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College of Health sciences

Department of Nursing
Clinical Nursing I for 2nd year BSc Nursing
Students

By: Shegaw Zeleke(BSc, MSc in Adult Health


Nursing)
Email: shegawzn@gmail.com
By Shegaw Z(MSc in AHN) 1
Objectives
• Define health assessment
• Explain the purpose of health assessment.
• Describe the factors that promote an effective
interview.
• Identify techniques of data collection
• List the components of a data base (health
assessment)
• Discuss the components of nursing process
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“Our job as nurses is to cushion the sorrow and celebrate
the joy every day, while we are just doing our jobs’’

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Introduction to clinical Nursing
Definition of assessment

 Is the collection of data about an individual’s health state.

Definition of health

• Health is a state of complete physical, mental, and


social well-being and is not merely the absence of
disease or infirmity and the ability to lead productive
life

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Introduction to clinical Nursing
Definition of Health Assessment
• Is a process by which we analyze and synthesize
collected information in order to make judgment
about health status of the client or to determine
a person’s needs for nursing care.

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Purposes of health assessment
To gather data that:
 Allows nurse to make judgment about patient’s
health state
 Will be used for rest of nursing
process
 Determines patient’s:
Baseline
Normal function
Presence of (or risk for) dysfunction
Strengths

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Types of Data Collection
• There are four kinds of database every examiner needs to
collect

1.Complete/Total

2.Episodic or problem centered

3. Follow up and

4. Emergency.

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1. Complete or Total Health Data Base

• This includes a complete health history and a full


physical examination.

• Initial assessment/triage

• It describes the current and past health state and form


a baseline.

• It is collected in any setting for well or ill person.

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Question
Why Complete Health Data Base is important
for well person?

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• For a well person, it describes the person’s

 health state perception of health

strength or assets such as health


maintenance behaviors, and

 any risk factors.

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• For the ill person, the database also includes a

description of the person’s health problems

perception of illness, and

response to problems.

• Based on the data base the nursing diagnoses could


farther be developed.

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2. Episodic or problem centered Data Base
• collects a “mini” data base, smaller in scope than the
completed database.

• It concerns mainly one problem or one system.

• It is used in all settings- hospital primary care or long term


care.

• For ex. 2 days following surgery, a patient suddenly


develops a congested cough, shortness of breath, and fatigue.

• The history and examination focuses primarily on the


respiratory and cardiovascular systems.
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3. Follow up Data Base
• The status of any identified problems should be evaluated
at regular and appropriate intervals.

• What change has occurred?

• Is the problem getting better or worse?

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4. Emergency Data Base
• This calls for a rapid collection of the data base with life-
saving measures.
• For ex, in a hospital emergency department, a person with
suspected poisoning the first history question could be “what
did you take?”
 The person is questioned simultaneously while the airway,
breathing and circulation are being assessed.
 It needs more rapid collection of data than the episodic data
base.
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The Nursing process

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Introduction to nursing process
Defn:-
 The nursing process is a systematic problem solving method

for providing individualized care for clients in all stages of


health.

 It is a decision making approach that promotes critical

thinking

 The ultimate goal of Nursing process is to improve the health

status of the client or assist the client in maintaining or


returning to his/ her optimal level of functioning and well-ness
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Purposes of Nursing process.
• To identify the client’s health status, actual or potential health
problems or needs.
• To establish plans to meet the identified needs and.
• To deliver specific nursing interventions to meet those needs.
• Nursing process is economical
• Stress the independent function of nurses
• Provides continuity of care and prevents duplication
• Increase the quality of care through deliberate action

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Characteristics of Nursing process.
Systematic

– The nursing process has an ordered sequence of activities


and each activity depends on the accuracy of the activity
that precedes it and influences the activity following it.

Dynamic

– The nursing process has great interaction and overlapping


among the activities and each activity is fluid and flows
into the next activity.

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Characteristics of Nursing process…
Interpersonal
– The nursing process ensures that nurses are client-centered
rather than task-centered and encourages them to work to
enhance client’s strengths and meet human needs.
Goal-directed
– The nursing process is a means for nurses and clients to
work together to identify specific goals (wellness promotion,
disease and illness prevention, health restoration, coping and
altered functioning) that are most important to the client, and
to match them with the appropriate nursing actions
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Characteristics of Nursing process…
Universally applicable
– The nursing process allows nurses to practice
nursing with well or ill people, young or old, in any
type of practice setting

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Characteristics of Nursing process…

• Interactive , purposeful

• Within the legal scope of nursing

• Prioritizing the needs of patients

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Components of Nursing Process

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1. ASSESSMENT
 Assessment is the first step in the nursing process and
includes systematic

–Collection,

–Verification,

–Organization,

–Interpretation, and

–Documentation of data for use by health care


professionals.
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ASSESSMENT …

• Nursing assessment don’t duplicate medical


assessment (which targets pathologic conditions)
but focuses on the patients responses to health
problems or potential health problems

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ASSESSMENT cont…
• Effective planning of client care depends on a complete
database and accurate interpretation of information.

• Incomplete or inadequate assessment may result in


inaccurate conclusions and incorrect nursing
interventions.

• Proper collection of assessment data directs decision-


making activities of professional nurses.

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ASSESSMENT cont…
• The goal of assessment is the collection and analysis
of data that are used in formulating

–nursing diagnoses,

– identifying outcomes

–planning care, and

–developing nursing interventions.

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Types of Data
Client data include information that the client
communicates concerning perceptions of his or her
own health status, as well as specific observations
made by the nurse.

These two types of information are referred to as

subjective and

objective data.

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Subjective data:
are data from the client’s point of view and include
feelings, perceptions, and concerns.

The data (also referred to as symptoms) are obtained


through interviews with the client.

They are called subjective because they rely on the


feelings or opinions of the person experiencing them
and cannot be readily observed by another.

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Objective data:
• are observable and measurable (quantitative) data that
are obtained through

»observation,

»standard assessment techniques performed


during the physical examination, and

»laboratory and diagnostic testing.

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Objective data cont…
• These data (also called signs) can be seen, heard, or
felt by someone other than the person experiencing
them.

• Assessments that are comprehensive and accurate


include both subjective and objective data.

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Sources of information
I. Primary sources-

• the primary source of information during assessment


is the clients themselves.

• The information obtained from the client is relatively


accurate and very important.

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Sources of information cont…
II. Secondary sources- secondary sources of
information during ass’t can be:

– Family members.

– Patient records.

– Other health care team.

– Laboratory results.

– X-ray results.

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Skills needed during assessment
• Assessment involves recognizing and collecting cues.

• Cues is Pieces of information about the patient’s


health status.

• It can be

- Subjective cues- symptoms

- Objective cues- signs.

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Observation
• It is the act of noticing the patient’s cue using sense
organs.

Ex.- By looking at the patients body part.

- By looking the general physical

appearance of the pt.

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Interviewing
• It is an essential skill for obtaining information from
the client.

• During interviewing information is generated through


the interaction b/n the nurse and the client [ asking and
answering]

• For the interviewing to be effective.

- The nurse should have communication skill.

- The patient should be willful.


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Physical examination

• It is the analysis of bodily functioning


by suing techniques of physical examinations.
i.e. - Inspection
- Palpation
- Percussion
- Auscultation

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Intuition
• Use of insight, instinct and clinical experience
to make clinical judgment about the client

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Validating Data
• Validation prevents omissions, misunderstandings, and incorrect

inferences and conclusions

DATA ORGANIZATION

• After data collection is completed and information is validated,

the nurse organizes, or clusters, the information together in order

to identify areas of strengths and weaknesses.

• This process is known as data clustering.

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Interpreting Data
Three critical components:

• Distinguishing between relevant and irrelevant data

• Determining whether and where there are gaps in the


data

• Identifying patterns of cause and effect

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Documenting Data
 Assessment data must be recorded and reported.
 Accurate and complete recording of assessment data is
essential for communicating information to health care
team.

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2. Nursing Diagnosis
• A medical diagnosis is a clinical judgment by the
physician that determines a specific disease, condition or
pathological state.

• A nursing diagnosis is a clinical judgment about


individual, family, or community responses to actual or
potential health problems/life processes.

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Difference b/n Nursing and medical diagnosis
Medical diagnosis
- Identification of disease condition based on specific
evaluation of signs, symptoms ,lab and procedures
- Goal is to identify cause of illness/injury and to design
treatment
- Physician directs treatment for medical diagnosis
- Remains constant as long as the disease present
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Nursing diagnosis
- Clinical judgment about the individual, family or
community responses to actual or potential health
problems/life process
- Goal is to identify actual and potential health problem
- Nurse treats problem with scope of independent nursing
practice
- May change may day today as the patient response
change

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Eg
NURSING Dx MEDICAL DX
• Ineffective breathing pattern COPD

• Activity intolerance CVA

• Acute pain Appendicitis

• Body image disturbance Amputation

• Risk of altered body temperature Strep throat

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Types of Nursing Diagnosis
• Actual nursing diagnosis: A problem exists; it is
composed of the diagnostic label, related factors, and
signs and symptoms.

• It is the diagnosis about current problem that is present


at the time of nursing assessment, based on the
presence of signs and symptoms

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2. Risk nursing diagnosis:
• A problem does not yet exist, but special risk factors are
present.
• Human response to health condition that may develop in
a vulnerable individual, family or community
• Eg: risk of aspiration related to reduced level of
consciousness

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3. Wellness nursing diagnosis:
• Indicates client’s desire to attain higher level of wellness in
some area of function

• A clinical judgment about person’s, family’s or


community’s motivation and desire to increase wellbeing
as expressed in the readiness to enhance specific health
behaviors' ,and can be used in any health stat

• Eg; readiness for enhance spiritual wellbeing


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3. Planning and Outcome Identification
• Planning combines with outcome identification to comprise the
third step of the nursing process.

Three Phases of Planning

• Initial Planning: developing a preliminary plan of care by the


nurse who performs the admission assessment.

• Ongoing Planning: continuous updating of client’s plan of care.

• Discharge Planning: Involves critical anticipation and planning


for client’s needs after discharge.

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Planning….
• “Planning is not used at all, unless it degenerates in
to work”
Peter Drunker

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Element of planning
1. Prioritizing the problem/nursing dx

2. Formulate goal/ desired out come

– Short term( to resolve with in few hours or day)

– Long term (to resolve over weeks or months)

3. Select nursing interventions

4. Write nursing interventions

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Implementation
• Provide the actual nursing activities and client responses

• Doing and documenting the activity

Skills need for Implementation

• Cognitive skill: problem solving and descion making


skill

• Interpersonal skill; verbal and non verbal response

• Technical skill: hand doing skill

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Implementation…
Categories of Nursing Implementation

• Independent: Actions initiated by nurse that do not require


direction or an order from another health care professional

• Interdependent: Actions implemented in collaborative manner by


nurse in conjunction with other health care professionals

• Dependent: Actions that require an order from a physician or


other health care professional.

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The Nursing Care Plan
• A written guide that organizes data about a client’s care into a
formal statement of the strategies that will be implemented to
help the client achieve optimal health.

Implementation

• This fourth step of the nursing process involves the execution of


the nursing care plan derived during the Planning phase.

Evaluation
• This fifth step of the nursing process, determining whether client
goals have been met, partially met, or not met.

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WRITING NURSING DIAGNOSIS
Three part statement (PES- format)

Includes:

• Problem (P) - statement of the client’s response.

• Etiology (E) – factors contributing or a probable


cause of response.

• Signs and symptoms(S)- defining characteristics


manifested by the client.

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WRITING NURSING DIAGNOSIS…..

• Actual nursing diagnosis can be documented by using


three part statements.

• The problem and etiology part of this nursing diagnosis


is connected by the phrase like “ related to “, but the
etiology and the manifestation part is connected by the
phrase like ‘’as manifested by’’ or ‘’as evidenced by
‘’ because signs and symptoms have been manifested.

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WRITING NURSING DIAGNOSIS…..
• Example:
problem Related to Etiology As manifested Sign and
by/ as symptom
evidenced by
Urinary Related to obstruction As manifested Full bladder
retention by
Excess fluid Related to fluid retention as evidenced Edema
volume by

Imbalance related to poor appetite as evidenced BMI is


nutrition less by 17.7835
than required

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WRITING NURSING DIAGNOSIS…..
Two- part statements [PE- format]
• Used to write potential nursing diagnosis and it
includes:-
• Problem ( P) – statement of client response.
• Etiology (E)- factors contributing to or probable
cause of the response.
E.g. Risk for injury related to confusion
Risk for fluid volume deficit related to vomiting
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Nursing care plan
Nursing Nursing Nursing plan Nursing intervention Nursing
No Assessment diagnosis Evaluation

1 Difficulty of Impaired gas exchange To improve - Raise head of bed 8 to 10 inches (20 to Respiratory rate 16 to
breathing related to disease oxygenation by 30 cm) reduces venous return to heart 20
process as evidenced positioning and and lungs; alleviates pulmonary no signs of crackles or
by difficulty of oxygen congestion. wheezes in lung field
breathing administration - Administer oxygen
- Auscultate lung fields

2 Exertion Activity intolerance To Improving - Increase patient’s activities gradually. Heart rate within
related to oxygen Activity Tolerance - Alter or modify patient’s activities to normal limits, rests
supply and demand after intervention keep within the limits of his cardiac between activities
imbalance as reserve.
evidenced by difficulty - Assist patient with self-care activities
in ADL early in the day.
- Be alert to complaints of chest pain or
skeletal pain during or after activities.

3 Pain Chest pain related to To reduce chest - Raise head of bed 20-30 cm - Pain is reduced
disease process as pain by positioning - Administer oxygen after treatment
evidenced by patient’s reducing oxygen - Administer antipain of 4 days as
verbalization demand evidenced by
patients
verbalization
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