HA

• Nursing Process

  Systematic, organized method
• Nursing


  Diagnosis and treatment of human responses to health and illness
• Initial Comprehensive

  1. Collection of subjective data

  2. History
• Focused/Problem-Oriented


  Specific health concern
• Diagnosis

  1. Clinical judgment

  2. Analysis of data
• Intervention

  1. Treatment based on clinical judgment

  2. Doing phase

  3. Carrying out the plan to achieve the goals
• Signs and Symptoms

  1. Observable assessment

  2. Patient behavior, physical signs
• Relied on natural senses

  Late 1800s–Early 1900s
• Evaluation


  1. Final step

  2. Effectiveness of the plan

  3. Monitoring client’s progress
• Objective Data

  1. Signs

  2. Measurable and observable
• • Graduated
  • Advance practices


  1990-Present
• LITERATURE - Journal, studies
• Interview

  1. Planned communication

  2. Give and get data
• Summary and Closing Phase

  Clarifying
• Pre-employment health stories

  1950-1969
• SUPPORT PEOPLE - Family, relatives
• Introductory Phase


  Explain purpose of interview
• Closed Questions

  Answerable by yes or no
• Neutral Questions

  Can answer without direction or pressure
• Physical Examination


  Head to toe approach
• Nursing

  • Both science and art
• Ongoing/Partial


  1. After comprehensive database

  2. Mini overview of client’s system
• Assessment

  1. Systematic collection of data

  2. Most important step

  3. Sets the tone for the process

  4. Patient’s strength and weakness
• Types of Intervention

  • Direct Care
  • Indirect Care
  • Independent
  • Dependent
  • Collaborative
• Types of Nursing Diagnosis

  • Actual Nursing Diagnosis
  • Potential Nursing Diagnosis
  • Possible Nursing Diagnosis
• Autonomous; active role


  1970-1989
• Planning

  1. Desired outcome

  2. Goal

  3. Short-term goal

  4. Long-term goal
• Emergency Assessment


  Life-threatening situations
• CLIENT - Best source of subjective data
• Subjective Data

  1. Symptoms

  2. The patient said
• Types of Nurses

  • Acute Care Nurse
  • Critical Care Outreach Nurse
  • Ambulatory Care Nurse
  • Home Health Nurses
  • Public Health Nurses
• OBSERVING - Using senses in data collection
• American Journal Public Health

  1930-1949
• Pre-Introductory Phase


  Review medical record before meeting client
• Open-Ended Question

  Invite client to elaborate and explore
• Leading Question


  Closed, directive, & persuasive
• HEALTH CARE PROFESSIONALS - Verbal reports
• Working Phase


  Longest phase
• Screening Examination

  Brief review of systems
• Information Gathering Interview

  Combination of direct and non