Nursing Process

Nursing Process - Presentation Transcript

NURSING PROCESS "the cornerstone of the nursing profession"

HISTORY

The term nursing process and the framework it implies are relatively new.

In 1955, Hall originated the term (care, cure,core), 3 steps: note observation, ministration, validation

Johnson (1959), “Nursing seen as fostering the behavioral functioning of the client”.

Orlando (1961), identified 3 steps: client’s behavior, nurse’s reaction, nurse’s action. “Nursing process set into motion by client’s behavior”

Weidenbach (1963) were among the first to use it to refer to a series of phases describing the process.

Wiche (1967) “Nursing is define as an interactive process between client and nurse”. 4 steps: Perception, Communication, Interpretation, Evaluation.

Yura and Walsh (1967) suggested the 4 components –APIE.

Knowles (1967) described nursing process as: discover, delve, decide, do, discriminate.

American Nurses Association

Published standards of nursing practice. Diagnosis distinguished as separate step of nursing process (1973)

Published Nursing – a Social Policy Statement. Diagnosis of actual and potential health problems delineated as integral part of nursing practice (1980)

Published Standard of Clinical Nursing Practice. Outcome identification differentiated as a distinct step of the nursing process. Therefore, the six steps of the nursing process are as follows: A.D.OI.P.I.E. (1991).

What is a Process?

It is a series of planned actions or operations directed towards a particular result or goal.

It is a systematic, rational method of planning and providing individualized nursing care.

Nursing Process

The Nursing Process

Is the underlying scheme that provides order and direction to nursing care.

It is the essence of professional nursing practice.

It has been conceptualized as a systematic series of independent nursing actions directed toward promoting an optimum level of wellness for the client.

It is cyclical; the components follow a logical sequence, but more than one component may be involved at any one time.

Purpose of Nursing Process

To identify a client’s health status, actual or potential health care problems or needs, to establish plans to meet the identified needs, and to deliver specific nursing interventions to meet those needs.

It helps nurses in arriving at decisions and in predicting and evaluating consequences.

It was developed as a specific method for applying a scientific approach or a problem solving approach to nursing practice.

Nursing Process... Organized Systematic Goal-Oriented Humanistic Care Efficient Effective

PHASES OF THE NURSING PROCESS

Assessment

Diagnosis

Outcome Identification

Planning

Implementation

Evaluation

ASSESSMENT

To establish baseline information on the client.

To determine the client’s normal function.

To determine the client’s risk for diagnosis function.

To determine presence or absence of diagnosis function.

To determine client’s strengths.

To provide data for the diagnostic phase.

Activities of Assessment

COLLECT DATA

VALIDATE DATA

ORGANIZE DATA

RECORDING DATA

Assessment involves reorganizing and collecting CUES:

Objective (overt) Subjective (covert)

Types of Assessment

Initial Assessment

- initial identification of normal function, functional status and collection of data concerning actual and potential dysfunction.

Focus Assessment

- status determine of a specific problem identified during previous assessment.

Time Lapsed Reassessment

- comparison of client’ current status to baseline obtained previously, detection of changes in all functioning health problems after an extended period of time .

Emergency Assessment

- identification of life threatening situation.

Clinical Skills used in Assessment

Observation – act of noticing client cues.

*looking, watching, examining, scrutinizing, surveying, scanning, appraising.

*uses different senses: vision, smell, hearing, touch.

Interviewing – interaction and communication.

Physical Examination

INSPECTION

PERCUSSION

AUSCULTATION

INTUITION

- defined as insights, instincts or clinical experiences to make judgment about client care.

4 PHASES OF INTERVIEW:

Preparatory Phase

(Pre-interaction)

Introductory Phase

(Orientation)

Maintenance Phase

(Working)

Concluding Phase

(Termination)

COMMUNICATION

A process in which people affect one another through exchange of information, ideas, and feelings.

Documentation/Recording is a vital aspect of nursing practice.

Include both oral and written exchange of information between caregivers.

Modes of Communication

Verbal Communication

- Uses spoken or written words.

Non-verbal Communication

- Uses gestures, facial expression, posture/gait, body movements, physical appearance (also body language), eye contact, tone of voice.

Characteristics of Communication

SIMPLICITY

- commonly understood words, brevity, and completeness

CLARITY

- exactly what is meant

TIMING and RELEVANCE

- appropriate time and consideration of client’s interest and concerns

ADAPTABILITY

- adjustment – depending on moods and behavior

CREDIBILITY

- worthiness of belief

Components of Communication sender (encoder) message receiver (decoder) response (feedback)

Documenting & Reporting

DOCUMENTATION

- Serves as a permanent record of client information and care.

REPORTING

- takes place when two or more people share information about client care

NURSING DOCUMENTATION : the charting of documents, the professional surveillance of the patient, the nursing action taken in the patient’s behalf, and the patient’s programs with regards to illness.

Purposes of Client’s Record /Chart

Communication

Legal Documentation

Research

Statistics

Education

Audit and Quality Assurance

Planning Client Care

Reimbursement

TYPES OF RECORDS

Source Oriented Medical Record

“traditional client record”

FIVE BASIC COMPONENTS:

Admission sheet

Physician’s order sheet

Medical history

Nurse’s notes

Special records and reports

B. Problem-oriented medical record (POMR)

- arranged according to the source of information.

FOUR BASIC COMPONENTS:

Database

Problem list

Initial list f orders or care plans

Progress notes:

Nurse’s notes

(SOAPIE)

Flow sheets

Discharge notes or referral summaries

KARDEX

Concise method of organizing and recording data.

Readily accessible to health care team.

Series of Flip cards

Ensure continuity of care

Tool for change of shift report

For planning & communication purposes.

Parts of a Kardex

Personal Data

Basic needs

Allergies

Diagnostic tests

Daily Nursing Procedures

Medications and IV therapy, BT.

Treatments like O 2 , steam inhalation, suctioning, change of dressings, mechanical ventilation.

Characteristics Of Good Recording

BREVITY.

USE OF INK / PERMANENCE.

ACCURACY.

APPROPRIATENESS.

COMPLETENESS & CHRONOLOGY / ORGANIZATION / SEQUENCE / TIMING.

USE OF STANDARD TERMINOLOGY.

SIGNED.

In case of ERROR.

CONFIDENTIALITY.

LEGAL AWARENESS.

LEGIBLE.

DO NOT use the word “PATIENT” or “PT” in the chart.

A HORIZONTAL LINE drawn to fill up a partial line.

REPORTING

CHANGE-OF-SHIFT REPORTS OR ENDORSEMENT.

-for continuity of care / health care needs.

TELEPHONE REPORTS.

-provide clear, accurate, & concise information

-includes: when, who made/was, whom, what info given/received.

TELEPHONE ORDERS.

- RN’s duty, must be signed w/in 24 hours.

TRANSFER REPORTS

- from one unit to another.

Some Legal Significance of CHARTING

Chart Accurately

Chart Objectively

Chart Promptly

Make No Mention of an Incident Report in the Chart

Write Legibly and Use Only Standard Abbreviations

THIRTEEN CHARTING RULES

Write Neat and Legibly

Use Proper Spelling and Grammar

Write with Blue or Black Ink and Use Military time

Use Authorized Abbreviations

Transcribe Orders Carefully

Document Complete Information About Medication

Chart Promptly

Never Chart Nursing Care or Observation Ahead of Time.

Clearly Identify Care Given by Another Member of the Health Care Team.

Don’t Leave Any Blank Spaces on Chart Forms.

Correctly Identify Late Entries.

Correct Mistaken Entries Properly.

Don’t Sound Tentative – Say What You Mean.

SIX More Charting Rules

Don’t Tamper with Medical Records.

Don’t criticize other Health Care Professionals in the chart.

Don’t Document any Comments that a patient or family member makes about a potential lawsuit against a health care professional or the hospital.

Eliminate bias from written descriptions of the patient.

Precisely document any information you report to the doctor.

Document any potentially contributing patient acts.

How to Document Non-Compliance

Refusing to comply with dietary restrictions.

Getting out of bed without asking help.

Ignoring follow-up appointments at the clinic, emergency department, out-patient or doctor’s office.

Leaving against medical advice (AMA)

Abusing or refusing to take medications.

Personal Items at the Bedside

Your notes should contain a description of what was found and how you disposed of it.

TAMPERING w/ MED. EQUIPMENT Document what you saw the patient doing or what you believe he’s doing.

SIX PHASES

NURSING

PROCESS

con't.

ASSESSMENT

To establish data base.

Sources of Data:

Primary: Patient / Client

Secondary: Family members, SOs, Record/Chart, Health team members, Related Lit.

Approaches to Collecting Data for Assessing Client’s Health:

ABDELLAH’S 21 Nursing Problems

DOROTHEA OREM’S Components of Universal Self-Care

GORDON’S Functional Health Patterns

Correlating a Body Systems Physical Examination with Data Gathered by Functional Health Area.

ABDELLAH’s 21 Nursing Problems:

To promote good hygiene and physical comfort.

To promote optimal activity, exercise, rest and sleep.

To promote safety through the prevention of

accident, injury, or other trauma and through the prevention of the spread of infection.

To maintain good body mechanics and prevent and correct deformities.

To facilitate the maintenance of a supply of oxygen to all body cells.

To facilitate the maintenance of nutrition of all

body cells.

To facilitate the maintenance of eliminations.

To facilitate the maintenance of

food and electrolyte balance.

To recognize the physiological responses of the body to disease conditions – pathological, physiological, and compensatory.

To facilitate the maintenance of regulatory mechanisms and functions.

To facilitate the maintenance of sensory functions.

To identify and accept the positive and negative expressions, feelings, and reactions.

To identify and accept the inter-relatedness of emotions and organic illness.

To facilitate the maintenance of effective

verbal and non-verbal communication.

To promote the development of productive interpersonal relationships.

To facilitate progress toward achievement of personal spiritual goals.

To create/or maintain a therapeutic environment.

To facilitate awareness of self as an individual with varying physical, emotional, and developing needs.

To accept the optimum goals in the light of physical and emotional limitations.

To use community resources as an aide in resolving problems arising from illness.

To understand the role of social problems

as influencing factors in the cause of illness.

Dorothea Orem’s Components of Universal Self-Care

Maintenance of sufficient intake of air, water and food.

Provision of care associated with elimination process and excrements.

Maintenance of a balance between solitude and social interaction.

Prevention of hazards to life, functioning and well-being.

Promotion of human functioning and development within social groups in accord with potential known limitations and the desire to be normal.

GORDON’S FUNCTIONAL HEALTH PATTERNS

Health Perception – Health Management Pattern

- describes client’s perceived pattern of health and well being and how health is managed.

Nutritional – Metabolic Pattern

- describes pattern of food and fluid consumption relative to metabolic need and pattern indicators of local nutrient supply.

Elimination Pattern

- describes pattern of excretory function (bowel, bladder, and skin)

Activity – Exercise Pattern

- describes pattern of exercise, activity, leisure, and recreation.

Cognitive – Perceptual Pattern

- describes sensory, perceptual, and cognitive pattern

Sleep – Rest Pattern

- describes patterns of sleep, rest, and relaxation.

7. Self-perception – Self-concept Pattern

- describes self-concept and perceptions of self (body comfory, image, feeling state)

Role – Relationship Pattern

- describes pattern of role engagements

and relationships.

Sexuality – Reproductive Pattern

- describes client’s pattern of satisfaction and dissatisfaction with sexuality pattern, describes reproductive patterns.

Coping – Stress Tolerance Pattern

- describes general coping patterns and effectiveness of the pattern in terms of stress tolerance.

Value – Belief Pattern

- describes pattern of values and beliefs, including spiritual and /or goals that guide choices or decisions.

DIAGNOSING

Clinical act of identifying problems.

Identify health care needs.

Prepare diagnostic statements.

Uses critical thinking skills of analysis and synthesis. (PRS – PES)

ACTIVITIES:

- organize cluster or group data.

- compare data against standards.

- analyze data after comparing with standards.

- identify gaps / inconsistencies in data.

- determine health problems, risks, and strengths.

- formulate Nursing Diagnosis.

Outcome Identification

refers to formulating and documenting measurable, realistic, client-focused goals.

PURPOSES:

To provide individualized care

To promote client participation

To plan care that is realistic and measurable

To allow involvement of support people

ESTABLISH PRIORITIES!!!

Classification of NURSING DIAGNOSIS:

High – priority

- life threatening and requires immediate attention.

Medium – priority

- resulting to unhealthy consequences.

Low – priority

- can be resolve with minimal interventions.

Characteristics of Outcome Criteria:

S - SPECIFIC

M - MEASURABLE

A - ATTAINABLE

R - REALISTIC

T - TIME – FRAMED

CAN BE SHORT TERM OR LONG TERM GOAL.

PLANNING

Involves determining beforehand the strategies or course of actions to be taken before implementation of nursing care.

To be effective, involve the client and his family in planning!

IMPLEMENTATION

Putting nursing care plan into ACTION!

To help client attain goals and achieve optimal level of health.

Requires: Knowledge, Technical skills, Communication skills, Therapeutic Use of Self.

…..SOMETHING THAT IS NOT WRITTEN IS CONSIDERED AS NOT DONE!!!

EVALUATION

IS ASSESSING THE CLIENT’S RESPONSE TO NURSING INTERVENTIONS.

COMPARING THE RESPONSE TO PREDETERMINED STANDARDS OR OUTCOME CRITERIA.

FOUR POSSIBLE JUDGMENTS:

The goal was completely met.

The goal was partially met.

The goal was completely unmet.

New problems or nursing diagnoses have developed.

Characteristics of NURSING PROCESS…

Problem-oriented.

Goal oriented.

Orderly, planned, step by step.

(systematic)

Open to new information.

Interpersonal.

Permits creativity.

Cyclical.

Universal.

Benefits of the NURSING PROCESS: for the Client

QUALITY CLIENT CARE

CONTINUITY OF CARE

PARTICIPATION BY CLIENTS IN THEIR HEALTH CARE

Benefits of the NURSING PROCESS: for the Nurse

CONSISTENT AND SYSTEMATIC NURSING EDUCATION.

JOB SATISFACTION.

PROFESSIONAL GROWTH.

AVOIDANCE OF LEGAL ACTION.

MEETING PROFESSIONAL NURSING STANDARDS.

MEETING STANDARDS OF ACCREDITED HOSPITALS.

HEART OF THE NURSING PROCESS…

KNOWLEDGE

SKILLS

- manual, intellectual, interpersonal.

CARING

- willingness and ability to care.

Willingness to CARE

Keep the focus on what is best for the patient.

Respect the beliefs / values of others.

Stay involved.

Maintain a healthy lifestyle.

CARING BEHAVIORS

Inspiring someone / instilling hope and faith.

Demonstrating patience, compassion, and willingness to persevere.

Offering companionship.

Helping someone stay in touch with positive aspect of his life.

Demonstrating thoughtfulness.

Bending the rules when it really counts.

Doing the “little things”

Keeping someone informed.

Showing your human side by sharing “stories”

The Nursing Process - Presentation Transcript

THE NURSING PROCESS

Objectives:

At the end of 3 hours, the student should be able to:

Define nursing process

State importance of nursing process in nursing profession

State and define interrelated phases of nursing process

Be able to identify subjective and objective data gathered

Be able to formulate nursing diagnosis according to NANDA using the nursing process

NURSING PROCESS

The cornerstone of the nursing profession

Includes: ADOPIE – Assessment, Diagnosis, Outcome identification, Planning, Implementation and Evaluation

NURSING PROCESS IS:

ORGANIZED & SYSTEMATIC

6 sequential and interrelated steps

HUMANISTIC

The plan of care is developed and implemented with great consideration to the unique needs and concerns of the individual client

It is individualized

It involves aspect of human dignity

EFFICIENT

Relevant to the needs of the client

Promotes client satisfaction and progress

EFFECTIVE

Utilizes resources wisely in terms of human, time, cost resources

THE HEART OF THE NURSING PROCESS

Knowledge – broad, varied

Skills

K – knowledge; S – skills; C - caring A. MANUAL B. INTELLECTUAL C. INTERPERSONAL TECHNICAL SKILLS

CRITICAL THINKING

careful deliberate, goal-directed – to solve problems/make decisions

check for evidence

Keeping an open mind

Avoid jumping into conclusions

TO ESTABLISH POSITIVE INTERPERSONAL RELATIONSHIPS, WITH CLIENT, CO-WORKERS (REQUIRES COMMUNICATION SKILLS)

CARING – WILLINGNESS AND ABILITY TO CARE

UNDERSTANDING OURSELVES

To be able to understand others

To be more objective / non-judgmental

Requires ability to listen empathetically

Listen with intent

Enter into another’s way of thinking and viewing the world

Connecting with another’s feelings and perception

Identify with another’s struggles, frustrations and desires

Being able to detach from feelings and returning to our own frame of reference

WILLINGNESS TO CARE

Keep the focus on what is best for the patient

Respect beliefs / values of others

Stay involved

Maintain a healthy lifestyle

CARING BEHAVIORS

Inspiring someone / instilling hope and faith

Demonstrating patience, compassion and willingness to persevere

Offering companionship

Helping someone stay in touch with positive aspect of the life

Demonstrating thoughtfulness

Bending the rules when it really counts

Doing the little things

Keeping someone informed

Showing your human side by sharing “stories”

ASSESSMENT

Collecting, validating, organizing and recording data about the client’s health status (individual, family, community)

PURPOSE: To establish a data base

ACTIVITIES:

COLLECTING DATA:

Gathering information.

Include the physical, psychological, emotional, socio-cultural, and spiritual factors

TYPES OF DATA:

SUBJECTIVE DATA (SYMPTOMS)

- experienced by the client

- EX. Pain, dizziness,

OBJECTIVE DATA (SIGNS)

- those that can be observed and measured

- EX. Pallor, diaphoresis, blood pressure, reddish urine, body temp.

METHODS OF COLLECTING DATA:

INTERVIEW. Planned purposeful conversation

OBSERVATION. (use of senses, lab results interpretation, physical examination)

SOURCE OF DATA:

PRIMARY: Patient/ Client

SECONDARY: Family members, S.O., patient’s chart/record, health team members, related literature

VERIFYING / VALIDATING DATA. Make sure your information is accurate.

ORGANIZING DATA. Cluster facts into groups of information (subjective and objective information)

Let’s review!

SUBJECTIVE OR OBJECTIVE???

Headache

Temp 37.9 C

RR: 20 bpm

Toothache

Client states, “ I haven’t moved my bowel since Friday (3 days).”

Cyanosis

Urine output: 60ml

Ate only half of the food served

DIAGNOSING

Is a process which results to a diagnostic statement or nursing diagnosis

The clinical act of identifying problems

It means to analyze assessment and derive meaning from this analysis.

PURPOSE: To identify the client’s health care needs and to prepare diagnostic statements

NURSING DIAGNOSIS

Is a statement of client’s potential or actual alteration of health status.

Uses critical thinking and skills analysis

Uses PRS/PES format

P- PROBLEM

R-RELATED TO FACTORS

S- SIGNS AND SYMPTOMS

P-PROBLEM

E-ETIOLOGY

S-SIGNS AND SYMPTOMS

ACTIVITIES DURING DIAGNOSING:

Organize cluster or group data. Ex. Pallor, dyspnea, weakness, fatigue – pertain to problems with oxygenation

Compare data against standards (accepted norms). Ex. Amber, clear urine VS cloudy urine or tea colored urine.

Analyze data after comparing with standards

Identify gaps and inconsistencies in data

Determine the client’s health problems, health risks, strengths

Formulate Nursing Diagnosis statements

Examples of Nursing Diagnoses:

Anxiety related to insufficient knowledge regarding surgical experience

Ineffective airway clearance related to tracheobronchial infection as manifested by weak cough, adventitious breath sounds, and copious green sputum production.

Types of Nsg. Diagnoses:

ACTUAL NURSING DIAGNOSIS

A judgment about the client’s response to a health problem that is present at the time of nursing assessment

Based on the presence of signs and symptoms

Ex. - ALTERED COMFORT: PAIN

- PAIN: SEVERE HEADACHE RELATED TO FEAR OF ADDICTION TO NARCOTICS

RISK NURSING DIAGNOSIS

A clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop

Ex. RISK FOR INFECTION

RISK FOR CONSTIPATION

POSSIBLE NURSING DIAGNOSIS

Is one in which evidence about a health problem is unclear or the causative factors are unknown.

Requires more data either to support or to refute it.

Ex. Possible Social Isolation related to unknown etiology

COMPONENTS of a NANDA NURSING DIAGNOSIS

PROBLEM (diagnostic label) and DEFINITION

Describes the client’s health status clearly and concisely in a few words

Qualifiers:

Deficient – inadequate in amount, quality, or degree; not sufficient

Impaired – made worse, weakened, damaged

Ineffective – not producing the desired effect

ETIOLOGY (related factors & risk factors)

Identifies one or more probable causes of health problem

Gives direction to what health needs to attend to.

DEFINING CHARACTERISTICS

A cluster of signs and symptoms that indicate the presence of a particular diagnostic label

ACTUAL DX: signs and symptoms

HIGH RISK/ RISK: factors that cause the client to be more vulnerable to the problem

Ex. ACTIVITY INTOLERANCE RELATED TO IMMOBILITY as manifested by verbal reports of fatigue or weakness during leg exercises

Formulating statements:

Problem – Etiology format

Problem – etiology – signs and symptoms format

OUTCOME IDENTIFICATION

Refers to formulating and documenting measurable, realistic, client – focused goals.

Provides the basis for evaluating nursing diagnosis and interventions.

ACTIVITIES INCLUDE:

ESTABLISH PRIORITIES.

Life-threatening should be given highest priority

ABC’s (airway, breathing, circulation)

Maslow’s hierarchy of needs (physiologic needs over psychosocial)

Unstable clients vs. clients with stable conditions

Actual problems vs. potential concerns

ESTABLISH GOALS & OUTCOME CRITERIA

GOALS: broad statements

SHORT-TERM GOAL (STG)

LONG-TERM GOAL (LTG)

OUTCOME CRITERIA: specific, measurable, realistic statements of goal attainment

S – M – A – R – T

Specific, measurable, attainable, time-framed

Ex.

GOAL: The client will be able to improve mobility and the ability to bear weight on left leg

DESIRED OUTCOMES:

By the end of the week, client will be able to ambulate with crutches

By end of the month, client will be able to stand without assistance

PLANNING

Involves determining beforehand the strategies or course of actions to be taken before implementation of nursing care.

Involve the client and his family

Begins with the first client contact until client is discharged from the facility

Activities:

Plan nursing interventions (also called nursing orders); may be dependent, independent, interdependent.

Write nursing care plan

a written summary of the care that a client is to receive.

the “blueprint” of the nursing process

the plan of care is a step-by-step process evidenced by the following:

Sufficient data are collected to support nsg. Diagnoses

At least one goal must be stated for each nsg. dx

Outcome criteria must be identified for each goal

Each intervention should be supported by scientific rationale

Evaluation. To assess whether goals are met or unmet.

TYPES OF PLANNING

Initial planning

Starts upon initial assessment/admission

Ongoing planning

Done by all nurses who work with the client to:

Determine change in the health status.

Set priorities for the client’s care during the shift.

Decide which problems to focus on during the shift.

Plan nursing activities during the shift.

Discharge planning

The process of anticipating and planning for needs after discharge.

Includes: ff. up care, referrals, medications, diet modifications, significant other/care provider, health teachings, which signs and symptoms to watch for.

IMPLEMENTATION

Putting the nursing care plan into action

Purpose: to carry out planned nursing interventions to help the client attain goals and achieve optimal level of health

Activities:

Set priorities. To determine the order in which nsg interventions are carried out.

Perform nsg. Interventions

Record actions. SOMETHING THAT IS NOT WRITTEN IS CONSIDERED NOT DONE!!!

EVALUATION

Is assessing the client’s response to nsg intervention and then comparing the response to predetermined standards or outcome criteria.

Purpose:

To appraise the extent to which goals and outcome criteria of nsg care have been achieved

Activities:

Collect data about the client’s response

Compare response to goals and outcome criteria

Assess whether goals are met (partially/completely) or unmet

Analyze reasons for outcomes

Modify care plan as needed

BENEFITS OF THE NURSING PROCESS FOR THE CLIENT

Quality client care. It meets standards of care.

Continuity of care.

Participation by the clients in their health care.

BENEFITS OF THE NURSING PROCESS FOR THE NURSE

Consistent and systematic nursing education

Job satisfaction

Professional growth

Avoidance of legal action

Meeting professional nsg standards

Meeting standards of accredited hospitals

NURSING PROCESS - Presentation Transcript

NURSING PROCESS

Ms.JEENA AEJY

THE NURSING PROCESS

A systematic problem-solving approach used to identify, prevent and treat actual or potential health problems and promote wellness.

Nursing process

A systematic way to plan, implement and evaluate care for individuals, families, groups and communities.

Characteristics of the Nursing Process

Dynamic

Client-centered

Planned

Interpersonal and collaborative

Universally applicable

Can focus on problems or strengths

Open, flexible

Humanistic and individualized

Cyclical

Outcome focused ( results oriented)

Emphasizes feedback and validation

STEPS IN NURSING PROCESS

Assessment

Nursing Diagnosis

Planning

Implementation

Evaluation

Nursing Process Assessment Nursing Diagnosis Planning Implementation Evaluation

Benefits of using the nursing process

Continuity of care

Prevention of duplication

Individualized care

Standards of care

Increased client participation

Collaboration of care

EVALUATION IMPLIMENTATION PLANNING ASSESSMENT DIAGNOSIS INTER RELATIONSHIP BETWEEN THE STEPS OF NURSING PROCESS

Assessment

Assessing is a continuous process carried out during all phases of nursing process. All phases of the nursing process depend on the accurate and complete collection of data.

Assessing is the systematic and continuous collection, organization, validation and documentation of data.

- Potter and Perry( 2006)

Assessment is the deliberate and systematic collection of data to determine a clients current and past health status and to determine the clients present and past coping patterns

- Carpenito 2000

Assessment is the systematic and continuous collection, validation and communication of patient data.

- Carol Taylor

Types of Assessment

1. Initial Assessment : Performed within specified time after admission to a health care agency

Eg. Nursing Admission Assessment

2. Problem Focused Assessment : Ongoing process integrated with nursing care to determine specific problem identified in an earlier assessment and to identify new or overlooked problems.

E.g.. Assessment of clients ability to perform self-care while assisting client to bathe.

3. Emergency Assessment : Done during psychiatric or physiological crisis of the client to identify life threatening problems

Eg. Rapid assessment of airway, breathing and circulation during cardiac arrest

4. Time lapsed-Reassessment : Done several months after initial assessment to compare the clients status to baseline data previously obtained.

Assessment ASESSMENT Collect data Organize data Validates Data Document data DIAGNOSIS PLANNING IMPLIMENTATION EVALUATION

1.COLLECTION OF DATA Data Collection is the process of gathering information about a clients health status .

Collection of Data:

Data base : A data base is all information about a client. It includes the nursing health history, physical assessment, the physician’s history, physical examination, results of laboratory and diagnostic tests and material contributed by other health personnel.

Medical vs. Nursing Assessments

Medical assessments

Target data pointing to pathologic conditions

Nursing assessments

Focus on the patient’s response to health problems

Types of Data:

SUBJECTIVE DATA : Also referred to as symptoms or covert data are apparent only to the person affected and can be described or verified only by that person

Eg. Itching, Pain, Feelings of worry

OBJECTIVE DATA : Also referred to as signs or overt data. These are detectable by an observer or can be measured or tested against an accepted standard.

They can be seen, heard, felt or smelled and they are obtained by observation or physical examination

Eg. A Blood Pressure Data

Discolouration of the Skin

Objective Data vs. Subjective Data

Objective data

Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them

E.g., elevated temperature, skin moisture, vomiting

Subjective data

Information perceived only by the affected person

E.g., pain experience, feeling dizzy, feeling anxious

Sources of Data:

Primary Source (Direct Source

client: Usually BEST source

Secondary Source (Indirect Source)

Family Members

Client’s records

1. Medical Records

Eg. Medical History, Physical Examination,

Operation notes, Progress notes,

Consultation done by Physicians

2. Records of therapies done by other health professionals

Eg. Social Workers, Dieticians, Physical Therapist

3. Laboratory Records

Other health care professionals Verbal reports

Literature

Data Collection

Consider

time

needs of patient

developmental stage

physical surroundings

past and present coping patterns

Data Characteristics

Complete

Factual

Accurate

Relevant

Data collection methods

OBSERVATION

INTERVIEWING

PHYSICAL ASSESSMENT

Observation

To gather data using senses

Eg: laboured breathing, pallor or flushing,pain

a lowered side rail ,functioning of an equipment , pt environment and people in it etc…

Interviewing

An interview is a planned communication or a conversation with a purpose

Types of questions and

Setting

Rapport are important

Collection of Health History

Four Phases of a Nursing Interview

Preparatory phase

Introduction

Working phase

Termination

Interview Phases

Preparatory

Nurse collects background info from previous charts

Ensure environment is conducive

Arrange seating

3 – 4 ft apart

Interviewer at 45° angle to patient

Allow adequate time

Phases cont’d.

Introduction

Nurse introduces self

Identifies purpose of interview

Ensure confidentiality of information

Provide for patient needs before starting

Phases cont’d.

Working

Nurse gathers info for sub jective data

Excellent communication skills are needed

Active listening

Eye contact

Open-ended questions

Phases cont’d.

Termination

Inform patient when nearing end of interview

Ensure patient knows what will happen with info

Offer patient chance to add anything

Physical assessment

Appraisal of health status

Usually by Review of Systems

Overview of symptoms

Observable, measurable data

Objective data

Possible approaches—body systems, head to toe, or functional health patterns

Methods of physical asessment

Inspection

Percussion

Palpation

Auscultation

Problems Related to Data Collection

Inappropriate organization of the database

Omission of pertinent data

Inclusion of irrelevant or duplicate data, erroneous or misinterpreted data

Failure to establish rapport and partnership

Recording an interpretation of data rather than observed behavior

Failure to update the database

2.ORGANISING DATA

Nurses uses a written or computerized format for arranging he data systematically

3.VALIDATING DATA

VALIDATING -THE ACT OF DOUBLE CHECKING

Verifies understanding of information

Comparison with another source

-patient or family member

-record

-health team member

4. DOCUMENTING DATA

Record in permanent record ASAP

Use patient’s own words in subjective data – enclose in “ ___” (quotation marks)

Avoid generalizations – be specific

Don’t make summative statements

Thank you