HA Flashcards
→ The term nursing process were used by
Hall (1955), Johnson
(1959), Orlando (1961), Wiedenbach ( 1963), ANA (1973)
a systematic; rational method of planning and providing
individualized nursing care.
NURSING PROCESS
NURSING PROCESS
organized, systematic, goal oriented, humanistic care BY
(Lydia
Hall)
→ provides legal framework for nursing practice
NURSING PROCESS
CHARACTERISTICS OF A NURSING PROCESS
- cyclic and dynamic in nature
- client-centered
- Focus: problem solving and decision making
- different but parallel to process used by physicians
- Interpersonal and Collaborative Style
- Universal applicability
- Use of critical thinking – logic, intuition and creativity
CHARACTERISTICS OF A NURSING PROCESS
1. cyclic and dynamic in nature
data from each phase provide input to the next
phase
regularly repeated event or sequence of events (a
cycle)
continuously changing (dynamic) – not static
→ discipline-specific
CRITICAL THINKING
→ reflective reasoning process
CRITICAL THINKING
→ PURPOSE:
✔ Guides a nurse in generating, implementing, and
evaluating approaches for dealing with client care and
professional concerns.
CRITICAL THINKING
COMPONENTS OF CRITICAL THINKING
critical analysis
Inductive and deductive reasoning
making valid inferences
differentiate facts from opinions
evaluating the credibility of information
clarifying concepts
recognizing assumptions
→ comprehensive assessment of one’s health status
HEALTH ASSESSMENT
→ PRIMARY COMPONENTS: HEALTH ASSESSMENT
✔ Nursing Health History
✔ Physical Assessment
PURPOSES OF HEALTH ASSESSMENT
To obtain baseline data
To supplement, confirm, or refute data.
To establish nursing diagnoses and plans of care.
To evaluate physiological outcomes of health care.
To make clinical judgments.
To identify areas for health promotion and disease
prevention.
→ systematic and continuous collection, organization,
validation, and documentation of data
ASSESSMENT
→ systematic and continuous collection, organization,
validation, and documentation of data
ASSESSMENT
→ a continuous process carried out during all phases of the
nursing process
ASSESSMENT
→ all phases of the nursing process depend on the accurate and
complete collection of data
ASSESSMENT
ASSESSMENT
→ PURPOSE:
✔ establish a database
ASSESSMENT: ACTIVITIES
- Collecting Data
- Organizing Data
- Validating Data
- Documenting Data
TYPES OF DATA:
A. Subjective data (symptoms)
→ itching, pain, and feelings of worry.
B. Objective data (signs)
→ BP 120/80, reddish urine.
- COLLECTION OF DATA
→ Formulation of DATABASE which contains:
nursing health history
physical assessment
primary care provider’s history
physical examination
results of laboratory and diagnostic tests
ASSESSMENT FORMAT
Conceptual Models / Frameworks
A. Gordon’s Functional Health Pattern
B. Orem’s Self-Care Model
C. Roy’s Adaptation Model
D. Wellness Model
E. Non-nursing Models
Body Systems Model
Maslow’s Hierarchy of Needs
Freud’s Developmental Theories
SOURCES OF DATA:
- Primary
→ client - Secondary
→ family, support persons, other health professionas,
medical - Records and Reports, Laboratory and Diagnostic,
Relevant literature
DATA COLLECTION METHODS
Observation - using senses
Interview - planned communication or a
conversation
→ act of “double-checking” or verifying data to confirm
that it is accurate and factual
- VALIDATION OF DATA
DOCUMENTING DATA: RECORDING OF DATA
→ must be accurate
→ Factual manner and not as interpreted by the nurse
→ Subjective data - virbatim
TYPES OF HEALTH ASSESSMENT
- Initial Comprehensive Assessment
- Ongoing or Partial Assessment
- Focused or Problem Oriented Assessment
- Emergency Assessment
CRTICAL THINKING IN HEALTH ASSESSMENT
→ a purposeful, goal-directed thinking process that strives
to problem solve patient care issues through the use of
clinical reasoning
→ It combines logic, intuition, and creativity
CRTICAL THINKING IN HEALTH ASSESSMENT
→ PURPOSE:
✔ is to establish potential strategies to assist patients in
reaching their desired health goals
COMPONENTS OF CRITICAL THINKING
1.Interpretation
2.Analysis
3.Inference
4.Explanation
5.Evaluation
6.Self-regulation
TYPES OF INTERVIEW QUESTIONS
→ Non-directive; invite clients to discover and explore,
elaborate, clarify, or illustrate their thoughts or feelings
Examples: “What” “How”
Open-Ended Questions
TYPES OF INTERVIEW QUESTIONS
1→ Directive Interview (gather short factual answers)
Examples: Yes or No Questions, “When” , “Where”
“Who”, “What”, “Do”, “Is”
. Closed-Ended Questions
TYPES OF INTERVIEW QUESTIONS
→ Without direction or pressure from the nurse (openended and non-directive
Neutral Questions
TYPES OF INTERVIEW QUESTIONS
→ Closed, directive interview
. Leading Questions
is a
systematic data collection method that uses observation
→ Physical examination or Physical assessment
PHYSICAL EXAMINATION (IPPA TECHNIQUE
Inspection
Palpation
Percussion
Auscultation
→ nurse uses a written (or computerized) format that organizes
the assessment data systematically in the form of:
- ORGANIZING DATA
→ a basic structure underlying a process, system, concept,
or text
FRAMEWORK
TYPES OF FRAMEWORK\
TYPES OF FRAMEWORKS
1.Functional Health Framework
2.Cephalocaudal Framework
3.Body Systems Framework
TYPES OF FRAMEWORKS
→ Evaluates the effects of mind, body and environment in
relation to a person’s ability to perform the ADLs
- FUNCTIONAL HEALTH FRAMEWORK
TYPES OF FRAMEWORKS
→ Data collection in terms of Gordon’s 11 Functional
Health Patterns
- FUNCTIONAL HEALTH FRAMEWORK
→ System data in an organized manner: head to toe
- CEPHALOCAUDAL FRAMEWORK
GORDON’S 11 Functional Areas:
- Health-perception-health management
- Nutrition-metabolic
- Activity-exercise
- Elimination
- Sleep-rest
- Cognitive –perceptual
- Self-perception-self-concept
- Roles-relationships
- Sexuality-reproduction
- Coping-stress tolerance
- Values-beliefs
→ Used to improve efficiency and expedite the actual
physical examination
- CEPHALOCAUDAL FRAMEWORK
→ maybe used during the focused assessment of an acutely
or critically ill client
BODY SYSTEM FRAMEWORK
→ a framework that medical practitioners commonly use as
it focuses more on the pathophysiology involved within
specific organ body systems
BODY SYSTEM FRAMEWORK
→ a disciplined, creative and reflective approach used
together with critical thinking
CLINICAL REASONING
COMPONENTS OF CRITICAL THINKING
→ decode hidden messages, clarify the meaning of the
information, categorize the information
→ (categorization, clarifying meaning)
→ Nursing Practice Application:
✔ Be systematic in data collection. Look for patterns to
categorizedata you are uncertain about.
. INTERPRETATION
COMPONENTS OF CRITICAL THINKING
→ speculates, derives, or reasons a specific premise based
on information and assumptions obtained from the patient;
can be challenging skill for the novice nurse because a
certain level of knowledge and experience must be
possessed in order to draw conclusions and provide
alternatives in any given scenario (examining evidence,
speculating or conjecturing alternatives, making
conclusions)
→ Nursing Practice Application:
✔ Look at the meaning and significance of findings. Are
there relationships between findings? Does the data
about the client help you determine that a problem
exists?
INFERENCE
COMPONENTS OF CRITICAL THINKING
→ ideas and data presented, identifies any discrepancies,
and reflects on the reason for the discrepancies
→ Nursing Practice Application:
✔ Be open-minded as you look at information about a
client. Do not make careless assumptions. Do the data
reveal what you believe is true, or are there other
options? Look for patterns to categorize data you are
uncertain about.
ANALYSIS
COMPONENTS OF CRITICAL THINKING
→ requires that the conclusions drawn from the inferences
are cored and can be justified.
→ The use of scientific and nursing literature constitutes the
basis for clinical justification
→ (stating results, justifying procedures)
→ Nursing Practice Application:
✔ Support your findings and conclusions. Use
knowledge to select strategies you use in the care of
clients
EXPLANATION
COMPONENTS OF CRITICAL THINKING
→ examines the validity of the information and hypothesis;
this leads to a final conclusion that can be implemented.
→ (assessing results, assessing arguments)
→ Nursing Practice Application:
✔ Look at all situations objectively. Use criteria (e.g.
expected outcomes, pain characteristics, learning
objectives) to determine results of nursing actions.
Reflect on your own behavior.
- EVALUATION
“Changes in color,
temperature, muscle strength, use of limbs, body output,
and degrees of nutrition, and hydration.”
(Nightingale,
1992)
HEALTH ASSESSMENT ACROSS TIME
1901
- Journal Records : examples of independent nursing
practice: inspection, palpation, and auscultation have been
recorded
HEALTH ASSESSMENT ACROSS TIME
1901- 1938
- American Journal of Nursing: RNs
doing gastrointestinal palpation, testing cranial nerve
function and examination of children in school systems
HEALTH ASSESSMENT ACROSS TIME
1930s
American Journal of Public Health: routine client
and home inspection by PHN
HEALTH ASSESSMENT ACROSS TIME
1970s
provision of primary health services and expansion
in conduct of health histories and physical/psychological
assessments
HEALTH ASSESSMENT ACROSS TIME
1980s
Acute care nurses employed the “primary care”
method of delivery of care
HEALTH ASSESSMENT ACROSS TIME
1990-Present
Priorities
downsizing, budget cuts, and
restructuring
= 1990s: Critical pathways or care maps
= Demand for documentation emerged
= APNs
= Reimbursement Issues
= Diagnosis-Related Groups (DRGs)
= Health care coverage plans (HMOs)
= Preferred provider organizations (PPOs).
HEALTH ASSESSMENT ACROSS TIME
21st Century
Emerging Roles and Its’ Impact on Health
Assessment
- Forensic
- Acute Care
- Ambulance Care
- Critical Care Outreach
- Ambulatory Care
- Home Health
- Public Health
- School
- Hospice
