NURSING PROCESS Flashcards
a systematic rationalized method
of planning & providing individualized nursing care.
NURSING PROCESS
CLIENT MAY BE;
- An individual
- Family
- Community
- Group
Data from each phase provide input to next phase
CYCLIC & DYNAMIC
Plan of care is according to client’s problems/ needs.
CLIENT CENTERED
Communicating with clients, significant others, and support groups.
- Collaborating with healthcare team
Interpersonal and Collaborative
- Identifying possible solutions and choosing the best one to implement.
- Approaches include trial and error,intuition, and research.
- Directed towards client’s responses to real
or potential disease/ illness.
Focus on Problem Solving and Decision Making
Nursing process is used as a framework for nursing care for all types of settings with clients from all age groups.
Universal Applicability
- Making clinical judgements based on knowledge base in nursing and clinical experience.
Use of Critical Thinking and Clinical Reasoning
Assessing all viewpoints and
avoiding biases or prejudice.
FAIR MINDEDNESS
Thinking for yourself and making
your own judgements.
INDEPENCE
Awareness of the limits of
one’s own knowledge
INTELLECTUAL HUMILITY
Examining one’s own
biases or customs; Self-awareness.
INSIGHT & EGOCENTRICITY
Being able to readily admit and
evaluate inconsistencies with and between one’s
belief and those of another
INTEGRITY
Courage to recognize that beliefs
are sometime false or misleading. Courage to be
open to new thinking.
Intellectual Courage to Challenge Status Quo and Rituals
in the reasoning
process and examining emotion ladenarguments. Anchored on the belief that wellreasoned thinking will lead to trustworthy
conclusions.
CONFIDENCE
Lifelong determination in finding
effective solutions to client and nursing problems
PERSEVERANCE
Examining traditions and exploring new options
CURIOSITY
Determining which is most
relevant and most important.
SETTING PRIORITIES
Explanations of priority
setting and nursing interventions.
Acts as a check for potential errors, justifies nursing actions and contributes to client safety.
DEVELOPING RATIONALE
- Understanding relevant
medical and nursing information and translate knowledge into plan of care.
Learning How to Act
Ability to recognize changes in client’s condition over time
Clinical Reasoning in Transition
Ability to detect changes, identify change in priorities, adjust nursing care and alert primary
care provider when appropriate.
Responding to Changesin the Client’s Condition
Identifying factors that improved
client care and those thaT required changing or
elimination.
- Thinking back / Reviewing interventions implemented and whether they were effective.
REFLECTION
Gather information about the
patient’s condition.
ASSESSMENT
Identify the patient’s problems.
DIAGNOSIS
Set goals of care and desired
outcomes and identify appropriate nursing
actions
PLANNING
Perform the nursing actions
identified in planning
IMPLEMENTATION
Determine if goals and expected
outcomes are achieved.
EVALUATION
TYPES OF ASSESSMENTS:
- Initial Assessment
- Problem-Focused Assessment
- Emergency Assessment
- Time-Lapsed Assessment
Performed within a specified time after admission to a health care
agency
Purpose: to establish a complete
database problem identification, reference and future comparison
INITIAL ASSESSMENT
Ongoing process integrated with nursing care.
Purpose: to determine the status of a specific problem identified in an earlier assessment
PROBLEM - FOCUSED ASSESSMENT
Done during any physiological or psychological crisis of the client.
Purpose: to identify life-threatening problems / To identify new or overlooked problems
EMERGENCY ASSESSMENT
– Done several months
after initial assessment.
Purpose: to compare the client’s current status to baseline data previously obtained
TIME LAPSED ASSESSMENT
is the process of gathering
information about a client’s health status
DATA COLLECTION
contains all the information of the
client. Includes nursing health history, physical assessment, primary care provider’s history and physical examination, results of laboratory and diagnostic tests and materials contributed by
other health personnel.
- Client data should include past
history and current problems.
DATABASE
2 TYPES OF DATA
SUBJECTIVE & OBJECTIVE
o Symptoms or covert data (unseen)
o Can be described or verified only by that person.
o Sensations, feelings, values, beliefs, attitudes, perceptions of personal health status and life situation
SUBJECTIVE DATA
o Signs or overt data (seen)
o Detectable by an observer or can be measured or tested against an accepted standard.
o Obtained by observation or physical examination.
OBJECTIVE DATA
Occurs whenever the nurse is in
contact with the client or support persons.
OBSERVING
Used mainly when taking the
nursing health history.
INTERVIEWING
– a planned communication; a
conversation with a purpose
INTERVIEW
- the nurse asks the
client
FOCUSED INTERVIEW
- Highly structured and elicits specific information
- The nurse establishes the purpose of the interview and controls the interview
- Client may have limited opportunity to ask questions or discuss concerns
- Usually used when time is limited (e.g. emergency situation)
DIRECTIVE INTERVIEW
- Also known as rapport-building
interview - Allows the client to control the purpose, subject matter and pacing
NON - DIRECTIVE INTERVIEW
-Used in directive interview
-Yes or No Questions
-What, When, Where, Who, Do, Did, Does, Is, Are, Was, Were
questions
-Often used when information is needed quickly
CLOSED QUESTION
-Used in non-directive interview\
-Invite clients to discover, explore, elaborate, clarify, or
illustrate their thoughts
-What and How
-Gives clients freedom to divulge only the information they are
ready to disclose
OPEN ENDED QUESTION
– Closed. Directs client’s answer and gives less opportunity to decide whether the answer is true or not. May create problems if client gives inaccurate answers to please the nurse.
LEADING
questions that client can answer
without pressure. Open-ended and nondirective.
NEUTRAL QUESTION
– Client communicates what they
think, feel, know, and perceive in response to questions from the nurse.
BODY
– Establish rapport and orient the
purpose and flow of interview.
OPENING
Offer to answer questions.
Conclude and provide the summary to verify accuracy and agreement. Thank the client and
express concern for their welfare. Plan the next
meeting ahead.
CLOSING
Major method used in physical
examination or physical assessment.
EXAMINING
data collection that uses
observation to detect health problems
SYSTEMATIC
Techniques used in examination:
▪ I
▪ A
▪ P
▪ P
▪ INSPECTION
▪ AUSCULATION
▪ PALPATION
▪ PERCUSSION
