HA

• The Nursing Process

  1. Assessing

  2. Analyzing

  3. Planning

  4. Implementing

  5. Evaluating
• Planning

  Write care plan to meet goals
• Assessment

  Collection & analysis of subjective & objective data pertinent to a client
• Diagnosing

  The process that results in diagnostic statement or nursing diagnosis
• Nursing Process

  Framework that helps organize and deliver nursing care
• Planning

  Involves determining beforehand the strategies of course of actions to be taken before implementation of nursing care
• The heart of nursing process includes Knowledge, Skills, and Caring
• Sources of assessment of data

  • Primary source - patient
  • Secondary source - family members, friends, Patient’s records, related literature
• Outcome Identification

  Refers to formulating and documenting measurable, realistic, patient-centered goals
• Evaluation

  Assessing the patient’s response to nursing interventions and then comparing the response to the predetermined outcome criteria
• Types of data

  • Subjective data
  • Objective data
• The Process of Communication

  1. The channel through which the interview is carried is communication

  2. Communication involves all behavior, conscious and unconscious, verbal and nonverbal

  3. Sending: Verbal and Nonverbal

  4. Receiving: Words and gestures must be interpreted in a specific context to have meaning
• Physical Environment

  • Temp of room in comfortable level
  • Sufficient lighting
  • Reduce noise
  • Remove distracting equipment or object
  • Maintain distance (4-5 feet from the patient)
  • Arrange “equal-status setting”
  • Face to Face
• The heart of nursing process

  • Knowledge: Broad, Varied
  • Skills: Manual/Technical, Intellectual, Interpersonal
  • Caring: Willingness and Ability to care
  • Ethico-Legal Consideration
• The Interview

  1. Is a purposeful conversation between the nurse and the patient

  2. Complete and accurate history is the foundation for data collection and assessment

  3. Purpose: Gather organized, complete and accurate data about the patient’s health state, establish rapport and trust, teach patient about the health state, begin teaching health promotion and disease prevention
• Nursing process

  1. Collect data about the patient’s response

  2. Compare the response to goals and outcomes criteria

  3. Analyze the reasons for the outcomes

  4. Modify the care plan as needed
• Internal Factors that affect communication

  • Liking others
  • Empathy
  • Ability to listen
• Informed Consent

  • Diagnosis
  • Name of procedure, test, or medication
  • Explanation of procedure, test, or medication
  • Reasons for recommending the procedure, test, or medication
  • Anticipated benefits
  • Major risks of the procedure, test, or medication
  • Alternative treatments
  • Prognosis if treatment is refused
• Open-ended questions

  1. Ask for narrative info

  2. Unbiased

  3. Spontaneous account

  4. Let the person express feelings

  5. It builds rapport
• Phases of Interview

  1. Preparatory Phases

  2. Introductory Phase

  3. Maintenance Phase

  4. Concluding Phase
• Space and Distance

  4 Distance Zones: Intimate Zone (0-1.5 feet), Personal Distance (1.5-4 feet), Social Distance (4-12 feet), Public Distance (12 or more feet)
• Maintenance Phase

  1. Keep focus on the task

  2. Encourage patient to express feelings, concerns or questions

  3. Use communication techniques

  4. Observe non-verbal cues or behavior

  5. Assess patient’s ability to continue with the interview

  6. Facilitate goal attainment by moving to the next step of discussion after needed data are collected
• Techniques of Communication

  1. Check your handouts

  2. Prepare for Interactive Discussion
• Introductory Phase

  1. Introduce self and explain the purpose of the interview

  2. Begin to establish rapport with the patient

  3. Observe patient’s behavior and listen attentively

  4. Let the patient know the duration of the interview

  5. Inform patient how information collected will be used and that confidentiality will be maintained

  6. Start with non-threatening, specific questions and proceed to open-ended questions

  7. Establish a verbal contract with the patient, incorporating the goals of the interview
• Physical Environment

  1. Temp of room in comfortable level

  2. Sufficient lighting

  3. Reduce noise

  4. Remove distracting equipment or object

  5. Maintain distance (4-5 feet from the patient)

  6. Arrange “equal-status setting”

  7. Face to Face Position
• Two types of questions used during interview

  • Open-ended questions
  • Close-ended questions
• Interview Interruptions

  • Physical Environment
  • Dress
  • Note-taking
  • Tape or Video Recordings
• Close-ended questions

  1. For specific information

  2. To fill in any details left out

  3. It limits rapport and leaves interaction neutral
• Concluding Phase

  1. Review goals and task attainment

  2. Summarize the highlights of the interview and its meaning to the nurse and the patient

  3. Encourage the patient to express feelings
• Components of Health History

  1. Biographic data

  2. Reasons for seeking care

  3. Present health or history of present illness

  4. Current medication

  5. Family history

  6. Review of systems

  7. Functional assessment of activities of daily living (ADL)
• Present health or history of present illness

  1. P - Provocation or Palliative

  2. Q - Quality or Quantity

  3. R - Region or Radiation

  4. S - Severity Scale

  5. T - Timing

  6. U - Understand patient’s perception
• People who may have challenges during health history taking

  • Hearing impaired people
  • Acutely ill people
  • People under the influence of street drugs or alcohol
  • Personal Questions
  • Sexually aggressive people
  • Crying
  • Anger
  • Threat of violence
  • Anxiety
• Review of Systems (ROS) - Hair

  Recent loss, change in texture, nails (shape, color, brittleness), health promotion related to sun exposure and self-care for skin and hair
• Purpose of the Comprehensive Health History

  • Provide the subjective database
  • Identify patient’s strengths
  • Identify patient’s health problems
  • Identify supports
  • Identify teaching needs
  • Identify discharge needs
  • Identify referral needs
• Current Medications

  Note all prescription and over-the-counter medications and herbal remedies, ask specifically for vitamins, aspirin, birth control, and antacids
• Review of Systems (ROS) - Eyes

  Difficulty with vision, eye pain, double vision, redness or swelling, watering
• Review of Systems (ROS) - Skin

  History of skin disease, changes in pigmentation, texture, moles, hair growth, excessive bruising
• Review of Systems (ROS) - General Overall Health State

  Present weight, fatigue, weakness, chills, sweat or night sweats
• Biographic data

  1. Name, address, and phone number

  2. Age and birthdate

  3. Birthplace

  4. Gender

  5. Marital status

  6. Race, ethnic origin

  7. Occupation (present and usual)

  8. Language
• Past Health History

  Patient’s previous health events including childhood illnesses, accidents or injuries, serious or chronic illnesses, hospitalization, operations, obstetric history, immunization, last examination date, allergies