funda -semi

• Nursing process


  A critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness (American Nurses Association, 2010)
• Nursing process


  A systematic method of providing care to clients
• Components of nursing process

  • Assessment (data collection), nursing diagnosis, planning, implementation, and evaluation
• Characteristics of Nursing Process

  • Cyclic
  • Dynamic nature
  • Client centeredness
  • Focus on problem solving and decision making
  • Interpersonal and collaborative style
  • Universal applicability
  • Use of critical thinking and clinical reasoning
• Assessment


  The systematic and continuous collection, organization, validation, and documentation of data (information)
• Types of assessment

  • Initial nursing assessment
  • Problem-focused assessment
  • Emergency assessment
  • Time-lapsed reassessment
• Initial nursing assessment


  Performed within specified time after admission to establish a complete database for problem identification
• Initial nursing assessment


  • Nursing admission assessment
• Problem-focused assessment


  To determine the status of a specific problem identified in an earlier assessment
• Problem-focused assessment


  • Hourly checking of vital signs of fever patient
• Emergency assessment


  During emergency situation to identify any life threatening situation
• Emergency assessment


  • Rapid assessment of an individual's airway, breathing status, and circulation during a cardiac arrest
• Time-lapsed reassessment


  Several months after initial assessment to compare the client's current health status with the data previously obtained
• Data collection


  The process of gathering information about a client's health status, including health history, physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel
• Types of Data

  • Subjective data (symptoms or covert data)
  • Objective data (signs or overt data)
• Subjective data


  Data that are clear only to the person affected and can be described only by that person (e.g. itching, pain, feelings of worry)
• Objective data


  Data that are detectable by an observer or can be measured or tested against an accepted standard (e.g. discoloration of the skin, blood pressure reading)
• Sources of Data

  • Primary (the client)
  • Secondary (family members, health professionals, records and reports, laboratory and diagnostic results)
• Methods of data collection

  • Observation
  • Interview
  • Examination
• Observation


  Gathering data by using the senses (vision, smell, hearing)
• Interview


  A planned communication or conversation with a purpose
• Approaches to interviewing


  • Directive (highly structured, nurse controls)
  • Nondirective (rapport building, client controls)
• Stages of an interview

  • The opening or introduction
  • The body or development
  • The closing
• Examination


  A systematic data collection method to detect health problems, using techniques of inspection, palpation, percussion and auscultation
• Organization of data


  The nurse uses a format that organizes the assessment data systematically, often referred to as nursing health history or nursing assessment form
• Validation of data


  The information gathered during the assessment is "double-checked" or verified to confirm that it is accurate and complete
• Documentation of data


  The nurse records client data, as accurate documentation is essential and should include all data collected about the client's health status
• Diagnosis


  The second phase of the nursing process where nurses use critical thinking skills to interpret assessment data to identify client problems
• Nursing diagnosis


  A clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community (NANDA definition)
• Status of the Nursing Diagnosis

  • Actual
  • Health promotion
  • Risk
• Actual diagnosis


  A client problem that is present at the time of the nursing assessment
• Health promotion diagnosis


  Relates to clients' preparedness to improve their health condition
• Risk nursing diagnosis


  A clinical judgement that a problem does not exist, but the presence of risk factors indicates that a problem may develop if adequate care is not given
• Components of a NANDA Nursing Diagnosis

  • The problem and its definition
  • The etiology
  • The defining characteristics
• Problem statement


  Describes the client's health problem
• Etiology


  Identifies causes of the health problem
• Defining characteristics


  The cluster of signs and symptoms that indicate the presence of a health problem
• PES format


  The basic three-part nursing diagnosis statement, including the Problem, Etiology, and Signs and symptoms
• Nursing diagnosis


  • Acute pain related to abdominal surgery as evidenced by patient discomfort and pain scale
• Medical diagnosis

  • Asthma
  • Cerebrovascular accident
  • Appendicitis
  • Amputation