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)
APPROACHES OF PHYSICAL ASSESSMENT
A.Cephalocaudal
B. Body systems approach
UPON ADMISSION ( PHYSICAL ASSESSMENT)
1.perform complete physical examination
2.Screening examination kr review system can be done
DURING OR ON-GOING ASSESSMENT
EXAMINE SPECIFIC BODY AREAS , SYSTEMS OR FUNCTIONS
To conduct a thorough physical assessment, the examiner should assist the client to
assume the various positions necessary for an adequate exposure of the regions and
aspects to be evaluated:
POSITIONING
TYPES OF POSITIONS
1.standing position
2.Supine Position
3. Dorsal Position
4.Lithotomy Position
TECHNIQUES
1.Inspection
2.Palpation
3.Percussion
4.Auscultation
Critical viewing of the patient by using the eyes to assess the general appearance of the
client and the condition of each body part.
The most difficult technique to master because it needs concentrated watching (clinical
and critical viewing).
Should be done thoroughly and systematically
Good lighting and exposure is essential
Each body area is inspected for size, shape, color, position, symmetry and presence of
abnormalities.
Inspection may also include the use of hearing and sense of smell. There are some
abnormalities that may not be recognized by other means.
INSPECTION
WHAT TO INSPECTS
- Body features and symmetry
- General appearance
- Nutritional state – weight
- Hair distribution
- Color and shape
- Posture and gait
- Manner of speaking
- Gross deviation: abnormal contour, visible masses, discoloration and swelling
uses the sense of touch; act of touching a patient in a therapeutic manner to elicit
specific information
PALPATION
considerations in doing palpation:
cut fingernails short (to avoid hurting the patient)
warm hands prior to placing them on the patient (cold hands can tense
patient’s muscles, distorting assessment findings)
encourage patient to continue breathing normally throughout palpation
inform the patient when, where and how the touch will occur (patient is
aware what to expect)
if pain is experienced during palpation, immediately discontinue
palpation
Tools in palpation
examiner’s hand
Dorsum – most sensitive to temperature changes
finger pads are usually used – most sensitive to tactile stimulation
palmar surface of fingertips and finger pads – discriminatory sensation (texture,
presence of fluid, size and consistency of mass)
striking of a body surface, usually with the tip of the finger to elicit sound or vibration
PERCUSSION
-constitute another source of objective data which is important in assessing many health
problems and condition
Using laboratory results
The nurse uses a written format that organizes the assessment data systematically.
This is often referred to as a nursing health history, nursing assessment, or nursing database form
ORGANIZING DATA
Models/Frameworks Used as Bases in Organizing Data (Models of Assessment)
A. Gordon’s Functional Health Pattern
B. Maslow’s Hierarchy of Needs
C. Review of Systems
D. Virginia Henderson’s ADL Components of Nursing Care
E. Abdellah’s 21 Activities of Daily Living
describes client’s perceived patterns of health & well- being & how their health is managed
Health-Perception-Health Management Pattern
describes consumption relative to metabolic need & nutrient
supply; includes pattern of food & fluid consumption, condition of skin, hair, nails & mucous
membranes, body temperature, height & weight.
Nutritional-Metabolic Pattern
describes patterns of excretory function (bowel, bladder & skin); includes
individual’s daily pattern, changes or disturbances & methods used to control excretion
ELIMINATION PATTERN
describes pattern of exercise, activity, leisure, & recreation;
includes activities of daily living, type and quality of exercise & factors affecting activity pattern
(such as neuromuscular, respiratory, & circulatory).
ACTIVITITY-EXERCISE PATTERN
describes pattern of sleep, rest & relaxation and any aids to change those patterns.
SLEEP-REST PATTERN
describes sensory-perceptual and cognitive patterns; includes
adequacy of sensory modes (vision, hearing, touch, taste and smell), reports of pain
perception, and cognitive functional abilities.
Cognitive-Perceptual Pattern
describes how persons perceive themselves; their
capabilities, body image and feelings.
Role Relationship Pattern
describes patterns of satisfaction or dissatisfaction with
sexuality; includes female’s reproductive state
Sexuality-Reproductive Pattern
describes general coping pattern and effectiveness of coping skills in stress tolerance.
COPING-STRESS TOLERANCE PATTERN
describes patterns of values, goals, or beliefs (including spiritual beliefs)
that guide lifestyle choices and decisions
VALUE-BELIEF PATTERN
Abraham Maslow’s hierarchy of needs proposes that an individual’s basic physiological needs
must be met before progressing to higher-level needs
MASLOW’S HIERARCHY OF NEEDS
- focus on achievement of the basic needs of a client
PHYSIOLOGIC NEEDS (BASIC SURVIVAL NEEDS)
- include both physical (e.g. protection from bodily harm) and psychological (e.g. security and stability)
SAFETY AND SECURITY NEEDS
includes the need to be a part of a group and to feel accepted by others
NEED FOR LOVE AND BELONGINESS
one’s judgment of one’s own worth
- derived from self and others
- its foundation is established during early life experiences
- may change from day to day or moment to moment
The level of self-esteem is dependent upon the self-perception of adequate
performance of his various social roles. Role refers to a set of expected
behaviors determined by familial, cultural, and social norms.
SELF-STEEM NEEDS
SELF-LACKING STRESSORS
• Lacking positive feedback from significant others
• Repeated failures
• Unrealistic expectations
• Abusive relationships
• Loss of financial securit
- the need to function at one’s optimal level, and to be personally fulfilled
SELF-ACTUALIZATION NEEDS
organizes data collection according to the organ and tissue
function in various body systems
- yields subjective data
- sometimes referred to as the medical mode
REVIEW OF SYSTEMS
- Breathe normally.
- Eat & drink adequately.
11 - Eliminate body waste.
- Move & maintain desirable posture.
- Sleep & rest.
- Select suitable clothing.
- Maintain body temperature.
- Keep the body clean and well groomed to protect the integuments.
- Avoid dangers in the environment and avoid injuring others.
- Communicate with others.
- Worship according to one’s faith.
- Work in such a way that there is a sense of accomplishment.
- Play or participate in various forms of recreation.
- Learn, discover or satisfy the curiosity that lead to normal development & health &
use available health facilities
HERDERSON’S 14 FUNDAMENTAL NEEDS
- To maintain good hygiene & physical comfort
- To achieve optimal activity, exercise, rest & sleep
- To prevent accident, injury or other trauma & prevent the spread of infection
- To maintain good body mechanics & prevent & correct deformities
- To facilitate supply of oxygen to all body cells
- To facilitate the maintenance of nutrition to all body cells
- To facilitate the maintenance of elimination
- To facilitate the maintenance of fluid & electrolyte balance
- To recognize the physiological responses of the body to disease conditionspathological, physiological & compensatory
- To facilitate the maintenance of regulatory mechanics and functions
- To facilitate the maintenance of sensory functions
- To identify & accept positive & negative expressions, feelings & reactions
- To identify & accept the interrelatedness of emotions& organic illness
- To facilitate the maintenance of effective verbal & non verbal communication
- To facilitate the development of productive interpersonal relationships
- To facilitate progress toward achievement of personal spiritual goals
- To create &/or maintain a therapeutic environment
- To facilitate awareness of the self as an individual with varying physical and
emotional & development needs - To accept the possible optimum goals in light of limitations- physical & emotional
- To use community resources as an aid in resolving problems arising from illness
- To understand the role of social problems as influencing factors in the cause of
illness
ABDELLAH’S 21 ACTIVITIES OF DAILY LIVING
- act of double-checking or verifying data to confirm that it is accurate and factual
- The nurse validates data when there are discrepancies between data obtained in the nursing
interview and the physical examination, or when the client’s statements differ at different times
in the assessment
VALIDATING DATA
Revording of client’s data in a factual manner
DOCUMENTING DATA
- Nurses use critical-thinking skills to interpret assessment data and identify client
strengths and problems. - Pivotal step in the nursing process.
- Activities preceding this phase are directed toward formulating the nursing
diagnosis; the care planning activities following this phase are based on the
nursing diagnoses. - Process of data analysis and problem identification.
- A form of decision making that the nurse uses to arrive at judgments and
conclusion about patient’s responses to actual or potential health problems
DIAGNOSING
To define, refine and promote taxonomy of Nursing Diagnosis terminology of general use to
professional nurses.
- Taxonomy was revised and is now referred as taxonomy II
NANDA (North American Nursing Diagnosis Association)
is a statement or conclusion regarding the nature of a phenomenon
DIAGNOSIS
standardized NANDA names for the diagnoses.
DIAGNOSTIC LABELS
TYPES OF NURSING DIAGNOSES
1.Actual nursjng diagnosis
2.Risk Nursing diagnosis
3.Wellness Diagnosis
4.Possible nursing Diagnosis
5.Syndrome Nursing Diagnosis
- client problem that is present at the time of the nursing assessment
- represent a problem that has been validated by the presence of major defining characteristics
- based on the presence of associated signs and symptoms
Examples: Ineffective Breathing Pattern
Anxiety
Ineffective airway clearance related to excessive and tenacious
secretions
Imbalanced nutrition: more than body requirements related to excessive
intake in relation to metabolic needs
ACTUAL NURSING DIAGNOSIS
clinical judgment that a problem does not exist, but the presence of risk factors
indicates that a problem is likely to develop unless nurses intervene
Examples: Risk for Infection
Risk for impaired skin integrity related to immobility secondary to
fractured hip.
Risk nursing diagnosis
describes human responses to levels of wellness in an individual, family or community that
have readiness for enhancement
- two cues must be present for a valid wellness diagnosis:
a. a desire for a higher level wellness
b. an effective present status or function
Examples: Readiness for Enhanced Spiritual Well-being
Readiness for Enhanced Family Coping
Readiness for Enhanced Health Maintenance
Readiness for Enhanced Parenting
Readiness for Enhanced Self-Esteem
WELLNESS DIAGNOSIS
- evidence about a problem is incomplete or unclear
- requires more data either to support or to refute
- statement describing a suspected problem for w/c additional data are needed
Examples: Possible Social Isolation r/t unknown etiology
Possible self-care deficit related to impaired ability to use left hand
secondary to presence of intravenous therapy
POSSIBLE NURSING DIAGNOSIS
- comprises a cluster of actual or risk nursing diagnoses that are predicted to be
present because of a certain event or situation
Examples: Rape Trauma Syndrome
Post Trauma Syndrome
Risk for Disuse Syndrom
SYNDROME NURSING DIAGNOSIS
COMPONENTS OF NURSING DIAGNOSIS
1.Problem
2.Etiology
3.Defining Characters
Problem statement – describes the client’s health problem/status or response for w/c nursing
therapy is given
- its purpose is to direct the formation of client goals & desired outcomes & it may suggest some
nursing interventions
PROBLEM (DIAGNOSTIC LABEL ) AND DEFINITION
– are words that have been added to some NANDA labels to give additional meaning to the diagnostic statement.
QUALIFIERS
identifies one or more probable causes of a health problem, gives direction to the required
nursing therapy & enables the nurse to individualize the client’s care
Etiology (related factors & risk factors)
- are clusters of signs & symptoms that indicate the presence of a particular diagnostic label
- for actual nursing diagnosis, the defining characteristics are the client’s signs & symptoms
- for risk nursing diagnosis no subjective & objective signs are presen
DEFINING CHARACTERISTICS
are multidisciplinary problems w/ diagnostic label potential for complication
- type of potential problem that nurses manage using both independent & physician-prescribed
interventions
COLLABORATIVE PROBLEMS
– identify significant cues
Comparing data with standards
- Process of determining the relatedness of facts and determining
whether any patterns are present, whether the data represents isolated
incidents and the data are significant
Clustering cues
Skillful assessment minimizes gaps and inconsistencies of data
Identifying gaps and inconsistencies of data
- identify problems that support tentative actual, risk and possible
diagnoses
Identifying health problems, risks, and strengths
most nursing diagnoses are written as two-part or three part statements
Formulating diagnostic statements
basic two-part statement
1. Problem (P) – statement of the client’s response
2. Etiology (E) – factors contributing to or probable causes of the
responses
- joined by related to (r/t) – implies a relationship
True
basic three-part statement
- is called PES format
- applicable for actual nursing diagnosis
1. Problem (P) – statement of the client’s response
2. Etiology (E) – factors contributing to or probable causes of the
responses
3. Signs and symptoms (S) – defining characteristics manifested by the
Clien
True
one-part statement
- consist of a NANDA label only
- some diagnostic statements, such as wellness diagnoses & syndrome
diagnoses
True
The Planning Process
- setting priorities
- establishing client goals/desired outcomes
- selecting nursing interventions/planning nursing interventions
- writing individualized nursing interventions on care plan
the process of establishing a preferential sequence for addressing nursing diagnoses and
interventions
During the process, the nurse and the patient, whenever possible, determine which problems
identified during the assessment phase are in need of immediate attention and which
problems may be dealt with at a later time.
17
Nurses can group nursing diagnoses as having high, medium, or low priority instead of rankordering diagnoses
SETTING PRIORITIES
life- threatening problems, i.e. loss of respiratory or cardiac function
High priority problems
health- threatening problems, i.e. acute illness and decreased coping
ability because they may result in delayed development or cause
destructive physical or emotional change
MEDIUM PRIORITY
arise from normal developmental needs or that requires only minimal
nursing support
Priorities change as the client’s responses, problems, and therapies change
LOW PRIORITY
EVALUATION STATEMENT CONSISTS OF 2 PARTS WHICH IS?
CONCLUSION & SUPPORTING DATA
Who, How & When of Evaluation
• Recipient of care & care giver
• Terminal behavior demonstrated by the patient
• Conditions under w/c the behavior is expected to occur
• Criterion for determining acceptable performanc
a planned, ongoing, purposeful activity
determining the client’s response to nursing interventions using the goals of care as criteria whether
they were met, partially met, or not met
goal met – the client’s response is the same as the desired
outcome
goal partially met – either the short term goal was achieved but the
long term goal was not, or the desired outcome
was only partially attained
shows the extent of progress toward goal achievement and enables the nurse to correct any
deficiencies and modify the care plan as needed
EVALUATION
