NURSING PROCESS Flashcards
a systematic, client-centered method for structuring the delivery of nursing care
Nursing Process
it provides structure for nursing practice,
entails gathering and analyzing data, and help enhance critical thinking
Nursing Process
central figure
patients
what are the 5 purpose of the nursing process?
- to identify client’s health status
- to identify actual or potential health care problems or needs
- to establish plans to meet identify needs
- to deliver specific nursing interventions to meet identified needs
- to evaluate and monitor the patient’s condition
what are the five phases of the nursing process?
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
systematically
gathering data, sorting and organizing the collected data, and documenting
the data in a retrievable format
Assessment
analyzing collected data to
identify the client’s needs or problems
Diagnosis
setting priorities,
establishing goals, identifying desired client outcomes, and determining
specific nursing interventions
Planning
putting the plan of care
into action and performing the planned interventions
Implementation
determining the client’s progress toward attaining the identified outcomes
and monitoring the client’s response to and effectiveness of the selected
nursing interventions.
Evaluation
- a systematic, rational method of planning and providing nursing care
- to identify clients health status and actual or potential problem
-to establish plans to meet the identified needs
Nursing Process
what are the two types of data?
- subjective data
- objective data
it has measurable standards such as signs and vital signs
- (observation)
objective data
it varies from person to person
- symptoms
subjective data
what is the example of constant? (no changes)
Blood type ( A+ , O , O+)
identify the type of phases of the nursing process:
2 days fever
T: 39.5 °C
- flushing of face/redness
- chills
- wound at left foot
Assessment
identify the type of phases of the nursing process:
- thermoregulation as evidence by temperature of 35.5 °C
Diagnosis
identify the type of phases of the nursing process:
after 4 hours of assessment intervention, the temperature will go down to 36.5°C
Planning
identify the type of phases of the nursing process:
INDEPENDENT
- tepid sponge bath
- monitor in 4 hours
DEPENDENT
- Administer paracetamol as ordered by doctor
Implementation
after 4 hours of assessment intervention, the patient’s temperature went down to 38.0°C
Evaluation
it should answer the question who, when, where, what, and why
Specific
it has criteria
Measurable
it has resources
attainable
it is relevant to the patient’s needs and it can be rationale
realistic
specific time frame or timeline
(ex. after the shift, the patient’s temperature will go back to normal)
time bound
it is the state of complete physical, mental, in social well-being and not merely the absence of disease.
Health
- systematic and continuous collection, organization, validation, and documentation
- to establish baseline data
Health Assessment in Nursing
- a continuous process
- specific needs of a person
- how does needs will be addressed
- includes health status
HEALTH ASSESSMENT IN NURSING
What are the components of health assessment in nursing?
health history and physical exam
what is the purpose of a health assessment?
- to collect data about physical, mental, and social well-being of client
- to identify problem in early stages
- to determine the cause and extent of disease
- to evaluate or monitor the changes in client’s health status
- to collect data systematically
- to alleviate the complication
- to determine the nature of treatment required for the client
determine the terminologies:
determination of the nature and extent of disease
diagnosis
determine the terminologies:
chance of recovery from disease ( good or bad)
prognosis
determine the terminologies:
it is the science of the cause of disease
- ______ - kapag hindi alam ang cause or pinagmulan
ETIOLOGY
- idiopathic
objective evidence of the disease (observation)
signs
subjective evidence of disease (patient’s feeling)
symptoms
type of data:
- it is the information that is spontaneously shared with you by the client or is in response to questions that you ask the client
subjective data
type of data:
- your senses
- health care professional gathers during a physical examination and consist of information that can be seen, felt, smelled, or heard by that healthcare professional
objective data
“masakit ang tagiliran ko, parang tinutusok” as verbalized by the client. What type of data is being described?
subjective data
this data should supported by the subjective data
objective data
what are the 5 different types of assessment?
- initial comprehensive assessment
- ongoing or partial assessment
- focus or problem oriented assessment
- emergency assessment
- time lapse assessment
this assessment establish complete database for problem identification reference and future comparison
initial comprehensive assessment
when does initial comprehensive assessment should be performed?
within a specified time after admission to a health care agency
what is the example of an initial comprehensive assessment?
nursing admission assessment
it is the reassessment of baseline data and brief assessment of clients normal body system or holistic health patterns to detect new problem
ongoing or partial assessment
this assessment determines the status of a specific problem in an earlier assessment
focus or problem oriented assessment
this assessment identify the threatening problems
emergency assessment
this assessment compares the client’s current status to baseline data
time lapsed assessment
ongoing or partial assessment
time performed:
whenever the nurse encounter with the client
Focus or problem oriented assessment
Time performed:
ongoing process integrated with nursing care
emergency assessment
time performed:
during any physiological or psychological crisis
time lapse assessment
time performed:
several months
what are the three steps in health assessment?
- collection of subjective data
- collection of objective data
- validation of data
- documentation of data
.
role of nurses in health assessment
nurses relied on their natural senses: the clients face and body
role of nurses in the past
it has technical advancement
role of nurses in the present
READ
PREPARING FOR ASSESSMENT
- review medical record
- keep an open mind and avoid judgment
- educate self about client, medical diagnosis and interventions
- reflect on your own feelings
- organize materials and equipment
it is the increased specialization and diversity of assessment skills for nurses
role of nurses in the future
HEALTH HISTORY GUIDELINES:
- the professional interpersonal and interviewing skills are necessary to obtain a valid nursing health history
Interview
what are the phases of the interview?
- Introductory Phase
- Working Phase
- Summary or closure Phase
phase of interview:
first time meeting with the clients
introductory phase
Phase of interview:
information summarized
summary or closure phase
READ
Non-verbal communication
- appearance
- demeanor
- facial expression
- attitude
- silence
- listening
READ!
TECHNIQUES
- using open ended questions
- using close ended questions
- using laundry list approach to obtain specific answers
- explore all data that deviate from normal deadline
- making observations
- restating or rephrase to reflect or clarify information
- encourage verbalizing and focusing
READ!
COMMUNICATION STYLES TO AVOID:
- excessive or insufficient eye contact
-doing other things while taking the history - biased or leading questions
- relying on memory to recall all the informations or recording all the details, instead of taking down notes
- rushing the client
- reading question from the history form, - distracting attention from the client
