Nursing Process - 1 Flashcards
the process of intentional higher-level thinking to define a client’s problem, examine the evidence-based practice of caring for the client, and make choices in the delivery of care
Critical Thinking
is the application of critical thinking to the clinical situation
Clinical reasoning
Use of Critical Thinking Skills:
Nurses use knowledge from other subjects and fields
Nurses deal with change in stressful environments
Nurses make important decisions
Critical thinking guides nurses in the process of solving problems of patients and the decision-making process with creativity to enhance the effect
Approaches to problem-solving:
- Trial And Error
- Intuition
3. Use of scientific basis - Use of the nursing process
In —, a number of approaches are tried until a solution is found.
The use of this method in nursing care can be dangerous because the client might suffer harm if an approach is inappropriate.
However, nurses often use this in the home setting due to logistics, equipment, and client lifestyle.
- Trial And Error
is a problem-solving approach that relies on a nurse’s inner sense.
It is a legitimate aspect of a nursing judgment in the implementation of care (Wilkinson, 2012).
Clinical judgment in nursing is a decision-making process to ascertain the right nursing action to be implemented at the appropriate time in the client’s care.
2. Intuition
Involves asking questions from resource persons, reading about information and evidence, and figuring out conclusions.
All of these actions are the basis for this method.
3. Use of scientific basis
CRITICAL THINKING ATTITUDES
- Independence
- Fair-mindedness - Insight
- Intellectual humility
- Intellectual courage to challenge status quo/rituals -Integrity
- Perseverance
- Confidence
- Curiosity
It is the systematic and continuous collection, validation, and communication of client data as compared to what is standard/norm.
It includes the client’s perceived needs, health problems, related experiences, health practices, values, and lifestyles.
It is a critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness (ANA,2010)
Nursing Process
Purposes of the nursing process:
- To identify a client’s health status and actual or potential healthcare problems or needs.
- To establish plans to meet the identified needs.
- To deliver specific nursing interventions to meet those needs.
Characteristics of Nursing
- According to Kozier
Cyclic and dynamic
Client-centered
Universally applicable
Focus on problem-solving
Presence of Interpersonal Collaboration
Use of critical thinking
Characteristics of Nursing
- According to Udan
Goal-oriented
Organized
Systematic`
Humanistic plan of care
Efficient and Effective Nursing Care
Characteristics of Nursing
- According to Kozier
Each phase provides input for the next phase
Cyclic and dynamic:
Characteristics of Nursing
- According to Kozier
It is an organized plan of care based on the client’s problems and needs
Client-centered
Characteristics of Nursing
- According to Kozier
It is used as a framework for nursing care.
Universally applicable
Characteristics of Nursing
- According to Kozier
Communicate with client, family, nursing/medical team, community, etc.
Presence of Interpersonal Collaboration
Characteristics of Nursing
- According to Kozier
Important in formulating the plan of care for clients.
Use of critical thinking
Steps of the Nursing Process
ADPIE
is the systematic and continuous collection, organization, validation, and documentation of data (information).
- Nursing Health History taking
- Physical Assessment
- Physician history and physical assessment
- Laboratory Results & other diagnostic test results
ASSESSMENT
Types of assessment
- Initial nursing assessment
2. Problem-focused assessment
3. Emergency assessment: - Time-lapsed reassessment
Types of assessment
Performed within a specified time after admission.
To establish a complete database for problem identification.
- Initial nursing assessment
Types of assessment
During emergency situation identify any life-threatening situations.
Rapid assessment of an individual
3. Emergency assessment:
Types of assessment
To determine the status of a specific problem identified in an earlier assessment.
2. Problem-focused assessment
Types of assessment
Several months after the initial assessment. To compare the client’s current health status with the data previously obtained.
- Time-lapsed reassessment
Steps of assessment
Steps of assessment
- Collection of data
2. Organizing data - Validating data
4. Documenting data
Steps of assessment
It is the process of gathering information on a client’s health status
It includes the health history, physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.
- Collection of data
Types of Data
also referred to as symptoms or covert data, are clear only to the person affected and can be described only by that person.
- Subjective data
Types of Data
- Subjective data
- Objective data
Types of Data
also referred to as signs or overt data, 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.
- Objective data
Sources of Data
Primary
Secondary
Sources of Data
It is the direct source of information.
The client is the primary source of data.
Primary
Sources of Data
All sources other than the client’s Family members, health professionals, records and reports, laboratory and diagnostic results
Secondary
Methods of Data Collection
Observation
Interview
Examination
It is gathering data by using the senses. Vision, Smell, and Hearing are used
Observation
It is a planned communication or a conversation with a purpose.
Interview
is highly structured and directly asks questions. And the nurse controls the interview.
The directive interview
or rapport-building interview and the nurse allows the client to control the interview.
A non-directive interview
Types of interview questions:
- Closed questions (Are you having pain now?)
- Open-ended question (what brought you to the hospital?)
- Neutral questions (how do you feel about that?)
- Leading questions (you are stressed about surgery tomorrow aren’t you?)
Planning the interview and setting:
- Time
- Place
- Seating arrangement
- Distance
- Language
An interview has three major stages:
- The opening or introduction
- The body or development
- The closing
Examination
should be conducted systematically:
Focused
head-to-toe assessment
Cephalocaudal approach
examine all the body system
Body System approach
examine only particular area affected
Review of System approach
Components of a Nursing Health History:
Biographic data
Reason for visit/Chief complaint
History of present Illness
Past Health History
Family History
Review of systems
Lifestyle
Social data
Psychological data
Patterns of healthcare
Components of a Nursing Health History:
Biographic data
Reason for visit/Chief complaint
History of present Illness
Past Health History
Family History
Review of systems
Lifestyle
Social data
Psychological data
Patterns of healthcare
name, address, age, sex, marital status, occupation, religion.
Biographic data
the primary reason why the client seeks consultation or hospitalization.
Reason for visit/Chief complaint
includes usual health status, chronological story, family history, and disability assessment.
History of present Illness
includes all previous immunizations, and experiences with illness.
Past Health History
reveals risk factors for certain disease diseases (Diabetes, hypertension, cancer, mental illness).
Family History
review of all health problems by body systems
Review of systems
includes personal habits, diets, sleep or rest patterns, activities of daily living, recreation, or hobbies.
Lifestyle
include family relationships, ethnic and educational background, economic status, home and neighborhood conditions.
Social data
information about the client’s emotional state.
Psychological data
includes all healthcare resources: hospitals, clinics, health centers, and family doctors.
Patterns of healthcare
The nurse uses a format that organizes the assessment data systematically. This is often referred to as a nursing health history or nursing assessment form.
2. Organizing data
