1. Primary → client 2. Secondary → family, support persons, other health professionas, medical 3. Records and Reports, Laboratory and Diagnostic, Relevant literature

HA Flashcards by Hanz Myko C. DIDULO

→ The term nursing process were used by

Hall (1955), Johnson
(1959), Orlando (1961), Wiedenbach ( 1963), ANA (1973)

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a systematic; rational method of planning and providing
individualized nursing care.

NURSING PROCESS

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NURSING PROCESS
organized, systematic, goal oriented, humanistic care BY

(Lydia
Hall)

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→ provides legal framework for nursing practice

NURSING PROCESS

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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

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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

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→ discipline-specific

CRITICAL THINKING

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→ reflective reasoning process

CRITICAL THINKING

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→ PURPOSE:
✔ Guides a nurse in generating, implementing, and
evaluating approaches for dealing with client care and
professional concerns.

CRITICAL THINKING

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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

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→ comprehensive assessment of one’s health status

HEALTH ASSESSMENT

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→ PRIMARY COMPONENTS: HEALTH ASSESSMENT

✔ Nursing Health History
✔ Physical Assessment

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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.

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→ systematic and continuous collection, organization,
validation, and documentation of data

ASSESSMENT

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→ systematic and continuous collection, organization,
validation, and documentation of data

ASSESSMENT

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→ a continuous process carried out during all phases of the
nursing process

ASSESSMENT

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→ all phases of the nursing process depend on the accurate and
complete collection of data

ASSESSMENT

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ASSESSMENT
→ PURPOSE:

✔ establish a database

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ASSESSMENT: ACTIVITIES

Collecting Data
Organizing Data
Validating Data
Documenting Data

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TYPES OF DATA:

A. Subjective data (symptoms)
→ itching, pain, and feelings of worry.
B. Objective data (signs)
→ BP 120/80, reddish urine.

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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

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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

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SOURCES OF DATA:

Primary
→ client
Secondary
→ family, support persons, other health professionas,
medical
Records and Reports, Laboratory and Diagnostic,
Relevant literature

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DATA COLLECTION METHODS

 Observation - using senses
 Interview - planned communication or a
conversation

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→ act of “double-checking” or verifying data to confirm that it is accurate and factual

3. 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

1. Initial Comprehensive Assessment 2. Ongoing or Partial Assessment 3. Focused or Problem Oriented Assessment 4. 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:

2. 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

1. FUNCTIONAL HEALTH FRAMEWORK

TYPES OF FRAMEWORKS → Data collection in terms of Gordon’s 11 Functional Health Patterns

1. FUNCTIONAL HEALTH FRAMEWORK

→ System data in an organized manner: head to toe

2. CEPHALOCAUDAL FRAMEWORK

GORDON’S 11 Functional Areas:

1. Health-perception-health management 2. Nutrition-metabolic 3. Activity-exercise 4. Elimination 5. Sleep-rest 6. Cognitive –perceptual 7. Self-perception-self-concept 8. Roles-relationships 9. Sexuality-reproduction 10. Coping-stress tolerance 11. Values-beliefs

→ Used to improve efficiency and expedite the actual physical examination

2. 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.

5. 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

1. Forensic 2. Acute Care 3. Ambulance Care 4. Critical Care Outreach 5. Ambulatory Care 6. Home Health 7. Public Health 8. School 9. Hospice