: Smooth and Soft Rough Thick 
o Temperature: Warm  Extremely warm  Extremely
cool  other____
o Moisture: Dry, Wet, Oily
o Turgor/skin pinch: Immediately ,Slowly, Very Slow
• Bilateral pitting oedema

Objective data ….

Objective data ….
Oral cavity
• Mucosa: Intact , lesion
Pink , pallor or red
Moist or dry
• Teeth: malformation, Dental caries
• Tongue: Pink, Pale
Dry, Moist
Lesions or Intact
Trash

3. Elimination pattern
o Describes the function of the bowel, bladder and
skin
o Helps determine regularity, quality, and quantity of
stool and urine.
Subjective data
Bowel habits
• Frequency, consistency and colour
• Pain: Yes No
• Use laxative: Yes No
• Enema: Yes No
• Hx of Bowel surgery
o Colostomy Yes No
o Illeostomy Yes No

3. Elimination pattern…
Subjective data…
Bladder habit
 Frequency ,amount and colour
 Pain: Yes No
 Haematuria: Yes No
 Incotinenance: Yes No
 Nocturia: Yes No
 Retention: Yes No
 Urinary Catheter: Yes No  Type____

Objective data
o Examine excretions for characteristics/color,
and consistency
o Abdominal assessment

Abdominal Exam

Abdomen Inspection…
Is the abdomen symmetric?
 Are there visible organs or masses?
 Look for an enlarged liver or spleen that has
descended below the rib cage.
 Asymmetry  an enlarged organ or mass.
 Lower abdominal mass  an ovarian or a
uterine tumor.

Peristalsis
o Observe for several minutes if you suspect
intestinal obstruction.
o Peristalsis may be visible normally in very thin
people.
o Increased peristaltic waves
 intestinal obstruction
 diarrhea

The skin, including:
 Scars: Describe or diagram their location.
 Striae: Old silver striae or stretch marks are
normal.
 Dilated veins: A few small veins may be
visible normally.
 Rashes and lesions
The umbilicus:
• contour and location, signs of inflammation or
hernia.

Abdominal Auscultation …
 Auscultation  bowel motility
 Listen to the abdomen before performing
percussion or palpation
these maneuvers may alter the frequency of
bowel sounds.
Bowel sounds: frequency and character
Normal sounds consist of clicks and gurgles
Frequency of 5 to 30 per minute

Abdominal Auscultation …
Note that
1. Use diaphragm of stethoscope
2. Skin depressed to approximately 1 cm
3. Listening in one spot is usually sufficient
4. Listening for 15-20 or 30-60 seconds
5. Bowel sounds cannot be said to be absent
unless they are not heard after listening for 3-
5 minutes in all 4 quadrants

Abnormal Findings Related to Bowel
Sounds
Absent/hypoactive
Listen for 3-5 minutes
o Bowel obstruction, peritonitis, paralytic
ileus
o Low Potassium
o Surgical manipulation
Increased Bowel sounds/hyperactive
Increased motility of fluids
o Diarrhea

Abdominal Percussion
 Helps to assess:
the amount and distribution of gas in the
abdomen
to identify possible masses that are solid or
fluid filled
 Percuss the abdomen lightly in all four
quadrants to assess the distribution of tympani
and dullness.
 A protuberant abdomen that is tympanitic
throughout suggests intestinal obstruction

Abdominal Percussion…
o Abdominal fluid
o Shifting dullness

Abdominal Percussion…
Determine the size of solid organs and
presence of masses, fluid and gas
Percuss for liver
Percuss for spleen
Percuss bladder if indicated
Normal percussion sound of the abdomen is
tympanic
Normally dull sound

Abdominal Percussion and Palpation
Liver Size
Span of liver
• Midclavicular
line
6-12 cm
• Midsternal
line:
4-8 cm

Abdominal Percussion and Palpation
Spleen Size
If tympany
existed: -ve sign
(normal spleen
size)
If tympany
changed to
dullness: +ve sign
(spleenomegally)

Abdominal Palpation
• With fingers together and flat on the abdominal
surface, palpate the abdomen with a light, gentle,
dipping motion
• On palpation watch the person's face, not your
hands!

Abdominal Palpation…
Light palpation
 Identify any superficial organs or masses
 Identify any area of tenderness
 Identify increased resistance to your hand
 If resistance is present, try to distinguish
voluntary guarding from involuntary muscular
spasm
Involuntary rigidity (muscular spasm) typically persists
despite these maneuvers
 indicates peritoneal inflammation

Deep palpation
This is usually required to detect any organ
enlargement, abdominal masses or swellings
Use one hand on top of another and push down
slowly.
Assess for rebound tenderness by pushing
slowly and then releasing your hand quickly
off the tender area.
Pain on withdrawal may indicate peritonitis

Palpate deeply
in all 4
quadrants
Use two hands
Press down
around 4 cm

Gentle palpation
• Tenderness
• Increased resistance
Deep palpation
• Tenderness
• Mass
Peritonitis
• Involuntary muscular
rigidity
• Ask the patient to
cough to localize pain
• Pain
 Rebound tenderness
(pain on withdrawal)

Group Reflection
Activity-Exercise

4. Activity- Exercise
o Focused on the activities of daily living requiring energy
expenditure, including self-care activities, exercise, and
leisure activities
Subjective data
o Daily Living Activities (ADL), any difficulties with:
Hygiene, cooking, house work, shopping, eating , toileting
Dyspnea: During Minor activity
During vigorous activity 
Chest pain, Stiffness
Weakness
Effect of illness on activity of daily living:_______

4. Activity- Exercise…
Objective Data
Vital signs
For every patient vital signs should be taken
1. Pulse rate
2. Respiratory rate
3. Blood pressure
4. Temperature
Prior to measuring vital signs, the patient
should have had the opportunity to sit for
approximately five minutes

1. Blood Pressure
Nursing alert!
The following condition may result in
falsely high blood pressure
• If the brachial artery is much below heart
level.
• The patient’s own effort to support the arm.
• A loose cuff or a bladder that balloons
outside the cuff leads
• Cuffs those are too short or too narrow.
• Using a regular-size cuff on an obese arm.

Normal BP
 Normal blood pressure
oSBP: 90 to 14o mmHg
oDBP: 60 to 90 mmHg
 The two arm readings should
be within 5-10 mm Hg.

2. Pulse
• Assessment of pulse
includes: rate, rhythm and
quality
• The normal pulse for
healthy adults ranges from
60-100bpm
 < 60bpm bradycardia
 >100bpm tachycardia

2. Pulse…
Factors affecting PR
• Age
• Blood loss
• Pain
• Emotion
Characteristics of pulse
 Rate: 60-100bpm
 Rhythm : regular,
irregular
 Quality : absent,
weak, palpable,
bounding

3. Respiratory Rate
Try to do this as surreptitiously
as possible.
Observe the
• Rate,
• Rhythm,
• Depth, and
• Effort of breathing

3. Temperature
 Can be taken from oral, rectal or axillary.
 Rectal temperatures are higher than oral
temperatures by an average of 0.4 to 0.5°C
(0.7 to 0.9°F).
 Axillary temperatures are lower than oral
temperatures by approximately 1°C, but take
5 to 10 minutes to register.
 Generally axillary temperature is considered
less accurate than other measurements.

Rectal temperature measurement
Contraindicated in clients with
cardiovascular alterations because the
thermometer may stimulate the vagus nerve
and cause an irregular cardiac rhythm.
Also contraindicated in leukemia and rectal
surgery clients because the insertion of the
thermometer may traumatize the mucosa or
incision line, causing bleeding.

Objective data
Examination of the musculoskeletal
system
 Patient for gait: steady or unsteady
 Any deformity
 Swelling of the lower extremities
 Symmetry of the body
 ROM: Active ROM if not Passive
ROM
 Decreased or optimal

4. Activity- Exercise… ,Musculoskeletal
system …
A gait
lacking
coordination
(reeling &
instability)
ataxia
Gait
Ask the patient to:
• Walk across the room or
down the hall, then turn, and
come back.
• Observe posture, balance,
swinging of the arms, and
movements of the legs.
• Normally balance is easy, the
arms swing at the sides, and
turns are accomplished
smoothly.

system …
Gait

system …
o Objective
data
o ROM

system …
Determine muscle tone
• Assess by feeling the muscle’s resistance to passive
stretch
• Take one hand with yours and, while supporting the elbow,
flex and extend the patient’s fingers, wrist, and elbow, and
put the shoulder through a moderate range of motion.
• On each side, note muscle tone-The resistance offered to
your movements
• If you suspect decreased resistance, hold the forearm and
shake the hand loosely back and forth-Normally the hand
moves back and forth freely but is not completely floppy

4. Activity- Exercise…,Muscle tone
Decreased resistance
• disease of the
peripheral nervous
system,
• cerebellar disease, or
• acute stages of spinal
cord injury
Marked floppiness:
• Hypotonic or flaccid
muscles
Increased resistance
• Worse at the extremes
of the range
spasticity
• Resistance that
persists throughout the
range and in both
directions

4. Activity- Exercise…, Muscle
Strength
 Ask the patient to move actively
against your resistance or to resist
your movement
 If the muscles are too weak to
overcome resistance, test them
against gravity alone or with gravity
eliminated

4. Activity- Exercise…, Muscle
Strength…

4. Activity- Exercise…,Musculoskeletal …

4. Activity- Exercise…, Decreased
Muscle Strength
• Impaired strength is called weakness
paresis
• Absence of strength
 paralysis (plegia)
• Weakness of one half of the body
 hemiparesis
• Paralysis of one half of the body
 hemiplegia
• Paralysis of the legs
 paraplegia
• Paralysis of all four limbs
quadriplegia

4. Activity and exercise…
Examination of respiratory system
 First examine posterior then anterior chest
 Posterior chest: Place client in a sitting
position, arms folded across chest (separates
scapulae), back exposed
 Anterior chest: patient sitting or lying

4. Activity and exercise…,Examination of
Posterior Chest
Posterior Chest Inspection
1. Symmetry
2. Shape of chest: AP ≈ ½ Transverse diameter
3. Signs of respiratory difficulty:
 Use of accessary muscles

Observe the shape of the
chest
Normally antero-
posterior (AP) diameter
is half of transverse
diameter
The AP diameter may
increase in COPD.
4. Activity and exercise…,Posterior Chest
Inspection…

Inspection…
Shape of the chest…
A. Barrel Chest
AP>Transverse
diameter
Occurs in
Infancy normally
Normal aging
(often)
COPD

Inspection…
B. Pigeon Chest (Pectus
Carinatum)
 The sternum is displaced
anteriorly
 AP>transverse diameter
 The costal cartilages adjacent to
the protruding sternum are
depressed

Inspection…
C. Funnel Chest (Pectus
Excavatum)
 Depression in the lower
portion of the sternum
 Compression of the heart
and great vessels may
cause murmurs

Shape of the
chest…
D. Thoracic kypho-
scoliosis
Abnormal spinal
curvatures and
vertebral rotation
Distortion of the
underlying lungs
Inspection…

4. Activity and exercise…,Posterior
Chest Inspection…
Intercostal Retraction
Abnormal retraction during inspiration
Most apparent in the lower interspaces
May be caused by:
Severe asthma
COPD
Upper airway obstruction

Impaired respiratory
movement on one or
both sides or a
unilateral lag (or
delay) in movement
Unilateral impairment
or lagging of
respiratory movement
suggests disease of the
underlying lung or
pleurae.
Inspection…

4. Activity and exercise…, Posterior Chest
Palpation
Palpate for
1. Tenderness
2. Masses
3. Lesions
4. Respiratory excursion
5. Vocal fremitus

4. Activity and exercise…, Posterior
Chest Palpation…
Testing chest expansion-Respiratory excursion
Place thumbs at 10th ribs close to
client’s spine and spread hands over
thorax
On deep inhalation and full
exhalation:
 note divergence of thumbs,
 feel for range
 note symmetry of movement
during

Palpation…
Testing chest expansion (Respiratory excursion)
Cause of unilateral decrease or delay:
Pleural effusion
Lobar pneumonia
Pneumothorax
Unilateral bronchial obstruction
Cause of bilateral decrease or delay:
When alveoli do not fully expand
Emphysema
Pleurisy

Chest Palpation…
Tactile Fremitus
Detection of sound vibration generated
by the larynx traveling distally along the
bronchial tree.

Chest Palpation…
Tactile Fremitus
Palpation Pattern
for Tactile
Fremitus

Chest Palpation…
Tactile Fremitus
Place ulnar aspect of your open hand at right apex
of lung and place the hand at each location on the
chest
Instruct client to say “44”
Use one hand or both
Note areas of increased or decreased fremitus
 An increase in solid tissue per unit volume of
lung will enhance fremitus– pneumonia
 An increase in air per unit volume of lung will
impede sound

Palpation…
Tactile Fremitus
Cause of decreased or absent Fremitus
Obstructed bronchus
 COPD
Separation of the pleural surfaces by:
 Fluid (pleural effusion)
 Fibrosis (pleural thickening)
 Air (pneumothorax)
A very thick chest wall

Percussion
 Avoid surface contact by any other part of
the hand, because this dampens out
vibrations. Note that the thumb, 2nd, 4th, and
5th fingers are not touching the chest
 Use quick sharp but relaxed wrist motion, to
strike the pleximeter finger using the right
plexor finger
 The striking finger should be almost at right
angles to the pleximeter
 Use the tip of the plexor finger, not the
finger pad
 Withdraw the striking finger quickly to avoid
damping the vibrations

Use
 To establish whether the underlying tissues
are air-filled, ﬂuid-filled, or solid
 To estimate the size and location of certain
structures within the thorax (e.g.,
diaphragm, heart, liver)
Percussion…

Percussion Notes
Have the patient keeps both arms crossed in
front of the chest
When percussing the lower posterior chest,
stand somewhat to the side rather than directly
behind the patient
When comparing two areas, use the same
percussion technique in both areas
Learn to identify ﬁve percussion notes
Percussion…

Percussion…

4. Activity and exercise…,Posterior
Chest Percussion…
Location of percussion

Pathologic Examples
Flatness  Large pleural effusion
Dullness --fluid or solid tissue replaces air-containing lung or
occupies the pleural space beneath percussing fingers,
occurring in:
 Lobar pneumonia,
 Pleural effusion,
 Hemothorax,
 Empyema,
 Fibrous tissue, or tumor
Hyper-resonance  Emphysema, pneumothorax
Tympany  Large pneumothorax
Percussion…

4. Activity and exercise…, Auscultation of
Posterior Chest
Used to assess air flow through the tracheobronchial
tree
Auscultation involves
1. Listening to the sounds generated by breathing
2. Listening for any adventitious (added) sounds
3. Listening to the sounds of the patient’s spoken or
whispered voice as they are transmitted through
the chest wall

 Listen to the chest as the patient breathes deeply with
mouth open
 Compare symmetric areas of the lungs
 Note the intensity of breath sounds
 Identifying any variations from normal vesicular
breathing
 Identify any adventitious sounds
 Listen for transmitted voice sounds
4. Activity and exercise…, Auscultation of
Posterior Chest…

4. Activity and exercise…, Chest
Auscultation
Breath Sounds (Lung Sounds)
Known by their normal location
Normal breath sounds are:
A. Vesicular
 Inspiratory sounds last longer than expiratory ones
 heard through inspiration
 Normally heard over most of both lungs
B. Bronchovesicular
 Normally heard in the 1st and 2nd interspaces anteriorly and
between the scapulae
 Inspiratory and expiratory sounds are about equal

4. Activity and exercise…, Chest
Auscultation
C. Bronchial
Expiratory sounds last longer than inspiratory ones
Normally heard Over the manubrium, if heard at
all
D. Tracheal
Inspiratory and expiratory sounds are about equal
Normally heard over the trachea in the neck

4. Activity and exercise…, Breath
sounds...
If bronchovesicular or bronchial breath sounds
are heard in locations distant from those listed,
suspect that air-filled lung has been replaced
by fluid-filled or solid lung tissue

4. Activity and exercise…, Adventitious
(Added) Sounds
Crackles
 Lung fibrosis
 Early CHF
 Chronic bronchitis
 Asthma
Pleural Rub
Inflamed and roughened
pleural surfaces
Stridor
Partial obstruction of
the larynx or trachea
Wheezes
 Asthma
 Chronic bronchitis
 COPD
 CHF (cardiac asthma)

(Added) Sounds …

(Added) Sounds …
Breath sounds may be decreased when air ﬂow is
decreased
 Obstructive lung disease or
 Muscular weakness
Breath sounds may be decreased when the
transmission of sound is poor
 Pleural effusion,
 Pneumothorax, or
 Emphysema

4. Activity and exercise…, Anterior
Chest Inspection
Inspect for
 Shape of the patient’s chest
 Movement of the chest wall
Note
Deformities or asymmetry
Abnormal retraction of the lower interspaces during
inspiration-Severe asthma, COPD, or upper airway
obstruction
 Local lag or impairment in respiratory movement-
Underlying disease of lung or pleura

4.Activity&exercise…,Cardiovascular
assessment
Inspection: JVD, heaves and lifts, abdominal blood
vessels, peripheral circulation
Palpation: Pulses, PMI
Percussion: Heart size
Auscultation: Heart sounds, bruits

4.Activity & exercise…, CVS Assessment…
Inspection
Jugular vein
distension
• Elevating the head of
the bed to 30-45o
• observe for the
distension of the
jugular vein, which
is not usually
appearing.

Heaves and lifts
• Look at the apex of the heart at 5th ICS MCL
for heaves and lifts
Visible blood vessels
• On the abdomen
4.Activity & exercise…, CVS Assessment…

4.Activity & exercise…, Palpation
Palpate the carotid artery
Useful for detecting stenosis or insufficiency
of the aortic valve.
 Quality of the carotid upstroke,
 Its amplitude and contour
 Presence or absence of any overlying thrills
or bruits

4.Activity & exercise…, CVS Palpation …
 For pulsation & thrill (vibration) in
all areas of the pericardium
o Apical area
o Palpate apical impulse (PMI)-If
pulsation present determine its size,
diameter, location & time it
pulsates within cardiac cycle
 Normally no pulsation palpable over
the aortic and pulmonic areas but at
the PMI

Abnormal finding
 In the left lateral
decubitus position, a
diameter greater than
3 cm
Left ventricular
enlargement
PMI diameter
 Usually 1-2.5cm
 Occupies only one
interspace
 May be larger in the
left lateral decubitus
position
4.Activity & exercise…, CVS Palpation …

4.Activity & exercise…, JVD
Auscultate for the
heart sound on
 S1, S2,
 Murmur and
 Gallop
At the shown sites

4.Activity & exercise…, Auscultation…
Use of stethoscope
 Diaphragm is better for picking up the relatively
high-pitched sounds of
o S1 and S2,
o Murmurs of aortic and mitral regurgitation, and
o Pericardial friction rubs
 Press the diaphragm firmly against the chest
 Bell is more sensitive to the low-pitched sounds of
o S3 and S4
o Murmur of mitral stenosis
 Apply the bell lightly, with just enough pressure to
produce an air seal with its full rim.

4.Activity & exercise…, Heart Sounds: S1
and S2

4.Activity & exercise…, Murmur & Gallop

Assesses sleep and rest patterns.
Subjective data
 Sleep time
 Adequacy
 Difficulty falling sleep
 Sleep aid
 Sleep medications
5. Sleep & Rest

Subjective data…
 Change in sleeping pattern
 Difficulty remaining sleep
 What facilitate sleep ?
 What hinders sleep?
5. Sleep & Rest…

5. Sleep & rest…
Objective data
 Yawning
 Concentration
 Flushed face

Group Reflection
Sexuality - Reproductive

Focused on the person's satisfaction or dissatisfaction
with sexuality patterns and reproductive functions
Subjective data
• Female Menstruation
• Date began: ______ Last cycle_________
Length______
• Gravida: ____ Para____ Abortion___ still
birth______
• Current Pregnancy: Yes No
• LNMP:_________EDD--------GA---------
6. Sexuality reproductive

6. Sexuality reproductive
 Fertility: Fertile infertile
 Male/Female
 Contraception: Yes No
 Undesirable side effects of contraceptives
 Problem with Sexual activities:________
 Effect of illness on Sexual activities:________
 STI: __________________________________
 Pain during intercourse: Yes No
 Burning during intercourse: Yes No
 Discomfort during intercourse: Yes No

6. Sexuality reproductive…
Objective data
Breast exam
Exam of genitalia

Group Reflection
Cognitive-Sensory-Perceptual

focused on the ability to comprehend and use
information and on the sensory functions
Assesses the five senses.
Subjective data
• Educational status:
• Able to read ____Write _____
• Primary language:______________
• Visual problem
• Aids for vision:
7. Cognitive-Sensory-Perceptual

7. Cognitive-perceptual…
Subjective data…
 Hearing problem
 Aid for hearing
 Taste problem
 Smelling problem
 Problem in sensation(skin)

Pain assessed by PQRST
Descriptions of pain
1.Precipitating/aggravating
2.Quality
3.Radiation
4.Severity/Site
5.Timing, including: onset, duration, and
frequency,

Objective data
• Level of consciousness :
Orientation to TPP:
Glasgow coma scale :
• Ability to speak Yes No
• Ability articulate words Yes No

The Glasgow coma scale for adults and older children
Response Score
Eyes open:
Spontaneously
To speech
To pain
Never
4
3
2
1
Best verbal response:
Orientated
Confused, disoriented
Inappropriate words
Incomprehensible sounds
None
5
4
3
2
1
Best motor response:
Obeys commands
Localizes pain
Withdraws (flexion)
Abnormal Flexion
posturing
Extension posturing
None
6
5
4
3
2
1
TOTAL 3-15
A total score
A. Score 3 or 4: Patients have an
85% of chance of dying or
remaining vegetative
B. Score <7: State of coma
C.Score <10: Semi-coma
D.Score above 11: Patients have
only a 5 to 10% likelihood of
death or vegetative state and 85
% of chance of moderate
disability or good recovery.

NB:
Un-rousable come is defined as having a score of < 3
The scores can be used repeatedly to assess improvement or deterioration.

7. Cognitive-perceptual…,Visual Acuity

7. Cognitive-perceptual…,Visual Acuity…
• Have the person cover one
eye at a time with a card
• Ask the person to read
progressively smaller
letters until they can go no
further
• Record the smallest line
the person read
successfully
• Repeat with the other eye

7. Cognitive-perceptual…,Visual Acuity…
Visual acuity is reported as a pair of numbers
(e.g., 20/20) where:
 The first number is how far the person is
from the chart and
 The second number is the distance from
which the "normal“ eye can read a line of
letters
o For example, 20/40 means that, at 20 feet
the person can only read letters that a
"normal" person can read from 40 feet

7. Cognitive-perceptual…,Inspection: Eyes
 Observe for ptosis, exophthalmos, lesions,
deformities, or asymmetry
 Ask the person to look up and pull down both
lower eyelids
o inspect the conjunctiva and sclera
 Next spread each eye open with your thumb and
index finger
 Ask the person to look to each side, upward and
downward to expose the entire bulbar surface.
o Note any discoloration, redness, discharge, or
lesions
o Note any deformity of the iris or lesion cornea

7. Cognitive-perceptual…,Inspection of
Conjunctiva…

7. Cognitive-perceptual…, Pupil examination
 Using pen light shine on one of the eyes to
check for PERRLA (pupil equal, round, and
reactive to light and accommodation)
 Normally both pupils should be
oEqual in size,
oRound and
oReactive to light and accommodation
 Further examination with ophthalmoscope

Examination of the Ear
Auricle
 inspect the auricle for any deformities, lumps, skin
lesions and discharge
 palpate for any tenderness
Ear canal and drum
 Straighten the ear canal by grasp the auricle firmly but
gently and pull it upward, backward, and slightly away
from the head
Using otoscope inspect the ear canal and drum

7. Cognitive-perceptual…,Examination of
the Ear…
 Inspect the eardrum, noting its color and
contour.
o Red bulging drum  acute purulent otitis
media
o Amber drum  a serous effusion

7. Cognitive-perceptual…, Examination of
the Ear …
Auditory acuity
• Test one ear at a time by asking the patient to
occlude one ear with a finger or, better still,
occlude it yourself.
• Stand at 1 or 2 feet away, exhale fully (so as to
minimize the intensity of your voice) and
whisper softly toward the un occluded ear.

the Ear…
Air and Bone Conduction
If hearing is diminished, try to distinguish
between conductive and sensorineural hearing
loss
Prepare a quiet room and a tuning folk with the
frequency in the range of human speech 300
Hz to 3000 Hz (usually 512Hz or 1024Hz).

the Ear…

7. Cognitive-perceptual…, Test for
lateralization (Weber test)
• Place the base of the lightly vibrating tuning fork firmly
on top of the patient’s head
• Normally the sound is heard in the midline or equally in
both ears.
In unilateral conductive hearing loss, sound is
heard in (lateralized to) the impaired ear.
May indicate
 Acute otitis media,
 Perforation of the eardrum, and
Obstruction of the ear canal, as by cerumen
In unilateral sensorineural hearing loss,
sound is heard in the good ear

7. Cognitive-perceptual…,Examination of
the Ear…
Compare air conduction (AC) and bone
conduction (BC) (Rinne test).
 Place the base of a lightly vibrating
tuning fork on the mastoid bone,
behind the ear and level with the canal.
 When the patient can no longer hear
the sound, quickly place the fork close
to the ear canal (facing the ‘U’ of tuning
fork forward) and ascertain whether the
sound can be heard again
 Normally the sound is heard longer
through air than through bone
(AC > BC)
Conductive hearing loss:
BC = AC or BC > AC
Sensorineural hearing
loss: AC >BC

Group Reflection
Self-perception- Self Concept

Focused on the person's attitudes toward self,
including identity, body image, and sense of
self-worth.
Subjective data
 What do you feel differently about yourself?
 Perception of abilities:____
 Things frequently make you angry ,fearful or
anxious
8. Self perception/self concept

Objective data
• Eye contact
• Body posture
• Appearance
• Grooming
• Mood (expression): Nervous ____ relaxed ____
• Speech: Pace of conversation:
–Appropriate inappropriate
• Tone of voice: Appropriate to the situations
Inappropriate to situations
8. Self perception/self concept…

Group Reflection
Coping - Stress

 Focused on the person's perception of stress and on his
or her coping strategies
Subjective data
 Any big changes in your life in last year or two years
 Any Crisis
 Tense or relaxed most of the time
 When tense, what helps? Use any medications, drugs,
alcohol to relax?
 When (if) there are big problems in your life, how do
you handle them
9. Coping-stress tolerance

Group Reflection
Role - Relationship

 Focused on the person's roles in the country, community,
work area or home and relationships with others
Subjective data
 Living arrangements, Family structure
 Marital status
 Family or others dependants
 concern of families/ about families after illness
 Belong to social groups, Close friends
 work environment distress
 If appropriate – income sufficient for needs
 Feel part of (or isolated in) your neighborhood
10. Role relationship

10. Role relationship…
 Role and Responsibility in family : _______
 Work role:__________
 Social role:________________
 Level of satisfaction:_____________
 Effect of illness on roles:____________________
 Lives alone?
 Employee?
 Self employee?
 Ability to pay:  Yes  No Comments:_____

10. Role relationship…
Objective data
 Interaction with family members or others if
present

Group Reflection
Value - Belief

Focused on the person's values and beliefs
(including spiritual beliefs), or on the goals that
guide his or her choices or decisions
Subjective data
Important plans for future?
Religion important to you?
Religious Restrictions
Religious practices
11. Value-Belief Pattern

11. Value-Belief Pattern …
Objective data
Presence of religious materials, leaders
When doing ritual process

Additional information
Clinical data
 Investigations
 Result, compared with reference value

Summary
1. Nursing assessment
2. Phases of assessment
3. Data: Type and Source
4. Techniques of physical examination
5. Gordon’s Functional Health Pattern

NURSING DIAGNOSIS
Set by: Rebira W.

After completing this session, the trainees will
be able to
• Describe nursing diagnoses
• Distinguish nursing diagnoses from medical
diagnoses
• Formulate various kinds of nursing diagnoses
• Identify Collaborative problems
Objectives

Outline
Introduction
Definition of nursing diagnosis
Purpose of nursing diagnosis
Nursing diagnoses Vs Medical diagnoses
Components of nursing diagnosis
Types of nursing diagnosis
Collaborative problem
Summary

Introduction
Transition from assessment to nursing diagnoses
Data
collection
Data
validation
Organizing
data in
cluster
Making inferences
Consult
NANADA
Writing nursing diagnostic
Statement

Definition of Nursing diagnosis
Nursing diagnosis
 Is the second step in the nursing process involving
further analysis & synthesis of data that have been
collected.
 Statement describing client’s actual or potential
response to health problems.
That the nurse is licensed and competent to
treatment.
 Is clinical judgment about an individual, family or
community response to actual or potential health
problem & life processes.
 Provides basis for selection of nursing interventions
to achieve outcomes for which the nurse is
accountable.

Definition of Nursing diagnosis…
NANDA: North American Nursing Diagnoses
Association
• It is a professional organization of nurses that
standardizes nursing terminology that develops
researches, disseminates and refines the
nomenclature, criteria, and taxonomy of nursing

NURSING DIAGNOSIS…
PURPOSE
 Nursing diagnosis Is unique in that it focuses on
a ct’s response to a health problem, rather than
on the problem itself, & it provides the structure
through which nursing care can be delivered.
 Nursing diagnosis also provide a means of
effective communication
 Holistic client, family, & community –focused
care are facilitated with the use of nursing
diagnosis

Exercise 3.1: Nursing diagnoses Vs Medical diagnosis ?
Instruction : Make 4 group & discuss
Time allotted: 5 min
Breakout

Differentiation of Nursing & Medical
Diagnosis
Nursing diagnosis
-Focus on un healthy
response to health & illness.
-Describe problems treated
by nurses within the scope
of independent nursing
practice.
-Describes clients response
-May change from day to
day as the client’s responses
change.
Medical Diagnosis
-Identify disease
-Describe problems for
which the physician
directs the primary
treatment
-Refers to the disease
process
-Remains the same for as
long as the disease is
present.

Diagnosis…
Nursing di
Nursing diagnosis
• Deals with two types of
health problems (1)
Human response problems
(2) Pathological problems
• Uses the six sequential
steps which need to be
followed strictly within
the scope of nursing
practice
• Considers the whole
person.
Medical Diagnosis
• Deals mostly with
problems with structure
and function of organs or
systems
• Uses medical approach
within the scope of
medical practice
• Mainly considers organ
and system function

Diagnosis…
Nursing diagnosis
• Focuses on teaching
individuals or groups how
to be independent on
activities of daily living
• Involve individuals, their
significant others, and
with groups in nursing
care provision
Medical Diagnosis
• Focuses on teaching
about how diseases
and trauma are treated
• Mostly involved with
individuals,
sometimes with
groups and families

Examples Nursing & Medical Diagnosis
1) Nursing Diagnosis
 Fear
Altered Health maintenance
Knowledge deficit
Pain
Altered tissue perfusion
2)Medical Diagnosis
Myocardial infarction / Heart Attack

Examples Nursing & Medical Diagnosis…
Nursing Diagnosis
-Ineffective breathing
pattern
-Activity Intolerance
-Acute pain
-Body Image
disturbance
-Risk for altered body
temperature
Medical Diagnosis
-Chronic obstructive
pulmonary disease
-Cerebrovascular
accident
-Appendectomy
-Amputation
-Strep throat

Components of nursing diagnosis
1) Diagnostic Label
P-Problem Statement
Q-Qualifier
2) Etiology
E
3) Defining Characteristics
S

Components of nursing diagnosis…
Diagnostic Label
• Problem:- Refers to health problem or health state of an
Individual , family, or community.
• Name of nursing diagnosis as listed in Taxonomy,
expressed in a short, clear, & precise word, words or
phrase.
• A taxonomy is a way of classifying or ordering things
into categories; is a hierarchical classification scheme of
main groups, subgroups, and items.
• Qualifier:- Used to give additional meaning to the
nursing diagnosis.

Note to Write Diagnostic Label
• DO NOT use medical diagnosis
• Must be a problem the nurse and /or the client can
change to do something about
• DO NOT relate the problem to unchangeable
situation
• DO NOT confuse the etiology with the problem (
statement)
• Focus on the human response to the problem
• Avoid the use of one piece of assessment data as a
nursing diagnosis. Example. Edema

• Be specific
• DO NOT combine nursing diagnosis
• DO NOT relate one nursing diagnosis to
another
• Nursing interventions should not be included
in the nursing diagnosis
• Keep your language non judgmental
• DO NOT make assumptions or statements you
can’t prove with assessment data
• Be sure your statement is legally advisable

Etiology
• Are any internal or external elements that have
an effect on the person, family, or community.
• And contribute to the existence or maintenance
of the person’s problem
• This is the related to, “R/T” portion of the
diagnosis
• What caused the client to have the problem
listed?
• At which will be affected by nursing
intervention

Note to Write Etiology
• DO NOT use medical diagnosis
• Must be a problem the nurse and /or the client
can change to do something about

Defining Characteristics-signs & symptoms
 These are the major and minor clinical cues
that validate the present of an actual nursing
diagnosis.
 Must have at least the major defining
characteristics as listed in the taxonomy and
minor characteristics will help support the
nursing diagnosis.

The Two- part Statement
Consists of two parts
I. Problem statement or diagnostic label
The diagnostic label is the name of the nursing
diagnosis as listed in the NANDA.
Examples: Stress urinary incontinence, Anxiety,etc.
II. The etiology
Is the related cause of contributor to the problem
These two parts are linked by term related to, “R/T”.

Descriptive words
 Terms that may be added to clarify specific nursing
diagnosis
 These descriptive terms are called qualifiers.
 Examples:-Acute, Chronic, Decreased, Deficient,
Depleted, Disturbed, Dysfunctional, Enhanced,
Excessive, Impaired, Increased, Ineffective,
Intermittent, Potential for, and risk.
 These terms specify a degree of qualification for the
identified nursing diagnosis and are placed before
the problem statement.

The Three- Part Statement
Consists of three parts.
The first two components are the diagnostic label and
etiology, and
The third component consists of defining
characteristics or collected data that are also known
as signs and symptoms,
Subjective and objective data, or clinical
manifestations.
The third part is joined to the first two components
with the connecting phrase “ as evidenced by”, (
AEB).

Nursing
Diagnosis
Two-Part
Statement
Three-Part
Statement
o Feeding self-care
deficit
o Ineffective
airway clearance
o Anxiety
o Feeding self-care deficit R/T
decreased strength and
endurance.
o Ineffective air way clearance
R/T fatigue
o Anxiety R/T change in role
functioning.
o Feeding self-care deficit R/T
decreased strength and
endurance AEB inability to
maintain fork in hand from
plate to mouth.
o Ineffective air way clearance
R/T fatigue AEB difficulty of
breathing at rest.
o Anxiety R/T change in role
functioning AEB sleeplessness,
poor eye contact & quivering
voice.

Nursing Diagnosis Two-Part
Statement
Three-Part
Statement
o Deficient Knowledge
o Spiritual distress
o Deficient Knowledge R/T
misinterpretation of
information
o Spiritual distress R/T
separation of religious
ties
o Deficient Knowledge R/T
misinterpretation of
information AEB
inaccurate return
demonstration of self-
injection.
o Spiritual distress R/T
separation of religious
ties AEB crying and
withdrawal.
o Data from the ANA 1997

Nursing diagnosis versus Collaborative
Problems
 If such problems require physician –prescribed and
nurse-prescribed action
 In case the nurse intervenes in collaboration with
personnel of other disciplines.
 Collaborative problems are complications from a
disease, test, or treatment that nurses cannot treat
independently.
 Nurses focus mainly on monitoring and preventing
such problems.
 Alerts the nurse that the client is either experiencing
or is at high risk to experience the problem.

Nursing diagnosis versus Collaborative
Problems…
The focus of nursing accountability for collaborative
problems is three- folds.
o Detecting and reporting early signs and symptoms of
potential complications
o Implementing Physician prescribed interventions;
o Initiating interventions within the nursing domain to
manage the problem.
e.g. Potential complications: paralytic ileus related to back
surgery.
• Arrhythmia, stroke, congestive heart failure related to
MI.

Types of Nursing Diagnosis
1. Actual Nursing Diagnosis
o Describe a human response to a health problem
that is being manifested.
o Written as three-part statements: diagnostic label,
Related factors or etiology and defining
characteristics.
o Example:- Acute pain R/T surgical trauma and
inflammation AEB grimacing and verbal reports
of pain.

Types of Nursing Diagnosis…
Rule for writing actual nursing diagnosis
Using the PRS /PES format (Problem, Related
factors, and Signs and Symptoms). Use the
words “Related to” and “As evidenced by” to
link the parts.
Diagnostic
label
Or
Problem
Related
to
Related
factor
Or
Etiology
As evidenced /as
manifested by
Defining
characteristics
Or
Sign and
symptoms

2. Risk /Potential nursing diagnosis
• As defined by NANDA, “describes human
responses to health conditions that may develop
in a vulnerable individual, family, or community.
• It is supported by risk factors that contribute to
increased vulnerability.
• Risk nursing diagnosis is a two-part statement.
• Example:-Risk for infection R/T surgery and
immunosuppression, Risk for impaired skin
integrity R/T inability to turn self from side to
side.

Rule for writing Risk /Potential nursing
diagnosis
• Use a two-part statement, using “related to” to
link the potential problem with the risk factors
present.
Risk for
Or
High risk
for
Diagnostic
label
Or
Problem
Related to
Risk
factor
Or
Etiology

3. Wellness-Nursing Diagnosis
Is a diagnostic statement that describe the human
response to levels of wellness in an individual,
family or community that have a potential for
enhancement to a higher state ( NANDA,2005).
Wellness-nursing diagnosis is one part statement
i.e. diagnostic label.
Two items should be present:
I. An increased desire for greater wellness &
II. Effective level of function should be present

Example
Readiness for enhanced spiritual well being.
Readiness for enhanced self-esteem.
Rule for writing wellness nursing diagnosis
• Statement will begin with “ potential for
Enhanced or Readiness for enhanced.
Readiness for
enhanced Diagnostic label

4. Possible nursing diagnosis
o Is made when not enough evidence supports the
presence of the problem but
o The nurse thinks that is highly probable and wants to
collect more information.
o Possible nursing diagnosis is a two part statement.
o i.e. diagnostic label and related factors (unknown).
o Example: Possible self-esteem disturbance R/T
unknown etiology, Possible self-care deficit R/T IV
in right hand, Possible impaired adjustment related to
unknown etiology

Rule for writing possible nursing diagnosis
List suspected problem and cause
Possible
Diagnostic
label
Or
Problem
Related to
Etiology

5. Syndrome nursing diagnosis
A cluster or group of nursing diagnoses that almost
always occur together.
Example: Rape Trauma Syndrome, Disuse
Syndrome, Post-trauma Syndrome, Relocation
Stress Syndrome
Rule: ...Syndrome.

Avoiding Errors in Writing Diagnostic
Statements
1. Don’t write the diagnostic statement in such a way
that it may be legally incriminating.
Incorrect- High risk for injury related to lack of side
rails on bed.
Correct- High risk for injury R/T disorientation.
2.Don’t state the nursing diagnosis using medical
diagnostic terminology; focus on the person’s
response to the medical problems.
Incorrect- Mastectomy related to cancer.
Correct- High Risk for Self-concept Disturbance
related to effects of mastectomy.

Avoiding Errors in…
3. Don’t rename a medical problem to make it
sound like a nursing diagnosis.
Incorrect- Alteration in hemodynamics related to
hypovolemia.
4. Don’t state the nursing diagnosis based on a
value judgment.
Incorrect- Spiritual Distress related to atheism as
evidenced by statements that she has never
believed in God.
5. Don’t state two problems at the same time.
Incorrect- Pain and Fear related to diagnostic
procedures

Instruction : Make 4 groups
Identify correctly stated nursing diagnosis
Discuss and present
Time allotted: 8 min
Breakout
Group Activities

Collaborative Problems
o Collaborative problems are complications from a
disease, test, or treatment that nurses cannot treat
independently.
o Nurses focus mainly on monitoring and
preventing such problems.
o Alerts the nurse that the client is either
experiencing or is at high risk to experience the
problem

Collaborative Problems/Complications…
The focus of nursing accountability for
collaborative problems is three- folds.
 Detecting and reporting early signs and
symptoms of potential complications
 Implementing Physician prescribed
interventions;
 Initiating interventions within the nursing
domain to manage the problem.

Collaborative Problems/Complications…
e.g. Potential complications: paralytic ileus
related to back surgery.
• Arrhythmia, stroke, congestive heart failure
related to MI.

Nursing Diagnosis Vs Collaborative
Problems
Nursing Diagnosis Collaborative
Problems/Medical diagnosis
 Focuses on identifying and
treating actual or potential
unhealthy responses to diseases
or life changes.
 Related signs and symptoms
respond to nurse-prescribed
interventions.
 Focuses on identifying
problems with structure or
function of organs or
systems.
 Related signs and
symptoms don’t respond to
nurse-prescribed
interventions alone.

Summary
 Actual nursing diagnosis has three parts
 PES
 Risk diagnosis has two parts
 Risk for P E
 Collaborative problems
 Resolved by both nurse initiated and physician
initiated interventions

NURSING PLANNING
Set by: Rebira W.

By the end of this presentation, trainees will be
able to:
 Define planning and outcome identification
 Prioritize nursing diagnoses
 Set goal for identified nursing diagnoses
 Write statement of client centered SMART
expected outcomes
 Develop individualized plan of nursing care for a
patient
Objectives

Outline
1. Definition of planning
2. Purpose of planning
3. Types of planning
4. Establishing priorities
5. Fundamental Principles of Setting Priorities
6. Setting goal
7. Outcome identification

Outline…
1. Steps in writing outcome identification
2. Components of outcome identification
3. Nursing intervention
4. Types of nursing intervention
5. Nursing instructions/orders
6. Elements of nursing instructions/orders

Definition of Nursing Planning
Is the formulation of guidelines that establish
the proposed course of nursing action in the
resolution of nursing diagnoses and the
development of the client’s plan of care.

Breakout
Purposes of planning?
5 min

Purpose of planning
o To facilitates communication between care
givers
o To directs care and documentation
o To provide a record that can later be used for
evaluation and research

Types of Nursing Planning
 Initial planning: Comprehensive plan of care
on admission assessment
 Ongoing planning: Continuous updating of
the client’s plan of care.
 Discharge planning: Critical anticipation and
planning for the client’s needs after discharge

Breakout
Activities of planning?
5 min

Planning involves the following
activities
1. Setting priorities
2. Setting goals
Globally written statement describing the
intended change in the client’s behavior,
response, or outcome
3. Outcome identification
4. Determining nursing interventions
5. Recording the plan of care

Breakout
How do you set priority?
5 min

Setting Priorities
The first step to get organized
To set priorities, look at the identified problems and ask
some key questions:
1. What problems need immediate attention?
2. What problems have simple solutions?
3. How many problems- list of all problems
4. What problems must be done by nurse or referred?
5. What problems must be recorded on the plan of care?

Fundamental Principles of Setting Priorities
(Maslow, 1943)

Priority 1 - Life threatening problems and those
interfering with physiological needs. E.g. Problems with
respiration, etc.
Priority 2 - Problems interfering with safety and security
e.g. fear
Priority 3 - Problems interfering love & belonging
e.g. Isolation
Priority 4 - Problems interfering with self esteem.
e.g. Inability to wash hair, perform normal activities.
Priority 5 - Problems interfering with the ability to achieve
personal goals.
Fundamental Principles of Setting Priorities…

Nursing Diagnosis Maslow’s hierarchy
of needs
Rank
Anxiety related to
hospitalization
Safety and security Moderate
Ineffective coping Self-esteem Low
Ineffective airway
clearance related to
excessive secretion
Physiologic High

Breakout
If you had someone with the following
problems, which problem would you need
to treat immediately?
A. Diarrhea related to bacterial infection as
evidenced by passage of loose stool 3-4
times/day
B. Ineffective breathing pattern as
evidenced by labored breathing
C. High risk for fluid volume deficit
10min

Breakout
1. Identify at least 3 nursing
diagnoses
2. Set priority
5 min

Planning: Goal Setting
• Goal is a broad term derived using the problem
statement in the nursing diagnoses.
• It should indicate the identified health problem
has been resolved, improved or prevented.
Examples
• To reduce anxiety before undergoing surgery
• To maintain a patent airway
• To relive pain

Definition
• Is a detailed, specific statement that describes goal is
achieved.
Writing Outcome Measures
• Identifying outcomes that clearly describe the evidence
that tells you the problems have been prevented,
corrected, or controlled.
e.g. of goal:- will demonstrate effective breathing pattern
Outcome Measures:- clear lungs and practicing deep
breathing and coughing every 2 hours.
Planning: Outcome Identification

Short-term goals (STG) are those that can be met
relatively quickly, often in less than a week
Long-term goals (LTG) are those that are to be achieved
over a longer period of time, often weeks or months.
o LTG may also include goals that are ongoing
e.g. of long term goal
 “ Tigist will dress herself every morning.”
 “Ato Daniel will maintain a fluid intake of 2000 ml a
day.”
Short and Long Term Outcomes

Short-Term Outcome Long-Term Outcome
““Fatuma will demonstrate how to
hold her newborn infant by
tomorrow (6/7).”
“Fatuma will demonstrate how to
dress, feed, and bathe her newborn
infant by discharge (15/7).”
305
Examples of Long-Term and Short-Term
Outcomes
Priority_Goal_Outcome_Instruction
“Ato Hailu will turn and reposition
himself from side to side every 2
hours.
“Ato Hailu will maintain good skin
integrity while he is on bed rest.”
“Ato Sium will demonstrate how to
change his colostomy bag within 2
days (by 7/7).”
“Ato Sium will demonstrate how to
give complete colostomy care
according to Hospital standards by
discharge (by 7/21).”
“Tekle will walk with crutches with
assistance by 3 days after surgery
(by 7/28).”
“Tekle will walk unassisted with a
crutch by discharge (by 8/10)/”
2/6/2024

Breakout
1. Identify at least 3 nursing
diagnoses
2. Set realistic STO or LTO
5 min

Writing more than one outcome
statement
 Sometimes you may decide to write more than
one outcome for a problem.
 The outcomes probably relate to the causes, or
related factors, of the problem rather than to
the problem itself only.
 However, make sure at least one of the outcomes
demonstrates resolution, improvement, control
or prevention of the nursing diagnosis.

Writing more than one outcome
statement…
Example
Nursing Diagnosis: Overweight (wt 76kg, ht 1.5m) related
to poor eating habits and minimal physical activity AEB
BMI of 28kg/m2.
• Outcome #1: Abera will verbalize his feelings about
changing eating habits, taking more vegetables and fruits.
• Outcome # 2: Abera will attend daily exercise classes.
• Outcome #3: Abera will lose 1 Kg per week beginning
26/01/2017 until he weighs between 60 and 70 Kg.

o Look at first clause of the nursing diagnoses itself or problem
statement (the word or words before “related to”)
Example- High risk for impaired skin integrity related to immobility.
o Now restate the first clause in a statement that describes
improvement, control, or absence of the problem
Example- The person will demonstrate no signs of skin irritation or
breakdown by discharge
o Restate the related factor and evidence that they are controlled,
prevented, improved, or absent
Example: The patient will use safety and comfort devises (pillow,
cotton ring, air ring) over bony prominence areas as of tomorrow.
Steps in identifying Outcomes from
Nursing Diagnoses

Nursing Diagnosis Corresponding Client Outcome
Imbalanced
nutrition: Less than
Body requirements
The client will demonstrate inclusion of vegetables and
fruits in lunch and dinner to increase appetite
The client will record of eating balanced meals with few
snacks every day.
Clients Outcomes Derived from Nursing
Diagnoses
Ineffective
Individual Coping
The client will demonstrate and relate effective coping
• The client will self report coping better and
• The client will ability to demonstrate good problem solving.
Constipation The client will demonstrate normal bowel function
• The client will have a normal stool every 1-2 per day by
statements of feeling as though bowels are moving well.

1. Subject: the person expected to achieve the goal?
2. Verb: actions the person take to achieve the goal?
Choosing verbs that measure progress will avoid
ambiguity and focuses on the behavior that will
measure progress.
Use measurable verbs in order to be specific:
Verbs like -identify, describe, perform, relate, state,
list, verbalize, hold, demonstrate, etc.
Don’t use Non Measurable Verbs: include -know,
understand, appreciate, think, accept, and feel.
Components of the outcome Identification

Components of the outcome Identification…
3. Condition: circumstances under which the person
perform the actions?
4. Criteria: how well is the person to perform the actions?
5. Specific Time: when the person expected to perform the
actions?
Example: Ato Hailu will walk with a crutch at least to the end
of the hall and back by Friday (Feb. 5, 2018)
• Subject: Ato Hailu
• Verb: will walk
• Condition: with a crutch
• Criteria: at least to the end of the hall and back
• Specific time- by Feb 5, 2018

 During determining client centered outcomes
 Be realistic in establishing goals.
 Set goals mutually with the client and others involved
in his/her health care.
 Establish both short and long term goals
 Be sure that the outcomes describe a client behavior or
action
 Follow the rules for writing outcome statements.
 Use measurable, observable verbs to describe actions
Components of the outcome Identification…

Breakout
1. Choose the outcomes that are
written correctly below.
2. Identify what is wrong with
the statements that are written
incorrectly.
10 min

1. Tesfaye will know the four basic food groups by Tahsas 1, 2009.
2. Wrt. Saba will demonstrate how to use her walker unassisted
within 3 days.
3. Ato Lemma will improve his appetite by Meskerm 11, 2010
4. Tullu will list the equipment needed to change sterile dressing by
09/05/2009 EC.
5. David will walk independently in the hall the day after surgery.
6. Wrt. Genet will understand the importance of maintaining a salt-
free diet.
7. Wrt. Tadeletch will appreciate the importance of exercise for pt.
with diabetes.
8. Ato Sium will feel less pain by Thursday (Jan 10, 2012)
Exercise

Planning: Nursing intervention
Definition
 A nursing intervention is an action planned by a
nurse that helps the client to achieve the results
specified by the goals and expected outcome.
 Identify as many nursing interventions as
possible so that if one proves to be unsuitable,
others are readily available.
 Prioritize interventions according to the order in
which they will be implemented.

Planning: Nursing intervention…
It could be carried out through:
Helping/assisting
Teaching
Counseling
Consulting &
Determining problem specific Interventions.
Priority_Goal_Outcome_Instruction

Planning: Nursing intervention…
Nursing Interventions are activities performed
by the nurse to:
1. Monitor health status
2. Prevent, resolve, or control a problem
3. Assist with ADL (bathing and so forth)
4. Promote optimum health and independence.

Planning: Nursing intervention…,Types
1. Independent interventions
 Interventions that require no supervision or directions from
others
 E.g. Demonstrating client about insulin self-injection.
 This intervention do not require any physicians order
2. Interdependent interventions
 Are type of interventions that are implemented in a
collaborative manner by the nurse with other health care
professionals

 e.g. Nursing interventions in operation theatre
with other health care team
3. Dependent interventions
o Are based on the interaction or written orders
by other health care provider
o e.g. Administering a medication, preparing a
client for different procedure
Planning: Nursing intervention…,Types…

Nursing Instructions/Orders
Definition
 A nursing order is a statement written by the
nurse that is within the realm of nursing
practice to plan and initiate.
 These statements specify direction and
individualize the client’s plan of care.

Elements of nursing order/instruction
Date
o The date on which the order is written.
o This information is updated to reflect review and
revision.
Action Verb
o Directs the nurses’ action.
o Example: Explain, demonstrate, auscultate

Detailed description
o Precisely clarifies what the nurse’s action will be.
o This phrase explains what, when, where, and how.
Time frame
o Describes when, how often, and how long the nursing
order is to be performed.
Signature
o Indicates the nurse who writes the order. This element
implies legal and ethical accountability
Elements of nursing order/instruction…

Making Nursing Instructions/Actions
Specific
To make it specific and clear, include the following:
Date: The date the order was written
Verb: Action to be performed
Subject: Who is to do it
Descriptive phrase:: How, when, where, how often,
how long
Signature: Whoever wrote the order should sign it.
e.g. 4/29/2012 Assist Guta to sit on the side of the
bed for 10 minutes tid. Tekle G. RN

Nursing actions vs nursing instructions
Nursing Action Nursing instructions
Ambulate
patient
 Ambulate patient the length of the hall using the walker
3 times a day
 Monitor ability to use walker appropriately and record
response daily on flow sheet.
Provide periods
of uninterrupted
rest
 Do not wake up the patient from midnight to 7 am
 Allow flow to rest from 1 pm to 3 pm (no visitors)
 Record the patient’s perception of hours slept
Manage airway
clearance
 Elevate head of bed. Avoid use of pillow under head, as
indicated.
 Encourage coughing/deep-breathing exercises and
frequent position changes.
 Suction (if necessary) with extreme care, maintaining
sterile technique.

Consider the following when writing
nursing instructions
 What to look for (assessing, or seeing)
 What to do
 What to teach or counsel
 What to record
 Example: High risk for ineffective airway
clearance related to history of smoking and
incision pain.

Nursing instructions to be carried in
caring for such a patient are:
Put the patient in upright sitting position
Check the respiration rate every hour
Auscultate lungs every 4 hours for secretions
Assist the person to perform coughing and deep breathing
exercises with pillow and hand over incision area every 4
hours.
Reinforce the importance of coughing and deep breathing.
Record lung sounds and sputum production once a shift

Breakout
Write specific nursing
instructions

Summary
1. Nursing Planning
2. Planning: Establishing priority
3. Planning: Setting goal
4. Planning: Outcome identification
5. Planning: Nursing intervention
6. Planning: Nursing instruction or order

Objectives
By the end of this presentation trainees will be
able to:
 Define implementation of nursing care
 Put plan of care into action using various
implementation methods
 Record the actual implementation

Outline
• Definition of implementation
• Implementation methods
• Process of implementation
• Implementation skills
• Summary

Definition of Implementation
 Is the fifth step in the nursing process.
 Is carrying out nursing instructions and
physician orders.
 Involves documentation.
 Involves the execution of the nursing plan of
care derived during the planning phase.
 It consists of performing nursing activities that
have been planned to meet the goals set with
the client.

Implementation…
 To complete implementation effectively,
the nurse must be knowledgeable about:
1. Types of interventions
2. Specific implementation method &
3. Implementation process

1. Intervention categories
Interventions categories as already mentioned
in the planning session.
• What are intervention categories?

2. Implementation Methods…
Methods
1. Assisting with ADLs
2. Counseling- to use problem solving process
and manage problems
3. Teaching- used to present correct principles,
procedures, and techniques of health care to
clients, to inform clients about their health
status and refer clients to social resources.

2. Implementation Methods…
4.Preventing Adverse Reactions- when providing
care and applying correct techniques in
administering care and preparing the client for
special procedures.
5.Compensating for Adverse Reactions- Nursing
actions that compensate for adverse reactions
reduce or counteract the reaction
Ex. Understanding the known potential side
effects of the drug, Assessing the client side
effects, or initiation life saving measures

Implementation skills
• To implement nursing interventions the
following skills are needed
1. Clinical Decision skill requires knowledge,
2. Interpersonal (communication) skill &
3. Psychomotor skills

Summary
• Implementation is the fifth step in nursing
process
• Puts plan of nursing care in to action.
• The nurse uses psychomotor, interpersonal and
critical thinking skills during implementation
of nursing care

Objectives
By the end of this presentation, participants will
be able to:
• Explain the relationship between expected
outcomes and goals of care
• Explain the function evaluation plays in
improving the quality of client care

Outline
o Definition of evaluation
o Purpose of evaluation
o Steps for Objectively Evaluation of Plan of
Care
o Care Plan Revision
o Progress Note
o Documentation of care plan

Evaluation
Definition
 Determines the patient’s responses to the
nursing interventions and the extent to which
the outcomes have been achieved.
 Is the regular review of the effect of nursing
interventions and the treatment regimen on the
patient’s health status and expected health
outcomes

The purpose of evaluation
• Assist the client in minimizing or resolving actual
health problems
• Preventing the occurrence of potential problems,
• Promoting the maintenance of a healthy state
• Measure how well the patient has achieved desired
outcomes
• Identify factors contributing to the patient`s success or
failure
• Modify the plan of care, if indicated.

Steps for Objectively Evaluation of Plan of
Care
1. Examine the goal statement (outcome) to
identify the exact desired client behavior or
response
2. Assess the client for the presence of that
behavior or response
3. Compare the established outcome criteria with
the behavior or response
4. Judge the degree of agreement between outcome
criteria and the behavior or response

Achievement of plan of care
1. Goal is Met (M)- if the client’s response
matches or exceeds the outcome criteria.
2. Goal is partially Met (P)- If the client’s
behavior begins to show changes, but does not
yet meet specified criteria.
3. Goal is Not Met (N) - If there is no progress.
Steps for Objectively Evaluation of Plan of
Care…

Care Plan Revision
Adjustments to nursing care plan after
evaluation
1. Goal successfully met
o Discontinue the portion of that care plan
2. Goal unmet and partially met goals
o Reactivate the nursing process sequence

Care Plan Revision…
Example
• Nursing Diagnosis: - Knowledge deficit regarding
insulin therapy related to inexperience
• Goals: client will self- administer insulin by 12/18
• Outcome criteria
• Client prepares insulin dosage in syringe by 12/17
• Client demonstrates self – injection by 12/18

Care Plan Revision…
• Evaluation finding (Client response)
• Client prepared accurate dosage in syringe on
12/17
• Client administered morning insulin dosage;
self – injection was correctly performed on
12/18
• Judgment: Goal achieved, no need to revise
this part of care plan

Progress Note
2/6/2024
TOT nursing care Standards March 2017
Adama
353

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