COMPETENCY APPRAISAL REVIEWER
• Inspection, Auscultation, Percussion,
NURSING PROCESS Palpation (Abdomen)
Steps in Assessment
A - Assessment 1. Collection of Data
D - Diagnosis 2. Validation of Data
P - Planning 3. Organization of Data
1 - Implementation 4. Categorizing or identifying patterns of
E - Evaluation data
An overlapping of process can be noted since it 5. Making influences or impressions of
is cyclic data
ASSESSMENT *After data collection, synthesis, analysis and
validation are performed
Types
1. Initial assessment
2. Problem focused assessment DIAGNOSIS
3. Emergency assessment
4. Time-lapsed assessment
Problem + etiology + defining symptoms
Data Collection - first step in assessment *Guided by the NANDA
1. Primary/ Secondary
2. Object (over)/ Subjective (covert) • Knowledge deficit - kulang sa kaisipan
• Knowledge deficiency - kulang sa
Methods of Gathering Data : kaalaman (preferred)
• Therapeutic and non-communication • Self-care deficit - acceptable
• Health History
Ø Medical history - disease focused Types of Nursing Diagnosis
(physiological) • Actual
Ø Nursing history - needs, • Risk for/ Potential for
psychosocial dimension, spiritual • Wellness - readiness and enhancement/
aspects achieve higher level of functioning
• Personal space • Syndrome - "syndrome"
Ø Intimate Space 1 1/2 foot • Possible - vague/ unclear -
Ø Personal Space 1 1/2-4 feet possible/probable
Ø Social Space 4-12 feet
Ø Public Space 12-15 feet Prioritization of Nursing Diagnosis (ABC)
Airway, Breathing, Circulation
Observation
• Use of senses to gather data
• Clinical eye - comes with practice and
experience PLANNING
Examination Short Range & Long Range
• Inspection, Palpation, Percussion, *Must be SMART Specific, Measurable,
Auscultation (General) Attainable, Realistic, Time
• bound)
, COMPETENCY APPRAISAL REVIEWER
*Classify as dependent, interdependent, and
collaborative
DOCUMENTATION
DOCUMENTATION or CHARTING
IMPLEMENTATION
STAT - now
• Reassess if the patient still needs Ad lib - as desired
intervention PRN - as required
• Determine it you need assistance OD - right eye/ once a day
• Carry out intervention, ensure that we OS - left eye
have background OU - both
• Document AD - right ear
AS - left ear
Process of Implementing AU - both ears
• Reassess client Ss – half
• Determine nurses' needs for assistance
• Implementing nursing interventions ERROR: draw a straight line, signature, initials
• Supervising the delegated care
Types of Documentation
• Documenting nursing activities 1. Source Oriented Recording - narrative
account by nurse: all the sheets in the
EVALUATION patient's chart (Standing Order,
Physician's Order etc.)
2. Problem Oriented Recording (POR) -
Purposes of evaluation: problems ranked according to priority
Determine the: by the health care team, date dissolved,
• Client's progress or lack of progress progress notes, problem list
• Overall quality of care provided a. FDAR - Focus, Data, Action, Response
• Promote nursing accountability (patient)
b. SOAPIER - subjective, objective, assessment,
planning, implementation, evaluation, revision
Guidelines for evaluation
1. Computer Assisted Recording - problem
• Systemic process with privacy
• On-going basis 2. Flow Chart
• Revision of the plan of care when 3. Charting by Exception (CBE) - only
needed significant change is documented
• Involve the client, significant others, and Case Management done with a Critical Pathway
other members of the health team Must Variance
be documented - Comprehensive and make sure that it won't
legally be implicated
Process - nurse
Structure - system
Outcome – patient
• Inspection, Auscultation, Percussion,
NURSING PROCESS Palpation (Abdomen)
Steps in Assessment
A - Assessment 1. Collection of Data
D - Diagnosis 2. Validation of Data
P - Planning 3. Organization of Data
1 - Implementation 4. Categorizing or identifying patterns of
E - Evaluation data
An overlapping of process can be noted since it 5. Making influences or impressions of
is cyclic data
ASSESSMENT *After data collection, synthesis, analysis and
validation are performed
Types
1. Initial assessment
2. Problem focused assessment DIAGNOSIS
3. Emergency assessment
4. Time-lapsed assessment
Problem + etiology + defining symptoms
Data Collection - first step in assessment *Guided by the NANDA
1. Primary/ Secondary
2. Object (over)/ Subjective (covert) • Knowledge deficit - kulang sa kaisipan
• Knowledge deficiency - kulang sa
Methods of Gathering Data : kaalaman (preferred)
• Therapeutic and non-communication • Self-care deficit - acceptable
• Health History
Ø Medical history - disease focused Types of Nursing Diagnosis
(physiological) • Actual
Ø Nursing history - needs, • Risk for/ Potential for
psychosocial dimension, spiritual • Wellness - readiness and enhancement/
aspects achieve higher level of functioning
• Personal space • Syndrome - "syndrome"
Ø Intimate Space 1 1/2 foot • Possible - vague/ unclear -
Ø Personal Space 1 1/2-4 feet possible/probable
Ø Social Space 4-12 feet
Ø Public Space 12-15 feet Prioritization of Nursing Diagnosis (ABC)
Airway, Breathing, Circulation
Observation
• Use of senses to gather data
• Clinical eye - comes with practice and
experience PLANNING
Examination Short Range & Long Range
• Inspection, Palpation, Percussion, *Must be SMART Specific, Measurable,
Auscultation (General) Attainable, Realistic, Time
• bound)
, COMPETENCY APPRAISAL REVIEWER
*Classify as dependent, interdependent, and
collaborative
DOCUMENTATION
DOCUMENTATION or CHARTING
IMPLEMENTATION
STAT - now
• Reassess if the patient still needs Ad lib - as desired
intervention PRN - as required
• Determine it you need assistance OD - right eye/ once a day
• Carry out intervention, ensure that we OS - left eye
have background OU - both
• Document AD - right ear
AS - left ear
Process of Implementing AU - both ears
• Reassess client Ss – half
• Determine nurses' needs for assistance
• Implementing nursing interventions ERROR: draw a straight line, signature, initials
• Supervising the delegated care
Types of Documentation
• Documenting nursing activities 1. Source Oriented Recording - narrative
account by nurse: all the sheets in the
EVALUATION patient's chart (Standing Order,
Physician's Order etc.)
2. Problem Oriented Recording (POR) -
Purposes of evaluation: problems ranked according to priority
Determine the: by the health care team, date dissolved,
• Client's progress or lack of progress progress notes, problem list
• Overall quality of care provided a. FDAR - Focus, Data, Action, Response
• Promote nursing accountability (patient)
b. SOAPIER - subjective, objective, assessment,
planning, implementation, evaluation, revision
Guidelines for evaluation
1. Computer Assisted Recording - problem
• Systemic process with privacy
• On-going basis 2. Flow Chart
• Revision of the plan of care when 3. Charting by Exception (CBE) - only
needed significant change is documented
• Involve the client, significant others, and Case Management done with a Critical Pathway
other members of the health team Must Variance
be documented - Comprehensive and make sure that it won't
legally be implicated
Process - nurse
Structure - system
Outcome – patient
