Learn how to apply the nursing process for accurate nursing assessment and diagnosis. Explore each step to ensure comprehensive patient care and better outcomes.

Nursing Assessment:

1. Definition

• Nursing assessment is the first and essential step in the nursing process. It involves the deliberate and systematic collection of data about a patient’s current health status. It also includes data about past health status. This information forms a basis for nursing diagnosis and interventions.

1. Purpose of Nursing Assessment

• Gather information about the patient’s health.
• Identify normal functions and health issues.
• Organize data for diagnosis.
• Aid in formulating nursing diagnoses.
• Recognize the patient’s strengths and areas needing health education.
• Provide data for the diagnostic phase and improve problem-handling skills.

Process of Data Collection

• Involves patient observation, interviews with the patient and family, physical examinations, and review of medical records.
• Collects both subjective (perceived needs, health beliefs) and objective (vital signs, physical findings) data.

Types of Assessments

• Initial Assessment: Conducted at admission to establish a comprehensive baseline for problem identification and care planning.
• Problem-Focused Assessment: Ongoing, narrow-focused assessments to monitor specific identified issues.
• Emergency Assessment: Quick, focused assessment during life-threatening situations to identify immediate health needs.
• Time-Lapsed Assessment: Periodic re-evaluation to monitor changes from baseline data over time.

Assessment Components

• Health History: In-depth interview for past and current health status.
• Physical Examination: Head-to-toe assessment of physical health.
• Vital Signs & Observations: Includes listening to patient comments, observing reactions and interactions, and assessing physical signs.

Types of Data

• Subjective Data (Symptom/Covert Data): Information provided by the patient or their family, including feelings, perceptions, and sensations that only the patient can describe (e.g., pain, nausea).
• Objective Data (Sign/Overt Data): Observable, measurable data obtained through physical examination or diagnostic testing (e.g., blood pressure, lab results).

Sources of Data

• Primary Source: Direct information from the patient through interviews and physical examinations, providing insights into health needs, lifestyle, and perceptions.
• Secondary Source: Information from family, medical records, and other healthcare professionals.

Components of Nursing Assessment

• Nursing Health History: A structured interview collects detailed patient history. It covers biographic data and chief complaint. It also includes the history of present illness, past health history, and family history. Additionally, it examines lifestyle, social data, psychological data, and pattern of health care.
• Psychological and Social Examination: Evaluates emotional, social, and intellectual health. It covers mental state, coping styles, relationships, support networks, and spiritual beliefs.
• Physical Examination: Observation and measurement of physical signs and symptoms using inspection, palpation, percussion, and auscultation techniques.

1. Techniques in Physical Examination

• Inspection: Visual examination of body parts to observe details such as skin color, respiratory effort, and wound size.
• Palpation: Using touch to assess temperature, pulse, texture, moisture, masses, and tenderness.
• Percussion: Tapping the body to assess underlying structures, checking for fluid or air presence.
• Auscultation: Listening to internal sounds (e.g., heart, lung, bowel) with a stethoscope to detect abnormalities.

Methods of Data Collection

1. Observation: Gathering data through the senses to note physical appearance, behavior, and environment.
2. Interview: Planned communication with the patient to obtain subjective data.
3. Examination: Systematic physical assessments, such as head-to-toe, body system, or focused area examinations.

Organizing Data

Organizing frameworks like Gordon’s Functional Health Patterns (e.g., health perception, nutrition, activity patterns) or the Body System Model help structure data collection for comprehensive assessment.

Validating Data

Validation confirms data accuracy, ensuring collected information is reliable. Techniques include rechecking measurements, confirming subjective data with objective findings, consulting with other healthcare professionals, and clarifying ambiguous statements.

Analyzing Data

Data analysis involves clustering related signs and symptoms. It focuses on identifying patterns and comparing with norms. This process helps in drawing reasoned conclusions to inform nursing care decisions.

Documenting Data

Accurate documentation is essential and must be factual, complete, accessible, and legible. Data can be recorded on paper or electronically, with specific data requiring immediate reporting based on the patient’s condition.

Purposes of Documentation in Nursing

1. Chronological Record: Maintains a sequential log of client assessment data, providing a clear outline of the care process.
2. Communication Tool: Ensures accessibility of information to all healthcare team members, aiding collaboration and preventing fragmentation, delays, and repetitive procedures.
3. Diagnostic Validation: Serves as a basis for screening and validating potential diagnoses.
4. Problem Identification: Helps identify emerging health problems, supporting continuous assessment and care adaptation.
5. Educational Basis: Identifies educational needs for the client, family, or caregivers.
6. Eligibility and Reimbursement: Supports eligibility determination and documentation for care and reimbursement, providing evidence for financial claims.
7. Legal Record: Acts as a permanent legal record, demonstrating care provided or omitted.
8. Epidemiological and Research Data: Supplies valuable data for research, public health studies, and education.

Guidelines for Effective Documentation

1. Legibility: Write legibly or print neatly in non-erasable ink.
2. Grammar and Brevity: Use correct grammar and spelling; avoid unnecessary words that create redundancy.
3. Concise Language: Use phrases instead of complete sentences for brevity.
4. Data Focus: Record findings rather than how they were obtained.
5. Objective Reporting: Document without judgment or premature diagnoses.
6. Client Perception: Include the client’s understanding and perception of issues.
7. Avoid “Normal”: Avoid labeling findings as “normal”; be specific.
8. Detail and Completeness: Provide comprehensive details of symptoms and observations.
9. Supportive Evidence: Back up objective data with specific observations.

Nursing Diagnosis:

Definitions

• NANDA: NANDA provides a definition for a nursing diagnosis. It is “a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.” This definition provides a foundation for nursing interventions.
• Gordon (1976): Describes it as “an actual or potential health problem that nurses are educated and licensed to treat.”
• Carpenito (1997): Defines it as a “statement that describes the human response (actual/potential) of an individual or group. The nurse can legally identify and address this response through specific nursing interventions.”

Characteristics of Nursing Diagnosis

1. Clearly states a concise health problem.
2. Identifies the client’s normal level of function.
3. Highlights client strengths and weaknesses.
4. Derives from existing evidence about the client.
5. Is potentially treatable through nursing interventions.
6. Provides a basis for planning nursing care.

Structure of Nursing Diagnosis Statements: PES Format

Nursing diagnoses are formulated using the PES format, developed by NANDA, which stands for:

1. Problem Statement (P): Identifies the client’s current health issue (e.g., impaired skin integrity, imbalanced nutrition).
2. Etiology (E): Lists the probable cause(s) or related factors of the problem, guiding appropriate nursing interventions.
3. Defining Characteristics (S): It indicates the observable signs and symptoms. These are, or risk factors when considering risk diagnoses, that support the chosen diagnosis.

Types of Nursing Diagnosis Statements

1. Problem-Focused Diagnosis: Describes a current health problem requiring intervention.
2. Risk Diagnosis: Indicates potential health issues that could develop without preventive measures.
3. Health Promotion Diagnosis: Focuses on improving overall wellness and health behavior.

Formulating Nursing Diagnosis Statements

The process of creating nursing diagnoses involves interpreting data based on nursing knowledge. It also relies on experience. This results in statements that reflect the client’s health status and contributing factors.

Guidelines for Formulating Nursing Diagnoses:

1. Use Clear and Concise Language: Avoid ambiguous terms.
2. Base on Evidence: Ensure diagnoses are supported by client data.
3. Consider Client Strengths and Weaknesses: Include factors that can support or hinder recovery.
4. Identify Treatable Conditions: Ensure the diagnosis is amenable to nursing intervention.
5. Individualize Care: Tailor the diagnosis to the client’s specific situation, allowing for personalized interventions.

Types of Nursing Diagnoses

1. 1. Actual Nursing Diagnosis: Identifies current health issues based on patient assessment. It has three components:

• Problem: The issue itself.
• Related Factors: Causes contributing to the problem.
• Defining Characteristics: Observable signs and symptoms.
• Examples:
  • Ineffective Breathing Pattern r/t pain, evidenced by pursed-lip breathing.
  • Impaired Physical Mobility r/t decreased muscle control, evidenced by lack of control in extremities.

1. 2. Risk Nursing Diagnosis: Addresses potential health problems. It includes:

• Problem and Risk Factors that increase the likelihood of the problem.
• Examples:
  • Risk for Infection due to immunosuppression.
  • Risk for Impaired Skin Integrity related to decreased circulation.

1. 3. Possible Nursing Diagnosis: Used when incomplete information is available but suggests a potential problem.

• Composed of Problem and Etiology (suspected cause).
• Examples:
  • Possible Nutritional Deficit.
  • Possible Low Self-Esteem r/t job loss.

1. 4. Wellness Nursing Diagnosis: Identifies opportunities for improved health and well-being.

• Uses phrases like “Readiness for Enhanced” to indicate a positive health behavior.
• Examples:
  • Readiness for Enhanced Immunization Status.
  • Potential for Enhanced Nutrition.

1. 5. Syndrome Nursing Diagnosis: Involves a group of related diagnoses, useful when multiple health problems present as a pattern.

• Examples:
  • Chronic Pain Syndrome.
  • Risk for Disuse Syndrome.

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Formulating Nursing Diagnoses

Nursing diagnoses can be written in one, two, or three-part statements based on the type of diagnosis:

1. 1. One-Part Statement: Primarily for wellness and syndrome diagnoses. It only contains the problem.

• Examples:
  • Readiness for Enhanced Breastfeeding.
  • Risk for Impaired Skin Integrity.

1. 2. Two-Part Statement: Used for risk diagnoses. It includes the Problem and Etiology (contributing factors).

• Examples:
  • Risk for Infection r/t compromised immunity.
  • Activity Intolerance r/t generalized weakness.

1. 3. Three-Part Statement: Also called the PES Format. Used for actual diagnoses with Problem, Etiology, and Signs/Symptoms.

• Examples:
  • Acute Pain r/t myocardial ischemia as evidenced by severe chest pain.
  • Fluid Volume Excess r/t compromised regulatory mechanisms as evidenced by edema and jaundice.

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Guidelines for Writing Nursing Diagnoses

1. Focus on the Problem: State the diagnosis based on the patient’s problem, not their needs.
2. Use Legal Terminology: Ensure that terms are legally sound (e.g., “Impaired Skin Integrity” rather than “poor skin care”).
3. Be Specific: Clearly define the issue and its cause to guide effective interventions.
4. Avoid Judgmental Language: Use neutral statements (e.g., “Spiritual Distress r/t chronic illness”).
5. Ensure Correct Cause and Effect: Confirm that the relationship between elements is accurate.
6. Avoid Redundancy: Don’t repeat the same concept within the diagnosis.
7. Use Nursing Terminology: Describe the patient’s response rather than medical conditions.
8. Clarify Probable Causes: Use nursing terms to explain potential causes, avoiding medical terminology.

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NANDA Approved Diagnosis

NANDA International (NANDA-I) was originally known as the North American Nursing Diagnosis Association. It plays a central role in developing standardized nursing diagnoses. These diagnoses are crucial for effective patient care. They also facilitate communication among healthcare professionals. Since its inception, NANDA-I has evolved, incorporating a global perspective and contributing significantly to the classification of nursing diagnoses.

Evolution of NANDA-I

• Formation: In 1973, NANDA held its first conference to formally define nursing diagnoses. The association was initially focused on North America. It expanded and adopted the name NANDA International in 2002 to reflect its growing global membership.
• Collaboration: NANDA-I developed Taxonomy II, a structured system that organizes nursing diagnoses. This taxonomy was created with the National Library of Medicine. It aligns with the International Standards Organization (ISO) for healthcare terminology.

NANDA-I Taxonomy II Structure

NANDA-I Taxonomy II classifies nursing diagnoses across three levels: domains, classes, and specific nursing diagnoses. This framework is based on patients’ responses to health conditions and organizes diagnoses under human response categories. There are 13 domains and 47 classes in total, each encompassing unique aspects of patient care.

The 13 NANDA-I Domains:

1. Domain 1: Health Promotion: Focuses on maintaining and enhancing well-being.
2. Domain 2: Nutrition: Involves nutrient intake and usage for energy and tissue repair.
3. Domain 3: Elimination: Addresses the body’s excretion of waste products.
4. Domain 4: Activity/Rest: Concerns the production, conservation, and balance of energy.
5. Domain 5: Perception/Cognition: Encompasses information processing, including senses and cognition.
6. Domain 6: Self-Perception: Centers on self-awareness.
7. Domain 7: Role Relationships: Covers connections between individuals or groups.
8. Domain 8: Sexuality: Addresses sexual identity, function, and reproduction.
9. Domain 9: Coping/Stress Tolerance: Relates to managing life events and stress.
10. Domain 10: Life Principles: Encompasses beliefs and behaviors with intrinsic value.
11. Domain 11: Safety/Protection: Focuses on freedom from harm and injury.
12. Domain 12: Comfort: Concerns mental, physical, and social well-being.
13. Domain 13: Growth/Development: Relates to physical and developmental milestones.

Latest NANDA-I Nursing Diagnoses (2018-2020 Edition)

In its 2018-2020 edition, NANDA-I introduced seventeen new diagnoses to address emerging healthcare needs. It also removed eight previous diagnoses. Additionally, seventy-two were revised to enhance clarity and relevance.

New Nursing Diagnoses Include:

• Readiness for enhanced health literacy
• Ineffective adolescent eating dynamics
• Acute substance withdrawal syndrome
• Risk for surgical site infection
• Risk for dry mouth
• Risk for metabolic imbalance syndrome
• Risk for venous thromboembolism
• Risk for unstable blood pressure
• Risk for complicated immigration transition

These additions reflect the evolving scope of nursing care, responding to diverse patient needs and global health concerns.

Retired NANDA Nursing Diagnosis

In the latest NANDA-I nursing diagnosis list (2018-2020 edition), eight nursing diagnoses were retired from the previous list (2015-2017 edition). These retirements reflect shifts in clinical focus. They also indicate updates in the taxonomy based on the changing needs and relevancy within nursing practice. Here’s an organized overview of these retired nursing diagnoses:

Retired NANDA Nursing Diagnoses (2018-2020 Edition)

1. Risk for Disproportionate Growth
2. Noncompliance (Nursing Care Plan)
3. Readiness for Enhanced Fluid Balance
4. Readiness for Enhanced Urinary Elimination
5. Risk for Impaired Cardiovascular Function
6. Risk for Ineffective Gastrointestinal Perfusion
7. Risk for Ineffective Renal Perfusion
8. Risk for Imbalanced Body Temperature

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Nursing Diagnoses Categories and Classes

These diagnoses span across various domains and classes, including Health Promotion, Nutrition, and Elimination. They reflect changes in terminology and understanding. Some diagnoses were retired due to overlap or redundancy. Others were incorporated into different diagnostic categories or refined for more accuracy.

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Domain 1: Health Promotion

Class 1: Health Awareness

• Decreased Diversional Activity Engagement (Nursing Care Plan)
• Readiness for Enhanced Health Literacy
• Sedentary Lifestyle (Nursing Care Plan)

Class 2: Health Management

• Frail Elderly Syndrome (Nursing Care Plan)
• Risk for Frail Elderly Syndrome
• Deficient Community Health
• Risk-Prone Health Behavior
• Ineffective Health Maintenance (Nursing Care Plan)
• Ineffective Health Management
• Readiness for Enhanced Health Management
• Ineffective Family Health Management
• Ineffective Protection

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Domain 2: Nutrition

Activities involving the intake, assimilation, and use of nutrients for tissue maintenance, repair, and energy production.

Class 1: Ingestion

• Imbalanced Nutrition: Less Than Body Requirements (Nursing Care Plan)
• Readiness for Enhanced Nutrition
• Insufficient Breast Milk Production
• Ineffective Breastfeeding (Nursing Care Plan)
• Interrupted Breastfeeding (Nursing Care Plan)
• Readiness for Enhanced Breastfeeding
• Ineffective Adolescent Eating Dynamics
• Ineffective Child Eating Dynamics
• Ineffective Infant Feeding Dynamics
• Ineffective Infant Feeding Pattern (Nursing Care Plan)
• Obesity Overweight
• Risk for Overweight
• Impaired Swallowing (Nursing Care Plan)

Class 2: Digestion

No diagnoses currently listed.

Class 3: Absorption

No diagnoses currently listed.

Class 4: Metabolism

• Risk for Unstable Blood Glucose Level (Nursing Care Plan)
• Neonatal Hyperbilirubinemia
• Risk for Neonatal Hyperbilirubinemia
• Risk for Impaired Liver Function
• Risk for Metabolic Imbalance Syndrome

Class 5: Hydration

• Risk for Electrolyte Imbalance
• Risk for Imbalanced Fluid Volume
• Deficient Fluid Volume (Nursing Care Plan)
• Risk for Deficient Fluid Volume
• Excess Fluid Volume (Nursing Care Plan)

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Domain 3: Elimination

Processes of secretion and excretion of body waste.

Class 1: Urinary Function

• Impaired Urinary Elimination
• Functional Urinary Incontinence
• Overflow Urinary Incontinence
• Reflex Urinary Incontinence
• Stress Urinary Incontinence
• Urge Urinary Incontinence
• Risk for Urge Urinary Incontinence
• Urinary Retention

Class 2: Gastrointestinal Function

• Constipation (Nursing Care Plan)
• Risk for Constipation
• Perceived Constipation
• Chronic Functional Constipation
• Risk for Chronic Functional Constipation
• Diarrhea
• Dysfunctional Gastrointestinal Motility
• Risk for Dysfunctional Gastrointestinal Motility
• Bowel Incontinence

Class 3: Integumentary Function

No diagnoses currently listed.

Class 4: Respiratory Function

• Impaired Gas Exchange

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Domain 4: Activity/Rest

Balance and management of energy resources.

Class 1: Sleep/Rest

• Insomnia
• Sleep Deprivation
• Readiness for Enhanced Sleep
• Disturbed Sleep Pattern

Class 2: Activity/Exercise

• Risk for Disuse Syndrome
• Impaired Bed Mobility
• Impaired Physical Mobility
• Impaired Wheelchair Mobility
• Impaired Sitting
• Impaired Standing
• Impaired Transfer Ability
• Impaired Walking

Class 3: Energy Balance

• Imbalanced Energy Field
• Fatigue
• Wandering

Class 4: Cardiovascular/Pulmonary Responses

• Activity Intolerance
• Risk for Activity Intolerance
• Ineffective Breathing Pattern
• Decreased Cardiac Output
• Risk for Decreased Cardiac Output
• Impaired Spontaneous Ventilation
• Risk for Unstable Blood Pressure
• Risk for Decreased Cardiac Tissue Perfusion
• Risk for Ineffective Cerebral Tissue Perfusion
• Ineffective Peripheral Tissue Perfusion
• Risk for Ineffective Peripheral Tissue Perfusion
• Dysfunctional Ventilatory Weaning Response

Class 5: Self-Care

• Impaired Home Maintenance
• Bathing Self-Care Deficit
• Dressing Self-Care Deficit
• Feeding Self-Care Deficit
• Toileting Self-Care Deficit
• Readiness for Enhanced Self-Care
• Self-Neglect

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Domain 5: Perception/Cognition

Human information processing, including attention, orientation, and memory.

Class 1: Attention

• Unilateral Neglect

Class 2: Orientation

No diagnoses currently listed.

Class 3: Sensation/Perception

No diagnoses currently listed.

Class 4: Cognition

• Acute Confusion
• Risk for Acute Confusion
• Chronic Confusion
• Labile Emotional Control
• Ineffective Impulse Control
• Deficient Knowledge
• Readiness for Enhanced Knowledge
• Impaired Memory

Class 5: Communication

• Readiness for Enhanced Communication
• Impaired Verbal Communication

Domain 6: Self-Perception

Awareness about the self.

Class 1: Self-Concept

• Hopelessness
• Readiness for enhanced hope
• Risk for compromised human dignity
• Disturbed personal identity
• Risk for disturbed personal identity
• Readiness for enhanced self-concept

Class 2: Self-Esteem

• Risk for chronic low self-esteem
• Chronic low self-esteem
• Situational low self-esteem
• Risk for situational low self-esteem

Class 3: Body Image

• Disturbed body image

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Domain 7: Role Relationship

The positive and negative connections between individuals or groups and the demonstration of those connections.

Class 1: Caregiving Roles

• Caregiver role strain
• Risk for caregiver role strain
• Impaired parenting
• Risk for impaired parenting
• Readiness for enhanced parenting

Class 2: Family Relationships

• Risk for impaired attachment
• Dysfunctional family processes
• Interrupted family processes
• Readiness for enhanced family processes

Class 3: Role Performance

• Ineffective relationship
• Risk for ineffective relationship
• Readiness for enhanced relationship
• Parental role conflict
• Ineffective role performance
• Impaired social interaction

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Domain 8: Sexuality

Sexual identity, function, and reproduction.

Class 1: Sexual Identity

• This class currently does not include any diagnoses.

Class 2: Sexual Function

• Sexual dysfunction
• Ineffective sexuality pattern

Class 3: Reproduction

• Ineffective childbearing process
• Risk for ineffective childbearing process
• Readiness for enhanced childbearing process
• Risk for disturbed maternal-fetal dyad

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Domain 9: Coping/Stress Tolerance

Managing life events and processes effectively.

Class 1: Post-Trauma Responses

• Risk for complicated immigration transition
• Post-trauma syndrome
• Risk for post-trauma syndrome
• Rape-trauma syndrome
• Relocation stress syndrome
• Risk for relocation stress syndrome

Class 2: Coping Responses

• Risk for ineffective activity planning
• Anxiety (nursing care plan)
• Defensive coping
• Ineffective coping
• Readiness for enhanced coping
• Ineffective community coping
• Readiness for enhanced community coping
• Compromised family coping
• Disabled family coping
• Readiness for enhanced family coping
• Death anxiety
• Ineffective denial
• Fear Grieving
• Complicated grieving
• Risk for complicated grieving
• Impaired mood regulation
• Powerlessness
• Risk for powerlessness
• Readiness for enhanced power
• Impaired resilience
• Risk for impaired resilience
• Readiness for enhanced resilience
• Chronic sorrow
• Stress overload

Class 3: Neurobehavioral Stress

• Acute substance withdrawal syndrome
• Risk for acute substance withdrawal syndrome
• Autonomic dysreflexia
• Risk for autonomic dysreflexia
• Decreased intracranial adaptive capacity
• Neonatal abstinence syndrome
• Disorganized infant behavior
• Risk for disorganized infant behavior
• Readiness for enhanced organized infant behavior

Domain 10: Life Principles

Principles that give meaning to life and guide decision-making.

Class 1: Values

• Impaired religiosity
• Risk for impaired religiosity
• Readiness for enhanced religiosity

Class 2: Beliefs

• Moral distress

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Domain 11: Safety/Protection

Freedom from harm or danger, both physical and psychological.

Class 1: Infection

• Risk for infection

Class 2: Physical Injury

• Risk for injury
• Risk for falls
• Impaired oral mucous membrane
• Risk for impaired oral mucous membrane
• Risk for perioperative positioning injury
• Risk for thermal injury
• Risk for vascular trauma
• Risk for suffocation
• Risk for trauma

Class 3: Violence

• Risk for self-directed violence
• Risk for suicide
• Risk for other-directed violence

Class 4: Environmental Hazards

• Contamination
• Risk for contamination
• Risk for occupational injury

Class 5: Defensive Processes

• Ineffective airway clearance
• Risk for aspiration
• Risk for adverse reaction to iodinated contrast media

Class 6: Security

• Risk for poisoning

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Domain 12: Comfort

The sense of physical, emotional, and social ease.

Class 1: Physical Comfort

• Acute pain
• Chronic pain
• Labor pain
• Nausea

Class 2: Environmental Comfort

• Impaired comfort
• Readiness for enhanced comfort

Class 3: Social Comfort

• Social isolation

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Domain 13: Growth/Development

The process of becoming physically, emotionally, and socially mature.

Class 1: Growth

• Risk for disproportionate growth

Class 2: Development

• Delayed development
• Risk for delayed development

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COURSES

GNM

BSC NURSING

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“Discover how critical thinking in nursing enhances each step of the nursing process. Learn the 5 essential phases that guide effective patient care and elevate nursing practice.”

Critical Thinking in Nursing:

1. Definition of Critical Thinking in Nursing:

• Critical thinking is a structured and reflective process essential in nursing for sound clinical decisions.
• It goes beyond the nursing process by incorporating higher-order skills like reasoning, evaluation, and outcome-based reflection.

2. Levels of Critical Thinking in Nursing:

• Basic: Relies on rules and step-by-step processes with limited independence.
• Complex: Starts questioning and analyzing methods, making decisions independently.
• Commitment: Fully accountable for decisions, acting autonomously based on knowledge and experience.

3. Critical Thinking Skills:

• Interpretation: Understand and assess data to identify relevant patient information.
• Analysis: Examine information to evaluate reliability and to make informed judgments.
• Evaluation: Assess outcomes to ensure optimal patient care.
• Inference: Derive logical conclusions based on evidence.
• Explanation: Clearly justify reasoning and thought processes.
• Self-regulation: Reflect on and refine one’s thinking processes.

4. Attitudes for Critical Thinking:

• Curiosity: Question assumptions and explore different perspectives.
• Open-mindedness: Remain receptive to various viewpoints without bias.
• Independence: Make decisions based on personal judgment and knowledge.
• Discipline: Follow a systematic approach and avoid rash conclusions.

5. Critical Thinking Competencies:

• Scientific Method: Systematically gather and analyze data for problem-solving.
• Problem Solving: Identify and implement effective solutions to patient-related issues.
• Decision Making: Choose the best course of action based on critical evaluation.
• Effective Communication: Communicate reasoning and decisions effectively with the healthcare team.

6. Steps in Critical Thinking:

• Identify the Problem: Narrowly define the issue for targeted solutions.
• Gather Information: Collect varied perspectives and data sources.
• Analyze and Evaluate Data: Check reliability and relevance.
• Identify Assumptions: Avoid biases in data interpretation.
• Establish Significance: Focus on critical information for decision-making.
• Make a Decision: Weigh options and choose the most supported solution.
• Communicate Conclusion: Share outcomes with stakeholders clearly.

7. Components of Critical Thinking:

• Mental Operations: Engage in reasoning and decision-making for effective problem-solving.
• Knowledge Base: Use interdisciplinary knowledge (science, psychology) in clinical settings.
• Attitude: Maintain a rational, inquisitive approach that allows questioning of norms.

8. Characteristics of Effective Critical Thinking:

• Logical & Reflective: Engages in systematic thought for logical outcomes.
• Creative & Independent: Innovates solutions and questions conventional practices.
• Free of Biases: Makes unbiased, fair judgments.
• Action-Oriented: Leads to decisive, patient-focused interventions.

Critical Thinking Competencies in Nursing

1. General Critical Thinking Competencies:

• Skills such as scientific process, hypothesis generation, problem-solving, and decision-making.
• These are universal and apply across many disciplines, not only in nursing.

1. Specific Critical Thinking Competencies in Clinical Situations:

• Includes diagnostic reasoning, clinical inferences, and clinical decision-making.
• These are particularly relevant to healthcare and are used by nurses and other clinical professionals.

1. Nursing-Specific Competency:

• The nursing process, which involves assessment, diagnosis, planning, implementation, and evaluation.
• While vital, the nursing process is just one aspect of critical thinking in nursing.

Attitudes for Critical Thinking

1. Confidence:

• Experience boosts confidence in clinical judgment and decision-making.

1. Independence:

• Thinking independently fosters growth in nursing practice by encouraging autonomous decision-making.

1. Fairness:

• Ensures that decisions and actions are just and unbiased.

1. Responsibility and Accountability:

• Nurses are accountable for providing care that aligns with professional standards.

1. Risk-Taking:

• Involves trying innovative solutions to solve complex issues while maintaining safety standards.

1. Discipline:

• A disciplined approach ensures systematic problem-solving and quality care.

1. Perseverance:

• Commitment to high standards and quality care is crucial for achieving positive outcomes.

1. Creativity:

• Allows nurses to find solutions beyond conventional care methods, enhancing patient care.

1. Curiosity:

• Encourages ongoing learning and the acquisition of new knowledge.

1. Integrity:
   • Nurses should be honest and transparent, recognizing and learning from mistakes.
2. Humility:
   • Recognizing personal knowledge and skill limitations fosters openness to learning.

Phases of Critical Thinking

1. Trigger Event:

• A situation is recognized as an opportunity for improvement.

1. Exploration:

• Seeking new solutions, ideas, or approaches.

1. Appraisal:

• Self-assessment of assumptions that influence decision-making.

1. Integration:

• Incorporating new knowledge and methods to improve clinical practice.

Levels of Critical Thinking in Nursing

1. Basic Critical Thinking:

• Trusts that experts have all the answers; relies on rules and established guidelines.
• Typical for beginners who learn from instructors and experienced nurses.

1. Complex Critical Thinking:

• Begins analyzing and questioning established protocols, considering multiple solutions.
• Shows a shift toward independent decision-making and acceptance of alternative approaches.

1. Commitment:

• Nurses make autonomous decisions based on evidence and experience, taking responsibility for outcomes.
• Involves accountability and reflective practice to assess the effectiveness of decisions made.

Overview of the Nursing Process

The nursing process is a systematic, problem-solving approach that guides nurses in providing individualized, goal-oriented, and organized care to patients. This process helps nurses assess health status, plan and implement care, and evaluate the effectiveness of interventions. It is used universally across healthcare settings, ensuring quality and consistency in nursing practice.

The nursing process is known as a GOSH approach:

• Goal-Oriented: Focuses on achieving specific patient outcomes.
• Organized: Follows a structured sequence of steps.
• Systematic: Uses a consistent method to address patient needs.
• Humanistic Care: Addresses the patient as a whole, considering physical, emotional, and social needs.

Phases of the Nursing Process

1. Assessment:

• Gathering data on the patient’s health status, which includes physical, psychological, and social information.
• Critical for forming a foundation to identify the patient’s needs and problems.

1. Diagnosis:

• Analyzing the assessment data to identify actual or potential health problems.
• Formulating nursing diagnoses to guide subsequent care.

1. Planning:

• Developing a plan of care with goals and expected outcomes that address the identified diagnoses.
• Setting priorities and creating a structured approach for care delivery.

1. Implementation:

• Putting the care plan into action through interventions designed to meet patient needs and achieve set goals.
• Involves nursing activities such as administering medications, providing education, and monitoring progress.

1. Evaluation:

• Assessing the effectiveness of the interventions and whether patient goals have been met.
• Adjusting the care plan as necessary to address unresolved problems or new issues.

Purposes of the Nursing Process

• To help the patient maintain health or recover from illness.
• To identify actual and potential health problems.
• To establish and implement a plan of care tailored to the patient’s needs.
• To provide holistic, individualized care that promotes maximum functioning.
• To ensure effective care delivery and a peaceful, dignified experience during terminal illness.

Characteristics of the Nursing Process

• Problem-Oriented: Focuses on addressing the patient’s current and potential health issues.
• Goal-Oriented: Aims for positive outcomes and patient-centered results.
• Client-Oriented: Centers around each patient’s unique health needs, ensuring tailored care.
• Universally Applicable: Follows a standardized process across various healthcare settings.
• Dynamic and Cyclic: Continuously adapts as the patient’s condition changes.
• Open and Flexible: Encourages collaboration with the patient to provide adaptable care.
• Systematic and Planned: Follows a specific order, ensuring a thorough, organized approach.
• Emphasis on Feedback: Relies on patient feedback to evaluate care effectiveness and make adjustments.
• Interpersonal and Collaborative: Involves teamwork among healthcare professionals and patient involvement.
• Inter-Related Steps: Each phase builds on the previous one, creating a cohesive cycle.

The Nursing Process Cycle

The cycle of Assessment → Diagnosis → Planning → Implementation → Evaluation is continuous. It is flexible, responding to each patient’s evolving needs. This interconnected sequence allows nurses to reassess and revise care as necessary, promoting optimal health outcomes and ongoing quality improvement.

Importance of the Nursing Process

The nursing process is vital to ensuring that quality, individualized, and effective care is provided to each patient. Here are key reasons for its importance:

1. Ensures Quality Care: Allows nurses to evaluate the quality and effectiveness of the care provided.
2. Creates a Systematic Care Plan: The hospital team uses a structured approach to patient care. This scientific method promotes consistency. It also provides clarity.
3. Enhances Communication and Cooperation: Written documentation of care activities fosters collaboration among healthcare staff, avoiding duplication or omissions.
4. Meets Patient Needs: Supports personalized care, addressing each patient’s unique preferences and health requirements.
5. Serves as a Legal Document: The documented nursing process provides a legal record of the care given.
6. Facilitates Learning: Acts as a valuable resource for medical students and new nurses.
7. Promotes Satisfaction and Flexibility: Nurses can derive satisfaction from achieving positive outcomes. They have the flexibility to adjust care as needed.
8. Improves Continuity of Care: Helps in maintaining consistent and continuous care, especially in cases involving multiple caregivers.
9. Encourages Patient Involvement: Engaging patients in their care plans enhances their sense of independence and self-care.

Advantages of the Nursing Process

The nursing process offers numerous advantages to nurses and the overall nursing practice:

1. Creates a Comprehensive Health Database: Enables the collection of critical health information.
2. Identifies Health Problems: Helps to determine the patient’s actual or potential health issues.
3. Establishes Care Priorities: Facilitates the setting of priorities for nursing interventions.
4. Defines Specific Nursing Actions: Supports the identification of targeted actions to meet patient needs.
5. Promotes Organized and Individualized Care: Ensures each patient’s care is tailored and systematically organized.
6. Encourages Innovation: Allows for creative and adaptable nursing interventions.
7. Provides Alternatives: Allows for flexibility and alternative actions in the nursing plan.
8. Fosters Autonomy and Accountability: Builds nurse independence and accountability in delivering care.
9. Increases Care Effectiveness: Enhances the overall effectiveness and quality of nursing care.

Phases of the Nursing Process

The nursing process consists of five main steps, each critical for delivering comprehensive and patient-centered care:

1. Assessment:

• Collects information about the patient’s condition to establish a health database.

2. Diagnosis:

• Identifies actual and potential health issues based on the data gathered.

3. Planning:

• Sets care goals, desired outcomes, and selects appropriate nursing interventions.

4. Implementation:

• Executes the planned nursing interventions.

5. Evaluation:

• Measures whether the goals and outcomes are met and adjusts the care plan as necessary.

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COURSES

GNM

BSC NURSING

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“Explore essential insights on human sexuality, its effects on health, and effective prevention strategies against STIs and unwanted pregnancies. Learn more!”

Human Sexuality

Introduction

• Human sexuality is a complex aspect that goes beyond reproduction, encompassing physical, psychological, sociocultural, and spiritual dimensions.
• It is influenced by the interaction between biological and social factors, forming an integral part of personal identity.

Key Components of Human Sexuality

1. Physical Aspects:

• Includes primary (genital) and secondary characteristics (e.g., breast development, hair distribution) distinguishing males from females.

1. Psychological Aspects:

• Gender identity and sexual behavior are shaped by social and cultural factors.
• Sexuality plays a role in self-concept and interpersonal interactions.

Development of Sexual Orientation

• Determined by a combination of genetic, hormonal, cognitive, and environmental factors, often solidifying in adolescence.
• Open expression of sexual orientation fosters higher self-esteem and emotional well-being.

Sexual Development Throughout Life

1. Infancy & Childhood:

• Sexual identity begins to form based on societal norms and family values.
• Early experimentation and curiosity about sexuality are natural parts of childhood development.

1. Adolescence:

• Time of heightened awareness of sexuality, body image, and peer acceptance.
• Experimentation and exploration are common, requiring open, supportive, and informative guidance.

1. Early Adulthood:

• Sexual maturity leads to the establishment of intimate relationships.
• Sexual expression continues to evolve with personal growth.

1. Middle Years:

• Emotional and sexual boundaries are explored.
• Major changes, like menopause, impact perceptions of sexual attractiveness.
• Self-concept plays a crucial role in how these changes are navigated.

1. Older Adulthood:

• Sexual activity can remain healthy and fulfilling.
• Physical changes (e.g., reduced erections in men, vaginal dryness in women) may require adaptation.
• Nurses can support older adults by providing information on maintaining a healthy sex life.

Role of Nurses in Promoting Sexual Health

• Nurses should foster a non-judgmental attitude and educate patients on sexual health.
• Being aware of one’s own values and beliefs is essential to provide unbiased care.
• Support includes offering accurate information and understanding societal influences on sexuality.

Highlights

• Sexuality Influences: Biological, psychological, sociocultural, and spiritual.
• Early Learning: Begins from infancy, influenced by family and societal norms.
• Adolescent Development: High sensitivity to body image and peer approval.
• Middle Age Challenges: Menopause and self-image concerns.
• Older Adults: Adaptation to physical changes is necessary for sexual well-being.

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Gender Identity, Social Gender Roles, and Sexual Orientation

Gender Identity reflects an individual’s internal understanding of their gender. This understanding may or may not align with societal expectations of male or female roles.

Sexual Orientation involves a person’s enduring romantic or sexual attraction. It exists along a continuum from homosexuality to heterosexuality. There are various forms of bisexuality.

• Heterosexual: Attraction to a different gender.
• Homosexual: Attraction to the same gender, often referred to as gay or lesbian.
• Bisexual: Attraction to two genders.
• Pansexual: Attraction to any gender.
• Asexual: May not experience sexual attraction.

Transgender individuals may feel a deep sense of being in the wrong body. This condition is known as

gender dysphoria.

It is often present from childhood. For some, gender reassignment treatments are vital. These treatments can include hormone therapy and surgery. They help align their physical appearance with their gender identity. It’s crucial for healthcare providers, like nurses, to create supportive environments to reduce stigma and stress related to these identities.

Factors Affecting Sexuality

1. Biological Factors: These include congenital abnormalities, hormonal imbalances, aging, injuries, pain, and fatigue. Such factors can influence sexual function and interest.
2. Environmental Factors: Lifestyle changes, lack of privacy, and changes in living situations can impact sexual relationships and function.
3. Psychological Factors: These include family disturbances, poor sexual education, traumatic first sexual experiences, relationship conflicts, unmet expectations, stress, and grief. Psychological well-being plays a significant role in a person’s sexual health.

Understanding these factors is essential for providing holistic and empathetic care in medical and nursing practice.

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Psychological Factors

1. Death of a Loved One: The loss of a significant person can lead to profound emotional distress. This may impact an individual’s sexual health and relationships.

Sexual Health History

• Multiple Partners: Engaging in unprotected sex with multiple partners carries a significant risk for acquiring HIV and other STIs. This risk is particularly high among youth.
• Sexually Transmitted Diseases (STDs): STDs can lead to severe complications, including:
• Cancer
• Infertility
• Ectopic pregnancy
• Spontaneous abortions
• Stillbirth
• Low birth weight
• Neurological damage
• Death

Women and adolescents are disproportionately affected by STDs and their consequences.

Stress Factors

• Psychological Stress: Includes conditions such as depression and anxiety.
• Physiological Stress: May manifest as nervousness and a lack of energy, affecting sexual interest and performance.

Prevention of STIs, Unwanted Pregnancy, and Sexual Harassment

Signs and Symptoms of STIs

Many STIs may be asymptomatic, but potential signs include:

• Sores or bumps on the genitals or in the oral/rectal area
• Painful or burning urination
• Discharge from the penis
• Unusual or odorous vaginal discharge
• Unusual vaginal bleeding
• Pain during sex
• Sore, swollen lymph nodes (especially in the groin)
• Lower abdominal pain
• Fever
• Rashes on the trunk, hands, or feet

Risk Factors for Poor Sexual Health

Individuals engaging in sexual activity may face increased exposure to STIs, especially with certain risk factors, including:

1. Unprotected Sex: Vaginal or anal penetration by an infected partner without a condom significantly raises the risk.
2. Multiple Sexual Partners: More partners increase the likelihood of exposure to STIs.
3. History of STIs: Previous infections make it easier to contract new STIs.
4. Forced Sexual Activity: Survivors of rape or assault must seek medical care for screening and support.
5. Substance Misuse: Alcohol and drug use can impair judgment, leading to risky sexual behaviors.
6. Injecting Drugs: Sharing needles can transmit infections like HIV and hepatitis.
7. Age: Many new STIs occur in individuals aged 15-24.
8. Maternal Transmission: STIs can be passed from mother to infant during pregnancy or childbirth. This poses serious health risks to the child.

Prevention Strategies

To reduce the risk of STIs and unwanted pregnancies, individuals can follow these guidelines:

1. Abstinence: The most effective way to avoid STIs is to abstain from sexual activity.
2. Monogamous Relationships: Maintain a long-term relationship with an uninfected partner.
3. Testing: Before engaging in sexual activity with a new partner, both individuals should be tested for STIs. Use protection, like condoms or dental dams, to reduce risk.
4. Vaccination: Vaccines for HPV, hepatitis A, and hepatitis B can prevent certain STIs. The CDC recommends HPV vaccination for preteens (ages 11-12) and Hepatitis vaccinations for newborns and at-risk individuals.
5. Condom Usage: Always use latex condoms or dental dams for protection during sex. Avoid oil-based lubricants with latex as they can degrade the material.
6. Avoid Substance Abuse: Reducing alcohol and drug use can lower the risk of engaging in risky sexual behaviors.
7. Communication: Discuss sexual health and safety practices with partners before engaging in sexual activity.
8. Male Circumcision: Evidence suggests that circumcision can lower the risk of acquiring HIV and other STIs.

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PSYCHOLOGICAL FACTORS

Death of a Loved One: The loss of a loved one can profoundly affect psychology. It influences mental health. It also impacts emotional stability.

SEXUAL HEALTH HISTORY

Multiple Partners: Engaging in unprotected sex with multiple partners poses a significant risk for Human Immunodeficiency Virus (HIV). It also increases the risk of other sexually transmitted infections (STIs) among youth.

Sexually Transmitted Diseases (STDs): STDs can lead to severe complications. These include cancers, infertility, ectopic pregnancy, spontaneous abortions, stillbirths, low birth weight, neurological damage, and death. Women and adolescents are disproportionately affected by STDs and their consequences.

STRESS

• Psychological Stress: Conditions like depression and anxiety can impact overall health and decision-making.
• Physiological Stress: Symptoms such as nervousness and lack of energy may arise from various stressors.

PREVENTION OF STIs AND UNWANTED PREGNANCY

STIs can present with a range of signs and symptoms, which may include:

• Sores or bumps in the genital or oral/rectal areas
• Painful or burning urination
• Discharge from the penis or unusual vaginal discharge
• Pain during sex
• Sore, swollen lymph nodes, particularly in the groin
• Lower abdominal pain, fever, or rash

RISK FACTORS FOR POOR SEXUAL HEALTH

Factors that increase the risk of STIs include:

• Unprotected Sex: Engaging in vaginal or anal penetration without using a condom.
• Multiple Partners: More sexual contacts increase the risk of STIs.
• History of STIs: Previous STIs make it easier to contract new infections.
• Sexual Assault: Victims should seek immediate medical attention for screening and support.
• Substance Misuse: Alcohol and drugs can impair judgment, leading to risky behaviors.
• Injecting Drugs: Needle sharing poses serious risks, including HIV and hepatitis.
• Young Age: Half of new STIs occur in individuals aged 15-24.
• Mother-to-Infant Transmission: STIs can be passed during pregnancy or delivery, necessitating screening for all pregnant women.

PREVENTION STRATEGIES

1. Abstinence: The most effective way to avoid STIs is to abstain from sexual activity.
2. Monogamous Relationships: Engaging in a long-term relationship with one uninfected partner reduces risk.
3. Testing: Avoid sex with new partners until both parties have been tested for STIs.
4. Vaccination: Vaccines are available for HPV, hepatitis A, and hepatitis B.
5. Condom Usage: Use latex condoms or dental dams consistently and correctly for all sexual activities.
6. Avoid Substance Abuse: Reducing alcohol and drug use can lower the likelihood of risky behaviors.
7. Communication: Discuss safer sex practices with partners before engaging in sexual activities.
8. Consider Male Circumcision: Evidence suggests circumcision may reduce HIV transmission risk in men.

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DEALING WITH INAPPROPRIATE BEHAVIOR

Everyone may encounter inappropriate behavior in the workplace. Below are some common examples:

• Offensive Language: This includes sexual or discriminatory remarks.
• Inappropriate Humor: Avoid jokes that are offensive or overly sexual.
• Unprofessional Conduct: This includes behaviors like harassment or taking credit for others’ work.
• Poor Work Ethics: Lack of effort and engagement can hinder team dynamics.
• Negative Attitude: Disrespect towards customers or coworkers can damage workplace morale.
• Gossiping: Creating an exclusive environment can alienate coworkers.
• Attendance Issues: Frequent tardiness or absenteeism affects team productivity.

HOW TO DEAL WITH INAPPROPRIATE BEHAVIOR

1. Establish Boundaries: Clearly define acceptable and unacceptable behaviors.
2. Communicate Expectations: Use a code of conduct and hold regular meetings to reinforce standards.
3. Prepare for Issues: Acknowledge that not all employees will behave perfectly.
4. Constructive Confrontation: Discuss concerns privately with employees exhibiting bad behavior.
5. Be Specific: When addressing issues, explain your concerns and what you expect moving forward.
6. Utilize Written Warnings: Document instances of poor behavior as a formal warning.
7. Create a Disciplinary System: Clearly outline the consequences of inappropriate behavior.
8. Enforce Consistently: Apply disciplinary measures uniformly to maintain authority.
9. Provide Professionalism Training: Offer courses or workshops to educate employees on expected behaviors.
10. Update Standards Regularly: Continuously evaluate and revise behavior standards as needed.

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COURSES

GNM

BSC NURSING

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