NURSING PROCESS Flashcards
A systemic, client centered method fro structuring the delivery of nursing care.
A goal oriented method of caring that provides a framework for nursing practice.
Provides a structure for the nursing practice
A framework which nurses use knowledge and a skills to express human caring
NURSING PROCESS
PURPOSES OF NURSING PROCESS
- To identify client’s health status
- To identify actual or potential health care problems or needs.
- To establish plans to meet the identified needs.
- To deliver/execute specific nursing interventions to meet those needs.
PHASES OF THE NURSING PROCESS:
(ADPIE)
1.ASSESSING
2. DIAGNOSING
3.PLANNING
4.IMPLEMENTING
5.EVALUATING
Collecting, organizing, validating, and documenting client’s data.
ASSESSING
ANALYSING AND SYNTHESIZING DATA
DIAGNOSING
DETERMINING HOW TO PREVENT, REDUCE, OR RESOLVE THE IDENTIFIED PRIORITY CLIENT’S PROBLEMS; HOW TO SUPPORT CLIENT’S STRENGTH; AND HOW TO IMPLEMENT NURSING INTERVENTIONS IN AN ORGANIZED, INDIVIDUALIZED AND GOAL-DIRECTED MANNER
PLANNING
CARRYING OUT OR DELEGATING AND DOCUMENTING THE PLANNED NURSING INTERVENSIONS.
IMPLEMENTING
Measuring the degree to which goals/outcomes have been acheived and identifying factors that positively and negatively influence goal achievements.
EVALUATING
CHARACTERISTICS OF THE NURSING PROCESS
1.Systematic
2.cyclic and dynamic nature
3.client-centered
4.focus on problem solving
5.focus on decision making
6.interpersonal and collaborative
7.universally applicable
8. Use of critical thinking
9.outcome oriented
10.proactive
11.evidene-based
A continuous process carried out during all phases of the nursing process. Focuses on client’s responses to a health problem and is therefore client-centered
ASSESSMENT/ASSESSING
TYPES OF ASSESSMENT
1.INITIAL ASSESSMENT / COMPREHENSIVE ASSESSMENT
2. PROBLEM- FOCUSED ASSESSMENT
3.EMERGENCY ASSESSMENT
4.TIME-LAPSED ASSESSMENT
Should include assessment of the physical and psychosocial aspects of the client’s health, the client’s perception of health, the presence of health risk factorsz and the client’s coping patterns
INITIAL / COMPREHENSIVE ASSESSMENT
To determine the status of a specific problem identified in an earlier assessment
PROBLEM-FOCUSED ASSESSMENT
To identify life threatening problems, to identify new or overlooked problems
EMERGENCY ASSESSMENT
To compare the clients current status to baseline data previously obtained
TIME-LAPSED REASSESSMENT
RELATED ACTIVITIES DONE DURING ASSESSMENT:
1.collecting data
2.organizing data
3.validating data
4.documenting data
Process of gathering information about a client’s health status.
Must be systematic and continous.
COLLECTING DATA ( DATA COLLECTION)
All information about a client includes:
A. Health history
B.physical assessment
C.laboratory and diagnostuc tests
D.materials contributed by other health personnel
DATABASE
Gives information (subjective data) on how a health condition came out
HEALTH HISTORY
BASIC COMPONENTS OF HEALTH HISTORY
- Demographic (Biographical Data)
2.Reason/s for seeking care ( chief complaint)
3.present health or history of present illness
Includes the general appearance of the client, height, and weight
GENERAL STATE OF HEALTH
Chronological account of how the chief complaint came out, amplifies the chief complaints and gives a full , clear, chronological acvoubt of how each of the symtopms developed and what events were related to them
HISTORY OF PRESENT ILLNESS (HPI)
Provides information on the patient’s health status from birth to the present. Includes a review of previous illness througout the client’s development , injuries, and hospitalizations, obstetric history( female), surgeries/operations, allergies ,immunizations, and use of medications
PAST MEDICAL/HEALTH HISTORY
Includes the health of the immediate family members and other blood relations, including the agez the cause of death or their present state of health/illness
FAMILY HISTORY
Information about the patient’s lifestyle that can affect health.
SOCIO-ECONOMIC DATA OR SOCIAL HISTORY
This assessment includes a person’s ability to perform instrumental activities of daily living and physical-self maintenance activities
FUNCTIONAL ASSESSMENT
the patient’s subjective response to a series of body system-related questions and
serves as a double-check that vital information is not overlooked
REVIEW OF SYSTEMS
TYPES OF DATA:
1.Subjective
2.Obective
also referred to as symptoms or covert data
o apparent only to the person affected
o can be described or verified only by the person affected
o include sensations, feelings, values, beliefs, attitudes and perception of personal
health status & life situation
o e.g.: pain, itching, health history
SUBJECTIVE
also referred to as signs or overt data
o can be measured or tested against an accepted standard
o can be seen, heard, felt, or smelled
o obtained by observation or PE
o e.g.: color of the skin, characteristic of breath sounds
o During physical examination, the nurse obtains objective data to validate the
subjective data.
o Both subjective and objective data are needed to complete a client’s database
OBJECTIVE DATA
SOURCES OF DATA:
1.Primary - Client/Patient
2. Secodary/Indirect -all sources than client/patient
- best source of data unless he is too ill, young or confused
- Primary data include statements made by the client and objective data that
are directly obtained by the nurse from the client (e.g.: gender)
PRIMARY
- include family members, health professionals, records and reports, laboratory
and diagnostic analysis
SECONDARY
DATA COLLECTION METHODS:
1.observing
2.interviewing /interview
- a conscious, deliberate skill in gathering data by using the senses (vision, smell,
hearing, touch) - results in objective, factual information
OBSERVING/OBSERVATION
a planned communication or a conversation with a
purpose (e.g.: nursing health history
INTERVIEW
APPROACHES TO INTERVIEW
1.Directive Interview
2.Nondirective/Rapport-Building Interview
-highly structured and elicits specific information
- nurse establishes the purpose of the interview and controls the
interview (at the start)
- used to gather or give information when time is limited (e.g.:
emergency situation)
Directive Interview
nurse allows the client to control the purpose, subject matter, and
pacing of the interview
(Rapport is an understanding between two or more people.
NonDirective/Rapport-Building Interview
TYPES OF INTERVIEW QUESTIONS:
1.Closed Questions
2.Open-ended Questions
3.Neutral Questions
4.Leading Questions
used in directive interview
- generally require “yes” or “no” or short factual
answers giving specific information
EXAMPLE: “Have you had surgery in the past year?”
CLOSED QUESTIONS
associated with nondirective interview
- specify broad topics to be discussed and invite longer answers
EXAMPLE: “Can u tell me your smoking habits?” “How do u manage your allergies on a daily basis?”
OPEN-ENDED QUESTIONS
can be answered by the client without direction or pressure from
the nurse, are open-ended and used in nondirective interview
NEUTRAL QUESTIONS
direct the client’s answer
- closed and used in a directive interview
EXAMPLE: “YOU HAVEN’T NOTICED ANY SIGNIFICANT CHANGES IN YOUR HEALTH, HAVE YOU?”
LEADING QUESTIONS
A complete health assessment
Way of examining the state of health of a client
Carried out in an orderly, systematic manner
Involves four basic skills – IPPA
provides objective data that can be used to:
• validate the subjective data obtained
• detect any findings not reported in the history
• obtain information about the individual’s status of health problem.
EXAMINING ( PHYSICAL EXAMINATION OR PHYSICAL ASSESSMENT)