nursing process Flashcards
is a systematic, deliberative and interactive process by which nurses use critical thinking to collect, validate, analyze and synthesize the collected information in order to make judgement about the
health status and life processes of individuals,
families and communities.
HEALTH ASSESSMENT
- a framework for providing QUALITY nursing care.
- systematic, rational method of
planning and providing individualized nursing care.
Nursing process
Continuously changing
Dynamic
Regularly repeated event or sequence of events
Cyclic
5 steps of nursing process
- assessment
- diagnosis
- planning
- implementation
- evaluation
Focus is client’s problems
Client centered
—parallel to but separate from medical model (used by physicians)
Adaptation of Problem Solving and Systems Theory
—involved in every phase of the nursing process
Decision-making
—requires the nurse to communicate directly and consistently with clients and families to meet their needs
Interpersonal and Collaborative
—used as a frame work of nursing care in ALL types of health care settings, with clients of ALL age groups.
Universal applicability
—reasonable reflective thinking that is focused on deciding what to believe ordo(Ennis,1987).
Critical thinking
—utilize clinical reasoning throughout the delivery of nursing care. The nurse determines whether the outcome of care was appropriate.
Clinical reasoning
NCP - NURSING CARE PLAN
ASSESSMENT
DIAGNOSIS
INFERENCE
PLANNING
IMPLEMENTATION
RATIONALE
EVALUATION
a systematic, dynamic way to collect and analyze data about a client.
* the first step in delivering nursing care.
* Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well
ASSESSMENT
TYPES OF ASSESSMENT
- INITIAL ASSESSMENT
- PROBLEM-FOCUSED ASSESSMENT
- EMERGENCY ASSESSMENT
- TIME-LAPSED ASSESSMENT
TIME PERFORMED: Performed within specified time after admission to a health care facility
PURPOSE: To establish a complete database for problem identification, reference, and future comparison.
EXAMPLE: Nursing Admission Assessment
INITIAL ASSESSMENT
TIME PERFORMED: Ongoing process integrated with nursing care
PURPOSE: To determine the status of a specific problem identified in an earlier assessment
EXAMPLE: Hourly assessment of client’s fluid intake and output in an ICU
PROBLEM-FOCUSED ASSESSMENT
TIME PERFORMED: During any physiological or psychological crisis of the client
PURPOSE: To identify life-threatening problems.
EXAMPLE: Rapid assessment of an individual’s airway, breathing status, and circulation during a cardiac arrest.
EMERGENCY ASSESSMENT
TIME PERFORMED: Several months after initial assessment
PURPOSE: To compare the client’s current status to baseline data previously obtained.
EXAMPLE: Reassessment of a client’s functional health patterns in a home care or outpatient setting or, in a hospital, at shift change
TIME-LAPSED ASSESSMENT
Steps of Health Assessment
The assessment phase of the nursing process has four major steps:
- Collection of subjective data
- Collection of objective data
- Validation of data
- Documentation of data
is the process of gathering information regarding a client’s health status. The process must be systematic and continuous in collecting data to prevent the omission of important information concerning the client.
COLLECTING data
- Client’s name, address, age, sex, marital status, occupation, religious preference, health car financing, and usual source of medical care.
BIOGRAPHIC DATA
- Reason for seeking medical care
- E.g. What is troubling you?/ What brings you to the hospital?
- *The chief complaint should be recorded in the client’s own words.
CHIEF COMPLAINT OR REASON FOR VISIT
- When the symptoms started
- Whether the onset of symptoms was sudden or gradual
- How often the problem occurs
- Exact location of the distress
- Character of the complaint (e.g. intensity of pain or quality of sputum, emesis, or discharge)
- Activity in which the client was involved when the problem occurred
- Factors that aggravate or alleviate the problem
- *COLDSPA method of questioning
HISTORY OF PRESENT ILLNESS
- Illnesses (such as chickenpox, mumps, measles, streptococcal infections etc.)
- Immunizations
- Allergies (drugs, animals, insects, environmental agents)
- Accidents and injuries ( How, when, where the incident occurred, type of injury, treatment received, and any complications)
- Hospitalization for serious illnesses ( reasons for the hospitalization, dates, surgery performed, course of recovery, and any complications)
- Medications ( all currently used prescription, over-the-counter meds, vitamins, and herbal supplements)
PAST HISTORY
- Personal Habits ( the amount, frequency, and duration of substance use (tobacco, alcohol, coffee, cola, tea, illegal or recreational drugs)
- Diet (Description of a typical diet on a normal day or any special diet, number of meals and snacks per day, who cooks and shop for food, ethnic food patterns, and allergies)
- Sleep patterns (usual daily sleep/ wake times, difficulties sleeping, and remedies used for difficulties)
- ADL- Activities of Daily Living (any difficulties experienced in the basic activities of eating, grooming, dressing, elimination, and locomotion)
- Recreation/ hobbies (exercise activity and tolerance, hobbies and other interests, and vacations)
LIFESTYLE
- Ethnic Affiliation( health customs and beliefs; cultural practices that may affect health care and recovery)
- Educational history (data about the client’s highest level of education attained)
- Occupational history (current employment status, the number of days missed from work because of illness, any history of accidents on the job, any occupational hazards with a potential for future disease or accident, and the client’s overall satisfaction with the work)
- Economic status(info. About how the client is paying for medical care)
- Home & Neighborhood conditions (home safety measures and adjustments in physical facilities that may be required to help the client manage a physical disability, activity intolerance, and ADL)
SOCIAL DATA
- Major stressors experienced and the client’s perception of them
- Usual Coping pattern for a serious problem or a high level of stress.
- Communication style: (ability to verbalize appropriate emotion, nonverbal communication- such as eye movement, gestures, use of touch, and posture, interactions with support persons; and the congruence of nonverbal behavior and verbal expression)
PSYCHOLOGICAL DATA
- All health care resources the client is currently using and has used in the past. These include the
primary care provider, specialists (e.g. ophthalmologist, or gynecologist), folk practitioners (e.g. herbalist or curandero), health clinic or health center
PATTERNS OF HEALTH CARE
-involve covert information
, such as feelings, perceptions, thoughts, sensations, or concerns that are shared by the patient and can be verified only by the patient, such as nausea, pain, numbness, pruritus, attitudes, beliefs, values, and perceptions of the health concern and life events
Subjective data
- are overt, measurable, tangible data collected via the senses, such as sight touch, smell, or hearing, and compared to an accepted standard, such as vital signs, intake and output, height and weight, body temperature, pulse, and respiratory rates, blood pressure, vomiting, distended abdomen, presence of edema, lung sounds, crying, skin color, and presence of diaphoresis
Objective data
are spoken or written data such as statements made by the client or by a secondary source. Verbal data requires the listening skills of the nurse to assess difficulties such as slurring, tone of voice, assertiveness, anxiety, difficulty in finding the desired word, and flight of ideas.
Verbal data
are observable behavior transmitting a message without words, such as the patient’s body language, general appearance,
facial expressions, gestures, eye contact, proxemics (distance), body language, touch, posture, clothing.
Nonverbal data
—information that does not
change over time such as:
race
blood type
Constant data
—data can change quickly, frequently, or rarely such as:
blood pressure
level of pain
age
Variable data
Sources of Data
Primary
Secondary
The client is the primary source of data
Primary
Family members or other support
persons, other healtH professionals, records and reports
Secondary
The best source of data is usually the client, unless the client is too ill, young, or confused to communicate clearly
Client
—Family members, friends, and caregivers They give information on client’s response to illness, the stresses the client was
experiencing before the illness, family attitudes on illness and health, and the client’s home environment
Support People
—include information documented by various healthcare professionals.
Client Records
Types of client records include:
- Medical records
- Records of therapies
- Laboratory records
—Nurses, social workers, primary care providers Sharing of information is important to ensure
continuity of care when clients are transferred to and from home and healthcare agencies
Healthcare Professionals
—professional journals and reference texts
Literature
- planned communication with a purpose
Ex: Nursing Health History
Interviewing
—highly structured, elicits specific information.
—purpose of interview is established, limited opportunity to discuss concerns.
Ex: Emergency situation
Directive interview
—rapport-building interview
—the nurse allows the client to control the purpose, subject matter, and pacing.
Non Directive Interview
—directive interview
—“yes” or “no” or short factual answers
Examples:
“What medication did you take?”
“Are you having pain now?”
“How old are you?”
“When did you fall?”
Closed questions
—nondirective interview
—to elaborate, clarify, or illustrate their thoughts or feelings.
Examples:
“How have you been feeling lately?”
“What brought you to the hospital?”
“How did you feel in that situation?”
Open-ended questions
—is a question the client can answer without direction or pressure from the nurse
—open ended
—nondirective interview
Examples:
“How do you feel about that?”
“What doyou think led tothe operation?”
Neutral question
—directs the client’s answer
—directive interview
Examples:
“You’re stressed about surgery tomorrow, aren’t you?”
“You will take your medicine, won’t you?”
Leading question
— client (comfortable and free of pain), minimal interruptions
Time
— well-lit, well-ventilated room, free of noise and distractions
Place
— the nurse sits at a 45-degree angle to the bed (less formal than sitting behind a table or standing at the foot of the bed)
Seating Arrangement
—maintain a distance of2 to3 feet during an interview
Distance
—convert complicated medical terms to common language
Language
- The nurse reviews the medical record before meeting the client
- Knowing some of the client’s already documented biographical information may assist the nurse with conducting the interview
- *For example, it may indicate that the client has difficulty hearing in one ear. This information will ensure that the nurse conducts the interview on the side on which the client hears best
Pre introductory Phase
- The nurse introduces himself to the client
- Nurse must explains the purpose of the interview
- Assures the client that the confidential information will remain confidential
- The nurse makes sure that the client is comfortable and has privacy
- At this point in the interview , it is essential to develop rapport, which are essential to promote full disclosure.
Introductory Phase
- The longest phase
- The nurse elicits data (Hx-taking)
- The nurse then listens, observes cues, and uses critical thinking skills to interpret and validate information received from the client
Working Phase
- The nurse summarizes information obtained during working phase and validates problems and goals with the client.
- The nurse identifies and discusses possible plans to resolve the problem with the client.
- The nurse makes sure to ask if anything else concerns the client and if there are any further questions
Summary & Closing Phase
PHASES OF INTERVIEW
- Pre introductory Phase
- Introductory Phase
- Working Phase
- Summary & Closing Phase
is an assessment tool that depends on the use of the five senses (sight, touch, hearing, smell, and taste) to learn information about the client. This information relates to characteristics of the client’s appearance, functioning, primary
relationships, and environment
Observation
Overall appearance
(body size, posture, grooming)
signs of distress or discomfort
facial and body gestures
skin color and lesions
religious or cultural artifacts (books, icons, candles, beads)
Vision
Body or breath odors
Smell
Lung and heart sounds;
bowel sounds,
ability to communicate;
language spoken;
orientation to time, person and place
Hearing
Skin temperature and moisture muscle strength (handgrip); pulse rate, rhythm, and volume palpable lesions (lumps, masses, nodules)
Touch
Nursing observations must be organized so that nothing significant is missed. A nurse walks
into a client’s room and observes, in the following order:
- Clinical signs of client distress
- Threats to the client’s safety
3.The presence and functioning of equipment
4.The immediate environment
Observing
Establishing a good physical assessment would, later on, provide a more accurate diagnosis, planning, and better interventions and evaluation.
EXAMINING
—Techniques of inspection, palpation, percussion and auscultation
—Carried out systematically
—Organized (head-to-toe, body systems approach)
Examining (Physical Examination)
also called a review of systems, is a brief review of essential functioning of various body parts or systems.
screening examination
*The nurse uses a written
(or electronic) format that
organizes the assessment
data systematically
ORGANIZING data
*The nurse uses a written (or
electronic) format that organizes the assessment data systematically. (Ex. Gordon’s 11 functional health patterns.
ORGANIZING data
- Validation is the process of verifying the data to ensure that it is accurate and factual. One way to
validate observations is through “double checking”
VALIDATING data
- subjective or objective data that is observed by the nurse.
(Ex: Incision is red, hot, swollen)
CUES
- nurse’s interpretation or conclusions made based on the cues
(Ex: The nurse makes the inference that the incision is infected)
INFERENCES
- Once all the information has been collected, data can be recorded and sorted.
- Excellent record-keeping is fundamental so that all the data gathered is documented and
explained in a way that is accessible to the whole health care team and can be referenced during evaluation
DOCUMENTING data
