funda quiz

• Nursing process is the framework for providing

  professional, quality nursing care.
• nursing process It directs nursing activities for health promotion,

  health protection, and disease prevention and is

  used by nurses in every practice setting and

  specialty
• Lydia Hall first referred to nursing as a "process" in

  a 1955 journal article, yet the term was not widely

  used until the late 1960s (Edelman & Mandle,

  2006).
• Referring to the "nursing process" as a series of

  steps, Johnson (1959), Orlando (1961), and

  Wiedenbach (1963) further developed this

  description of nursing
• Initially, the nursing process involved only three

  steps: assessment, planning, and evaluation
• Purposes of nursing process

  ● To identify a client's health status and actual

  or potential health care problems or needs.

  ● To establish plans to meet the identified

  needs.

  ● To deliver specific nursing interventions to

  meet those needs.
• Characteristics of Nursing Process (PIC)

  Patient-centered

  Interpersonal

  Collaborative

  Dynamic and cyclical

  Requires critical thinking
• Components of Nursing Process

  ● Assessment

  ● Diagnosis

  ● Outcome Identification and Planning

  ● Implementation

  ● Evaluation
• The Nursing Process, Yura and Walsh (1967)

  identified four steps in the nursing process

  ● Assessing

  ● Planning

  ● Implementing

  ● Evaluating
• Fry (1953) first used the term nursing

  diagnosis, but it was not until 1974, after the

  first meeting of the group now called the

  North American Nursing Diagnosis

  Association (NANDA), that nursing

  diagnosis was added as a separate and

  distinct step in the nursing
• The ANA made revisions to the standards in

  1991 to include outcome identification as a

  specific part of the planning phase.
• Steps in the nursing process are:

  ● Assessment

  ● Diagnosis

  ● Outcome Identification and Planning

  ● Implementation

  ● Evaluation
• Patient-centered- The unique approach of the

  nursing process requires care respectful of and

  responsive to the individual patient's needs,

  preferences, and values. The nurse functions as a

  patient advocate by keeping the patient's right to

  practice informed decision-making and maintaining

  patient-centered engagement in the health care

  setting.
• Interpersonal- The nursing process provides the

  basis for the therapeutic process in which the nurse

  and patient respect each other as individuals, both

  of them learning and growing due to the interaction.

  It involves the interaction between the nurse and

  the patient with a common goal.
• Collaborative- The nursing process functions

  effectively in nursing and inter-professional teams, promoting open communication, mutual respect,

  and shared decision-making to achieve quality

  patient care.
• Dynamic and cyclical- The nursing process is a

  dynamic, cyclical process in which each phase

  interacts with and is influenced by the other

  phases.
• Requires critical thinking- The use of the nursing

  process requires critical thinking which is a vital skill

  required for nurses in identifying client problems

  and implementing interventions to promote effective

  care outcomes.
• Assessment - is the first step in the nursing

  process and includes collection, verification,

  organization, interpretation, and documentation of

  data.
• Objective 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
• Subjective data 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.
• Verbal 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 or voice, assertiveness, anxiety, difficulty in finding the desired

  word, and flight of ideas.
• Nonverbal 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 obtained can sometimes be

  more powerful than verbal data, as the

  client's body language may not be

  congruent with what they really think or feel.

  Obtaining and analyzing nonverbal data can

  help reinforce other forms of data and

  understand what the patient really feels.
• Sources of Data

  Primary Source

  Secondary Source

  Tertiary Source
• The client is the only primary source of

  data and the only one who can provide

  subjective data
• A source is considered secondary data if it

  is provided from someone else other than

  the client but within the client's frame of

  reference.
• Primary Source

  Anything the client says or reports to the

  members of the healthcare team is

  considered primary.
• Secondary Source

  Information provided by the client's family or

  significant others are considered secondary

  sources of data if the client cannot speak for

  themselves, is lacking facts and

  understanding, or is a child.
• Secondary Source

  the client's records and

  assessment data from other nurses or other

  members of the healthcare team are

  considered secondary sources of data.
• Tertiary Source

  ● Sources from outside the client's frame of

  reference are considered tertiary sources of

  data. Examples of tertiary data include

  information from textbooks, medical and

  nursing journals, drug handbooks, surveys,

  and policy and procedural manuals.
• Methods of Data Collection

  Health Interview

  Physical Examination

  Observation

  Validating Data

  Inferences

  Documenting Data
• Documenting Data

  ● Once all the information has been collected,

  data can be recorded and sorted.
• Documenting Data

  ● 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
• Nursing Process: Diagnosis

  ● The second step of the nursing process is

  the nursing diagnosis.
• DIAGNOSIS\

  The nurse will analyze all the gathered

  information and diagnose the client's condition and

  needs.
• Diagnosing involves analyzing data, identifying

  health problems, risks, and strengths, and

  formulating diagnostic statements about a patient's

  potential or actual health problem.
• Nursing diagnosis


  An effective teaching tool to sharpen problem-solving and critical thinking skills for nursing students
• Purpose of nursing diagnosis

  • Helps identify nursing priorities
  • Helps direct nursing interventions based on identified priorities
  • Helps formulate expected outcomes for quality assurance requirements of third-party payers
• Nursing diagnoses


  Provide a common language and form a basis for communication and understanding between nursing professionals and the healthcare team