1 Flashcards
- Is a systematic, rational method of planning, and providing quality and individualized nursing care.
- Series of phases describing the practice of nursing
- GOSH approach for efficient and effective provision of nursing care.
Goal oriented
Organized
Systematic
Humanistic care
The Nursing Process
- Cyclic and dynamic
- Client centered
- Universally applicable
- Focus on problem solving
- Interpersonal collaborative
- Used to critical thinking
Characteristic of nursing process
- Goal oriented
- Organized
- Systematic
- Humanistic
- Efficient and effective nursing care
According to Udan
5 steps of the Nursing Process
- Assessment
- Diagnosis
- Planning
- Intervention
- Evaluation
- Collection, organization, validation and documentation of data. The most important step.
- Begins during the first meeting of the nurse and the client
- Continuous process carried out during all phases of the nursing process. Identifies the patient’s strengths and limitations.
Assessment
4 sections of Assessment
- History of present health concern
- Past health history
- Family history
- Lifestyle and health practice
Steps of assessment
- Collection of data
- Organizing data
- Validation of data
- Documentation of data
Sources of data
o Primary
o Secondary
- Data elicited and verified by the client
- Client, Client record, Other healthcare professionals
- Client interview
- Interview and therapeutic communication skills
examples:
- “I can’t breathe” , “I have a stomach pain”, “I can’t sleep”
SUBJECTIVE
Types of data
SUBJECTIVE
OBJECTIVE
- Data directly/indirectly observed through measurement
- Observation and physical assessment findings of the health professionals
- Documentation of the assessment made in the client record
- Observation made by the family or significant others
- Observation and physical examination
examples:
- Heart rate of 110bpm
- UTZ reveals the client is pregnant for 18weeks
- X-ray film reveals PTB
OBJECTIVE
- A statement or conclusion regarding the nature of phenomena
- Analyzing subjective and objective data to make
a professional judgement - Provides basis for the selection of nursing
intervention
Diagnosis
about individuals, family, or
community responses to actual and potential
health problems and life process.
- Clinical judgement
Types of Nursing Diagnosis
Wellness Diagnosis
Actual Diagnosis
Risk Diagnosis
Possible Diagnosis
Syndrome Diagnosis
Describes human response to level of wellness in an individual, family, or community that have a readiness for enhancement
Wellness Diagnosis
Problem is present (+) signs and symptoms
Actual Diagnosis
Problem does not exist, but the present of risk factors indicate a problem is likely to develop unless nurses intervene
Risk Diagnosis
Health problem is incomplete or
unclear
Possible Diagnosis
Associated with a cluster of other diagnosis
Syndrome Diagnosis
words that have been added to NANDA labels to
give additional meaning
o Deficient
o Impaired
o Decreased
o Ineffective
o Compromised
Qualifiers
- Deliberative, systematic phase of nursing process that involves decision making and problem
solving - Involves setting goals and outcomes
- Individualized plan of care for patient once diagnosis have been prioritized.
Planning
Planning should be:
Specific
Measurable
Attainable
Realistic
Time-bound
- Also called “Intervention”
- Putting the nursing care plan into action
- Purpose: to carry out planned nursing interventions to help the client attain goals and achieve optimal health.
- Any treatment based on clinical judgement and knowledge that a nurse performs to enhance patience outcomes.
- The “doing” phase
Implementation
Actions that require an order from a health care provider
Dependent
o Interdependent interventions
o Therapies that require the combined knowledge, skills, and expertise of multiple health care providers
Collaborative
- Assessing client’s response to nursing progress toward health care and effectiveness of nursing
care plan - Final step of the nursing process
- Crucial to determine if the patient’s condition improved or worsen after application of the first four steps of nursing process.
Evaluation
- A comprehensive record of the client’s past and current health.
- This is gathered during the initial assessment interview.
Health history
- To document the responses of the client and actual and potential concerns.
- To obtain information about the client’s health.
Purpose
- Obtaining a valid nursing health history requires professional, interpersonal and interviewing skills
Interviewing
- Establishing rapport and trusting relationship
- Client’s response to the health concern as a whole person
Focuses of Interview
Planning the Interview and Setting (TP SA DL)
- Time
- Place
- Seating Arrangement
- Distance
- Language
- When client is physically comfortable and free from pain
- Minimal interruptions
Time
- Well lighted, well ventilated
- Free of distractions
- Place where others cannot overhear or see client
Place
- Client in bed – 45-degree angle to bed
- Initial admission – overbed table between
- Standing and looking down at a client can be intimidating
Seating Arrangement
- Neither too small or too far
- 2 to 3 feet during interview
- Also varies in ethnicity
o 8-12 inches – Arab
o 24 inches – Britain
o 18 inches – US
o 36 inches – Japan
Distance
Phases of Interview
preintroductory
Introductory
Working
Summary and closing
- Convert medical terminology into common
English usage - Interpreters / translators if nurse don’t speak the
same language or dialect
Language
- Facial Expression
- Appearance
- Demeanor
- Silence
- Attitude
- Listening
Non-verbal communication
- Closed-ended question
o (when or did) - Open-ended question
o (how or what) - Rephrasing
- Inferring
- Providing information
Guidelines of an effective interview
Verbal communication
o Lasts only through the expected recovery period
o Does not last longer than six months
o Eventually resolves with or without treatment after injured it area heals
o Unrelieved acute pain can progress to chronic pain
o It increases the vital signs of the client
Acute pain
o Ongoing pain and last longer than 6 months
o People suffer chronic pain even when there is no past injury or any body damage
Chronic pain
COLDSPAA symptom analysis mnemonic
character
onset
location
duration
severity
pattern
associated factors
affects the patients
- A systematic way of collecting objective data from a client using the four examination techniques.
Physical Assessment
Positioning you Patient
- Standing / Erect
- Sitting
- Dorsal Recumbent
- Sim’s
- Prone
- Lithotomy
- Knee-chest / Jack Knife
4 assessment
- collecting data
- organizing data
- validating data
- documenting data
