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• Nursing Process


  A method of planning nursing actions in providing patient-focused care. A form of scientific reasoning and requires the nurse's critical thinking to provide the best care possible to the client. A series of organized steps designed for nurses to provide excellent care

  
• Characteristics of the nursing process

  • Patient-centered
  • Interpersonal
  • Collaborative
  • Dynamic and cyclical
  • Requires critical thinking

  
• Nursing Process Steps


  1. Assessment

  2. Diagnosis

  3. Planning

  4. Implementation

  5. Evaluation

  
• ADPIE


  Acronym to remember the components of the nursing process
• Assessment


  The first phase of the nursing process. It involves: Collection of Data, Organization of Data, Validation of Data, Documenting the clients' health status

  
• 4 Types of Assessment

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

  
• Subjective Data


  Feelings, perceptions, thoughts, sensations, or concerns that are shared and described only by the patient
• Objective Data


  Data collected via the senses, such as sight, touch, smell, or hearing, and compared to an accepted standard
• Verbal Data


  Spoken or written data such as statements made by the client or by a secondary source
• Nonverbal Data


  Observable behavior transmitting a message without words, such as body language, general appearance, facial expressions, gestures, eye contact, proxemics, body language, touch, posture, clothing
• Primary Source


  The client is the only primary source of data and the only one who can provide subjective data
• Secondary Source


  A source is considered secondary data if it is provided from someone else other than the client, such as family members, support persons, records and reports, other health professionals, laboratory and diagnostics
• Methods of Data Collection

  1. Interviews

  2. Physical examination

  3. Observation
• Health Interview


  The most common approach to gathering important information. An intended communication or a conversation with a purpose to obtain or provide information, to identify problems
• 3 Phases of Interview

  1. Introductory Phase

  2. Working Phase

  3. Termination Phase
• Directive Interview


  Nurse directly asks the questions, the nurse controls the interview
• Non-directive Interview


  Rapport building interview, the nurse allows the client to do the talking
• Physical Examination


  The nurses uses techniques of inspection, auscultation, palpation and percussion to provide a more accurate diagnosis, planning, and better interventions and evaluation
• Observation


  Gathering of data by using the senses, such as sight, touch, hearing, smell, and taste
• Validating Data


  The process of verifying the data to ensure that it is accurate and factual
• Organizing Data


  Nursing health history form or Nursing assessment form

  
• Documenting Data


  Recording and sorting the information gathered, to create accessible documentation for the healthcare team
• 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
• information collection/ gathering data


  assessment
• a method of planning nursing actions in providing patient- focused care

  nursing process
• nursing process


  a form of scientific reasoning and requires the nurse's critical thinking to provide the best care possible to the client.
• Nursing process


  a series of organized steps designed for nurses to provide excellent care
• Initial-nursing assessment


  -performed within specified time after admission

  -to establish a complete data base for problem identification

  ex. nursing admission assessment
• Problem-focused assessment


  -monitor the status of a specific problem identified in an early assessment

  ex. hourly checking of vital signs of patient with fever or increase BP check
• Emergency assessment


  assessment done during emergency situations to identify any life- threatening situations

  ex. rapid assessment of individuals airway, breathing status, and circulation during a cardiac arrest
• Time-lapsed reassessemnt


  -several months after initial assessment

  -to compare the clinet's current health status with the data previously obtained

  ex. follow-up visits
• Subjective data


  Also referred to as SYMPTOMS
• Subjective data


  involove feelings, perceptions, thoughts, sensations, or concerns that are shared and described only by the patient
• Subjective


  Data is usually documented in the clients own words
• 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 words, and flight of ideas.
• Health Interview


  an intended communication or a conversation with a purpose
• Directive and Non-directive


  2 Approaches of Health Interview
• validating data


  ensure that the nurse does not come to a conclusion without adequate data to support the conclusion
• validating data

  • acquire additional detail that may have been overlooked.
  • distinguish between cues and inferences.
• Nursing Process


  A method of planning nursing actions in providing patient-focused care. A form of scientific reasoning and requires the nurse's critical thinking to provide the best care possible to the client. A series of organized steps designed for nurses to provide excellent care