Unit 1 AHN

Unit I- Overview of Nursing process
BY
SEHRISH NAZ
RN, Post RN, MSN
Lecturer, Institute of Nursing Sciences, Khyber
Medical University
Subject: Adult Health Nursing
11/12/2019 1Post RN semester one

• Day will be started from:
1. Tilawat-e-QURAN-E-PAK
2. A short memorable Hadith-e-mubaraka
3. A short story of bed-side nursing of any student related to assessment
• Ground rules for the class:
1. Please bring your laptops in every class of Adult Health Nursing
2. Please don’t use your cell phone for calls or messages except when necessary
3. Please make sure that your cell phone is on silent mode during the class
4. Please respect each other
5. Please don’t talk to each other except when necessary
6. Please feel free to ask questions about course work, exams criteria and
schedules
7. Please don’t spread rumors except true information about teachers, students,
exams, holydays.
8. Please be unite both genders (united we stand divided we fall)
9. Please use university internet for academic purposes
10. Wi-Fi password for kmu , kmu staff OR kmu staff2; staff222, staff 111 OR
staff 666
11. CAT (continue assessment test) will be taken before & after the end of the
class.

OBJECTIVES
At the end of this session learners will be able to:
• Define the purposes of nursing process
• Review the components of the nursing process.
• Describe the Functional Health approach to nursing process
• Develop a concept map-Nursing Care Plan
11/12/2019 Post RN semester one 3

HEALTH
Health is a state of complete psychical, mental, social and spiritual
well being and not merely the absence of disease or infirmity.
WHO recently added, the ability to lead a socially and economically
productive life.
ASSESSMENT
• The action of assessing someone or something.
• The act of judging or deciding the amount, value, quality, or
importance of something

NURSING PROCESS
The nursing process consists of five dynamic and
interrelated phases:
1. Assessment
2. Nursing Diagnosis
3. Planning
4. Implementation
5. Evaluation

NURSING ASSESSMENT
– Collection of subjective and objective data to determine a
client’s overall level of functioning in order to make a
professional clinical judgment.
– Focus on the client as a person & reach to the optimal
level of wellness (Holistic approach)
MEDICALASSESSMENT
– Focus primarily on the client’s physiologic changes
(diagnosis & treatment)

DISEASE
A disorder of structure or function in a human, animal, or plant,
especially one that produces specific symptoms or that affects a
specific location and is not simply a direct result of physical injury.
WELLNESS
Is generally used to mean a healthy balance of a body, mind and
soul that results an overall feelings of wellbeing.
ILLNESS
It is an abnormal highly personal and subjective feelings in which
individual’s physical, emotional, intellectual, social, developmental
or spiritual function is thought to be diminished or impaired.

HEALTH ASSESSMENT
• The process of collecting, validating, and clustering data about
the health.
OR
• A health assessment is a plan of care that identifies the specific
needs of a person and how those needs will be addressed by
the healthcare system or skilled nursing facility.
OR
• Health assessment is the evaluation of the health status by
performing a physical exam after taking a health history.

IMPORTANCE OF ASSESSMENT IN NURSING
PROCESS
 First step in nursing process.
 Sets the tone for the rest of the process.
 Identifies patient’s strengths and limitations. (cooperative or
uncooperative, could or could not care for him/herself)
 Performs continuously throughout the nursing process.

SKILLS OF ASSESSMENT
Assessment requires;
3 H learning skills (head, hand and heart)
– Cognitive (Head)
– Problem-solving
– Psychomotor (Hand)
– Affective/interpersonal (Heart)
– Ethical skills

PURPOSE OF ASSESSMENT
 To collect data relevant to the patient’s health
status, to identify deviations from normal
 To discover the patient’s strengths and coping
resources
 To identify actual problems
 To mark factors that place the patient at risk for
health problems

TYPES OF HEALTH ASSESSMENT
Focus
Assessment
Initial
Assessment
Time-lapsed
Assessment Emergency
Assessment
Assessment

COMPREHENSIVE ASSESSMENT
– Is usually the initial assessment and includes detailed
health history and physical examination and examine
the client's overall health status
FOCUSED ASSESSMENT
– Is problem oriented and may be the initial assessment
or an ongoing assessment
1411/12/2019 Post RN semester one

1. INITIAL ASSESSMENT
 An initial assessment, also called an admission
assessment, is performed when the client enters a ward
through OPD.
 The purpose is to evaluate the client’s health status, to
identify functional health patterns that are problematic,
and to provide an in-depth, comprehensive database,
which is critical for evaluating changes in the client’s
health status in subsequent assessments.

2. PROBLEM-FOCUSED ASSESSMENT
 A problem focused assessment collects data about a problem that
has already been identified.
 This type of assessment has a narrower scope and a shorter
time frame than the initial assessment.
 In problem focused assessments, nurse determine whether the
problems still exists and whether the status of the problem has
changed (i.e. improved, worsened, or resolved).
 This assessment also includes the appraisal of any new,
ignored, or misdiagnosed problems.
 In intensive care units, problem focused assessment may be
performed every few minutes.

3. TIME-LAPSED ASSESSMENT OR ONGOING
ASSESSMENT
 Time lapsed reassessment, another type of assessment, takes
place after the initial assessment to evaluate any changes in
the clients functional health.
 Nurse perform time-lapsed reassessment when substantial
periods of time have elapsed between assessments (e.g.,
periodic output, patient clinic visits, home health visits,
health and development screenings).

4. EMERGENCYASSESSMENT
 Emergency assessment takes place in life-threatening
situations in which the preservation of life is the top
priority.
 Often the client’s difficulties involve airway, breathing
and circulatory problems (the ABCs).
 Sudden changes in self-concept (suicidal thoughts) or
roles or relationships (social conflict leading to violent
acts) can also initiate an emergency.
 Emergency assessment focuses on few essential health
patterns and is not comprehensive.

1. Systematic and continuous collection of client data
2. It focuses on client’s responses to health problems
3. The nurse carefully examine the client’s body parts to
determine any abnormalities
4. The nurse relies on data from different sources which
can indicate significant clinical problems
19
IMPORTANCE OF NURSING HEALTH
ASSESSMENT

5. Provides a base line used to plan the clients care
6. Helps the nurse to diagnose client’s problem & the
intervention
7.Complete health assessment involves a more detailed
review of client’s condition
8.Health assessment influences the choice of therapies
& client's responses

ASSESSMENT PROCESS
Assessment
Collect data Organize data Validate data
Documenting
data

1. COLLECTION OF DATA
 Gathering Of Information About The Client
 Includes Physical, Psychological, Emotion, Socio-cultural,
Spiritual Factors That May Affect Client’s Health Status
 Includes Past Health History Of Client (Allergies, Past
Surgeries, Chronic Diseases,)
 Includes Current/Present Problems Of Client (Pain, Nausea,
Sleep Pattern, Religious Practices, Medication Or Treatment
The Client Is Taking Now)

TYPES OF DATA
When performing an assessment the nurse gathers
subjective and objective data.
Subjective data (symptoms or covert data):
are the verbal statements provided by the Patient.
Statements about nausea and descriptions of pain and
fatigue are examples of subjective data.

Objective data (signs or overt data), are
detectable by an observer or can be measured or
tested against an accepted standard. They can be
seen, heard, felt, or smelt, and they are obtained
by observation or physical examination. For
example: discoloration of the skin.
Objective Data

DATA COLLECTION METHODS
1. Observing: to observe togather data by using the
senses.
2. Interviewing: an interview is a planned communication
or conversation with a purpose.
3. Examining: performance of a physical examination. the
physical examination is often guided by data provided
by the patient. a head-to-toe approach is frequently used
to provide systematic approach that helps to avoid
omitting important data

2. ORGANIZING DATA
The nurse uses a written or computerized
format that organizes the assessment data
systematically. The format may be modified
according to the client's physical status.

3. VALIDATING DATA
The information gathered during the assessment phase
must be complete, factual, and accurate because the
nursing diagnosis and interventions are based on this
information.
Validation is the act of "double-checking" or
verifying data to confirm that it is accurate and factual.

PURPOSES OF DATA VALIDATION
 Ensure That Data Collection Is Complete
 Ensure That Objective And Subjective Data
Agree (congruent)
 Obtain Additional Data That May Have
Been Overlooked (missing)
 Avoid Jumping To Conclusion
 Differentiate cue (signs) And Inferences
(supposition)

4. DOCUMENTING DATA
Approaches to documentation:
–Source-oriented medical record (SOMR)
–Problem-oriented medical record (POMR)

Source-oriented Medical Record (SOMR)
In a SOMR or source oriented medical record,
the record is kept together by subject matter
(labs are all together, progress notes are all
together).
It is done by department, so each healthcare
group has a section to document findings.

Problem Oriented Medical Record (POMR)
Everyone involved in the care of the patient
charts on the same form.
This allows for better communication of data
to resolve the patient’s problems
collaboratively.

METHODS OF POMR
• PIE(Problem, Intervention, Evaluation)
• DAR(Data, Action, Response)

Planning
• The planning stage is where goals and
outcomes are formulated that directly impact
patient care based on EDP guidelines. These
patient-specific goals and the attainment of
such assist in ensuring a positive
outcome. Nursing care plans are essential in
this phase of goal setting.

Types of planning
1- Initial Planning
• Develops initial comprehensive plan of care
• Begun after initial assessment

2- Ongoing Planning
Done by all nurses
Individualization of initial care plan
At the beginning of a shift
Determine whether client's health status changed
Set priorities for client's care during shift
Decide which problems to focus on
Coordinate nurse's activities so that more than one
problem can be addressed at each client contact

3- Discharge Planning
• Process of anticipating and planning for needs
after discharge
• • Addressed in each client's care plan
• •Begins at first client contact
• •Involves comprehensive and ongoing
assessment

Developing Nursing Care Plans
• 1- Informal nursing care plan
• A strategy for action that exists in nurse's mind
• 2- Formal nursing care plan
• Written or computerized guide
• 3- Standardized care plan
• A formal plan that specifies actions for a group
of clients with common needs
• 4- Individualized care plan
• Tailored to meet the unique needs of a specific
client

Standardized Approaches to Care
Planning
• • Standards of care
• Nursing actions for clients with similar medical
conditions
• Achievable rather than ideal nursing care
• Interventions for which nurses are accountable
• Usually, there are agency records that may be
referred to in client's care plan.
• Written from the perspective of the nurse's
responsibilities
• Do not contain medical interventions

Protocols
• Indicate actions commonly required for a
particular groups of clients
• May include both primary care provider's
orders and nursing interventions
• Example: Protocol for admitting a client to
the intensive care unit
• • Policies and procedures
• Example: Policy specifying the number of
visitors a client may have

The Planning Process •
• Consists of the following activities:
• Setting priorities
• Establishing client goals/desired outcomes
• Selecting nursing interventions
• Writing individualized nursing interventions
on care plans

Setting Priorities
• 1- Establishing priorities sequence for
nursing diagnoses and interventions
• High priority (life-threatening)
• Medium priority (health-threatening)
• Low priority (developmental needs)

2- Factors to consider
• Client's health values and beliefs
• Client's priorities
• Resources available
• Urgency of the health problem
• Medical treatment plan

Establishing Client Goals/Desired
Outcomes
• Goals
• Broad statements about the client's status
• Desired outcomes
• More specific, observable criteria used to
evaluate whether goals have been met

Purpose of desired goals/outcomes
• Provide direction for planning interventions
• Serve as criteria for evaluating progress
• Enable the client and the nurse to determine
when the problem has been resolved
• Help motivate the client and nurse by
providing a sense of achievement

Short-term and long-term goals
• By the end of the week or in over the course
of many weeks(long)
• Short-term goals useful for clients who:
• • Require health care for a short time
• • Are frustrated by long-term goals that seem
difficult to attain
• • Need the satisfaction of achieving a short-
term goal

Relationship of goals/desired
outcomes
• • to nursing diagnoses
• Goals derived from diagnostic label
• Diagnostic label contains the unhealthy
response (problem)
• Goal is opposite, healthy response
• How client will look or behave if health
response is achieved (observable, time limited)
Achieving goal demonstrates resolution of
the problem

Guidelines for writing goals/desired
outcomes
• Write in terms of client responses
• Must be realistic
• Ensure compatibility with therapies of other
professionals
• Derive from only one nursing diagnosis
• Use observable, measurable terms
• Make sure client considers goals important

Formats for Nursing Care Plans
• Student care plans
• Rationale • Evidence-based principle given
as the reason for selecting a particular nursing
intervention
• Concept maps • Visual tool in which ideas
or data are enclosed in circles or boxes with
relationships indicated by lines or arrows

Computerized care plans
• Create and store nursing care plans
• Can be accessed at a centrally located
terminal at nurses' station or in clients' rooms
• Appropriate diagnoses selected from a
menu suggested by the computer

Multidisciplinary (Collaborative)
Care Plans
• • known as critical pathways
• • Sequence care that must be given on each day
during projected length of stay for each
condition
• • Usually organized with a column for each day
listing interventions and outcomes for that day
• • Includes medical treatments to be performed
by other providers

Guidelines for Writing Nursing Care
Plans
• 1. Date and sign the plan
• 2. Use category headings
• 3. Use standardized/approved medical or
English symbols and key words rather than
complete sentences to communicate your ideas
unless agency policy dictates otherwise
• 4. Be specific
• 5. Refer to procedure books or other sources of
information

Conti…
• 6. Tailor the plan to the unique characteristics of
the client by ensuring that the client's choices, such
as preferences about the times of care and methods
used, are included
• 7. Ensure that the nursing plan incorporates
preventive and health maintenance aspects
• 8. Ensure that the plan contains ongoing
assessment of the client
• 9. Include collaborative and coordination activities
in the plan
• 10.Include plans for the client's discharge and home
care needs

Selecting Nursing Interventions and
Activities
• • Actions nurse performs to achieve goals
• • Focus on eliminating or reducing etiology of
nursing diagnosis
• • Treat signs and symptoms and defining
characteristics
• • Interventions for risk nursing diagnoses
should focus on reducing client's risk factors

Types of nursing interventions
I. Independent interventions
Activities nurses are licensed to initiate (i.e., physical
care, ongoing assessment)
II. Dependent interventions
Activities carried out under primary care provider's
orders or supervision, or according to specified
routines
III. Collaborative interventions
Actions nurse carries out in collaboration with other
health team members

Criteria for choosing nursing
interventions
• Safe and appropriate for the client's age, health,
and condition
• Achievable with the resources available
• Congruent with the client's values, beliefs, and
culture
• Congruent with other therapies
• Based on nursing knowledge and experience or
knowledge from relevant sciences
• Within established standards of care

Cont…
• Date when they are written
• • Verb
• Action verb starts the interventions and must
be precise.
• • Conditions
• • Modifiers
• • Time element
• How long or how often the nursing action is
to occur

Delegating Implementation
• • Delegation occurs during planning.
• Who is decided to do each task?
• • Nurse is responsible for correct implementation
of task delegated, analysis of data, and evaluation
of outcome

Functional health patterns
1. Health Perception and Management
2. Nutritional metabolic
3. Elimination patterns
4. Activity exercise
5. Sleep & Rest
6. Cognitive-perceptual
7. Self perception/self concept
8. Role relationship
9. Sexuality reproductive
10.Coping-stress tolerance
11.Value-Belief Pattern

References
1. Dillon PM., Nursing Health Assessment; A
Critical Thinking, Case Studies Approach, 2nd
ed. Copyright © 2007 by F. A. Davis.
2. Kozier & Erb, G. K., (2015). Fundamentals of
Nursing: Concept, process and practice (10th
ed.). Addison:

THANKS FOR
ATTENTION

Unit 1 AHN

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