UNIT 4 PROBLEM SOLVING APPROACH IN

NURSING
Structure
4.0 Objectives

4.1 Introduction

4.2 Problem Solving and Nursing Process

4.2.1 Actual Health Problems
4.2.2 Potential Health Problems
4.2.3 Types of Nursing Functions
4.2.4 Comparison of the Problem Solving Process and Nursing Process

4.3 Assessment
4.3.1 Collection of Data
4.3.2 Organization of Data: Subjective and Objective
4.3.3 Documentation of Data

4.4 Nursing Diagnosis

4.4.1 Classification, Analysis and Interpretation of Data
4.4.2 Identification of the Problem: Actual and Potential
4.4.3 Validation
4.4.4 Documentation of Diagnostic Statement

4.5 Planning
4.5.1 Developing Outcomes and Prioritizing Them
4.5.2 Developing Interventions
4.5.3 Documentation: Nursing Care Plan

4.6 Implementation
4.6.1 Preparation
4.6.2 Action / Intervention
4.6.3 Documentation

4.7 Evaluation
4.7.1 Gathering Data Re-assessment
4.7.2 Making Judgement and Revising the Plan

4.8 Let Us Sum Up

4.9 Answers to Check Your Progress

4.10 Activities

Format for Problem Solving Using Nursing Process

Annexures

4.0 OBJECTIVES
After studying this you should be able to:

l relate steps of problem solving approach to steps of nursing process;

l recognize cognitive, affective and psychomotor abilities of nurses needed in problem

solving through nursing process;

l collect subjective and objective data in order to assess client’s responses/health status
patterns to identify clients actual and potential problems;
66
l diagnose and state the problems as per the given format; Problem Solving
Approach in Nursing
l plan the expected outcomes and interventions needed to assist clients;

l implement the care plan for selected clients in the hospital setting;

l evaluate the problem solving activity in terms of change in client is response/health

status/progress; and

l document assessment findings make nursing diagnosis, plan and implementation of care
and evaluation.

4.1 INTRODUCTION
The nature of nursing is complex and efforts to define it are still continuing. Virginia Henderson
(1961) viewed nursing as assisting the individual sick or well in the performance of those
activities contributing to health or its recovery (or to peaceful death) that hes/he would perform
unaided if s/he had the necessary strength, will or knowledge. Nursing is concerned with the
psychological social spiritual and physical aspects of the person rather than only the clients
diagnosed medical condition. Focus of nursing is on the needs, patterns, responses, strengths
or deficits of the whole person interacting with the environment. Nursing is assisting the client
(individual person, family, groups or community) solve his/her health problems. Problems are
the unmet basic needs, barriers in normal human responses, health status or self care deficits.
These may be the actual or potential threats to enjoying sense of well being.

4.2 PROBLEM SOLVING AND NURSING PROCESS

By now you must have realized that the human responses, needs or patterns are the phenomena
of concern to nurses who encounter two types of problems:

4.2.1 Actual Health Problems

Such as impact of illness on physiological (e.g. respiratory function, metabolism, homeostasis,
level of consciousness), physical (e.g. comfort, nutrition, clothing), safety (e.g. from physical,
psychosocial trauma/insult), socialization, self-concept and self-esteem (identity), industry,
integrity, roles, achievement), and self-actualization (sense of spiritual fulfilment) status of
clients.

4.2.2 Potential Health Problems

Such as risk for complications, failure or non-adherence to treatment/therapy, educational needs
for information and concern to develop health oriented attitudes and skills.

Human responses are dynamic in nature and change as the client progresses along the
continuum between health and illness. The nurse assists the clients solve these problems
through three types of nursing functions:

4.2.3 Types of Nursing Functions

l Indepenent e.g. initiating intake and output recording.
l Interdependent e.g. educating client about the therapeutic nutrition in consultation with
the dietitian.

l Dependent e.g. maintains intravenous therapy. That is carrying out doctors order on
medication.
Remember, whatever the type of functions the nurse carries out, the nurse uses a problem
solving approach or nursing process. This deliberate approach requires following skills:
l Cognitive or mental abilities e.g. applying knowledge, thinking critically, analyzing,
judgement and decision making.
l Affective e.g. attitudes, values, acceptance and respect for self and clients, inter-actional
activities.

l Psychomotor e.g. technical skills such as administering medicines, dressing and bathing.
67
Practical Manual ---- 4.2.4 Comparison of the Problem-Solving Process and the Nursing Process
Nursing Foundation
The problem process involves:
1) The systematic identification of a problem
2) Determination of goals related to the problem
3) Identification of possible solutions to achieve these goals
4) Implementation of selected solutions
5) Evaluation of goal achievement.

We use problem-solving approach in daily activities and nursing practice. For example, you use
problem solving in deciding what to wear, when it is raining or while nursing a tracheotomy
patient how to communicate.

The nursing process is a subset of problem solving process (see Fig. 4.1). You have already
learnt the steps as:

1) Assessment
2) Nursing diagnosis
3) Planning
4) Implementation
5) Evaluation and modification of plan

The problem solving process and the nursing process are cyclic (Burns and Grove, 1987).

Problem Solving Process Nursing Process

l Data Collection l Assessment

l Data collection
l Data Interpretation
l Problem Definition l Nursing Diagnosis
l Plan l Plan
l Goal Setting l Goal Identification
l Identify Solution l Plan Intervention
l Implementation l Implementation
l Evaluate and Revise Process l Evaluation and Modification

Corporation of the problem solving and the nursing process.

Problem solving through nursing process is described, Fig. 4.1 in the following manner.

68 Fig. 4.1: Problem solving/nursing process

In order to solve the nursing and medical problems of your clients, you must learn the use of Problem Solving
systematic problem solving techniques. Identify the following prerequisites for efficient use of Approach in Nursing
nursing process:

l Comprehensive knowledge base

l Experience and skills in the field

l Professional commitment (such as belief, ethical base accurately).

Let us now go through each stage of this problem solving process for solving our client health
problems. Apply this knowledge while practicing nursing in selected clinical areas.

Nursing Process
Identification of client
Collection of current historical

subjective - objective information ASSESSMENT
Organization of data
Documentation : Subjective - Objective data

Classification analysis, interpretation

of data as human response patterns

Identification of problems: actual/potential NURSING
validation DIAGNOSIS
Documentation: Statement of the problem

Priority setting
Stating the outcomes/possible solutions

Planning possible interventions PLANNING
Documentation: Nursing Care Plan

Implementation: prepration of personnel

equipments-facilities, environment
Implementation: action/interventions

Documentation: Nurses notes, problem- IMPLEMENTATION
oriented records (SOAPIER format)
flow sheets, lesson plan, computer-
assisted records.

Evaluation of outcomes:
Reassessment of clients health status

making judgement about achievement EVALUATION
of client-outcomes
Revisions of the plan of care

Fig. 4.2: Relationship between problem-solving and nursing process

4.3 ASSESSMENT
Definition
Assessment is the first phase of the nursing process focusing on gathering information or data
through history taking and observation including physical examination. The data relate to the
client, family, group or community system, present and past medical history etc.
Assessment is a continuous process through which you identify the human response patterns
or functional health status of your clients (refer Annexure A).
Prerequisites
l A broad knowledge base
l Effective communication and interpersonal skills
l Systematic observation involving inspection, palpation, auscultation and percussion.
l Accurate interpretation and documentation 69
Practical Manual ---- Steps:
Nursing Foundation
l Data Collection

l Organization of Data

l Documentation

4.3.1 Collection of Data

1) Identify the client by name, age, gender, address, Dr-in-charge and registration

2) Collect data as current and past health history of illness, family history of illness,
psychosocial patterns.

Example: Identify each of the following as current and historical data

Data Current Historical

l Smoked three packs of cigarettes per day until last month 3

l Diminished breath sounds at the base of left lung 3

l No one in the family had TB, cancer, asthma, COPD 3

l Has low grade fever 3

l Was immunized for The in childhood 3

3) Use primary and secondary sources to obtain pertinent data

Example:
Primary Source e.g. Secondary Source e.g.
l Client l Family/significant, other individuals in
clients immediate environment

l Other members of health team

l Medical records/reports

4) Use different methods of data collection such as observation, physical examination. Four
observation techniques are inspection, palpation, auscultation and percussion. Clinical/
laboratory examination: Read reports, examination such as testing may be done by the
nurses.

5) Clarify doubts and validate subjective data by secondary sources and objective data.

4.3.2 Organization of Data: Subjective and Objective

You have a comprehensive information about your client. Organize it in a meaningful manner as
current and historical subjective and objective data. Often you can use forms meant for
documentation. Objective data indicate signs that you can observe and measure. Subjective
data include those which the clients or others state, but you can not measure than overtly.

Data Subjective Objective

l I feel tired all the time 3

l Respiratory rate is 20/mt 3

l Crepitations present in left lower lobe 3

l She becomes breathless when she climbs the stairs 3

l She is dysgenic 3

4.3.3 Documentation of Data

You must realize that assessment is incomplete without accurate documentation. Remember
that data that are accurately collected, organized and documented. Use recording forms, some
70 essential elements are tested.
Characteristics Problem Solving
Approach in Nursing
1) Documents must be easily accessible to different team members

2) Well documented data: Minimize repetitions, prevent gaps and provide baseline
information

3) Facilitate delivery of quality care allow the nurse to validate, clarify and update data

4) Assured evaluation of individualized care, assist in demonstrating compliance with the

accepted standards (useful in audits)

5) Create a permanent legal record. May be used in protecting the client, the care providers
and the agency.

6) Provide the foundation for nursing research.

Guidelines for Documentation of Client Data

1) Write entries objectively without bias, value judgements or personal opinions. Use
question marks to clearly identify subjective statements. For example I think I am losing
weight and have lost my appetite.

2) Support data with objective observations. For example Emotional status: depressed, sits
alone, rarely initiates, conversation, limited eye contact and cries frequently.

3) Avoid generalization such as normal, good, moderately. Be specific, for example, normal
bowel movement is more clearly defined as moves bowel every other day without the use
of laxatives

4) Describe findings as thoroughly as possible. For example include details of

measurements, depth, colour, odour, drainage while describing clients ulcer.

5) Write or print legibly in non-erasable ink, avoid erasing, crossing out and overwriting the
entry.

6) Use correct grammar, 1spelling and abbreviations, avoid slang, labels, short forms.

7) Feed the organized data into the computer as per the policy of agency/unit. (Refer
Annexures B, C, D, E, F for guidelines/sample assessment forms).

Check Your Progress 1

1) List the steps of problem solving process.

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2) List the steps of nursing process.

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..............................................................................................................................................

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71
Practical Manual ---- 3) Identify objective and subjective data from the following examples:
Nursing Foundation
Data Subjective Objective

a) Abdominal Pain

b) Abdominal rigidity, Absent bavel

sounds, Inguiral mess

c) Partial dentures

d) Low fat diet preference

e) B.P.140/80, T 10l.2°F

f) Skin Warm

g) Concerned about weight

4) Identify current and Historical data from the following examples:

Current Historical

a) Vital Sign

b) Smokes two packs of cigarette daily

c) No previous surgery

d) Skin warm and diaphoretic

e) Nocturia for last six months

f) Has been a non vegetarian

g) Has pain in chest for two days

5) Identify Primary and secondary sources of data from the following:

Primary Secondary

a) Loboratory data

b) Physical exam. Report

c) History given by patient

d) History given by borther of patient

e) History given by mother of infant

f) Emergency department nurse

g) Nurses notes

4.4 NURSING DIAGNOSIS

Diagnostic process, the second phase of nursing process is a complex intellectual function. You
have been introduced to the concept of nursing diagnosis its background, scope and use in
theoretical section of BNS-101 and Unit 3 of this Block.

Definition: A nursing diagnosis is a clinical judgement about individual, family, group, or

community response to actual and potential health problems or life processes. Nursing
diagnosis provides the basis for selection of nursing interventions to achieve outcomes
(results) for which nurse is accountable (Annexure A)

Prerequisites: Broad theoretical and clinical knowledge base, intellectual skills and practice.

Steps: Classification, analysis and interpretation of data.

Identification of problem
Validation
Documentation : diagnostic statement
72
4.4.1 Classification, Analysis and Interpretation of Data Problem Solving
Approach in Nursing
i) Classify the clients raw data by sorting out information into specific categories:

l Signs and symptoms related to specific system e.g.

---- Respiratory, nervous

l Signs and symptoms that need immediate attention e.g.

---- Pain, vomiting, fever

l Patterns (human response/functional health) such as

---- sleep, rest, activity

l Spiritual history e.g.

---- Prays daily

l Abilities/strengths e.g.

---- Knowledge and acceptance of desease

l Deficits e.g.

---- Has fear of hospitalization

ii) Analyse and interpret data to obtain cues. A cue is nurse’s perception of obtained
information. Make judgement or draw conclusions (inferences) bases upon cluster of
cues

Example:

Date Cue

Temperature 102 ° F oral) Client has high fever

Grimacing Could be having pain

Cluster of cues Inference

Temperature 102 ° F (fever) Inflammatory

While blood count high Response due to Infected incision

Red and swollen incision Purulent discharge

4.4.2 Identification of the Problem: Actual and Potential

i) Identify actual and potential problems.

Example:

Actual problems Potential problems

Constipation Potential for dehydration
Altered comfort Potential for altered skin integrity
Ineffective air way clearance Potential for aspiration

ii) Identify the problem and its etiology or related factor. Problem is something that needs to
be changed/suggests outcomes and related factor suggests intervention.
Example:
Problem Related factors
Constipation Immobility and decreased fluid intake

4.4.3 Validation
i) Validate the interpretation of data by verifying its accuracy. Use reflective statements
while talking to the client. 73
Practical Manual ---- Example: Nurse notices that Santosh a 30 year old client who is admitted for laparoscopic
Nursing Foundation
cholecystectomy is easily distracted, wrings her hands and speaks very rapidly. These
cues could lead the nurse to infer that this client is nervous ‘about the surgery’.
Nurse: You seem anxious, Mrs. Santosh
Client: Yes, I am upset

Nurse: Upset? If it the surgery? (Reflective statement)

Client : I am really worried about my four year old son who is side at home. I am waiting
for my husband’s phone to the me what the doctor told :

Nurse validated the presence of anxiety and also its cause by using reflective statement.

ii) Validate information/clarify doubts with other professionals/team members/medical

records or reference sources.

4.4.4 Documentation of Diagnostic Statement

i) Formulate the nursing diagnosis in two parts: statement formed by using following guidelines.

ii) Write the first part of the statement in terms of client’s response rather than nursing need.
First part of the statement is the actual or potential client problem and suggests
outcomes.
Example:
Incorrect (×
(×) Correct (3)
l Needs suctioning because she has. l Potential for aspiration or
excessive secretions ineffective airway clearance
l Needs frequent rest periods l Activity intolerance
because of shortness of breath

iii) Use ‘related to’ rather than ‘due to’ or ‘caused by’ to connect the two parts of the
statement.

Example:

Incorrect (×
(×) Correct (3)

l Potential for aspiration caused by l Potential for aspiration related to

excessive secretions (r/t)

iv) Write the related factor in terms that can be changed (dependent variables) through
nursing interventions.

Example:

Incorrect (×
(×) Correct (3)

l Knowledge deficit r/t pregnancy* l Knowledge deficit r/t prenatal

diet*

*(you can change the factor)

v) Write the diagnosis in legally advisable terms.
Example:
Incorrect (×
(×) Correct (3)
l Potential for Injury r/t l Potential for injury r/t hazards
inadequately maintained traction of skin traction
vi) Write diagnosis without value judgement. Do not use words such as inadequate, poor,
unhealthy in diagnostic statements.
vii) Avoid reversing the parts of the statement. Remember the first part of the statement
identifies the human response/health pattern (actual or potential problem) and suggests
outcomes. The second part defines the related factors (etiology of problem) and suggests
74 nursing intervention.
Example Problem Solving
Approach in Nursing
Incorrect (×
(×) Correct (3)

l Sensory overload r/t sleep. l Sleep pattern disturbance r/t

pattern disturbance sensory overload

viii) Avoid using single cues in the first part of the statement.

ix) Do not include medical diagnosis in the nursing diagnostic statements.

Example

Incorrect (×
(×) Correct (3)

l Ineffective breathing pattern r/t l Ineffective breathing pattern r/t

emphysema retained secretions

l Congestive heart failure r/t l Non compliance (cardiac medications)

failure to take medications r/t lack of knowledge about action and
correct
x) State the diagnosis clearly dosage and concisely
Example
Incorrect (×
(×) Correct (3)
l Ineffective individual copying r/t l Ineffective individual copying r/t
belief that he had cancer because feeling of guilt
of heavy smoking

xi) Validate the statement by verifying its accuracy; look for gaps in data, misinterpretation of
cues. Ask, whether related factor contributes to the problem and can the nursing
diagnosis be altered by nursing interventions?

xii) Refer to the standardized classification of nursing diagnosis by NANDA, based upon human
response patterns or functional health status patterns.

xiii) Review, revise and eliminate the diagnostic statements as per the change in client’s
response/health status.

Check Your Progress 2

1) Write the inference for the following cues:

Cluster of Cues Inference

a) Temperature 102°F since two days .........................................

b) Decreased skin turgor .........................................

c) Dry tongue
Urine output 200ml/8hrs

2) Identifying correct and incorrect diagnostic statements

Statement Correct Incorrect

a) Dysfunctional grieving r/t death of spouse 3 ×

b) Ineffective airway related to effects of sedation 3 ×

c) Decreased calorie intake r/t altered nutrition 3 ×

d) Potential constipation r/t surgery 3 ×

4.5 PLANNING
Planning is the third stage or step of nursing process. The nursing care plans are initiated,
revised and documented by registered nurses, following the first contact with the client. They
must be readily available to all personnel responsible for the care of the client. 75
Practical Manual ---- Steps
Nursing Foundation
l Developing and prioritizing outcomes

l Developing interventions

l Documentation of the care plan

Prerequisites
l Planning requires cognitive abilities:
l Broad knowledge base and its application.
l Foresight and positive thinking.
l Rationalization (Reasoning).
l Ability to analyze and synthesize information.

4. 5.1 Developing Outcomes and Prioritizing Them

i) Develop expected outcomes, goals or behavioral objectives for modifying the human
response. Outcomes are the possible solutions of client’s problems.

ii) Use the given guidelines for writing outcomes.

a) Outcomes should be related to the human response as identified and stated in the
first part of the nursing diagnosis.
Example 1: Nursing Diagnosis: Altered nutrition, less than the body requirements
related to chewing difficulties.
Outcome: Consumes 1800 calories of puresd and liquid foods each 24- hour period

b) Outcomes should be client centered preferably agreed upon mutually by client and
nurse.
Example 2: Nursing Diagnosis: Potential impaired skin integrity related to
decreased mobility.
Outcome: No evidence of skin breakdown over bony prominence throughout
hospitalization.
c) Outcomes should be clear and concise

Example 3: Nursing Diagnosis: Ineffective airway clearance related to retained

secretions.
Outcome: Coughs, deep breathes and performs postural drainage independently of
2 hourly.
d) Outcome should be realistic
Example 4: It will be unrealistic to write an outcome related to use of glucometer for
glucose monitoring at home for a diabetic with low income.

e) Outcomes should describe behaviour that is measurable and observable.

Example 5: Nursing Diagnosis: Non compliance to diabetic diet (1800 calorie)
Outcome: Prior to discharge states importance of adhering to 1800- calorie diabetic
diet.
f) Outcomes should be time limited (short term and long term)

Example 6: Nursing Diagnosis: Impaired physical mobility related to recurrent leg

pain.
Outcome: Ambulates with assistance in room within 18 hours
iii) Organize expected outcomes as per the priority of client’s needs. Classify them as short
term and long term.
76
Example Problem Solving
Approach in Nursing
Nursing Diagnosis Outcomes

a) Ineffective airway clearance a) Short term: Patient airway no

r/t excessive secretions signs of accumulated secretions

b) Altered nutrition: Less than b) Short term: Nutritional status as

body requirement r/t altered per body requirement, 2000
consciousness calories per 24 hours received.

4.5.2 Developing Interventions

i) Develop nursing interventions or activities required to assist the client in achieving
outcomes. Ensure that nursing interventions are based on the related factors of nursing
diagnosis statements.

Example

Nursing Diagnosis Interventions

l Potential for trauma r/t l Verbalization about environmental

hazardous home environment hazards at home

l Potential modifications in hazardous

conditions
ii) Predict or hypothesize alternatives that are appropriate to reach the desired outcome;
apply scientific principles, your knowledge of client’s abilities and similar past
experiences.
iii) Generate ideas (brainstorming) from more than one person. After all possible alternatives
are developed, each should be judged in terms of its feasibility and probability of
success. Choose those that are most appropriate for the client.
iv) Ensure that the interventions help to promote, maintain or restore client’s health.
Remember interventions are:
l Independent /Dependent nursing functions
l Consistent with total plan of medical/nursing care
l Scientifically based
l Individualized
l Safe and provide therapeutic environment
l Inclusive of teaching-learning activities
l Effective in terms of resources (standards)

4.5.3 Documentation: Nursing Care Plan

i) Document the nursing diagnosis, outcomes and planned interventions as per the priority
of client’s needs/problems. Remember, nursing care plans designed to promote quality
nursing rare by facilitating:
l Individualized care
l Continuity of care
l Communication-economy of time and effort
l Evaluation
ii) Ensure that plan is based on current data nursing diagnosis and interventions.
iii) Use precise action verbs for specific actions e.g. monitoring, listening, assisting, and
administering. Write the date and sign.
iv) Update the nursing care plan frequently (make use of kardex documentation form for
recording medical and nursing prescriptions) . 77
Practical Manual ---- v) Make use of standardized care plans (printed forms) or computerized plans as per the
Nursing Foundation
policy of the unit/agency. (for student, nurses it is advisable to generate
individually constructed care plans manually) Refer to Annexure A-E for developing
care plans.
vi) Use printed forms with 3-4 columns as shown below:
Date:
Sign:
S. No. Nursing Diagnosis Outcomes Interventions Rationale
(Planned)

Check Your Progress 3

1) Match the following incorrectly stated outcomes in column A with the errors in column B
Column A Column B
a) To prevent skin breakdown i) Cannot be measured
during hospitalization
b) C, D, P performs PD indep. ii) Not very specific
2h (Coughs, Deepbreathes, postural
drainage independently)
c) Understands importance of iii) Not time specific
adhering to 1800 calories diabetic diet
d) Drinks adequate amount of iv) Not clear due to unfamiliar
fluids in one day abbreviations
e) Moves bowels v) Not client centered
2) The following is the list of interventions that are written incorrectly. By using the
guidelines given in the text, state them correctly.
Date/Nurse Interventions (Incorrect) Correct Statement
9/12 a) Make client comfortable
S. Kanta R.N.
8/7 b) Teach about diabetes
T. Rana R.N.
29/8 c) No evidence of signs of
M. Walia R.N infection
17/7 d) Force fluids
Shobha C.R.N
1/6 e) Hickman catheter care daily
at 10 A.M.
3/2 f) Provide preferred fluids
Sonia M R.N.

4.6 IMPLEMENTATION
So far, you have practiced assessment of client responses/functional status, diagnosis of
problems, planning interventions.
Implementation is the initiation/carrying out of the nursing care plan to achieve specific
outcomes. Specific nursing interventions are implemented to modify factors contributing to
clients problems
Prerequisites
l Positive attitude and acceptance of clients observation skills
l Technical skills, ability to use resources
l Communication abilities
l Teaching learning skills
78 l Counselling skills
Steps Problem Solving
Approach in Nursing
l Preparation
l Action/intervention
l Documentation
4.6.1 Preparation
i) Review the nursing interventions identified in the planning phase.
ii) Analyze the clients potentials/abilities and how much nursing assistance would be required.
iii) Recognize the potential complications associated with specific nursing activities.
iv) Determine and provide necessary resources:
Personnel, material/equipment. Identify the level of knowledge and type of skills required
by personnel to perform.
v) Prepare an environment conducive to the types of activities required.
vi) Identify the ethical and legal concerns associated with intervention. Follow hospital policy.
vii) Use appropriate nursing care approach/care delivery system to achieve outcomes e.g.
functional nursing, team nursing, primary nursing, case management; individualized
critical care/progressive patient care etc.
4.6.2 Action/Intervention
i) Make a quick assessment of the client and environment just before the intervention .
Example: Nursing intervention required ambulation of post operative client. You notice
that the client is short of breath and diaphoreuc based on this observation. You must
check the vital signs and postpone ambulation at that time:
ii) Carry out preventive/promotive/corrective (curative) rehabilitative or palliative nursing
actions to eliminate the related factors in nursing diagnosis.

Example
Nursing diagnosis Outcome Plan Implementation

l Potential l No l Close observation l Closely observed for

for Trauma r/t evidence of l Padding the bed any seizure
effects of accident/i njury rails activity
seizures during l Anticonvulsants l Checked bed rails and
hospitalization l Teaching padding
l Anticonvulsants given
l Taught about safety
measures

iii) Recognize independent, inter dependent and dependent nursing actions. Collaborate
with other nursing team members (nurse specialist) doctors, dietitian, physiotherapist,
anesthetist, technician, psychologist, medical social worker and others associated with
care of client.
iv) Use various opportunities for communicating teaching and supporting client.
v) Refer to nursing prescriptions/hospital or unit Protocols/procedure manual /nursing
standards for carrying out appropriate nursing interventions. Select standard protocols
from a computerized menu.
4.6.3 Documentation
Document all implemented nursing actions accurately in the appropriate chart/source notes
(nurses notes)/flow sheet/health teaching record or care plan (Refer Annexure A-E).
Check Your Progress 4
S. Sharma, a 67 year old retired man was admitted to the hospital two days ago with a
diagnoses of stomach cancer. While interviewing him, he shares this information with you,
“I don’t like the khichri served by the dietary dept, I would like to have my wife’s home made
rice preparation.” When you observed Mr. Sharma’s trays, you noted that he ate only 1/3 rd of
the khichri within 3 days he lost 1.5 kg. weight. You consult the physician and the dietitian and
talk to Mrs. Sharma. Following is a segment of Mr. Sharma’s Care plan: 79
Practical Manual ----
Nursing Foundation Nursing Diagnosis Outcome Interventions

Altered nutrition less than Loses no more than 2.5 kg. l Provide small frequent
body requirements related to during hospitalization meals at 8 A.M., 12 M.D,
decreased oral Intake 4 P.M., 8 P.M.

l Supplemental feeding: Ensure

at 10A.M. and 9 P.M.

l Assess likes/dislikes

l Monitor food intake

l Weigh daily at 8 A.M.

l Encourage food from home
after consulting doctor/
dietitian.

Bases on the information given above, document the care, using (a) Source Oriented (b) Problem
Oriented/SOAPIER) Charting.

4.7 EVALUATION
You have learnt how to collect data for assessment how to analyze it for identification of clients’
problems how to state the nursing diagnosis, how to plan interventions (solutions) and how to
implement actions to achieve outcomes. Evaluation is an integral part of all phases of nursing
process and it is carried out at the end point of nursing process to determine if:

l clients expected outcome is achieved/not achieved

l the care plan is appropriate, realistic, current or in need of revision.

Prerequisites

l Comprehensive knowledge base

l Analytical thinking ability

l Judgement

l Decision making

l Standards

Steps

l Gathering data about clients current health status or reassessment

l Comparing the gathered data with the outcomes

l Making a judgement about the clients’ progress toward achieving the outcomes. Revision
the plan of care

4.7.1 Gathering Data/Re-assessment

i) Collect objective and subjective data using different techniques, for the purpose
evaluation

l Interview e.g., asking about pain relief .

l Direct observation e.g., signs of discomfort.

l Physical examination e.g., palpation for tenderness.

l Clinical

l Review of documents e.g., previous report/record.

80
ii) Assess the degree/intensity/level of problem or health status after the interventions. Problem Solving
Approach in Nursing
Example
Nursing diagnoses Outcome Current data

Potential for altered skin Throughout hospitalization Skin condition normal. No

integrity r/t prolonged no evidence of skin-breakdown redness over bony prominences.
immobility over bony prominences Record shows 2 hourly positions.

4.7.2 Making Judgement and Revising the Plan

i) Analyze the information on clients’ current health status and make:
l a judgement
l the outcome was not achieved.
ii) Use critical thinking (inductive and deductive reasoning) for making judgements.
iii) Revise nursing diagnoses and care plan if needed.

4.8 LET US SUM UP

Nursing refers to assisting the client (individually person, family, group, community) solve his/
her/basic needs, barriers in normal human responses/health status or self care deficits. These
may be actual problems, Potential problems/threats.

The nurse assists the clients solve their problems through independent. Interdependent and/or
dependent nursing interventions. Nurses use problem solving approach or nursing process,
which is a deliberative, systematic and scientific way of helping clients achieve their expected
health status/response. Nurses need to identify and develop cognitive, affective, psychomotor
abilities to utilize various steps of problem solving process:

i) Assessment: Identification of client, collection of data as subjective and objective

information, Organization of data and accurate documentation of data.

ii) Nursing diagnoses: Classification, analysis, interpretation of data as human response

patterns/functional status patterns, identification of actual/potential problems, validation
and documentation of diagnostic statement.

iii) Planning: Prioritizing the nursing diagnoses development of expected outcomes/possible

solutions for the clients, possible interventions and documentation of the nursing care plan.

iv) Implementation: Preparation phase, action or intervention phase, documentation of care

as nurses notes, problem-oriented records using SOAPIER format, flow sheets lesson
plans and computer-assisted records.

v) Evaluation: Evaluation is an ongoing process in which reassessment of clients status,

making judgement about achievement of expected outcomes (progress) is done. One the
basis of judgement revision in the nursing care plans are made. Nurses need to
communicate their observations, challenges and innovations with their co-professionals,
while solving unique problems of their clients.

4.9 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1
i) a) Data Collection b) Problem Solving c) Planning
d) Implementation e) Evaluation and Review
ii) a) assessment b) Diaperies c) Plan
d) Implement e) evaluance
iii) a) Subjective b) Objective c) Objective
d) Subjective e) Objective f) objective g) Subjective
iv) a) Current b) Current c) Historical
d) Current e) Historical f) Current g) Current
v) a) Second any b) Second any c) Primary
d) Second any e) Primary f) Second any g) Second any
81
Practical Manual ---- Check Your Progress 2
Nursing Foundation
i) a) C1ient has dehydration due to high fever

b) Resulting into fluid volume deficit.

c) - do -

a) Incorrect because the related factor can not be changed

b) The first part should be altered nutrition

c) Related factor should be immobility/decreased fluid intake instead of surgery

Check Your Progress 3

i) Column B (i) c (ii) d (iii) e (iv) b (v) a

ii) a) Position on left side with two pillows

b) Teach correct 1) foot care 2, oral administration of medicines.

c) (Its an outcome) Maintain sterility of urinary drainage

d) Administer 3000 ml fluid in 24 hours

e) Should be signed by R.N.

f) Provide preferred fluids. Client likes cola and orange juice.

Check Your Progress 4

a) Source -Oriented Note

Date Time Nurse’s Notes

7.5.2000 8:00 A.M. Discussed dietary preference with client; indicates that he
wanted rice preparations cooked by his wife instead of
khichri supplied by hospital dietary dept. weight 62 kg.
this A.M. Ate breakfast.

10:00 A.M. Dr ........................visited -discussed weight loss -dietary

consult order revised

12:00 M.D. Consumed 1/3rd of lunch

Visited by dietician. Will make changes in diet -will

discontinue khichri

Wife visited -agreed to bring home made rice preparations.

(Signed..........RN)

4.10 ACTIVITIES
1) Select a patient from medical/surgical unit/area of your work identify problem and carry
out problem solving by nursing process approach (use the format).

2) Identify a problem from your place of work (which affects its smooth functioning) and
solve the problem using nursing process approach. Problems can be in terms of

---- Man

---- Material

---- Education

---- Administration

82
 Problem Solving
Annexure F Approach in Nursing

FORMAT FOR PROBLEM SOLVING USING NURSING PROCESS

i) Assessment

a) Identification Data (if problem solving involves a patient).

Name
Age
Sex
Diagnosis

b) History

c) Signs/symptoms of patient

ii) Diagnosis

a) Analyse and validate the data

b) Formulate the Diagnosis or state the problem to be solved

iii) Develop outcomes/goals that you want to achieve, keep the priority of needs in mind

iv) Carry out Inventions to achieve the goal

v) Evaluate all the steps of nursing process and assess whether you are able to solve the
problem or not.

vi) Document all the steps of problem solving.

Note : You may refer an sample given at me end of this unit at 4.12

Sample of Problem Solving

i) Assessment to Identify the problem

i) Data

Name: Mr. Shankar Wd -12 medical

Age: 60 years B B ed No. -8

Sex : Male Diagnosis -C.V.A

ii) Brief H/O illness: Mr. Shankar is known case of Hypertension. He was not taking medicine
regularly. On 2/2/04 he c/o headache, vomiting, loss of speech and movement of
extremities.

iii) Presenting Complaints

---- Anorexia Present
---- Lack of movement
---- Incontirence of urine
---- Skin excoriation at the sacral region present
iv) Nursing Diagnosis and intervention of one need apply.
a) Statement of Problem
Altered skin integrity R/T lmmobility (Bed sores).
b) Goals
---- Maintenance of skin integrity
---- Prevention of further complication
---- Promotion of health maintenance
83
Practical Manual ---- c) Nsg. Interventions to Solve the Problem
Nursing Foundation
---- Frequent (2 hrly) change of position

---- Pprovide back care

---- Bed sore dressing B. D using hydrozen

Peroxide or Betadine solution

---- Provide adequate nutrition

d) Evaluation

---- healing present.

---- patient able to move

---- patient skin is healthy

v) Conclusion

Mr. Shanker’s problem was identified from the collected data. Appropriate mrg Interventions
helped Mr. Shanker to achieve good health, condition of Bed Sore improved, and complications
could be prevented. Thus his problem was resolved.

84
 Problem Solving
Approach in Nursing

Annexure A
Nanda Taxonomy of Nursing Diagnoses
Pattern 1: Exchanging 5.2.1.1 Noncompliance (Specify)
1.4.1.1 Altered (Specify Type) Tissue 5.3.1.1 Decisional Conflict (Specify)
Perfusion 5.4 Health Seeking Behaviors (Specify)
(Renal, Cerebral, Cardiopulmonary. Pattern 6: Moving
Gastrointestinal, Peripheral)
6.1.1.1 Impaired Physical Mobility
1.4. 1.1.1 Fluid volume Excess
6.1.1.2 Activity Intolerance
1.4.1.2.1.1 Fluid Volume Deficit (1)
6.1.1.2.1 Fatigue
1.4.1.2.2.1.1 Fluid Volume Deficit (2)
6.1.1.3 Potential Activity Intolerance
1.4.1.2.2.1.2 Potential Fluid Volume Deficit
6.2.1 Sleep Pattern Disturbance
1.4.2.1 Decreased Cardiac Output
6.3.1.1 Diversional Activity Deficit
1.5.1.1 Impaired Gas Exchange
6.4.1.1 Impaired Home Maintenance
1.5.1.2 Ineffective Airway Clearance
Management
1.5.1.3 Ineffective Breathing Pattern
6.4.2 Altered Health Maintenance
1.6.1 Potential for Injury
6.5.1 Feeding Self-Care Deficit
1.6. 1. 1 Potential for Suffocation
6.5.1.1 Impaired Swallowing
1.6.1.2 Potential for Poisoning
6.5.1.2 Ineffective Breastfeeding
1.6.1.3 Potential for Trauma
6.5.1.2.3 Effective Breastfeeding
1.6.1.4 Potential for Aspiration
6.5.2 Bathing/Hygiene Self-Care Deficit
1.6.1.5 Potential for Disuse Syndrome
6.5.3 Dressing/Grooming Self-Care Deficit
1.6.2 Altered Protection
6.5.4 Toileting Self-Care Deficit
1.6.2.1 Impaired Tissue Integrity
6.6 Altered Growth and Development
1 6.2.1.1 Altered Oral Mucous Membrane
Pattern 7: Perceiving
1.6.2.1.2.1 Impaired Skin Integrity
7.1.1 Body Image Disturbance
1.6.2.1.2.2 Potential Impaired Skin Integrity
7.1.2 Self-Esteem Disturbance
Pattern 2: Communicating
7.1.2.1 Chronic low Self-Esteem
2.1.1.1 Impaired Verbal Communication
7.1.2.2 Situational Low Self-Esteem
Pattern 3: Relating
7.1.3 Personal Identity Disturbance
3.1.1 Impaired Social Interaction
7.2 Sensory/Perceptual Alterations (Specify)
3.1.2 Social Isolation (Visual. Auditory. Kinesthetic. Gustatory.
3.2.1 Altered Role Performance Tactile. Olfactory)
3.2.1.1.1 Altered Parenting 7.2.1.1 Unilateral Neglect
3.2.1.1.2 Potential Altered Parenting 7.3.1 Hopelessness
3.2.1.2.1 Sexual Dysfunction 7.3.2 Powerlessness
3.2.2 Altered Family Processes Pattern 8: Knowing
3.2.3.1 Parental Role Conflict 8.1.1 Knowledge Deficit (Specify)
3.3 Altered Sexuality Patterns 8.2 Altered Thought Processes
Pattern 4: Valuing Pattern 9 : Feeling
4.1.1 Spiritual Distress (distress of the 9.1.1 Pain
human spirit) 9.1.1.1 Chronic Pain
Pattern 5: Choosing 9.2.1.1 Dysfunctional Grieving
5.1.1.1 Ineffective Individual Coping 9.2.1.2 Anticipatory Grieving
5.1.1.1.1 Impaired Adjustment 9.2.2 Potential for Violence: Self-directed or
5.1.1.1.2 Defensive Coping directed at others
5.1.1.1.3 Ineffective Denial 9.2.3 Post-Trauma Response
5.1.2.1.1 Ineffective Family 9.2.3.1 Rape-Trauma Syndrome
Coping:Disabling 9.2.3.1.1 Rape-Trauma Syndrome: Compound
5.1.2.1.2 Ineffective Family Coping: Compro- Reaction
mised 9.2.3.1.2 Rape-Trauma Syndrome: Silent Reaction
5.1.2.2 Family Coping: Potential for Growth 9.3.1 Anxiely
9.3.2 Fear
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Practical Manual ---- Annexure B
Nursing Foundation

Body Systems Assessment Criteria

General Appearance
l Observations - age, sex, race, height, weight, nutritional status, development
Vital Signs
l Temperature
l Pulse (rate)
l Respirations
l Blood pressure- supine, sitting, right, and left arms
Neurological System
l Level of consciousness
l Skull -- size,contour, symmetry, colour, pain ,tenderness, lesions, edema
l Eyes -- acuity, visual loss, glasses, contacts, prosthesis, diplopia, photophobia,colour
vision, pain burning, eyelid ptosis,edema, styles, exophathamos, extraocular movement,
position and alignment, strabismus,nystagmus, conjunctival, colour, discharge, vascular,
changes, corneal reflex, scleral colour, vascularity, jaundice, pupil size, shape, equality,
reaction to light.
l Neck-symmetry, movement,range of motion, masses,scars, pain, stiffness,lymph node size
shape, mobility, tenderness,enlargement.
l Reflexes-Deep tendon reflexes(DTRs), Babinsk, posturing
Musculoskeletal System
l Activity level--prescribed, actual, range of motion
l Extremities-- size, shape, symmetry, temperature, colour, pigmentation, scars,hematoma,
bruises, rash, ulceration, numbness, paresis, swelling, prosthesis, fracture
l Joints-- symmetry, active and passive mobility, deformities stiffness, fixation, masses,
swelling, fluid, bogginess, crepitation, pain, tenderness
l Muscles--symmetry, size, shape, tone, weakness, cramps, spasms, rigidity, tremors
l Back--scars, scars,sacral edema, spinal abnormalities, kyphosis, scoliosis, tenderness,
pain
Respiratory System
l Nose -- smell, nasal size,symmetry, flaring, sneezing, deformities, mucosal colour,edema,
exudate, bleeding, furuncles, pain, tenderness, sinus pain
l Chest -- size, shape, symmetry, deformities, pain, tenderness, expansion, crepitation,tactile
fremitus
l Trachea -- deviation, scars
l Breathing patterns -- rate, regularity, depth, ease, use of accessory muscles,
cyanosis,clubbing
l Sounds -- normal, adventitious, intensity, pitch, quality, duration, equality, vocal
res-onance
Cardiovascular System
l Cardiac patterns --rate, rhythm, intensity, regularity, skipped or extra beats, point of
maximum impulse, bruits, thrills, minimum rubs
l Precordial movements,neck veins, right and left cardiac borders,pacemaker
Gastrointestinal System
l Mouth and throat -- odor, pain, ability to speak, bite, chew swallow, taste,tongue size,
shape, protrusion, symmetry, colour, hydration, marking, ulcers, burning, swelling,
coating, gum colour, edema bleeding, retraction, pain, number, of teeth, absence, caries,
caps, dentures, sensitivity, to heat, cold, gag reflex, throat soreness, cough, sputum,
hemoptysis
86
l Abdomen -- size, colour, contour, symmetry, fat, muscle tone, turgor, hair distribution,scars, Problem Solving
Approach in Nursing
umbilicus, striac, rashes, distention, abnormal pulsations, sounds, absent, hypoactive,
hyperactive, tenderness, rigidity, free fluid, liver border, air bubble, splenic dullness, air
rebound, muscle spasm, masses, guarding, pain
l Rectum -- pigmentation, hemorrhoids,excoriation, rashes, abscess, pilonidal cyst, masses,
lesions, tenderness, pain, itching,burning
Renal System
l Urinary patterns -- amount, colour, timing, odor, sediment, frequency, urgency, hesitancy,
burning, pain, dribbling, incontinence, hematuria, nocturia, oliguria, change in stream,
enuresis, flank pain, polyuria,, retention, stress incontinence, bladder distention
Reproductive system
l Male-penis -- discharge, ulceration, pain, size, prepuce, scrotum: size, colour,nodules,
swelling, ulceration, tenderness, pain, testes:size, shape, swelling, masses, absence
l Female -- labia majora and minora, urethral and vaginal orifices, discharge, swelling,
ulcerations, nodules, masses, tenderness, pain, pruritus, pap smear, menstrual flow,
menopause.

Body Systems Assessment

General Appearance

ENT
Cardiovascular
Eyes, ears,
Apical, radial pulses,
nose, throat
B/P, PMI,
heart sounds
Respiratory
peripheral pulses
Airway, respiratory
rate, rhythm,
Neurologic
breath sounds
Level of consciousness,
pupil, ocular movement,
Gastrointestinal
motor and sensory
Stomach abdomen,
coordination,
bowel sounds,
reflexes
liver, spleen

Genitourinary
Musculoskeletal
Reproductive

Integumentary

87
Practical Manual ----
Nursing Foundation
Annexure C
Human Response Pattern
Assessment Criteria
Exchanging
Cardiac -- apical rate, rhythm, point of maximum impulse, blood pressure (sitting,
supine,standing, right and left)
Cerebral -- level of consciousness, pupils, eye opening best verbal response, best motor
response
Peripheral -- pulses, skin temperature, colour, capillarry refill, clubbing edema
Skin Integrity - reashes, petechiae, abrasions, lesions, bruises, surgical, incisions, other
Oxygenation -- respiratory rate, rhythm, depth,use of accessory muscles, dyspnea including
precipitating factors, orthopnea, splinting, cough, sputum colour/amount/consistency, breath
sounds
Physical Regulation -- lymph nodes, temperature
Nutrition-eating patterns, number of meals per day, special diet, food prefernces/intolerances,
food allergies, caffeine intake, appetite changes, nausea/vomiting, condition of mouth/
throat,height, ideal body weight.
Elimination -- usual bowel habits, alterations from normal, constipation, diarrhoea,incontinence,
bowel sounds, usual urinary habits, alterations from normal, incontinence, retention, urine
colour/consistency/odor
Communcating
Read/write/understand Englis, other languages, impaired speech, other forms of communication
Relating
Relationship -- marital status, age/health of significant other, number of children/sex/ages, role
in home, financial support, occupation, job satisfaction/concerns, physical/mental energy
expenditures, sexual relationships, physical difficulties/effects of illness on sexuality
Socialization-quality of relationships with others, patient’s description, significant other’s
description, staff observations, virbalization of aloneness
Valuing
Religious preference, important religious practices, spiritual concerns, cultural orientation,
cultural practices
Choosing
Coping -- client/significant other usual problem-solving methods, client/significant other
method of managing stress, client affect, physical, manifestations, available support systems
Participation -- compliance with past/current health care regimens, willingness to comply with
future health care regimen
Judgment -- deccision- making ability, client perspective, other perspectives
Moving
Activity -- history of physical disability, limitations in daily activities, verbal reports of fatigue/
weakness, exercise habits
Rest -- hours slept per night, feeling rested upon awakening, sleeping aids, difficulty falling/
remaining asleep
Recreation -- leisure activities, social activities
Environmental maintenance -- size and arrangement of home/stairs/bathroom, safety needs,
home responsibilities
Health maintenance -- health insurance, regular checkups, medications prescription/availability
Self-Care -- client’s description of self, effects of illness/surgery on self-concept
88
Meaningfulness -- verbalizes hopelessness,verbalizes/ perceives loss of control Problem Solving
Approach in Nursing
Sensory-perception -- history of restricted environment, impaired vision, glasses, impaired
hearing aid, body position/motion, taste, touch, smell, reflexes.
Perceiving
Self-concept -- client’s deseription of self effects of illness/surgery on self -concept
Meaningfulness -- verbalizes hopelessness, verbalizes/perceives loss of control
Sensory perception -- history of restricted environment, vision impaired glasses, contact lenses,
prosthesis, auditory impaired, hearing aid, body position motion, taste,touch, smell, reflexes
Knowing
Current health problems (client/significent other’s perception)
Health history -- previous illnesses/hospitalizations/ surgery, diseases of heart, peripheral
vascular system, lungs, liver, kidneys, cerbrovascular disorders, rheumatic fever, thyroid, others
Current medications -- name, dosage, frequency, action
Risk factors -- hypertension, hyperlipidemia, smoking, obesity, diabetes,sedentary life style,
stress,alcohol use, oral contraceptives, family history
Readiness -- perception/ knowledge of illness/tests /surgery, expectations of therapy,
misconceptions, readiness to learn, requests for information concerning ............ educational
level, learning barriers
Orientation -- level of alertness, orientation to person/ place/time,appropriate behaviour/
communication
Memory -- intact, recent only, remote only
Feeling
Pain/discomfort --onset, duration, location, quality, rediation, associated/ aggravating/
alleviating factors
Emotional integrity/status -- recent stressful life events, fears, anxiety, grieving, source, physical
manifestations

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Practical Manual ----
Nursing Foundation
Annexure D
Functional Health Pattern
Assessment Criteria
Health Perception--Helth Management
l Description of health (usual, current), preventive measures, previous hospitalizations and
expectations of current hospitalization, description of illness (onset, cause), prior
treatment (including compliance, anticipted self-care problems
Nutritional-Metabolic
l Usual daily food and fluid intake, appetite, food restrictions or preferences, food
supplements, recent weight change, swallowing, chewing, feeding problems
Elimination
l Bowel--usual time, frequency, color, consistency, assistive devices (laxatives,
suppositories enemas), constipation, diarrhoea
l Bladder--usual frequency, problems with frequency, urgency, burning, retention,
incontinence dribbling, dysuria, polyuria, assistive devices
l Skin--condition, colour, temperature, turgor, lesions, edema, pruritus
Activity-Exercise
l Usual daily/weekly activities, occupation, leisure exercise patterns, limitations in
am bulation, bathing, dressing, toiting, dyspnea, fatigue
Sleep-Rest
l Usual sleep pattern--bedtime, hours, sleep aids, problems falling asleep, staying asleep,
feeling rested
Cognitive-Perceptual
Sensory deficits - hearing, sight, touch, problems with vertigo, heat or cold sensitivity,
ability to read, write
Self-Perception
l Major concerns, health goals,self-description, effects of illness on self-perception,factors
contributing to illness, recovery, health maintenance
Role-Relationship
l Communication-language, clear and relevant speech, expression, understanding
l Relationships-living arrangement, support system, family life, complaints (parenting
relatives, abuse, marital problems).
Sexuality-Reproductive
l Changes anticipated or experienced because of condition(fertility, libido, erection,
pregnancy, contraception, menstruation)
Coping-Stress Tolerance
l Decilion- making (independent, assisted), major life changes (past, future, desired), stress
management (eat, sleep, take medication, seek help), comfort/security needs
Value-Belief
l Sources of strength, meaning, religion (importance, type, frequency of practice), recent
changes in values, beliefs, needs during hospitalization
l Breasts--contour, symmetry, colour, shape, size, inflammation, scars, masses: location, size,
shape, mobility, tenderness, pain, dimpling, swelling, nipples:colour, discharge, ulceration,
bleeding, inversion, pain, axillac: nodes, enlargement, tenderness, rash, inflammation
Integumentary System
l Color--pink, pale,red, jaundice, mottled, blanched, cyanotic
l Patterns--pigmentation, vascularity, temperature, texture, turgor, lesions (type, colour, size,
shape, distribution, bruises, bleeding, scars, edema, dryness, echymoses, masses (size,
shape, location, mobility, tenderness), odors, petechiae, pruritus, bruises, bleeding, scars,
90 edema.
 Table 1: Functional Health Patterns Assessment Guide Problem Solving
Approach in Nursing
Health perception/ health management General appearance
Nutritional / metabolic Vital signs, heigh, weight
Elimination Eyes
Activity/ exercise Mouth
Sleep / rest Hearing
Cognitive/perceptual Pulses
Self - perception Respirations
Sexuality / sexual functioning Skin
Coping/ stress management Functional ability
Value/ belief systems Mental status
Physical examiniation

Table 2: Human Respons Patterns Assessment Guide

Exchanging

Cariac Cerebral
Peripheral Skin Integrity
Oxygenation Physical regulation
Natrition Elimination
Communicating
Read/write/understand English, Other languages, impaired speech, other forms of com-munication
Relating
Relatioships Socialization
Valuing
Religious preference, important religious practices, spiritual concerns, cultural orientation, cultural
practices
Choosing
Coping Participation in health regimen
judgment
Moving
Activity Rest
Recrreation Environmental maintenance
Health maintenance Self- care
Meaningfulness Sensory-perception
Perceiving
Self-concept Meaningfulness
Sensory perception
Knowing
Current health problems Health history
Current medications Risk factors
Readiness to learn Mental status
Memory
Feeling
Pain/discomfort associated/aggravating/alleviating factors
Emmotional integrity/ status

Physical Assessment
l General appearance, weight, and height
l Eyes, appearance, drainage, pupils, vision
l Mouth, mucous, membranes, teeth
l Hearing, acuity, aids
l Pulses, rate, rhythm, volume
l Respirations, rate, quality, sounds
l Blood pressure
l Temperature
l Skin colour, temperature, turgor, lesions, edema, pruritus
l Functional ability, dominant hand, use of arms, legs, hands, strength, grasp, range of
motion, gait, use of aids, weight-bearing
l Mental status, orientation, memory, affects, eye, contact
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Practical Manual ---- Annexure E
Nursing Foundation
Sample Nursing Assessment and Data-Base
1) General Information : _________ Date __________ Time ___________ Informant : ________
Primary Language : ______________________________________ ID BAND : Yes No
Allergles : _____________________________________________________________________
_____________________________________________________________________________
Whom to Notify
in Emergencey : ________________________________________________________________
(Name) (Relationship) (Phone)
Mode of Admission : l Ambulatory l Wheelchair l Stretcher
l Oriented to Unit
‘‘Release of Personal Effects’’ form completed Prosthesis : ________________________
T: ______ P:______ R: ______ B/P R:_______ Ht. :______It/in.(cm) Wt.:______lb (Kg.)
List of Personal Belongings
Sent Home ____________________________________________________________________
Kept by Patient : _______________________________________________________________
II) HEALTH HISTORY/HOSPITALIZATIONS MEDICATIONS TAKEN AT HOME/DATE STARTED:

_________________________________ _______________________________________
_________________________________ _______________________________________
_________________________________ _______________________________________
_________________________________ _______________________________________
_________________________________ _______________________________________
Patient’s Understanding of
reason for Hospitalization : _______________________________________________________
Personal Medication l none l sent to pharmacy l sent home
l at bedsude
l‘Receipt for Patient Medication’’ form signed
III) Activities of Daily Living : l Discharge Plannning :
Smoking l Yes l No Pack/Day_______ l Anticipate return to self care
ETOH : Daily Intake : __________________ l Social Work referral
Diet Type : ___________________________ l Appliance/Equipment needs
Sleep/Risk peatterns : __________________ l Home Health Care needs
Fails Risk l Yes l No Prevention of Falls protocol implemented l Yes l No
IV) SOCIAL HISTORY (if pertinent : Home situation, occupation, education, cultural practices etc.)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
________________________________________________________________________ , R.N.
Signature : _____________________________________________________________________
* ITEMS TO BE COMPLETED FOR PATIENTS STAYING LESS THAN 48 HOURS

92
 Problem Solving
V) PRESENT FINDINGS: Approach in Nursing

l Resplratory: Rhythm:_________________ l Cough

Breath sounds: l Clear l congested l wheeze
l Cardiovascular: Rhythm:_______________ l chest pain l edema
Comments: ___________________________________________________________________
Mouth/Gums/Teeth: l Intact l odor l Bleeding l Dentures Comments:___________
_____________________________________________________________________________
l Gastrointestinal: Usual Time & Frequency:_____________ Time of Last B.M.:____________
l Change in Bowel Habits l Constipation l Diarrhoea l Bowel Sounds Absent
l Bleeding
l Change in Apptite Nausoa Vomiting Weight Change
Comments:___________________________________________________________________
Genitourinary: Time of Last Voiding: ____________________________________________
l Change in Bladder Habits l Frequency l Retention l Incontinence
Comments: __________________________________________________________________
Reproductive: l Change in Menstrual Cycle LMP_________________
l Veginal Discharge l Self Breast Exam l Breast Changes
Comments:
____________________________________________________________________________
l Prostate Problems l Penile Discharge
Comments:
_____________________________________________________________________________
l Musculoskeletal: l Independent l Needs Assistance l Change in Mobility l Fractures

l Paralysis l Prosthesis

Comments:____________________________________________________________________
l Integumentary: l Intact l Lacerations l Discolorations l Rash l Dry l Warm

l Cool l Diaphoretic

Comments:__________________________________________________________________
Neurological: L.O.C. l Alert l Lethargic l Comatose
Oriented: l Person l Place l Time Pupils:_____________ l Paresi
l Vision: l No difficulty l Blurred l Diplopia l Blind l Glasses l Contact Lenses
l Artificial Eye
l Hearing: l No difficulty l Limited l Deal l Tinnitus l Hearing Aide
l Speech: l No difficulty l Slurred l Aphsic

Comments: ___________________________________________________________________
____________________________________________________________________________
Appearance/Behaviour: Affect: l Appropriate l Flat l Agitated
Comments: ____________________________________________________________________
VI) Identified problems (Consider Discharge Concerns): ___________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Signature _________________________________________________________________ R.N.
l ITEMS TO BE COMPLETED FOR PATIENTS STAYING LESS THAN 48 HOURS

93