NSG PROCESS
1. Assessment
2. Nursing Diagnosis.
3. Planning.
4. Implementation.
5. Evaluation.
1.Assessment-
It is collecting verifying organizing date about the client’s health status Data about physical emotional, developmental, social, cultural and spiritual aspect of the client’s are obtained from a variety of sources.
2.Nursing Diagnosis-
It is a process of making a clinical judgment about a client’s actual health problem Nsg. Diagnosis is the statement of judgment.
3.Planning-
It involves a series of steps in which the nurse and client set proprieties, formulates goals and expected out comes establish a written care plan for Nsg. Interventions.
4.Implementation-
Phase of the nursing process, involves recording the patient response to the nursing plan, putting the nursing plan into action-
delegating specific nursing intervention and coordinating the patient’s activity.
5.Evaluation-
Phase is to determine whether nursing intervention have enabled to patient to meet desired goals.
Types of Data-
Subject Data-
which are give information by the client eg. Dizziness, nausea, vomiting.
Objective Data
- examiner selfly observe the client ex.-cyanosis pale, redness.
Method of Data collection-
-Observation- carefully observation.
-Interviewing- Nurse interviews the patient and obtains data.
-Examination-
Nurse performs physical assessment to obtain objective data by inspection, palpation, percussion, auscultation and manipulation.
PHYSICAL ASSESSMENT.
Subjective Data
Objective Data
Assessment-IPPAO
1. Inspection - is the use of vision, hearing and smell to distinguish from normal to abnormal finding.
Inspect each area for size, shape, color, position.
2. Palpation is often used for visual inspection-
Palpation- palpation involves the use of the hands to touch body parts to make sensitive assessments.
- Palpate the skin for temperature, moisture, thickness- Palpate organ such as liver for, size or shape.
Before palpating, help the patient to relax and be comfortable because muscle tension during palpation impairs effective assessments.
For light palpates abdomen- depress about (1 c.m. (1/2 inch)
Light, intermittent pressure is best when palpating heavy, prolonged pressure causes loss of sensitivity in your hands.
For deeper palpation- Depress the area examined approximately 2.4 cm (1-2 inch).
The most sensitive part of the hand is pads of fingers tips.
Radial pulse is detected with pads of fingertips.
Dorsum of hand detect temperature variation in skin
The bony part of the palm at base of the fingers detect vibration.
3. Percussion-
involves tapping the body with the fingertips to produce a vibration that travel through the body tissue.
The vibration is transport through the body tissue and the Chest of the sound heard depends on the density of the underlies tissue.
4. Auscultation-
Ausc.Involves listening to sounds made by body organ to detect variants from normal.
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