SCIENCES.
SUBMITTED BY ,
SUBMITTED TO ,
Mr. ShreyasWalvekar
Mrs. ManishaGholap.
M.Sc.(N) 1st Year Student
Assistant Professor
KINS, Karad.
KINS, Karad
Index
Sr. no. Content
1. Introduction
3. Analysis of data
5. Summary
6. Conclusion
7. Bibliography
Aims:
At the end of this seminar, the post-graduate students will be able to understand the methods of data
collection, analysis, utilization of data related to nursing process.
Objectives:
At the end of this seminar the post-graduate students will be able to:
Observation:
Observation is an assessment tool that relies on the use of the five senses (sight, touch, hearing, smell, and
taste) to discover information about the client. This information relates to characteristics of the client’s
appearance, functioning, primary relationships, and environment.
Visual Observation:
Sight provides an abundance of clues that you must continually process when assessing the client. A few
examples to consider are body movements, general appearance, mannerisms, facial expressions, mode of
dress, nonverbal communication, interaction with others, use of space, skin color and appearance, and
cleanliness. You use visual observation to collect subjective data, such as when noting the client’s facial
expression and body language. You also use visual observation to collect objective data, such as when you
inspect the client’s skin for rashes or irritation and note the cleanliness and level of safety of the client’s
immediate environment.
Tactile Observation.
The sense of touch provides valuable information about the client. For example, touch or palpation of the
skin assesses factors such as muscle strength, temperature, moisture, edema, rash, or swelling.
Auditory Observation.
Hearing allows you to listen actively to the client and family as they interact with you and other members of
the healthcare team. You may also use specialized equipment to listen for information. For example, data
collected by auscultation (listening to the heart, lung, or bowel sounds with a stethoscope) depend on your
sense of hearing and level of skill in interpreting such sounds. Similarly, you must be able to hear the sounds
of the pulse when measuring blood pressure with a sphygmomanometer and stethoscope.
Olfactory or Gustatory Observation.
The sense of smell identifies odors that can be specific to a client’s condition or state of health. Some
microorganisms’ infections have specific, identifiable odors. Olfactory observation includes noting body and
breath odors, which might indicate alcohol intoxication, poor hygiene, or metabolic acidosis. The senses of
smell and taste may also help you to detect harmful chemicals in the air. It should be noted that a client
wholacks a sense of smell often is anorexic (lacks an appetite
To observe is to gather data by using the senses. Observing is aconscious, deliberate skill that is
developed through effort andwith an organized approach. Although nurses observe mainlythrough
sight, most of the senses are engaged during carefulobservations.
Observing has two aspects: (a) noticing the data and (b) selecting, organizing, and interpreting the
data.
A nurse who observesthat a client’s face is flushed must relate that observation to findings such as
body temperature, activity, environmental temperature, and blood pressure.
Nurses often need to focus on specific data in order not to be overwhelmedby a multitude of data.
Observing, therefore, involves distinguishing data in a meaningful manner.
The experienced nurse is often able to attend to an intervention (e.g., give a bed bath or monitor an
intravenous infusion) andat the same time make important observations (e.g., note a changein
respiratory status or skin color).
Nursing observations must be organized so that nothing significant is missed.
Most nurses develop a particular sequencefor observing events, usually focusing on the client first.
Forexample, a nurse walks into a client’s room and observes, in thefollowing order:
1. Clinical signs of client distress (e.g., pallor or flushing, labored breathing, and behavior indicating
pain or emotionaldistress)
2. Threats to the client’s safety, real or anticipated (e.g., alowered side rail)
3. The presence and functioning of associated equipment (e.g., intravenous equipment and oxygen)
4. The immediate environment, including the people it.
Interviewing:
Disadvantages
Nurse: Hello, Ms. Goodwin, I’m Ms. Fellows. I’m a nursing student, and I’ll be assisting with your
care here today.
Client: Hi. Are you a student from the college?
Nurse: Yes, I’m in my final year. Are you familiar with thecampus?
Client: Oh, yes! I’m an avid football fan. My nephew graduated in 2008, and I often attend football
games with him.
Nurse: That’s great! Sounds like fun.
Client: Yes, I enjoy it very much.
Step 2—Orientation
Nurse: May I sit down with you here for about 10 minutesto talk about your care while you’re here?
Client: All right. What do you want to know?
Nurse: Well, to plan your care after your operation, I’d liketo get some information about your usual
daily activities andwhat you expect here in the hospital. I’ll take notes while wetalk to get the
important points and have them available to the other staff who will also look after you.
Client: OK. That’s all right with me.
Nurse: If there is anything you don’t want to talk about, please feel free to say so. Everything you
tell me will beconfidential and only be shared with others who have the legal right to know it.
Client: Sure, that will be fine
The Body
In the body of the interview, the client communicates what he or she thinks, feels, knows, and
perceives in response to questions from the nurse.
Effective development of the interview demands that the nurse use communication techniques that
make both parties feel comfortable and serve the purpose of the interview.
The Closing
The nurse terminates the interview when the needed information has been obtained. In some cases,
however a client terminates it, for example, when deciding not to give any more information or when
unable to offer more information for some other reason—fatigue, for example.
The closing is important for maintaining rapport and trust and for facilitating future interactions.
1. Offer to answer questions: “Do you have any questions?” “I would be glad to answer any questions you
have.” Be sure to allow time for the person to answer, or the offer will be regarded as insincere.
2. Conclude by saying “Well, that’s all I need to know for now” or “Well, those are all the questions I have
for now.” Preceding a remark with the word “well” generally signal that the end of the interaction is near.
3. Thank the client: “Thank you for your time and help. The questions you have answered will be helpful in
planning your nursing care.” You may also shake the client’s hand.
4. Express concern for the person’s welfare and future: “I hope all goes well for you.”
5. Plan for the next meeting, if there is to be one, or state what will happen next. Include the day, time,
place, topic, and purpose: “Let’s get together again here on the fifteenth at nine a.m. to see how you are
managing then.” Or “Ms. Goodwin, I will be responsible for giving you care three mornings perweek while
you are here. I will be here each Monday, Tuesday, and Wednesday between eight o’clock and noon. At
those times, we can adjust your care as needed.”
Summarizing serves several purposes:It helps to terminate the interview, it reassures the client that
the nurse has listened, it checks the accuracy of the nurse’s perceptions, it clears the way for new
ideas, and it helps the client to note progress and a forward direction.
PAST HISTORY
Illnesses, such as chickenpox, mumps, measles, rubella (German measles), rubeola (red measles),
streptococcal infections, scarlet fever, rheumatic fever, hepatitis, polio, and other significant
illnesses
Immunizations and the date of the last tetanus shot
Allergies to drugs, animals, insects, or other environmental agents, the type of reaction that occurs,
and how the reaction is treated
Accidents and injuries: how, when, and where the incident occurred, type of injury, treatment received,
and any complications
Hospitalization for serious illnesses: reasons for the hospitalization, dates, surgery performed, course
of recovery, and any complications
Medications: all currently used prescription and over-the. counter medications, such as aspirin, nasal
spray, vitamins, or laxatives
LIFESTYLE
Personal habits: the amount, frequency, and duration of substance use (tobacco, alcohol, coffee, cola,
tea, and illegal or recreational drugs)
Diet: description of a typical diet on a normal day or any special diet, number of meals and snacks
per day, who cooks and shops for food, ethnic food patterns, and allergies
Sleep patterns: usual daily sleep/wake times, difficulties sleeping, and remedies used for difficulties
Activities of daily living (ADLs): any difficulties experienced in the basic activities of eating,
grooming, dressing, elimination, and locomotion
Instrumental ADLs: any difficulties experienced in food preparation. shopping. transportation,
housekeeping, laundry, and ability to use the telephone. handle finances, and manage medications
Recreation/hobbies: exercise activity and tolerance, hobbies and other interests, and vacations
SOCIAL DATA
Family relationships/friendships: the client's support system in times of stress (who helps in time of
need?), what effect the client's illness has on the family, and whether any family problems are
affecting the client.
Ethnic affiliation: health customs and beliefs; cultural practices that may affect health care and
recovery.
Educational history: Data about the client's highest level of
education attained and any past difficulties with learning.
Occupational history: current employment status, the number of days missed from work because of
illness, any history of accidents on the job, any occupational hazards with a potential for future
disease or accident, the client's need to change jobs because of past illness, the employment status
of spouses or partners and the way child care is handled, and the client's overall satisfaction with
the work.
Economic status: information about how the client is paying for medical care (including what kind of
medical and hospitalization coverage the client has), and whether the client's illness presents
financial concerns.
Home and neighborhood conditions: home safety measures and adjustments in physical facilities that
may be required to help the client manage a physical disability. activityintolerance, and activities of
daily living; the availability of neighborhood and community services to meet the client's needs.
PSYCHOLOGICAL DATA
Major stressors experienced and the client's perception of them
Usual coping pattern for a serious problem or a high level of stress
Communication style: ability to verbalize appropriate emotion; nonverbal communication—such as
eye movements, gestures, use of touch, and posture; interactions with support persons; and the
congruence of nonverbal behavior and verbal expression
Gordon’s framework:
Health perception health-management pattern. Describes the client's perceived pattern of health
and well-being and how health is managed.
Nutritional-metabolic pattern. Describes the client's pattern of food and fluid consumption
relative to metabolic need and pattern indicators of local nutrient supply.
Elimination pattern. Describes the patterns of excretory function (bowel, bladder, and skin).
Activity-exercise pattern. Describes the pattern of exercise, activity, leisure, and recreation.
Sleep pattern. Describes patterns of sleep and relaxation.
Cognitive-perceptual pattern. Describes sensory-perceptual and cognitive patterns.
Self-perception-self-concept pattern. Describes the client's self-concept pattern and perceptions
of self (e.g., self-conception worth, comfort, body image, feeling state).
Role-relationship pattern. Describes the client's pattern of role participation and relationships.
Sexuality-reproductive pattern. Describes the client's patterns of satisfaction and dissatisfaction
with sexuality pattern; describes reproductive patterns.
Coping-stress-tolerance pattern. Describes the client's general coping pattern and the effectiveness
of the pattern in terms of stress tolerance.
Value-belief pattern. Describes the patterns of values, beliefs (including spiritual), and goals that
guide the client's choices or decisions.
Orem’s self -care model
UNIVERSAL SELF CARE REQUISITES
1. The maintenance of a sufficient intake of air.
2. The maintenance of a sufficient intake of water.
3. The maintenance of a sufficient intake of food.
4. The provision of care associated with elimination processes and excrement.
5. The maintenance of a balance between activity and rest.
6. The maintenance of a balance between solitude and social interaction.
7. The prevention of hazards to human life, human functioning, and human well-being.
8. The promotion of human functioning and development within social groups in accord with human
potential, known human limitations, and human desire to be normal. (Normalcy is used in the sense of that
which is essentially human and that which is in accord with the genetic and constitutional characteristics and
the talents of individuals.)
Roy’s adaptation model:
ADAPTIVE MODES
1. Physiological needs
Activity and rest
Nutrition
Elimination
Fluid and electrolytes
Oxygenation
Protection
Regulation: temperature
Regulation: the senses
Regulation: endocrine system
2. Self-concept
Physical self
Personal self
3. Role function
4. Interdependence
ELIMINATION
Usually no problem
Decreased urinary frequency and amount x 2 days
Last bowel movement yesterday, formed, states was "normal"
ACTIVITY/EXERCISE
No musculoskeletal impairment
Difficulty sleeping because of cough
"Can't breathe lying down"
States "I feel weak"
Short of breath on exertion
Exercises daily
COGNITIVE/PERCEPTUAL
No sensory deficits
Pupils 3 mm, equal, brisk reaction
Oriented to time, place, and person
Responsive, but fatigued
Responds appropriately to verbal and physical stimuli
Recent and remote memory intact
States "short of breath" on exertion
Reports "pain in lungs," especially when coughing
Experiencing chills
Reports nausea
ROLES/RELATIONSHIPS
Lives with husband and 3-year-old daughter
Husband out of town; will be back tomorrow afternoon
Child with neighbor until husband returns
States "good" relationships with friends and coworkers
Working mother, attorney
SELF-PERCEPTIOWSELF-CONCEPT
Expresses "concern" and "worry" over leaving daughter with neighbors until husband returns
Well-groomed; says, "Too tired to put on makeup"
COPING/STRESS
Anxious: "I can't breathe"
Facial muscles tense; trembling
Expresses concerns about work: "I'll never get caught up"
VALUE/BEUEF
Catholic
No special practices desired except anointing of the sick
Middle-class, professional orientation
No wish to see chaplain or priest at present
MEDICATION/HISTORY
Synthroid 0.1 mg per day
Client has history of appendectomy, partial thyroidectomy
NURSING PHYSICAL ASSESSMENT
28 years old
Height 158 cm (5 ft, 2 in.); weight 56 kg (125 Ib)
TPR 39.4°C (103°F). 92, 28
Radial pulses weak, regular
Blood pressure 122/80 sitting
Skin hot and pale, cheeks flushed
Mucous membranes dry and pale
Respirations shallow; chest expansion < 3 cm
Cough productive of small amounts of pale pink sputum
Inspiratory crackles auscultated throughout right upper and lower chest
Diminished breath sounds on right side
Abdomen soft, not distended
Old surgical scars: anterior neck, RLQ abdomen
Diaphoretic
Analyzing Data
In the diagnostic process, analyzing involves the following steps:
Compare data against standards (identify significant cues).
Cluster the cues (generate tentative hypotheses).
Identify gaps and inconsistencies.
Comparing Data with Standards:
Nurses draw on knowledge and experience to compare client data to standards and norms and
identify significant and relevant cues.
A standard or norm is a generally accepted measure, rule, model, or pattern. The nurse uses a wide
range ofstandards, such as growth and development patterns, normalvital signs, and laboratory
values.
A cue is considered significant if it does any of the following:
Points to negative or positive change in a client’s health status or pattern. For example, the client
states: “I have recently experienced shortness of breath while climbing stairs” or “I have not smoked
for three months.”
Varies from norms of the client population. The client may consider a pattern—for example, eating
very small meals and having little appetite—to be normal. This pattern, however, may not be healthy
and may require further exploration
Comparing cues to standards and norms:
Clustering Cues:
Data clustering or grouping of cues is a process of determining the relatedness of facts and
determining whether any patterns are present, whether the data represent isolated incidents,and
whether the data are significant. This is the beginning of synthesis.
Experienced nurses may cluster data as they collect and interpret it, as evidenced in remarks or
thoughts such as “I’m getting a sense of . . .” or “This cue doesn’t fit the picture.”
The novice nurse does not have the knowledge base or the clinicalexperience that aids in recognizing
cues.
Thus, the novice must take careful assessment notes, search data for abnormal cues,and use textbook
resources for comparing the client’s cues withthe defining characteristics and etiologic factors of the
accepted nursing diagnoses.
Data clustering involves making inferences about the data.
The nurse interprets the possible meaning of the cues, and labels the cue clusters with tentative
diagnostic hypotheses.
Identifying Gaps and Inconsistencies in Data:
Skillful assessment minimizes gaps and inconsistencies indata. However, data analysis should
include a final check to ensure that data are complete and correct.
Inconsistencies are conflicting data. Possible sources ofconflicting data include measurement error,
expectations, andinconsistent or unreliable reports.
For example, a nurse may learn from the nursing history that the client reports not having seen a
doctor in 15 years, yet during the physical health examination he states, “My doctor takes my blood
pressure everyyear.”
All inconsistencies must be clarified before a valid pattern can be established.
Utilization of data relevant to nursing process:
EXAMPLE
While providing nursing care the nursing process can be used & followed. In all settings nursing care
can be provide through above elaborated steps of nursing process as
Assessment
Diagnosis.
Planning
Implementing.
Evaluation.
Any example can be take to get familiar with the concept of nursing care using nursing process
approach.
Vijay Singh is a 39-year-old secretary who was admitted to the hospital with an elevated
temperature, fatigue, rapid, labored respirations; and mild dehydration. The nursing history reveals
that Ms. Singh has had a “bad cold” for several weeks that just wouldn’t go away. She has been
dieting for several months and skipping meals. Ms. Singh mentions that in addition to her fulltime
job as a secretary she is attending college classes two evenings a week. She has smoked one package
of cigarettes perday since she was 18 years old. Chest x-ray confirms pneumonia.
Physical Examination
o Height: 167.6 cm (5′6′′)
o Weight: 54.4 kg (120 lb)
o Temperature: 39.4°C (103°F)
o Pulse: 68 BPM
o Respirations: 24/minute
o Blood pressure:
o 118/70 mm Hg
o Skin pale; cheeks flushed;
o chills; use of accessory muscles; inspiratory crackles with
o diminished breath sounds
o right base; expectorating thick,
o yellow sputum
Diagnostic Data
2. Anne-Marie Brady, Catherine McCabe, Margaret McCann November 2013, ©2012, Wiley-Blackwell
Fundamentals of Medical-Surgical Nursing: a Systems Approach