 Within a shift (4-6 hours).

Comprehensive Nursing Process  Must be SMART:

Reviewer  Specific
 Measurable
1. Nursing Process Overview  Attainable
 Realistic
 Nursing Diagnoses: Problem Identification  Time-bound
o 3 Parts: o Long-Term Goals:
 Problem  Days to weeks.
 Etiology (root cause)  Define desired patient outcomes and
 Signs and Symptoms prioritize interventions.
 Frameworks for Prioritization:
o Maslow’s Hierarchy of Needs.
o ABCs: Airway, Breathing,
2. Assessment Circulation.

 Gather data through interviews, physical

exams, and observations.
 Data Types: 4. Implementation
o Subjective Data: Verbalized by the
patient (e.g., pain, feelings).  Carry out nursing interventions and
o Objective Data: Observable or collaborate with other healthcare
measurable (e.g., vital signs, lab professionals.
results).  Types of Interventions:
 Components: o Independent: Performed by the
nurse without needing a doctor’s
1. Demographic Data: Name, age, sex, order.
religion, address, marital status, o Dependent: Based on a doctor’s
occupation. instructions.
2. Chief Complaint (C/C): Reason for o Collaborative: Requires teamwork
seeking care (e.g., headache, chest with other healthcare providers.
pain).
3. Present Health History: Details of
current condition, symptoms,
medications. 5. Evaluation
4. Past Health History: Medical,
surgical, and familial history.  Assess Outcomes:
5. Lifestyle Factors: Diet/nutrition, o Were the goals met?
sleep patterns, substance use, o Examples:
hygiene, exercise.  "Patient’s pain scale
 Additional Psychosocial Considerations: decreased from 8/10 to 3/10."
o Assess mental health, emotional  "Patient gained 1 kg over two
state, coping mechanisms, and weeks."
cultural/spiritual needs.  Document findings effectively and adjust
care plans as needed.

3. Planning
6. Vital Signs Monitoring
 Set Goals and Objectives:
o Short-Term Goals: 1. Temperature
o Normal range: 36.5 - 37.5°C. o Pain scale: 8/10
o Abnormal:
 Below 35°C: Hypothermia. Nursing Diagnosis
 Above 38°C: Fever
(Hyperthermia).  "Pain related to infection as evidenced by
o Causes of Variations: patient’s complaint of abdominal pain and
 Infection, dehydration, or pain scale of 8/10."
environmental exposure.
2. Pulse Rate Planning
o Normal: 60-100 bpm.
o Assess rhythm, strength, and  Short-Term Goal: Decrease pain level to
regularity. 4/10 within 8 hours.
o Causes of Variations:  Long-Term Goal: Patient reports no
 Tachycardia: Fever, pain, abdominal pain within 3 days.
anxiety, or anemia.
 Bradycardia: Medications, Interventions
hypothermia, or athletic
conditioning. 1. Administer prescribed pain medication.
3. Respiration Rate 2. Provide a warm compress to the abdomen.
o Normal: 12-20 breaths per minute. 3. Educate the patient on relaxation techniques.
o Note depth, rhythm, and effort.
o Causes of Variations: Rationale
 Tachypnea: Fever, anxiety, or
acidosis.  Pain relief allows better rest and promotes
 Dyspnea: Asthma, heart healing.
failure, or pneumonia.
4. Blood Pressure (BP) Evaluation
o Normal: 120/80 mmHg.
o Assess trends over time.  Pain scale decreased to 4/10 within the shift.
o Causes of Variations:  Patient reports improved comfort.
 Hypertension: Stress, obesity,
or kidney disease.
 Hypotension: Dehydration or
blood loss. 8. Lifestyle Considerations

1. Diet/Nutrition: Balanced meals, hydration.

2. Substance Use: Smoking, alcohol, drugs.
7. Example Nursing Care Plan 3. Hygiene: Personal cleanliness and
grooming.
Case: Patient with abdominal pain 4. Exercise: Regular physical activity.
5. Stress Management: Coping mechanisms.
Assessment

 Subjective: "I feel severe pain in my

abdomen." 9. Special Populations
 Objective:
o Vital signs:  Pediatric Assessment:
 Temp: 37.5°C o Use age-appropriate communication
 HR: 88 bpm and techniques.
 RR: 18 breaths/min o Assess growth milestones and
 BP: 120/80 mmHg immunization records.
 Geriatric Assessment:  Diet and nutrition.
o Focus on mobility, mental status, and  Habits and substance use (smoking, alcohol,
risk of falls. drugs).
o Consider chronic conditions and  Sleeping patterns.
polypharmacy.  Stress levels.
 Pregnancy Assessment:  Social media and hobbies.
o Monitor maternal and fetal well-  Activities of daily living.
being.  Hygiene and environment.
o Assess for signs of complications
like preeclampsia.

3. Physical Assessment Techniques

Nursing Reviewer: Assessment and Care Four Techniques:

Planning
1. Inspection: Visual observation (e.g., skin
color, swelling).
2. Palpation: Touch to assess temperature,
1. Nursing Process (ADPIE) tenderness, and texture.
3. Percussion: Tapping for vibration and
A. Assessment: sound.
4. Auscultation: Listening with a stethoscope
1. Data Collection: (e.g., heart, lungs, abdomen).
o Gather data.
o Organize data.
o Validate data.
o Document data. 4. Vital Signs
2. Types of Data:
o Subjective Data: Information 1. Temperature:
verbalized by the patient. o Normal: 36.5°C - 37.5°C.
o Objective Data: Measurable and o Variations:
observable data (seen, heard,  Below 35°C: Hypothermia.
smelled, or measured).  Above 38°C: Hyperthermia
3. Sources of Data: or fever.
o Interview: Verbal and non-verbal 2. Pulse Rate (PR):
communication. o Normal: 60-100 beats per minute.
o Health History: Past illnesses, o Terms:
surgeries, medications, allergies,  Tachycardia: Above 100
family and genetic history, and social bpm.
habits.  Bradycardia: Below 60 bpm.
o Physical Examination: 3. Respiratory Rate (RR):
 Laboratory procedures. o Normal: 12-20 breaths per minute.
 Vital signs. o Abnormalities:
 General survey.  Tachypnea: Rapid breathing.
 Dyspnea: Difficulty
breathing.
 Apnea: No breathing.
2. Lifestyle Assessment 4. Blood Pressure (BP):
o Normal: 120/80 mmHg.
Key Areas: o Hypertension: Above 140/90 mmHg.
o Hypotension: Below 100/60 mmHg.
5. Nursing Diagnosis (NANDA)

Problem Identification:

1. Problem.
2. Etiology (cause).
3. Signs and symptoms.

6. Planning

Setting Goals and Objectives:

 Short-Term Goals: Specific, measurable,

realistic, and time-bound (e.g., within 4-6
hours).
 Long-Term Goals: Focus on days or weeks
for broader improvement.

7. Evaluation

1. Assess whether the patient’s goals have been

met.
2. Adjust the care plan as needed based on
patient outcomes.

8. Systems Review

1. Head to Toe Examination:

o Skin, hair, nails.
o Head and neck.
o Eyes, ears, nose, and throat.
o Chest, abdomen, and extremities.
2. Abdomen Inspection:
o Auscultation, palpation, and
percussion.
3. Peripheral Vascular System:
o Assess circulation and swelling.
4. Musculoskeletal System:
o Joint movement and posture.
5. Neurological Assessment:
o Reflexes, orientation, and motor
function.
Nursing Care Plan (NCP) Guide o Etiology (cause): Why the issue
exists (e.g., “related to surgical
incision”).
Creating an effective Nursing Care Plan (NCP)
o Signs and Symptoms: Evidence of
involves using a systematic approach that ensures
the issue (e.g., “as evidenced by pain
patient-focused care. This guide provides step-by-
scale of 8/10 and grimacing”).
step instructions based on the nursing process
(ADPIE) to help you master NCPs.
Example:

 Diagnosis: “Acute Pain related to surgical

incision as evidenced by patient’s verbal
1. Assessment report of pain 8/10 and facial grimacing.”

Purpose: Gather and document relevant Common NANDA Diagnoses:

patient data.
 Ineffective Breathing Pattern
Steps:  Impaired Skin Integrity
 Risk for Infection
1. Collect Data:
o Subjective Data: What the patient
says (e.g., “I feel pain in my
stomach”). 3. Planning
o Objective Data: Observable and
measurable data (e.g., blood
Purpose: Set goals and determine
pressure: 120/80 mmHg).
2. Organize Data: Use categories like: interventions.
o Physical health (e.g., vital signs, lab
results). Steps:
o Psychological health (e.g., mood,
mental status). 1. Set Goals:
o Social factors (e.g., support system, o Short-Term Goals: Achievable
living conditions). within a few hours or a shift.
3. Validate Data: Ensure accuracy by cross- o Long-Term Goals: Achievable
checking findings (e.g., verify abnormal lab within days or weeks.
values). 2. Write SMART Goals:
4. Document Data: Record information in a o Specific: Focused on one issue.
clear, concise, and factual manner. o Measurable: Quantify the goal.
o Attainable: Realistic given the
patient’s condition.
o Relevant: Directly related to the
diagnosis.
2. Nursing Diagnosis o Time-bound: Includes a deadline.

Purpose: Identify the patient’s problems Example:

using NANDA-I terminology.
 Short-Term Goal: “Patient will report pain
Steps: level of 4/10 within 4 hours.”
 Long-Term Goal: “Patient will be pain-free
1. Write a 3-Part Statement: within 3 days.”
o Problem (NANDA diagnosis): The
patient’s issue (e.g., “Acute Pain”). 3. Prioritize: Use frameworks like:
o ABCs: Airway, Breathing, o Partially Met: Progress made but
Circulation. goal not fully achieved.
o Maslow’s Hierarchy of Needs. o Not Met: No progress toward the
goal.
2. Revise Care Plan:
o Modify goals or interventions if
needed.
4. Implementation o Identify barriers to success.
3. Document Results: Clearly state whether
Purpose: Carry out planned interventions the goal was met and what actions will
to achieve goals. follow.

Steps:

1. Types of Interventions:
o Independent: Actions the nurse can
Example Nursing Care Plan
perform without orders (e.g.,
repositioning). Case: Post-Operative Patient with
o Dependent: Actions requiring a Abdominal Pain
doctor’s order (e.g., administering
medications). Assessment
o Collaborative: Actions requiring
teamwork (e.g., working with  Subjective: “I have severe pain in my
physical therapists). abdomen.”
2. Perform Interventions: Follow the care  Objective:
plan while considering patient preferences o Vital signs: BP 130/85 mmHg, HR
and safety. 92 bpm, RR 20 breaths/min.
3. Document Actions: Record what was done, o Pain scale: 8/10.
when, and how the patient responded.
Diagnosis
Example Interventions:
 Acute Pain related to surgical incision as
 Administer prescribed pain medications. evidenced by pain scale 8/10 and facial
 Provide a warm compress to alleviate pain. grimacing.
 Educate the patient on deep breathing
exercises. Planning

 Short-Term Goal: Reduce pain to 4/10

within 6 hours.
 Long-Term Goal: Patient will report no
5. Evaluation pain within 3 days.

Purpose: Determine if the patient’s goals Interventions

were met.
1. Administer prescribed analgesics as ordered.
Steps: 2. Encourage the patient to use relaxation
techniques.
1. Assess Outcomes: Compare patient’s 3. Reassess pain level every 2 hours.
current status to goals.
o Met: Goals achieved (e.g., “Pain Evaluation
decreased to 4/10 within 4 hours”).
 Pain reduced to 4/10 within 4 hours.
 Care plan adjusted to focus on mobility
improvement.

Quick Tips for Success

1. Start Simple: Practice writing care plans for
straightforward scenarios.
2. Use Templates: Pre-made care plan
templates can save time.
3. Understand NANDA-I: Familiarize
yourself with common nursing diagnoses.
4. Collaborate: Seek input from instructors,
peers, or preceptors.
5. Reflect: Review completed care plans to
identify areas for improvement.