LESSON 1 - BEGINNING THE ASSESSMENT Flashcards
A systematic, rational method of planning and providing individualized nursing care
NURSING PROCESS
3 Purpose of Nursing Process:
- Identify a client health status and actual or potential health care problems and needs.
- Establish plans to meet the identifying needs.
- Deliver specific nursing intervention to meet needs.
5 Characteristic of nursing process:
•planned.
•universally applicable.
•goal directed.
•cyclic and dynamic.
•client centered.
Benefits of Nursing Process:
•Provides an orderly & systematic method for planning & providing care
•Enhances nursing efficiency by standardizing nursing practice
•Facilitates documentation of care
•Provides a unity of language for the nursing profession
•Stresses the independent function of nurses
•Increases care quality through the use of deliberate actions
The Nursing Process consist of a series of five component or phases which are:
1- Assessing.
2- Diagnosis.
3- Planning.
4- Implementing.
5- Evaluating.
Is a systematic and continuous collection, organization, validation and documentation of data.
ASSESSMENT
Nursing ______ focus upon client’s responses to a health problem.
ASSESSMENT
The assessment process involve four closely activities which are:
I- Collecting data.
II- Organizing data.
III- Validating data.
IV- Documenting data.
Is the process of gathering information about clients, and health status.
COLLECTING DATA
these data that can be described or verified only by that person.
e.g itching, pain, feelings, stress.
Subjective data (symptoms)
obtained through OBSERVATION and are verifiable and that can be seen heard, felt, or smelled, by observation and physical examination.
e.g discoloration, lungs sounds, vomited 100ml.
Objective data (signs)
4 Sources of data:
a- client.
b- Health care professionals.
c- Support people
d- Client records.
a Data collection method where it gathers data by using the five senses.
Observing
in doing this, before you begin, you’ll need to create an environment in which the patient feels comfortable, establish rapport and explain what you’ll cover in the ________.
Interviewing
to make the most of your patient interview, before you begin, you’ll need to ________
- create an environment in which the patient feels comfortable
- establish rapport
- explain what you’ll cover in the interview.
The things to consider to create the proper environment are:
- Settling in
- Watch what you say
- Communicate Effectively
Settling in covers:
- choose a quite, private, well-lit interview setting
- make sure that the patient is comfortable
- introduce yourself and explain the purpose of the health history and assessment
- reassure the patient that everything he says will be kept confidential
- tell the patient how long the interview
Watch what you say means to:
- assess the patient to see if language barriers exist
- speak slowly and clearly
- address the patient by a formal name
Realize that you and the patient communicate nonverbally as well as verbally. Being aware of these two forms of communication will aid you in the interview process.
Communicate Effectively
2 communication strategies
a. Nonverbal communication strategies
b. Verbal communication strategies
5 Nonverbal communication strategies
➢Listen attentively and make eye contact frequently
➢Use reassuring gestures (nodding)
➢Watch for nonverbal cues that indicate the patient is uncomfortable
➢Be aware of your nonverbal behaviors
➢Observe the patient closely to see if he understands each question
It range from alternating between open-ended and closed-ended questions to employing such techniques
Verbal communication strategies
it is a way of encouraging the patient to continue talking, and also gives you a chance to assess his ability to organize thoughts.
silence
using such phrases as “please continue”, “go on”, and even “uh-huh” encourages the patient to continue with his story.
Facilitation
it helps ensure that you and the patient are on the same track. For example, you might say, “If I understand you correctly, you said..”
Confirmation
it is repeating something that the patient has just said to help you obtain more specific information
Reflection
when information is vague and confusing, use this technique. For example, if your patient says, “I can’t stand this”, you might respond, “what can’t you stand?”
Clarification
this technique ensures that the data you’ve collected are accurate and complete. It signals that the interview is about to end.
summary
this gives the patient the opportunity to gather his thoughts and make any pertinent final statements. You can do this by saying, “I think I have all the information I need now. Is there anything you would like to add?”
Conclusion
A complete health history requires information from each of the following categories
Reviewing General Health
this includes the name, address, telephone number, birth date, age, marital status, religion and nationality.
Biographic data
try to pinpoint why the patient is seeking health care.
Chief complaint
ask the patient about past and current medical problems, such as hypertension, diabetes and back pain.
Medical history
questioning the patient about his family’s health is a good way to uncover his risk of having certain diseases.
Family history
find out how the patient feels about himself, his place in society, and his relationships with others. Ask about his education, economic status, and responsibilities.
Psychosocial history
find out what’s normal for the patient by asking him to describe his typical day. Ask about his diet and elimination, exercise and sleep, work and leisure, use of alcohol, tobacco and other drugs, religious observances.
Activities of daily living
Factors for Assessment
P- Palliative factors
Provocative factors
Q- Quality
R- Radiation
S- Severity
T- Temporal factors
‘What makes it better?’ refers to what factor of assessment ?
Palliative factors
“What makes it worse?’ refers to what factor of assessment ?
Provocative factors
‘What exactly is it like?” refers to what factor of assessment ?
Quality
‘Does it spread anywhere?’ refers to what factor of assessment ?
Radiation
‘How severe is it?’ / ‘How much does it affect your life?’ refers to what factor of assessment ?
Severity
‘Is it there all the time or does it come and go?’ refers to what factor of assessment ?
Temporal factors
is a clinical judgment about individual, family or community responses to actual and potential health problems/life processes.
Nursing Diagnosis
Types of nursing diagnosis:
1- An actual diagnosis
2- A risk nursing diagnosis
is a client problem that is present at the time of nursing assessment, and is based on the presence of associated signs and symptoms.
Actual Diagnosis
is a clinical judgment that a problem does not exit, but the presence of risk factors indicate that a problem is likely to develop unless nurses intervention.
Risk Nursing Diagnosis
impaired mobility is an example of _____
actual diagnosis
risk for infection is an example of _____
Risk Nursing Diagnosis
There are words that have been added to some NANDA label to give additional meaning
Problem: ( diagnostic label )
identifies one or more probable causes of the health problem.
Etiology (related factor and risk factor)
Are cluster of sign and symptoms that indicate the presence of a particular diagnostic label.
Defining characteristics
3 Nursing Diagnosis process:
1- Analyzing data.
2- Identifying health problem, risks and strengths.
3- Formulating diagnostic statement.
Ineffective breathing pattern R/T decreased lung expansion AEB dyspnea is an example of:
Nursing Diagnosis
Disturbed body image R/T amputation AEB patient’s verbalization “nahuya ko makita sang tawo nga utod tiil ko” id an example of:
Nursing Diagnosis
Risk for electrolyte imbalance R/T purging is an example of:
Nursing Diagnosis
words that have been added to some NANDA label to give additional meaning are:
altered , impaired , decrease, ineffective, acute , chronic, Knowledge deficit. Ineffective breathing pattern
is a deliberative, systematic phase of nursing process that involve decision making and problem solving
Planning
Types of planning:
1- Initial planning
2- Ongoing planning
3- Discharge planning
The process of anticipating and planning for needs after discharge.
Discharge planning
Is done by all nurses who work with the client.
Ongoing planning
It is the beginning of shift as the nurse plans the care to be given that day.
Ongoing Planning
the nurse who performs the admission assessment usually develops the initial comprehensive plan of care.
Initial Planning
4 Planning Process:
1- Setting priorities.
2- Establishing client goals/desired out comes.
3- Selecting nursing strategies.
4- Writing nursing orders.
Selecting nursing intervention and activities are actions that nurse performs to a achieve client goals.
Implementing
The specific strategies chosen should focus on eliminating or reducing the etiology.
Implementing/Intervention
Types of Nursing Intervention:
1- Independent intervention
2- Dependent intervention
3- Collaborative intervention
are those activities that nurses are licensed to initiate on the basis of their knowledge and skills.
Independent intervention
are activities carried out under the physician orders.
Dependent intervention
are actions the nurse carries out in collaboration with other health team member.
Collaborative intervention
Is the phase in which the nurse puts the nursing care plan into action.
Implementing
Process of implementing:
1- Reassessing the client.
2- Determining the nurse need for assistance.
3- Implementing the nursing orders (strategies).
4- Delegating and Supervising.
5- Communicating the nursing actions.
Is to judge or to appraise.
Evaluating
______ is a planned, ongoing, purposeful activity in which clients and health care professionals determine:
- The clients progress toward goals an achievement.
- The effectiveness of the nursing care plan.
Evaluating
Process of evaluating client responses:
1- Identify the desired out comes.
2- Collecting data related to desired out comes.
3- Compare the data with desired out comes
4- Relate nursing actions to client goals/desired outcomes.
5- Draw conclusions about problem status.
6- Continue to modify or terminate the clients care plan.
